ANOTHER SUGGESTION FOR THE TREATMENT OF CHOLERA.
By Surgeon-Major Augustus R. Hall, Army Medical Department, in Medical charge, British
Troops,
Fortress Gwalior.
Since in the
writing my paper last month, which appeared September number of the Indian Medical Gazette, I have had some cases of cholera, of a very severe type, Two of them proved fatal rapidly, the purging to treat. and vomiting being so incessant that the blood lost a very large quantity of serum in a very short time. Choral Hydrate was injected into the muscles in large quantities, but with no permanent benefit. Although they were forced to drink plenty of water, the stomach rejected even very small quantities immediately, and probably not any of it was absorbed. Now, we know
that very gr eat temporary benefit has often followed the injection of warm saline solutions into the veins, or into the rectum, in cholera collapse. But the effect
has not been lasting. And, on consideration, it may appear obvious that as long as the cause of the rapid loss of fluid from the blood continues in operation, the fresh liquid injected cannot be retained. But if, as is presumed here, that cause is essentially a state of undue
stimulation, or irritation of the sympathetic and
vaso-motor
centres, and Chloral Hydrate is able to subdue that irritation in cases where the blood has lost so much serum that it cannot circulate so that the pulse can be felt at the wrist, a combination of the two methods of injection may be beneficial. The last case I have had, I saw at about 3 o'clock A. 11. Both heart sounds could be heard, and the pulse at the nerve
wrist was then pretty distinct; but vomiting and purging were very severe, hands very cold and shrivelled, although the temperature in the axilla was 97-2? F. He had twenty-four grains of chloral put into his muscles, and eighty grains given by stomach, fifty of which lie
retained, within seven hours. But about 10 o'clock the pulse could not be felt at the ivrist; so, although there was a great deal of diarrhoea, an enema of water, about 1(J0? F. temperature, was administered,?two pints being into the rectum. It came away in a few miThe idea then struck me that the man's bladder was empty, and that it might be utilized. I consequently passed a large-sized catheter, and with an ordinary glass syringe squirted some water of 100? F. temperature
pumped nutes.
into the bladder. At first the water returned immediately, but after a few more injections some of it was retained,?about one dozen syringefuls. The orifice of the catheter was then plugged with a piece of woodi and the instrument held in the bladder for about twenty minutes. Meanwhile some more water temp. 100? F. The result was most was pumped into the rectum. satisfactory ; the pulse, within half an hour, could be felt at the wrist; the cramps, vomiting and purgHe had sis enemata altogether. At night he had a scruple more chloral by mouth, which made him sleep ; and with the exception of distressing hiccough
again
ing subsided.
for several
days,
suggestion
that I
he has made a good recovery. The follows. now wish to make is as
October 1,
1878.]
SALICYLATE OF
SODA,
&c.?BY SURO. EDWARD
When a patient is seen in collapse, inject at once, say, twelve grains of chloral dissolved in a hundred and twenty minims of water in a muscle?deltoid. Then pump into the bladder a quantity of plain water, temperature about 100? F. (not too hot). Keep on squirting in the water through the catheter till a considerable quantity of it is
the orifice of the catheter ; or, if necessary, escaping by the side of the instrument, apply a small bandage round the penis, near the pubis. If the patient should be a female, perhaps the injection could be made through a full-sized male catheter, with a towel wrapped round it, without
retained,
then on
plug
account of the water
any exposure of the person. Keep the instrument in about twenty minutes. If a bad stricture should exist, this plan may be impossible?then enemata of hot water, about temperature 110? F., may be thrown into the
rectum. Never mind if it be ejected, continue pumping it in, and some will surely be absorbed. Or, in very severe cases, the recommendation of Surgeon-Major Kellett, A. M. D., may be followed, and water put under the skin, so as to produce artificial dropsy. But under all circumstances, whether injections are made into the bladder or not, frequent enemata will probably be found After twenty minutes the heart, pulse, very useful. and temperature may be observed, and, if necessary, twelve more grains of Chloral injected into another muscle. If the blood by this time has become more diluted with the water, this quantity of the drug, if
properly absorbed, nerve
while water
may
be
sufficient
to soothe the
perhaps produce sleep. All the encourage the patient to drink as much cold as possible. Theoretically, it probably would
centres,
and
be well to get cholera patients to drink hot water in the shape of tea, milk and water, &c., but they crave for cold drinks, and will not take a sufficient quantity of hot ones. If the sickness of stomach should have become less, any more chloral requisite may be given by mouth. It does not appear that saline solutions are indispensIf the blood can get a sufficient supply of pure water, it seems to be able to perform its functions well enough till nourishment in the form of milk, beef tea, &c., can be conveyed to it through the usual channels.
able.
In my former paper I have so strongly recommended the avoidance of all alcoholic stimulants as well as opiates till convalescence be established, that perhaps a repetition of that advice may be considered superfluous here. But reports that have been published, show that chloral and alcohol very often are given together. Dr. Oscar Liebreich, the discoverer of chloral, and many other
experimenters, have proved that it is a very powerful vascular depressant, and we ail know that alcohol is a cardiac stimulant, at all events in the first stages of its action, till a large amount has been consumed quickly. Surely, then, the exhibition of the two simultaneously, or following each other, must be incompatible ! If it be determined to employ chloral, let that remedy be trusted to alone, to the exclusion of alcohol and opium. The latter drug has been proved to be most pernicious in cholera collapse. Dr. John Harley describes its action as that of a stimulating narcotic, causing death by coma and apncea. Chloral being a
LAWRIE,
M. D.
269
sedative, tends
to depress the heart's action and And as the heart, in cholera syncope. produce collapse, is supposed here to be in a state of tonic spasmodic contraction, its use is advocated by me. I hope, therefore, that Medical Officers will give this last suggestion of mine a trial. There ar e other sedatives that may be used with true
benefit, which I have not yet tried. Now, if injections of hot water into the bladder and rectum enable the injections of chloral to be circulated and carried to the nerve centres by the blood, a plan of treatment may at last have been happily hit upon which will rescue the patient from impending death. 8th September, 1878.
L
By Surgeon-Major Augustus R. Hall, Army Medical Department, in Medical charge, British
Troops,
Fortress Gwalior.
Since in the
writing my paper last month, which appeared September number of the Indian Medical Gazette, I have had some cases of cholera, of a very severe type, Two of them proved fatal rapidly, the purging to treat. and vomiting being so incessant that the blood lost a very large quantity of serum in a very short time. Choral Hydrate was injected into the muscles in large quantities, but with no permanent benefit. Although they were forced to drink plenty of water, the stomach rejected even very small quantities immediately, and probably not any of it was absorbed. Now, we know
that very gr eat temporary benefit has often followed the injection of warm saline solutions into the veins, or into the rectum, in cholera collapse. But the effect
has not been lasting. And, on consideration, it may appear obvious that as long as the cause of the rapid loss of fluid from the blood continues in operation, the fresh liquid injected cannot be retained. But if, as is presumed here, that cause is essentially a state of undue
stimulation, or irritation of the sympathetic and
vaso-motor
centres, and Chloral Hydrate is able to subdue that irritation in cases where the blood has lost so much serum that it cannot circulate so that the pulse can be felt at the wrist, a combination of the two methods of injection may be beneficial. The last case I have had, I saw at about 3 o'clock A. 11. Both heart sounds could be heard, and the pulse at the nerve
wrist was then pretty distinct; but vomiting and purging were very severe, hands very cold and shrivelled, although the temperature in the axilla was 97-2? F. He had twenty-four grains of chloral put into his muscles, and eighty grains given by stomach, fifty of which lie
retained, within seven hours. But about 10 o'clock the pulse could not be felt at the ivrist; so, although there was a great deal of diarrhoea, an enema of water, about 1(J0? F. temperature, was administered,?two pints being into the rectum. It came away in a few miThe idea then struck me that the man's bladder was empty, and that it might be utilized. I consequently passed a large-sized catheter, and with an ordinary glass syringe squirted some water of 100? F. temperature
pumped nutes.
into the bladder. At first the water returned immediately, but after a few more injections some of it was retained,?about one dozen syringefuls. The orifice of the catheter was then plugged with a piece of woodi and the instrument held in the bladder for about twenty minutes. Meanwhile some more water temp. 100? F. The result was most was pumped into the rectum. satisfactory ; the pulse, within half an hour, could be felt at the wrist; the cramps, vomiting and purgHe had sis enemata altogether. At night he had a scruple more chloral by mouth, which made him sleep ; and with the exception of distressing hiccough
again
ing subsided.
for several
days,
suggestion
that I
he has made a good recovery. The follows. now wish to make is as
October 1,
1878.]
SALICYLATE OF
SODA,
&c.?BY SURO. EDWARD
When a patient is seen in collapse, inject at once, say, twelve grains of chloral dissolved in a hundred and twenty minims of water in a muscle?deltoid. Then pump into the bladder a quantity of plain water, temperature about 100? F. (not too hot). Keep on squirting in the water through the catheter till a considerable quantity of it is
the orifice of the catheter ; or, if necessary, escaping by the side of the instrument, apply a small bandage round the penis, near the pubis. If the patient should be a female, perhaps the injection could be made through a full-sized male catheter, with a towel wrapped round it, without
retained,
then on
plug
account of the water
any exposure of the person. Keep the instrument in about twenty minutes. If a bad stricture should exist, this plan may be impossible?then enemata of hot water, about temperature 110? F., may be thrown into the
rectum. Never mind if it be ejected, continue pumping it in, and some will surely be absorbed. Or, in very severe cases, the recommendation of Surgeon-Major Kellett, A. M. D., may be followed, and water put under the skin, so as to produce artificial dropsy. But under all circumstances, whether injections are made into the bladder or not, frequent enemata will probably be found After twenty minutes the heart, pulse, very useful. and temperature may be observed, and, if necessary, twelve more grains of Chloral injected into another muscle. If the blood by this time has become more diluted with the water, this quantity of the drug, if
properly absorbed, nerve
while water
may
be
sufficient
to soothe the
perhaps produce sleep. All the encourage the patient to drink as much cold as possible. Theoretically, it probably would
centres,
and
be well to get cholera patients to drink hot water in the shape of tea, milk and water, &c., but they crave for cold drinks, and will not take a sufficient quantity of hot ones. If the sickness of stomach should have become less, any more chloral requisite may be given by mouth. It does not appear that saline solutions are indispensIf the blood can get a sufficient supply of pure water, it seems to be able to perform its functions well enough till nourishment in the form of milk, beef tea, &c., can be conveyed to it through the usual channels.
able.
In my former paper I have so strongly recommended the avoidance of all alcoholic stimulants as well as opiates till convalescence be established, that perhaps a repetition of that advice may be considered superfluous here. But reports that have been published, show that chloral and alcohol very often are given together. Dr. Oscar Liebreich, the discoverer of chloral, and many other
experimenters, have proved that it is a very powerful vascular depressant, and we ail know that alcohol is a cardiac stimulant, at all events in the first stages of its action, till a large amount has been consumed quickly. Surely, then, the exhibition of the two simultaneously, or following each other, must be incompatible ! If it be determined to employ chloral, let that remedy be trusted to alone, to the exclusion of alcohol and opium. The latter drug has been proved to be most pernicious in cholera collapse. Dr. John Harley describes its action as that of a stimulating narcotic, causing death by coma and apncea. Chloral being a
LAWRIE,
M. D.
269
sedative, tends
to depress the heart's action and And as the heart, in cholera syncope. produce collapse, is supposed here to be in a state of tonic spasmodic contraction, its use is advocated by me. I hope, therefore, that Medical Officers will give this last suggestion of mine a trial. There ar e other sedatives that may be used with true
benefit, which I have not yet tried. Now, if injections of hot water into the bladder and rectum enable the injections of chloral to be circulated and carried to the nerve centres by the blood, a plan of treatment may at last have been happily hit upon which will rescue the patient from impending death. 8th September, 1878.
L
