Section Ii.--Physiological Condition of the Blood.

ITS NON-AERATION--NON-OXYDATION.

In the preceding section we alluded to the suggestions and doctrines advanced by the learned Dr. C. W. Bell, Physician to the Manchester Infirmary, and late Physician to H. M. Embassy in Persia--and also to Dr. George Johnson, of Kings College, whose views and doctrines, relative to the Pathology, illustrative of the congestive character and non-aeration of the blood, coincide with those of Dr. Bell. A brief examination of their philosophy and doctrines will show very conclusively the first direct impression of the poison--the gradually altered condition of the blood, and the corresponding loss of nerve power--the impeded arterial circulation and the general tendency to congestion, as well as the altered condition and stagnation of the blood, especially during the stage of collapse.

The question is asked, "What is the pathological explanation of this remarkable train of symptoms?" and the answer is given, "The one great central fact is this, that during the stage of collapse, the passage of blood through the lungs, from the right to the left side of the heart, is in a greater or less degree impeded." Very conclusive evidence as to the existence of impeded pulmonary circulation during life is afforded by the appearances observed in the heart, blood-vessels, and lungs after death.

After adducing the evidence of this impediment from post-mortem examinations, and affirming that the blood does not flow freely through the lungs and pulmonary arteries, which are often filled and much distended with blood, it is observed--"The most interesting and conclusive evidence that arrest of blood in the lungs is the true key to the pathology of choleraic collapse, is to be found in the simple yet complete explanation which it affords of all the most striking chemical phenomena of the disease, the imperfect aeration of the blood, and the suppression of bile and urine."

And again, says the learned author, "It is obvious that the stream of blood from the pulmonary capillaries to the left side of the heart is the channel by which the supply of oxygen is introduced into the system. One necessary consequence, then, of a great diminution in the volume of blood transmitted to the left side of the heart must be, that the supply of oxygen is lessened in a corresponding degree. This position, probably, will not be disputed by any one who will give the subject a moment's consideration. Nor, again, can it be denied or doubted that certain results must of necessity follow this limited supply of oxygen." * * *

"The blood in cholera is black and thick only during the stage of collapse; in other words, during the stage of pulmonary obstruction and defective aeration."

Again, in his explanation of the injection of the solution of soda into the veins of the suffering patient, it is affirmed, "The benefit, however, is of but short duration, for the primary cause of the impeded circulation, namely, the poisoned condition of the blood, being still in operation, * * * the stream of blood through the lungs will soon again be obstructed, and the patient thus passes into a state of collapse as profound as, and more hopeless than, before. It appears, therefore, that the hot saline injection into the veins and the operation of venesection, when it rapidly relieves, as it often has done, the symptoms of collapse, have this effect in common, that they facilitate the passage of the blood through the lungs, and thus lessen that embarrassment of the pulmonary circulation which is the essential cause of choleraic collapse. But whereas the hot injections act by removing the impediment which results from spasmodic contraction of the arteries; venesection acts by relieving over-distension of the right cavities of the heart, and thus increasing the contractile power of their walls."

Such are, in brief, the views of the learned Drs. Johnson and Bell, whose works are very highly commended by their American editor to the notice of the profession. These views, coming as they do from the highest authority, fully sustain the doctrine that the earliest impression of the disease is made upon the blood, and hence it becomes altered and changed in its most essential life-sustaining principle; for its oxygen becomes diminished, its consistency augmented, and its flow through the lungs impeded. Through this channel the effect of the poison soon makes an impression on the ganglionic mechanism, and the nerve-power becomes correspondingly diminished, and the action of the ganglionic nerves essentially deranged. But this is not all: they exhibit in the clearest manner the congestive character of the disease, and show the necessity of prompt and decided means to arrest this tendency. Hence, they urge, in the strongest terms, the importance of observing carefully this essential feature, and endeavor to exhibit fully the condition of this vital fluid at a particular stage of the disease, when bleeding, as recommended in their practice, is required, and may be performed to the best advantage for the relief of the partially congested blood-vessels, and to stimulate and give freedom to the circulation. The passage of the blood, they affirm, is impeded, clogged, and partially suspended. To remove this obstruction, relieve spasm, and secure the prompt aeration of the blood, in hope of arresting the progress of this disease, is ostensibly the object. However, they seem studiously to avoid the most logical conclusions of their explanations, and justify a practice that can give no hope of permanent relief, while every fact and symptom is ominously suggestive of the wants of the system, which imperiously demands the aid of electrified oxygen, ozone, or free caloric, for the oxydation of the blood.

Says Dr. Reid, "I believe the true explanation of the arrest of blood in the lungs to be this: The blood contains a poison, whose irritant action upon the muscular tissue is shown by the painful cramps which it occasions. The blood thus poisoned excites contraction of the muscular walls of the minute pulmonary arteries, the effect of which is to diminish, and, in fatal cases, entirely to arrest the flow of blood through the lungs."

Says Dr. Wallis, "The phenomena which are exhibited when the deleterious air has been drawn into the lungs are these: the great gastro-pulmonary nerve is either wholly or partially paralyzed; the consequences are the cessation of all its functions, either wholly or partially. This great nerve is a nerve of function, and performs the functions of digestion and respiration, and influences all secretions."

Dr. Maxwell, of Calcutta, uses the following language: "The development of the stages of fever entirely depends on the changes the leaven has effected. If this change has been such that the blood has become too thick to flow through the lungs, then, as a matter of course, the collapse stage is developed in excess; in other words, cholera asphyxia is exhibited. The blood, unable to pass through the middle passage into the arteries, collects and swells out the veins, giving that deadly or blue color to the skin. When the vomiting and spasms come on, this mass of blood in the veins is squeezed with great force, and hence the clammy moisture that is forced from every part during these fits. There is no pulse, because there is no blood in the arteries." "There are also lethargy and languor, and oppression in breathing, caused by the blood being collected in the veins. These make up the principal links in the chain of mechanical symptoms."

Dr. Bell, dwelling on this congestive character of the blood, and endeavoring to point out the best mode of relief, observes, "When this has reached to such a point as to oppress the action of the heart, yawning first and then shivering, or a sense of suffocation and pain in the precordia, are the indications of oppressed circulation, and of the commencing effort of the heart to overcome the mass of blood which is stifling it. If, by the application of tourniquets to the limbs, or by bleeding, part of the blood which is rushing from the extremities to increase this congestion is prevented from reaching the great veins, the heart, excited to increased action, is enabled, by this relief, more quickly to overcome the obstruction and restore the balance of the circulation, and the paroxysm passes off. If not thus mechanically aided, the heart, after a severe struggle to maintain the circulation during the period of constriction, is at length relieved by this nervous disturbance or spasm of the capillary circulation passing off of itself, and then the heart and arteries, so long excited by the struggle, maintain for a time their increased action after the obstruction in the capillaries is removed, and produce apparent febrile action. Presently this excitement subsides, the vessels become relaxed, and sweat succeeds. The vessels continue in this state for a longer or shorter period, according to circumstances, till they at length recover their ordinary tone and action in the intermission. This fever, however, is not fever properly so called, but reaction; and the sweating not critical, or essential, but relaxation. The cold stage is alone essential, and is the physiological cause of the subsequent stages."

From the passages we have cited, it is quite evident that Drs. Johnson, Bell, Parkes, Reid, Wallis, Maxwell, Massy, and many others, admit this congestive character and impeded circulation of the blood to be the result, or consequent of a primary affection of the blood, as we have already observed in a former paper. The term "Algide" is peculiarly expressive of the diminished animal heat, and, as Dr. Bell represents, it is the cold stage which is alone essential, and is the physiological cause of the subsequent stages. It is the specific disease-poison, so often referred to, that has been inhaled, the leaven that has effected such obvious changes in the blood. The poison, virulent, and subtle, and unknown, so marvelously active in its operations, that is exhibited so prominently in all the works we have perused as the one great, mysterious, and efficient cause which produces the disease called cholera, and all the phenomena of its development. To its direct and specific action, therefore, must be attributed all the phenomena of the disease as the resulting subsequent consequences.

It is also further evident, from the pathological facts and arguments adduced in support of this theory of congestion, that the abnormal condition or state of the blood-vessels is the result and the product of the activity of the primary or final cause, and must be regarded in relation to it as cause and effect. On this principle alone, the thickening of the blood, the contraction of the left ventricle of the heart, and of the capillary and pulmonary arteries, assigned by some as the cause of choleraic collapse, must be accounted for. These effects are not and cannot be from a process independent and outside of the primary disease action, but are the result of such primary action.

Again, it is evident, from the views and doctrines cited above, that the disease is decidedly congestive in its tendency and character from its very commencement. The impeded flow of the blood--the comparative emptiness of the left ventricle of the heart and arteries--and the excessive loss of temperature, all indicate a rapid process of congestion attending the progress of disease. This is one of the peculiar and prominent features of cholera, and is strikingly exhibited in the morbid appearances observed in all those instances where death has occurred within a few minutes from the first indications of attack.

When the attack is violent, the process is rapid; when mild, it is slow; and even in the collapse stage progresses tardily. In either case it is the direct resulting consequent of the primary cause. How else can the violent attacks, suddenly terminating in death, be accounted for? To what other principle can this altered condition and stagnation of the blood be attributed? The evidence confirmatory of this position is abundant and conclusive. Many instances of the apparently rapid action of the cholera poison are related by Dr. Milroy, in a historical sketch of the epidemic of 1817; and at Kurrachee in 1855 and 6, it is said, that within little more than five minutes, hale and hearty men are seized, cramped, collapsed, and dead!!

When the disease broke out at Teheran, in May, 1846, Dr. Milroy states that those who were attacked dropped suddenly down in a state of lethargy, and at the end of two or three hours expired, without any convulsions or vomitings, but from a complete stagnation of the blood.

In the paper before us, it is stated, that "in a great majority of cases in which death has occurred during the stage of collapse, the right side of the heart and the pulmonary arteries are filled, and sometimes distended with blood; the auricle being partially, and the ventricle completely and firmly contracted. The tissue of the lungs is, in most cases, of pale color, dense in texture, and contains less than the usual amount of blood and air. There is something surprising in the contrast between the almost constant occurrence of this extremely anæmic condition of the lung, from which scarcely even a few drops of blood flow when the tissue is cut, and the hyperæmia of most of the other viscera." This impeded flow of the blood through the lungs, resulting, as it must, in a very scanty supply of blood to the arteries, in connection with the corresponding fact of the increased expansion of the veins, filled with black, and thick, and stagnant blood which, by the action of a powerful poison, or malignant disease, has become disorganized and unfitted for circulation, furnishes indubitable evidence of one prominent and characteristic feature of cholera which we term congestion, and to which we alluded in our remarks when the question under consideration was first introduced; in this view we are happy to find ourselves, on a more thorough examination of the subject, ably sustained by eminent pathologists and authors, who have arisen during the half century last past, and whose works are said to embrace all that is known and reliable on the character and treatment of Epidemic Cholera.

It is worthy of notice, before passing from this part of our subject, that according to Dr. Bell's views, the blood is forcibly sent into the great central veins, and there stopped in its course without any attempt to account satisfactorily for its singular arrest, at that point--Dr. Johnson comes to his relief, lifts the veil, and explains why it is kept there and cannot get any further. If the road, he tells us, had been clear and uninterrupted through the lungs, the blood would easily have got round to the left ventricle, and have again gone its round, but it is stopped by the spasmodic contraction of the minute branches of the pulmonary artery, which will not even allow the blood to enter the pulmonary capillaries, as shown by the remarkable anæmia of the texture of the lungs.

In this connection may be introduced an opinion as to the cause of the disease and some of its phenomena, which has obtained at least some celebrity, and attracted the attention, if not the careful consideration of the profession. It will account, in part, if founded in fact, for the physiological condition under consideration.

It is said, some have observed a chemical change in the constitution of the atmosphere, and have attributed the cause of the cholera to the loss or diminution of its ozone--a principle which is understood to represent what is very properly termed electrified oxygen. Ozone is, therefore, the vital element of the air. It is said that oxygen cannot be assimilated or combined with the blood except when it is in an electrified state constituting the peculiar property or state of ozone. In this state it produces vital electricity of the blood, which is the life. The brain is considered and represented as the reservoir of this vital electricity, and the nerves are the telegraphic wires or conductors of it. As a necessary consequence, all acts of material and intellectual life depend upon this double cause. The absence, then, it is affirmed, of this principle, termed ozone--or electrified oxygen--from the atmospheric air in certain localities and the consequent non-aeration or non-oxydation of the blood, may be considered as an efficient cause which will account for some of the most striking phenomena of the cholera.

Whether this electrified oxygen, or ozone, is identical with free caloric, it is unnecessary for our purpose at present to determine. It will be admitted that oxygen is the source of animal heat, and when introduced into the system generates its free caloric, which is an essential life-sustaining principle.

Dr. Massy, after describing a severe and advanced stage of cholera, observes, "The treatment of this case depends in the first instance on bleeding, and largely, if the patient's pulse is good, giving at the same time twenty grains of calomel with one of opium. This, he thinks, will be found the best practice. After twenty minutes, he gives ten grains more of calomel and half a grain of opium. He considers, however, a reliance on opium in this form of cholera most faulty--but observes, as you draw blood, stimulate, give punch, brandy, or wine and water, or carbonate of ammonia. Apply friction, with stimulating and hot liniments to the extremities, warm sand-bags to the feet, sinapisms to the calves of the legs and pit of the stomach; for, if you can once raise the pulse, the chances in favor of recovery will be vastly increased." The practice of bleeding and stimulating at the same time is deemed of vast importance. Dr. Bell coincides in this view, and devotes much space to the necessary instruction as to the time when and under what circumstances to bleed and to what extent, endeavoring to show the advantages arising from a strict observance of certain rules in carrying out this practice.

We have thus traced, in extenso, the views and doctrines of eminent surgeons and authors on the changes of the blood, and especially of the impeded circulation, to show, if practicable, the inconsistency of the more common and prevailing practice, and its utter inadaptation to the pathology and phenomena of disease. On the latter there seems to be little or no discrepancy--on the former there is a great diversity--as there has been no general principle established and laid down as the basis of treatment and cure of cholera. It has often been observed there is no disease on which so many different modes of practice have prevailed, some purely experimental, others empirical--and all without discovering an antidote to the poison, or any efficient mode of relief. The cause, or the poison producing the disease, still remains undiscovered. The direct mode of suspending and removing it, or counteracting its power and neutralizing its effect, and subsequently eliminating it from the system, remains still in doubt. What course, then, should the epidemic cholera again prevail in our midst, shall we pursue? Shall we rest satisfied with the diversified modes of treatment now prevailing? Or guided by the light of reason, science and experience, endeavor to adopt a general principle of practice, and exhibit and establish an efficient and judicious system, consistent with the pathology and the phenomena of the disease? Does then the practice, the prominent features of which are given above, accord with the indications required? In short, does the exhibition of bleeding and calomel and opium, accompanied with sinapisms, and hot, stimulating applications to the surface, meet the pathological condition and the phenomena of the disease? We have seen that the rapid changes in the blood, and the consequent direct tendency to congestion, are the proper and distinguishing features of the disease;--and hence the diminution of animal heat and general loss of temperature and their consequent effect, impeding the circulation, depressing and prostrating the nervous power--impairing and paralyzing the respiratory organs--suspending the functions of the liver and kidneys--enfeebling the action of the heart, and causing the capillary vessels of the mucous surfaces to pour off the serous fluid from the blood, and every muscle and tissue of the system with great rapidity, essentially constitute the phenomena of the cholera;--and that the constantly increasing augmentation of the poison and its intensified effects, measure the malignity, the violence, and the rapidity of the disease. Is there, then, any tendency in bleeding to arrest this rapid process of disease so disorganizing, depreciating, and enfeebling to the vital life-sustaining fluid, the blood? Can abstracting a portion of it, however large, suspend the poison, or its activity, or even check its progress in its rapid course and fatal termination? Can it have, under its depressing and depleting process, any tendency or power to relieve the congestion that is taking place, or change in any good degree the poisonous principle which is now generally admitted to exist in the blood, and to be the sole and efficient cause of its altered character and condition? The poison, once introduced into the blood, like the leaven hid in three measures of meal, will continue its activity, increasing its energy, and multiplying its forces, till the whole circulation becomes affected, and its life-sustaining power is destroyed and utterly lost, unless, by the exhibition of some remedial agent, it shall be promptly arrested in its progress, and suspended and eliminated. Again we ask, Will calomel fulfill any of the indications required? Has it any influence or power to arrest this disease, to quiet the nervous system, relieve the cramps, or restore warmth to the body? Its specific action, so far as known, can have no tendency whatever to relieve the system in any essential particular, or stay the progress of disease, or delay its inevitable result, if it remain unsubdued by the action of other remedies. Its action upon the liver, however prompt it may be, is only of a secondary importance. The primary cause must be overcome, its activity and energy suspended and the system generally relieved, or there is little hope in the case.

Here we may ask, Will opium aid, or give the relief so urgently demanded? However serviceable as an astringent and anodyne in the premonitory stage of the disease, it cannot be exhibited in the second stage to so good an advantage, as its direct influence is to aid and promote congestion in those cases, where a tendency of this kind is already in existence. Hence, its continuance in the true or collapse stage of cholera is now generally considered faulty.

Once more: The auxiliaries employed in aid of the leading remedies already noticed may be summed up in the language of the celebrated Dr. Massy, in his instructions and directions on the subject of the treatment now under consideration. He observes, "But, as you draw blood, stimulate, give punch, brandy, or wine and water, or carbonate of ammonia. Apply friction, with stimulating and hot liniments to the extremities; warm sand-bags to the feet, sinapisms to the calves of the legs and pit of the stomach; for, if you can once raise the pulse, the chances in favor of recovery will be vastly increased."

To these directions there can be no special objections, except in the first instance in which he, indirectly, commends the use of means tending to deplete and depress the system, already brought by disease to the very verge of utter exhaustion. Remedies of this tendency are contra-indicated, and cannot, to say the least, be employed to advantage.

Depressing remedies generally, instead of checking, or counteracting the disease, will inevitably aid and hasten its fatal termination. Stimulants, such as are prompt and diffusive in their character, must be regarded as essential, and may be employed to great advantage. It will be found, however, exceedingly difficult in most cases, even where there is no depletion from bleeding, to keep up the waning powers, and carry the patient, through this formidable disease, to a favorable termination. Of the utility of warm applications to the surface generally, there can be no question; yet, our main reliance is on internal remedies, as has been already shown: the lost temperature of the body must be restored, the production and diffusion of heat, or caloric, must be internal through the administration of remedies, that will promptly and kindly produce this result.

What are, then, the remedies? We have ventured in this discussion to recommend the internal use of chloroform, and believe it will be found in combination with other prompt and diffusive stimulants, specially adapted to meet this condition. In this recommendation, we feel ourselves fully sustained by the result of various experiments heretofore made, and the recent trials of its use, as an internal remedy in the various stages of the disease.

The earliest record of the use of chloroform in cholera is probably to be found in the London Lancet for November, 1848, in which Dr. Hill reports a case of its successful use by inhalation. He placed the patient in bed, covered with warm blankets, and applied friction, stimulant liniments, and heated bags of bran to the surface, and kept the patient under the gentle influence of chloroform, till the more urgent symptoms entirely subsided. At intervals brandy-and-water, and thin arrow-root or milk was given. All other medicines were avoided. Though the urgent symptoms returned at first, as the effects of the chloroform passed off, they were easily controlled by the repetition of the inhalation. By persevering in its use, reaction set in, and the patient became convalescent.

Other cases, afterwards, were treated in the same way, with a similar result. Some, however, required the gentle use of chloroform by inhalation, at intervals, for twenty-four hours; after which, none seems to have been administered. For aught that appears these cases all recovered.

Another very interesting case is related by Mr. Brady, who observes that an elderly lady was seized with slight diarrhoea, which, on the following morning, had become very profuse: excessive vomiting supervened, accompanied by spasms in the calves of the legs, fingers and toes. Under these urgent symptoms, the usual remedy, brandy, was administered without avail; the dejections became incessant, and the spasms increased in intensity, presenting the features of a decided case of malignant cholera. In this condition, the physician was called in haste, as it was believed and affirmed the patient was dying. In describing this case, the physician observes: "On my arrival, I found the patient presenting all the symptoms of malignant Asiatic cholera, in an advanced stage; the features collapsed and ghastly; extremities and tongue cold; burning sensation in the stomach and oesophagus; pulse rapid and scarcely perceptible; voice diminished to a whisper; stomach exceedingly irritable, and the dejections from the bowels presenting the characteristic rice-water appearance; and all the voluntary muscles of the body were affected by spasm, so that the patient actually writhed in agony." Ordered the following: Rx. Chloroform dram j; Ol. Terebinth. ounce j; aq. Dist. dram iij. M. And gave immediately a large tea-spoonful, in a wine-glass, of dilute brandy; and applied sinapisms to the calves of the legs and abdominal and thoracic surfaces. Thirst was relieved by drinking plentifully of water nearly cold. Though the stomach was irritable, the chloroform was retained, as well as the fluid drank after it, and was followed by no dejection. Half an hour after, two pills were administered, composed according to the following: Rx. Calomel gr. v; fellis. bov. inspis. gr. x; Ft. Pil. ij. Half an hour after these were given, vomiting ensued, but soon subsided; the diarrhoea had apparently ceased; the cramps had diminished in frequency and severity. A second dose of chloroform, now one hour after the first, was administered, and soon after this two more of the pills, both of which were retained, and gave decided relief. The pulse rose in power and became slower, the spasms less frequent, and, in an hour after the second dose, the patient was bathed from head to foot in a warm perspiration, and expressed herself comparatively free from all uneasy sensations. The attack had been completely subdued, leaving behind a good deal of pyrexia and debility, from which she rapidly recovered.

Here it is worthy of notice, that in this case, severe as it was, only two doses of the chloroform mixture were administered, each containing about six minims of chloroform and forty of turpentine; the pills would naturally tend to perpetuate rather than relieve the nausea and vomiting, and in one hour after the administration of the second dose, all the urgent symptoms were assuaged.

In another case, the attending physician reports that, after giving calomel, combined with opium, which was immediately rejected, the following mixture was ordered: Rx. Chloroform vj minims; brandy dram iij; water ounce iijss, one-third of which was given immediately, and was thrown up in half an hour; a second dose was then given, and was retained. The vomiting and diarrhoea ceased; the spasms became less severe. In two hours after, gave the remaining third part; and during the next six hours, administered in two doses six minims more of the chloroform, with the most decided benefit, and the patient soon became convalescent. To the extreme tenderness over the region of the epigastrium flannel soaked in spirits of turpentine was applied; and as no urine was secreted, I am firmly of the opinion that the usual remedies would not have met this case. "I candidly confess," says the physician, "I had no hope of success from its severity; and, but for a knowledge of Mr. Brady's case, I believe I should have lost my patient."

Dr. Davies reports a case in which he used chloroform fifteen hours after the seizure with relief, but not with success, and observes that, in a number of cases occurring in the hospital, there were 22 cases in which, as severe symptoms came on, the chief remedy was chloroform, administered internally, in doses of from seven to ten minims every hour, half hour, or quarter of an hour, according to the severity of the symptoms. Of these 22 cases, 8 terminated fatally, and 14 recovered.

Again: "Out of 9 cases of cholera, and 13 of the worst cases of diarrhoea occurring in my own practice, and treated with chloroform, one died. All these were in the better ranks of life. In some of them, the warm bath (salt water) was used as an auxiliary, and the diet consisted of nothing but cold milk and water, with some carbonate of soda, ad libitum. The fatal case was that of a drunkard, who, probably, did not take the remedy. These cases varied in severity, from sickness and diarrhoea, and mild collapse, to sickness, diarrhoea, severe cramps, and great collapse, with almost clear watery evacuations, passing away involuntarily * * * Of 14 cases of cholera treated by Mr. Towers, Medical Resident of the Infirmary, many of them under my own observation, one died. The fatal case was that of a woman aged 63, who was previously suffering great depression, consequent on extreme destitution."

Again, says Dr. Davies, "It will probably be remembered that, in my second report, I expressed a very favorable opinion of chloroform in this deadly malady. I considered I had strong grounds for so doing, after observing the large proportion of cases which recovered under its administration. From the history of this last visitation in the county prison, however, the fact turns out, that, under some uncertain circumstances, the use of chloroform will not prevent the proportion of deaths being considerable. I have reason to believe that it was, from over-anxiety, given in too frequent doses in some cases, and that it thus rather added to the coma, which is one of the characteristics of the malady.

At the commencement of the outbreak, the doses were repeated every hour, or every two hours, and it is to be noted that the first seven cases recovered.

As the cases multiplied, the remedy was given every half hour, and, in some instances, every quarter of an hour; the result was that the next six cases died. Whether these cases had anything in them inherently more fatal, it is difficult to tell. The symptoms at first were about equal, and the differences did not show themselves until towards the end. There was next a recovery of seven cases in succession; in these the remedy was administered less frequently, but subsequently two deaths occurred under the less frequent administration.

The chloroform was administered also by inhalation, in some of the more severe cases of cramps, with the effect of affording relief in every instance. The inhalation was not carried so far as to produce insensibility. Although I am still of the opinion that chloroform properly regulated is the remedy of all others hitherto tried to be depended on, yet it cannot be considered a specific for cholera."

Mr. Steadman reports a very interesting case treated by chloroform. He observes, "The spasms were universal and extremely violent, as if knots were being tied in the bowels, countenance livid and cold, voice feeble, and all medicines rejected. In this condition gave chloroform combined with 'aquæ vitæ' and distilled water. The first dose had a partial but most satisfactory effect. In two hours after, as the symptoms manifested a disposition to return, gave a second dose, which entirely controlled all spasms, vomiting and purging. The patient was ordered cold rice and mucilaginous drinks, and had the chalk mixture with nitric ether prescribed. A dose of oxgall (gr. x) was given in course of the day, which produced the desired effect. In two days the patient was declared convalescent." The daughter, who had nursed the mother in this case, was seized soon after in a similar manner, except the dejections were more abundant and frequent. The mother having some of the chloroform mixture left, gave it to the daughter without advice or hesitancy, and obtained the same magic results. The first dose was only partial in its effect, but the second completely subdued the disease.

Such are the results of some of the experiments which have been made by the administration of chloroform; and, so far as appears, the first cases treated by inhalation were severe malignant cholera in the advanced stage, all of which recovered. So, also, those treated by the remedy used internally, combined with a prompt and decided stimulant like the spirits of turpentine, or aquæ vitæ and brandy, recovered. In all these cases the remedy appeared to meet the urgent demand, to remove the impediment to the circulation, to relieve the nausea and vomiting, and purging and cramps, and restore, in a very short time, the general action and normal tone of the system. Still we must admit, that some cases, treated by its internal administration, and also by inhalation, proved, on some accounts not satisfactorily explained, unsuccessful. Were these cases given in detail, it would be much easier to detect the cause of failure, or its questionable use in such cases; but we have only the bare fact that they were thus treated, without the manner or character of the combination, if any were made, being given.

Hence Dr. Davies, under whose direction these cases occurred, remarks, in view of this result, "that no reliance could be placed on chloroform alone." The correctness of this opinion cannot be questioned, for the experiments we have cited all show the necessity of a prompt and diffusive stimulant in aid of its action, to render it sufficiently prompt and powerful to meet and overcome the disease in the more rapid and severe cases. Chloroform, properly combined, offers the best hope of relief, and is, without doubt, the most perfectly adapted of any remedy known to the pathology and phenomena of the disease. There is no remedy, when properly combined, so capable of meeting all the indications required as this, and none that can be administered with more certainty of success.

In conclusion, we may, with much propriety, refer again to the pathology suggested by the authors cited above, and inquire whether the action of chloroform as a remedy in these cases be consistent? and whether as such it has that curative influence, or direct controlling power, to arrest, suspend, and cure the disease, so imperiously demanded? We have seen that, according to the opinion generally prevailing, the first impression of the poison is made upon the blood, and through it upon the nerves, especially those which, from their anatomical position, bear the most intimate relation to the blood-vessels. Through this channel the first invasion appears to be made on the ganglionic, the nerves of circulation. These nerves are distributed chiefly to the viscera and blood-vessels, and are at least very early involved and essentially disturbed, for their healthful action depends in no small degree on the aeration or oxydation of the blood. Says an eminent author, "The action of every ganglionic mechanism depends on the existence of certain physical conditions, among which the most prominent and important is the due supply of arterialized blood. If this be stopped but for a moment the nerve mechanism loses its power, or, if diminished, the display of its characteristic phenomena correspondingly declines." Hence the loss of power in these nerves, and their deranged action, the contraction of the capillary and pulmonary arteries, the impaired and impeded circulation and all the phenomena arising therefrom.

Again, the great pneumogastric nerve, which is composed of both motor and sensitive filaments, has a very extensive distribution in the upper part of the abdominal cavity. It supplies the organs of voice and respiration with motor and sensitive fibres, and the pharynx, oesophagus, stomach and heart with motor influence. This very important nerve, through the primary action and deteriorating process of the cholera poison, becomes early involved, and its functions greatly, and, in fatal cases, permanently deranged. The evidence of this disturbance and loss of nerve-power is too obvious to be overlooked or disregarded in the treatment of this disease.

In confirmation of this, we may, with great propriety, adduce the testimony of Dr. Wallis on the loss of nerve-power, and the process through which the result is produced, who observes, that "the phenomena which are exhibited when the deleterious air has been drawn into the lungs are these: the great gastro-pulmonary nerve is either wholly or partially paralyzed, the consequences are the cessation of all its functions either wholly or partially. This great nerve is a nerve of function, and performs the functions of digestion and respiration, and influences all secretions."

Hence it appears the nervous power generally, as before observed, is very early and essentially impaired, and to such an extent that there can be no rational hope of relief, unless some remedial agent can be found that will exercise such a controlling influence and power, as shall be adequate to restore the tone of the nervous system.

Hence, we are forced to the conclusion that the prominent, leading, and most urgent symptoms requiring special attention, are "the Algide" or loss of temperature, the loss of nerve-power in the ganglionic and pneumogastric nerves and their branches, the altered or disorganized condition of the blood, the impaired or obstructed circulation, and the early and direct tendency to congestion. These are the prominent and essential features to be observed in the treatment. They are too intimate, dependent and inseparable, to warrant any attempt to mark the precise order of their development. They are the essential phenomena, proceeding equally and directly together from the primary cause and disease action, and strictly constitute the complex character of the cholera, and exhibit its main, distinguishing features, which must necessarily govern and dictate the maxims of rational practice in the treatment of this disease. The object, then, of first importance is to restore the lost temperature, the caloric already eliminated, and prevent its further depression; to restore, at the same time, the lost nerve-power to the nerves again; to arrest the process of disorganization of the blood, and equalize the circulation; to relieve and suspend the congestion; and then, according to all the experiments which have been made, the consequent and dependent phenomena of the cramps and the vomiting and the purging will disappear.