ON CERTAIN DOUBTFUL POINTS IN THE PATHOLOGY OF CHOLERA. By F. W. A.
Assistant-Surgeon, There is
an
lieolee
DeFabeck, Irregular Force, and tical Agency.
possible,
us
in the treatment of cholera.
u
llaraotee Toll-
earnest desire abroad in the profession to reach, solution of all the ditliculties which beset
if
true
With
a strong share in this give publicity to the following remarks and suggestions, in the hope that they may receive their full share of criticism, confident that if even they are found to
desire, I have been induced
exert
edge
no
to
practical influence in themselves towards our knowimportant subject, jet that the discussion, which I
of this
ambitious enough to hope they may provoke, will bring us few steps further upon our difficult inquiry. Let this be my apology for the succeeding observations. am
a
That which attracts
our
attention
most
forcibly
on
first
patient suffering from cholera, is the sunken appearance of the face, and the cold clammy skin, shrivelled at
examining
a
the extremities.
There is no doubt that the coldness of the skin
dependent on a deficiency of blood in the capillary vessels, and that the clammy condition is due, not to exosmosis of the watery is
constituents of the blood, but to the lowered temperature of the itself, which, in condensing the quondam vapory exhalations from the follicles, now converts into visible
surface
sudoriparous
that
was
previously invisible transpiration.
The shrunken
I^biittaey 1, 1869.]
THE
OF CHOLERA.?BY E. ~W. A. DeEABECK.
PATHOLOGY
appearance of the face, and , in general, of all parts of the surface, supported by any considerable thickness of the cellular layer,
together
with the shrivelled appearance cf the skin of the extremities, sufficiently proves that the watery particles conin these situations health have passed into the
*J""ed
during
circulation by
the process of endosmosis. we examine into the state of the Patients who die from this disease, we find
aie
tl'e
ernPty, (2) the smaller
larger ones,
venous
circulatory system of (1) that the capillaries trunks moderately full,but (3)
they approach the heart,
as
more
or
less distended
Av'th dark, thickened blood. The condition of the pulmonary surface presents a marked similarity to the appearances just
,note'l. Dr. Goodeve, in the 1st volume of Reynolds' System of ^'edicino" (p. 168), has given such an admirable account of these "
aPPenrances in the lungs, as "inke no apology for quoting
observed
Dr.
by
it in full.
Parkes, that I previously
"It was
supposed that the lu ngs and heart
were gorged with blood, hut (Dr. Parkes) pointed out accurately what was the precise S'tuation of the congestion. He showed that the gorged part3 Were the vessels of the right side of the heart and the pulmonary artery, in the roots of the lungs, from the ri-rht side of the heart to the smaller branches ; and that the smaller vessels, the
lie
Pulmonary the
heart,
capillaries, the pulmonary veins, nearly empty : in fact, that the capillaries of the lungs as in
were
Wrested in '"it in the arteries short of them.
bleeding
111
the Por
the present,
:
more
condition of the
Johnson,
parts of the body also.
Let us imagine a column heart, circulating through
leaving the left sido of the capillaries and venous system in the natural way, traversing tho right side of the heart, entering the pulmonary artery, and there meeting with an unusually constricted channel. A portion of this stream forces its way through into tho capillaries and pulmonary veins, but the remainder is thrown hack upon the heart. From this state deficiency of blood on the arterial plethora
of things, there results
the venous side of the circulatory system. This pressure the latter, however, is not sufficiently great to overcome the obstructions of tho valves in the veins with the spasmodic conon
on
supposed
On scction there
asphyxia, was
free
lungs, but there was little or none they were generally ex-sanguine."
I defer examination into the state of the
this disease, in which the blood is not arrested in the To what or smaller veins, l>ut in the smaller arteries.
as
well
become empty, because the deficient, and because the
place
in the veins is
tion it meets.
Hence
we
able balance of the elastic and muscular force which regulates tlie flow of blood through the arteries, and assists its progress similar arrangement, we know, exists, to a minor extent, in the veins, but the walls of the capillaries forming the peripheral connexion, between the arteria land venous systems have neither of these ??wanls
clastic
or
through
the
contractile
capillaries.
A
precisely
properties.
Dr. George Johnson has advanced the theory that, as far as the lungs are concerned, the obstructed condition of the arterial branches is due to spasm of the muscular fibres entering iuto the composition of their parietes ; but while this theory appears to explain, better than any hitheito suggested, the Pathological conditions of the thoracic viscera, and .sonic of the
general symptoms of cholera, it does for all the peculiarities of this disease.
Post-mortem
not
examination shows that the
sufficiently
account
peripheral
circula-
is in a similar tion all over the body (excluding the abdomen) condition to that observed in the lungs; and if a certain mechanical cause be admitted as explanatory of this state in one situation, it will be applicable to nil. Anatomical c%i-
necessarily
endosmosis of all the serous
have, because of the deficient arterial circulation, diminished
absence of all the usual
buted to the larger trunks, while they are abundantly dispersed over the walls of the smaller branches ; and that inversely the proportional strength of the elastic tissue decreases, according t? its distance from the centre of circulation. It is this admir-
have
for cold skin, with clammy transudation, sinking and shrinking of certain portions of it, and, associated with these conditions,
We know that the arterial walls throughout t'>e system are niainly composed of elastic tissue, whose action is purely niechanical, and in harmony with all the established laws of
plemented by
we
derived from the tissues which surround the capillaries, both in the lungs and over the surface of the body generally ; accounting, in the first situation, for dyspnoea, cold breath, partial aphonia, and anxiety of countenance ; and, in the other,
particles
pulse.
further know that this elastic tissue is supmuscular fibres, which are hut sparingly distri-
to have attacked the venous
The capillaries, therefore, supply of blood from the arteries is regurgitant action which docs take not strong enough to overcome th 5 obstruc-
as
is this obstruction in the smaller arteries due ?
We
tho
the arterial.
I shall presently have occasion to show that the condition of the circulation there presents marked differences from that which now forms the subject of our investigation. Let us pause and examine this phenomenon, peculiar, as I
elasticity.
of blood
dition which is now
common
explanatory
thoracic circulation, is applicable to other
branches
not
abdominal organs, as
believe, to capillaries,
and the capillaries empty. Now, if an obstruction than usual, to the reflux of the pent-up blood in tho larger veins, did not exist, we should have full capillaries, exosmosis from their walls, and all the well-known consequences of obstructed venous circulation : appearances, in fact, directly the reverse of those peculiar to this disease. Now, let us see if the theory suggested by Dr. as of the
distended,
the blood
from the roots of the
peripheral parts
dence, and conclusions logically drawn from certain reinarkablo symptoms, establish this fact, that the large venous trunks aro
and the left side of was
33'
That a similar lesion exists in the head, is evidenced by There is remarked
as
an
symptoms of cerebral effusion. a phenomenon peculiar to cholera, constantly occurring in fatal cases of that disorder, not observed
in any other disease. I allude to the elevation of temperature, the fillover the surface, which occurs shortly after death, and ing up of parts previously shrunken. By no theory, hitherto is this strange condition to be so satisfactorily With death, the spasmodic condition of the arteries becomes relaxed, and the warm arterial blood now flows into the empty capillaries ; and these, resuming their
maintained,
accounted for.
peacefully properties, permit of serous tissue in which they ars embedded.
natural
exosmosis into the cellular
We hare now seen that this supposed spasmodic state of the' muscular fibres of the smaller arteries and veins is abundantly sullicient to account for the phenomena observed in all parts of the bedy except the abdominal cavity and its contained viscera ; wo shall now endeavour to ascertain how far a similar con-
and
dition may
explain
morbid appearances in these.
Let
us
first
examine the very urgent symptoms which occur in the stomach and intestines, and compare them with the post-mortem appearThe symptoms arc ances usually observed in these situations. vomiting and purging of fluid matter, which, whether ejected bv the oral or anal apperture, bears pretty much tho same characteristics in both cases. The post-mortem appearances are, of the stomach an cedcmatous condition of the mucous membrane nnd intestines, sometimes associated with considerable venous which occasionally proceeds to actual rupture of
hvpercemia,
THE INDIAN MEDICAL GAZETTE.
34 the coats of the
capillaries
and smaller
veins, causing partial
ccchvmosis. The first thing that strikes us here is the complete antithesis of these symptoms to those which we have just been considering. Let us now, therefore, enquire how the state of arterial obstruction, caused by spasm of the muscular fibres of the blood vessels, may harmonise with this obviously opposite condition. Allusion has already been made to the observations of Dr. Parkes,
quoted by Dr. Goodeve, cholera, irrespective within the larger venous
that the
venous congestion which exists of the abdominal viscera, is localised trunks as they approach the heart. With regard to the condition of the abdominal veins, however, we learn that " the larger hepatic veins, and the branches of the por-
in
tal vein, generally those leading from the stomach, duodenum, and small intestines, and their small ramification, are full, both on the mucous and peritoneal surface of these organs. Now, when it is recollected that the hepatic veins are the first branches of the inferior vena-cava, counting backwards from the heart, that
they
rcceive the full
weight
of the accumulated fluid within the
upper portion of the vena-cava, and that, moreover, these veins have uo valves, it can readily be understood that a pressure which was not sufficient to overcome more potent obstacles met with in the veins, situated at a greater distance from the centre
of
here be strong
regurgitation, might
enough
to
repel
the weaker obstacles in its way, and thus throw back tlip venous blood upon the hepatic veins. Simultaneously with this condition, there is a deficient supply of arterial blood traversing the hepatic artery, by roason of the pre-supposcd
spasmodically contracted state of its walls; and hence, with regurgitant hepatic blood from the hepatic vein, and obstructed arterial supply from the hepatic artery, the whole circulation of the liver is obviously brought to a standstill. Under such a state of things, it is nothing but natural that we should find the portal circulation entirely obstructed, and all the venous branches belonging to this system (none of which are furnished with valves) gorged in the highest degree. At the same time, arterial blood, although in diminished quantity, continues to
[February 1, 1869.
produced by excitation from within. Moreover, it is reasonable to conclude that the ducts both of the liver and kidneys the are closed by the same obstructive cause3 which act upon
be
As regards the liver, it is found, after death from cholera, that the normal secretion of this organ, for though undoubtedly diminished, is not totally arrested, the gall-bladder is generally observed to be full. Microscopic examination of the substance of the liver in such cases has funcrevealed to indicate the existence of
circulatory system.
suppressed
nothing
The obstruction, therefore, must lie in the ductus communis choledochus ; and as there is no other cause to be assigned for this obstruction, we must conclude that it is due to
tion.
spasmodic contraction of its walls. The same condition, doubtless, obtains in the urinary organs. The ureters are closed by spasmodic contraction, the excretion of the kidneys is thrown
.
back upon itself, and this state of matters accounts fully f?r the morbid appearances we observe, and for the remarkable
symptom of ischuria presented in this disease.
present
Now, it the primary
cause of cholera is, as our of its nature induces us to assume it is, some that toxic agent which finds its way into the blood, we argue either (1) this materies morbi has the peculiar property, when, taken into the circulation from of stimulating the
limited
knowledge
without,
of nerves to an unusual degree, and that such stimulation results in obstructive phenomena in the cir-
sympathetic system
culatory system in the viscera both of the thorax and abdomen, and ultimately culminates in the train of symptoms so peculiar to this disease ;
or (2) there may be some peculiar conditions, electric, in the atmosphere, .during cholera which have the property of either directly causing this irritable state of the sympathetic ganglia, or of so affecting
magnetic epidemics,
or
of the normal constituents of the blood from
within, that produce the conditions we have been considering. This leads me to point out the insufficiency of Dr Johnson's partial theory, which assumes a spasmodic condition of the pulmonary
some
these
arterial branches alone.
In both of the above conclusions, the
flow into the capillaries of the stomachal and intestinal walls ; but it is there arrested by the stasis within the branches of the mesenteric and gastric veins, and profuse exosmosis of serous
morbid matter is supposed to find its way into the circulation ; and if so, there can be no reason whatever why it should alone
fluid is the natural result, accounting fully for the post-mortem appearances above noted, and for the rice-water evacuations
that the
which
are
equally expelled by
the stomach and intestines.
affect the
pulmonary arterial sympathetic ganglia
branches ; and if it be
supposed
and that morbid matter admitted into the circulation, it 13 difficult to conceive that such an affection should be limited
there is
are
primarily affected,
no
the uervous filaments which
supply
the
pulmonary arterial
We have now, if the theory hero advanced be admitted to agree, more than any other hitherto prevailing, with all the facts,
to
symptomatic and pathological, observed in cholera, to extend our investigations, and discover, if possible, a remoter cause for the abnormities which that theory assumes. A condition of spasm of any portion of the muscular apparatus within the body naturally suggests one of exalted excitability of the nervous centres supplying it ; and as, in this case, the irregularity of
That the series of phenomena which have formed the subject of our investigation cannot possibly be due to depression, or paralysis of the sympathetic nerves, as is supposed by some, is evident from the following considerations :?
muscular action lies in the fibres distributed over the channels of circulation, we infer that the cause lies in the sympathetic system of nerves, the arterial branches of which are inde-
pendent of wanting to of organic
the
cerebrospinal
centres.
Nor
lead to the conclusion that the nervous
supply
arc
more
or
are
other indications
ganglionic
centres
less under the influence
unusual excitement. The whole of the alimentary tract, from the stomach to the rectum, is thrown into violent activity,
of
obviously not the result of irritation from without, acrid discharges exuded into their cavities, (for these exhibit no characteristics indicative of such acridity),* it must
and as this is
through
One of the uses of bile is ita stimulating property, by virtue of its acridity, upon the intestinal mucous membrane ; and it is well known that, diminution of this discharge, the intestines become sluggish, and coustipatiou is the result. *
under
branches.
no proof that secretion is suppressed from want force, but much to show that this condition, if existing at all, is due to deficiency of the circulating fluid from which that secretion is derived. Moreover, there is no
1.
of
There is
nervous
proof that secretion is suppressed. On the contrary, the pathological anatomy of this disease informs us that secretion is not arrested, though impaired, but that the discharge of t-ecreted matter
is obstructed in the ducts.
above that the peculiar appearances seen post-mortem examination in the circulatory system must be due to a spasmodic condition of the vascular channel. Paralysis of the sympathetic would, on the contrary, produce a relaxed state of the arterial and venous walls, and we should have, as above indicated, gorged capillaries and exosmosis into the cellular tissue of the body, resulting in general 2.
We
observed
anasarca.
on
have
THE PATHOLOGY OP CHOLEKA.?BY F. "W. A. DeEABECK.
February 1, 1869.] 3-
I admit that the existence of
painful cramps, which are patients suffering from cholera,
generally observed
to attack proof of the presence of a similar condition in muscular issues supplied by the sympathetic ; but although these cramps OWe their origin undoubtedly to sensory-motor influences, the no
existence of which
have every reason to connect with the
we
operation of the morbific matter to which all the other changes ln the system are attributed, yet it is much more probable that such an excited state of one division of the nervous system should be reciprocated by the other, than that this latter should Assume a state of paralysis. These muscular spasms, therefore, of which the patient is sensible, constitute a strong a fortiori argument in favor of the existence of similar spasmodic actions ln
situations where, from their physiological characters, they insensible.* The following considerations may tend to strengthen this view :? are
a?
?A
is one of the urgent symptoms of cholera. condition of the production of vomiting is obstruc-
Vomiting,
necessary
tion of some kind at the pylorus. In this disease, there can be no other cause for such obstruction than spasmodic contraction of the muscular fibres of the lower third of the stomach. b.
The pain and uneasiness felt in the epigastric and precordial regions can only, as far as I know, be satisfactorily accounted for
of the stomach, diaspasmodic by and associated muscular structures making itself felt
phragm,
the
state
in this way. c.
The intestinal canal is almost
nervous were
entirely dependent sympathetic. If this nervous supply as it would be in paralysis, we should have the suppressed discharge of bile, above adverted to, powerful causes to produce a state of constipation.
supply arrested,
this, and acting as
for its
on
the
Thus then there is nothing to show that the peristaltic action of the intestines is, in any way, impaired ; and if it be granted that there is no positive proof to indicate that that action is
exalted,
of
which,
I
establish that it is not 4.
Lastly,
if
sympathetic system of nerves, injury or impairment of function of this system, under other conditions, could produce results similar to those observed in cholera, which, it is well known, is very far from being the case. There are many points in the consideration of this important subject, which, for want of sufficient collection of verified facts, we must necessarily leave to conjecture. We sadly need carefully conducted enquiries regarding post-mortem appearances after death, before the reflux of blood into its produced that increase of temperature
natural channels has
after death, and especially with regard to the condition of the blood-vessels and glandular ducts ; also results of experimental stimulation in animals, of the whole of
generally noticed shortly
the sympathetic system, and also of suppression in its function. I do not wish to say much regarding treatment, while the theory of the pathology of cholera here advanced is yet so
conjectural suggests 1.
;
are
it is
enough
the following
In the earlier stages of the disorder, before the characteristic flux from the stomach and intestines has set in, remedies may be admitted to the stomach ; but it must be borne in mind that there is one class of drugs which is useful in the first stage, positively poisonous in the reactionary stage of cholera ; and another which is useful in both. The first class must be
exposed
to the action of the stomach with great caution, since, if any portion of them lie in the stomach when collapse iias once set in, there is much danger of their remaining inert, until the first effort at reaction causes their absorption with detriment to recovery. Of this nature are narcotics and diffusible stimuli. The other class may be administered with freedom, because, the period of their inactive retention in the stomach
after
during collapse, they are presented for absorption at the very instant when reaction sets in, and thus act beneficially at the precise moment of commencing recovery. Of this nature are calomel and other allied medicines.* The state of the dermal
to
remark that the indications it
:?
capillaries permits
of
applications
the skin, with the hope of their absorption ; and with this view, mercurial inunctions, fluid preparations of opium in the to
earlier stage, with or without chloroform, and perhaps quinine, may be of use. The surface, however, which gives us the
greatest promise of speedy absorption of remedies applied to it, is the pulmonary mucous membrane; and I believe that made in this direction would lead to beneficial results. Of the advantage of chloroform inhalations, we have already had some proof; but much remains to be tried in the exhibition of other remedies in this form, princi-
experiments carefully most
mercurial vapor.
I have
spoken so much in in my own practice, I have had reason to bo well satisfied with their efficacy?an pally, perhaps,
experience which
much,
as
the
To soothe the nervous system after the excitement under laboured, and to ensure healthy reaction.
at any period during health. with a paralyzed were associated
there is
condition of the
immediately
3.
flow, ami to restore kidneys, stomach, and intestines.
which it has
favor of mercurial
free
cholera
allow the blood to resume its normal
proper secretions of liver,
there is none to
believe, as
to
35
preparations, because,
is borne out by that of many of my professional brethren, both in this country and at home. Of these,
of course, calomel holds the chief place. It is difficult to conceive a remedy more likely to be of use in this disease Dr. Christison states,
"
an irritant, sedative, cathartic, diuretic, diastimulant, antiphlogistic phoretic, cholagogue, sialagogue, and alterative." Latterly, the application of ice to the spine has been much extolled by European practitioners. I have no personal experience of this mode of treatment, although I am disposed to think that, bo as an adjunct to other remedies, already mentioned, it may useful. In closing one of his lectures on tetanus, Dr. Watson Dr. Todd has suggested to mo tho application of observes, ice to the spine?a measure which he has found eminently beneficial in convulsions. This mode of employing cold as a remedy in tetanus seems well worthy of trial. It would have the advantage of not inflicting any shock which might excite or disturb the reflex function of the cord through its incident
than
one
which is at once,
as
or
"
nerves."
To promote elimination of the morbific matter from the
body. To release the state of spasmodic contraction of the channels of circulation, and of the biliary and venal ducts, so as 2.
*
It is a question whether the cramps usually complained of in cholera 'Day not be induced secondarily by reason of diminished supply of blood we know certain forms to the cerebro-spinal centres?a cause from which information is needed. disease arise : on this
spasmodic
point
* Although tho act of absorption is generally in abeyance during tho first interrup. period of collapse, it is not necessarily completely so from its however brief, tion until the moment of reaction. There may be periods, action may during which the balance between healthy and disordered
which there is no waver, when fluttering efforts towards recovery, of external indication, may occur; and no doubt, at such moments, remedios " absorbed. It is, I partially lying ready in the stomach may become " to assume the possibility of some think well," says Dr. Morehead,
degree of absorption."
Assistant-Surgeon, There is
an
lieolee
DeFabeck, Irregular Force, and tical Agency.
possible,
us
in the treatment of cholera.
u
llaraotee Toll-
earnest desire abroad in the profession to reach, solution of all the ditliculties which beset
if
true
With
a strong share in this give publicity to the following remarks and suggestions, in the hope that they may receive their full share of criticism, confident that if even they are found to
desire, I have been induced
exert
edge
no
to
practical influence in themselves towards our knowimportant subject, jet that the discussion, which I
of this
ambitious enough to hope they may provoke, will bring us few steps further upon our difficult inquiry. Let this be my apology for the succeeding observations. am
a
That which attracts
our
attention
most
forcibly
on
first
patient suffering from cholera, is the sunken appearance of the face, and the cold clammy skin, shrivelled at
examining
a
the extremities.
There is no doubt that the coldness of the skin
dependent on a deficiency of blood in the capillary vessels, and that the clammy condition is due, not to exosmosis of the watery is
constituents of the blood, but to the lowered temperature of the itself, which, in condensing the quondam vapory exhalations from the follicles, now converts into visible
surface
sudoriparous
that
was
previously invisible transpiration.
The shrunken
I^biittaey 1, 1869.]
THE
OF CHOLERA.?BY E. ~W. A. DeEABECK.
PATHOLOGY
appearance of the face, and , in general, of all parts of the surface, supported by any considerable thickness of the cellular layer,
together
with the shrivelled appearance cf the skin of the extremities, sufficiently proves that the watery particles conin these situations health have passed into the
*J""ed
during
circulation by
the process of endosmosis. we examine into the state of the Patients who die from this disease, we find
aie
tl'e
ernPty, (2) the smaller
larger ones,
venous
circulatory system of (1) that the capillaries trunks moderately full,but (3)
they approach the heart,
as
more
or
less distended
Av'th dark, thickened blood. The condition of the pulmonary surface presents a marked similarity to the appearances just
,note'l. Dr. Goodeve, in the 1st volume of Reynolds' System of ^'edicino" (p. 168), has given such an admirable account of these "
aPPenrances in the lungs, as "inke no apology for quoting
observed
Dr.
by
it in full.
Parkes, that I previously
"It was
supposed that the lu ngs and heart
were gorged with blood, hut (Dr. Parkes) pointed out accurately what was the precise S'tuation of the congestion. He showed that the gorged part3 Were the vessels of the right side of the heart and the pulmonary artery, in the roots of the lungs, from the ri-rht side of the heart to the smaller branches ; and that the smaller vessels, the
lie
Pulmonary the
heart,
capillaries, the pulmonary veins, nearly empty : in fact, that the capillaries of the lungs as in
were
Wrested in '"it in the arteries short of them.
bleeding
111
the Por
the present,
:
more
condition of the
Johnson,
parts of the body also.
Let us imagine a column heart, circulating through
leaving the left sido of the capillaries and venous system in the natural way, traversing tho right side of the heart, entering the pulmonary artery, and there meeting with an unusually constricted channel. A portion of this stream forces its way through into tho capillaries and pulmonary veins, but the remainder is thrown hack upon the heart. From this state deficiency of blood on the arterial plethora
of things, there results
the venous side of the circulatory system. This pressure the latter, however, is not sufficiently great to overcome the obstructions of tho valves in the veins with the spasmodic conon
on
supposed
On scction there
asphyxia, was
free
lungs, but there was little or none they were generally ex-sanguine."
I defer examination into the state of the
this disease, in which the blood is not arrested in the To what or smaller veins, l>ut in the smaller arteries.
as
well
become empty, because the deficient, and because the
place
in the veins is
tion it meets.
Hence
we
able balance of the elastic and muscular force which regulates tlie flow of blood through the arteries, and assists its progress similar arrangement, we know, exists, to a minor extent, in the veins, but the walls of the capillaries forming the peripheral connexion, between the arteria land venous systems have neither of these ??wanls
clastic
or
through
the
contractile
capillaries.
A
precisely
properties.
Dr. George Johnson has advanced the theory that, as far as the lungs are concerned, the obstructed condition of the arterial branches is due to spasm of the muscular fibres entering iuto the composition of their parietes ; but while this theory appears to explain, better than any hitheito suggested, the Pathological conditions of the thoracic viscera, and .sonic of the
general symptoms of cholera, it does for all the peculiarities of this disease.
Post-mortem
not
examination shows that the
sufficiently
account
peripheral
circula-
is in a similar tion all over the body (excluding the abdomen) condition to that observed in the lungs; and if a certain mechanical cause be admitted as explanatory of this state in one situation, it will be applicable to nil. Anatomical c%i-
necessarily
endosmosis of all the serous
have, because of the deficient arterial circulation, diminished
absence of all the usual
buted to the larger trunks, while they are abundantly dispersed over the walls of the smaller branches ; and that inversely the proportional strength of the elastic tissue decreases, according t? its distance from the centre of circulation. It is this admir-
have
for cold skin, with clammy transudation, sinking and shrinking of certain portions of it, and, associated with these conditions,
We know that the arterial walls throughout t'>e system are niainly composed of elastic tissue, whose action is purely niechanical, and in harmony with all the established laws of
plemented by
we
derived from the tissues which surround the capillaries, both in the lungs and over the surface of the body generally ; accounting, in the first situation, for dyspnoea, cold breath, partial aphonia, and anxiety of countenance ; and, in the other,
particles
pulse.
further know that this elastic tissue is supmuscular fibres, which are hut sparingly distri-
to have attacked the venous
The capillaries, therefore, supply of blood from the arteries is regurgitant action which docs take not strong enough to overcome th 5 obstruc-
as
is this obstruction in the smaller arteries due ?
We
tho
the arterial.
I shall presently have occasion to show that the condition of the circulation there presents marked differences from that which now forms the subject of our investigation. Let us pause and examine this phenomenon, peculiar, as I
elasticity.
of blood
dition which is now
common
explanatory
thoracic circulation, is applicable to other
branches
not
abdominal organs, as
believe, to capillaries,
and the capillaries empty. Now, if an obstruction than usual, to the reflux of the pent-up blood in tho larger veins, did not exist, we should have full capillaries, exosmosis from their walls, and all the well-known consequences of obstructed venous circulation : appearances, in fact, directly the reverse of those peculiar to this disease. Now, let us see if the theory suggested by Dr. as of the
distended,
the blood
from the roots of the
peripheral parts
dence, and conclusions logically drawn from certain reinarkablo symptoms, establish this fact, that the large venous trunks aro
and the left side of was
33'
That a similar lesion exists in the head, is evidenced by There is remarked
as
an
symptoms of cerebral effusion. a phenomenon peculiar to cholera, constantly occurring in fatal cases of that disorder, not observed
in any other disease. I allude to the elevation of temperature, the fillover the surface, which occurs shortly after death, and ing up of parts previously shrunken. By no theory, hitherto is this strange condition to be so satisfactorily With death, the spasmodic condition of the arteries becomes relaxed, and the warm arterial blood now flows into the empty capillaries ; and these, resuming their
maintained,
accounted for.
peacefully properties, permit of serous tissue in which they ars embedded.
natural
exosmosis into the cellular
We hare now seen that this supposed spasmodic state of the' muscular fibres of the smaller arteries and veins is abundantly sullicient to account for the phenomena observed in all parts of the bedy except the abdominal cavity and its contained viscera ; wo shall now endeavour to ascertain how far a similar con-
and
dition may
explain
morbid appearances in these.
Let
us
first
examine the very urgent symptoms which occur in the stomach and intestines, and compare them with the post-mortem appearThe symptoms arc ances usually observed in these situations. vomiting and purging of fluid matter, which, whether ejected bv the oral or anal apperture, bears pretty much tho same characteristics in both cases. The post-mortem appearances are, of the stomach an cedcmatous condition of the mucous membrane nnd intestines, sometimes associated with considerable venous which occasionally proceeds to actual rupture of
hvpercemia,
THE INDIAN MEDICAL GAZETTE.
34 the coats of the
capillaries
and smaller
veins, causing partial
ccchvmosis. The first thing that strikes us here is the complete antithesis of these symptoms to those which we have just been considering. Let us now, therefore, enquire how the state of arterial obstruction, caused by spasm of the muscular fibres of the blood vessels, may harmonise with this obviously opposite condition. Allusion has already been made to the observations of Dr. Parkes,
quoted by Dr. Goodeve, cholera, irrespective within the larger venous
that the
venous congestion which exists of the abdominal viscera, is localised trunks as they approach the heart. With regard to the condition of the abdominal veins, however, we learn that " the larger hepatic veins, and the branches of the por-
in
tal vein, generally those leading from the stomach, duodenum, and small intestines, and their small ramification, are full, both on the mucous and peritoneal surface of these organs. Now, when it is recollected that the hepatic veins are the first branches of the inferior vena-cava, counting backwards from the heart, that
they
rcceive the full
weight
of the accumulated fluid within the
upper portion of the vena-cava, and that, moreover, these veins have uo valves, it can readily be understood that a pressure which was not sufficient to overcome more potent obstacles met with in the veins, situated at a greater distance from the centre
of
here be strong
regurgitation, might
enough
to
repel
the weaker obstacles in its way, and thus throw back tlip venous blood upon the hepatic veins. Simultaneously with this condition, there is a deficient supply of arterial blood traversing the hepatic artery, by roason of the pre-supposcd
spasmodically contracted state of its walls; and hence, with regurgitant hepatic blood from the hepatic vein, and obstructed arterial supply from the hepatic artery, the whole circulation of the liver is obviously brought to a standstill. Under such a state of things, it is nothing but natural that we should find the portal circulation entirely obstructed, and all the venous branches belonging to this system (none of which are furnished with valves) gorged in the highest degree. At the same time, arterial blood, although in diminished quantity, continues to
[February 1, 1869.
produced by excitation from within. Moreover, it is reasonable to conclude that the ducts both of the liver and kidneys the are closed by the same obstructive cause3 which act upon
be
As regards the liver, it is found, after death from cholera, that the normal secretion of this organ, for though undoubtedly diminished, is not totally arrested, the gall-bladder is generally observed to be full. Microscopic examination of the substance of the liver in such cases has funcrevealed to indicate the existence of
circulatory system.
suppressed
nothing
The obstruction, therefore, must lie in the ductus communis choledochus ; and as there is no other cause to be assigned for this obstruction, we must conclude that it is due to
tion.
spasmodic contraction of its walls. The same condition, doubtless, obtains in the urinary organs. The ureters are closed by spasmodic contraction, the excretion of the kidneys is thrown
.
back upon itself, and this state of matters accounts fully f?r the morbid appearances we observe, and for the remarkable
symptom of ischuria presented in this disease.
present
Now, it the primary
cause of cholera is, as our of its nature induces us to assume it is, some that toxic agent which finds its way into the blood, we argue either (1) this materies morbi has the peculiar property, when, taken into the circulation from of stimulating the
limited
knowledge
without,
of nerves to an unusual degree, and that such stimulation results in obstructive phenomena in the cir-
sympathetic system
culatory system in the viscera both of the thorax and abdomen, and ultimately culminates in the train of symptoms so peculiar to this disease ;
or (2) there may be some peculiar conditions, electric, in the atmosphere, .during cholera which have the property of either directly causing this irritable state of the sympathetic ganglia, or of so affecting
magnetic epidemics,
or
of the normal constituents of the blood from
within, that produce the conditions we have been considering. This leads me to point out the insufficiency of Dr Johnson's partial theory, which assumes a spasmodic condition of the pulmonary
some
these
arterial branches alone.
In both of the above conclusions, the
flow into the capillaries of the stomachal and intestinal walls ; but it is there arrested by the stasis within the branches of the mesenteric and gastric veins, and profuse exosmosis of serous
morbid matter is supposed to find its way into the circulation ; and if so, there can be no reason whatever why it should alone
fluid is the natural result, accounting fully for the post-mortem appearances above noted, and for the rice-water evacuations
that the
which
are
equally expelled by
the stomach and intestines.
affect the
pulmonary arterial sympathetic ganglia
branches ; and if it be
supposed
and that morbid matter admitted into the circulation, it 13 difficult to conceive that such an affection should be limited
there is
are
primarily affected,
no
the uervous filaments which
supply
the
pulmonary arterial
We have now, if the theory hero advanced be admitted to agree, more than any other hitherto prevailing, with all the facts,
to
symptomatic and pathological, observed in cholera, to extend our investigations, and discover, if possible, a remoter cause for the abnormities which that theory assumes. A condition of spasm of any portion of the muscular apparatus within the body naturally suggests one of exalted excitability of the nervous centres supplying it ; and as, in this case, the irregularity of
That the series of phenomena which have formed the subject of our investigation cannot possibly be due to depression, or paralysis of the sympathetic nerves, as is supposed by some, is evident from the following considerations :?
muscular action lies in the fibres distributed over the channels of circulation, we infer that the cause lies in the sympathetic system of nerves, the arterial branches of which are inde-
pendent of wanting to of organic
the
cerebrospinal
centres.
Nor
lead to the conclusion that the nervous
supply
arc
more
or
are
other indications
ganglionic
centres
less under the influence
unusual excitement. The whole of the alimentary tract, from the stomach to the rectum, is thrown into violent activity,
of
obviously not the result of irritation from without, acrid discharges exuded into their cavities, (for these exhibit no characteristics indicative of such acridity),* it must
and as this is
through
One of the uses of bile is ita stimulating property, by virtue of its acridity, upon the intestinal mucous membrane ; and it is well known that, diminution of this discharge, the intestines become sluggish, and coustipatiou is the result. *
under
branches.
no proof that secretion is suppressed from want force, but much to show that this condition, if existing at all, is due to deficiency of the circulating fluid from which that secretion is derived. Moreover, there is no
1.
of
There is
nervous
proof that secretion is suppressed. On the contrary, the pathological anatomy of this disease informs us that secretion is not arrested, though impaired, but that the discharge of t-ecreted matter
is obstructed in the ducts.
above that the peculiar appearances seen post-mortem examination in the circulatory system must be due to a spasmodic condition of the vascular channel. Paralysis of the sympathetic would, on the contrary, produce a relaxed state of the arterial and venous walls, and we should have, as above indicated, gorged capillaries and exosmosis into the cellular tissue of the body, resulting in general 2.
We
observed
anasarca.
on
have
THE PATHOLOGY OP CHOLEKA.?BY F. "W. A. DeEABECK.
February 1, 1869.] 3-
I admit that the existence of
painful cramps, which are patients suffering from cholera,
generally observed
to attack proof of the presence of a similar condition in muscular issues supplied by the sympathetic ; but although these cramps OWe their origin undoubtedly to sensory-motor influences, the no
existence of which
have every reason to connect with the
we
operation of the morbific matter to which all the other changes ln the system are attributed, yet it is much more probable that such an excited state of one division of the nervous system should be reciprocated by the other, than that this latter should Assume a state of paralysis. These muscular spasms, therefore, of which the patient is sensible, constitute a strong a fortiori argument in favor of the existence of similar spasmodic actions ln
situations where, from their physiological characters, they insensible.* The following considerations may tend to strengthen this view :? are
a?
?A
is one of the urgent symptoms of cholera. condition of the production of vomiting is obstruc-
Vomiting,
necessary
tion of some kind at the pylorus. In this disease, there can be no other cause for such obstruction than spasmodic contraction of the muscular fibres of the lower third of the stomach. b.
The pain and uneasiness felt in the epigastric and precordial regions can only, as far as I know, be satisfactorily accounted for
of the stomach, diaspasmodic by and associated muscular structures making itself felt
phragm,
the
state
in this way. c.
The intestinal canal is almost
nervous were
entirely dependent sympathetic. If this nervous supply as it would be in paralysis, we should have the suppressed discharge of bile, above adverted to, powerful causes to produce a state of constipation.
supply arrested,
this, and acting as
for its
on
the
Thus then there is nothing to show that the peristaltic action of the intestines is, in any way, impaired ; and if it be granted that there is no positive proof to indicate that that action is
exalted,
of
which,
I
establish that it is not 4.
Lastly,
if
sympathetic system of nerves, injury or impairment of function of this system, under other conditions, could produce results similar to those observed in cholera, which, it is well known, is very far from being the case. There are many points in the consideration of this important subject, which, for want of sufficient collection of verified facts, we must necessarily leave to conjecture. We sadly need carefully conducted enquiries regarding post-mortem appearances after death, before the reflux of blood into its produced that increase of temperature
natural channels has
after death, and especially with regard to the condition of the blood-vessels and glandular ducts ; also results of experimental stimulation in animals, of the whole of
generally noticed shortly
the sympathetic system, and also of suppression in its function. I do not wish to say much regarding treatment, while the theory of the pathology of cholera here advanced is yet so
conjectural suggests 1.
;
are
it is
enough
the following
In the earlier stages of the disorder, before the characteristic flux from the stomach and intestines has set in, remedies may be admitted to the stomach ; but it must be borne in mind that there is one class of drugs which is useful in the first stage, positively poisonous in the reactionary stage of cholera ; and another which is useful in both. The first class must be
exposed
to the action of the stomach with great caution, since, if any portion of them lie in the stomach when collapse iias once set in, there is much danger of their remaining inert, until the first effort at reaction causes their absorption with detriment to recovery. Of this nature are narcotics and diffusible stimuli. The other class may be administered with freedom, because, the period of their inactive retention in the stomach
after
during collapse, they are presented for absorption at the very instant when reaction sets in, and thus act beneficially at the precise moment of commencing recovery. Of this nature are calomel and other allied medicines.* The state of the dermal
to
remark that the indications it
:?
capillaries permits
of
applications
the skin, with the hope of their absorption ; and with this view, mercurial inunctions, fluid preparations of opium in the to
earlier stage, with or without chloroform, and perhaps quinine, may be of use. The surface, however, which gives us the
greatest promise of speedy absorption of remedies applied to it, is the pulmonary mucous membrane; and I believe that made in this direction would lead to beneficial results. Of the advantage of chloroform inhalations, we have already had some proof; but much remains to be tried in the exhibition of other remedies in this form, princi-
experiments carefully most
mercurial vapor.
I have
spoken so much in in my own practice, I have had reason to bo well satisfied with their efficacy?an pally, perhaps,
experience which
much,
as
the
To soothe the nervous system after the excitement under laboured, and to ensure healthy reaction.
at any period during health. with a paralyzed were associated
there is
condition of the
immediately
3.
flow, ami to restore kidneys, stomach, and intestines.
which it has
favor of mercurial
free
cholera
allow the blood to resume its normal
proper secretions of liver,
there is none to
believe, as
to
35
preparations, because,
is borne out by that of many of my professional brethren, both in this country and at home. Of these,
of course, calomel holds the chief place. It is difficult to conceive a remedy more likely to be of use in this disease Dr. Christison states,
"
an irritant, sedative, cathartic, diuretic, diastimulant, antiphlogistic phoretic, cholagogue, sialagogue, and alterative." Latterly, the application of ice to the spine has been much extolled by European practitioners. I have no personal experience of this mode of treatment, although I am disposed to think that, bo as an adjunct to other remedies, already mentioned, it may useful. In closing one of his lectures on tetanus, Dr. Watson Dr. Todd has suggested to mo tho application of observes, ice to the spine?a measure which he has found eminently beneficial in convulsions. This mode of employing cold as a remedy in tetanus seems well worthy of trial. It would have the advantage of not inflicting any shock which might excite or disturb the reflex function of the cord through its incident
than
one
which is at once,
as
or
"
nerves."
To promote elimination of the morbific matter from the
body. To release the state of spasmodic contraction of the channels of circulation, and of the biliary and venal ducts, so as 2.
*
It is a question whether the cramps usually complained of in cholera 'Day not be induced secondarily by reason of diminished supply of blood we know certain forms to the cerebro-spinal centres?a cause from which information is needed. disease arise : on this
spasmodic
point
* Although tho act of absorption is generally in abeyance during tho first interrup. period of collapse, it is not necessarily completely so from its however brief, tion until the moment of reaction. There may be periods, action may during which the balance between healthy and disordered
which there is no waver, when fluttering efforts towards recovery, of external indication, may occur; and no doubt, at such moments, remedios " absorbed. It is, I partially lying ready in the stomach may become " to assume the possibility of some think well," says Dr. Morehead,
degree of absorption."
