DR. CFLAPMAN ON CHOLERA.*
A WORK which professed to put forth new views on the nature and treatment of such a disease as Cholera would at all times be received and looked into with attention, and now, when even in the depth of winter outbreaks of the plagtze have taken place at Calmar- von, in Dublin, and in Jersey, a book such as that recently pat forth by Dr. Chapman, with its very title premising novelty, or rather threatening revolution in the realm of Therapeutics, assuredly calls for a notice at our hands. Dr. Chapman believes in the efficacy for the cure of cholera of a line of practice based upon certain advances recently made, or supposed to have been made, in our knowledge of the functions of certain systems of nerves. Be- lieving in this with a fervour and pertinacity to which every page he has written bears witness, and which with reference to other creeds is as exterminating as Islam, he has been constrained to "hasten the publication of his work," though himself "painfully sensible of its defects." His enthusiasm indeed is much like that with which Plato tells us in the Philebus their introduction to the use of the Socratic method filled his fellow pupils in that first dawn of Western Dialectics, the preacher in the one case and the disciples in the other being simply irrepressible in advocating and applying their universal solvents. Further claims on the forbearance of a reviewer are constituted, by the debt of gratitude which every one must acknowledge himself to owe to a man who feels that he has a message to deliver on a subject of such importance and also of such obscurity as the "Treatment of Cholera ;" and these claims, which we must say Dr. Chapman does not put forward himself with the view of deprecating criticism, are yet further strengthened by the consideration that the treatment he advocates is consider- ably more sound than the theory on which he has based it, and his practice consequently, as he himself says (p. 46) is the cue with others, considerably better than his creed. That creed • Diarrhcea and Cholera. Their Nature, OnaIintcl Treatment through the Agency of the Nervous System. By John Chap Edition, enlarged. London: Triibner and Cm. M.R.C.P" Se"aa and that practice we will, without further preface, proceed to expound to our readers. The proximate cause of cholera Dr. Chapman believes to act primarily upon the nervous system as a "subtle agent," working probably in the way of "a sort of exunsive electric exaltation of its functions." (pp. 99 and 126.) By it the nerve-centres within the spinal canal, that is to say, the spinal cord, and those also which lie along either side and in front of the spinal column, that is to say, the sympathetic nerve-chains and plexuses, are both alike brought into a condition of over-full- bloodedness, which condition of hypemmia, again, brings both alike into a condition of over-activity. The hypemmia and over-activity of the spinal cord call the glandular tissues of the intestine into an over-activity of their own, and this over-activity overcomes that of the sympathetic, which, as a "negative motor power," would constringe and clasp up the blood-vessels of that tube. But the sympathetic, though conquered along the line of the intestine, is victorious along that leading from it to the liver, -and throwing the vessels passing from the former to the latter organ into spasms, produces thus the congestion which is so char- acteristic of this disease. (See pp. 6, 27, 99, 100, 112, 113, 120, 194.) Such is Dr. Chapman's theory, as we believe, fairly .stated, and at all events verifiable by the references we have given. And not only do we believe that every one of the proposi- tions in which we have summed it up is "non proven," but we are very strongly inclined to believe that they may all be disproved. Dr. Chapman's therapeutics we are glad to be able to speak of in other terms. The cause of the mischief being in his view a hyperas- mia, he aims at the reduction of this supposed cause ; and this he -does by the application of ice in ice-bags, in the nearest local, though not, as we think, in the nearest physiological, relation to the nerve- =centres he supposes to be thus hypertemic—down, that is in plain English, and along-the spine of the back. With the application of his spinal ice-bags Dr. Chapman combines eclectically and wisely (pp. 182, 185, 187, 235) the unremitting application of heat along the extremities, abdomen, and hips. Theory, however, has in- -duced Dr. Chapman to set his face against the use of ice internally -and of iced drinks. (p. 189.) We are well assured this must have been much against his own wishes, and we know it would be against the entreaties, and we believe also against the interests of his patients. This, and the limitation of the ice-bags' application to the spinal region, are the main blots in the purely therapeutical part of Dr. Chapman's treatise.
We must now proceed to state our objections to Dr. Chapman's theory, and having done this, we will, in our turn, put forward a theory which; if neurophysiology can explain cholera at all, has, we believe, better claims to acceptance than his.
To Dr. Chapman's statement (p. 46) that "no proof whatever has been tendered of the existence of an organic poison" in the blood of a choleraic patient, it might be sufficient to mention in reply the names of Dr. Snow and Professor Pettenkofer, of the results come to by the latter of whom a sketch appeared in our columns last August. But it may be well to state, as we shall thus show the analogy of the cholera to other poisons—and as no Palmer nor Dove can be encouraged by our statement into wife-murdering, or if he is, will assuredly be hanged for his pains, and without benefit of chemistry, chemists, or doctors—that more than half a century ago very similar results to those produced by cholera were shown by the elder Brodie to be producible in the digestive tract by no less.typical a poison than arsenic. (Phil. Trans., 1812, p. 215.) And if any toxicologist of repute will accept Dr. Chapman's objec- tion, as given at p. 95, that the analogy of inorganic poisons does not hold for organic, we shall then be prepared to find a physicist of note accepting the wonderful tale of the St. Petersburgh magnet, which Dr. Chapman gives at p. 150 of his test without 'comment, though at p. viii. of his preface he very properly hints that it may need confirmation. This magnet, we should say, is here reported to have had a normal sustaining power of seventy- five pounds to the square inch, and during a cholera epidemic to have had it reduced to one of fifteen pounds ; whereas in Dr. Graves' Studies, published after his death, and only so recently as 1863, we find that whilst its reputed strength was but up to forty pounds, its epidemic debility was reported to have fallen as low as four or five. Science is quantitative, this story is variable and various, and with a strong recommendation of Dr. Graves' admir- able paper, and especially of his remarks on the myth of the magnet at p. 372 of his book, we leave this strange tale, and return for a moment to the poison analogies. Dr. Wilke, one of the best known English pathologists, has commented quite recently on the resemblance borne by the choleraic to the arsenical intestine after death, as also to that which may be borne by the symptoms of the one to those of the other sufferer during life ; and to this
we may add, that just as arsenic:often produces paralysis, as also does lead, so one of the least mistakable, but also happily one of the least common, forms of cholera is known as the paralytic variety of it. Finally, an inorganic and imponderable agency would not be limited as to the rate at which it travelled by the speed of human conveyance ; electric and magnetic disturbances, "spurning sails and scorning oars," crows whole continents in a night, and sow infiuenzas and such disorders broadcast and world- widely; whilst the journeyings of cholera are slow, and though the electric telegraph may announce its coming, its arrival never anti- cipates that of the train.
Dr. Chapman's second proposition, as stated by us, is that in cholera the two nerve systems already specified are thrown into a state of congestion or hyperaemia, whence in the case of both of them over-activity arises. Now, firstly, on Dr. Chapman's own showing (p. 78.), Virchow, well known of late as an advanced Prussian Liberal, and better known for a long while back as one of the first, if not the very first, of living pathologists, reports himself as having found no structural changes in the choleraic spinal cord. Dr. Beale, again, in England has pronounced himself to the same effect as to the intestinal sympathetic ; whilst Dr. Gull has shown how little foundation in facts certain hypotheses as to variations in the vascularity of the spinal cord were really pos- sessed of. But as authorities are not wanting on the other side, and as, moreover, many affections of the nervous system, as, for example, tetanus or lock-jaw, may kill without leaving in that nervous system any traces of their fatal work, we are content to waive the question of fact, the difficulty of deciding which only experts can estimate, and to address ourselves to the question, —does a hyperaemia of these nerve-centres ordinarily or neces- sarily lead to such consequences in the intestine as cholera does? Now, inflammation, which has hyperaemia for one of its initial factors, may be taken as likely to show us at one time or other the working of this hypemmia, and the history of inflammation of the spinal cord or its membranes may seem not ill fitted to throw some light on this question. Cases of these diseases have been unhappily, or rather happily, somewhat rare in pathological records till lately, when the Siberian plague, to which the late Cesarevitch fell a victim, broke out in Europe. Now, of both these diseases it may be said that in their early stages, that is, just when hypenemia is least complicated with any other of the elements of inflammation, they bring about in the functions of the intestine just the reverse of those diagnos- tic and differential changes which cholera produces there, and from the universally allowed existence of which Dr. Chapman has argued back to his hypothetical lijipera3mize. Granting, then, what, however, is still open to question, that these hyperte- miae really exist, or axe, in Newton's language, vertu awns, it is clear that we cannot say of them, " Pluenomenis explicandis sufficiunt."
Hypera3mia does, however, exist, beyond all question, and entails only too palpable consequences along the course of the choleraic small intestine. Now, such a hyperaemia, and somewhat similar consequences, have been shown to be producible in many organs, not by throwing the sympathetic or spinal cord into over-activity, but simply by putting the former into abeyance. And if neurophyaio- logy as at present existing can explain cholera, this is the explana- tion it would give of it. Man's special liability to this particular disease it might explain by the specially great evolution in him of the sympathetic system, teaching, and indeed knowing, as it does, that organs which we find the last to be superadded, and systems which we find the latest to attain their full development in as- cending the scale of life, are also usually the first to yield to debilitating and poisoning influences. The frequent—which is, however, by no means the entire—immunity from the disease which the lower animals enjoy, is rendered thus intelligible : their sym- pathetic system has attained so much smaller a . development, and has incurred consequently so much smaller a liability to derangements. There is no need, physiological or philosophical, for Dr. Chapman's hypothesis of the over-activity of two seta of nerves, if the debilitation of one set can be shown to be com- petent to produce the effects in question. Newton knew as well as most of us that two causes, as, for instance, gravitation and the tangential force, may be required for the production of one effect, but for all that he endorsed the scholastic brocard, " Entia non aunt multiplicanda pmter necessitatem."
The poison of cholera falls, we may suppose, upon one particular set of nerves, just as the poison of lead falls upon one particular set of muscles, or that of phosphorus on one particular set of bones. This set of nerves it reduces into a condition of inertness which, in the physical, as also, Lord Melbourne notwithstanding, sometimes in the political body, may be more hurtful than over-activity. Sense, sensation, and voluntary motion it often impairs but little, at least primarily, and hence we consider the spinal cord and brain to be ordinarily and primarily, unaffected by it. If the sys- tem can by its various eliminatory or emunctory organs clear it- self of this poison, as it might clear itself of opium, alcohol, or woorara, before it is worn out by its violence or structurally ilamaeed by the changes its working entails, all will go well. To give this eventuality its best chance of being realized, we strive to replace the morbid impressions of the self-localized poison by localizing upon the affected organs those more healthy impressions which heat and cold ordinarily, and, we should add, chloroform, champagne, and ipecacuanha occasionally, furnish us with the means of producing there.
By such means as these, on the one hand, we gain time for the system to right itself and for the poison to exhaust itself, and on the other, just as we strive to save life and health and the chance of final recovery for a paralyzed limb by the application to it of electrical shampooing and other stimuli, so by the application of the specified and other stimuli to the paralyzed sympathetic, we strive to prevent the deadening influence which has passed upon it from deepening into death itself.
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