NOTES ON CHOLERA. BY GEORGE J. ROSS.
During the summer and autumu of 1888 there were two outbreaks of cholera iu the Rawul Pindi Jail necessitating the removal of
the prisoners into camp twice, and as, besides the jail, several Europeans and others were treated by the same method which proved extremely successful, a brief account of the experience gained may be of general service. In all about 100 cases were treated with 19
deaths. I may
that
cholera outbreaks inyears of abnormal rainfall, mostly when the fall is scanty and there is a prevalence of hot winds, which produce an unfavorable influence on the general health, marked by dyspepsia and diarrhoea. During this state of predisposition the poison of cholera is readily absorbed, its medium of
premise
variably occur during
transmission
being undoubtedly
water.
The physiological effects of cholera poison may be summed up in a few words. There is constant vomiting and purging from irritability of the stomach and intestines; the blood being drained of its fluid parts, causing intense thirst, and instead of coursing rapidly through the vessels, as it does in health, stagnates in the great veins of the thorax and abdomeu. There is, iu short, disturbance of the circulation and excessive intestinal secretion. (Lauder JBrunton.) The remedy must be one therefore which has the power of removing these conditions, and it has been proved that the elimination of a poison is not required iu order to prevent its injurious or fatal action; for the administration of an antidote will deprive it of its hurtful power.
(Lauder Brunton).
muscarin, isolated from a poisonous mushroom, the agonicus muscarin, produces a physiological effect on the circulaThe
alkaloid
tion similar to the poison of cholera, and as atropiu has been found to be a perfect antidote to muscarin, its use in cholera has been advocated especially by American physicians. As, however, the excessive intestinal secretion has to be mainly considered, a remedy must be administered which will check such a condition, and opium is undoubtedly the most powerful agent we possess for that purpose. Hence a combination of atropin with the most useful alkaloid of opium, morphine affords au effective
THE INDIAN MEDICAL GAZETTE.
172
The solutiou should be the epigastrium. The stages of cholera attack may be divided into the congestive or stage of incubation and the inflammatory or that of invasion followed by collapse. In the first stage of incubation, when the stomach possesses active digestive power, alkalines must be given ; as, according to a known law, alkalines produce an acid reaction ; they thus tend to check the alkaline secretions in which the cholera organisms so
and
speedy remedy.
injected
over
rapidly propagate. During the stage of invasion when all remedies poured into the stomach pass through it unaltered, acids must be used for the same and combined with hypodermic of atropin and morphia in the pit of the stomach they will be found to produce a speedy effect in checking the diarrhoea and vomiting. Both remedies must be persevered in, every 20 minutes if necessary, until a decided effect is produced, when this is done, aud the patient kept quiet or bv himself, he will fall asleep or wake either well or in a fair and hopeful state. In the collapse which always occurs, more or less, it is necessary to guard against overfeeding or over-stimulation, both of which are certain to increase the chances of uraemic poisoning, suppression of urine continuing even when reaction has set in. During this stage no remedies are of service, absorption is arrested, and ether with iced congee water or crushed ice in small quantities, and frequently, is all that hand rubbing with can be done internally; rubefacients and sinapisms should be now tried. When reaction sets in care must be taken that the patient on 110 account sits up, as a relapse may occur, or his circulation may fail, from the thickened state of the blood should purging come on again, recourse must be had to the Hypodermic Syringe and the acid with ether mixtures. It is of the greatest importance, next to prompt treatment, to isolate cases as much as possible, or, at any rate, to place them in groups according to the stage of the disease. To put a man with violent purging into a tent where there are other patients recovering, is a sure way to start the disease afresh in the latter; fear being so powerful a factor. Crushed ice must be given freely; it has a marvellous effect in allaying thirst and stopping the vomiting, thus supplying the waste of the fluids of the body. The following procedure was adopted in the and soda and jail. For diarrhoea wereindigestion, In used. obstinate ammonia with gentian and and when chalk opium, diarrhoea prepared the latter were found useless, the acid mixbelow was exhibited. "W hen a case ture reason;
injections
given
was
Taken
with
vomiting aud purging,
a
hy-
[June,
1889.
podermic injection of morphia \ grain and atropiu grain was put into tlie skin below the en si form cartilage. A sinapism was applied over
the abdomen, and the
following
mixture
given
S. Acid Giillic Acid Sid ph. dil. Tinct. Catechu Tinct. Cardamon Spt. Chloroform Acid Carbolic Aquam ad. M. ft. Haust.
,,,
...
...
gr. x m. xx
...
...
...
...
...
...
w. xv
...
...
...
m.
xx
m
xv
...
...
...
...
gr. i
Ji.
Crushed ice was freely given, also iced water; and the injection repeated congee every 20 minutes till the patient fell asleep and the waste ceased. During collapse, the following stimulant was used :? R. 01.
Cajeput
gtt. ij
...
Spt. Auiuion Arom. Spt. Ether Nitris Aqua Camphor
...
...
...
...
...
...
...
...
...
in.
xx
in.
xv
3i.
M. ft. Haust.
reactions ice was still used ad libitum mild diuretic with acid given.?
During
and
a
R. Acid Acetic Spt. Ether Nitris
...
...
Aqua Camphor
...
...
m. xx
...
...
m. xv
...
...
in.
...
M. ft. Haust.
Ji.
The hypodermic injections were used when there was any tendency to restlessness even during the fever of reactions. A regular routine was observed ; one attendant had charge of the syringe, another the sinapisms, another the acid mixture, and a fourth ice, thus they went round the tents treating the 75 cases that occurred, and I feel certain that but for an unfortunate panic which took them on the death of the hospital assistant when the epidemic was at its very worst, the mortality would have been very trifling. ?
?
During the summer and autumu of 1888 there were two outbreaks of cholera iu the Rawul Pindi Jail necessitating the removal of
the prisoners into camp twice, and as, besides the jail, several Europeans and others were treated by the same method which proved extremely successful, a brief account of the experience gained may be of general service. In all about 100 cases were treated with 19
deaths. I may
that
cholera outbreaks inyears of abnormal rainfall, mostly when the fall is scanty and there is a prevalence of hot winds, which produce an unfavorable influence on the general health, marked by dyspepsia and diarrhoea. During this state of predisposition the poison of cholera is readily absorbed, its medium of
premise
variably occur during
transmission
being undoubtedly
water.
The physiological effects of cholera poison may be summed up in a few words. There is constant vomiting and purging from irritability of the stomach and intestines; the blood being drained of its fluid parts, causing intense thirst, and instead of coursing rapidly through the vessels, as it does in health, stagnates in the great veins of the thorax and abdomeu. There is, iu short, disturbance of the circulation and excessive intestinal secretion. (Lauder JBrunton.) The remedy must be one therefore which has the power of removing these conditions, and it has been proved that the elimination of a poison is not required iu order to prevent its injurious or fatal action; for the administration of an antidote will deprive it of its hurtful power.
(Lauder Brunton).
muscarin, isolated from a poisonous mushroom, the agonicus muscarin, produces a physiological effect on the circulaThe
alkaloid
tion similar to the poison of cholera, and as atropiu has been found to be a perfect antidote to muscarin, its use in cholera has been advocated especially by American physicians. As, however, the excessive intestinal secretion has to be mainly considered, a remedy must be administered which will check such a condition, and opium is undoubtedly the most powerful agent we possess for that purpose. Hence a combination of atropin with the most useful alkaloid of opium, morphine affords au effective
THE INDIAN MEDICAL GAZETTE.
172
The solutiou should be the epigastrium. The stages of cholera attack may be divided into the congestive or stage of incubation and the inflammatory or that of invasion followed by collapse. In the first stage of incubation, when the stomach possesses active digestive power, alkalines must be given ; as, according to a known law, alkalines produce an acid reaction ; they thus tend to check the alkaline secretions in which the cholera organisms so
and
speedy remedy.
injected
over
rapidly propagate. During the stage of invasion when all remedies poured into the stomach pass through it unaltered, acids must be used for the same and combined with hypodermic of atropin and morphia in the pit of the stomach they will be found to produce a speedy effect in checking the diarrhoea and vomiting. Both remedies must be persevered in, every 20 minutes if necessary, until a decided effect is produced, when this is done, aud the patient kept quiet or bv himself, he will fall asleep or wake either well or in a fair and hopeful state. In the collapse which always occurs, more or less, it is necessary to guard against overfeeding or over-stimulation, both of which are certain to increase the chances of uraemic poisoning, suppression of urine continuing even when reaction has set in. During this stage no remedies are of service, absorption is arrested, and ether with iced congee water or crushed ice in small quantities, and frequently, is all that hand rubbing with can be done internally; rubefacients and sinapisms should be now tried. When reaction sets in care must be taken that the patient on 110 account sits up, as a relapse may occur, or his circulation may fail, from the thickened state of the blood should purging come on again, recourse must be had to the Hypodermic Syringe and the acid with ether mixtures. It is of the greatest importance, next to prompt treatment, to isolate cases as much as possible, or, at any rate, to place them in groups according to the stage of the disease. To put a man with violent purging into a tent where there are other patients recovering, is a sure way to start the disease afresh in the latter; fear being so powerful a factor. Crushed ice must be given freely; it has a marvellous effect in allaying thirst and stopping the vomiting, thus supplying the waste of the fluids of the body. The following procedure was adopted in the and soda and jail. For diarrhoea wereindigestion, In used. obstinate ammonia with gentian and and when chalk opium, diarrhoea prepared the latter were found useless, the acid mixbelow was exhibited. "W hen a case ture reason;
injections
given
was
Taken
with
vomiting aud purging,
a
hy-
[June,
1889.
podermic injection of morphia \ grain and atropiu grain was put into tlie skin below the en si form cartilage. A sinapism was applied over
the abdomen, and the
following
mixture
given
S. Acid Giillic Acid Sid ph. dil. Tinct. Catechu Tinct. Cardamon Spt. Chloroform Acid Carbolic Aquam ad. M. ft. Haust.
,,,
...
...
gr. x m. xx
...
...
...
...
...
...
w. xv
...
...
...
m.
xx
m
xv
...
...
...
...
gr. i
Ji.
Crushed ice was freely given, also iced water; and the injection repeated congee every 20 minutes till the patient fell asleep and the waste ceased. During collapse, the following stimulant was used :? R. 01.
Cajeput
gtt. ij
...
Spt. Auiuion Arom. Spt. Ether Nitris Aqua Camphor
...
...
...
...
...
...
...
...
...
in.
xx
in.
xv
3i.
M. ft. Haust.
reactions ice was still used ad libitum mild diuretic with acid given.?
During
and
a
R. Acid Acetic Spt. Ether Nitris
...
...
Aqua Camphor
...
...
m. xx
...
...
m. xv
...
...
in.
...
M. ft. Haust.
Ji.
The hypodermic injections were used when there was any tendency to restlessness even during the fever of reactions. A regular routine was observed ; one attendant had charge of the syringe, another the sinapisms, another the acid mixture, and a fourth ice, thus they went round the tents treating the 75 cases that occurred, and I feel certain that but for an unfortunate panic which took them on the death of the hospital assistant when the epidemic was at its very worst, the mortality would have been very trifling. ?
?
