BARIVELL ON ASIATIC 'CHOLERA...

THIS treatise is the result of considerable experience of Asiatic Cholera at St. Thomas's Hospital, and in Southwark generally, during the visitation in 1849; observation being accompanied by powers both of reflection and speculation. Mr. Barwell's theory may be more or less erroneous, and the practice recommended, which is in a measure independent of the theory, may not, in the long run, succeed any better than other remedies which have had a temporary success ; but his theory on the origin of cholera coincides with facts, his view of the immediate cause of the algide symptoms is in harmony with what actually takes place, and the treatment recommended is based on reason. At all events, Mr. Barwell's volume presents the most intelligible view of the whole subject we have yet met with, and has this mark of soundness about it, that it tends to strip the cholera of much that looks mysterious. In Mr. Barwell's opinion, cholera is a virulent substitute or successor to ague and typhus ; an atmospheric poison aggravating into cholera the disease which otherwise would have taken the form of continuous or remittent fever. As a proof of this, he points to the local coincidence : those places or districts which are the usual seats of typhus or ague suffer the most severely from cholera. As a further proof, Mr. Barwell refers to the registra- tion of deaths ; where he finds, that before cholera approaches, the mortality from fevers and diarrhcea increases, till ma- lignant cholera finally comes to override all. Be the nature or origin of cholera what it may, the immediate cause of the virulent symptoms Mr. Barwell attributes to internal congestion. The blood is driven inwards, and settles in the great organs ; hence the external cold and the virulent affection of the stomach and bowels. To restore the surface circulation, and relieve the organs from their load of blood, is the first thing to be attempted ; but in practice we have not any medicines that will accomplish this re- sult. We must look mainly to external applications. Of these, the hot air-bath failed even when the temperature was raised to 180'. The hot sheet was frequently successful; the idea being de- rived from the power of the cold sheet of hydropathy in producing external warmth. As soon as the balance of the circulation is re- stored, attention is to be paid to the other symptoms ; but medi- cine will be of little use till external warmth appears,—that is, till the circulation is got back to something like a normal state and the internal congestion is relieved.

This treatment is by no means certain of success, any more than is the treatment of any other acute disorder. It may fail alto- gether ; or the external warmth may be restored and yet the patient be lost, either from a relapse, or during the after treat- ment; for if the choleraic symptoms are cured, there is still a con- secutive fever to overcome, analogous to the hot fits of ague, which is sometimes fatal. Mr. Barwell agrees as to the general tractability of the premonitory diarrhcea, though he does not subscribe to the uti- lity of the chalk mixture ; he prefers astringents, stimulants, and aromatics. At the same time, he does not hold that the disease invariably gives warning of its approach. Of 85 patients at the Hospital the attack in 8 cases was sudden ; in 19 cases there was a warning diarrhoea of less than ten hours; in 23 cases, of less than twenty-four hours ; and in 35 cases, of some days.

These facts, however, are limited in number ; and,ywing to the class of patients, and their condition frequently when brought to the Hospital, should perhaps be received with caution. Mr. Bar- well has indeed left out of his table all the less reliable cases ; but persons in a much higher station of life than Borough Hospital patients, and in a better state of health than that of algide cholera, cannot always be trusted in minute statements about their previous condition.

The remark on the choleraic statistics may be applied to. the book medically speaking. It requires the teat of a wider observa- tion as to the theory, and of more extensive experiments as to the practice it recommends, before either one or the other can be con- sidered established; and both seem worthy of that attention. In a literary point of view, all the opinions advanced have a logical coherence with each other, and are reasonable in themselves. Mr.

• Asiatic Cholera ; its Symptoms, Pathology. and Treatment ; with which is em- bodied its Morbid Anatomy, general and minute, translated from a Paper by Drs. Reinhardt and Leubuscher. By Richard Barwell, Fellow (by Examination) of the Royal College of Surgeons; late House-Surgeon and now Demonstrator of Anatomy, at St. Thomas's Hospital. Published by Churchill,

Barwell's is the most hopeful as being the most consistent and in- telligent theory upon the subject. In the mere outline here presented there are of course many omissions of detail, as well as of secondary medicines ; the object being simply to convey an idea of Mr. Barwell's hypothesis and treatment. Besides matter directly relating to these, the book contains several incidental topics, bearing upon public hygiene and the condition of the poor. The following contains some curious facts, as well in relation to the public constitution, so to speak, as to the cholera.

" Fever and influenza preceded the cholera in Russia, an increase of scarlet and intermittent fever in Hamburg, intermittent fever and diarrhcea in Berlin; and when we consider that the favourite lurking-places of these diseases are the chosen haunts of cholera, it would be difficult not to see some close connexion between the one class and that which has been too much regarded as a disease per se. "It appears, then, that cholera—or rather that influence which produces cholera—travels from East to West ; that alone it cannot produce the dis- ease, but that it must also be aided and abetted by some local conditions, which, on their part alone, would produce diarrhoea, typhus, or intermittent fever, as the case may be : but whether epidemic cholera be caused by the operation of a mixture of these two influences, or whether the cholera influence produce that malady by operating on a system well prepared for the attack by a typhus-fever-producing condition, cannot now be Judged. Nor is it of great importance ; the material point being, that we can estimate the amount i of epidemic force in any part of England, by studying the returns of deaths in those parts from zymotic diseases ; that when these gradually go on in- creasing for a number of years, and when all diseases more and more incline towards a low, malignant character, then may we suppose that a time is approaching when some great epidemic shall scourge the land. When we find, moreover, as in London, that all diseases have, in about the last twenty years,. altered considerably in character, and deviated from the previous sthenic, to a debile asthenic [low, weak] type, so that the treatment of many such has lately become stimulant, instead of antiphlogistic,—then may we justly conclude that something in our sanitary arrangements is grievously wrong, for which, sooner or later, the population must suffer."

This is a ghastly picture of some of the more obvious symptoms of true cholera, about which those who have once seen it are never mistaken.

"There is something peculiar in the coldness of surface, tongue, and breath ; it is greater in sensation than that of a corpse, or of polished metal, while the expired air is colder than the surrounding atmosphere. I take blame to myself that I never actually tested the temperature of a patient's body or breath with the thermometer, though the instrument is perhaps not as good a guide, in these sort of circumstances, as sensation ; but there can, I believe, be no doubt but that the temperature is very low ; the skin so far loses its elasticity, that if a fold be pinched up, it continues erect, and an in- dentation with the finger remains whiter than the surrounding parts. The surface is often clammy and bedewed with perspiration, often dry and hard ; and some differences in the results of the cases, in which one or the other of these states has occurred, have led me to attach some importance to the presence or absence of perspiration. If the victim of this complaint die in collapse, the corpse becomes warmer after death, often much warmer than after any other mode of dissolution ; and may remain so for two hours or more, and,jhen will turn as cold as the body of a dead person usually is. • •• •

"The blueness of skin, and the peculiar appearance of the face and hands, when once seen, in a strongly-marked case, will never be forgotten : it gives a peculiarly unpleasant, horrid aspect, sometimes as though the patient had been starved, and when combined with the anxious expression, as thougb.he had been terrified into insanity ; for the suffusion of the eyes imparts a wild look, and the discoloration about the mouth an appearance such as Virgil imputes to his Harpies. The hands shrivelled like a washerwoman's, blue, with dark nails, with crooked, stiff, and claw-like fingers, either soaked with perspiration, or dry and hard, will be recognized, as soon as seen, for choleraic.

"The pulse is always very low, but generally remains regular, as long as it can be felt ; the only peculiarity is, that it usually gets extinct before the first sound of the heart has lowered as much in comparison : which probably depends on one of two causes,—either that the blood is too thick to travel through the vessels, or that but very little finds its way to the left side of that organ, which contracts with considerable force on the small quantity which it does contain. It is perhaps to the first of these causes that the cessation of the second sound is due. The sufferers will remain alive for hours after all pulse at the wrist has ceased, and will even in that state answer questions quite rationally, ; for the intellect remains sound to a very late period, and the condition of brain is not coma, but rather a state of utter listlessness and apathy.

"The accession, intensity, and duration of cramps, are extremely variable ; nor is, I believe, much importance to be attached to their presence or absence, either as a diagnostic or prognostic sign."

The following passage embraces the gist of the author's theory, though not the particular facts and reasoning by which it is sup- ported, of the identity of typhus and ague with cholera.

In considering these and other such cases, and in coupling with them the fact that typhus fever increases in any country as cholera approaches, and moreover, that that fever acquires a greater and greater tendency to ab- dominal complication, we must be struck with the close connexion between the two seta of diseases ; and the fluctuations in the cases quoted lead us still further towards the supposition—which is not offered as a truth, but simply as an hypothesis—that under the influence of the particular poison, typhus fever becomes a virulent remittent, the cold stage of which is algide cholera ; that this particular form is always accompanied by a peculiar alvine disorder, or, perhaps, is rather preceded, and in part induced, by an action causing al- vine disturbance- and this idea gains additional weight when it is remem- bered that in H,amburg and other Continental towns remittent fever was a forerunner of the cholera. The difference, in reality, between intermit- tent, remittent, and continued fevers, is really very small • so slight, that in the same climate and in the same malaria, a difference of as to Beason, will change the aspect of the disease from the one to the other. The view most favoured by medical men, practising in warm climates where yellow fever is rife, is that this disease is a remittent, and has, apparently, not unfrequently en algide stage, as mentioned by Dr. Bartlett, in which that phase of cholera is closely imitated—in which, even, it would be very difficult to distinguish the one disease from the other, except by judging from the prevalence of either malady. Moreover, although it at first sight may appear paradoxical to speak of the remittent quality of continued fever, I conceive that all medical men will acknowledge to have occasionally seen continued fevers in which was a greater or less tendency to remit, only shown, perhaps, by an irregularly periodical shivering, slight exacerbation, or sweating; and most readily can it be conceived, that the addition of ano- ther poison might cause such fevers to intermit altogether, and add to them a cold stage of an intensity like that of cholera. "In the cold stages of a regular intermittent ague, for instance, the blood leaves the surface of the body, causing contraction and shrinking of the face and bands, and a peculiar rough sensation of the skin ; and in cholera, the blood leaves the surface and remains pent up in the internal cavities - the body is cold in both : in time, if all goes well, warmth returns, which soon becomes heat and fever. The difference of this symptom, in fact, is more in degree than kind. The cholera patient often dies before the hot stage comes on, and never lives, as far as my experience goes, through a second cold fit to the next hot : the ague patient survives very many. Thus, though no one could say, with an approach to truth, that cholera is merely a deadly form of ague, yet it appears true, that it is a peculiarly deadly disorder with a de-

cided remittent type ; and that the sufferer is apt to die in chill, before the circulation, disturbed by the great power of this

fully restored. In all eases of cholera which live beyond the algide stage, a consecutive fever supervenes."

Various circumstances combined to prevent extensive post-mor- tem examinations at St. Thomas's. Mr. Barwell has therefore in. eluded in his work a translation of part of a paper by Doctors Reinhardt and Leubuscher, which gives an account of all morbid appearances, general and miscroscopic, observed after death from cholera. The object is to prove the congested state of the internal organs.