Imatges de pàgina
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vomiting by the hot draught with laudanum when the patient could not keep down any bolus. This was the case in the cholera patient alluded to, who was admitted at Colombo, on the 15th of July, with blue skin, shrivelled hands, and weak voice, after vomiting and purging all night.

On our arrival here, and during the hot weather with cold nights in March, we had about a dozen cases of men brought into hospital, many of them off guard, in a state of great exhaustion from vomiting and purging, having generally had diarrhoea for twenty-four hours or more previously. None of them were exactly cases of cholera, but they very closely approximated to it, having cramps and great coldness of skin. In every instance, "Maxwell's dose" was immediately given and acted like a charm.Med. Times and Gazette, Oct. 8, 1853, p. 365.

162.—Treatment by Quinine, &c.

[The EDITOR OF THE 'MEDICAL TIMES AND GAZETTE' observes that the lesson we may learn from the experience of the past, is not to persevere in modes of treatment which have proved useless. He remarks :]—Of all the remedies used during the previous epidemics, with the exception, perhaps, of opium as a palliative in certain stages, quinine probably is most deserving of a further trial. Modern experience in India is leading to increasing confidence in its powers. Towards the close of the epidemic of 1849, it was used in London. Mr. Spencer Wells injected a solution into the veins in four cases. Dr. Parkes did so in two others. He also injected solution of salicine without any marked effect, besides alcohol, both in simple warm water and in saline solutions. The experiments were only made in desperate cases, and no recoveries followed, but the power and duration of the reaction which took place were very remarkable, and, as phlebitis only followed in one case, encouragement is afforded for a repetition of the trials in cases not so absolutely hopeless as those in which they were formerly made.—Med. Times and Gazelle, Oct. 8 1853, p. 376.

163.-Treatment by Saline Injections.

[Dr. G. Owen REES, F.R.S., observes on this method of treatment:]—As the cholera has again visited this country, I venture to direct the attention of the profession to a point of considerable importance as respects the application of one of the remedies for the disease. With the view of recovering some of the worst cases, and when other remedial means have been unsuccessfully tried, practitioners have occasionally injected saline fluids into the veins. As this proceeding has been attended with great advantage in several recorded cases, and has produced in nearly all a temporary good effect, it has appeared to me that had the injected fluids been composed in more strict accordance with the chemical and physical constitution of the blood than was the case, we might have obtained advantages from the injections very far exceeding those we have on record.

With regard to the chemical constitution of the fluid, it would appear that we can scarcely venture to interfere with the organic constituents of the blood, nor imitate the animal extractives and protein compounds of the circulating fluid, in order to supply them if deficient. There is, however, no occasion for this in Asiatic cholera, for the evacuations from the intestinal surface, which destroy the healthy characters of the blood in that disease, appear to contain but little organic matter, being chiefly made up of water, holding the salts of the blood in solution. Thus Vogel and Wittstock agree in describing cholera motions as containing intestinal mucus, traces of albumen, and the ordinary salts of the blood, with carbonate of soda somewhat in excess. The analysis of cholera blood again points clearly to the necessity of supplying more especially salts and water, if we desire to restore it to the healthy standard.

With these facts before us, it is obvious that if we inject the veins at all, a solution of the salts of the blood is indicated in the case of Asiatic cholera; and it would seem well that those who may think it advisable to have occasional recourse to that plan of treatment for the recovery of severe and advanced cases, should keep a mixture of saline ingredients, combined in the proportions (or as nearly so as possible) observed in healthy blood. In order to answer the above requirements, I would recommend the following powder to be prepared, and kept ready for solution:

Chloride of sodium, three ounces; phosphate of soda, one ounce; carbonate of soda, one ounce and a half; sulphate of soda, half an ounce.

As regards the physical peculiarities of the fluid for injection, it is quite as important that its characters in this respect should be attended to as that its chemical constitution should bear its proper relations to the blood. The specific gravity and temperature of the injection will require to be carefully adjusted before we can expect to put our patient under the conditions most favourable for recovery when mixing it with the blood. With regard to temperature, but little need be said; 98° Fahr. is necessary, as being that of healthy blood; and I would only remark, that it should be determined by a correct thermometer, and not by one of those cheap instruments with which the market is just now unfortunately inundated. The specific gravity should be adjusted by gradually diluting a strong solution of the saline mixture above described with small portions of distilled water, at the temperature of from 58° to 63° Fahr., occasionally testing it with a saccharometer (the ordinary instrument used in the examination of urine), until the instrument indicates a specific gravity of 1030. This being attained, the fluid has merely to be brought to the temperature of 98° Fahr. to fit it for use.

It is not my intention to enter, on this occasion, upon the reasons why it is so absolutely necessary to attend to the specific gravity of the injected fluid, further than to state that I have adopted that of the serum of the healthy blood, which has a specific gravity such as acts on the blood corpuscles by producing a gradual endosmosis, and thus avoids the evil effects which solutions varying much from the same weight inflict on those bodies.

In conclusion, I would beg to refer those who may be interested in this question of the effects produced on the blood by solutions of varying specific gravity, to a paper by Mr. Samuel Lane and myself, contained in the thirteenth number of the Guy's Hospital Reports,' and also to remarks having reference to the physical structure of the blood, contained in the second edition of my work on the Blood and Urine.-Lancet, Oct. 1, 1853, p. 313.

164.-Treatment by Enemata of Tincture of Catechu, &c.

[Mr. A. J. J. CHITTY states that in 1847 the cholera broke out in the 37th regiment (about 1,100 strong), stationed at Colombo, in Ceylon. Mr. Chitty was one of the surgeons in attendance. The mortality was by no means equal to the general rule, being only about one death to four and three-quarter recoveries. Mr. Chitty believes this to be due to the peculiar treatment adopted. He says:]-On post-mortem examination of the fatal cases, we were struck with the uniformly turgid, erected, and prominent condition of the villi of the intestinal canal, and of its glandular system generally; and there were frequent incipient ulcerations of Peyer's patches and the solitary glands,-in cases, however, rapidly fatal. It appeared to us that we required some medicament that would exercise a powerful astringent effect on these villi, extended throughout their location. Strong decoction of catechu seemed to offer this provision, and on that our successful treatment mainly depended. Enemata to the amount of two wash hand basinfuls were administered continuously, after a first or second trial with smaller quantities, until abdominal distension obliged us to desist from its injection; and in more than one instance was it in part evacuated by the mouth, proving that it had traversed the intestinal canal. Laudanum, turpentine, ether, ammonia, &c., were severally conjoined, according to the circumstances of each case, and the condition of the patient. The decoction was taken too by the mouth with laudanum; indeed it was required that all soldiers affected with the least diarrhoea were to be brought to the hospital to be placed under surveillance, and to commence the catechu. Its value was so esteemed, that many of the officers, as well as men, would come daily to request the nauseous draught as a preventive of the epidemic. The various systems of treating cholera recommended by different authors had a fair trial at our hands,-salines, calomel, creosote, cajeput, &c. (excepting the acid sulphuric oil, which did not at the time strike us as an appropriate remedy), but were all laid aside for catechu in the urgent stages of the disease. The action of sulphuric acid I believe is in the main similar to catechu, inasmuch as its chief property and value in cholera would depend on its astringent action in the capillaries; but to effect this it must enter the circulation, and whereas at this juncture digestion and absorption are almost effectually interrupted, the exosmotic princi

ples being in the ascendant, it would seem to yield a precedency to the external topical astringent, catechu. I never saw calomel of the slightest benefit, nor can I imagine upon what deductions it is administered in the urgent stage of cholera with a hope of being useful.

The intense burning pain felt in the epigastrium, and the vomiting I have observed, are best relieved by spirits of turpentine applied as hot as can be borne to the stomach, and iced drinks, especially champagne, which, too, has the advantage of being a less powerful stimulant than brandy. The administration of stimulants in excess in this disease I have found fraught with danger; it excites or restores too rapidly the force of the circulation, and thus allows a continued or more copious exudation of the serum of the blood; it is invariably followed by increased vomiting or purging. The inhalation of ether was tried at Colombo at this period, to relieve the muscular spasm, with questionable success; but in some instances its administration was followed by a remarkable and happy restoration of cuticular warmth, increased force and fulness of the pulse, sleep, and convalescence. Chloroform was unknown to us, and our inhaling apparatus (a truly military one!) almost worthless, or I could have written more confidently of the value of the anesthetic.

I would also beg to mention that in one instance I was permitted to inject the venous system with a warm alkaline solution (sesquicarbonate of soda with warm water), by means of an anatomical injecting syringe. It was effected through the external malleolar vein, in a soldier already in articulo mortis, the pulsations of whose heart were only discernible by the stethoscope. In a few seconds the pulse returned to the wrist, the respiration became accelerated, warmth was restored to the surface of the body, and animation became so far perfected that the soldier rose up in bed and spoke, but instantly an excessive vomit occurred, and he fell back and died. I was not allowed to repeat the experiment; but I have since thought that had the injection been adopted earlier in the period of his existence,-had it been done a little more slowly, cautiously, and not so excessively (for I injected nearly a gallon), -the result might have been successful, and a valuable lesson gained. I am, however, so impressed with the force of that experiment, that on convenient opportunity, and friends permitting, I would not, as a dernier ressort, hesitate to repeat it.-Lancet, Sept. 24, 1853, p. 282.

165.-Treatment by Chloroform Inhalation.

[Mr. G. H. HEATH, of Newcastle-on-Tyne, remarks that we sometimes meet with cases of cholera in which, although the symptoms are by no means malignant, yet the vomiting is excessive; and that chloroform inhalation is admirably adapted for such cases. In the following case the most obstinate vomiting had existed for twenty-four hours, and the patient was rapidly sinking into collapse.]—Without the slightest effect I tried successively hydrocyanic acid, chloroform in spirits of wine, -which have been much employed here,-morphia, and bismuth. I sat with him for some time watching him, and found that whatever was introduced into the stomach, whether medicine, food, or cold water, was instantly rejected; so that it was impossible that any drug given in the ordinary way could produce its effect. I then determined to try the inhalation of chloroform, after the following manner. First, I caused him to inhale a small quantity of the vapour, sufficient merely to quiet the stomach for the moment, without producing insensibility: he was then got to swallow half a grain of morphia, and immediately was put fully under the influence of chloroform, and kept so for a few minutes; when sensibility returned, he declared himself free from all feeling of sickness. He was then kept sufficiently under the influence of chloroform to prevent vomiting, for an hour and a quarter. When this time had elapsed, he became drowsy; the inhalation was discontinued; he slept for some time, and remained entirely free from sickness for twenty-four hours. Afterwards he had a slight return of vomiting, which was checked in the same way. He has now, except on one or two occasions, for several days continued free from vomiting, and appears likely to recover.

The principle of this mode of treatment is, to keep the stomach quiet by the inhalation of chloroform, until some powerful anti-emetic medicine has had time to affect the system; and from my experience of it, I should most strongly recommend its adoption.-Lancet, Oct. 15, 1853, p. 378.

166.-Treatment by external Stimulants.

[Mr. T. M. GREENHOW says:]-It appears that in the most desperate cases, even when life has appeared extinct, the native Indians are accustomed to apply the actual cautery freely to the abdomen, not unfrequently with the happy result of restored vitality. The remedy, based on the same principle, which I have employed in three cases with complete success in the Borough Gaol of Newcastle, is precisely similar in kind, though somewhat less harsh and formidable in degree. A piece of linen dipped in brandy is placed over the epigastrium or abdomen and ignited; the brandy burns away in a minute or so, producing a considerable feeling of pain, which renders it necessary to secure the hands of the patient. Slight vesication will probably follow, and, if successful, in a short time heart and pulse begin to return, and the feelings of the patient are greatly improved; vomiting will also generally be put a stop to. It is probable that the application may soon require repetition, the situation being somewhat varied. In one case, now convalescent, in which death was apparently close at hand, the most complete effect was produced by a third application along the spine in the lumbar region.

Time will not permit me to give details of cases; but having now tried the brandy blister in seven or eight cases of total collapse, I repeat that in three it has been entirely successful, and in others has had the effect of temporarily rousing the patients; and if, as experience has since taught me, in some of these it had been repeated with more energy, greater success might possibly have resulted. The patients now convalescent say that it is a severe remedy; but are quite conscious of its beneficial effects, and attribute to its use, without any hesitation, their restoration from impending death.-Lancet, Oct. 1, 1853, p. 323.

167.-Treatment by Cold Water Affusion or Douche.

[Mr. E. M. MACPHERSON, late surgeon in the army, during nine years' service in India, had several opportunities of seeing the valuable effect of this treatment. He says:]-At Cawnpore, in June, 1845, cholera broke out in the 53rd regiment, to which I then belonged, with the same virulence as attended it in various localities throughout India during that and the succeeding year. Two men, the last survivors of several who had been attacked within two days, were sinking under that fatal collapse which alone, without any other symptoms, marked all the cases that had occurred in the regiment.

Every remedy that could be devised to produce reaction had been tried in vain; they might as well have been put into the patients' breeches pockets, or applied to the bed-post. The exhibition of the nitrous oxide gas was not only fruitless, but far from encouraging. The breathing under its use became more oppressed and hurried; there was no pulse, nor was it rendered perceptible by the gas; and as its continued exhibition distressed the patient, it was thrown aside as worse than useless. In despair at the utter want of the most trivial effect from the remedies employed, I made trial of the cold water affusion. I desired the water-carrier to pour water from his leathern bag over one of the patients and, as the effect was good, then over the other patient, placed naked on a bedstead in the verandah. Attendants were at the same time employed in rubbing the limbs and trunk with their palms, and afterwards with dry towels. A refreshing sensation and comparative re-animation having followed each repetition of this operation, it was had recourse to at intervals, though only with the success of having prolonged life, which was ebbing fast for some hours.

This success, poor though it was, seemed to warrant the conclusion that, had the remedy been applied while somewhat more of life remained, recovery might have been the result. To test this conclusion by experiment, an opportunity was not long wanting. On the same evening, as if by some fatal blast sweeping over the barracks, several men were suddenly struck down in a state of collapse. Some retained consciousness (cholera asphyxia); a few lost it, and were in a state of complete coma (apoplexia), with stertorous breathing; in three cases, attended with convulsions; others, especially towards morning, and during the two following days, were affected by vomiting, cramps, purging, with rice-water dejection, and the usual concomitants of cholera in Europe.

How many came under treatment at this time I cannot now venture to affirm;

but I believe I am correct in stating that, of all admitted, but two died-one of apoplexy; the other, who was allowed a warm bath, of cholera. The rest, all of whom recovered from the cholera, were treated by the cold water affusion.

Since the period above alluded to, I have not had an opportunity of treating cases of epidemic cholera. Several cases, however, of endemic cholera among Europeans, while it was, as often happens, epidemic among the natives, have been treated by me, in every instance with success.

One of the most remarkable of these endemic cases occurred at Meerut, in August, 1848. A corporal of the 9th Lancers, an atrabilious subject, was brought to hospital at four p.m., almost pulseless, having been purged during the morning, and having passed several rice-water dejections on admission into hospital. There were slight cramps, and occasional efforts to vomit. He was immediately placed in a hip-bath, and water was poured over him, while hospital attendants rubbed the limbs and trunk. This was continued until he became chilly, and shivered. He was then removed from the bath, dry rubbed, and placed in bed, much revived by the operation, as was shown by less oppression in breathing, and a more distinct pulse. After remaining in bed for about half an hour, he began to relapse; the pulse sank; vomiting, purging of rice-water, and cramps, returned. He was replaced in the bath with the same effect as before. Being again placed in bed, he again relapsed. The water was again had recourse to, and repeated at intervals as above, according to symptoms, until ten p.m., six hours after its first application. The respiration then became free, the pulse soft and distinct; the natural warmth was restored, and remained; and the patient slept until morning, when he awoke with a furred tongue, feeling weak and drowsy, but without that consecutive fever so often more fatal than the disease itself, and which has always seemed to me to follow most in those cases in which brandy, opium, ammonia, or other stimulants, have been freely administered.

Meagre and unsatisfactory as the above statements must appear, taken as evidence of the efficacy of the treatment advocated, yet, if the action of the remedy shall be thought to afford a satisfactory explanation of its curative effect, one case successfully treated in the manner prescribed will carry more weight than accurate details of numerous cases, treated by the unknown action of some occult remedy. The first effect of cold water, poured over the head and chest in a small stream from a water ewer, held at a greater or less height by a person standing on a chair or raising his arm over the patient placed in a bath, while frictions are applied to the trunk and limbs, is to produce, as in cases of ordinary asphyxia, a convulsive gasp or forced inspiration, succeeded by two or three strokes of quickened respiration. With each gasp, as by a convulsive throe, the parietes of the thorax, before immovable, will be observed to expand, and the diaphragm will descend. Simultaneously with each effort of inspiration, the impeded circulation will be found to flow, the pulse to partake of the impulse, and the sluggish pupil to resume its wonted sensibility. These are the first and immediate effects of the water douche. When continued, they constitute reaction; and if this is maintained, the vital energy, even at its last ebb, the natural heat of the surface, and the colour of the skin will be restored. This is effected by the imbibition into the blood, through respiration, of atmospheric air taken in at each forced inspiration; the entire surface being at the same time stimulated by frictions to the limbs. It being evident, according to this view, that the stimulating effect of the cold water douche is to be attributed to its power of exciting the respiratory function to take oxygen into the system, it may be inquired how the experiment with the nitrous oxide gas, above alluded to, failed so signally. One essential condition to its action was wanting; viz. that expansion of the thorax for the reception of air into the lungs, upon which the effect of the water douche so much depends. Since I have become aware of this as an essential condition in the effect produced by the water douche, I have not had an opportunity of repeating it in conjunction with the gas; but may it not be presumed that, taken together, if they do not prove an antidote to the disease, they are, at least, worthy of a trial? That the want of oxygen in the blood is the cause of cholera, has often been advanced, if not generally admitted; but the effect of this want upon the brain in producing vital depression seems to have been overlooked; whilst its effect, or that of some poisonous miasm in the system, upon almost every other organ of

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