CHOLERA?WHAT IS ITS PROPER THERAPEUTIC TREATMENT ? By Haymah Senior Medical
Thornhill, M.B.,
Officer, Ceylon Medical Service. Having recently had to deal with a small outbreak of cholera here?166 cases with 83 deaths?I daily experienced anxiety as to which was the proper or best line of treatment to adopt, and to direct subordinates to adopt as a routine. I therefore propose to ask the Indian Medical Gazette to help me, and others similarly placed, by making this question one for collective investigation. 2. I therefore suggest below a series of questions, and would ask each subscriber to the
132
INDIAN MEDICAL GAZETTE.
who has had personal experience of cholera to answer such questions, and treating also to get non-subscribers who have had similar experience to answer them, each" doing so on a separate sheet of paper headed Cholera Treatment, Collective Investigation, 1898 (but only the index numbers and letters of the headings need be written), and to post such papers to one or other ot the associated editors of the Indian Medical Gazette at Calcutta, Bombay, or Madras, and that the answers received by each editor should be tabulated, and the final result published in the Indian Medical Gazette (I have filled in my own answers to indicate how the questions should be answered especially in cases where precise records are not available).
Gazette,
Summarised
4. Cholera is tlie disease in which there should certainly be a recognised routine treatment, and yet there is no disease in which the treatment recommended in text-books is so diverse and actually antagonistic"; these methods
described by (1) The opium treatment, Macnamara in Quain's Dictionary of Medicine. as
(2)
The evacuation
(3)
The Italian and American treatment
recommended by Sir
or
calomel, treatment
as
George Johnson. as
recommended by Cantain and Shakespeare? vide Wilson's American Text-Book of Applied
Therapeutics, 1896. calomel
This treatment is the
method,
evacu-
opium or astringent in mouth the any stage, even in by being given the so-called premonitory diarrhoea, with the use of intestinal antiseptics such as salol, betanaphthol, &c., in the early stages, and in the later stages enteroclysis or large warm enemas of tannic acid and laudanum, or saline fluid; hypodermoclysis, or the subcutaneous infusion of pints or even quarts of warm saline fluid and loarm baths (immersion up to the neck) every or
treatment is
:?
Enteroclysis Hypodermoclysis Warm Baths
)
^
)
.
fchl.rd staSe, or when col*aPae i8 threatened or exists.
5. During the recent epidemic here, my assistants and I carried out botli the opium and the calomel methods, each in a considerable number of cases both in those seen, and treated only after the attack was fully developed, and also in those seen, and treated immediately on the first loose motion, and I can safely say that was obtained with either no special success method that would enable us to give the preference to it, the result being daily mental torture to ourselves as to which method we would adopt for the next case that occurred. I may say the same with reference to ; we used it often, but cannot say that we observed any special benefit from it. G.
enteroclysis 7.
Hypodermoclysis
we
used,
to use, two or three times : our that the fluid would not pass by
or
rather tried
experience was gravitation into
the subcutaneous tissues, and we had to force it in with a pump as recommended by Williams in the Boston Medical Journal of October 1894 (quoted in the British Medical Journal Epitome We did not observe of 17th November 1894.) any benefit from this treatment, but I am free to confess that the cases in which it was used were only two or three in number, and that they were very far advanced in collapse, and, further, that only a small quantity of fluid was injected. 8. Warm baths we also used in several cases both of mild and severe collapse, but did not notice any benefit, but, on the contrary, the exhaustion produced was often marked and finally deterred us from using it again in the same or other cases. The benefit or otherwise of stimulants, which I mean large quantities of brandy or whiskey and subcutaneous injections of ether, is another point that needs collective investigation. In some of our cases we used brand}7 largety ; in some it apparently did no harm even if it did no good, but in others I fear there is no doubt that it did harm by producing or increasing a typhoid state or cerebral 9.
are :?
ation
Shakespeare's
1898.
Salol or betanaphthol in first stage. Calomel (5 to 10 grs.) in second stage.
"
3. As I propose to seek information only to establish what is the most frequently adopted or most successful therapeutic method of treating cholera, I have not included any question regarding Haffkine's anti-cholera inoculations though from the results already obtained and published, it is clear that, if they were applied at the commencement or at any time during the existence of an outbreak of cholera, they would, in proportion to the extent to which they were used, enormously reduce the number of cases, and hence the deaths would thus lead to a speedier termination of the outbreak just as vaccination and re-vaccination would do in the case of an epidemic of small-pox, and, of course, I do not allude to the much-wished-for cholera antitoxic serum, which we earnestly hope Haffkine or Pfeiffer will yet produce and make available to all concerned in treating cases of cholera.
[April
two or three hours.
no
by
symptoms.
10. I would here quote from Dr. Mitra's excellent paper on "Treatment of Cholera" in the Transactions of the 1894-95
published
Indian Medical Congress
:?
The average mortality in fully established 60 per cent, in the cases is about of the epidemic ; 50 per cent, during beginning its course; gradually falling to 25 per cent, or less at the end of the epidemic. Any drug to have a distinct curative effect must reduce this mortality by at least 15 per cent." "
cholera
Where records not available to show actual numbers treated by each method give, if possible, here? 1G6 Total No. of cases 83 Recoveries 83 Deaths... 50*00 Mortality per cent. ...
...
...
...
...
...
...
...
...
...
THERAPEUTIC TREATMENT OF CHOLERA.
i
|
...
COLLECTIVE INVESTIGATION. 1RQR *
j Precise Records
General views where Pre-
AVAILABLE.
cise RECORDS NOT AVAILABLE. 0>
d
adopted. d
5 ?
ti
o
?
?
.2 ftg ?
^
OS
Entirely astringent,
or
opium
or
calomel
on
91
0.
Astringent opium in first stage, evacuation calomel in second stage
on
( F. G.
3.5 ?*-5
treatment given
Intravenous saline
Hypodermoclysis Hot baths
J.
Ether
$
K.
Brandy
? 2--S
L.
??o C
O
o
8
e
cs
^
o
m r*
3
M. N. (. O. P.
...
20 15
13
18
19
or
Office.
20
D.
86*06
Uf. Not used.
...
D.
...
Uf.
liypodermically or
whisky liberally
Ditto
moderately
Ditto
nil
or
F. Not used.
B. naphthol
Haffkine's anti-cholera, inoculation
applied
None had been Haffkinised.
Name_
Station
Qualification and Bank
Date
Note.?Regarding Haffkine's
Uf.
...
Camphor Salol
17
D.
H. o3
a >
16
D.
Enteroclysis
I.
tc
15
a
o
Uf.
20
...
i
14
O
or
Evacuation or calomel in first stage, astringents or opium in second stage seen or no
13
OC
D.
20
or
Cases not
12
ci
Sir G. John-
Entirely evacuation son's lines
E.
11
u rH
S
Macnamara's
...
B.
D.
ffl
ft
ii
[March
lines
cS
10
ftls ? se .2 "
5""
'ft o
o
Wo
a
s ft j
6 A.
rS
> c3 c3
?
ft-K
ft
c a3 ? c
pH ?+H
Inoculation enter the number of
only those who had received it not less than 10 days previous to the attack of cholera, and insert the index letter to show how these had been treated therapeutically.
1898.
Method
GAZETTE. MEDICAL INDIAN
...
April
INVESTIGATION INTO MALARIA: ROSS.
1898.]
I entirely agree with the above, but would make the last sentence to read any drug, or line of treatment to be regarded as successful must reduce the total mortality to at least 30 or 35 per cent." 11. I would also invite attention to another excellent paper on Cholera and its Treatment" by Dr. B. C. Sen, in the same Transactions, and would say that, until some other line of treatment is proved to be more successful, I intend in any future cases of cholera to adopt the treatment exactly as recommended by him. 12. In thus giving a half-hearted support to the opium versus the calomel treatment, I am forced to admit that theoretically the evacuation or calomel treatment and not the opium one is the naturally and scientifically " the correct method, for, as Shakespeare says, evacuatiou of the infectious and toxic contents of the intestinal tract is an end to be sought and encouraged rather than to be interfered with and checked. The danger resides mostly in the presence of the comma-bacilli and their products and not so much in their extension,"and this reasoning is supported by what we noticed in three or four cases during the recent epidemic, viz., that though the surface of the body was warm, and though there was no vomiting or purging after the first stage?one case passing even a semi-solid foeculent motion?yet the heart's action was seriously affected and death resulted in a manner pointing, I think, to extreme intoxication and indicating the necessity for calomel. 13. With these conflicting lines of treatment and the high mortality attending the use of either of them, and the failure of either to show a persistently lower mortality than the other, I feel inclined to become a medical Agnostic as regards the therapeutic treatment of cholera, aud to add a fourth, viz., " Do nothing to the other three methods, especially as I fear the usual experience is that there are at least two forms of cholera, viz., the mild, and the severe?that the former generally recover, and that the latter almost invariably die in spite of treatment by any method yet tried. 14. This frame of mind is encouraged by the fact that in many cases during the late epidemic, we were able to treat the patients from the very first symptom, and did so energetically with large and repeated doses of chlorodyne, or of acid astringent mixture with laudanum, or ot lead and opium pills, with rest, dieting, &c., and yet many of these went on to severe and fatal cases of cholera, though some, of course, resulted in only mild cases of the disease which quickly recovered, but the question occurs were these mild cases of cholera at all ? (Unfortunately I was unable to carry out bacteriological or even microscopical examinations of the stools for cholera bacilli). 15. I must say that I will in future be sceptical as to whether checking the early "
"
"
"
"
183
diarrhoea does really cut short the progress or of a case of cholera, unless it is proved that iu such cases the cholera bacilli were really present, though even then there would be an element of doubt, for we know that the commabacilli are sometimes present without producing any symptoms whatever. 1G. That all cases of purging or even of purging and vomiting occurring amongst those in houses or places where cholera is prevalent are not cases of cholera (though it is right that they should be regarded and dealt with as if they were), was forcibly suggested during the late epidemic here. Two inhabitants of two different houses in which cholera occurred began to purge and vomit, they were immediately treated with astringents and recovered, the cases naturally being regarded and recorded as mild cases of cholera, but clearly they were not, for both of them within three weeks subsequently contracted cholera, of which they quickly died, thus I think indicating that the first attack was merely acute diarrhoea and not cholera. 17. It would be interesting to have the statistics of any cases of undoubted cholera which recovered without any specific treatment, or at least without opium or calomel, and I have, therefore, included a question asking for such statistics, but would ask that it be answered only with respect to cases regarding svhich there could be no reasonable doubt, but that they were genuine cholera, and that, if any other drugs or modejof treatment was used, that they will be mentioned.
severity
Thornhill, M.B.,
Officer, Ceylon Medical Service. Having recently had to deal with a small outbreak of cholera here?166 cases with 83 deaths?I daily experienced anxiety as to which was the proper or best line of treatment to adopt, and to direct subordinates to adopt as a routine. I therefore propose to ask the Indian Medical Gazette to help me, and others similarly placed, by making this question one for collective investigation. 2. I therefore suggest below a series of questions, and would ask each subscriber to the
132
INDIAN MEDICAL GAZETTE.
who has had personal experience of cholera to answer such questions, and treating also to get non-subscribers who have had similar experience to answer them, each" doing so on a separate sheet of paper headed Cholera Treatment, Collective Investigation, 1898 (but only the index numbers and letters of the headings need be written), and to post such papers to one or other ot the associated editors of the Indian Medical Gazette at Calcutta, Bombay, or Madras, and that the answers received by each editor should be tabulated, and the final result published in the Indian Medical Gazette (I have filled in my own answers to indicate how the questions should be answered especially in cases where precise records are not available).
Gazette,
Summarised
4. Cholera is tlie disease in which there should certainly be a recognised routine treatment, and yet there is no disease in which the treatment recommended in text-books is so diverse and actually antagonistic"; these methods
described by (1) The opium treatment, Macnamara in Quain's Dictionary of Medicine. as
(2)
The evacuation
(3)
The Italian and American treatment
recommended by Sir
or
calomel, treatment
as
George Johnson. as
recommended by Cantain and Shakespeare? vide Wilson's American Text-Book of Applied
Therapeutics, 1896. calomel
This treatment is the
method,
evacu-
opium or astringent in mouth the any stage, even in by being given the so-called premonitory diarrhoea, with the use of intestinal antiseptics such as salol, betanaphthol, &c., in the early stages, and in the later stages enteroclysis or large warm enemas of tannic acid and laudanum, or saline fluid; hypodermoclysis, or the subcutaneous infusion of pints or even quarts of warm saline fluid and loarm baths (immersion up to the neck) every or
treatment is
:?
Enteroclysis Hypodermoclysis Warm Baths
)
^
)
.
fchl.rd staSe, or when col*aPae i8 threatened or exists.
5. During the recent epidemic here, my assistants and I carried out botli the opium and the calomel methods, each in a considerable number of cases both in those seen, and treated only after the attack was fully developed, and also in those seen, and treated immediately on the first loose motion, and I can safely say that was obtained with either no special success method that would enable us to give the preference to it, the result being daily mental torture to ourselves as to which method we would adopt for the next case that occurred. I may say the same with reference to ; we used it often, but cannot say that we observed any special benefit from it. G.
enteroclysis 7.
Hypodermoclysis
we
used,
to use, two or three times : our that the fluid would not pass by
or
rather tried
experience was gravitation into
the subcutaneous tissues, and we had to force it in with a pump as recommended by Williams in the Boston Medical Journal of October 1894 (quoted in the British Medical Journal Epitome We did not observe of 17th November 1894.) any benefit from this treatment, but I am free to confess that the cases in which it was used were only two or three in number, and that they were very far advanced in collapse, and, further, that only a small quantity of fluid was injected. 8. Warm baths we also used in several cases both of mild and severe collapse, but did not notice any benefit, but, on the contrary, the exhaustion produced was often marked and finally deterred us from using it again in the same or other cases. The benefit or otherwise of stimulants, which I mean large quantities of brandy or whiskey and subcutaneous injections of ether, is another point that needs collective investigation. In some of our cases we used brand}7 largety ; in some it apparently did no harm even if it did no good, but in others I fear there is no doubt that it did harm by producing or increasing a typhoid state or cerebral 9.
are :?
ation
Shakespeare's
1898.
Salol or betanaphthol in first stage. Calomel (5 to 10 grs.) in second stage.
"
3. As I propose to seek information only to establish what is the most frequently adopted or most successful therapeutic method of treating cholera, I have not included any question regarding Haffkine's anti-cholera inoculations though from the results already obtained and published, it is clear that, if they were applied at the commencement or at any time during the existence of an outbreak of cholera, they would, in proportion to the extent to which they were used, enormously reduce the number of cases, and hence the deaths would thus lead to a speedier termination of the outbreak just as vaccination and re-vaccination would do in the case of an epidemic of small-pox, and, of course, I do not allude to the much-wished-for cholera antitoxic serum, which we earnestly hope Haffkine or Pfeiffer will yet produce and make available to all concerned in treating cases of cholera.
[April
two or three hours.
no
by
symptoms.
10. I would here quote from Dr. Mitra's excellent paper on "Treatment of Cholera" in the Transactions of the 1894-95
published
Indian Medical Congress
:?
The average mortality in fully established 60 per cent, in the cases is about of the epidemic ; 50 per cent, during beginning its course; gradually falling to 25 per cent, or less at the end of the epidemic. Any drug to have a distinct curative effect must reduce this mortality by at least 15 per cent." "
cholera
Where records not available to show actual numbers treated by each method give, if possible, here? 1G6 Total No. of cases 83 Recoveries 83 Deaths... 50*00 Mortality per cent. ...
...
...
...
...
...
...
...
...
...
THERAPEUTIC TREATMENT OF CHOLERA.
i
|
...
COLLECTIVE INVESTIGATION. 1RQR *
j Precise Records
General views where Pre-
AVAILABLE.
cise RECORDS NOT AVAILABLE. 0>
d
adopted. d
5 ?
ti
o
?
?
.2 ftg ?
^
OS
Entirely astringent,
or
opium
or
calomel
on
91
0.
Astringent opium in first stage, evacuation calomel in second stage
on
( F. G.
3.5 ?*-5
treatment given
Intravenous saline
Hypodermoclysis Hot baths
J.
Ether
$
K.
Brandy
? 2--S
L.
??o C
O
o
8
e
cs
^
o
m r*
3
M. N. (. O. P.
...
20 15
13
18
19
or
Office.
20
D.
86*06
Uf. Not used.
...
D.
...
Uf.
liypodermically or
whisky liberally
Ditto
moderately
Ditto
nil
or
F. Not used.
B. naphthol
Haffkine's anti-cholera, inoculation
applied
None had been Haffkinised.
Name_
Station
Qualification and Bank
Date
Note.?Regarding Haffkine's
Uf.
...
Camphor Salol
17
D.
H. o3
a >
16
D.
Enteroclysis
I.
tc
15
a
o
Uf.
20
...
i
14
O
or
Evacuation or calomel in first stage, astringents or opium in second stage seen or no
13
OC
D.
20
or
Cases not
12
ci
Sir G. John-
Entirely evacuation son's lines
E.
11
u rH
S
Macnamara's
...
B.
D.
ffl
ft
ii
[March
lines
cS
10
ftls ? se .2 "
5""
'ft o
o
Wo
a
s ft j
6 A.
rS
> c3 c3
?
ft-K
ft
c a3 ? c
pH ?+H
Inoculation enter the number of
only those who had received it not less than 10 days previous to the attack of cholera, and insert the index letter to show how these had been treated therapeutically.
1898.
Method
GAZETTE. MEDICAL INDIAN
...
April
INVESTIGATION INTO MALARIA: ROSS.
1898.]
I entirely agree with the above, but would make the last sentence to read any drug, or line of treatment to be regarded as successful must reduce the total mortality to at least 30 or 35 per cent." 11. I would also invite attention to another excellent paper on Cholera and its Treatment" by Dr. B. C. Sen, in the same Transactions, and would say that, until some other line of treatment is proved to be more successful, I intend in any future cases of cholera to adopt the treatment exactly as recommended by him. 12. In thus giving a half-hearted support to the opium versus the calomel treatment, I am forced to admit that theoretically the evacuation or calomel treatment and not the opium one is the naturally and scientifically " the correct method, for, as Shakespeare says, evacuatiou of the infectious and toxic contents of the intestinal tract is an end to be sought and encouraged rather than to be interfered with and checked. The danger resides mostly in the presence of the comma-bacilli and their products and not so much in their extension,"and this reasoning is supported by what we noticed in three or four cases during the recent epidemic, viz., that though the surface of the body was warm, and though there was no vomiting or purging after the first stage?one case passing even a semi-solid foeculent motion?yet the heart's action was seriously affected and death resulted in a manner pointing, I think, to extreme intoxication and indicating the necessity for calomel. 13. With these conflicting lines of treatment and the high mortality attending the use of either of them, and the failure of either to show a persistently lower mortality than the other, I feel inclined to become a medical Agnostic as regards the therapeutic treatment of cholera, aud to add a fourth, viz., " Do nothing to the other three methods, especially as I fear the usual experience is that there are at least two forms of cholera, viz., the mild, and the severe?that the former generally recover, and that the latter almost invariably die in spite of treatment by any method yet tried. 14. This frame of mind is encouraged by the fact that in many cases during the late epidemic, we were able to treat the patients from the very first symptom, and did so energetically with large and repeated doses of chlorodyne, or of acid astringent mixture with laudanum, or ot lead and opium pills, with rest, dieting, &c., and yet many of these went on to severe and fatal cases of cholera, though some, of course, resulted in only mild cases of the disease which quickly recovered, but the question occurs were these mild cases of cholera at all ? (Unfortunately I was unable to carry out bacteriological or even microscopical examinations of the stools for cholera bacilli). 15. I must say that I will in future be sceptical as to whether checking the early "
"
"
"
"
183
diarrhoea does really cut short the progress or of a case of cholera, unless it is proved that iu such cases the cholera bacilli were really present, though even then there would be an element of doubt, for we know that the commabacilli are sometimes present without producing any symptoms whatever. 1G. That all cases of purging or even of purging and vomiting occurring amongst those in houses or places where cholera is prevalent are not cases of cholera (though it is right that they should be regarded and dealt with as if they were), was forcibly suggested during the late epidemic here. Two inhabitants of two different houses in which cholera occurred began to purge and vomit, they were immediately treated with astringents and recovered, the cases naturally being regarded and recorded as mild cases of cholera, but clearly they were not, for both of them within three weeks subsequently contracted cholera, of which they quickly died, thus I think indicating that the first attack was merely acute diarrhoea and not cholera. 17. It would be interesting to have the statistics of any cases of undoubted cholera which recovered without any specific treatment, or at least without opium or calomel, and I have, therefore, included a question asking for such statistics, but would ask that it be answered only with respect to cases regarding svhich there could be no reasonable doubt, but that they were genuine cholera, and that, if any other drugs or modejof treatment was used, that they will be mentioned.
severity
