TREATMENT. 589 Hæmorrhages occasionally occur during convalescence, which, as they indicate great debility of the system, and an atonic condition of the vessels, and tend to increase, by the loss of blood they occasion, the very cause on which they depend, must be checked with the least possible delay. In these cases, acids internally, and nitrate of silver, creasote, or the tincture of iron externally, cool air, as well as remedies calculated to impart tone to the system at large, are employed with advantage. Quiet and cheerfulness of mind must be secured, and sleep must be encouraged. They are essential to a rapid and complete recovery. So long as debility is prominent, bodily exertions must be avoided; but, as soon as the strength admits of it, exercise, alternating with rest, and graduated to the condition of the patient-short, and frequently repeated-must be enjoined. The venereal act-to which, convalescents are prone-should be carefully avoided, as always highly detrimental, and often, when indulged in to any excess, of fatal tendency. Great stress must, at the same time, be laid on cleanliness and free ventilation, but more particularly on change of locality, and removal from the infected to a pure and cool atmosphere. When circumstances will permit, and convalescence is long and tedious, a sea voyage, and a residence in a cold climate, must be recommended. EDITOR.] XXIX. EPIDEMIC CHOLERA. Epidemic Cholera. This disease, when it runs its full course, terminates in a state which is unquestionably one of fever, and as that fever is often attended by a characteristic eruption, it appears to approach more nearly to the eruptive fevers than to any other class of diseases, yet to avoid the imputation of theory, we have not connected it with any. In the larger proportion of cases, the development of this frightful disease is preceded by a premonitory stage, of which the symptoms are those of simple diarrhoea, though generally of a more than usually obstinate character. In some instances, too, the patient does not feel generally ill, and though, from the prevalence of the disease at the time, he may have some misgivings as to its true nature, he is willing to flatter himself, and eagerly assures his friends, that his diarrhoea is of a healthy or conservative character. In others, again, there is, during this premonitory stage, more or less of a feeling of general illness; pains in the abdomen, and especially across the epigastrium; coldness of the extremities, slight cramp in the calves of the legs, exhaustion, anxiety, and alarm, After these symptoms have continued, in some cases for several days, in others for only a few hours, the true choleraic symptoms declare themselves more or less quickly. Sometimes, on the other hand, the attack is fearfully sudden. The patient is seized without any previous warning, often about two o'clock in the morning, with a pain across the epigastrium, commonly attended with desire to go to stool; he does so, and passes a copious, often a bulky and healthy evacuation. This is very soon followed by another, and then another and another in rapid succession, the motions passing quickly into the true choleraic character, of a liquid resembling thin rice-water, sometimes even a limpid fluid, with just a few shreds of a white substance suspended in it. With this purging there is commonly vomiting, the matter ejected from the stomach being the same in appearance as that passed from the bowels. Sometimes the purging is so incessant, that the liquid streams from the patient without his having the power to restrain it. There are now severe cramps, commencing generally in the calves of the legs, and extending to the abdomen and upper extremities, sometimes affecting even the muscles of the face, and not unfrequently, judging by the character of the pain, the diaphragm; there is also a total suppression of the urine, and, as may be inferred from the colourless appearance of the stools, of the bile also. There is urgent thirst; the patient is deathly cold to the touch, but complains much of heat; the skin streams with a cold perspiration; the extremities become shrunken and sodden, as if they had been long immersed in water; the hands SYMPTOMS. 591 and feet, and eventually the whole surface assumes a livid, leaden hue; the pulse becomes almost imperceptible at the wrist, sometimes quite so; the tongue is white and cold, the breath like a stream of cold air, and the surface of the body exhales a cadaveric odour; there is incessant jactitation of the limbs, resembling that of exhaustion by hæmorrhage. The cheeks are hollow, the countenance dark and dusky, and round the eyes, which are sunk in their orbits, there is a still darker circle. The voice is plaintive, and like a hoarse whisper, and startling the attendants by its unearthly sound. In many of the severest cases, the purging ceases after it has continued for many hours, apparently because the system is thoroughly drained, and a state of most profound collapse may continue for many hours, when, if no reaction takes place, the patient dies. The mode of death is somewhat remarkable; the organic life seems to be the first extinct, after that the animal powers of voluntary motion, and lastly the intellect, which remains undisturbed till death. This appears to be, in fact, a manner of dying different from those which we have hitherto noticed. It is not death from the heart, or death from the brain, but death beginning in the extreme of circulation, the heart, and lastly the brain failing in their functions, from want of blood, the supply of which is cut off by the drain from the mucous surfaces and the skin; or it may be said to be death from the blood, which when drawn is black and pitchy, from having been drained of its liquid. If the patient do not die in this stage, reaction, as it is termed, ensues, the pulse returns at the wrist, and the skin recovers its warmth; after a time, the secretions of bile and urine reappear, and the patient, exhausted indeed, and emaciated, but apparently free from disease, steadily, and sometimes with astonishing rapidity, regains his health. In a large number of cases, unfortunately it is not thus, but reaction leads to fever, and the fever is apparently of a specific character. After three or four days the patient begins to pass urine, generally of a dingy color; there is frequent vomiting of a green bilious fluid, and at the same time there are signs of stupor, or coma. The pulse is sharp, with a light back-stroke, and very compressible. Many--by far the greater number of patients thus affected, pass into a state of most profound coma, and so die. In the course of the consecutive fever just noticed, an exanthematous rash frequently makes its appearance, which has been described by Dr. Babington, who was the first to call attention to it: "After this" (the typhoid consecutive fever) "has existed several days, some red spots are observed about the wrists and hands, and the face becomes tumid, as on the approach of erysipelas. If this occur in the evening, on the following morning the arms, the forehead, up to the roots of the hair, and the face generally, will be covered with large elevated patches, of a bright-red color, more raised than measles, and more defined than scarlatina, much resembling nettle-rash, especially in the circumstance of their disappearance on pressure, and instant recurrence when that pressure is removed." Such are the more prominent features of this frightful malady, which we have been compelled to sketch thus brifly. Into the different opinions which have been entertained respecting its pathology, we cannot of course enter, but we submit that which seems to us most in accordance with general pathology, and the facts of the case. The morbid anatomy of cholera tells us little, as no appearances have been found, which in any way account for the symptoms. The most important are perhaps the capillary hyperæmia, the venous congestion, and the oedema of the mucous membrane of the stomach and small intestines, more especially of the duodenum. There is, too, another, to which we believe an exaggerated importance has been attached, namely, the distension of the gall-bladder with bile. The state of the intestinal membrane indicates the irritation that has been set up there, and this, too, seems to show that there has been an arrest of the capillary circulation, that arrest being followed, as we have elsewhere seen to be the case, by an exudation of the watery parts of the blood; that this is so is further shown by the oedematous condition of the sub-mucous areolar tissue. This seems to be the first link in the chain of diseased action which we are at present able to reach. But granting this, and that from hence the serosity of the blood is continually draining, the other phenomena follow as a matter of course; hence the thick tarry state of the blood, hence the suppression of urine (p. 35), hence the thirst (p. 78), hence the urea in the blood (p. 35), hence the suppression of bile (p. 35), hence the cramps (p. 393), hence the failure of the heart's action, of the circulation, and of animal heat; hence the uræmic poisoning, and subsequent death by stupor or coma. We would here remark that some importance has been attached to the gall-bladder being full; now it does by no means appear that this proceeds from any excessive secre tion, it is merely, as Dr. Gull has remarked, such a condition as is common when the digestive function is long interrupted, and indicates rather a passive than an active state; but, as the same physician remarks, there are cases where the membrane of the ducts and gallbladder is the seat of the cholera process. We believe that in many cases, the fulness of the gall-bladder is produced, not by pure bile, but by choleraic effusion from its lining membrane, colored by bile which had been already secreted. The seat, then, of the mischief is in the mucous membrane, beginning at the stomach and small intestines, and extending throughout its surface, so that the skin, which is one of its prolongations, is also similarly implicated, and further loss of fluid takes place from thence. We may here remark that a frequent and troublesome sequel of cholera is gastric irritation, some patients being subject to it for months and years afterwards. In the consecutive fever, too, there is evidence of acute irritation of the gastro-intestinal mucous mem brane. May not the rash have been an analogous affection of the skin? The diagnosis of cholera, when established, is obvious. From the English cholera it may be distinguished by the absence of bile in the ejected matters, by the voice, and by the tongue. When there is premonitory diarrhoea, the signs of impending cholera are duskiness of the extremities, cold tongue, failing pulse. The prognosis of true epidemic cholera is in the main unfavourable; at the commencement of an epidemic of cholera, nine out of ten die. Upon an average, at least one half of the cases of developed cholera. Towards the termination of an epidemic the proportion of deaths becomes small. Of the causes of cholera we know but little; it may be said to prevail epidemically, though upon what this depends we know not, and this is not the place to enter into the nature of this epidemic influence: it is but little controlled by climate; it infests chiefly low situations, and the banks of rivers. Its spread is favoured by impurities in the air and water, and therefore by bad ventilation and drainage, and by neglect of personal cleanliness, and apparently by the defect of ozone in the atmosphere of large towns; by whatever, in fact, favours the spread of contagious diseases. Is it then contagious?-probably not highly so; but there can be no doubt that in many instances it has been conveyed by human intercourse. It affects mainly those in middle life, but no age is exempt. Debility may give some increased susceptibility, but the strongest and healthiest are not secure. There can be no stronger proofs of the great fatality of this disease, than the variety of remedies which have been announced as of certain efficacy, and of which the worthlessness of most, and the perniciousness of some, have been found to be as certain. In the treatment of this disease all theories must be discarded. Many opinions which have been entertained as to its essence might at first sight appear as harmless as they are weak, were it not that they have been made the grounds of the most pernicious treatment. Of this kind is the notion that a material poison has got into the blood which must be driven out of it that recovery may take place. Now we have pointed out the fact of the morbid action which takes place in the intestinal mucous membrane, and have traced its fatal consequences: the obvious indications must be to restrain this, and not to aggravate it. In the commencement of the disease check the diarrhoea. This is best done by opium and astringents. If there be moderate diarrhoea let the ordinary combination (F. 97)* be employed, and enjoin strict rest, that is confinement to bed, or, if not, to a couch; arrow-root and rice milk may be given, and if there be exhaustion let some brandy be added. If the diarrhoea increases, or if there be sickness, let a grain of calomel with one or two of opium, according to the urgency of the case, be given. If the choleraic symptoms appear to be setting in decidedly, give, in the first instance, half a drachm of compound chalk powder with opium, with half a drachm * (F. 97) R Confectionis Aromat. Ziiss. Tinct. Catechu, 3 j. Mist. Cretæ, 3 v. Aq. Cinnam. a sufficient quantity to make an viii mixture of which 3j is to be taken after each fluid stool. |