Two lectures on cholera and intermittent fever

Front matter

DR. BELL ON CHOLERA AND f

BRIGHTON AND SUSSEX

EXTRACT

Preface

Owing to the variety of forms in which cholera appeared in Persia, in 1842-3, the author was led to entertain peculiar opinions respecting its nature and treatment. In the course of conversation on the subject, some of his colleagues in the Manchester Royal Infirmary were pleased to say that they would gladly hear the views then advocated by the author, stated at greater length in the form of a lecture.

The following pages are the result of his endeavours to comply with this desire, and their delivery was honored by the attendance of many distinguished members of the medical profession in Manchester and its neighbourhood, who, in a very flattering manner, expressed a hope that the lectures might be published. In venturing now to submit these observations to the profession at large, before the approaching epidemic should have enabled him by further experience more fully to substantiate or to correct his conclusions, he has been moved solely by the hope, that the inquiries here iv

PREFACE.

suggested might prove useful to others in assisting investigation of this obscure disease. He wishes them to be received solely as suggestions, and has therefore abstained as much as possible from detailing the results of his own experience, desirous of attempting to reason on the subject rather than to dogmatise.

Firmly believing in the analogy of cholera with quotidian ague, he has ventured into print thus early, lest by delay the opportunity of confirming or negativing a point of so much importance should be lost to others, to whom circumstances may have been less favorable than to himself in suggesting the points of their similarity.

94, Mosley Street, Manchester.

ON CHOLERA.

Gentlemen, —

Both as students of the science of medicine, and as professors of the healing art, we are all at present peculiarly interested in investigating the nature of cholera. Thirty-two years have now elapsed since that fatal disease first became known to our countrymen in India, and through them to the inhabitants of other countries j but it was long regarded by the nations of Europe and America, as belonging rather to another world, than as ever likely to become personally interesting to themselves.

It was only on its actual appearance among us in 1832 that we became convinced of our mistake, and were thrown into all the conslernatinn that attends a mysterious and unexpected object of terror. At that time every human attempt made to arrest its progress proved in vain; and, selling almost every variety of climate at defiance, cholera completed the wide circuit of the world.

No sooner, however, was the danger past, than we relapsed into our false notion of security, until this was again dispelled by appalling accounts of its^ renewed progress through Asia, and of its having again passed the boundary of the Caucasus, invading Europe by the identical route which it had followed seventeen years before, with no other difference than that its front was now more extended.

It might reasonably have been expected that, afier the disease had extended itself over nearly the whole globe, and the press of every country had absolutely teemed with essays upon the subject, some definite agreement would have been arrived at by the profession with regard to its essential nature, and to the principles upon which its treatment should be conducted. It is, then, little flattering to our professional pride, to be obliged to acknowledge that this expectation has been disappointed.

The medical press gives almost daily evidence, that little information of importance has been added to that which had been collected by the earliest observers of the disease ; our practice is still almost entirely empirical, the principles on which it should be conducted are as little determined, and the opinions of the profession as little settled as they were on its first visitation.

Even the great question of the capability of cholera being communicated by contagion, is still a moot point, and all the evidence collected on the subject is insufficient to convince our legislature that quarantine regulations in regard to it, are only a useless and cruel grievance. Under such circumstances, and after many of^the first medical authorities of the past and present generation have failed to elucidate Us nature, it is only natural that every new attempt to throw light upon the subject should be received with distrust, and that any one who now ventures on the discussion, will do so at considerable risk to his professional reputation ; I cannot, thereforOj but feel much diffidence in doing so, and that much apology is due to you for requesting your attendance here for that purpose.

My reason for making the attempt is, simply that I believe the circumstances under which I have had an opportunity of studying the disease have been peculiar, and such as to lead to conclusions of great importance, and that I should be acting little in unison with the spirit of our profession, and be neglecting a great duty, if I failed in laying that information which chance has accorded me, before its members. I may, it is true, have overrated the value of my opportunities (this is for you to judge,) but believing, as I do, that what I have witnessed, if fairly set forth, will lead to the determination of a principle, rather than a rule of practice, I have felt it imperative on me to submit the subject to your consideration, in the same light in which it had appeared to myself.

After becoming acquainted with cholera, under very favourable circumstances, in Edinburgh, in 1832-3, and in London, in 1833-4, it was my lot to be stationed for several years in Persia, a country, situated both geographically, and in point of climate, midway between India and Europe, and there I had the opportunity of observing closely the first approaches of the identical cholera, which is now sweeping irresistibly towards us. The disease was there ushered in by a regular succession of epidemics, commencing in a fever apparently continued, but by and by assuming more the character of a remittent, and this very gradually changed to an intermittent of quotidian type; of this the cold stage gradually became prolonged, and assumed all the appearances of an attack of cholera, and then came the cholera, as it has everywhere been known, without any obvious stages or intermission. This again in its turn disappeared, and the epidemic resumed the character of remittent and continued fever for a time. These various changes occupied a period of eighteen months.

Having thus witnessed the disease analysed and dissected as it were, into its component parts, and seen continued fever gradually resolve itself into cholera, — and cholera into continued fever, by slow gradations, in a manner which does not appear to have ever been presented with the same perspicuity to any author, having, too, been obliged to follow each varying type of that epidemic with appropriate treatment, 1 have been led insensibly to those views of the nature and treatment of cholera, which I shall endeavour to submit to you, as shortly as may consist with my intention of leading you into the same train of reasoning which I myself pursued.

By considering this fatal disease rather as an exaggerated example of others better known, and whose treatment is more familiar to us, than as something anomalous and unlike every other disease, we shall, 1 trust, escape the necessity for vainly searching for some principle capable of reconciling modes of treatment so much at variance as hot air-baths and warm stimulant potations on the one hand, and snowbaths and iced-drinks on the other, ^ther, alcohol, tartar emetic, calomel, lead, lunar caustic, croton oil, naphtha, assafoetida, quinine, opium, peppermint, bleeding, blistering, and the actual cautery, are only a few of the remedies that hare been proposed for the same stage of the same disease, all equally failing— all equally recommended as infallible.

Still, there is one valuable conclusion to be drawn from the very contrariety of the means employed, viz., that almost all have felt that the more obvious indications (which the well-marked symptoms of cholera would lead us to follow,) are not to be trusted as guides in the treatment of the disease ; that some broader principle is necessary to direct our practice than the fallacious one of opposing the cold of the body bv external heat, the collapse and sinking of the vital powers by stimulants, or the purging and muscular spasms by opium. Indeed, the abandonment of this method of treating symptoms, and the loss of faith in heat and stimulants are what chiefly distinguish the more recent works of experienced authors from those of more ancient date, and of less practical acquaintance with the disease.

In concluding these prefatory observations, I beg to remark, that I have endeavoured to avoid discussing the opinions of others, because this is unnecessary to the audience I am addressing, who are not only well acquainted with the works of the best authors on the subject, but also possess a large amount of unpublished knowledge of the disease from their own practical experience.

The similarity of cholera to the cold stage of ague is too obvious not to have occurred to many, but there were, unfortunately, two circumstances which contributed much to prevent this analogy from being pursued to its full extent — the first being the want of any obvious stage of reaction, relaxation, or intermission ; the other, that quinine and arsenic were not found eflfectual in the treatment.

It was observed that recovery from the cold stage of cholera in this country, was not unfrequentlyfollowed by a low form of continusd — I should rather say remittent-fever, and this, instead of being regarded as one of the modifications of the disease, induced by climate, or, as a secondary eflTect of primary disorder, was considered by too many as the hot fit which belonged to the protracted cold stage that had preceded it.

I shall endeavour to point out that this form of fever (., not unfrequently precedes and follows cholera as an epidemic, even at long periods, before and after the appearance of the major malady, and sometimes occurs as its substitute ; and that while it prevails in a country, the" epidemic constitution" to which it belongs, more or less influences the course of almost every other form of disease, by producing a greater than usual tendency to venous congestion, and diminished or irregular action in the capillary circulation ; and that the type of sporadic fever in this country has for several years approached very nearly to this, especially in the last few weeks ; — as also in Edinburgh in 1843, in Liverpool in 1844-5, and has been more particularly displayed in those cases of fever that have arisen spontaneously from putrid vegetable matter.

Finally, I hope to convince you that the alliance of cholera with other diseases, of which quotidian periodicity is a marked characteristic, gives us reason to believe that even when apparently most destitute of regularly recurring periods, it is not utterly so in reality.- That it is, in fact, by considering cholera as an aggravated congestive ague of quotidian type, that we shall most nearly arrive at just principles on which to conduct its treatment, and that the means by which cure is effected in the one, are both theoretically and practically those which are most appropriate to the other.

DISTINCTION BETWEEN MALARIOUS AND CONTAGIOUS FEVERS.

Before we enter on the consideration of those diseases with which cholera is allied, and of which class it may be considered one of the .extremes, it will be well to devote a few minutes to consider the broader points of distinction between this class and those diseases which are communicable by contagion.

By active disease, we mean either the direct effects of toxical or mechanical injury to some portion of the system, or the indirect effects produced by the resistance opposed by the vital powers to the operation of such causes — or, lastly, the effects of the struggle between the noxious influence and the vis medicatrix.

Fever is the most obvious and most frequent evidence of the activity of the vital powers to resist a noxious influence, and of the attempts of the powers of life to repair the effects or remove the cause of injury; but in considering fever in general, it is usual to limit the term from its wider sense to that condition which follows the absorption of certain poisons into the blood. When, therefore, we find fever to be the consequence of absorbed poison, it is of the utmost importance to endeavour at the outset to ascertain, as nearly as we can, upon what part of the system, and in what manner the effect is produced, and what are the actions by which its influence is resisted.

That the cause of both contagious and sporadic fever is introduced into the system by the blood, few indeed doubt; but the important question is, does the cause produce its effects directly on the blood itself by essentially changing its constitution, or is it only conveyed by the blood, like digitalis, aconite, opium, &c., and without causing any essential change upon the blood, operate by affecting the nervous system ?

In an admirable essay on « Spotted Typhus," read before the Provincial Medical Association in August, 1848, Dr. Davies, of Balh, drew a broad distinction between the two classes of poisons which are known to produce fever, viz., animal poison, and malaria. There is one kind of poison, he said, which, arising in the blood, and finding the elements of its reproduction in the blood of another, produces a fever capable of being propagated from man to man ; and there is another class of poisons, which, arising in elements extraneous to the blood, does not find its elements there, and though it produces fever, cannot reproduce itself, and is not capable of being propagated from one to another.

The second class is that which is now to occupy our attention, at least, that portion of it which embraces fevers produced by malaria, whose characteristic is speriodicity,* and I shall venture to enunciate the proposition with regard to these even more broadly : — That although the first class of poisons — that, namely, which produces the exanthemata, — operates on theblood and changes its constitution, the second operates not on, but through, the blood, and produces its efi'eots by its agency on the sympathetic system.

• Some malarious poisons do undoubtedly contaminate theblood itself, and require special action for their elimination, as the Egyptian plague by boils ; but these form a distinct genus of contagion, and do not fall under our immediate consideration. Thuse now to be discussed are all characterized by intermitting action till they reach their climax in cholera.

Both classes no doubt produce effecls on the sympathetic, but the first, (the animal poison,) acting by a continuous irritation, produces a persistent eflFortof the emunctuaries to remove the poison from the blood, or continued fever; the second, (malaria,) acting solely by nervous impression on the sympathetic, produces merely a struggle between the impression which is opposed to vitality, and those sensations and actions that are provided for the maintenance of animal life. This struggle is what we observe to take [jlace in the intermitting and congestive fever, &c.

If malarious poison actually changed the constitution of the blood, it would be as impossible to cut short a fit of ague as an attack of small-pox or scarlatina; 'but it is possible to cut short an ague, by means which (as we shall see when we consider the treatment of intermittent,) are not one of them calculated to produce an essential change on the blood itself. There would, too, in all probability, be some evidence of an elimination of the poison by the fit, as by the skin in the exanthemata, which there is not; or some diflferenoe in the blood drawn several hours before and after the fit'; but in both cases it is equally incapable of propagating the disease by inoculation. Besides, it appears scarcely possible to account for the leading, characteristic of the whole class of these fevers— their periodicity— on any principle but by the law of^nw^vou^ impressions,— viz., that long-continued impression of an object upon a nerve of sensation impairs its sensibility, but that a change of impression restores it ; as the eje long fixed upon a point becomes insensible to the impression of light, but recovers its sensibility on being turned to other objects.

So the continued impression of the poison on the sympathetic subdues its sensibility to its appropriate stimuli, — namely, that excitability which resides in the vital organs, whose action the sympathetic governs and regulates, but its irritability becomes re-excited, and its energies are restored by the new impression caused by change from a natural to a disturbed condition of the organs, which is the consequence of the withdrawal of the influence that combines and regulates their functions. Like the eye, restored to a sensibility to light by change of object, where the energy of the sympathetic is thus restored by the new impression, the recovery of its natural sensibilities would be permanent, were it not again submitted to the same influence by which it had been paralysed at first ; but as the optic nerve will again become insensible when the gaze is again fixed as before, and this sooner or later, as the object is more or less illuminated, so does the sympathetic require to be again undisturbedly submitted to the noxious impression after recovery of its sensibilities before the effect is again produced, and that for a longer or shorter time, according to the power of that impression.

If we shall see reason to believe that the efi"ects of the malaria under consideration are not caused by actual change operated on the blood, it will be evident that they can only be produced through the agency of the sympathetic, for we shall have frequent examples of malaria, aflfecting at one time the cjrculation merely, as in ordinary ague ; at another only the b.o\vel3. as by diarrhoea or nervous constipation ; at another the cerebro-spinal system, with convulsion, paralysis, or neuralgia; or, again, we have either two combined, or all three, as in cholera; and we know that with the exception of the blood, there is no other element in the system but the sympathetic, which is in such intimate contact or connection with the organs of circulation, of digestion, and with the cerebro-spinal nerves, as to be capable of producing these effects.

We find, too, that what we should expect from our acquaintance with anatomy, really is the case,— viz., that the capillary circulation is the part of the system which most frequently, most easily, and most completely, submits to the influence of malaria acting through the sympathetic, because almost every other part of the system,— the heart, stomach, lungs, viscera, &c., are all supplied by other nerves, the capillaries alone depending entirely on the agency of the sympathetic, whose branches are distributed to every, (even the minutest,) vessel in which our instruments enableus to trace it. This view is further borne out by considering the change^from the healthy functions of this part of the system that are manifested when influenced by the morbid impression. In a state of health we know that certain chemical reactions take place between the blood and the terminal structures of the capillaries, by which perpetual slow absorption and deposition of the tissues, is effected, certain secretions are produced, and animal heat is evolved, and that while those actions go on undisturbed, the blood flows freely and unimpeded through the gently distended, but still very minute, veins, without exhibiting the least tendency to adhere to tbem, as would be the case in inanimate capillary tubes of equal diameter ; neither does the contained blood exhibit any tendency to coagulate. We know that this property of preventing capillary adhesion of the blood to the coats of the vessels, and of preserving the fluidity of the blood, is peculiar to the living inner coat, and not to living structures generally, for extravasaled blood, in whatever part of the body, immediately coagulates. We are also aware that the capillary circulation possesses local excitability, (independent of the heart,) and the power to resist injury or repair its effects, and that excitability is a reflex action, commencing in sensibility, therefore that this latter quality depends upon the nerves of the vessels.

To prove that all these qualities are bestowed by the sympathetic nerve would lead us too far from our present object; suffice il to remark, that the first stage of ague and cholera is marked by diminution, or cessation of all these qualities and actions. Of the effect of this on the change of the tissues we have little evidence, but we see secretion stopped and converted into exudation, which physiology teaches is directly the opposite of vital action; the evolution of animal heat ceases; the veins contract like those of the dead body ; the blood returns from the terminal structures in a condition very different from that of health — not coursing freely through the vessels, but slowly, and as if adhering to their coats, and in a half coagulated state; and, lastly, by the application of stimuli, which would prodace immediate reaction in the healthy skin, we find it almost impossible to excite these vessels in cholera. The direct conclusion from all this is, that impaired excitability, nervous energy, and vitality of the capillary circulation, is the first and most essential effect which we perceive of the impression of ague or cholera, and that the change produced upon the blood is more probably the secondary effect of the cessation or diminution of those changes which are produced upon it in the capillaries of the lungs, and of the system in health, than in any way attributable to direct influence of the poison on the blood. In the whole class of diseases now under consideration, we shall find evidence of disorder of the sympathetic system in one or more of its vital functions, displayed either in the capillary circulation, the digestive, or in the cerebro-spinal system; but in not one of them is any conclusive evidence to be found of a poison eliminated from the system by the fit, in any way resembling that which is thrown off from the blood in fevers produced by animal poisons of the class exanthemata, nor can we conceive any source of constant and universal irritation to the constitution, such as would result from essentially diseased condition of tlie blood, to be characterized by intermissions, or to be capable of cure by means addressed to the mere interruption of periodicity.

In such a case, on the contrary, we should expect only a continued and persistent action , till the end to be accomplished by the elimination of the poison is attained. Moreover, if it be granted that continued fever is the effect of a constant source of irritation existing in the blood, it would appear to be a corollary to the proposition that intermittent, as opposed to continued reaction, is direct evidence of the absence of a source of irritation in the blood, and produced by means diametrically opposite, which we have fair grounds for concluding to be the absence of that irritability in the very structures which becotn^ excited by a source of irritation existing in the blood in continued fever, or by their natural stimulant in health, viz., distension by the vis a iergo of the heart*

On these grounds, considering simple ague as the type of the whole class of diseases which we are about to study, we shall proceed to examine its symptoms and the indications for treatment.

• The above reflections may serve to suggest the question to physiologists,— whether the circulation of the blood by successive pulsations of the heart instead of by a continuous action, may not be a wise provision of nature to avoid the exhaustion of nervous sensibility in the capillaries by continued impression.

SYMPTOMS AND TREATMENT OF INTERMITTENTS.

Intermittent fever has been generally described as consisting of a cold stage, with shivering; a hot or febrile stage; and a stage of perspiration and relaxation, followed by intermission. This description cannot, however, be received as a definition, because of these stages there is only one that is constant, — viz., periodical return of the cold stage, while the febrile and sweating stages are only the consequences of subsequent reaction and relaxation, and sometimes they are altogether absent. But shivering is by no means an essential to the cold stage; on the contrary, in the most dangerous forms of ague, shivering is often absent, as it is in cholera, because the disturbance of the circulation in the cold stage is such as to overpower this symptom.

Shivering may practically be considered not so much a symptom of the impression of cold on the body in health, or of the cold stage of ague, as an evidence that reaction is taking place in the system, and that the heart possesses the power to overcome the obstruction opposed to its action ; it is, in fact, the first step of the febrile stage, and in the more malignant forms of ague, is the surest harbinger of recovery, and the best evidence of reaction.

In the medical treatment of ague, little is generally attempted in the cold stage beyond giving a stimulant diaphoretic, or in the febrile beyond cooling diluents.

It is customary to trust entirely to the means of prolonging and confirming the intermission by the use of antiperiodic medicines. But this routine method of treatment is not applicable in all agues, for these differ materially in the urgency of their symptoms, according to their various types, and the duration of their period of intermission.

Thus, both in quartan and in tertian ague, febrile reaction generally runs so high as to cause this stage to be most dreaded by the patient, and the congestive stage is of comparatively little moment, being accompanied with shivering almost from the first; but in quotidian the case is very different, the fever, where it exists, being slight and of short duration, and both this and the sweating stages often absent or imperceptible, and the interval between the fits is sometimes so short as to be insufficient to restore natural irritability to the system by repose. The congestive or cold stage is, on the other hand, extremely severe, and such as to endanger the vital m-gans, and even to give lise to the. dread that the attack may prove fatal before it reaches the stage of reaction. In such a case, then, — and such it will appear is cholera, — not fever, but the opposite condition, is to be feared, and all our efforts must be directed to obviate or relieve congestion.

There cannot be a doubt that this is the most essential part of cholera, and the great source of danger in congestive ague; we shall, therefore, devote the remainin? portion of this hn'tiive to the ooii«irlcrfilinn nf the congestive stage in its cause, course, symptoms, and effects, and to the mechanical means of relieving and curing it, whether natural or artificial, reserving what we have to say on the medicinal part of the treatment for a future lecture.

It is customary to date the commencement of a fit of ague from the commencement of shivering, and of cholera from the first purging, but this is an important error, for long before this symptom comes on, a certain shrivelled appearance of the skin maybe observed; the expression of the eyes changes; there is a feeling of malaise and confusion in the head ; the nails look blue and bloodless, and are marked with a red and white streak, and there is a tendency to yawn, and a feeling of oppression about the heart, accompanied with sighing.

The essential part of ague has begun, perhaps, as much as two hours before the shivering occurs ; the blood is gradually forsaking the extremities, and is driven in upon the heart more quickly than it can be sent through the pulmonary circulation, whose capillaries also resist the free transmission of blood; it therefore accumulates in the great veins, so that a great part of that fluid which a short time before was circulating in the extremities, being now rejected by the capillaries, is forced to find room in the venous reservoirs, and great vascular organs of the chest and abdomen, while the arterial system is left comparatively empty.

The consequence of this congested condition of the great veins is the disturbance of the circulation in the thoracic and abdominal viscera, and oppression of the action of the heart. This disturbance of function produces an excitement in the organs themselves (that is, upon and through the sympathetic nerves,) to resist oppression, by increased efforts to preserve life, or what is called reaction. When this effect is felt, the whole frame partakes of the influence, and manifests it by convulsive shivering. The struggle of the powers of life against the disturbed or oppressed action of those organs whose office it is to sustain life continues, till at length the highly-excited powers of the heart and arteries overcome the inertia of the capillary circulation, and the blood once more courses freely through the veins. But this excess of action does not immediately cease with its victory, a period of fever succeeds, till at length, exhausted, the capillary circulation becomes relaxed, perspiration bursts from every pore, the excitement of the heart subsides, and the circulation returns to its natural condition for a time. This period of repose is not, however, permanent; by and by the capillaries again succumb to the effects of renewed impression, the same effects are produced as before, and tbe same struggle ensues. The duration of the cold fit depends upon the susceptibility of the sympa. thetic, to be sooner or later roused to perception of the disturbance of the vital functions which is taking place, and on its ability to excite the organs of circulation to more healthy action, for according to this will the struggle be more or less severe and protracted, and in like manner the severity of the congestion and abridgement of the period of intermission will be in proportion to the power of the impression to produce the paralytic condition of the capillary vessels by its agency on their nerves, till the climax is reached in cholera where intermission is either wanting, and consequently fatal, or very imperfect.