Treatise on cholera asphyxia, or epidemic cholera, as it appeared in Asia, and more recently in Europe. With practical remarks on the disease in Europe, an appendix of cases, and the reports and regulations of the Boards of Health of London and Edinburgh

Front matter

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A. very extraordinary phenomenon has been observed at. Valenciennes, in France, inthe grounds of two bleachers, | which are more than 600 -yards from each other,'the imnen laid out'to whiten has become as red as if it had been dyed | with blood. The water with which the linen was dressed was analysed, and found not to contain the least acid. When the cholera became extinct, this coulour ceased. A chemist ofthe town attributes it to the effect of certain acid exhalations, from whence he supposes the cholera proceeded.

Contents

INTRODUCTORY OBSERVATIONS, : : : een Page: |

Sect. I—NaTURE OF THE DISEASE, : ; : : 3

Names—Varieties—Premonitory Symptoms—Stages —Character of blood drawn during disease—Duration of disease—State of mind during disease—Muscular contractions after death—Anomalies—Post-mortem appearances— Venous congestion—General question of bloodletting—Collapse not necessarily the result of high arterial action, ‘ : . 3-23

Section I. Nature Of The Disease

Ir is of the utmost importance in the outset to counteract, if possible, the false inferences resulting from the inappropriate names which this disease has received.

The epidemic of India has been called Cholera Morbus, Cholera Spasmodica, Cholera Indica, Cho- Iera Epidemica, and, more lately and more appro- _priately, Cholera Asphyxia *.

Of all these appellations, that of Cholera Morbus is the most unfortunate, though perhaps more likely to mislead the student than the practitioner. To the latter, the first case of the disease points out the inapplicability of the name; whereas the student can never get rid of the idea that he is studying a disease which is seated in the abdominal viscera. It will be seen in the sequel, that it is of the utmost consequence to forget that the Indian disease has ever received a name, so likely to interfere with our attaining a correct acquaintance with its nature. |

* Mr Kennedy calls the disease Contagious Cholera. To say nothing of the reasoning on which he has arrived at the conclusion that Cholera is contagious, it is enough to observe, that while so many medical men deny contagion, in the sense in which Mr Kennedy uses it, there is neither courtesy nor propriety in giving the disease a name, which necessarily assumes the eg tion of contagion to be determined.

Cholera Spasmodica is not much more appropriate, as spasms not only occur in the common Cholera Morbus, but are far from being invariably an accompaniment of the Indian epidemic; indeed, it often happens that in the most unmanageable cases there are no spasms

Mr Scott, in the Madras Report on Cholera, has proposed the term Cholera Asphyxia. And though it would be an advantage to get rid of the word Cholera altogether, still it has become too commonly received a name for this disease to admit of our disusing it*. Asphyxia, in its original signification, is particularly appropriate .and distinctive; the disease never continuing for any length of time without. producing a suspension of the pulse. In this treatise, therefore, the name which Mr Scott has proposed for the disease shall be used.

Cholera Asphyxia, as it affects different individuals, and from variety, perhaps as to the state of concentration of its cause, varies so much, as to have induced some practitioners to propose that it should be divided into two species. ‘There can be no doubt that the disease is sometimes much more unmanageable than at others: at such times, every patient seems to be immediately struck with death, and all the efforts of his medical attendants prove unavailing to arrest its fatal progress. This is often found to be the case on

_* Whether we derive Cholera from oan, bile, or from xoras, intestine, it is equally inappropriate to this disease. Bile dues not even appear to be secreted during its progress, and the alimentary discharges are merely symptoms ; but, as has been said in the text, it does not now appear advisable to alter a term which has been so long considered applicable to the disease.

the first breaking out of the disease; and it is remarkable, that as the disease is disappearing, it seems to become milder. ‘The insidious nature of Cholera, to a certain extent, accounts for this ; for persons not aware of the disease, and unprepared for it, are often beyond recovery before they are known to be attacked ; whereas, after the alarm has spread, the first symptoms are watched, and the patient is immediately put under medical treatment. But whether mild or uncontrollable, the symptoms and course of the disease are always so well marked, that there appears no reason to encumber our nomenclature by subdividing it into species. — |

Mr Kennedy, a late writer on Cholera, in order to meet some distinctions which have occurred to Doctors Barry and Russel in the progress of their inquiries in Russia, proposes to add Chronic Chofera to the classification. I see no good reason for this. During the prevalence of Cholera, affections of the chylopoetic organs are common, and these, whether the effect of alarm or of miasma, no doubt predispose to Cholera, just as a debauch or any other debilitating cause predisposes. But a looseness surely has no claim to be considered a chronic type of Cholera. The subsequent fever, which occurs more frequently in Europe than in Asia, is likewise regarded by some as a stage of the disease. This fever, however, appears to me to be rather the natural effect of re-action when the blood is in the unhealthy state to which Cholera reduces it; and I should as soon think of calling an attack of fever, which sometimes follows suspended animation from immersion in water, chokedamp or the like, a stage in the accident, as of class- 2 ing this fever as a stage in the peculiar disease under consideration.

The prominent symptoms of Cholera Asphyxia are very frequently the first intimation to the patient or his friends of the accession of the disease ; so that the pulse may be gone, and many of the peculiar serous evacuations have taken place, before the victim is aware of his having more than a slight indisposition. ‘This insidious disease, like the marsh fevers of Rome, commences so frequently during sleep, that some have been inclined to consider this as one of its peculiarities. | |

There has been naturally much anxiety to discover premonitory symptoms of a disease, which is thus often far advanced to its fatal termination before it is known to exist. But there is no reason to believe that there is any such stage in Cholera Asphyxia ; although no doubt, while Cholera prevails in a city or camp, peculiar feelings of indigestion, loss of appetite, and disordered bowels, are very general. So much indeed is this the case, that “ false alarms” are, at such times, of frequent occurrence. And it would even appear, that there is.a tendency to chylopoetic derangements during the prevalence of Cholera, beyond what may naturally be supposed to result from the dread and horror excited by exposure to the hidden causes of so rapidly fatal a disease, having apparently its seat in the abdomen *.

* I am informed, however, that in Sunderland and Newcastle a diarrhoea of one or more days’ continuance generally precedes an attack of collapse. Such a premonitory symptom cannot but be regarded as fortunate, and ought never to be neglected whereever the disease is prevalent.

NATURE OF THE DISEASE. v

In describing this disease, it may be useful to attend to what may be called four stages :—

1. The invasion of Cholera is so insidious, that the individual attacked may be quite unconscious of the presence of the first stage of it. Very often, indeed, it is only to be detected by those well acquainted with the disease, and by careful observation. Not only in this stage, but throughout the whole course of the disease, the appearance of the countenance is one of the most highly characteristic symptoms. An intimate friend perhaps, observes, that the person attacked has an expression of anxiety, that his complexion is unnaturally earthy, and that his eyes seem sunk in his head. In reply to inquiries, the patient will perhaps deny that he is unwell: he may say, however, that. he is a little deaf; and if minutely questioned, he may admit that he has indescribable sensations of being out of order; that he has oppression at the chest, and is unaccountably depressed and listless : he may have no nausea, but he has tormina of the bowels, and perhaps an uncomfortable sensation of heat at the pit of the stomach: his pulse is quick and weak (I have seen no case in which it had the febrile throb) ; the hands and feet feel cold; the nails are blue, and he has had one or more unnatural alvine discharges. The first of these is generally characteristic; there is a sudden call, and the whole intestines seem to be at once emptied, noe by a feeling of weakness. | Thus, “while the servant (a Hindoo) of Captain H. was bringing in breakfast, his master was struck with his appearance, and asked him what ailed him ? he replied he had nothing to complain of but deafness, Which he ascribed to sleeping in the cold night wind. His master, alarmed at his looks, sent him to the hospital tent (the epidemic was prevailing in the camp to which this gentleman belonged): on minute examination the man was found to have had some suspicious stools, his pulse had sunk, his skin was cold : He had Cholera, and became rapidly worse; and though he was put immediately under treatment, and was a man of good habits, and strong constitution, he had a hard struggle for his life *.” |

It is unfortunate that the first stage of Cholera is to be discovered only by the most experienced eye ; and that even when the patient has a suspicion of his condition, the risk of exposing himself to ridicule, from its being a “ false alarm,” may keep him silent, while the acknowledgment of his fears might have been the means of saving his life. It is to this insidious approach of a malady at all times so mortal, that, in part at least, must be ascribed its being so alarmingly destructive on its first breaking out at an Indian station; patients being extremely apt to allow it to go beyond remedial means before they seck assistance. |

2. In the second stage Cholera is more easily recognised : ‘The pathognomic character of the countenance, to those who have ever seen the disease, is no longer doubtful: the eyes are sunk in the head, the lips are blue, there is a ghastly look about the mouth, and the whole features are shrunk. ‘The patient does not now deny being unwell; he acknowledges having passed some peculiar stools, and probably has had vomiting ; these have been followed by great prostration of strength : there is tinnitus aurium, often slight

* Author’s Case-Book, and many similar instances might be mentioned.

deafness and vertigo ; the pulse is more decidedly affected, it is weak and thready; the skin is cold; there is much thirst, and a burning pain at the pit of the stomach ; but the tongue is not dry—it is moist, white, and cold. When the ratio symptomatum of the disease is under consideration, it will be necessary to take particular notice of the fiuid which is passed from the stomach and bowels; at present it is sufficient to say, that it is not alimentary, or excrementitious ; it is either a homogeneous and almost limpid, or a turbid fluid; or it is like water in which grain has been boiled, with pieces, more or less numerous, of opaque white or yellowish coagulated matter floating in it. The manner in which the discharges take place is characteristic—the desire is sudden, unaccompanied by griping or nausea, and the stomach or bowels are emptied at once, and with some violence : the gastric and intestinal evacuations are nearly similar in their appearance and nature.

3. In the third stage, the sinking of the countenance is still the most prominently characteristic symptom. ‘The eyes, surrounded by a dark circle, are completely sunk in the sockets ; the whole countenance is collapsed; the skin is livid; and the expression is so altered, that the patient’s most intimate friend can hardly recognise him. ‘The surface is now generally covered with a cold sweat, the nails are a pearly blue, and the skin of the hands and feet is corrugated, as if they had been long steeped in water ; the sensibility of the whole surface is deficient, but it is by no means. uncommon for patients to complain of a burning heat in their cold skin. Vesicatories do not act; even boiling water does not raise a blister. If the case be attended with spasms, the suffering of the patient is much ageravated, and is sometimes excruciating. The spasms commence in the hands and feet like cramp; they stretch up the limbs to the trunk, which however they do not always reach. In some cases, again, the muscles of the abdomen are principally affected, and they are drawn towards the spine during the whole course of the disease. ‘These spasms may have commenced early in the disease, being on some occasions the very first symptom. ‘The discharges from the stomach and bowels are at this stage very irregular ; in some cases they are still very frequent, in others, after one or two evacuations, they wholly cease. The pulse at the wrist, if it have not ceased, is scarcely perceptible, and the heart beats feebly. When the spasms are severe, they frequently, even though the pulse be still quite distinct, stop it during the paroxysm,—the same effect is produced by excessive vomiting. The breathing is slow and oppressed: this also sometimes occurs early in the disease ; the voice is low, and but few words can be spoken with one expiration ; the exhaled breath is cold; and though the heat of the body is many degrees below the standard, the patient throws off the bed-clothes, and entreats the bystanders to allow him cool air and cold water. Eliccup is not uncommon, and is rather a favourable than an unfavourable symptom.

4. In the last stage the intestinal evacuations have most likely ceased; the eyes, completely sunk in their orbits, are glazed and flaccid, turned upwards, and half-covered with the eyelids; the spasms are now commonly at an end; the extremities, indeed the whole body, is that of a corpse, and the impression communicated by the skin has been well likened to that of “a damp hide.” Every artery has ceased to pulsate, and the action of the heart, if perceptible, is a mere flutter; the whole body is bathed in a cold and clammy sweat: it is painful to witness the oppression of respiration and jactitation of the sufferer. The dying man can still be roused, but when undisturbed, he generally appears in a state approaching to stupor ; and though perhaps in a humour which might almost be termed sulky, is in most cases coherent to the last.. These symptoms are the immediate forerunners of death.

If blood be drawn during the progress of the dis- — ease, it is found in the outset dark-coloured ; as the case advances, the blood becomes thick, there is a deficiency of serum, it coagulates quickly, and does not assume the buffy coat. In the latter stages of the disease the current in the veins has stopped, and the blood is so grumous that it can scarcely be forced out, in the smallest quantity, through a large orifice.

The whole course of these stages, generally speaking, does not exceed sixteen hours, and, unluckily, the practitioner is seldom called in until the first, and. part of the second, stage have passed. The period consumed by each of the above artificial divisions varies in every case. I have seen instances in which death ensued in less than four hours after the commenecement of the disease; and others, in which its latter stages, with the pulse quite imperceptible, had already lasted a whole day.

The condition of the mind is remarkably collected during the whole progress of this terrible illness; for, though patients, as the malady advances, are unwilling to be disturbed with questions, this appears rather to result from the want of physical energy than from any intellectual failure. Indeed, as the fatal event approaches, the only wish a patient seems to have is’ to be allowed cold water, and to be left to die in peace. It has been well said, that a patient, in the Jast stage of cholera, may be called “a living corpse.”

A curious phenomenon has been several times observed :—After a patient has been some time to all appearance dead, and when the attendants were dressing the corpse, spasmodic twitches have taken place in the limbs, having, in some instances, even extended to the muscles of the body, and general spasmodic contractions have supervened *.

Cases often occur in which one or more of the above detailed symptoms do not appear. ‘There may be no spasms; the vomiting and purging may early cease, or there may have been only one large alvine discharge, followed by a mortal collapse, the patient seeming to be at once struck with death ; and though, on the very first appearance of the disease, he has walked to the Surgeon, his pulse is found to be gone, his heart has ceased to beat, blood can be got only in drops from the veins, he lays down his head, and dies without a complaint.

These anomalies are not eoneedl to individual instances, but are found to occur, as Mr Scott well expresses it, in “ local epidemic visitations.” Thus, he says, ‘ when the disease appears epidemically in a town or district, or in the lines of a corps or the camp of a marching regiment, it may on one occasion be distin-

* This peculiarity has led to some very improper attempts to excite popular clamour, on the risk of being buried alive. After death, from failure in the circulation of the blood, as is the case in cholera, resuscitation is impossible,—insensibility, from sensorial injury, leaves the system in a different condition, as I shall have occasion to show in a subsequent chapter.

guished throughout, by the absence of vomiting, and the prevalence of purging; and on another, by the excess of vomiting, and, thougli more rarely, by the absence of purging. Spasm may be generally present in one instance of invasion ; in another, it may not be distinguishable*.” |

I was on one occasion called upon to send assistance to a district in which the disease was thus described — “ It commences by attacking the sufferer with an agonizing heat in the stomach, vomiting and purging, and lock-jaw; death ensues in two hours, and often more rapidly : it bids defiance to every remedy.” Extract from letter of the Honourable Mr Harris, Principal Collector, Soonda. |

But in all cases in which the disease has established itself, there are the collapsed countenance, blue lips and nails, shrunken fingers, the total failure of the usual secretions, deficient animal heat, suspension of the pulse, and remora in the venous circulation.

Post-Mortem Appearances.—The appearance of the body after death from Cholera Asphyxia, is always peculiar; the whole surface is livid, the countenance collapsed, and the body shrunken, resembling rather the body of a patient who had suffered from a prolonged illness, than that of a victim to a disease of a few hours’ duration. It must be borne in mind; however, that the present description is confined to dissections made on bodies in which death has proceeded azmmedzately from an active attack of the disease, and that organic lesions are not included, which,

* Madras Report, p. 21.

though evidently unconnected with the cause of death, have frequently been particularly noted in descriptions of dissections of the bodies of persons who have died from Cholera.

On opening the abdomen, the first peculiarity which presents itself is the gorged appearance of the veins, and semi-fluid state of the venous blood. The peritoneum and omentum have nothing unnatural in their appearance ; the characteristic colour of the viscera is a light pinky hue, shading to purple; and the veins, wherever they are to be seen, appear loaded with black blood. The floating viscera generally feel more pulpy than usual, as if their coats were thickened ; the solid viscera look purple, or are mottled : the stomach may appear full; in general, however, it is partially. contracted: the small intestines, though full, are not always distended. And I have almost invariably found alternate portions of the great intestines contracted and dilated. ‘The whole canal is sometimes distended with flatus. The mesenteric veins are In a state of great congestion.

On a more minute examination, the contents of the alimentary canal are found to be a muddy fluid, resembling that which has been passed in such quantities, from the stomach and bowels, during the disease: there are no feces, but always more or less flatus. The enteric mucous membrane, particularly at the upper portions of the canal, is often coated with a glary and tenacious matter, which would appear to be an accumulation of the coagulated opaque substance which’is passed with the serous fluid. This is not unfrequently in such quantities, at particular parts of the canal, as almost to fill up the tube: its colour is not. always opaque white; it has been described as a dark grey; and I have seen it of a greenish tinge. It is said to be sometimes bloody These slight variations in the colour of this matter, do not appear to affect the nature of the disease; and from Mr Annesley’s experiments they would appear often to be attributable to admixture with the medicines prescribed ; nor is this matter invariably present. The internal coat of the stomach, and sometimes of a portion of the duodenum, has very generally a peculiar appearance ; there are vascular patches, not of inflammation, but as if vessels had burst, and blood had been extravasated between the coats. _'These spots, though no doubt commonly a congeries of congested veins, do certainly sometimes arise from extravasation. Patches also are described as having the character of inflammation, generally near the pylorus; which are by some considered the result of local irritation, produced by portions of the remedies prescribed having adhered to these parts of the stomach; and they must be taken as a proof that reaction had commenced before death. Worms are very frequently found in the intestinal canal.

Having removed the alimentary canal, venous congestion is still found to be the most remarkable feature of the dissection. The large veins are gorged, and there is nowhere a trace of arterialized blood perceptible : indeed this has been found to be the case during life; for one surgeon attempted in vain to get blood from the brachial artery*. The liver is in most cases dark-coloured, and mottled, being at its dependent parts usually gorged with black blood ;

* Dr Davy on one occasion, in bleeding from the temporal artery, in Cholera, found very little difference between the appearance of arterial and venous blood.

46 NATURE OF THE DISEASF.

but it is said to have been found, in some dissections, perfectly natural in its appearance. ‘The gall-bladder is generally, but not invariably, full of bile. I have always found marks of congestion in the spleen ; but the appearance of this organ seems to be very vaviable. Dr Christie mentions a case in which he found it empty, and, in the dissections made by the Ceylon practitioners, it seems to have been often found smaller than usual. | ee

The urinary bladder is always contracted and empty; the kidneys are healthy, but partake of the character of venous congestion; the substance of the liver, when cut into, is found gorged with black blood, not coagulated, but thicker than usual; the colour of the bile in the gall-bladder is generally green, but I have seen it healthy m appearance; the great veins of the trunk and liver are full of thick impure blood, as are the right auricle and ventricle of the heart. The lungs are black, and in appearance almost of a fleshy structure, and, when cut into, freely give out the same grumous black blood. In some. instances this impure blood is even found in the left side of the heart, and to have reached the aorta; and cases are mentioned in which black blood was found in the carotids.

In the brain there is the same character of venous congestion ; but here there is generally some slight appearance of arterial blood:—there is often found a small quantity of serum in the ventricles, or at the base of the brain. The descriptions which have been given, as if portions of the brain had been in a state of high inflammation, are wholly at, variance with the character of the disease in its course, and seem rather to belong to a disordered state of the circulation than to this disease; except indeed in cases in which death had not proceeded immediately from Cholera, and when reaction had taken place.

Such is generally the condition of the body after death, arising from a pure case of Cholera. It may be remarked, however, that in particular dissections, some of the organs here described as being in a state of congestion, are found not perceptibly different from their healthy condition ; and instances are said to have been met with, in which the whole abdominal viscera presented nothing very peculiar in appearance. In such eases, (none of which have fallen within my experience), the lungs, or encephalon, will no doubt be found highly congested, and the external veins much loaded.

The above description of the disease, and of the appearances on dissection, which are the result of observations made when I was unbiassed by theory or hypothesis, will be found, I am confident, to correspond with the descriptions given by all those who have treated of the disease under similar circumstances. But before attempting to give the ratio symptomatum of Cholera, a sketch of the progress of an actual case of the disease will greatly assist this elucidation. Every one practically acquainted with the disease, must have met with such a case as the following :— |

A patient is brought into the hospital, in what I have called the third stage of the disease: his countenance is sunk; he has vomiting and purging; his skin is cold; his nails are blue; his pulse is scarcely perceptible; his breathing is oppressed, and he has spasms in the extremities. He is immediately placed B in warm blankets; stimulants, including a dose of calomel, are administered; and a vein is opened in each arm, with the largest orifice. At first the blood flows very sluggishly, perhaps it is only procured by kneading the arms, but by-and-by the stream is more free, and as the blood flows it is improved in its colour; the patient feels the greatest relief, the pulse . rises, and the colour of the blood testifies that the lungs are restored to their function. Little else is necessary ; the patient has a second dose of calomel administered to him, is left in a warm bed, and falls asleep. In the course of a few hours a cathartic is prescribed, to remove the colluvies which the restored secretions are pouring into the intestinal canal. It only remains to guard against local congestion and reaction; but it was generally found in India, that, in a case treated as above, there was no such interference with recovery. The suspended functions seemed to be at once restored: the blood was arterialized; the animal heat returned; the excrementitious secretions took place, and the kidneys resumed their function. And it is particularly worthy of notice, that even persons the most ignorant of the doctrine of diseases, who are at all accustomed to see eases of Cholera, are aware that the passing of urine by the patient, is an unerring test that the disease has been overcome.

This summary of a successfully treated case of Cholera is given, not as an anticipation of the observations on the practice (which, of course, belong to a subsequent division of this Work), but because the rationale of treatment is often an important help in our endeavours to understand the nature of a disease.

And what has been said seems fully to warrant the conclusion, that Cholera is, early in its progress, a disease in which the due proportion between venous and arterial blood is destroyed. No stage of the disease has been hitherto discovered, in which venous blood does not preponderate in the system: let it be observed, too, that this is found to be the case so immediately after what must be considered the accession of the disease, that had the venous congestion been the consequence of high action, that stage must have ‘been discovered. For instance, a man in high health and spirits accompanies his companions to bathe; he 4s seized, while in the water, with vomiting and purging, or with spasm, is brought immediately to a surgeon, and is found in what I have called the second stage of the disease. This is not by any means an extraordinary example of the sudden and unlookedfor manner in which this remarkable disease makes its attacks. Or a man goes to bed perfectly well, and is roused at three o’clock in the morning by a call to stool; animal heat has already failed, and in three hours he is dying.

In what to all appearance, therefore, is the very outset of the disease, the animal heat sinks, the action of the heart is lowered, arterial secretion has ceased ; and if death ensue, every vein is found congested, while the arteries are empty. But what is far more valuable in a practical point of view, this position may be illustrated by the effect of the medical treatment: We have a patient suffering under extreme prostration of strength, and the pulse is scarcely perceptible, perhaps is not to be felt; we remove blood, and as it flows the pulse rises, the powers of life return, and if we can sufficiently relieve