SUGGESTIONS FOR THE TREATMENT OF CHOLERA.
By
Surgeon-Major Augustus R.
Army
Medical
Department,
Hall,
in Medical
charge
British Troops, Fortress Gwalior. Daring the recent epidemic at Morar, in the month of May, I had an opportunity afforded me by Dr. Ivellie,
Superintending Surgeon-Major, Gwalior Circle, of treating some cases of cholera; and as the results produced a very favourable impression among those acquainted with the facts, it may be of advantage to have the details brought to the notice of the Profession in India, in the pages of the Indian Medical Gazette. A full report of these cases has, of course, been sent to the
but
Surgeon-General,
as cases
of cholera
beneficial to relate here, I may commence by one woman
H. M.'s British Forces at Simla ; are now frequent, it may be
briefly, the method stating that I had
carried out. six men and
to treat from the commencement, in whom
the
of Chloral Hydrate was employed. Of these five men recovered, one lived for fifteen days, and all symptoms of cholera had disappeared. A post mortem examination showed fatty degeneration of the heart. The woman died in collapse. One man, a Driver of the Royal Artillery, aged 21, the first case that occurred in this battery, had as much as eighty-one grains of Chloral injected into him. Another man, aged 23, had fifty-seven grains injected, and an-
hypodermic injection
37, had fifty-one grains put into his They all recovered, the second one having had suppression of urine for ninety-two hours. These facts tend to prove that very large quantities of Chloral may be used, and indeed may be absolutely required, in cholera collapse. The following are the principal points that I beg to recommend specially. During the prevalence of cholera, let all medicines containing opium, or alkalies, be avoided. If a person should suffer from painless diarrhoea, dilute Sulphuric Acid will probably be found the best remedy. Thirty to sixty minims, in four to six ounces of water, or a bottle of gingerade, will be found au agreeable drink, which may be repeated two or three times if necessary. Let the public be assured that it is the painless diarrhoea that is to be guarded against; people very often get colic, or griping, and fly to the brandy or chlorodyne bottle ; they get relief from these, and often think they have averted other,
aged
muscles.
THE INDIAN MEDICAL GAZETTE.
942
But in true cholera colic is not I of the abdomithere (of may be cramp nal muscles, which is quite another thing.) In the painless diarrhoea characteristic of the disease, all stimulants and opiates had better be avoided, as well as alkalies) and the dilute Sulphuric Acid employed alone. In those cases that are first seen when collapse is iman
attack of cholera.
met with
course
pending, or has set in, Chloral is recommended to be used at But the hypodermic injection is only to be employonce. ed in cases where it is absolutely necessary, on account of the sickness at stomach. When a patient is admitted with the usual symptoms of collapse, I at once examine the heart's action with the stethoscope. If both sounds are heard distinctly, and there is little vomiting, 30 to 40 grains of Chloral, diluted with giii or ?iv of water, may be given by mouth, and, if retained, may soon bring on sleep with very satisfactory results. But, in severe cases, the second sound may be lost, and the first sound be indistinct, and in very bad cases even the first sound
may be inaudible. It is in these that the employment of large doses of Chloral hypodermically is strongly advocated here. The clinical thermometer is always employed to ascertain the temperature in the axilla, and observations recorded every hour if necessary, and the lower the temperature, the more Chloral may be injected. A solution composed of one part of Chloral to ten of water, (say, ji dissolved in ?i, 5ij aquas) is kept well corked, (of course, the Chloral must be fresh and good). If the extremities of the patient be very cold, and the temperature in axilla about 95? F., 320 minims of the
solution, containing thirty-two grains of Chloral, may be
following manner. Most of the syringes twenty-five drops. Supposing one is used holding twenty drops, taking care that it is in good working order, and the point very clean and sharp, the canula is to be plunged vertically into the substance of a muscle, say one of the deltoids, to a depth of (1?) one inch and a half. The solution is then to be injected into the muscle. The cylinder is then to be unscrewed from in the
injected
hold twenty
or
the canula, and handed to an assistant, who will refill the syringe with the solution. The operator, meanwhile, withdraws the canula from the substance of the muscle, until the point reaches the areolar tissue. It is then insay at an
clined, angle of about 45?, and pushed into the muscle in this direction to the same depth. The body of the syringe is then to be screwed on tightly, and this second quantity of the solution injected. This process may be repeated twice more, thus altogether inof troducing eighty minims of the solution?eight grains
Chloral into four different portions of the muscle, with only one puncture through the skin, thus lessening the chance of irritation of the cutaneous nerves. It is considered essential that the solution should be put into the muscles as it may not be absorbed when placed merely under the skin. Then the other deltoid may be treated in the two others, the gluteus, or rectus pectoralis, or those of the back may also be injected, till 320 drops of the solution have been expended. Plenty of cold water may be given to drink, irrespective of the vomiting and purging, but no stimulants of any sort, nor opium in any form. The quantity of Chloral same
manner, and
femoris,
or
named above
[September 2,
probably
will
produce sleep,
1878.
and the surface
temperature will begin to rise. But if not, inject again twenty or thirty grains within the hour. The last cases I have had to treat, a few days ago, were two, the wife of
a
to the
hospital.
soldier in this fortress, and a bheestee attached The English woman was taken ill at 4 A. M., but did not come to hospital till 9-15 A. M. The pulse could not be felt, even in the brachial artery, the heart sounds were inaudible, hands very cold, temperature in axilla 97*2 F. I injected twenty-six grains of Chloral into four muscles and gave her 5ss of chloral by mouth as well, which she retained. In about a quarter of an hour she was asleep, and continued so for more than one hour. The cramps, which were very distressing, soon ceased. About two hours after the injections I could hear both sounds of the heart distinctly. She dozed a good deal all the day, and had water and soda-water to drink, but nothing else. She had 9i more Chloral at night, as a sleeping draught, and passed a good night, and has made a good recovery with only milk, beef tea, chicken broth, no stimulants of any sort.
The bheestee
seized about
was
noon on
the
day. When brought up and seen by me, twenty grains of Chloral were given by mouth but immediately
same
After
rejected.
a
few minutes this
but with the same result.
was
again tried,
of Chloral were injected into his muscles. This soon put him to sleep, his surface temperature rose, and he has also recovered well. These cases happened just one week ago. I wish in this paper to confine myself strictly to facts., and avoid all theories, and so have jotted down what has occurred in my own hands, up to the present. In
Twenty grains
conclusion, perhaps it may be well to place before the reader, in a concise form, the details that are recommended by me. During the so-called premonitory diarrhoea, let all opium, alkalies and stimulants be avoided, and jss to 3i doses of dilute Sulphuric Acid be given, say in a bottle of gingerade. When collapse is impending, before vomiting sets in, 3ssto 3ii of Chloral Hydrate, in 3iii or ^iv aquae, perhaps with some syrup added, may be given by mouth. If this be retained, it will probably induce sleep, and the patient may wake up very much relieved.
If symptoms are not relieved within half an hour repeat the dose, twice if necessary. If collapse be present, with much vomiting, let the Chloral be introduced into the muscles subcutaneously at once ; listen to the heart and take the temperature in the axilla. If the sounds of the heart are inaudible, and temperature low, say 96? F., hands and tongue very cold, introduce about thirty grains of Chloral as soon as possible, and inject fifteen or twenty grains more if the temperature does not begin to rise within half be
one
an
hour.
part of Chloral
specific gravity
be too
Let the to ten
high
of the solution If the water. it will not be absorbed
strength
parts of
ulceration or even sloughing. If the patient gets a good sleep it may be hoped that
properly,.but
cause
recovery will take place, without any other treatment. When the pulse can be again felt at the wrist, its character may be noted. Should reaction be established the
pulse
will be felt
its normal condition.
full
and hard before
returning
to
September 2,
be
1878.]
A MIRROR OF HOSPITAL PRACTICE.
Let plenty of water, cooled with ice, but not too cold, irrespective of the vomiting or purging. In
given,
be encouraged to drink it. A little lemonade, may be given if asked for, but on no account any wine, spirits, or other stimulants, or any Till reaction be thing containing opium or morphia. established, cold water alone may be given in large quantities. If there be prolonged suppression of urine, dry cup over the loins repeatedly, and give water to drink,
fact,
let the
soda water,
patient or
hut no stimulants whatever nor diuretics.
The
kidneys are diuretics, especially stimulatgreatly congested, ing ones, will do positive injury. Should reaction by these means happily be established, bland fluid nourishment, such as milk, chicken broth, beef tea may be given in gradually increasing quantities. But until convalescence be thoroughly secured, it is strongly recommended that no alcoholic stimulants be given?until, and any
in fact, solid food can be taken. If secondary fever should supervene quinine may be relied on to reduce the
temperature, or its use may be supplemented by packing Should there be cerebral congestion, in a wet sheet. blisters to the head or neck may be required. Should of the lungs manifest itself, poultices of meal to envelope the whole of the thorax (jackets) with quinine and non-stimulating nourishment will probably be found all that is requisite. But, as a
congestion
linseed
rale, it is recommended that all alcoholic stimulants be avoided till ail the symptoms of cholera or its sequelae have disappeared. I have written these suggestions in the earnest hope that those of my professional brethren who may read them will give them an impartial trial. If they will do so and publish the re suits, it will probably not be very long before it can be decided whether Chloral Hydrate, in the quantities here recommended, be or be not a valu-
remedy in cholera collapse. August 10th, 1878.
able
243
By
Surgeon-Major Augustus R.
Army
Medical
Department,
Hall,
in Medical
charge
British Troops, Fortress Gwalior. Daring the recent epidemic at Morar, in the month of May, I had an opportunity afforded me by Dr. Ivellie,
Superintending Surgeon-Major, Gwalior Circle, of treating some cases of cholera; and as the results produced a very favourable impression among those acquainted with the facts, it may be of advantage to have the details brought to the notice of the Profession in India, in the pages of the Indian Medical Gazette. A full report of these cases has, of course, been sent to the
but
Surgeon-General,
as cases
of cholera
beneficial to relate here, I may commence by one woman
H. M.'s British Forces at Simla ; are now frequent, it may be
briefly, the method stating that I had
carried out. six men and
to treat from the commencement, in whom
the
of Chloral Hydrate was employed. Of these five men recovered, one lived for fifteen days, and all symptoms of cholera had disappeared. A post mortem examination showed fatty degeneration of the heart. The woman died in collapse. One man, a Driver of the Royal Artillery, aged 21, the first case that occurred in this battery, had as much as eighty-one grains of Chloral injected into him. Another man, aged 23, had fifty-seven grains injected, and an-
hypodermic injection
37, had fifty-one grains put into his They all recovered, the second one having had suppression of urine for ninety-two hours. These facts tend to prove that very large quantities of Chloral may be used, and indeed may be absolutely required, in cholera collapse. The following are the principal points that I beg to recommend specially. During the prevalence of cholera, let all medicines containing opium, or alkalies, be avoided. If a person should suffer from painless diarrhoea, dilute Sulphuric Acid will probably be found the best remedy. Thirty to sixty minims, in four to six ounces of water, or a bottle of gingerade, will be found au agreeable drink, which may be repeated two or three times if necessary. Let the public be assured that it is the painless diarrhoea that is to be guarded against; people very often get colic, or griping, and fly to the brandy or chlorodyne bottle ; they get relief from these, and often think they have averted other,
aged
muscles.
THE INDIAN MEDICAL GAZETTE.
942
But in true cholera colic is not I of the abdomithere (of may be cramp nal muscles, which is quite another thing.) In the painless diarrhoea characteristic of the disease, all stimulants and opiates had better be avoided, as well as alkalies) and the dilute Sulphuric Acid employed alone. In those cases that are first seen when collapse is iman
attack of cholera.
met with
course
pending, or has set in, Chloral is recommended to be used at But the hypodermic injection is only to be employonce. ed in cases where it is absolutely necessary, on account of the sickness at stomach. When a patient is admitted with the usual symptoms of collapse, I at once examine the heart's action with the stethoscope. If both sounds are heard distinctly, and there is little vomiting, 30 to 40 grains of Chloral, diluted with giii or ?iv of water, may be given by mouth, and, if retained, may soon bring on sleep with very satisfactory results. But, in severe cases, the second sound may be lost, and the first sound be indistinct, and in very bad cases even the first sound
may be inaudible. It is in these that the employment of large doses of Chloral hypodermically is strongly advocated here. The clinical thermometer is always employed to ascertain the temperature in the axilla, and observations recorded every hour if necessary, and the lower the temperature, the more Chloral may be injected. A solution composed of one part of Chloral to ten of water, (say, ji dissolved in ?i, 5ij aquas) is kept well corked, (of course, the Chloral must be fresh and good). If the extremities of the patient be very cold, and the temperature in axilla about 95? F., 320 minims of the
solution, containing thirty-two grains of Chloral, may be
following manner. Most of the syringes twenty-five drops. Supposing one is used holding twenty drops, taking care that it is in good working order, and the point very clean and sharp, the canula is to be plunged vertically into the substance of a muscle, say one of the deltoids, to a depth of (1?) one inch and a half. The solution is then to be injected into the muscle. The cylinder is then to be unscrewed from in the
injected
hold twenty
or
the canula, and handed to an assistant, who will refill the syringe with the solution. The operator, meanwhile, withdraws the canula from the substance of the muscle, until the point reaches the areolar tissue. It is then insay at an
clined, angle of about 45?, and pushed into the muscle in this direction to the same depth. The body of the syringe is then to be screwed on tightly, and this second quantity of the solution injected. This process may be repeated twice more, thus altogether inof troducing eighty minims of the solution?eight grains
Chloral into four different portions of the muscle, with only one puncture through the skin, thus lessening the chance of irritation of the cutaneous nerves. It is considered essential that the solution should be put into the muscles as it may not be absorbed when placed merely under the skin. Then the other deltoid may be treated in the two others, the gluteus, or rectus pectoralis, or those of the back may also be injected, till 320 drops of the solution have been expended. Plenty of cold water may be given to drink, irrespective of the vomiting and purging, but no stimulants of any sort, nor opium in any form. The quantity of Chloral same
manner, and
femoris,
or
named above
[September 2,
probably
will
produce sleep,
1878.
and the surface
temperature will begin to rise. But if not, inject again twenty or thirty grains within the hour. The last cases I have had to treat, a few days ago, were two, the wife of
a
to the
hospital.
soldier in this fortress, and a bheestee attached The English woman was taken ill at 4 A. M., but did not come to hospital till 9-15 A. M. The pulse could not be felt, even in the brachial artery, the heart sounds were inaudible, hands very cold, temperature in axilla 97*2 F. I injected twenty-six grains of Chloral into four muscles and gave her 5ss of chloral by mouth as well, which she retained. In about a quarter of an hour she was asleep, and continued so for more than one hour. The cramps, which were very distressing, soon ceased. About two hours after the injections I could hear both sounds of the heart distinctly. She dozed a good deal all the day, and had water and soda-water to drink, but nothing else. She had 9i more Chloral at night, as a sleeping draught, and passed a good night, and has made a good recovery with only milk, beef tea, chicken broth, no stimulants of any sort.
The bheestee
seized about
was
noon on
the
day. When brought up and seen by me, twenty grains of Chloral were given by mouth but immediately
same
After
rejected.
a
few minutes this
but with the same result.
was
again tried,
of Chloral were injected into his muscles. This soon put him to sleep, his surface temperature rose, and he has also recovered well. These cases happened just one week ago. I wish in this paper to confine myself strictly to facts., and avoid all theories, and so have jotted down what has occurred in my own hands, up to the present. In
Twenty grains
conclusion, perhaps it may be well to place before the reader, in a concise form, the details that are recommended by me. During the so-called premonitory diarrhoea, let all opium, alkalies and stimulants be avoided, and jss to 3i doses of dilute Sulphuric Acid be given, say in a bottle of gingerade. When collapse is impending, before vomiting sets in, 3ssto 3ii of Chloral Hydrate, in 3iii or ^iv aquae, perhaps with some syrup added, may be given by mouth. If this be retained, it will probably induce sleep, and the patient may wake up very much relieved.
If symptoms are not relieved within half an hour repeat the dose, twice if necessary. If collapse be present, with much vomiting, let the Chloral be introduced into the muscles subcutaneously at once ; listen to the heart and take the temperature in the axilla. If the sounds of the heart are inaudible, and temperature low, say 96? F., hands and tongue very cold, introduce about thirty grains of Chloral as soon as possible, and inject fifteen or twenty grains more if the temperature does not begin to rise within half be
one
an
hour.
part of Chloral
specific gravity
be too
Let the to ten
high
of the solution If the water. it will not be absorbed
strength
parts of
ulceration or even sloughing. If the patient gets a good sleep it may be hoped that
properly,.but
cause
recovery will take place, without any other treatment. When the pulse can be again felt at the wrist, its character may be noted. Should reaction be established the
pulse
will be felt
its normal condition.
full
and hard before
returning
to
September 2,
be
1878.]
A MIRROR OF HOSPITAL PRACTICE.
Let plenty of water, cooled with ice, but not too cold, irrespective of the vomiting or purging. In
given,
be encouraged to drink it. A little lemonade, may be given if asked for, but on no account any wine, spirits, or other stimulants, or any Till reaction be thing containing opium or morphia. established, cold water alone may be given in large quantities. If there be prolonged suppression of urine, dry cup over the loins repeatedly, and give water to drink,
fact,
let the
soda water,
patient or
hut no stimulants whatever nor diuretics.
The
kidneys are diuretics, especially stimulatgreatly congested, ing ones, will do positive injury. Should reaction by these means happily be established, bland fluid nourishment, such as milk, chicken broth, beef tea may be given in gradually increasing quantities. But until convalescence be thoroughly secured, it is strongly recommended that no alcoholic stimulants be given?until, and any
in fact, solid food can be taken. If secondary fever should supervene quinine may be relied on to reduce the
temperature, or its use may be supplemented by packing Should there be cerebral congestion, in a wet sheet. blisters to the head or neck may be required. Should of the lungs manifest itself, poultices of meal to envelope the whole of the thorax (jackets) with quinine and non-stimulating nourishment will probably be found all that is requisite. But, as a
congestion
linseed
rale, it is recommended that all alcoholic stimulants be avoided till ail the symptoms of cholera or its sequelae have disappeared. I have written these suggestions in the earnest hope that those of my professional brethren who may read them will give them an impartial trial. If they will do so and publish the re suits, it will probably not be very long before it can be decided whether Chloral Hydrate, in the quantities here recommended, be or be not a valu-
remedy in cholera collapse. August 10th, 1878.
able
243
