OBSERVATIONS

THE PATHOLOGY AND TREATMENT OF

CHOLERA.

By BAMLET W. SWITZER, F.R.C.S.L,

Assistant Surgeon, Bengal Abmy.

In offering this paper for the perusal of my Medical brethren I will frankly state, at the outset, that I have no new or startling theory to propound, nor have I any infallible plan of treatment to recommend. My object is solely an endeavour to establish the pathology of cholera on a correct basis, believing that, until

this is done, the treatment of the disease will never be satisfac- torily reduced to plain rules; for, I grieve to say, empiric remedies suggested by men outside our profession?and who can have no possible knowledge either of the disease they profess to cure or the frame which is the subject of that disease?too often find support from the public, until sad experience has taught them the wortlilessness of what common sense in the beginning would have equally shown. Some years ago, a very eminent and

learned clergyman of a mathematical turn of mind took to think-

ing about cholera, and, deeming that, in his study, he could by a

logical process arrive at a specific, crammed himself with the

symptoms of the disease. Amongst others, he found that cholera

patients sometimes suffered from clonic spasm, and with, I sup-

pose, some dim shadow of Si nilia similibus curantur floating be- fore his brain, he rushed to the conclusion that strychnia was the long-sought-for panacea. Some experiments on frogs con- firmed this idea; and it was given to the world,?need I say with what result ? The numberless drugs, the most opposite in their

effects, which have from time to time been used by their warm

supporters, quinine to quassia, vinegar to verdigris, down to the

last absurdity which was presented to the French Academy of Sciences in October 1865, as an 'infallible receipt,' viz.,?' That the patient should be enveloped in a blanket of new wool, and made to swallow the wing of a fowl, very hot!' All these are

but indications tc us how unsettled is the pathology of the disease ; and that, instead of grasping the few facts certainly known, and

by them arguing from effect to cause, the fearful nature of the disease has prompted a wild rush into the boundless prairie of

speculation, in the hope that some one will, with a cry of ' Eureka,'

accidentally drop on the hidden treasure we hope for?a

specific. The Etiology of the disease I would not be under- stood to include in the foregone remark, for as speculation, .

on this point can do no injury to our practical treatment, those disposed for theoretical inquiry may safely exercise their bent in this field. The prevention of cholera and its cause, we

February 1, 1866.] THE PATHOLOGY AND TREATMENT OF CHOLERA, BY B. W. SW1TZER. 27

must admit, are at present wrapped in obscurity, and lionestly in the words of an eminent authority:?" It is best to acknowledge that all hitherto advanced as to the proximate cause of cholera is mere conjecture, and that we are in a state of entire ignorance on the subject." Prevention is no doubt better than cure, but until

perseverance or cbance has given us knowledge we do not at

present possess, the study of the disease itself will repay better than a search after either a specific or a prophylactic.

In considering the Pathology of cholera, we will be aided by recollecting that this disease must be subject to many of the laws wbich govern the presence of other diseases in the human

body. Cholera, per se, is no more wonderful than the class

of malignant typhoid fevers, small-pox, tetanus, syphilis, or many of the other ills that flesh is heir to; and as we look at a case of small-pox, so let us look at one of cholera. In

both, there is a period of incubation; in both nature, unaided, at- tempts to rid herself of the disease ; in both the actual potency or virulence of the blood poison may kill; in both the strength of the patient may be worn cut, and death result from consecutive weak- ness ; in both nature, in the strictest sense of the word, may eli- minate the disease and cure ; in both, speaking equally strictly, human aid never can cure. As the stout ship suddenly finding herself in the midst of shoals and quicksands, fires the signal gun for the skilful pilot, who, knowing the dangers from previous experience, brings her safely through by avoiding the hidden rock and controlling her movements when facing certain destruc- sion, so is the cry for help to our profession that the physician may guide his patient through the quicksands of disease, and past the rock of death, though as powerless to remove that disease

himself as the pilot is to lift his ship into mid-ocean. If cholera, then, be not subject to entirely different laws, but equally with other diseases bound to obey some rules, a comparison of two di- seases will eliminate characteristics common to both. In small-

pox we know there is a stage of incubation which extends over

many days, and during which time tne subject must be considered as stricken with disease; but as it is unrecognizable in this con- dition, we are unable to define it as small-pox. The poison lurks, but it is invisible, until the time has come that the system can no longer bear the incubus ; then the effort is made to throw it off by discharging the poison through the skin, by means of a copious purulent eruption. This is the distinctive feature by which we recognize the disease; and though, in fact, it is the at-

tempted cure, as worked by nature, we call it the disease, only then recognizing its specific character. "We never try to cure

small-pox by checking this salutary discharge; we rather encour-

age it. Knowing well that nature selects for the exodus of the

poison the most ready and favorable outlet, in such a case our

task is not to cure, but to aid, guide, and control her efforts so

often unsuccessful from her own inability to direct them. Putting aside accidental or concurrent causes, death in this disease takes

place either primarily from the virulence of the poison itself striking the patient ruthlessly and carrying him off in convul- sions or coma, ere the eruption has time to act as a safety valvo to the system ; or, secondarily, by mere exhaustion of the vital

powers consequent en the effort at elimination ; and in this way death has no special connection with the special disease, as any disease which produced the same amount of exhaustion, would

equally be followed by death. In treating smoll-pox, we act as the sentry over life, challenging the approach of insidious ene- mies, and endeavouring to guard our charge in the perilous hour of danger, while that danger, so often incapable of any allevia- tion by us, hangs over, or until it passes by.

A rational solution of the Pathology of cholera may be assisted

by looking at the disease in a similar way to that in which small- pox has been glanced at. A stage of incubation in cholera is

believed in by many, and some state that they have been able to detect cholera in the countenance many hours before its presence was shown by other symptoms ; this, I think, if? doubtful, although some well-authenticated cases -are

recorded of people having felt and announced the moment of tlie advent of the disease. As we do not know the manner

in which small-pox enters the system, neither have we sufficient

data to decide the open question, whether cholera is primarily generated in the body or introduced from without by atmospheric causes, or through the natural ingesta; suffice it for us at present that the subtle poison having gained an entrance, and polluted the blood, its presence being incompatible with the continuance of life, nature either yields at once to its over-mastering force, or endeavours to preserve life, by rejecting it from the blood. It

is rare that the potency of the poison kills without the preservative effort, but there is doubt of its occurrence, predisposing con-

ditions of access and process conducing to it. In the more

common struggle between the victim and the disease, the fclimi- native process is set up; and in cholera this consists in the rapid expulsion from the system of the poison dissolved, suspended, or otherwise in connection with the water of the blood. Little

proof is required that this is the fact, if we bear in mind that

we now look at cholera in the same light, and compare it

in the same way with small-pox. A pustular eruption in the one case and a watery discharge in the other are, respectively, the modes chosen. "Why cholera poison should select water as its

carrier, we are as unable to say as why a pustular eruption through the skin should be the chosen path of exit for the poison of variola; that such is the case, admits of no doubt, for it is well known that inoculation of the pus from a small-pox pustule, or the introduction into a healthy stomach of either the vomit or alvine discharge from a cholera patient, * will in both cases

produce the respective disease. Cholera poison then selecting, nc doubt, the best means of leaving the system, seizes on the water of the blcod, and by every channel through which water can be most rapidly got rid of is it poured forth in the effort to save. Stomach, bowels, lungs, skin, all open as flood-gates for this suicidal cure, and the constant vomiting, purging, sweating, and exhalation from the lungs soon reduces the amount of water in the blood to a minimum ; thus, the functions of absorption and assimilation being in abeyance, the cure is as bad as the disease. The blood loses such a quantity of its water that it becomes like clotted gore or tar, and refuses to flow; the lungs are choked, and the weakened heart clogged, so that it cannot pump the

stream of life; the strength goes, the eye glazes, the lethargy of death approaches, and all is soon over. Here death is mechanical and begins at the heart; and, if all this be true, it will lead to

the conclusion that the patient dies more often from the injuries produced in Nature's attempted cure, than from the excessive

killing power of the disease; thus, after a protracted attack

during which large quantities of water have been lost, the

poison will doubtless have been got rid of completely, and the patient then dies from the weakness produced in the struggle, it-

self the result of the stagnant condition of the blood. A cure in

theory here at once presents itself; namely, the re-liquefaction of the blood by supplying it with water, and this doubtless would be a practical cure did we arrive at the proper manner, means, and

time for doing it. To facilitate the consideration of this subject, I propose to divide the disease into three stages, and examine it

as thus shown. This is only an arbitrary division, and, I believe, not a correct one, but it is convenient: 1st, Premonitory; 2nd, Established ; 3rd, Collapsed.

I. Premonitory.?"When cholera prevails in any military sta- tion, one of the first duties of every medical officer has always been to warn the men under his charge not to neglect the most trifling diarrhoea ; this is the best advice that could be given, for we know how easily and, too often, how rapidly, in a cholera sea- son, an ordinary case of sporadic diarrhoea passes into cholera. As a result of this warning, many men apply for medicine and thus ward off the disease. We see, however, occasionally two ro- bust men placed in exactly similar positions, perhaps eating from

* This revolting experiment was actually tried by two French students who fell victims to their mistaken zeal.

28 THE INDIAN MEDICAL GAZETTE. [February 1, I860.

the same dish, and .sleeping beside each other, who together apply complaining of this diarrhoea, which at any other season would

he looked on as a trifle and relieved by a dose of castor oil. These men both obtain the same remedy; yet, in the one case

cholera sets in within a few hours, and death ensues before

night; in the other, a perfect return to health is the result. Now, as these. two men have been in all respects exposed to the

same producing causes, are we to look on this diarrhoea as al-

ready a premonitory stage of cholera, from which but one

recovered; or as a predisposing cause, owing to which the disease bad more ready access to the other ? The latter will, I think, be found the true view : and this sporadic diarrhoea, so generally looked upon as the premonitory stage of cholera, has, I believe, no further connection with it than in the fact that, being neg- lected, it places the individual in the most favourable position to receive the more serious disease. Were we to consider the

diarrhoea as a result of the poison already permeating the system, the recovery in the one case would lead us to suppose that

either from the diminished potency, or the small quantity of

poison present, the diarrhoea was sufficient to remove it; while, in the other, the attempted elimination being checked, the poison generated in excess and resulted in cholera. This would be a

most dangerous doctrine to countenance ; for it would lead to the neglect of this premonitory diarrhoea, or to our hesitating to control it, either of which courses would be most fatal. We may therefore reasonably doubt whether there is any premonitory stage to

cholera, though we cannot doubt that there is a predisposing disease.

II. Established.?Sometimes, without any predisposing diar-

rhoea the disease is abruptly ushered in, or the diarrhoea continu-

ing unchecked or uncheckable, it culminates in true cholera, the characteristic mark of which is the rapid expulsion from the

system of its contained water. From all analogy we learn that

it must be the fittest process which is selected for discharging the poison, but we equally know that a fatal result will follow

from the absence of the water. Our difficulty is thus apparent. If this be Nature's method of cure, any attempt to control the

watery flux is simply opposing the means selected for the safety of the life. So far as we know, the poison can be got rid of in no other way, and it3 retention will as surely kill. The truth of all

this is proved at the bedside, for our attempts to control the

watery purgation, or end the constant emesis, are generally useless; they go on unchecked,, whilst any poison remains to be rejected ; but when this is accomplished they quietly cease of themselves. We know that, in the majority of fatal cases, all purging and

vomiting cease some hours before death, and with their cessation the disease has also terminated ; the patient might then be con-

sidered as cured of cholera, and the battle successfully fought, were it not for the fatal drain the victory has caused with the

cure; one of the essential elements of life has been abstracted, and

the victim is as badly off when cured of cholera as he was be-

fore, on account of the absence of the water of his blood. We

can no more hope to stop the flux while any poison remains, or make the disease yield in the presence of the poison, than we

can hope to cure small-pox by suppressing the eruption, or

urannia by checking the perspiration. III. Collapsed.?I have said above that the disease, per se,

ends with the discharges ; and if this be true, collapse must be looked on more as tiie result than as any part of the disease itself. As predisposing diarrhoea is to cholera in its advent, so is collapse in its exit; the one is the condition of body which lays the individual more open to the diaease ; the other, the condition resulting from the disease. The severity cr amount of collapse should then depend as well on the relative virulence of the par- ticular attack, as on the strength of constitution of the indivi-

dual suffering it, or the rapidity with which the blood loses its water; for although we see cases of almost sudden death from

cholera, that is, death in two or three hours, without any great external discharge of watsr, the intestines in such cases will

be found full of the rice-water fluid, and it may be fairly ques- tioned -whether the sudden and rapid extraction from the blood

of a comparatively small quantity of water would not produce this quick depression and death, when, the slower withdrawal

of a much larger quantity is more gradually followed by a similar result. If this be not the explanation of such deaths, it must be found in the supposition that a l?rger portion of the poison finds entrance and is of itself sufficient to kill, or that one

subject is less able to bear up against the same quantity and

quality of poison than another. As a rule, the more healthy a man is the better able is he to encounter the disease with

success, and when it is spent, the better chance was the vis

mcdicatrix naturcc to bring him round. The apparently random selection it makes of its victims is one of the curious vagaries of the disease?the strong being often taken and the weak left.

Again, those who fear cholera always get it when brought in contact with it; those who do not fear it rarely suffer. Established cholera having been present for some time and the discharge of water going on unimpeded, the blood as it loses its fluidity is

unable to circulate with the rapidity necessary for its

oxygenation. Carbonized blood then slowly flows through the

system, and cold is the result. That this cold is in any way

primarily connected with nervous influence, I do not believe, but the nervous centres of course participate in Ihe general effects

of the disordered circulation equally with the other parts of the body. The poison of cholera, whatever it maybe, does not affect the sensorium; the clear intellect neither excited nor depressed shows that the brain, the great nervous centre, is the least and the last affected; not until death approaches does the cholera patient ever lose his perfect self-possession; there is no delirium here, no coma ; as long as the blood remains tolerably pure, and the heart can pump the scanty supply the brain requires, reason reigns un- harmed. Pain, the greatest evidence of nervous activity, is acutely felt by the cholera patient, who will feel and call out for the re- moval of too hot a bottle from his side. There are no facts at

present known which could warrant the conclusion that cholera is in any way connected with nerve lesion. It is far more a

disease of the circulatory apparatus, for that is the first affected

by the established disease ; and any nervous phenomena can all be traced to this primary disturbance. Collapse, then, is not other- wise connected with cholera than as a result; and the bearing this in'mind will lead us to the healthful consideration that this, the most fatal period of the attack, ought, from the disease

having already spent itself, to be the most hopeful. The adage " Whilst there is life there is hope" is peculiarly appropriate here ; for those who have seen much of cholera must have witnessed instances of recovery little short of miraculous. Men moribund

have been snatched from the jaws of death most wonderfully, by some sudden impression ; the most opposite means have produced this, such as the emotions of joy and fear, brandy, champagne, electricity, fire, &c.; thus showing that the disease having left, any fillip given to the system sufficient to re-establish the ab-

sorptive function, will save the life. The stomach, bowels, and

skin may continue to expel water, even after all the poison is

got rid of, merely from the original impression remaining, or

what would correspond with inertia in mechanical force ; and

this absolute waste may go on for a time during collapse, until,

by some counter-impression, it is removed. We do not expect to succeed in restoring a drowned person while submerged, nor

ought we to expect we can prevent collapse continuing, while the system is still expelling water. We resuscitate the apparently drowned, by restoring what is lost?air to the lungs and heat to

the body. So ought we to recover the collapsed patient by the

supply of water to his blood. As I fear the continuance of thjs paper would demand more space in a single number of the Indian Medical Gazette than it might be convenient to surrender, I will defer the further consideration of the subject to a future occa-

sion.

Jessore, January 1866.