Another consequence of the blood constantly losing its watery constituents is this: This circulation of the capillaries becomes impaired, if not entirely prevented. However, as soon as this takes place in the capillaries of the heart-muscle, it causes, according to physiological and pathological experience, a paresis of the heart, and thus arise characteristic feebleness and faintness of the heart’s impulses and sounds, and the small, feeble, faint pulse of the radial and carotid arteries in cholera; thus, also develop the cyanotic symptoms, the blueness of the skin, the blue tongue, by which severe cases of cholera are characterised.
On the same condition of the blood, also depends, that anguish for breath, and hunger for air-that deep inspiration and short moaning expiration- which is always present in severe cases of cholera; for, in order that free expiration be possible, it is necessary, not only that there should be a free admission of air into the air-cells, but, also that a corresponding change of blood in the capillaries of the lungs should constantly be going on. A retardation of the flow, causes an imperfect purification of the blood from its carbon, which fact can be demonstrated by an analysis of the exhaled air, which contains less carbonic acid gas than it does normally. The air passes out nearly unchanged, causing thus the characteristic cold breath of cholera patients, and as the vocal organs partake of the general drying process, they become rigid, and naturally causes the voice of the patient to become changed into the peculiar cholera-voice, which is rough and coarse, with imperfect articulation.
The very distressing and painful spasms or cramps, which contract the muscles into hard, round knobs, are doubtless caused by central irritation, and it is quite probable that this irritation originates in the same drying out process which pervades the whole system. During the algid stage the temperature sinks to 93.5 degree, in rare cases to 88 degree F.; the pulse is from the beginning feeble, and little, or not at all quickened; exceptionally it attains a quickness of 96 to 100 per minute. Often it becomes thready and hardly perceptible; even the heart’s diastole may, in bad cases, be no longer recognisable, while its systole continues.
Dr. Niemeyer has found an able supporter in the person of Dr. B. C. Loveland about the utility of water in diet and therapeutics. Dr. Loveland mentions some instances where apparently serious disease was cured by the administration of a tonic and increasing the water consumed by the patient, as he notes that, besides relieving thirst, water is a simple fluid, so that acting as a solvent for ailment, aids in the absorption of the food material which it takes with it on its way to the blood, where it forms a medium for the solution and suspension of the various compounds needful for the nourishment of the tissues and helps the effete materials on their way to the excretory organs, and here again water re-exerts its solvent power in the removal of urea, kreatine, chlorides, phosphates, sulphates and some other materials that the blood has no use for and needs constant cleansing from. If the water becomes deficient, osmosis is impeded to a greater or less degree, the bowels suffer, the digestive fluids become too thick to do their work properly, and according to the natural laws of crystallisation, too great concentration (i.e. insufficient dilution) leads to the precipitation of soluble ingredients to form calculi of various sorts and deposits of a harmful nature in the tissues. Lack of water in the blood predisposes to arterial degeneration, uric acid diathesis and congestions, with their attendant evils, while the retention by concentration by the blood of excrementitious material, converts the life-stream into a slow poison producing mental depression and other reflex symptoms of a grave nature, and as the great majority of diseases are really due to insufficiency of fluid in the body, the judicious use of water will change the character of the blood and restore the body to a healthy tone.
From what you have, however, heard about Dr. Parkes’s observations-which observations apply to both varieties of cholera-you will easily understand that modern pathology inclines rather to the view, that the disturbance in the lungs cannot be entirely accounted for by a paresis of the heart; in fact, cardiac paresis is only secondary. Primarily, we know from Dr. Hall’s statement, and from a vast clinical experience besides,- primarily the action of the heart is rather in excess; that the balance of evidence in the case of diarrhoeic cholera is, moreover, in favour of a double action of the cholera poison an action on the blood on the one hand, and an action on the pulmonary vaso-motor nerves, on the other.
In my test lecture I shall endeavour to show, that there exists a casual connexion between the haematic and the secondary neurotic action of the specific poison under consideration.
Before attempting to do so, I consider it, however, worthwhile to say a few words about this supposed two fold toxic action as manifested in the disease under discussion. At first sight it might appear strange that one and the same toxic agent should be endowed with two different modes of action. Some vague consideration of this kind might, indeed, have prompted many pathologists to explain, as well as they could, all the choleraic phenomena on the exclusive principle of a primary, haematic disorder. A glance at the long list of pharmacodynamic agents of the mineral and vegetable kingdom, as to their effects upon man and animals suffices however to show, that such a double toxicological action, as the cholera poison is supposed to be endowed with, is by no means rare. Dr. Fayrer in his Climate and Fever of India-says (P. 78), `where a party of men have been exposed to the emanation of some malarial locality different types of fever may result; one may have ague another remittent, a third may only feel rather ill; another may have dysentery and even choleraic symptoms. Again, amongst the inhabitants of notoriously malarial districts a considerable portion do not suffer from either ague or remittent fever but present a sallow anaemic appearance with blanched lips and eyelids, pearly eyes, tumid abdomen, weak and irritable heart, haemic murmurs, and a general appearance of cachexia, dullness and hebetude or there may be neuralgia, asthma, albuminuria or it may be anasarca or ascites. We have only to think of such a well-known drug as Arsenic. This drug is known to passes a distinct and peculiar action upon the nerves, and as distinct and peculiar an action upon the blood. It would nevertheless, be a vain attempt, to fix, say in each case of arsenic-poisoning, upon an invariable and uniform mode of action. No toxicologist could venture to tell beforehand with any thing approaching certainty, how a given quantity of arsenic would act on a given individual; and yet there is hardly a drug whose pharmacodynamic qualities have been studied with more accuracy than those of Arsenic. Its grand and peculiar characteristics in the way how it assails and ultimately destroys life are well-known; but the details of execution vary in different individuals. In the one the neurotic, in the other the haematic element may prevail; in extreme cases, that is to say, when the dose has been excessively large, or the receptivity of the victim has been exceptionally great either in the neurotic or in the haematic sphere, we may actually find the one element totally overshadowing the other, and this is especially the case at the beginning of the attack. In the measure as toxic action advances we find, as a rule, that nervous and haematic symptoms act and re-act upon, and ultimately blend into each other, so as to establish an unmistakable state of Arsenic poisoning.
Now something similar to what takes place with regard to the drug just mentioned, and many other of potent drugs, does take place with regard to the action of cholera poison. Venosity of blood is the characteristic speciality of its action; it is the common pathological platform of both varieties of cholera, the spasmodic as well as the non-spasmodic. But in the former it is the contraction of the small pulmonary arteries which is the chief, and often the only factor-the subsequent flux of blood towards the alimentary canal and the watery transudation which follows, manifesting themselves by purging and vomiting, being simply as many adjuvants. While in the non-spasmodic variety the role is reversed. Vomiting and purging has been shown to be sufficient by themselves, to effect a complete state of venosity; the spasms, including the contraction of the pulmonary arteries, play here the part of the adjuvants, and might, as far as deleterious effect is concerned, even be absent altogether-just as in the spasmodic variety, death may actually take place in the absence of any vomiting and purging.
