« AnteriorContinuar »
disease, but a long one too.” (Sydenham's Works, translated by Dr. Latham. Sydenham Society. Vol. i, pp. 163-4.) This statement is quite in accordance with my own experience, that the effect of astringents, and especially of opiates, in the early stage of epidemic diarrhea, is to prolong the disease, and in the same degree to increase the risk of disaster.
The only period of the disease at which opium can be given with safety and advantage, is after the elimination of the intestinal excreta. It then allays pain and irritation, and often affords great relief and comfort to the patient. Whenever a dose of opium appears speedily to arrest an attack of choleraic diarrhoea, it is because the process of intestinal elimination had been well nigh completed before the dose was given ; whereas, if given earlier, when the bowel contains an abundance of morbid secretions, the opium retards their exit, and so prolongs the disease. Whether an opiate does harm or good, then, will depend upon the period of the disease at which the dose is given. The rule is, not to close the door until “ the enemy” has been expelled.
The cholera poison, whatever may be its nature and source, whether it be "ponderable" or not, is a reality, and no figment of the imagination. And it is as drastic a purgative as any drug in the list of the materia medica. This violent purgative action of the poison is a result, probably, of morbid zymotic changes which it induces in some of the blood-constituents; and, since it is likely that the longer it remains in the system the greater will be the mischief which it occasions, it seems obvious that nothing should be done to prevent the speedy exit of so active and so destructive an agent. Those who, under the influence of an erroneous theory as to the essential cause and nature of collapse, would not dare to give a purgative in cholera, are apparently blind to the fact that the tendency of their opiate treatment is to retain within the system an agent rapidly self-multiplying, and more violently purgative than any ordinary drug. Henceforth, let them bear in mind that so long as the morbid poison remains in the system, there is going on a rapid manufacture of cholera-cathartine, which must and will purge itself away.
Fortunately, in most instances, the purgative action of the poison is sufficient to overcome the astringency of the opium, just as a large dose of elaterium, in combination with opium, would purge itself away. And so choleraic diarrhoea, treated from the first by opium, in the great majority of cases, comes to an end, only somewhat less speedily than it would have done if left alone.
Dr. Handfield Jones asks whether the cholera poison is a thing conceivably capable of being eliminated. And he says that “the malarious
poison, which much resembles choleraic, is not got rid of by any purging.' Now, as to the cholera poison, there is a something thrown out of the body with the morbid excreta which is very generally believed to be poisonous ; and it is considered highly important to disinfect, destroy, and put out of the way these poisonous excreta as speedily as possible, in order to prevent the spread of the disease. And here let me ask, is it possible that these cholera stools can be at once innocuous to the patient while they are retained with his body, and yet a source of danger to others when they are discharged from his bowels? If the cholera excreta are so poisonous that the discharges from a single patient, if allowed to pass into the sewers without previous admixture with disinfectants, may, as is supposed, infect a whole district (See Dr. Wm. Budd's papers in Association Journal. 1854), is it conceivable that they can be artificially retained within the intestines without detriment to the patient? Is there not an inconsis. tency here between the attempt to restrain the evacuations by opiates and astringents and the practice of disinfecting the stools? If the excreta are poisonous, they surely ought to be allowed—nay, assisted—to escape as speedily as po-sible from the patient's bowels. If they are not poisonous, why take the trouble to disinfect them before they pass into the drains ?*
Then, as to the malarious poison, I would ask Dr. Jones what evidence he has that it resembles the cholera poison. I am not aware that we have any knowledge of morbid poisons, except that which we gather from ob. serving their effects upon the functions and structure of the body; and, as the history and symptoms of cholera are certainly very different from those of ague, I should infer that their specific causes are essentially different. Dr. Jones surely will not maintain that the fact of the malarious poison being irremoveable by purging is evidence in favour of the astringent or against the eliminative treatment of cholera. What would Dr. Jones say to this argument ? The malarious poison and the cholera poison much resemble each other. Quinine will not cure cholera : probably, therefore, it is not a cure for ague !
Again, Dr. Jones says that “ the analogy of most other diseases of a
. Surely the advocates for the opiate and astringent treatment of choleraic diarrhæa, in opposition to the eliminative method, must be the legitimate therapeutical descendants of those amongst the cotemporaries of Sydenham, who, on theoretical grounds, so violently opposed that alarming innovation—the admission of cold and fresh air into the chambers of small-pox patients. They thought it essential for the safety of these unhappy patients to close the doors and windows, and thus to surround them with a poisoned atmosphere. Sydenham ventured to admit fresh air, and so to eliminate the poison.
toxic kind would lead us to think that the morbific action is to be counteracted rather by endeavours to prevent its morbid effects, or to strengthen and hold up the vital forces against it, than by any process of elimination." Now, in reply to this statement, I would remark that, in most instances, we have no power to prevent the effects of morbid poisons. How powerless, for instances, we are to arrest the morbid phenomena of small-pox or typhus fever! And, again, in those rare instances in which we have the power to prevent certain effects of morbid poisons, we find that repressive measures are injurious. Take, for instance, the eruption on the skin in the case of scarlatina. By continued exposure of the surface to cold, we can drive in the eruption, and relieve the sensation of heat and tingling; but a very common result would be inflammation of the kidneys and dropsy. Surely the true aim of scientific medicine is to study the phenomena of each disease, with a view to ascertain their nature and origin, and especially to determine the natural process of cure; to be very careful in arguing by analogy from one disease to another; and in all cases to avoid such measures as would tend to repress a natural effort at cure.
This principle, I conceive, would equally forbid the use of cold lotions to the skin in scarlatina, and opiates in choleraic diarrhea. Would Dr. Jones consider it good practice to check the profuse acid perspirations of rheumatic fever by cold, or by other direct repressive means ?
So unwilling is Dr. Jones to admit the principle of elimination, that he endeavours to account for the good effects of purgatives in some cases by supposing that they substitute“ another kind of action, of less pernicious character, for the original;" and he gives what I cannot but consider a most incomprehensive and improbable theory of choleraic collapse, to show that castor-oil may be beneficial as a “ modifier of an irritated state of the intestinal surface.” In confirmation of this view, he states that he lately observed an instance “in which a dose, taken on account of some abdominal uneasiness, removed the symptoms speedily, without acting at all on the bowels." He means, of course, without acting as an aperient. But I venture to suggest that the oil in this case may have relieved the patient by driving some irritating material from the more highly sensitive small intestines into that more torpid receptacle, the large bowel. When castoroil expels offensive and irritating secretions from the bowel, it seems more reasonable to attribute the relief to that kind of elimination, than to any mysterious alterative influence of the oil upon the surface of the intestine. There are some pathologists who, assenting to the doctrine that the natural cure of cholera is effected by the elimination of the morbid excreta, yet maintain that the poison itself is sufficiently emetic and purgative, and that no attempt should be made to increase the discharges by artifi
Now I admit that, so far as regards the excretion from the blood-vessels into the stomach and bowels, no artificial aid is needed. So long as the circulation remains free, this process will be sufficiently active; and when the circulation fails in consequence of the arrest in the lungs, as it does in cases of extreme collapse, no purgative will keep up the excretory process. But the process of elimination may be arrested in what I have before referred to as the third stage, that of intestinal elimination. The morbid secretions may accumulate in the gastro-intestinal canal, or they may be but slowly and incompletely discharged; and then artificial aid may be of real value. Absorption is very active during the stage of reaction after collapse; and then poisonous excreta which have been retained within the bowel may re-enter the circulation and excite mischief. By copious draughts of cold water or other simple diluent drinks, by an occasional emetic, and by some mild but quickly acting purgative, the stomach and bowels may be freed from their poisonous excreta—the gastro-intestinal sewer may be flushed—and this with great advantage to the patient. Castor-oil, as a purgative in these cases, has the advantage of being very quick in its action, and yet it is unirritating, and has very little tendency to increase the drain of liquid from the blood.
It is to be hoped that a more rational pathology of collapse will henceforth lessen the unfounded dread of excessive purging. Death may result of excessive purging in cholera ; but it is a comparatively rare result; and the probable reason in this. When the poison is so abundant
virulent that its excretion would involve a fatal loss of blood-constituents, it so affects the circulation through the lungs that the flood-gates of the pulmonary artery are closed; the excretory process then ceases for want of arterial blood; and death results, not from exhaustion, but from an arrest of the circulation.
I venture to suggest that collateral evidence in favour of an eliminative and against an astringent and repressive treatment of choleraic diarrhea, is deducible from the fact that many practitioners of eminence and repu te finding that the treatment by opium is unsuccessful, have long been accustomed to treat these cases by large doses of mineral acids. They give from half a drachm to a drachm of dilute sulphuric acid in water every half-hour, or even oftener, until three or four doses have been taken ; and they declare that the diarrhea thus dealt with ceases much more speedily than when treated by opiates, or when opiates or aromatics are combined with the acid. Now, those who believe that an astringent is essential for the arrest of a diarrhea, probably consider this to be an astringent method of treatment. But it is an indisputable fact these large doses of mineral acid tend to irritate the bowel, and thus have more of a purgative than
of an astringent action. If any one dispute this proposition, let him, when not suffering from diarrhea, put the matter to the test by taking four half-lrachm doses of dilute sulphuric acid in the course of two hours. He will probably find that these large doses of sulphuric acid act as an unpleasant griping purgative.
Some practitioners are of opinion that the mineral acids act as a chemical antidote to the cholera poison. But, according to Mr. Wakefield's experience before referred to, an alkaline treatment might, with equal reason, be considered antidotal. We know nothing of chemical antidotes for the cholera poison, and probably we never shall.
I am told that there are some weak brethren who are haunted by the fear lest, in treating cholera by purgatives, they be supposed to act upon the homeopathic dogma, similia similibus curantur. If the commonly received theory of collapse were true, there would be some ground for this fear; but I have elsewhere endeavoured to show that mere purging will not give rise to the peculiar and distinctive symptoms of cholera, and that purging is not the disease but the cure. The way, then, to escape the dreaded suspicion of an alliance with homeopathy is to adopt a truly scientific pathology. In conclusion, however, I would warn those who persist in giving opiates and astringents, that a do-nothing system of homeopathic globulism will be more successful than theirs. In other words, Nature weighted with narcotics and astringents will lose the race in competition with Nature not so encumbered.-British Medical Journal.
TREATMENT OF ASIATIC CHOLERA.
By R. M. FORSAYETH, M.D. At a time when a visitation of Asiatic cholera is not unlikely from its proximity in neighbouring countries, unless otherwise ordained by Providence, I feel called upon to offer a few practical remarks upon alcoholic medication in its treatment, and also such statistics as have come within our reach upon that subject, preventive or curative. A prevalent idea occupies the public mind, that some preventive measure, as alteration or change of diet, or medicine is neceessary at such a time. This seems true only in one or two particulars :
1st. If the mode of life or diet is acting detrimentally on the health, a change may prove benificial.
2nd. An early abandonment of habits of intemperance. Any other precautionary changes impressing the mind with the likelihood of an attack act injuriously.
A Russian physician states, “ It is a positive fact that cholera does