121

CHOLERA

PERHAPS ASCRIBABLE TO

DISEASE OF THE SOLAR PLEXUS.

To the Editor of THE LANCET.

SiR,I have perused with much pleastirethe letter of Mr. French on " cholera," con.tained in the last number of your very excel-lent Periodical. The observations of thai

gentleman are exceedingly interesting. I

perfectly agree with Mr. French, that thedisease which is called " cholera" is both" simple in its nature," "and abounding inphenomena so general in their application topathology, that a careful study of the subjectcannot but be repaid by an increase to ourknowledge." In a paper published in THELANCET in the year 1836, at which time Iresided at Portsmouth (I write from memory),I endeavoured to draw attention to the pa-thology of the ganglionic system, more parti-cularly I believe than it had then, or everhas, hitherto, been done. From that periodto now the subject has uninterruptedly en-gaged my attention, and I am induced tobelieve, most implicitly, that the only replywhich the question that Mr. French has pro.pounded to us, viz., " What is cholera?"will really admit of, is to be found in the

paper alluded to, and to which I take theliberty very respectfully to refer those ofyour readers who may feel desirous to inves-tigate the matter.

Cholera, so called, holds the same relationto the solar plexus that dementia does to thebrain. What does physiology teach us inconnection with it? Do we not recognisethe solar plexus as the centre of every vitalfunction, as the source of that power whichenables the heart and its vessels to circulatethe blood, and the lungs to decarbonise it ? Do we not see that this same organ it iswhich enables the liver to secrete its bile, thestomach to digest its contents, the intestinalabsorbents to take up their chyle, and thekidneys to excrete their peculiar fluid ? Dowe doubt that the solar plexus is the princi-pal, nay the only, source of animal heat ?The morbid phenomena presented to us inpersons labouring under ″ cholera," consistof no more or less than a deprivation of theseparticular vital functions. What furtherevidence then can be required to prove myposition ! If the heart and its vessels didcontinue to beat with their accustomed andnormal energy,-if the lungs still retainedtheir power to decarbonise the blood,-if theliver continued the secretion of healthy bile,&c. &c., then only could I doubt that thesolar plexus is the seat of the disease underconsideration. What is the effect of a heavyblow on the epigastrium? A paralysis of thesolar plexus. How indicated ? By a tempo-rary suspension of the vital functions; bysyncope : which has proved fatal. Similar

abnormal effects are produced by narcoticpoisons, as well as by the bites of poisonousserpents. The case of poisoning from anoverdose of digitalis quoted by Mr. French,proves to me that the power of the drug wasexpended on the solar plexus; and hence the" vomiting and retching," the great faint-ness and cold sweats." The interruption tothe function of the heart which your intel-ligent correspondent speaks of, I am dis-posed to regard as the mere sequence of apre-existing cause ; but this is easily seenfrom the observations already made. Mylate friend, Mr. Twining,-now deceased,-in his very admirable work" on the Diseasesof Bengal," alludes to the deranged functionof the heart in cholera, as sympathetic of theabnormal condition of the stomach andbowels, without, however, suspecting theseat of the disease to be the solar plexus.Such then being the view that I take of

the pathology of ″° cholera," allow me tomake a few observations on the treatment ofthis formidable disease. Inasmuch as themedical attendant has to combat a diseasewhich, as Magendie has said, ″ beginswhere others end-in death;" inasmuch, ashe has to struggle against a disease whichinvolves the very seat of life, it is high timethat the profession’ were agreed on the bestcourse to adopt. The indications of treat-ment I conceive to be, first, to support thevis vitæ; secondly, to restore the suspendedfunctions of the abdominal organs ; and,thirdly, to be on the look out for particularsymptoms. The first is to be accomplishedby frequently repeated and full doses of sti-mulants, more particularly brandy or ammo-nia, perhaps both. I am in the habit ofprescribing a mixture, containing aromaticspirits of ammonia, strong camphor mixture,and mint water, to which, for the relief ofthe vomiting, I add more or less of the seda-tive liquor of opium, thus :-

R Comp. sp. of ammonia, 3j ; Sed. liq. cfopium, m. vj ; Strong cmnph. mixt.,3vj ; Peppermint water, 3iij. Mix.

I direct this to be taken every fifteenor twenty minutes, and continued accordingto circumstances. Artificial means of warmthexternally applied, must be at the same timeassiduously persevered in. Considerablereaction will generally follow this plan oftreatment; and then I prefer to give theeffervescing draught, with six or eight or tengrains of the carbonate of ammonia, witheach dose, repeated every few hours. Whilstsuch means are being had recourse to for thefulfilment of the first indication of treatment ;the second, viz., ″ to restore the suspendedfunctions of the abdominal organs," must noton any account be overlooked. With thisview I invariably accompany the treatmentabove described with the administration ofcalomel and extract of colocynth, united tosome essential oil or capsicum, thus :-

122

R Submur. of mercury, gr. iss ; Comp.extr. of colocynth, gr. v; Oil of carui,m. ij. Mix.

This pill I direct to be taken every houror two. I am, of course, directed in its con-tinuance by the general and particularsymptoms. Within these few weeks I havehad under my care five cases of " cholera"of the worst description ; and in neither onewas it necessary to give more than five dosesof the pill in so quick succession, though ithas been found indispensable to the entirerestoration of the abdominal secretions, torepeat such from time to time, during thetwo or three days subsequent to the attack.The first effect of the pills is the appearanceof bilious matter in the stools, when it is ge-nerally proper to discontinue their furtheremployment, or else the purging will conti-nue troublesome, though the evacuationswill have lost their peculiar and abnormalcharacter. Those gentlemen who mayhave been in the habit of prescribing chalkmixture and astringents will be probablydisposed to condemn the practice I adopt.It will be perhaps satisfactory to add, thatthe treatment hereinmentioned I found infull operation at the General Hospital, Cal-cutta, in 1834, at which time I enjoyed theopportunities of witnessing the practice ofthe late lamented Mr. Twining, one of theprincipal medical officers of that most nobleinstitution, and to whose admirable workbefore mentioned I take this opportunity torecommend the attention of all who are de-sirous of the best information on the ″ dis-eases of Bengal."With respect, however, to the utility of

purgative medicines in ″ cholera," I begleave to add, as the result of a very large ex-perience in the management of this distress-ing and awful disease, that they will befound the very best to remedy the diarrhœa,which is so troublesome a symptom to thepatient. As regards the third indication, itwill in itself suggest to the philosophicalmedical attendant all I could say relative toit. The dietetic treatment is, of course, ofmuch importance. The patient must be

supported throughout the disease by smallquantities of good beef-tea, arrow-root, andsuch like; and subsequently, during conva-lescence, his diet should consist, in addition,of fish, light pudding, &c.The less frequent occurrence in this coun-

try, than in India, of local inflammatory dis-ease, either as an accompaniment or se-quence of

" cholera," is, I apprehend, to beattributed to the much milder character ofthe disease here than there : for, although Ihave not seen during a residence of a yearand a half in Bengal, and elsewhere in In-dia, patients ″ knocked down dead as if bylightning," I have not infrequently seen mendie after twenty or thirty minutesBillness. Insuch cases the symptoms are those only of

syncope or asphyxia.* * Vomiting and purg-ing, it should be well remembered, are notalways present in attacks of the kind herebeing considered. I met with a dreadfullysevere case of " cholera" about six monthssince, in which, although the vomiting wasmost urgent, the bowels were obstinatelyconfined. Such is by no means uncommon.Mr. French truly observes, that ″

a personlabouring under the influence of fear, whilehe feels oppressed at the precordia, is at.tacked with diuresis; a more intense fear isattended with diarrhcea and cold clammysweats." The depression of the heart’saction, however, I cannot do otherwise thanregard as a mere effect of a sudden depriva-tion of nervous energy to that organ, the con-

sequence of a temporary and partial suspen-sion of the function of the solar plexus;being, in point of fact, the very same thingwhich transpires in cholera so called, f

It is to be regretted that so little attentionhas been paid to the physiology and patho-logy of the ganglionic system ; the subjecthas very particularly engaged my attentionfor many years, and the more I reflect somuch the more I am convinced that to itshealthy and diseased conditions we mustrefer very many phenomena which are at

present deemed unsatisfactory. The excito-

motory system of Dr. Marshall Hall is in-

complete without the aid that this much-neglected portion of our nervous systemsupplies. In the medusa, and others of thesame class, we observe a mass of organisedmatter devoid of a cerebro-spinal system, yetpossessed of an instinctive power, compel-ling it to recede from what may prove hurt-ful to it, &c. Does not this arise from aninherent principle, similar to that which in-duces even us, in the moment of danger anddoubt, to place our extended palm acrossthe precordia? Are not both ″excito-

motory" actions, so to speak ? Is it not inman as in the beroe and actinias, an instinc-tive and preservative act, arising out ofsome peculiar impression acting on the vitalclass of nerves, and of which, of course, theanimal is almost wholly composed? Theaffected Miss, though ignorant of physiologyor pathology, and perhaps of all other

ologies, if either alarmed, or professing tobe, at any sufficient or insufficient cause ofpersonal danger, quickly applies her hand tothe precordia, as if the solar plexusscreamed ″ take care of me now." Thebrain with us, of course, takes cognisance ofthe danger, should there be any, and whichin the medusarise must be supplied by seit-

sation, through the medium of the tenta-

* Syncopal asphyxia." M. Chevalier.t This circumstance I regard more parti-

cularly in reference to the anatomical rela-tionship of the greater splanchnic nerve,being connected as that nerve is with both

the thorax and the abdomen.

123

culae, a sensation which exists, too, indepen-dent of a cerebro-spinal system.* Patho-

. logy, if I mistake not, will supply us withphenomena in which this same sensation,variously modified in the human race, willenable us eventually to illustrate the precisenature of diseases, concerning which almostall we now know is conjectural.A very interesting question which presents

itself for our consideration, in reviewing therelative physiological powers of the differentnervous centres is, What instinctive agencydetermines the young of the mammiferoustribes to seek its particular means of sup-port ? Why is so keen a choice displayedfor that which nature has so especially pre-destined for its use ? We cannot hope tosolve this question by any reference to thedemonstrated functions of the cerebro-spinalsystem. I make no doubt the fact has anexclusive dependency on the solar plexus,the centre of the ganglionic system. Whatmore reasonable than to expect that thatorgan, the sum of whose function may be, inone word, described as life, should presideover actions so indispensable to both its in-tegrity and well-being. Among the lowerclasses of animals, viz., the genera molluscaand articulata, &c., we observe the opera-tion of a peculiar instinct,t which enablesthe animal both to guard against contingen-cies and anticipate difficulties ; to providefor all the necessaries of life, whether theyrelate to the kind of habitation, mode of pro-gression, the kind of food required for its sus.tenance, &c. Now I take the liberty tosuggest that this peculiar instinct constitutesthe function of the vital class of nerves, orthe great sympathetic, as it has been termed.And should this position be ultimatelv veri-fied, the great objection of Dr. Pritchard tophrenology will be removed.t Thoughanatomists may demonstrate a cerebro-spinalsystem in insects, yet we cannot well referall their mental qualifications, if such theymust be called, to the exclusive operationof the cerebrum: so, however, it appears to

me.In conclusion, I would briefly direct at-

tention to the pathology of the great sympa-thetic. The quality of the blood in fevers andcholera has been shown to be similar by theexperiments of Dr. Stevens. This fact I

regard as the consequence of the abstraction

’" See the late Dr. Fletcher’s (Edinburgh)very splendid lectures on physiology. ’

t See Roget’s Bridgewater Treatise.

See Pritchard on Disorders of theMind. Appendix.

§ In the instances of decapitated ani-

mals, as fowls, &c., and in those of acepha-lous monsters, conclusive reasoning may besupplied, if I mistake not.

of nervous energy from the lungs, as beforeshown, whereby the decarbonisation of theblood is discontinued. Carbonic acid (saysDr. Stevens) will decompose the blood, as isseen in cholera and fever.

Miiller, in his ’ Elements of Physiology,"says carbonic acid has

″ a narcotic actionon the system, producing asphyxia, withoutexciting any symptoms of suffocation."Cholera and fever is identical, say Dr. Ali.son* and Dr. Billing.t Dr. John Davytells us that the expired air of personslabouring under cholera and fever containsless of carbonic acid than it should do ; andDr. Wilson Philip assures us that the sameresult is obtained by tying or dividing thepar vagum. The inference from all whichis too apparent to require mention. Choleraand fever I consider to involve probably thewhole of the sympathetic, though they havetheir rise in the solar plexus. Other dis-eases appear to have a local dependence :thus, anginapectoris, I believe, dependent onsome abnormal condition of the cardiac

plexus,:!: holding the same relation to eachother which I conceive asthma does to thepulmonic plexus, pertussis to the internalbranches of the superior cervical ganglion,and diabetes to the renal ganglion.You will remember, Mr. Editor, receiv-

ing a paper from me, some two or three

years since, containing the autopsy of a boywho had died of diabetes, and in whom therenal plexus presented a very diseased ap-pearance. The paper was mislaid by somechance. It is well known that injury ordisease of " the superior cervical ganglion"

produces ″ inflammation of the eye, witheffusion of lymph." Chorea and hysteria, Ihave reason to believe, is associated with thegreat sympathetic nerve, as well as chlorosisand anemia, &c.

If these observations have the effect of

drawing the attention of the profession moreparticularly to the subject of this paper, Ishall be very glad. Within the compassafforded me I could not be expected toadduce a very great deal of evidence to provemy positions: however, such might yetappear. I am, Sir, your most obedient

servant,JAS. GEO. DAVEY, M.R.C.S.

One of the Surgeons of the CountyLunatic Asylum at Hanwell.

Hanwelt, Middlesex,Oct. 1, 1842.

* See Alison’s Outlines of Pathology.t See Billing’s Elements of Medicine,

Preface to 2nd or 3rd edit.

t Laennee located this disease in thepneumogastric nerves.