want of water in the blooil, and unless this
can
be in some way
supplied, no remedial means will ever avail. In lucky cases, even although the dreadful collapse has set in, if absorption be in a slight degree established, it is sufficient to tide the patient over his troubles, and a little precious time will enable the tired-oot system to rally. I have endeavoured to show that death from cholera, as it is commonly called, is only death from the absence of the water of the blood, and we may trace to the same cause all the peculiar phenomena of cholera, spasm, restlessness, thirst, loss of heat, smell, &c., &c. Spasm is a constant and most painful accompaniment of this disease. The dreadful shriek heard in the cholera ward shows as well the acute sensibility of the nervous
the extreme nature of the agony which calls it forth. be supposed that this clonic spasm was caused by the direct action on the spinal cord of the poison circulating in the blood, but this, I think, would be an error ; for if the worst and most dangerous symptom of cholera, viz., the loss of water,
system,
It
as
might
is of itself intended to be salutary, spasm may be looked upon also, more or less, as one of nature's curative efforts. To explain this, it is only necessary to trace it to its cause. The nutrition of muscular fibre is dependent on the movement of the blood in the which movement relies as much for its mainlocal force directly applied by muscular action and the elasticity of the carrying tubes, as upon the " vis a tergo" or propelling influence of the heart's action, for pulsation ceases iu these vessels and the flow is continuous. These capillaries being so
ultimate tenance
OBSERVATIONS ON
THE PATHOLOGY AND
TREATMENT OF
CHOLERA. Bt BAMLET W.
SWITZER, F.R.C.S.I., Assistant-Sdiigeon, Bengal Armt. PART
In
a
previous
voured to view
II.
number of the Indian Medical Gazette I endeathe pathology of cholera in a common-sense
light, comparing the disease with another, and trying to deduce from such comparison the principles of a rational mode of treatment. I would as briefly as may be continue my subject. If we carefully examine the circulatory phenomena presented to us in a case of established cholera, it will aid in proving the truth of the views advanced. A robust man struck down by cholera speedily becomes cold, his lips livid, his skin blue, slow and
thready ; the action of the heart is laboured and weak ; and the oppression in breathing so great as to cause frequent long inspiratory sighs. The blue finger-nails and livid lips point, to venous congestion ; the precordial anxiety shows an overcharged heart. If a vein in the arm of such a subject be opened, instead of the bright jet which usually meets the lancet's point, there is an entire absence of any blood, or at best but a single black drop : the hydrostatic condition of the blood is such that motion or circulation is almost impossiand
ble. a
his
pulse
When we make pressureinthe direction of the venous current, drops exude, and by continuing the pressure a little
few tarry
blood,
more
resembling black currant jelly
may be collected. Compare such a state tion in the healthy man, or one suffering does not exhaust the blood of its water. out with its natural fluidity, and the full
than
of
anything I know, things with venesec-
from any disease which In the one, it force of
springs
active heart pumping the vital stream ; in the other, the gory fluid hardly moving from its own inherent gravity, refuses to flow but from an adventitious force. What must be the result when such a fluid arrives at the heart and lungs ? The former, clogged an
by a nearly solid mass, is unable to contract with vigour to expel it; the abortive efforts to do so only the more weaken its failing strength ; the latter, with their parenchyma choked by carbonized blood, and the respiratory muscles senii-paraIvzed for want of nutrition, barely gasp at the air so necessary to re-empty them. Let the primary cause of cholera be what it may, the proximate cause of death is the
capillaries,
on
almost impervious to the flow of thickened blood, which therefore stagnates in them ; muscular regeneration, includingthe carrying off of effete matter, always going on must now cease, and the carbonized blood performs the part of a mechanical irritant. The afferent nerves of the excito-motory system are hereby
minute, are
impression is transmitted through the nervous branches, distributed to the muscular fibre, causing clonic spasm for the purpose of mechanically emptying these gorged capillaries. The proof is that it is in the affected,
and the
centre to
the motor
muscles which are situated at the greatest distance from the heart, and therefore from its propelling influence on the capillary circulation, that cramp is most usually seen, namely, those of the extremities, and the lower more frequently than the upper. The need of interstitial absorption and the removal of organic detritus, or, in other words, the conservancy of the system
being suspended, causes so prominent in
that
jactitation
and extreme rest-
cholera ; no position is comfortable ; the arms toss, the body turns from side to side, the muscles are perpetually moving to empty, by pressure, the too full capillaries. The thirst of the cholera patient is at once the most lessness
prominent, frequent, and distressing symptom brought before us, entreaty for water, to my mind, clearly points out that Nature here, as in many other diseases, endeavours to show where she wants help. In the plethoric man threatened with apoplexy, copious bleeding from the nose is Nature's effort to avert death. In the pleuritic stitch from a broken rib, she asks for rest; in tlic strongly contracted muscles around a diin the gasping breath do not move me seased joint, she says, of the asthmatic, she wheezes out, give me airin the fearful thirst of cholera, she urgently pleads, "give me water." We will seldom err if we listen to Nature's cry and give heed to her admonitions j she can always best tell, what she wants, though, not necessarily able to take it when offered. Many people believe that the worst thing a cholera patient can drink is water, but I have seen men who held this opinion compelled by their feelings to yield to the heart-rending supplications of a dying patient. The loss of heat in a cholera patient is awfully rapid. When the disease is established, the cold, clammy skin, shrivelled fingers, and charnel cold breath are present. As the blood, the great carrier of animal heat, is unable to circulate with any stream, and the small quantity that does move being highly carbonized, no heat is supplied ; add to this the secondary nervous and this constant
"
"
THE INDIAN MEDICAL GAZETTE.
S6
depression from the same cause, and the great evaporation taking place from skin and lungs, and then the diminution of temperature, is readily accounted for. No amount of covering placed over a cholera patient can keep him warm; in fact it will not be borne, for to him it keeps in cold, not heat, and is thrust aside. Hot bottles, warm bricks, frictions in vain endeavour to preserve the natural temperature, and notwithstanding all this loss of heat, it is rarely the sufferer asks for anything but cold water ; occasionally warm drinks are preferred, but it is rare; brandy aud water, hot, will not be taken, when the same, cold, will be eagerly swallowed. Very early in my cholera experience I noticed, though 1
am
unaware
whether others have
also
remarked,
a
very
peculiar smell from a cholera patient; it is that of flesh sodden by water, and may also be got from a body recently drowned, or from beef steeped in water for a night. I first
remarked this smell in the cholera ward, and considered it pathognomonic of the disease; afterwards I found it from the other two causes also : it is one of the earliest marks of the advent of malignant cholera. The only other trustworthy mark
choleraica, or choleraic expression of only be learnt by experience. To diagnostic symptoms, I will relate the case
I know of is the fades countenance, which can illustrate these
as
European soldier attached to the Allahabad Convalescent Depot in the year 1859, during the cholera epidemic* Being in charge of the depot myself, I warned the men not to neglect even trifling diarrhoea. Acting on this, at my midday visit to the cholera ward of the General Hospital, this man camc saying he that he had one or two loose motions, but that was not ill, and only wanted a dose and to go back to of
a
barracks. Now, cholera was written on this man's face, and he had the sodden smell; he was admitted into hospital, and, notwithstanding the most early and prompt treatment, which This was was unremitting, he was dead in about four hours. one
of those cases I before alluded to, in which either the quantity of the poison killed before Nature's
virulencc or the
eliminative process had time to come to the rescue. I can offer no rational explanation of this smell, unless it is developed in the muscular tissue as the water oozes through, or that it is the smell of the poison itself. It is stronger in those cases where much water is lost, but is present before any is discharged, and leaves the body shortly after death. It would be tedious,
uninteresting,
and of
no
practical value
to
put
on
record
a
of cholera cases, many treated dissimilarly and all varying results. Every surgeon can draw largely on his own experience for such, and will doubtless well remember the many disheartening scenes he has been an actor in, when the utmost human skill was unavailing. Passing through such, and feeling utterly foiled and beaten, set me to think of the disease and try to fix some principle upon which to ground my treatment. I never put the slightest faith in any of the million infallible cures every day sown broadcast in the public prints ; empirics can show no reason why their vaunted specifics should cure, and the few cases which have survived in spite of their remedies are all the evidence they can adduce to coerce any into wasting human life in a re-trial of patent absurdities. The list of specifics in therapeutics is a small one, and to it has not yet been added one for cholera. A prophylactic may be discovered, as vaccine lymph has done for small-pox, so may some hidden rteans of warding off cholera come to light; but until this is the case, the dispassionate consideration of the best means we have for averting death is what will most reward us. I stated in the beginning of this paper that I had no infallible plan of treatment to recommend, no one drug to hymn the praises of. The alluring theory which conviction of its truth has brought home to me I hold as my creed, viz., that when all discharge of water has ceased from the system, Nature herself has accomplished the cure. The physician believing this, meets the collapsed patient without despair, and treats him from number
with
[April 1,
Pandora's box, which always has What has been considered the most
1866.
bright hope at the bottom. hopeless stage of the disease
is the most
hopeful, and while one weak throb of life redespair. My three postulates are?1st, that predisposing diarrhoea is not cholera, nor a stage of it, and is to be treated secundum artem for itself only; 2nd, that it is useless and hurtful to endeavour by medicines of any kind to check Nature's salutary discharge?Nature's cure; 3rd, that when this has ceased of itself, the time for action has come. Predisposing diarrhoea is the only one of the three arbitrary and mains,
we
need not
incorrect stages of cholera, which for convenience I assume, in which the administration of opium is allowable ; the murderous practice of giving solid opium after established cholera has set in, cannot be too strongly deprecated. I say murderous ! a strong word no doubt, but not the less true; for although the stomach rejects plentifully the water containing the poison, solid elements sink to the greater curvature, remain there till the disease has departed, and then, as the absorbents resume
their
functions,
narcotised and the stomach of
the unfortunate
dies comatose. a
patient
There has
cholera corpse
as
been
much solid
is
speedily
taken
from
in four healthv For predisposing diarrhoea, whatever line of treatment men. the physician most approves of for cutting it short, should be the form of pill, as would suffice to
poison
three
opium
or
adopted. In cholera times it is not always safe to give even a purgative to remove indigestible matter. Castor oil well guarded by opium is the only one I would ever use, and its action should be promptly checked. The usual remedies, chalk or other astringent mixtures with opium, and acetate of lead, gallic acid, &c.., generally suffice. Chlorodyne, that invaluable preparation, or the per-chlorodvne of Bathgate's, which is equally good, well when given in small and frequently repeated acts
mild
doses ; but the treatment of this diarrhoea is the same as any If it has been satisfactorily ascertained that a large meal has been eaten a short time before, but not otherwise, a other.
large mustard emetic should be given ?, two tablespoonfuls in eight ounces of water must be insisted on. It is a very disagreeable, but admirable, means of emptying the stomach, withI always hesitate out which giving medicine would be useless. to give this, except in the above circumstances, as the emesis produced may continue and usher in the true disease. When, no doubt that the uncheckable diarrhoea has to the watery stools, vomit, and sweating, the administration of the mustard emetic becomes imperatively necessary. After it large lumps of undigested meat, fruit, vegetables, often issue from a European soldier's stomach, which may have
however, there is
given place
lain there for forty-eight hours. It also cleans out all the medicine which has proved useless to check the diarrhoea, and acts directly as an internal blister to the absorbents on the mucous coat of the stomach. It is the most useful and successful adjuvant, and should always form the primary treatment of established cholera when not
previously given for the diarrhoea. After this drugs are of little avail ; in fact, they do more harm than good, until the cessation of the discharges. Nature is at work. Let her alone. Brandy and water, chloroform, chlorodyne, cholera tincture, hydrocyanic acid, opium, &c., are all out of place here. The only useful thing I know of is ice, which, if procurable, allays very often the extreme thirst; otherwise anything not absolutely hurtful that the patient fancies; he may take champagne, tea, lemonade, or plain water, matters little ; it generally all returns, and is useless while the emesis and purging continue?nay, often only increasing them. It seems a hard doctrine to inculcate that nothing can be done towards saving the patient whilst the waste is going on, and the system losing what will so soon be missed and so sadly wanted ; neither is it a line of practice calculated to produce confidence in the patient, when his physician stands by doing nothing. But, nevertheless, I fear it is a true doctrine, and in my experience meddling interference with the disease iu attempts I believe
April 1, 1866.]
ON CHOLERA. BY B. W. SWITZER.
to check the discharge of the poison, only more certainly bring a fatal issue. The usual formulary of the sick-room is to torment the patient with hot bottles, bricks, mustard plasters, about
kneading the limbs, administering opium, assafoetida, brandy, ammonia, chloroform, See., 8cc.rad nauseam ; it is all useless, and the patient asks only to be left alone, for nothing soothes the troubled stomach; at last the looked-for, wished-for lull takes place, and the discharge of water gradually ceases as profound collapse comes on. The patient now has reached the point where, cured of the disease, he has to encounter the result, and Here the physician steps in, the fight for life is a tough one. and the one sole object to be kept steadily in view is, that the absorptive function in skin, lungs, stomach, and intestines must be re-established, and by this means water supplied to the blood. I know of no certain way of bringing this about ; I wish I did, for then the problem would have been solved ; but perseverance in rational treatment is most frequently crowned with success, and the returning heat of the pulse and the brightening eye well repay one for a night's loss of rest, while battling with disease. The plan of treatment which I have found most successful in collapse may be briefly described ; to be thoroughly carried out, it requires the appliances of a cholera hospital. And in times of epidemic* visitation all, both high and low, should be treated in such. This may be practically a Utopian idea, but theoretically it is a very sound one. As soon as the alvine discharge ceases, the patient should be placed in a tepid reclining bath, not hot enough to be disagreeable, say about 90? F., and the temperature very gradually raised until it reaches 105? F., or higher, if it can be borne. The effect of this is threefold?\st, it draws the blood from the congested organs internally to the surface, unloading the semUparalysed heart and relieving the eugorged lungs ; 2nd, it supplies the heat so much wanted, and which cannot otherwise be given; 3rd, it offers to the skin and its absorbents the thing sought to be introduced into the system, and presents it in the most favorable manner to the largest absorbing If the warm-bath surface. be adopted early, the pulse immediately rises on immersion, and continues for some time to do so ; this should be carefully watched, for it is the guide to our perseverance in its use. When the pulse remains stationary, or when it begins to lessen in either strength or number, the patient should be removed, dried, and placed between warm blankets ;
the bath may be repeated three times, but it is not often necessary more than once; immediately after this a large injection of warm milk, or arrowroot and milk, sweetened as for
drinking,
should be thrown far up the colon through Re id's long tube; if this is retained, a favorable result may be hoped for. The administration of food is too often neglected; it should early be
given
arrowroot
nature; thin sago made with water, and flavoured with wine or
in small or
acidulated with
quantities
and
of a
palatable
lemon, is generally agreeable, is freely taken, usually remains. A critical sleep frequently comes on after the bath, and if food ha3 been administered, and the injection retained, the change for the better is evident when the awakening comes. The next most favorable means of introducing water ns by the inhalation of steam. Water finding its way in minutely divided particles to the lungs, is readily absorbed and directly conveyed to the venous blood. The cholera ward should always contain an atmosphere saturated with warm moisture; could it be filled with clouds of condensing steam, it would be a model ward. Food to support strength, and water to liquify the blood, are indicated instead of drugs ; the use of stimulants, carminative astringents, and sedatives must be left to the discretion of the physician; I would only urge the harm the latter may do. if in the early efforts at absorption, they lull the vessels to a fatal sleep. When all still fails, the most powerful means of rousing the sinking heart, and which I have over and over again seen sueand
87
cessful, is the application, over the heart, and to the diaphragmatic region, of the temperature of boiling water. This is best done by keeping water boiling at the bedside in a lota, and placing two ordinary tablespoons in it; these when taken from the water at a temperature of 212? P., and their bowls placed over the regions indicated, will cause immediate action of the heart and inspiratory muscles. The most moribund patient will wince at the application of this, and the pulse quickly rises under its use, as well as the respirations ; used at intervals of ten or fifteen minutes, it is a valuable adjuvant in restoring from collapse. Much objection will be made to the severe pain it causes, but the cnly bad result following it is the removal of the cuticle or the effects of a scald ; it is doubly valuable as a means of powerful stimulation, from being always readily procurable. The abstraction of a small quantity of blood from the arm sometimes wonderfully relieves oppression, and I know of nothing which better removes cramp. An ounce or two withdrawn from the right arm, followed in an hour by the same from the left, instead of weakening, strengthens and brightens the patient. Further than this I would not go. not
so far until there was some evidence of the re-admittance of water into the circulation. Demulcent, nourishing, or stimulating drinks of any kind,
which the patient may ask for, he should freely have when the stomach will retain them: food, water, and heat supply all the wants of the collapsed. The principle of treatment kept in view, minor matters will
suggest their
best remedies; mustard to the epigastrium, temples, friction to the extremities or trunk, icecaps, blisters, &c., &c., may all be useful and required. I did not propose to myself to write a history of the disease or its treatment, and have been betrayed into writing at greater length than I originally intended. These observations are the result of the experience of three epidemics in this country, as well as the A numerous isolated sporadic cases of every-day occurrence. marked and most happy change in the type of the disease was noted in the epidemic from which the Hidgelee district suffered in the early part of last year, after the ravages of the cyclone; the predisposing diarrhoea was short hut well marked, and was frequently cured by the ordinary cholera pill and mixture. When it refused to yield, the established disease with its characteristic accompaniment came and lasted generally three to six hours, being succeeded by a collapse which was peculiarly long, often lasting three days, and this made the epidemic far more manageable than usual; for I looked on such cases as cured of cholera, and only requiring careful treatment and constant watching to bring them round. Most gratifying results followed in thosa to whom I could myself attend, for secondary fever never occurs own
leeches to the
where over-stimulation has not been used. In conclusion, I would ask that the disease be treated on principle, not empirically. Others may find more successful means of doing what I have
endeavoured, but that the timely supply, by artificial or natural means, of water to the waterless blood is as well the rational as the sufficient cure of cholera, the bed-side physician will soon
acknowledge. Jessore,
February
18G6.
can
be in some way
supplied, no remedial means will ever avail. In lucky cases, even although the dreadful collapse has set in, if absorption be in a slight degree established, it is sufficient to tide the patient over his troubles, and a little precious time will enable the tired-oot system to rally. I have endeavoured to show that death from cholera, as it is commonly called, is only death from the absence of the water of the blood, and we may trace to the same cause all the peculiar phenomena of cholera, spasm, restlessness, thirst, loss of heat, smell, &c., &c. Spasm is a constant and most painful accompaniment of this disease. The dreadful shriek heard in the cholera ward shows as well the acute sensibility of the nervous
the extreme nature of the agony which calls it forth. be supposed that this clonic spasm was caused by the direct action on the spinal cord of the poison circulating in the blood, but this, I think, would be an error ; for if the worst and most dangerous symptom of cholera, viz., the loss of water,
system,
It
as
might
is of itself intended to be salutary, spasm may be looked upon also, more or less, as one of nature's curative efforts. To explain this, it is only necessary to trace it to its cause. The nutrition of muscular fibre is dependent on the movement of the blood in the which movement relies as much for its mainlocal force directly applied by muscular action and the elasticity of the carrying tubes, as upon the " vis a tergo" or propelling influence of the heart's action, for pulsation ceases iu these vessels and the flow is continuous. These capillaries being so
ultimate tenance
OBSERVATIONS ON
THE PATHOLOGY AND
TREATMENT OF
CHOLERA. Bt BAMLET W.
SWITZER, F.R.C.S.I., Assistant-Sdiigeon, Bengal Armt. PART
In
a
previous
voured to view
II.
number of the Indian Medical Gazette I endeathe pathology of cholera in a common-sense
light, comparing the disease with another, and trying to deduce from such comparison the principles of a rational mode of treatment. I would as briefly as may be continue my subject. If we carefully examine the circulatory phenomena presented to us in a case of established cholera, it will aid in proving the truth of the views advanced. A robust man struck down by cholera speedily becomes cold, his lips livid, his skin blue, slow and
thready ; the action of the heart is laboured and weak ; and the oppression in breathing so great as to cause frequent long inspiratory sighs. The blue finger-nails and livid lips point, to venous congestion ; the precordial anxiety shows an overcharged heart. If a vein in the arm of such a subject be opened, instead of the bright jet which usually meets the lancet's point, there is an entire absence of any blood, or at best but a single black drop : the hydrostatic condition of the blood is such that motion or circulation is almost impossiand
ble. a
his
pulse
When we make pressureinthe direction of the venous current, drops exude, and by continuing the pressure a little
few tarry
blood,
more
resembling black currant jelly
may be collected. Compare such a state tion in the healthy man, or one suffering does not exhaust the blood of its water. out with its natural fluidity, and the full
than
of
anything I know, things with venesec-
from any disease which In the one, it force of
springs
active heart pumping the vital stream ; in the other, the gory fluid hardly moving from its own inherent gravity, refuses to flow but from an adventitious force. What must be the result when such a fluid arrives at the heart and lungs ? The former, clogged an
by a nearly solid mass, is unable to contract with vigour to expel it; the abortive efforts to do so only the more weaken its failing strength ; the latter, with their parenchyma choked by carbonized blood, and the respiratory muscles senii-paraIvzed for want of nutrition, barely gasp at the air so necessary to re-empty them. Let the primary cause of cholera be what it may, the proximate cause of death is the
capillaries,
on
almost impervious to the flow of thickened blood, which therefore stagnates in them ; muscular regeneration, includingthe carrying off of effete matter, always going on must now cease, and the carbonized blood performs the part of a mechanical irritant. The afferent nerves of the excito-motory system are hereby
minute, are
impression is transmitted through the nervous branches, distributed to the muscular fibre, causing clonic spasm for the purpose of mechanically emptying these gorged capillaries. The proof is that it is in the affected,
and the
centre to
the motor
muscles which are situated at the greatest distance from the heart, and therefore from its propelling influence on the capillary circulation, that cramp is most usually seen, namely, those of the extremities, and the lower more frequently than the upper. The need of interstitial absorption and the removal of organic detritus, or, in other words, the conservancy of the system
being suspended, causes so prominent in
that
jactitation
and extreme rest-
cholera ; no position is comfortable ; the arms toss, the body turns from side to side, the muscles are perpetually moving to empty, by pressure, the too full capillaries. The thirst of the cholera patient is at once the most lessness
prominent, frequent, and distressing symptom brought before us, entreaty for water, to my mind, clearly points out that Nature here, as in many other diseases, endeavours to show where she wants help. In the plethoric man threatened with apoplexy, copious bleeding from the nose is Nature's effort to avert death. In the pleuritic stitch from a broken rib, she asks for rest; in tlic strongly contracted muscles around a diin the gasping breath do not move me seased joint, she says, of the asthmatic, she wheezes out, give me airin the fearful thirst of cholera, she urgently pleads, "give me water." We will seldom err if we listen to Nature's cry and give heed to her admonitions j she can always best tell, what she wants, though, not necessarily able to take it when offered. Many people believe that the worst thing a cholera patient can drink is water, but I have seen men who held this opinion compelled by their feelings to yield to the heart-rending supplications of a dying patient. The loss of heat in a cholera patient is awfully rapid. When the disease is established, the cold, clammy skin, shrivelled fingers, and charnel cold breath are present. As the blood, the great carrier of animal heat, is unable to circulate with any stream, and the small quantity that does move being highly carbonized, no heat is supplied ; add to this the secondary nervous and this constant
"
"
THE INDIAN MEDICAL GAZETTE.
S6
depression from the same cause, and the great evaporation taking place from skin and lungs, and then the diminution of temperature, is readily accounted for. No amount of covering placed over a cholera patient can keep him warm; in fact it will not be borne, for to him it keeps in cold, not heat, and is thrust aside. Hot bottles, warm bricks, frictions in vain endeavour to preserve the natural temperature, and notwithstanding all this loss of heat, it is rarely the sufferer asks for anything but cold water ; occasionally warm drinks are preferred, but it is rare; brandy aud water, hot, will not be taken, when the same, cold, will be eagerly swallowed. Very early in my cholera experience I noticed, though 1
am
unaware
whether others have
also
remarked,
a
very
peculiar smell from a cholera patient; it is that of flesh sodden by water, and may also be got from a body recently drowned, or from beef steeped in water for a night. I first
remarked this smell in the cholera ward, and considered it pathognomonic of the disease; afterwards I found it from the other two causes also : it is one of the earliest marks of the advent of malignant cholera. The only other trustworthy mark
choleraica, or choleraic expression of only be learnt by experience. To diagnostic symptoms, I will relate the case
I know of is the fades countenance, which can illustrate these
as
European soldier attached to the Allahabad Convalescent Depot in the year 1859, during the cholera epidemic* Being in charge of the depot myself, I warned the men not to neglect even trifling diarrhoea. Acting on this, at my midday visit to the cholera ward of the General Hospital, this man camc saying he that he had one or two loose motions, but that was not ill, and only wanted a dose and to go back to of
a
barracks. Now, cholera was written on this man's face, and he had the sodden smell; he was admitted into hospital, and, notwithstanding the most early and prompt treatment, which This was was unremitting, he was dead in about four hours. one
of those cases I before alluded to, in which either the quantity of the poison killed before Nature's
virulencc or the
eliminative process had time to come to the rescue. I can offer no rational explanation of this smell, unless it is developed in the muscular tissue as the water oozes through, or that it is the smell of the poison itself. It is stronger in those cases where much water is lost, but is present before any is discharged, and leaves the body shortly after death. It would be tedious,
uninteresting,
and of
no
practical value
to
put
on
record
a
of cholera cases, many treated dissimilarly and all varying results. Every surgeon can draw largely on his own experience for such, and will doubtless well remember the many disheartening scenes he has been an actor in, when the utmost human skill was unavailing. Passing through such, and feeling utterly foiled and beaten, set me to think of the disease and try to fix some principle upon which to ground my treatment. I never put the slightest faith in any of the million infallible cures every day sown broadcast in the public prints ; empirics can show no reason why their vaunted specifics should cure, and the few cases which have survived in spite of their remedies are all the evidence they can adduce to coerce any into wasting human life in a re-trial of patent absurdities. The list of specifics in therapeutics is a small one, and to it has not yet been added one for cholera. A prophylactic may be discovered, as vaccine lymph has done for small-pox, so may some hidden rteans of warding off cholera come to light; but until this is the case, the dispassionate consideration of the best means we have for averting death is what will most reward us. I stated in the beginning of this paper that I had no infallible plan of treatment to recommend, no one drug to hymn the praises of. The alluring theory which conviction of its truth has brought home to me I hold as my creed, viz., that when all discharge of water has ceased from the system, Nature herself has accomplished the cure. The physician believing this, meets the collapsed patient without despair, and treats him from number
with
[April 1,
Pandora's box, which always has What has been considered the most
1866.
bright hope at the bottom. hopeless stage of the disease
is the most
hopeful, and while one weak throb of life redespair. My three postulates are?1st, that predisposing diarrhoea is not cholera, nor a stage of it, and is to be treated secundum artem for itself only; 2nd, that it is useless and hurtful to endeavour by medicines of any kind to check Nature's salutary discharge?Nature's cure; 3rd, that when this has ceased of itself, the time for action has come. Predisposing diarrhoea is the only one of the three arbitrary and mains,
we
need not
incorrect stages of cholera, which for convenience I assume, in which the administration of opium is allowable ; the murderous practice of giving solid opium after established cholera has set in, cannot be too strongly deprecated. I say murderous ! a strong word no doubt, but not the less true; for although the stomach rejects plentifully the water containing the poison, solid elements sink to the greater curvature, remain there till the disease has departed, and then, as the absorbents resume
their
functions,
narcotised and the stomach of
the unfortunate
dies comatose. a
patient
There has
cholera corpse
as
been
much solid
is
speedily
taken
from
in four healthv For predisposing diarrhoea, whatever line of treatment men. the physician most approves of for cutting it short, should be the form of pill, as would suffice to
poison
three
opium
or
adopted. In cholera times it is not always safe to give even a purgative to remove indigestible matter. Castor oil well guarded by opium is the only one I would ever use, and its action should be promptly checked. The usual remedies, chalk or other astringent mixtures with opium, and acetate of lead, gallic acid, &c.., generally suffice. Chlorodyne, that invaluable preparation, or the per-chlorodvne of Bathgate's, which is equally good, well when given in small and frequently repeated acts
mild
doses ; but the treatment of this diarrhoea is the same as any If it has been satisfactorily ascertained that a large meal has been eaten a short time before, but not otherwise, a other.
large mustard emetic should be given ?, two tablespoonfuls in eight ounces of water must be insisted on. It is a very disagreeable, but admirable, means of emptying the stomach, withI always hesitate out which giving medicine would be useless. to give this, except in the above circumstances, as the emesis produced may continue and usher in the true disease. When, no doubt that the uncheckable diarrhoea has to the watery stools, vomit, and sweating, the administration of the mustard emetic becomes imperatively necessary. After it large lumps of undigested meat, fruit, vegetables, often issue from a European soldier's stomach, which may have
however, there is
given place
lain there for forty-eight hours. It also cleans out all the medicine which has proved useless to check the diarrhoea, and acts directly as an internal blister to the absorbents on the mucous coat of the stomach. It is the most useful and successful adjuvant, and should always form the primary treatment of established cholera when not
previously given for the diarrhoea. After this drugs are of little avail ; in fact, they do more harm than good, until the cessation of the discharges. Nature is at work. Let her alone. Brandy and water, chloroform, chlorodyne, cholera tincture, hydrocyanic acid, opium, &c., are all out of place here. The only useful thing I know of is ice, which, if procurable, allays very often the extreme thirst; otherwise anything not absolutely hurtful that the patient fancies; he may take champagne, tea, lemonade, or plain water, matters little ; it generally all returns, and is useless while the emesis and purging continue?nay, often only increasing them. It seems a hard doctrine to inculcate that nothing can be done towards saving the patient whilst the waste is going on, and the system losing what will so soon be missed and so sadly wanted ; neither is it a line of practice calculated to produce confidence in the patient, when his physician stands by doing nothing. But, nevertheless, I fear it is a true doctrine, and in my experience meddling interference with the disease iu attempts I believe
April 1, 1866.]
ON CHOLERA. BY B. W. SWITZER.
to check the discharge of the poison, only more certainly bring a fatal issue. The usual formulary of the sick-room is to torment the patient with hot bottles, bricks, mustard plasters, about
kneading the limbs, administering opium, assafoetida, brandy, ammonia, chloroform, See., 8cc.rad nauseam ; it is all useless, and the patient asks only to be left alone, for nothing soothes the troubled stomach; at last the looked-for, wished-for lull takes place, and the discharge of water gradually ceases as profound collapse comes on. The patient now has reached the point where, cured of the disease, he has to encounter the result, and Here the physician steps in, the fight for life is a tough one. and the one sole object to be kept steadily in view is, that the absorptive function in skin, lungs, stomach, and intestines must be re-established, and by this means water supplied to the blood. I know of no certain way of bringing this about ; I wish I did, for then the problem would have been solved ; but perseverance in rational treatment is most frequently crowned with success, and the returning heat of the pulse and the brightening eye well repay one for a night's loss of rest, while battling with disease. The plan of treatment which I have found most successful in collapse may be briefly described ; to be thoroughly carried out, it requires the appliances of a cholera hospital. And in times of epidemic* visitation all, both high and low, should be treated in such. This may be practically a Utopian idea, but theoretically it is a very sound one. As soon as the alvine discharge ceases, the patient should be placed in a tepid reclining bath, not hot enough to be disagreeable, say about 90? F., and the temperature very gradually raised until it reaches 105? F., or higher, if it can be borne. The effect of this is threefold?\st, it draws the blood from the congested organs internally to the surface, unloading the semUparalysed heart and relieving the eugorged lungs ; 2nd, it supplies the heat so much wanted, and which cannot otherwise be given; 3rd, it offers to the skin and its absorbents the thing sought to be introduced into the system, and presents it in the most favorable manner to the largest absorbing If the warm-bath surface. be adopted early, the pulse immediately rises on immersion, and continues for some time to do so ; this should be carefully watched, for it is the guide to our perseverance in its use. When the pulse remains stationary, or when it begins to lessen in either strength or number, the patient should be removed, dried, and placed between warm blankets ;
the bath may be repeated three times, but it is not often necessary more than once; immediately after this a large injection of warm milk, or arrowroot and milk, sweetened as for
drinking,
should be thrown far up the colon through Re id's long tube; if this is retained, a favorable result may be hoped for. The administration of food is too often neglected; it should early be
given
arrowroot
nature; thin sago made with water, and flavoured with wine or
in small or
acidulated with
quantities
and
of a
palatable
lemon, is generally agreeable, is freely taken, usually remains. A critical sleep frequently comes on after the bath, and if food ha3 been administered, and the injection retained, the change for the better is evident when the awakening comes. The next most favorable means of introducing water ns by the inhalation of steam. Water finding its way in minutely divided particles to the lungs, is readily absorbed and directly conveyed to the venous blood. The cholera ward should always contain an atmosphere saturated with warm moisture; could it be filled with clouds of condensing steam, it would be a model ward. Food to support strength, and water to liquify the blood, are indicated instead of drugs ; the use of stimulants, carminative astringents, and sedatives must be left to the discretion of the physician; I would only urge the harm the latter may do. if in the early efforts at absorption, they lull the vessels to a fatal sleep. When all still fails, the most powerful means of rousing the sinking heart, and which I have over and over again seen sueand
87
cessful, is the application, over the heart, and to the diaphragmatic region, of the temperature of boiling water. This is best done by keeping water boiling at the bedside in a lota, and placing two ordinary tablespoons in it; these when taken from the water at a temperature of 212? P., and their bowls placed over the regions indicated, will cause immediate action of the heart and inspiratory muscles. The most moribund patient will wince at the application of this, and the pulse quickly rises under its use, as well as the respirations ; used at intervals of ten or fifteen minutes, it is a valuable adjuvant in restoring from collapse. Much objection will be made to the severe pain it causes, but the cnly bad result following it is the removal of the cuticle or the effects of a scald ; it is doubly valuable as a means of powerful stimulation, from being always readily procurable. The abstraction of a small quantity of blood from the arm sometimes wonderfully relieves oppression, and I know of nothing which better removes cramp. An ounce or two withdrawn from the right arm, followed in an hour by the same from the left, instead of weakening, strengthens and brightens the patient. Further than this I would not go. not
so far until there was some evidence of the re-admittance of water into the circulation. Demulcent, nourishing, or stimulating drinks of any kind,
which the patient may ask for, he should freely have when the stomach will retain them: food, water, and heat supply all the wants of the collapsed. The principle of treatment kept in view, minor matters will
suggest their
best remedies; mustard to the epigastrium, temples, friction to the extremities or trunk, icecaps, blisters, &c., &c., may all be useful and required. I did not propose to myself to write a history of the disease or its treatment, and have been betrayed into writing at greater length than I originally intended. These observations are the result of the experience of three epidemics in this country, as well as the A numerous isolated sporadic cases of every-day occurrence. marked and most happy change in the type of the disease was noted in the epidemic from which the Hidgelee district suffered in the early part of last year, after the ravages of the cyclone; the predisposing diarrhoea was short hut well marked, and was frequently cured by the ordinary cholera pill and mixture. When it refused to yield, the established disease with its characteristic accompaniment came and lasted generally three to six hours, being succeeded by a collapse which was peculiarly long, often lasting three days, and this made the epidemic far more manageable than usual; for I looked on such cases as cured of cholera, and only requiring careful treatment and constant watching to bring them round. Most gratifying results followed in thosa to whom I could myself attend, for secondary fever never occurs own
leeches to the
where over-stimulation has not been used. In conclusion, I would ask that the disease be treated on principle, not empirically. Others may find more successful means of doing what I have
endeavoured, but that the timely supply, by artificial or natural means, of water to the waterless blood is as well the rational as the sufficient cure of cholera, the bed-side physician will soon
acknowledge. Jessore,
February
18G6.
