In this discussion we shall avail ourselves of the researches and investigations of eminent Professors, whose observations, experience, and position give their views the highest authority. The latest and most deserving record on this subject is from the pen of Professor Aiken, of Edinburgh, who observes, "There are few diseases for the cure of which so many different remedies and modes of treatment have been employed as in Cholera, and, unfortunately, without our discovering an antidote to the poison. In Moscow it is said that the mortality was not greater among the destitute of medical aid than among those who had every care and attention shown them. It may be fairlyinferred, therefore, that in the severer forms of the disease, the action of this poison is so potent as to render the constitution insensible to the influence of our most powerful remedial agents. When, however, the disease is mild, or on the decline, much may be done by obviating symptoms to promote the recovery of the patient."
"The heroic remedies that have been employed in Cholera are bleeding, and calomel and opium, either separately or conjointly. With respect to bleeding, it may be stated, that in every country the patients bore bleeding badly in any stage, and that the practice in Europe was at length limited to a few leeches occasionally to the head. As to calomel, that medicine was used to the greater part of an ounce in the twenty-four hours, but with so little success that many patients have been seized and have died under the full influence of mercury. On the appearance of cholera in Europe, opium was administered in the doses recommended by the Indian practitioners to the greater part even of an ounce of laudanum; but itwas soon seen that in the cold stage it was inefficient in controlling the vomiting or purging; that it did not allay the spasms, and, moreover, hardly produced any narcotic effect. The action of the accumulated doses of opium, however, though suspended during the cold stage, was often fully developed in the last stage, and occasioned so much affection of the head that most practitioners either abandoned its use or limited it to a mere fractional dose of that usually given in India, namely, from three to twelve minims of the tincture of opium, or half a grain to a grain of solid opium every four or six hours."
Let us now turn to a paper by the justly celebrated Professor Maclean, whose observations and experiences have been more extensive than perhaps those of any other professional gentleman either in Europe or America. Unlike many of his brethren, he holds on this subject the safer doctrines of practice, and very frankly and earnestly expresses the same in the following language: "Opium in cholera should be givenonly in the premonitory diarrhœa. At this stage, in combination with a stimulant, it is of the highest value. If persevered in, particularly in the strong doses (justly reprobated), it is a dangerous remedy, inducing fatal narcotism, or, at the least, interfering with the functions of the kidneys, and so leading directly to uræmic poisoning."
"Urgent thirst is one of the most distressing symptoms in cholera; there is incessant craving for cold water, doubtless instinctive, to correct the inspissated condition of the blood, due to the rapid escape of the liquor sanguinis. It was formerly the practice to withhold water—a practice as cruel as it is mischievous. Water in abundance, pure and cold, should be given to the patient, and he should be encouraged to drink it, even should a large portion of it be rejected by the stomach; and when the purging has ceased, some may, with much advantage, be thrown into the bowel from time to time.
In the stage of reaction, the fever may be moderated by cold sponging, or by the wetsheet; the secretion of urine may be promoted by dry cupping over the loins by the use of chlorate of potash, and the like. But suppression of this secretion is most to be dreaded where opium has been too freely used in the treatment. In men of intemperate habits, we often see, during the stage of reaction, obstinate vomiting of thick, tenacious, green, paint-looking matter, probably bile pigment, acted on by some acid in the stomach or alimentary canal. It is a symptom of evil omen, and often goes on uncontrolled until the patient dies exhausted, and this although all other symptoms may promise a favorable issue. I have known it last for a week, resisting all remedies, and proving fatal when the urinary secretion had been restored and all cerebral symptoms had subsided. Alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses offer the best hope of relief. The patient should be nourished more by the bowel than the stomach when vomiting is present. Ice should benot only to dissolve in the mouth, but to swallow in pieces of convenient size."
"Another heroic plan," says Dr. Aiken, "peculiar, perhaps, to this country, which was practiced when the inefficiency of medicines was generally admitted, was an injection of a solution of half an ounce of muriate of soda, and four scruples of sesquicarbonate of soda in ten pints of water, of a temperature varying from 105 to 120 Fah., into the veins of the suffering patient. The solution was injected slowly; half an hour being spent in the gradual introduction of the ten pints, and the immediate effects of this treatment were very striking. The good effects were rapid in proportion to the heat of the solution, but a higher temperature than what is stated could not be borne. After the introduction of a few ounces, the pulse, which had ceased to be felt at the wrist, became perceptible, and the heat of the body returned. By the time three or four pints had been injected the pulse was good, the cramps had ceased, the body, that could not be heated, had becomewarm, and instead of cold exudation on the surface, there was a general moisture; the voice, before hoarse and almost extinct, was now natural, the hollowness of the eye, the shrunken state of the features, the leaden hue of the face and body had disappeared, the expression had become animated, the mind cheerful, the restlessness and uneasy feelings had vanished, the vertigo and noises of the ear, the sense of oppression at the precordia had given way to comfortable feelings; the thirst, however urgent before the operation, was assuaged, and the secretion of urine restored, though by no means constantly so. But these promising appearances were not lasting; the vomiting continued, the evacuations became more profuse, and the patient soon relapsed into his former state, from which he might again be aroused by a repetition of the injections; but the amendment was transient, and the fatal period not long deferred. Of 156 patients thus treated at Drummond Street Hospital, Edinburgh, under the direction of Dr. Macintosh, only25 recovered; a lamentably small proportion; and, small as it is, it seems doubtful if the recoveries were final or complete."
But let us turn to another page, whose beauty is especially marred by unreasonable expedients: "The warm bath," says the writer, "was at first tried, but discontinued from the uncontrollable nature of the vomiting and purging, and the oppressive sensation of heat it produced on the patient's feelings. Mr. Dalton's vapor bath and Turkish baths in the Hospital at Scutari have been used, but without benefit, and to the disappointment of the hopes which had been entertained of them."
"Other methods of restoring warmth were had recourse to, such as frictions with the hand or by the flesh-brush, or rubbing the body with some strong stimulant embrocation, compounded of garlic, capsicum, camphor, cantharides, or other powerful irritants. Mustard poultices also were often applied to the feet and abdomen, blisters with or without an addition of oil of turpentine,the part having been previously rubbed with hot sand; and in cases supposed to be urgent, the mineral acids, and even boiling water, were employed for the purpose of producing instant vesication."
"And, again, we read of those who tried to stimulate the waning powers of life by galvanism, acupuncture of the heart, issues, setons, moxas, actual cautery along the spine, and, lastly, by small pieces of linen dipped in alcohol distributed over the body and then set fire to!!!" Such are some of the means which have been used in the treatment and cure of cholera.
"The failure of such powerful means at length caused most practitioners to confine themselves to checking the diarrhœa, which so frequently precedes cholera, and subsequently, to obviating symptoms as they arose," and for this purpose, returned to and adopted a very simple stimulating mixture, recommended by the Board of Health:
Tinc. Kino, or the decoctum Hæmatoxyli, were sometimes added.
These remedies, it is said, frequently arrested the attack altogether. If, however, the disease proceeded and the cold stage of cholera formed, the same remedies were prescribed in an effervescing draught. "To promote reaction in cholera and diarrhœa, the following formula has met with most universal approval in this country and in India. So highly is it valued, indeed, that it is ordered to be always in store, and in readiness in theMedical Field Companionof the army when on the march:
M.——S.: ten drops every fifteen minutes, in a table-spoonful of water. An opiate may be given with the first and second dose, but should not be continued."
The learned author to whom we have referred, after detailing some of the various expedients employed in the treatment and cure of cholera, sums up the whole under the common term—failure—and, in effect, declares the most powerful remedial agents ineffective and useless in controlling and subduing this disease.
This declaration is made in reference to the general result of the remedies and the various expedients adopted mainly by one class of physicians, to which special reference has been made. It is therefore partial, and confined solely to what is erroneously termed the regular practice. In declaring all remedial agents a failure, does not the author himself commit a greater failure in omitting to survey the whole subject of treatment, and to trace out and to show from the application of the pathology of the disease the probable cause of such failure?
However formidable this disease may appear, on account of its rapidity and its firm, unyielding grasp upon the vital powers, the forbidding and almost hopeless prospect of relief, and the lamentable results which have attended some modes of treatment, it seems particularly unfortunate for the profession that there should have been a disposition on the part of this learned author to abandon all remedial agents as comparatively useless, without a more thorough investigation into the cause of failure. On this point no effort or inquiry even is made. This is the more remarkable and surprising after dwelling at length on the pathology of the disease. It would seem as if all the light and science derived from this source for nearly half a century had been overlooked, or the pathology of the disease, from some cause not satisfactorily explained, had been deemed unworthy at least in this instance to dictate the course of treatment. This should govern in cases of cholera as in all other forms of disease, or else all our efforts and remedies will proveabortive. Now, had the doctor carefully investigated the various modes of treatment and compared the results of each, he might have come to a different conclusion. But, being confined and limited in his investigations, he is unable to discover anything reliable or worthy his commendation, except the formulas above and the recommendation of Dr. Maclean. Among all the remedies and expedients named, there is only one tending to fulfil, the indications required, and that one, though prompt and magical in its effects, has been unequivocally condemned, without looking beyond the transient result for any light it might shed upon the subject. How it should have escaped his notice and passed so long unobserved by the numerous professional gentlemen who had often witnessed the effect, and were anxiously searching for light and the means of affording relief to the suffering patient, is a most singular circumstance which can only be accounted for on the principle that they all were anticipating some strange phenomenon, or developmentof cure as mysterious as the disease itself, which led them to overlook the simple and effective means of relief so clearly represented and shown in their numerous experiments for something more heroic and powerful than as yet the imagination ever conceived.
If we trace the action of calomel, the use of opium, the effect of cupping, bleeding, blistering, etc., etc., we shall obtain no very desirable information; nothing valuable tending to indicate a correct principle of practice. If we go still further, and examine the tendency and effects of the various baths exhibited at Scutari, the use of the flesh-brush, the bare hand, the heated sand, the embrocations, the turpentine and other irritants, the boiling water, or the burning alcohol, skinning and cooking the patient alive, we shall be shocked at the enormous cruelty and barbarity that have been pursued, and turn from the repulsive exhibition, without discovering one ray of light to guide us in the right direction. Disappointed and baffled in our inquiries,shall we here abandon our investigations and dismiss the whole subject, because our course is involved in difficulties? Would intelligence and reason justify the neglect to improve the means at command? We think not; but rather induce us to advance in search of truth if the elements of success are not quite exhausted. Let us be encouraged and stimulated to untiring perseverance so long as there remains any experiment untraced and uninvestigated in its bearing upon the direct action of the disease. Had Dr. Aiken, or those other eminent surgeons who took part in those numberless experiments, instituted on the Continent and in England, especially those who initiated the process of injecting into the veins a solution of soda raised to a temperature from 105° to 120° Fahr., continued their investigations patiently and assiduously, they might probably have discovered long ago the correct theory of practice for the treatment and cure of cholera.
But they failed to see, or, if they saw atall, rejected the feeble ray of light struck out by the experiments in which they had themselves participated, and like the celebrated Dr. Hunter, who refused to listen to the discoveries made by his pupil, the indefatigable Jenner, who traced the identity of the variola with the common disease affecting the kine; and thence extracted the vaccine lymph and established a principle by which that loathsome disease and often recurring epidemic has been nearly banished from the earth. Though they have thus failed, they have nevertheless left on record, in unmistakable language, the result of their bold experiments, which we may investigate, and appropriate the instruction drawn thence for our own and the advantage of our fellow-men.
What, then, are these results, regarded as shedding light on this intricate subject? We refer only to one the most obvious which we have already cited above. Let us repeat and analyze, and, if practicable, show the principle evolved. There was, on various occasions, the solution of sodainjected into the veins at the temperature from 105° to 120° Fahr.: a higher temperature could not be borne. This process was performed slowly, thirty minutes being occupied in injecting the ten pints. Now mark the result as the operation proceeds. Says Dr. Aiken, "After the introduction of a few ounces, the pulse, which had ceased to be felt at the wrist, became perceptible, and the heat of the body returned." Mark the language: "only a few ounces" were required to arrest for the time being, the progress of the disease and restore warmth to the body; a very remarkable fact, replete with instruction, as will appear as we proceed. Again says the Dr., "by the time three or four pints had been injected the pulse wasgood, the cramps had ceased, the body, that could not be heated, had become warm, and instead of cold exudation on the surface, there was a general moisture. The voice, before hoarse and almost extinct, was now natural; the hollowness of the eye, the shrunken state of the features, the leaden hue of the face and body had disappeared;the expression had become animated, the mind cheerful, the restlessness and uneasy feelings had vanished; the vertigo and noises of the ear, the sense of oppression at the precordia, had given way to comfortable feelings; the thirst, however urgent before the operation, was assuaged, and the secretion of urine restored, though by no means constantly so." Such is the astonishing result obtained by this experiment, and this, too, when only three or four ounces had been injected—all the urgent symptoms mitigated and relieved. What, we ask, could have been more satisfactory, or better calculated to aid the discovery of an important truth? Every distinctive and fatal symptom for the time is relieved, and the normal condition and functions of the system restored; a result which could only have been obtained by the evolution of a principle of sufficient promptness and power and diffusibility to arrest and utterly suspend for a time the force of this disease.
What, then, was the principle evolved inthis experiment, which gave immediate relief? Did it consist in the half ounce of muriate of soda alone, or in the four scruples of sesquicarbonate of soda alone, or in the ten pints of water alone, or in the whole combined, or more especially in the high temperature to which the solution was raised? It is a well-established fact that, in order to raise the temperature of cold water to blood heat and above, a large amount of free caloric must necessarily be absorbed, and exist mechanically in the fluid; and, in this condition, the solution was introduced into the veins, and there evolved its vast amount of free caloric, which immediately permeated every organ of the system, arresting disease, raising the temperature of the body, and restoring its normal functions. Of this there can be little doubt. For free caloric is one of the most prompt, effective and diffusive stimulants known, and was evidently in this case the remedial agent which produced the result. True, it may be said the effect was transitory, and passed off as soon as thecaloric became eliminated. This, however, cannot alter the nature, character, or influence of the principle on which it was produced. It is usually admitted that a remedy that has power to control disease, will, by its continued action and influence, restore the normal condition of the system permanently, or at least aid Nature to repair her own work. By this we would not be understood as advising a repetition of the experiment under consideration, even under the most urgent circumstances; far otherwise would be our advice. We are arguing for the purpose of evolving and establishing a general principle of practice.
The great question, then, is, Did the principle evolved fulfill the indications required? and if so, is it available and consistent with the pathology and the peculiar phenomena, or symptoms of the disease? To settle this point, we need only turn to the law and the testimony, the very highest authority on the subject. The doctrine now universally accepted and prevailing regarding its pathology is, that a poison, virulent, andsubtle, and unknown, has been absorbed and infects the blood, so that, after a longer or shorter time, a primary disease of this vital fluid is produced, by which the vital energy is impaired, and all other morbific changes induced. The term "Algide," first used by the French Pathologists, very accurately describes one of the most remarkable and constant symptoms, viz., the diminution of animal heat. On this depend the altered condition of the blood, the depression of the nervous power, the impaired functions of the respiratory and all the vital organs which are essentially involved by the disease. The icy coldness of the surface, the breath, the extremities and general loss of temperature, all show the character of the disease and the wants of the system.
Did, then, the principle evolved accord with the pathology and phenomena of disease? And did it fulfill the indications required? If not, we ask by what means was the disease arrested, and all the urgent symptoms mitigated and relieved, or bywhat were the good effects produced, and the normal action for a time restored? Can the result be reasonably accounted for on any other principle than the one assigned—the stimulating power of the free caloric? We think not; for it accords most perfectly with the pathology and the peculiar phenomena of the disease. It assuaged the more urgent symptoms, answered the imperious demand of the waning powers, revivified and reinvigorated the vital energies, and restored for the time the normal tone of the system. What more could be desired in any single agent than the result here obtained? That it accomplished all this, there can be no question, according to the statement of the learned professors who have repeatedly witnessed and described the results.
The question, however, will arise, Can this principle be rendered available? Most certainly it can; and though it may not be convenient to introduce free caloric into the stomach, we can, by combination, introduce a stimulant of equal potency which shall beequally as prompt, effective and diffusive in its action, similar in its influence, and similar in its results. It is the principle—not the precise element for which we contend.
It is universally admitted that in many instances we may learn much from observing the manner of death which, in a majority of these cases of cholera, may be described by the term asthenia—a death similar to that which occurs in congestive fevers, and in some cases of accidental poisoning. Perhaps the most striking fact observed in these cases is the perfect exhaustion attending the last moments of existence, and the quiet, undisturbed manner in which life terminates. This very clearly shows the exhausting nature and congestive character of the disease, and gives us an idea of the course of treatment necessary to be pursued. If, then, there is anything to be learned from this source relative to its treatment, it does most certainly corroborate and strengthen the position we have here taken.
Another feature of the case in aid of ourposition consists in its entire accordance with the modes of treatment which have been most successful in the cure of cholera. The two formulas cited above, and now most universally adopted in Europe and India, are based on a similar principle. So in this country 1832,-33 and 34, the successful modes of treatment consisted in the adoption of a principle essentially similar. Hence we infer from the teachings of this experiment, and from all the collateral facts on the subject, that the general principle to be observed in the treatment of this disease is a prompt and diffusive stimulant; and hence we deduce the doctrine already apparent, that every form of treatment, to be successful, must be based on a prompt and effective stimulant of sufficient power to meet as speedily the indications required, as did the free caloric in the experiment to which we have referred.
Here we might pause for a moment and examine the suggestion and doctrines advanced by the learned Drs. Bell, Johnson, and many other eminent practitioners inIndia and Europe. We might further investigate the principles and trace the practical philosophy of such eminent surgeons, as Drs. Mackintosh, Thompson, Wallis Maxwell, Massy, Hill and Brady, all of whom have had opportunity of investigating the nature and character of the disease and extensive experience in its treatment.
We might also, in a further examination of the subject, embrace a host of American authors whose works teem with every shade of doctrine, and almost every variety and description of practice, some evincing a degree of skepticism on the subject more wonderful and marvelous than is becoming the great apostles of medicine. It would seem as if the guiding light of science and experience had forsaken them in this, the hour of their need; that facts and arguments had failed to illumine their minds, or direct their inquiries in the proper course for the discovery of "the truth." Their conclusions on this subject are, therefore, marvelously inconsistent and conflicting. Overthis mass of specious and conflicting testimony we might long ponder, without deriving any very valuable information worthy an elaborate effort, or making any discovery to aid in the establishment of a general principle of practice for the cure of cholera. But this investigation must be deferred to another occasion, when time may permit a more thorough and critical examination of their doctrines and practice than can be presented in this brief essay. We would, however, remark in passing, that in some instances their philosophy, doctrines, and results may lead us to the same conclusion to which we have arrived from other sources as above, and from our regard and belief in the progress of science, feel compelled to advocate the same, as offering the best hope of success in the treatment of this disease.
In the employment of an anti-miasmatic principle and remedial agent, we feel ourselves abundantly sustained, by the concurrent testimony, of those English surgeons connected with the Medical Bureau in the departmentof India, whose numerous experiments and carefully detailed clinic cases occurring in the recent irruption and prevalence of the disease in that section, exhibit its utility in such a striking contrast with all former practice, as to leave no doubt as to its direct and specific action in the cure of cholera. It is in allusion to these experiments, and in answer to the question, what is deemed the most successful mode of treatment, that the learned Professor Maclean unhesitatingly observes, "Alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses, offer the best hope of relief." As this opinion comes from such high authority, and is compatible with the pathology of the disease, we may, without fear of controversy, add in conclusion, in any and every form of medication for the cure of cholera, we must not forget that chloroform is our sheet-anchor; and must be so combined and administered as to meet promptly the indications required.
In the preceding section we alluded to the suggestions and doctrines advanced by the learned Dr. C. W. Bell, Physician to the Manchester Infirmary, and late Physician to H. M. Embassy in Persia—and also to Dr. George Johnson, of Kings College, whose views and doctrines, relative to the Pathology, illustrative of the congestive character and non-aeration of the blood, coincide with those of Dr. Bell. A brief examination of their philosophy and doctrines will show very conclusively the first direct impression of the poison—the gradually altered condition of the blood, and the corresponding loss of nerve power—the impeded arterial circulation and the general tendency to congestion, as well as the altered condition and stagnation of the blood, especially during the stage of collapse.
The question is asked, "What is the pathological explanation of this remarkable train of symptoms?" and the answer is given, "The one great central fact is this, that during the stage of collapse, the passage of blood through the lungs, from the right to the left side of the heart, is in a greater or less degree impeded." Very conclusive evidence as to the existence of impeded pulmonary circulation during life is afforded by the appearances observed in the heart, blood-vessels, and lungs after death.
After adducing the evidence of this impediment frompost-mortemexaminations, and affirming that the blood does not flow freely through the lungs and pulmonary arteries, which are often filled and much distended with blood, it is observed—"The most interesting and conclusive evidence that arrest of blood in the lungs is the true key to the pathology of choleraic collapse, is to be found in the simple yet complete explanation which it affords of all the most striking chemical phenomena of the disease,the imperfect aeration of the blood, and the suppression of bile and urine."
And again, says the learned author, "It is obvious that the stream of blood from the pulmonary capillaries to the left side of the heart is the channel by which the supply of oxygen is introduced into the system. One necessary consequence, then, of a great diminution in the volume of blood transmitted to the left side of the heart must be, that the supply of oxygen is lessened in a corresponding degree. This position, probably, will not be disputed by any one who will give the subject a moment's consideration. Nor, again, can it be denied or doubted that certain results must of necessity follow this limited supply of oxygen." * * *
"The blood in cholera is black and thick only during the stage of collapse; in other words, during the stage of pulmonary obstruction and defective aeration."
Again, in his explanation of the injection of the solution of soda into the veins of the suffering patient, it is affirmed, "The benefit, however, is of but short duration, for theprimary cause of the impeded circulation, namely, the poisoned condition of the blood, being still in operation, * * * the stream of blood through the lungs will soon again be obstructed, and the patient thus passes into a state of collapse as profound as, and more hopeless than, before. It appears, therefore, that the hot saline injection into the veins and the operation of venesection, when it rapidly relieves, as it often has done, the symptoms of collapse, have this effect in common, that they facilitate the passage of the blood through the lungs, and thus lessen that embarrassment of the pulmonary circulation which is the essential cause of choleraic collapse. But whereas thehot injections actby removing the impediment which results from spasmodic contraction of the arteries;venesection actsby relieving over-distension of the right cavities of the heart, and thus increasing the contractile power of their walls."
Such are, in brief, the views of the learned Drs. Johnson and Bell, whose works are very highly commended by their Americaneditor to the notice of the profession. These views, coming as they do from the highest authority, fully sustain the doctrine that the earliest impression of the disease is made upon the blood, and hence it becomes altered and changed in its most essential life-sustaining principle; for its oxygen becomes diminished, its consistency augmented, and its flow through the lungs impeded. Through this channel the effect of the poison soon makes an impression on the ganglionic mechanism, and the nerve-power becomes correspondingly diminished, and the action of the ganglionic nerves essentially deranged. But this is not all: they exhibit in the clearest manner the congestive character of the disease, and show the necessity of prompt and decided means to arrest this tendency. Hence, they urge, in the strongest terms, the importance of observing carefully this essential feature, and endeavor to exhibit fully the condition of this vital fluid at a particular stage of the disease, when bleeding, as recommended in their practice, is required, and may be performedto the best advantage for the relief of the partially congested blood-vessels, and to stimulate and give freedom to the circulation. The passage of the blood, they affirm, is impeded, clogged, and partially suspended. To remove this obstruction, relieve spasm, and secure the prompt aeration of the blood, in hope of arresting the progress of this disease, is ostensibly the object. However, they seem studiously to avoid the most logical conclusions of their explanations, and justify a practice that can give no hope of permanent relief, while every fact and symptom is ominously suggestive of the wants of the system, which imperiously demands the aid of electrified oxygen, ozone, or free caloric, for the oxydation of the blood.
Says Dr. Reid, "I believe the true explanation of the arrest of blood in the lungs to be this: The blood contains a poison, whose irritant action upon the muscular tissue is shown by the painful cramps which it occasions. The blood thus poisoned excites contraction of the muscular walls of theminute pulmonary arteries, the effect of which is to diminish, and, in fatal cases, entirely to arrest the flow of blood through the lungs."
Says Dr. Wallis, "The phenomena which are exhibited when the deleterious air has been drawn into the lungs are these: the great gastro-pulmonary nerve is either wholly or partially paralyzed; the consequences are the cessation of all its functions, either wholly or partially. This great nerve is a nerve of function, and performs the functions of digestion and respiration, and influences all secretions."
Dr. Maxwell, of Calcutta, uses the following language: "The development of the stages of fever entirely depends on the changes theleaven has effected. If this change has been such that the blood has become too thick to flow through the lungs, then, as a matter of course, the collapse stage is developed in excess; in other words,cholera asphyxiais exhibited. The blood, unable to pass through the middle passage into the arteries, collects and swells out the veins,giving that deadly or blue color to the skin. When the vomiting and spasms come on, this mass of blood in the veins is squeezed with great force, and hence the clammy moisture that is forced from every part during these fits. There is no pulse, because there is no blood in the arteries." "There are also lethargy and languor, and oppression in breathing, caused by the blood being collected in the veins. These make up the principal links in the chain of mechanical symptoms."
Dr. Bell, dwelling on this congestive character of the blood, and endeavoring to point out the best mode of relief, observes, "When this has reached to such a point as to oppress the action of the heart, yawning first and then shivering, or a sense of suffocation and pain in the precordia, are the indications of oppressed circulation, and of the commencing effort of the heart to overcome the mass of blood which is stifling it. If, by the application of tourniquets to the limbs, or bybleeding, part of the blood which is rushing from the extremities to increasethis congestion is prevented from reaching the great veins, the heart, excited to increased action, is enabled, by this relief, more quickly to overcome the obstruction and restore the balance of the circulation, and the paroxysm passes off. If not thus mechanically aided, the heart, after a severe struggle to maintain the circulation during the period of constriction, is at length relieved by this nervous disturbance or spasm of the capillary circulation passing off of itself, and then the heart and arteries, so long excited by the struggle, maintain for a time their increased action after the obstruction in the capillaries is removed, and produce apparent febrile action. Presently this excitement subsides, the vessels become relaxed, and sweat succeeds. The vessels continue in this state for a longer or shorter period, according to circumstances, till they at length recover their ordinary tone and action in the intermission. This fever, however, is not fever properly so called, but reaction; and the sweating not critical, or essential, but relaxation. The cold stageis alone essential, and is the physiological cause of the subsequent stages."
From the passages we have cited, it is quite evident that Drs. Johnson, Bell, Parkes, Reid, Wallis, Maxwell, Massy, and many others, admit this congestive character and impeded circulation of the blood to be the result, or consequent of a primary affection of the blood, as we have already observed in a former paper. Theterm"Algide" is peculiarly expressive of the diminished animal heat, and, as Dr. Bell represents, it is the cold stage which is alone essential, and is the physiological cause of the subsequent stages. It is the specific disease-poison, so often referred to, that has been inhaled, the leaven that has effected such obvious changes in the blood. The poison, virulent, and subtle, and unknown, so marvelously active in its operations, that is exhibited so prominently in all the works we have perused as the one great, mysterious, and efficient cause which produces the disease called cholera, and all the phenomena of its development. To its direct and specificaction, therefore, must be attributed all the phenomena of the disease as the resulting subsequent consequences.
It is also further evident, from the pathological facts and arguments adduced in support of this theory of congestion, that the abnormal condition or state of the blood-vessels is the result and the product of the activity of the primary or final cause, and must be regarded in relation to it as cause and effect. On this principle alone, the thickening of the blood, the contraction of the left ventricle of the heart, and of the capillary and pulmonary arteries, assigned by some as the cause of choleraic collapse, must be accounted for. These effects are not and cannot be from a process independent and outside of the primary disease action, but are the result of such primary action.
Again, it is evident, from the views and doctrines cited above, that the disease is decidedly congestive in its tendency and character from its very commencement. The impeded flow of the blood—the comparativeemptiness of the left ventricle of the heart and arteries—and the excessive loss of temperature, all indicate a rapid process of congestion attending the progress of disease. This is one of the peculiar and prominent features of cholera, and is strikingly exhibited in the morbid appearances observed in all those instances where death has occurred within a few minutes from the first indications of attack.
When the attack is violent, the process is rapid; when mild, it is slow; and even in the collapse stage progresses tardily. In either case it is the direct resulting consequent of the primary cause. How else can the violent attacks, suddenly terminating in death, be accounted for? To what other principle can this altered condition and stagnation of the blood be attributed? The evidence confirmatory of this position is abundant and conclusive. Many instances of the apparently rapid action of the cholera poison are related by Dr. Milroy, in a historical sketch of the epidemic of 1817; and at Kurrachee in 1855 and 6,it is said, that within little more than five minutes, hale and hearty men are seized, cramped, collapsed, and dead!!
When the disease broke out at Teheran, in May, 1846, Dr. Milroy states that those who were attacked dropped suddenly down in a state of lethargy, and at the end of two or three hours expired, without any convulsions or vomitings, but from a complete stagnation of the blood.
In the paper before us, it is stated, that "in a great majority of cases in which death has occurred during the stage of collapse, the right side of the heart and the pulmonary arteries are filled, and sometimes distended with blood; the auricle being partially, and the ventricle completely and firmly contracted. The tissue of the lungs is, in most cases, of pale color, dense in texture, and contains less than the usual amount of blood and air. There is something surprising in the contrast between the almost constant occurrence of this extremely anæmic condition of the lung, from which scarcely even a few dropsof blood flow when the tissue is cut, and the hyperæmia of most of the other viscera." This impeded flow of the blood through the lungs, resulting, as it must, in a very scanty supply of blood to the arteries, in connection with the corresponding fact of the increased expansion of the veins, filled with black, and thick, and stagnant blood which, by the action of a powerful poison, or malignant disease, has become disorganized and unfitted for circulation, furnishes indubitable evidence of one prominent and characteristic feature of cholera which we term congestion, and to which we alluded in our remarks when the question under consideration was first introduced; in this view we are happy to find ourselves, on a more thorough examination of the subject, ably sustained by eminent pathologists and authors, who have arisen during the half century last past, and whose works are said to embrace all that is known and reliable on the character and treatment of Epidemic Cholera.
It is worthy of notice, before passingfrom this part of our subject, that according to Dr. Bell'sviews, the blood is forcibly sent into the great central veins, and there stopped in its course without any attempt to account satisfactorily for its singular arrest, at that point—Dr. Johnson comes to his relief, lifts the veil, and explains why it is kept there and cannot get any further. If the road, he tells us, had been clear and uninterrupted through the lungs, the blood would easily have got round to the left ventricle, and have again gone its round, but it is stopped by the spasmodic contraction of the minute branches of the pulmonary artery, which will not even allow the blood to enter the pulmonary capillaries, as shown by the remarkable anæmia of the texture of the lungs.
In this connection may be introduced an opinion as to the cause of the disease and some of its phenomena, which has obtained at least some celebrity, and attracted the attention, if not the careful consideration of the profession. It will account, in part, if founded in fact, for the physiological condition under consideration.
It is said, some have observed a chemical change in the constitution of the atmosphere, and have attributed the cause of the cholera to the loss or diminution of its ozone—a principle which is understood to represent what is very properly termed electrified oxygen. Ozone is, therefore, the vital element of the air. It is said that oxygen cannot be assimilated or combined with the blood except when it is in an electrified state constituting the peculiar property or state of ozone. In this state it produces vital electricity of the blood,which is the life. The brain is considered and represented as the reservoir of this vital electricity, and the nerves are the telegraphic wires or conductors of it. As a necessary consequence, all acts of material and intellectual life depend upon this double cause. The absence, then, it is affirmed, of this principle, termed ozone—or electrified oxygen—from the atmospheric air in certain localities and the consequent non-aeration or non-oxydation of the blood, may be considered as an efficient cause which willaccount for some of the most striking phenomena of the cholera.
Whether this electrified oxygen, or ozone, is identical with free caloric, it is unnecessary for our purpose at present to determine. It will be admitted that oxygen is the source of animal heat, and when introduced into the system generates its free caloric, which is an essential life-sustaining principle.
Dr. Massy, after describing a severe and advanced stage of cholera, observes, "The treatment of this case depends in the first instance on bleeding, and largely, if the patient's pulse is good, giving at the same time twenty grains of calomel with one of opium. This, he thinks, will be found the best practice. After twenty minutes, he gives ten grains more of calomel and half a grain of opium. He considers, however, a reliance on opium in this form of cholera most faulty—but observes, as you draw blood, stimulate, give punch, brandy, or wine and water, or carbonate of ammonia. Apply friction, with stimulating and hot liniments to the extremities, warm sand-bags to thefeet, sinapisms to the calves of the legs and pit of the stomach; for, if you can once raise the pulse, the chances in favor of recovery will be vastly increased." The practice of bleeding and stimulating at the same time is deemed of vast importance. Dr. Bell coincides in this view, and devotes much space to the necessary instruction as to the time when and under what circumstances to bleed and to what extent, endeavoring to show the advantages arising from a strict observance of certain rules in carrying out this practice.
We have thus traced,in extenso, the views and doctrines of eminent surgeons and authors on the changes of the blood, and especially of the impeded circulation, to show, if practicable, the inconsistency of the more common and prevailing practice, and its utter inadaptation to the pathology and phenomena of disease. On the latter there seems to be little or no discrepancy—on the former there is a great diversity—as there has been no general principle established and laid down as the basisof treatment and cure of cholera. It has often been observed there is no disease on which so many different modes of practice have prevailed, some purely experimental, others empirical—and all without discovering an antidote to the poison, or any efficient mode of relief. The cause, or the poison producing the disease, still remains undiscovered. The direct mode of suspending and removing it, or counteracting its power and neutralizing its effect, and subsequently eliminatingitfrom the system, remains still in doubt. What course, then, should the epidemic cholera again prevail in our midst, shall we pursue? Shall we rest satisfied with the diversified modes of treatment now prevailing? Or guided by the light of reason, science and experience, endeavor to adopt a general principle of practice, and exhibit and establish an efficient and judicious system, consistent with the pathology and the phenomena of the disease? Does then the practice, the prominent features of which are given above, accord with the indications required?In short, does the exhibition of bleeding and calomel and opium, accompanied with sinapisms, and hot, stimulating applications to the surface, meet the pathological condition and the phenomena of the disease? We have seen that the rapid changes in the blood, and the consequent direct tendency to congestion, are the proper and distinguishing features of the disease;—and hence the diminution of animal heat and general loss of temperature and their consequent effect, impeding the circulation, depressing and prostrating the nervous power—impairing and paralyzing the respiratory organs—suspending the functions of the liver and kidneys—enfeebling the action of the heart, and causing the capillary vessels of the mucous surfaces to pour off the serous fluid from the blood, and every muscle and tissue of the system with great rapidity, essentially constitute the phenomena of the cholera;—and that the constantly increasing augmentation of the poison and its intensified effects, measure the malignity, the violence, and the rapidity of the disease.Is there, then, any tendency in bleeding to arrest this rapid process of disease so disorganizing, depreciating, and enfeebling to the vital life-sustaining fluid, the blood? Can abstracting a portion of it, however large, suspend the poison, or its activity, or even check its progress in its rapid course and fatal termination? Can it have, under its depressing and depleting process, any tendency or power to relieve the congestion that is taking place, or change in any good degree the poisonous principle which is now generally admitted to exist in the blood, and to be the sole and efficient cause of its altered character and condition? The poison, once introduced into the blood, like the leaven hid in three measures of meal, will continue its activity, increasing its energy, and multiplying its forces, till the whole circulation becomes affected, and its life-sustaining power is destroyed and utterly lost, unless, by the exhibition of some remedial agent, it shall be promptly arrested in its progress, and suspended and eliminated. Again we ask, Will calomel fulfillany of the indications required? Has it any influence or power to arrest this disease, to quiet the nervous system, relieve the cramps, or restore warmth to the body? Its specific action, so far as known, can have no tendency whatever to relieve the system in any essential particular, or stay the progress of disease, or delay its inevitable result, if it remain unsubdued by the action of other remedies. Its action upon the liver, however prompt it may be, is only of a secondary importance. The primary cause must be overcome, its activity and energy suspended and the system generally relieved, or there is little hope in the case.
Here we may ask, Will opium aid, or give the relief so urgently demanded? However serviceable as an astringent and anodyne in the premonitory stage of the disease, it cannot be exhibited in the second stage to so good an advantage, as its direct influence is to aid and promote congestion in those cases, where a tendency of this kind is already in existence. Hence, its continuance in the true or collapse stageof cholera is now generally considered faulty.
Once more: The auxiliaries employed in aid of the leading remedies already noticed may be summed up in the language of the celebrated Dr. Massy, in his instructions and directions on the subject of the treatment now under consideration. He observes, "But, as you draw blood, stimulate, give punch, brandy, or wine and water, or carbonate of ammonia. Apply friction, with stimulating and hot liniments to the extremities; warm sand-bags to the feet, sinapisms to the calves of the legs and pit of the stomach; for, if you can once raise the pulse, the chances in favor of recovery will be vastly increased."
To these directions there can be no special objections, except in the first instance in which he, indirectly, commends the use of means tending to deplete and depress the system, already brought by disease to the very verge of utter exhaustion. Remedies of this tendency are contra-indicated, and cannot, to say the least, be employed to advantage.
Depressing remedies generally, instead of checking, or counteracting the disease, will inevitably aid and hasten its fatal termination. Stimulants, such as are prompt and diffusive in their character, must be regarded as essential, and may be employed to great advantage. It will be found, however, exceedingly difficult in most cases, even where there is no depletion from bleeding, to keep up the waning powers, and carry the patient, through this formidable disease, to a favorable termination. Of the utility of warm applications to the surface generally, there can be no question; yet, our main reliance is on internal remedies, as has been already shown: the lost temperature of the body must be restored, the production and diffusion of heat, or caloric, must be internal through the administration of remedies, that will promptly and kindly produce this result.
What are, then, the remedies? We have ventured in this discussion to recommend the internal use of chloroform, and believe it will be found in combination with otherprompt and diffusive stimulants, specially adapted to meet this condition. In this recommendation, we feel ourselves fully sustained by the result of various experiments heretofore made, and the recent trials of its use, as an internal remedy in the various stages of the disease.
The earliest record of the use of chloroform in cholera is probably to be found in the LondonLancetfor November, 1848, in which Dr. Hill reports a case of its successful use by inhalation. He placed the patient in bed, covered with warm blankets, and applied friction, stimulant liniments, and heated bags of bran to the surface, and kept the patient under the gentle influence of chloroform, till the more urgent symptoms entirely subsided. At intervals brandy-and-water, and thin arrow-root or milk was given. All other medicines were avoided. Though the urgent symptoms returned at first, as the effects of the chloroform passed off, they were easily controlled by the repetition of the inhalation. By persevering in its use, reaction set in, and the patient became convalescent.
Other cases, afterwards, were treated in the same way, with a similar result. Some, however, required the gentle use of chloroform by inhalation, at intervals, for twenty-four hours; after which, none seems to have been administered. For aught that appears these cases all recovered.
Another very interesting case is related by Mr. Brady, who observes that an elderly lady was seized with slight diarrhœa, which, on the following morning, had become very profuse: excessive vomiting supervened, accompanied by spasms in the calves of the legs, fingers and toes. Under these urgent symptoms, the usual remedy, brandy, was administered without avail; the dejections became incessant, and the spasms increased in intensity, presenting the features of a decided case of malignant cholera. In this condition, the physician was called in haste, as it was believed and affirmed the patient was dying. In describing this case, the physician observes: "On my arrival, I found the patient presenting all the symptoms of malignant Asiatic cholera, in anadvanced stage; the features collapsed and ghastly; extremities and tongue cold; burning sensation in the stomach and œsophagus; pulse rapid and scarcely perceptible; voice diminished to a whisper; stomach exceedingly irritable, and the dejections from the bowels presenting the characteristic rice-water appearance; and all the voluntary muscles of the body were affected by spasm, so that the patient actually writhed in agony." Ordered the following: ℞. Chloroform ʒ j; Ol. Terebinth. ℥ j; aq. Dist. ʒ iij. M. And gave immediately a large tea-spoonful, in a wine-glass, of dilute brandy; and applied sinapisms to the calves of the legs and abdominal and thoracic surfaces. Thirst was relieved by drinking plentifully of water nearly cold. Though the stomach was irritable, the chloroform was retained, as well as the fluid drank after it, and was followed by no dejection. Half an hour after, two pills were administered, composed according to the following: ℞. Calomel gr. v; fellis. bov. inspis. gr. x; Ft. Pil. ij. Half an hour after thesewere given, vomiting ensued, but soon subsided; the diarrhœa had apparently ceased; the cramps had diminished in frequency and severity. A second dose of chloroform, now one hour after the first, was administered, and soon after this two more of the pills, both of which were retained, and gave decided relief. The pulse rose in power and became slower, the spasms less frequent, and, in an hour after the second dose, the patient was bathed from head to foot in a warm perspiration, and expressed herself comparatively free from all uneasy sensations. The attack had been completely subdued, leaving behind a good deal of pyrexia and debility, from which she rapidly recovered.
Here it is worthy of notice, that in this case, severe as it was, only two doses of the chloroform mixture were administered, each containing about six minims of chloroform and forty of turpentine; the pills would naturally tend to perpetuate rather than relieve the nausea and vomiting, and in one hour after the administration of thesecond dose, all the urgent symptoms were assuaged.
In another case, the attending physician reports that, after giving calomel, combined with opium, which was immediately rejected, the following mixture was ordered: ℞. Chloroform vj minims; brandy ʒ iij; water ℥ iijss, one-third of which was given immediately, and was thrown up in half an hour; a second dose was then given, and was retained. The vomiting and diarrhœa ceased; the spasms became less severe. In two hours after, gave the remaining third part; and during the next six hours, administered in two doses six minims more of the chloroform, with the most decided benefit, and the patient soon became convalescent. To the extreme tenderness over the region of the epigastrium flannel soaked in spirits of turpentine was applied; and as no urine was secreted, I am firmly of the opinion that the usual remedies would not have met this case. "I candidly confess," says the physician, "I had no hope of success from its severity; and, but for a knowledgeof Mr. Brady's case, I believe I should have lost my patient."
Dr. Davies reports a case in which he used chloroform fifteen hours after the seizure with relief, but not with success, and observes that, in a number of cases occurring in the hospital, there were 22 cases in which, as severe symptoms came on, the chief remedy was chloroform, administered internally, in doses of from seven to ten minims every hour, half hour, or quarter of an hour, according to the severity of the symptoms. Of these 22 cases, 8 terminated fatally, and 14 recovered.
Again: "Out of 9 cases of cholera, and 13 of the worst cases of diarrhœa occurring in my own practice, and treated with chloroform,one died. All these were in the better ranks of life. In some of them, the warm bath (salt water) was used as an auxiliary, and the diet consisted of nothing but cold milk and water, with some carbonate of soda,ad libitum. The fatal case was that of a drunkard, who, probably, did not take the remedy. These cases varied in severity,from sickness and diarrhœa, and mild collapse, to sickness, diarrhœa, severe cramps, and great collapse, with almost clear watery evacuations, passing away involuntarily * * * Of 14 cases of cholera treated by Mr. Towers, Medical Resident of the Infirmary, many of them under my own observation,one died. The fatal case was that of a woman aged 63, who was previously suffering great depression, consequent on extreme destitution."
Again, says Dr. Davies, "It will probably be remembered that, in my second report, I expressed a very favorable opinion of chloroform in this deadly malady. I considered I had strong grounds for so doing, after observing the large proportion of cases which recovered under its administration. From the history of this last visitation in the county prison, however, the fact turns out, that, under some uncertain circumstances, the use of chloroform will not prevent the proportion of deaths being considerable. I have reason to believe that it was, from over-anxiety,given in too frequent doses in some cases, and that it thus rather added to the coma, which is one of the characteristics of the malady.
At the commencement of the outbreak, the doses were repeated every hour, or every two hours, and it is to be noted that the first seven casesrecovered.
As the cases multiplied, the remedy was given every half hour, and, in some instances, every quarter of an hour; the result was that the next six cases died. Whether these cases had anything in them inherently more fatal, it is difficult to tell. The symptoms at first were about equal, and the differences did not show themselves until towards the end. There was next a recovery of seven cases in succession; in these the remedy was administered less frequently, but subsequently two deaths occurred under the less frequent administration.
The chloroform was administered also by inhalation, in some of the more severe cases of cramps, with the effect of affording relief in every instance. The inhalation was notcarried so far as to produce insensibility. Although I am still of the opinion that chloroform properly regulated is the remedy of all others hitherto tried to be depended on, yet it cannot be considered a specific for cholera."
Mr. Steadman reports a very interesting case treated by chloroform. He observes, "The spasms were universal and extremely violent, as if knots were being tied in the bowels, countenance livid and cold, voice feeble, and all medicines rejected. In this condition gave chloroform combined with 'aquæ vitæ' and distilled water. The first dose had a partial but most satisfactory effect. In two hours after, as the symptoms manifested a disposition to return, gave a second dose, which entirely controlled all spasms, vomiting and purging. The patient was ordered cold rice and mucilaginous drinks, and had the chalk mixture with nitric ether prescribed. A dose of oxgall (gr. x) was given in course of the day, which produced the desired effect. In two days the patient was declared convalescent."The daughter, who had nursed the mother in this case, was seized soon after in a similar manner, except the dejections were more abundant and frequent. The mother having some of the chloroform mixture left, gave it to the daughter without advice or hesitancy, and obtained the same magic results. The first dose was only partial in its effect, but the second completely subdued the disease.
Such are the results of some of the experiments which have been made by the administration of chloroform; and, so far as appears, the first cases treated by inhalation were severe malignant cholera in the advanced stage, all of which recovered. So, also, those treated by the remedy used internally, combined with a prompt and decided stimulant like the spirits of turpentine, or aquæ vitæ and brandy, recovered. In all these cases the remedy appeared to meet the urgent demand, to remove the impediment to the circulation, to relieve the nausea and vomiting, and purging and cramps, and restore, in a very short time,the general action and normal tone of the system. Still we must admit, that some cases, treated by its internal administration, and also by inhalation, proved, on some accounts not satisfactorily explained, unsuccessful. Were these cases given in detail, it would be much easier to detect the cause of failure, or its questionable use in such cases; but we have only the bare fact that they were thus treated, without the manner or character of the combination, if any were made, being given.
Hence Dr. Davies, under whose direction these cases occurred, remarks, in view of this result, "thatno reliancecould be placed on chloroform alone." The correctness of this opinion cannot be questioned, for the experiments we have cited all show the necessity of a prompt and diffusive stimulant in aid of its action, to render it sufficiently prompt and powerful to meet and overcome the disease in the more rapid and severe cases. Chloroform, properly combined, offers the best hope of relief, and is, without doubt, the most perfectly adapted of anyremedy known to the pathology and phenomena of the disease. There is no remedy, when properly combined, so capable of meeting all the indications required as this, and none that can be administered with more certainty of success.
In conclusion, we may, with much propriety, refer again to the pathology suggested by the authors cited above, and inquire whether the action of chloroform as a remedy in these cases be consistent? and whether as such it has that curative influence, or direct controlling power, to arrest, suspend, and cure the disease, so imperiously demanded? We have seen that, according to the opinion generally prevailing, the first impression of the poison is made upon the blood, and through it upon the nerves, especially those which, from their anatomical position, bear the most intimate relation to the blood-vessels. Through this channel the first invasion appears to be made on the ganglionic, the nerves of circulation. These nerves are distributed chiefly to the viscera and blood-vessels, and are at least veryearly involved and essentially disturbed, for their healthful action depends in no small degree on the aeration or oxydation of the blood. Says an eminent author, "The action of every ganglionic mechanism depends on the existence of certain physical conditions, among which the most prominent and important is the due supply of arterialized blood. If this be stopped but for a moment the nerve mechanism loses its power, or, if diminished, the display of its characteristic phenomena correspondingly declines." Hence the loss of power in these nerves, and their deranged action, the contraction of the capillary and pulmonary arteries, the impaired and impeded circulation and all the phenomena arising therefrom.
Again, the great pneumogastric nerve, which is composed of both motor and sensitive filaments, has a very extensive distribution in the upper part of the abdominal cavity. It supplies the organs of voice and respiration with motor and sensitive fibres, and the pharynx, œsophagus, stomach and heart with motor influence. This very importantnerve, through the primary action and deteriorating process of the cholera poison, becomes early involved, and its functions greatly, and, in fatal cases, permanently deranged. The evidence of this disturbance and loss of nerve-power is too obvious to be overlooked or disregarded in the treatment of this disease.
In confirmation of this, we may, with great propriety, adduce the testimony of Dr. Wallis on the loss of nerve-power, and the process through which the result is produced, who observes, that "the phenomena which are exhibited when the deleterious air has been drawn into the lungs are these: the great gastro-pulmonary nerve is either wholly or partially paralyzed, the consequences are the cessation of all its functions either wholly or partially. This great nerve is a nerve of function, and performs the functions of digestion and respiration, and influences all secretions."
Hence it appears the nervous power generally, as before observed, is very early and essentially impaired, and to such an extentthat there can be no rational hope of relief, unless some remedial agent can be found that will exercise such a controlling influence and power, as shall be adequate to restore the tone of the nervous system.
Hence, we are forced to the conclusion that the prominent, leading, and most urgent symptoms requiring special attention, are "the Algide" or loss of temperature, the loss of nerve-power in the ganglionic and pneumogastric nerves and their branches, the altered or disorganized condition of the blood, the impaired or obstructed circulation, and the early and direct tendency to congestion. These are the prominent and essential features to be observed in the treatment. They are too intimate, dependent and inseparable, to warrant any attempt to mark the precise order of their development. They are the essential phenomena, proceeding equally and directly together from the primary cause and disease action, and strictly constitute the complex character of the cholera, and exhibit its main, distinguishing features,which must necessarily govern and dictate the maxims of rational practice in the treatment of this disease. The object, then, of first importance is to restore the lost temperature, the caloric already eliminated, and prevent its further depression; to restore, at the same time, the lost nerve-power to the nerves again; to arrest the process of disorganization of the blood, and equalize the circulation; to relieve and suspend the congestion; and then, according to all the experiments which have been made, the consequent and dependent phenomena of the cramps and the vomiting and the purging will disappear.