July 1,
SURGEON SIBTHORPE ON THE TREATMENT OF CHOLERA.
18S0.J
ORIGINAL COMMUNICATIONS. SOME NOTES
THE
ON
CHOLERA AND THE
TREATMENT
OF
ADMINISTRATION
Madras Medical Service. one of so constantly recurring interest to all medical officers in this country, that I think the following notes, founded on experience gained in several different epidemics both in this country and in Ireland, may be of interest. The idea of recording some remarks on the adminisration of cholera hospitals was suggested to me by the painful memories of the Khyber cholera hospitals " during the famous march of death" last year, and of is
the difficulties at other times 1 myself have experienced, and have known other medical officers to experience, in organizing such hospitals. During the past five years the following number of patients were admitted into the General Hospital, Madras : 106, of whom 42 died. Europeans and East Indians Natives 999, of whom 479 died. ...
...
...
...
The first case was admitted in August 1875 ; there had not been any cases treated in hospitals during the earlier part of that year. The two last cases were admitted
in
January 1879. The epidemic reached its height during the prevalence of the famine, and a large proportion of the patients admitted had suffered severely from privation. The following table shows the number of admissions and deaths yearly during the period :? 1877.
1878.
1879.
Total.
42
Europeans Natives
gradually disappeared a
was
thirty-three.
treatment I was taught as a student well explained by my venerated teacher Dr. Stokes, when speaking at the College of Physicians in Ireland in 1867 on the subject of the treatment pursued in Dublin was
By Surgeon C. Sibthorpe,
subject
; and during 1878 there were few isolated admissions. The greatest number under treatment on any one day was on the 20th January 1877, namely forty-four patients, and the average during the month of January 1877
ease
only
Treatment.?The
OP CHOLEIIA HOSPITALS.
The
479
during the epidemic
Of the deaths amongst Europeans 14 took pluce within 24 hours of their admission iuto hospital, and of the Natives 291. The number of admissions, which had varied from one to twenty-seven a month from August 1875, attained to
eighty-five
mum
and
in December
in January 1877,
ninety-nine
seven
died.
cases
This
1876, and reached its maxiduring which month one hundred were admitted, of whom seventy,
was
the time of year when the famine
severely on the people in Madras. Durof the month February 1877 there were one hundred ing and twenty-one admissions, of whom fifty-five died. The was
telling
very
number of admissions gradually decreased till May, when there was another accession, and they rose to one hundred and eight, of whom fifty-six died. After this the dis-
of 18U6. He says :
"
As to treatment
has been discovered for cholera, and no cure, no specific was sought for. In this respect cholera was not peculiar. There is no cure for any essential fever ; no man could venture to say that this or that treatment will cure an essential fever. The physician guides it to no cure
He
the system is exposed to two and steering between the two rocks, he guides it until the clock strikes and the disease ends of itself either in death or recovery so with cholera." The great German master of our profession Lebert finishes his valuable article on cholera in Ziemssen's Cyclopoedia of Medicine in the following words : "The best treatment of cholera therefore, in the state of our present knowledge, is a carefully regulated regimen and a correctly interpreted symptomatic treatment with the avoidance of all perturbatory methods in the last degree inutile if not injurious." recovery.
knows and
dangers,?debility
secondary disease,
.
Dr Goodeve records
as
his
opinion
in
"
Reynolds' System
That treatment is most successful when commenced before collapse. In fuli collapse it js pretty certain, as remedies cannot be absorbed, that they cannot be of much use. Still it must not be supposed that all treatment is useless in cholera, or even that it is useless in all states of the stage of collapse. It cannot do much good in perfect and complete collapse, but in all the other stages of the disease it is as beneficial as in any other severe and dangerous of
Medicine,
vol.
I,
illness." Premonitory Diarrhoea.?Very few cases were admitted into the hospital in this stage, but there are three medicines which have been prescribed by me during several epidemics of the disease which are the combination of the acerecommended by Professor of any use it must be given as recommended by him, viz., freely. I have been in the habit of giving it in five grain doses of the pharmacopceial preparation after each loose motion, each dose equals 3| grains of acetate of lead and f grain of opium. On more than one occasion I have found these pills so hard that they were not digested, and were very valuable.
233 116 774 361
Total
169
tate of lead and Graves ; to be
passed
Firstly, opium
as
in the same state as
they
had been swallowed.
They should always be made up freshly when wanted. When the pills cannot be taken, the combination of acetate of lead with dilute acetic acid and solution of the acetate of morphia in a mixture can be relied upon, and is preferred by some. The combination of dilute sulphuric acid and tincture of opium in ten minim doses has also been found
extremely
useful.
During
an
epidemic
in
Baghelkund
in
170
THE INDIAN MEDICAL .GAZETTE.
?
1874, and
on the return march from Afghanistan in Panjanb during the hot weather of 1879, the cholera pills ( Patterson's) supplied by the Madras Medical Stores, of which the following is the composition?calomel, camphor gr. J, chilly powder gr. ?, acetate of lead gr. 1, aromatic powder gr. ij alcohol,
the
,
acetic acid, distilled water, of each
sufficiency?were extensively prescribed by me. This pill, combined with one containing a grain of opium repeated every hour, often checks the premonitory symptoms of diarrhoea a
and cramps. During this stage and until the first symptoms of decided cholera set in, these remedies should be pushed : their efiects being closely watched. A patient suffering from anything like severe diarrhoea should be kept as quiet as possible, and the diet confined to simple broths, milk and conjee in small quantities repeatedly given. With troops I have kept such cases in a tent separated from the cholera tents, and think that the moral effect of doine; so has often saved some patients, "who would have passed into the more serious stages. The necessity of having well-trained subordinates lookafter such doses of opium
ing
cases are
is self evident when such large I have never seen any ill
given.
effects when the cases have been properly watched ; and when it is impossible to have this done, it is safer to diminish the quantities of opium very considerably, or even omit them altogether. Too much attention cannot be given to the state of the digestive tract when cholera is epidemic ; every epidemic that I have seen has illustrated the well known, fact that cholera often follows on some derangement of the bowels. During the epidemic in Madras in 1876 and 1877 this was often proved. The use of a cholera belt, especially on the line of march during an epidemic, and indeed at all times, should not be on
neglected by a chill.
; it often
prevents diarrhoea being brought
During the epidemic in Madras of 187G and 1877 as the patients showed the characteristic rice-water
soon as
evacuations they
were
placed on the cholera (Stevens) in doses
*Chloride of sodium 150 grs. Bicarb, of potash 30 ,, 50 ,, Pliosp. of soda Bioarb. of soda 30 ? Solution of chlorinated ?soda 2Jfldrs. Water to ten fluid ounces. ..
..
..
..
..
from half ounces
an
every
saline* varying
ounce
to two
two
hours ;
water, aromatic spirits of ammonia or spirits of chloroform being added to it when
considered necessary. Nearly every patient was given this medicine, which appeared to check the vomiting and relieve the thirst if it had no more durable effects. Ice and soda water were given freely, especially to the Europeans and Eurasians, and seemed often to do good in allaying the thirst and vomiting. Food was given in the shape of mutton or chicken broth, milk and conjee. Hydrate of chloral was given both by the mouth and hypodermically in several cases, but no marked results were noted ; this medicine has certainly the effect of relieving the cramps to a great extent, but the hypodermic injection was often followed by the formation of sloughs. Cramp's appeared to be relieved by hand frictions with better still, with the liniment of chloroform; this particular epidemic the cramps
turpentine,
or
as a rule
during
[July 1,
1880.
not so prominent a symptom as they often are ; the inhalation of a few drops of chloroform is also very effective in relieving them. Alcoholic stimulants were scarcely used at all during this stage. Fumigation with sulphurous acid gas was freely carried out during the months of December 1876 and January and February were
1877, but mortality
without any marked results on the general of the disease beyond what might be attributed
to the
extra heat given out by the fires. Daring cold weather it would seem to be always advisable to keep I up the temperature of the ward by artificial means. that the extra heat helped some was quite certain of these patients through the collapse stage. The sulphur fumes gave rise to a good deal of conjunctivitis both amongst the patients and the ward attendants, and to some cases of bronchial catarrh. Hsemorrhage from the bowels was noted in several cases ; such cases rarely if ever recover, it is a symptom of the worst import. Turpentine administered in 10 to 15 minim doses, or gallic acid in 20 grain doses, appeared of some use
in these
same
cases.
treatment
Daring the stage of collapse the persevered with, if it was slight in heat being kept up by the use of
was
external bottles filled with hot water, hot sand bags, extra blankets, &c. "When the collapse was profound, the external treatment by hot bottles, extra blankets, and friction was alone relied upon, and any symptoms of commencing reaction closely watched for, when the internal remedies and food were again given. A few words on the treatment of some of the more
degree;
prominent symptoms. 1.? Vomiting did not appear to be a very marked symptom, especially amongst the natives, during this epidemic.
use of ice and soda water and the cholera saline seemed to allay the Vomiting in the earlier stages. Some cases of persistent vomiting continuing after the graver symptoms had subsided, appeared to depend on the presence of round worms in the intestines, and was relieved after they had been expelled by the use of santonin? and castor oil. Others, in which no exciting cause could be ascertained, were relieved by the application of a sinapism to the epigastrium, or by small" doses of chloroform, the hypodermic injection of morphia, or by the creosote mixture of the British Pharmacopoeia. 2.?Diarrhcea. Persistent diarrhoea often appeared to
The
depend was
on
relieved
the
same
as soon as
persistent vomiting, and patient got rid of the worms.
cause as
the
The acetate of lead and opium mixture, or the aromatic chalk powder with opium in doses of from 20 to 40. grains, were very useful in some of these cases: when the tongue was foul and there were symptoms of the liver not acting sufficiently, podophyllin was often used with successful results. In some cases the compound rhubarb
powder
seemed of
use.
Great
difficulty
was,
in persuading found, especially amongst the natives, idea seemed to be their only to take them simple food, that they should be supplied with curry and rice as and often they soon as they were able to eat anything, even brought on serious sympand diarrhcea the kept up toms of relapse by partaking of the curry and rice allowed to convalescents
July
SURGEON SIBTHORPE ON THE TREATMENT OF CHOLERA.
1, 1880.]
3. Hiccup.?This was often a troublesome symptom, and appeared to depend occasionally on the same cause
(intestinal worms) as the vomiting and diarrhoea. One case in particular resisted all treatment, and the patient left the hospital several days after having recovered from an acute attack of cholera with a hiccup still persisting. Ice in small lumps given occasionally, or a sinapism to the epigastrium, sometimes relieved it. Morphia injected liypodermically over the epigastrium seemed in some cases to do good. In one case a blister, the size of a crown piece, was raised over the epigastrium and dressed with morphia ointment with the desired effect. An ice bag was applied to the spine in one or two troublesome cases and appeared to do good. 4. Sleeplessness was often a troublesome symptom. When it could not be relieved by simple means, either 15 to 20 grains of hydrate of chloral was given by the mouth, especially in those cases where there was ar.y tendency to uraemic poisoning, or one-twelfth to onesixth of a grain of morphia was injected hypodermically. The bromides of potassium or ammonium in 15 to 30 grain doses, were used in several cases where there was a good deal of nervous excitement. 5. Imperfect Reaction was combated by assiduous care particularly in keeping up the external heat and in small
giving these
cases
of food repeatedly. It was in that alcoholic stimulants in the form of
quantities
were used, but never to any great the circulation being the test by on the effect extent, which the amount was regulated. A general idea
brandy
and arrack
appeared to be held that they increased poisoning that might exist.
any
tendency
to
urtemic
Urcemic poisoning did not appear to be so common the epidemic as it sometimes is, though there were several severe cases of it varying very much in degree. It is met with generally in cases in which the collapse stage had been prolonged. In such cases the importance of watching closely the quantity of urine, the amount of solid matters and albumen passed was often shown. When the uraemia appeared to depend on congestion of the kidneys every attempt was made to get the skin and bowels to act freely by the use of hot blanket baths, diaphoretics and purgatives; the use of dry cupping when thoroughly and properly applied seemed often beneficial in stimulating the action of the G.
during
I do not remember a case in which uraemic convulsions set in that recovered. Ice bags to the scalp, or the cold douche to the head, or the inhalation of chloroform generally relieved the more severe symptoms. 7. Secondary fever caused often a great deal of anxiety, but nothing can be done for it beyond trying
kidneys.
9.
Constipation
was
and then
troublesome best treated by until the bowels had time to
now
symptom during convalescence, and the
use
regain
of simple their tone.
enemas
l7l
a
was
Ulceration of the Cornea, though not very comrequires to be closely watched, especially in patients who have passed through a prolonged collapse ; to save the sight in many of these cases will call for the most careful general and local treatment. Locally cleanliness, the free use of atropine, extract of Belladonna or some preparation of dhatura, a pad and bandage, with as good a diet as the patient can digest, are the principal points to attend to. In one very bad case good results were obtained after the administration of 60 grain doses of 10.
mon,
the confection of turpentine B. P. three times a day. 11. Debility.?It is very remarkable how a number of patients go through a very severe attack of cholera and appear shortly afterwards to be very little the worse for it. The debility that does follow it is best treated by the judicious administration of as good food as the
patient can get, with some stimulants. Decoction of bark with carbonate of ammonia was given in a few cases. Small doses of quinine, 1 to 2 grains, was given in others. Administration. It is a recognised fact that to give a patient attacked with cholera a fair chance of recovery, he must be thoroughly well looked after during the whole time that the disease is in an active stage ; this cannot be done in such hospitals as one ordinarily sees organised during a cholera epidemic. If hospitals are to be anything better than lazarettos, they must cost money. The advantages of careful looking after patients are well illustrated by the statistics quoted ; when we consider that amongst the natives treated during a season of famine only 479 died out of 999 admissions, and of these 291 died before they had been 24 hours in hospital, the results are not bad. Every medical officer knows how much easier it is at such times to get European and East Indian patients nursed ; of these classes there were only 42 deaths out of 106 admissions, 14 of whom died within 24 hours of their admission. When cholera first broke out severely in Madras towards the end of 1876 all the cases that were admitted
into the General
pitched
on
the
Hospital were treated in sepoys' pals grounds, and scarcely anything could be
unsatisfactory. The Madras sepoys' pSl is extremely badly ventilated, and there is no means of lighting it except by the door. The cases treated in them did not do well, and very soon the air inside the tents became more
they were unpleasant to enter : when this represented, one large and three smaller temporary kidneys to act properly and to sheds were put up. They were erected on mud platforms keep down the hyperpyrexia by the use of wet packing one foot high, the walls being made of split bamboos and quinine, though this latter drug is often worse than (tatty or chettai work), and the roof of Palmyra leaves.
patient's
up the tered food, to get the to
keep
strength by judiciously adminis-
useless when there is renal congestion. 8. Retention of urine.?It is important to remember that retention of urine from atony of the bladder occasionally occurs after cholera; it is not an uncommon liiug to see a distended bladder which requires relief by the use of the catheter.
so
foul that
was
These sheds
well ventilated, lightsome and allowed each cot. They for a store room and a separate shed as bath-room and latrine, another as a cook-room and another as a disinfecting-room for the private clothing of the patients and the hospital were
ample room, viz. 90 superficial feet for were provided with a partitioned place
THE INDTAN MEDICAL GAZETTE.
172
and clothing. The large hut was devoted to natives males, one of the smaller to native females, another to European males, and the other for European females. Altogether there was accommodation for 48
bedding
following medicines and huts for immediate use :?
Medical attendance and nursing.?The treatment of the was under the orders of different medical officers. The Apothecary on duty in the hospital was required to visit the sheds constantly both by day From and night, and to see each case on admission. seven at night one of the clinical clerks was detailed for a tour of three hours' duty to administer medicines and keep the ward attendants up to their work. The male and female ward attendants were the great stand-by in the ward work ; of these there were plenty, the departmental order being that one should be employed for each patient admitted : this was never
Turpentine.
patients
On duty there was always about patients, they were divided into two classes, one for day and one for night duty, being relieved regularly at roll call ; the tour of duty was long, but did not appear to be injurious,?only two out of the whole number were attacked with cholera during the one
caste
At first these
men
had to be
ordinary coolies (as many as possible being men) from the bazaar, but they were soon trained, as
and several of them are the hospital.
the permanent establishBesides the ward attendants there was a toty or sweeper on day and another on night duty. A special dhobee was employed to work in the hospital grounds ; a special water-man and a cook were also entertained. The cook was required to keep hot conjee and broth ready at all hours of the day and night. now on
ment of
The diet of convalescents was sent over from the general kitchen. Drinking water for the caste patients and others was kept in separate chatties in the different huts. The huts were lit at night by kerosine oil?a point of no small importance when such a class of patients have to be looked after. A tent was pitched at the enbed and stretcher kept until admitted, in order to prevent the necessity of their entering the main building. Each native patient on admission was supplied with an open earthen chatty and an earthen pot for water. The natives were supplied with a large red hospital cloth and the Europeans with the ordinary trance to the
placed,
in which
hospital
to which all
suspicious
was
a
cases were
hospital clothing, viz., a pair of pyjamas, a shirt, a pair of slippers, &c. The bedding for both consisted of blankets, chintz quilts and pillows. The huts for Europeans were supplied with knives, forks, plates, bowls, tin pots, towels, &c., with a small box for their safe custody. The furniture in each hut consisted of the cots, a teapoy to each cot, one screen, a tin bed head ticket for each patient, a number of close stools, spitting pots, large open chatties to receive vomited matters, a hanging kerosine lantern, a basin, soap and towel for the use of the medical officer and
cines. There
was one
to hut at
night
subordinates,
and
a
table for medi-
hand lantern to carry about from hut and another for the cook-room. The
in the
>-
Condy's disinfecting fluid Carbolic lotion 1 to 40. MacDougal's powder. An enema syringe. A set of
cupping glasses.
male and female. Measure glasses for medicines. A hypodermic syringe A clinical thermometer. A urinometer with spirit lamp.
Catheters,
to be necessary.
prevalence of the disease.
kept
were
Chloroform liniment.
Test
tubes, nitric and acetic Bed pans, pewter.
to three
taken
1880.
Stevens' cholera saline. Sulphuric acid and opium mixture. Acetate of lead and opium pill.
beds.
found
appliances
[,Tuly 1,
acids,
&e.
Urinals, pewter. Feeding cups. Empty bottles for hot water. All regular prescriptions were made up in the General Dispensary. The cots were simple inexpensive wooden frames on wooden legs with canvas laced over it, the canvas being pierced in the centre so that one of the night stools or a large chatty might be placed under it in cases of violent purging : these holes were easily covered over The by means o? a draw sheet when not required. night stools were simple wooden boxes with a round hole cut in them, in which was placed a metal pan ; these the natives used without any difficulty, as they were large enough for them to sit upon native fashion. Bedding and clothing were supplied in ample quantities from the hospital stores, and at all times there was sufficient to keep the patients clean. There was a
partitioned off in
one of the huts, in which box for the clean clothing which had been returned from the dhobee.
store room was
kept
a
large
The disinfection of clothing.? As soon as clothing was removed from a patient it was placed to steep in a large tub full of carbolic acid and water 1 to 100 for twentyfour hours, then boiled for four hours in large open
chatties, then exposed for six hours to the fumes of sulphurous acid gas in the hut before referred to, and was
then handed
over
to the dhobee to be washed.
All the excreta was buried in deep trenches. A cuthing about this occurred when the motions were kept to be shown to the Visiting Medical Officers, they were always placed outside the hut in the chattiest rious
until these were provided with covers, the crows, of which there are thousands about the hospital, over and over again drank the contents apparently with impunity. March
26th,
1880,
SURGEON SIBTHORPE ON THE TREATMENT OF CHOLERA.
18S0.J
ORIGINAL COMMUNICATIONS. SOME NOTES
THE
ON
CHOLERA AND THE
TREATMENT
OF
ADMINISTRATION
Madras Medical Service. one of so constantly recurring interest to all medical officers in this country, that I think the following notes, founded on experience gained in several different epidemics both in this country and in Ireland, may be of interest. The idea of recording some remarks on the adminisration of cholera hospitals was suggested to me by the painful memories of the Khyber cholera hospitals " during the famous march of death" last year, and of is
the difficulties at other times 1 myself have experienced, and have known other medical officers to experience, in organizing such hospitals. During the past five years the following number of patients were admitted into the General Hospital, Madras : 106, of whom 42 died. Europeans and East Indians Natives 999, of whom 479 died. ...
...
...
...
The first case was admitted in August 1875 ; there had not been any cases treated in hospitals during the earlier part of that year. The two last cases were admitted
in
January 1879. The epidemic reached its height during the prevalence of the famine, and a large proportion of the patients admitted had suffered severely from privation. The following table shows the number of admissions and deaths yearly during the period :? 1877.
1878.
1879.
Total.
42
Europeans Natives
gradually disappeared a
was
thirty-three.
treatment I was taught as a student well explained by my venerated teacher Dr. Stokes, when speaking at the College of Physicians in Ireland in 1867 on the subject of the treatment pursued in Dublin was
By Surgeon C. Sibthorpe,
subject
; and during 1878 there were few isolated admissions. The greatest number under treatment on any one day was on the 20th January 1877, namely forty-four patients, and the average during the month of January 1877
ease
only
Treatment.?The
OP CHOLEIIA HOSPITALS.
The
479
during the epidemic
Of the deaths amongst Europeans 14 took pluce within 24 hours of their admission iuto hospital, and of the Natives 291. The number of admissions, which had varied from one to twenty-seven a month from August 1875, attained to
eighty-five
mum
and
in December
in January 1877,
ninety-nine
seven
died.
cases
This
1876, and reached its maxiduring which month one hundred were admitted, of whom seventy,
was
the time of year when the famine
severely on the people in Madras. Durof the month February 1877 there were one hundred ing and twenty-one admissions, of whom fifty-five died. The was
telling
very
number of admissions gradually decreased till May, when there was another accession, and they rose to one hundred and eight, of whom fifty-six died. After this the dis-
of 18U6. He says :
"
As to treatment
has been discovered for cholera, and no cure, no specific was sought for. In this respect cholera was not peculiar. There is no cure for any essential fever ; no man could venture to say that this or that treatment will cure an essential fever. The physician guides it to no cure
He
the system is exposed to two and steering between the two rocks, he guides it until the clock strikes and the disease ends of itself either in death or recovery so with cholera." The great German master of our profession Lebert finishes his valuable article on cholera in Ziemssen's Cyclopoedia of Medicine in the following words : "The best treatment of cholera therefore, in the state of our present knowledge, is a carefully regulated regimen and a correctly interpreted symptomatic treatment with the avoidance of all perturbatory methods in the last degree inutile if not injurious." recovery.
knows and
dangers,?debility
secondary disease,
.
Dr Goodeve records
as
his
opinion
in
"
Reynolds' System
That treatment is most successful when commenced before collapse. In fuli collapse it js pretty certain, as remedies cannot be absorbed, that they cannot be of much use. Still it must not be supposed that all treatment is useless in cholera, or even that it is useless in all states of the stage of collapse. It cannot do much good in perfect and complete collapse, but in all the other stages of the disease it is as beneficial as in any other severe and dangerous of
Medicine,
vol.
I,
illness." Premonitory Diarrhoea.?Very few cases were admitted into the hospital in this stage, but there are three medicines which have been prescribed by me during several epidemics of the disease which are the combination of the acerecommended by Professor of any use it must be given as recommended by him, viz., freely. I have been in the habit of giving it in five grain doses of the pharmacopceial preparation after each loose motion, each dose equals 3| grains of acetate of lead and f grain of opium. On more than one occasion I have found these pills so hard that they were not digested, and were very valuable.
233 116 774 361
Total
169
tate of lead and Graves ; to be
passed
Firstly, opium
as
in the same state as
they
had been swallowed.
They should always be made up freshly when wanted. When the pills cannot be taken, the combination of acetate of lead with dilute acetic acid and solution of the acetate of morphia in a mixture can be relied upon, and is preferred by some. The combination of dilute sulphuric acid and tincture of opium in ten minim doses has also been found
extremely
useful.
During
an
epidemic
in
Baghelkund
in
170
THE INDIAN MEDICAL .GAZETTE.
?
1874, and
on the return march from Afghanistan in Panjanb during the hot weather of 1879, the cholera pills ( Patterson's) supplied by the Madras Medical Stores, of which the following is the composition?calomel, camphor gr. J, chilly powder gr. ?, acetate of lead gr. 1, aromatic powder gr. ij alcohol,
the
,
acetic acid, distilled water, of each
sufficiency?were extensively prescribed by me. This pill, combined with one containing a grain of opium repeated every hour, often checks the premonitory symptoms of diarrhoea a
and cramps. During this stage and until the first symptoms of decided cholera set in, these remedies should be pushed : their efiects being closely watched. A patient suffering from anything like severe diarrhoea should be kept as quiet as possible, and the diet confined to simple broths, milk and conjee in small quantities repeatedly given. With troops I have kept such cases in a tent separated from the cholera tents, and think that the moral effect of doine; so has often saved some patients, "who would have passed into the more serious stages. The necessity of having well-trained subordinates lookafter such doses of opium
ing
cases are
is self evident when such large I have never seen any ill
given.
effects when the cases have been properly watched ; and when it is impossible to have this done, it is safer to diminish the quantities of opium very considerably, or even omit them altogether. Too much attention cannot be given to the state of the digestive tract when cholera is epidemic ; every epidemic that I have seen has illustrated the well known, fact that cholera often follows on some derangement of the bowels. During the epidemic in Madras in 1876 and 1877 this was often proved. The use of a cholera belt, especially on the line of march during an epidemic, and indeed at all times, should not be on
neglected by a chill.
; it often
prevents diarrhoea being brought
During the epidemic in Madras of 187G and 1877 as the patients showed the characteristic rice-water
soon as
evacuations they
were
placed on the cholera (Stevens) in doses
*Chloride of sodium 150 grs. Bicarb, of potash 30 ,, 50 ,, Pliosp. of soda Bioarb. of soda 30 ? Solution of chlorinated ?soda 2Jfldrs. Water to ten fluid ounces. ..
..
..
..
..
from half ounces
an
every
saline* varying
ounce
to two
two
hours ;
water, aromatic spirits of ammonia or spirits of chloroform being added to it when
considered necessary. Nearly every patient was given this medicine, which appeared to check the vomiting and relieve the thirst if it had no more durable effects. Ice and soda water were given freely, especially to the Europeans and Eurasians, and seemed often to do good in allaying the thirst and vomiting. Food was given in the shape of mutton or chicken broth, milk and conjee. Hydrate of chloral was given both by the mouth and hypodermically in several cases, but no marked results were noted ; this medicine has certainly the effect of relieving the cramps to a great extent, but the hypodermic injection was often followed by the formation of sloughs. Cramp's appeared to be relieved by hand frictions with better still, with the liniment of chloroform; this particular epidemic the cramps
turpentine,
or
as a rule
during
[July 1,
1880.
not so prominent a symptom as they often are ; the inhalation of a few drops of chloroform is also very effective in relieving them. Alcoholic stimulants were scarcely used at all during this stage. Fumigation with sulphurous acid gas was freely carried out during the months of December 1876 and January and February were
1877, but mortality
without any marked results on the general of the disease beyond what might be attributed
to the
extra heat given out by the fires. Daring cold weather it would seem to be always advisable to keep I up the temperature of the ward by artificial means. that the extra heat helped some was quite certain of these patients through the collapse stage. The sulphur fumes gave rise to a good deal of conjunctivitis both amongst the patients and the ward attendants, and to some cases of bronchial catarrh. Hsemorrhage from the bowels was noted in several cases ; such cases rarely if ever recover, it is a symptom of the worst import. Turpentine administered in 10 to 15 minim doses, or gallic acid in 20 grain doses, appeared of some use
in these
same
cases.
treatment
Daring the stage of collapse the persevered with, if it was slight in heat being kept up by the use of
was
external bottles filled with hot water, hot sand bags, extra blankets, &c. "When the collapse was profound, the external treatment by hot bottles, extra blankets, and friction was alone relied upon, and any symptoms of commencing reaction closely watched for, when the internal remedies and food were again given. A few words on the treatment of some of the more
degree;
prominent symptoms. 1.? Vomiting did not appear to be a very marked symptom, especially amongst the natives, during this epidemic.
use of ice and soda water and the cholera saline seemed to allay the Vomiting in the earlier stages. Some cases of persistent vomiting continuing after the graver symptoms had subsided, appeared to depend on the presence of round worms in the intestines, and was relieved after they had been expelled by the use of santonin? and castor oil. Others, in which no exciting cause could be ascertained, were relieved by the application of a sinapism to the epigastrium, or by small" doses of chloroform, the hypodermic injection of morphia, or by the creosote mixture of the British Pharmacopoeia. 2.?Diarrhcea. Persistent diarrhoea often appeared to
The
depend was
on
relieved
the
same
as soon as
persistent vomiting, and patient got rid of the worms.
cause as
the
The acetate of lead and opium mixture, or the aromatic chalk powder with opium in doses of from 20 to 40. grains, were very useful in some of these cases: when the tongue was foul and there were symptoms of the liver not acting sufficiently, podophyllin was often used with successful results. In some cases the compound rhubarb
powder
seemed of
use.
Great
difficulty
was,
in persuading found, especially amongst the natives, idea seemed to be their only to take them simple food, that they should be supplied with curry and rice as and often they soon as they were able to eat anything, even brought on serious sympand diarrhcea the kept up toms of relapse by partaking of the curry and rice allowed to convalescents
July
SURGEON SIBTHORPE ON THE TREATMENT OF CHOLERA.
1, 1880.]
3. Hiccup.?This was often a troublesome symptom, and appeared to depend occasionally on the same cause
(intestinal worms) as the vomiting and diarrhoea. One case in particular resisted all treatment, and the patient left the hospital several days after having recovered from an acute attack of cholera with a hiccup still persisting. Ice in small lumps given occasionally, or a sinapism to the epigastrium, sometimes relieved it. Morphia injected liypodermically over the epigastrium seemed in some cases to do good. In one case a blister, the size of a crown piece, was raised over the epigastrium and dressed with morphia ointment with the desired effect. An ice bag was applied to the spine in one or two troublesome cases and appeared to do good. 4. Sleeplessness was often a troublesome symptom. When it could not be relieved by simple means, either 15 to 20 grains of hydrate of chloral was given by the mouth, especially in those cases where there was ar.y tendency to uraemic poisoning, or one-twelfth to onesixth of a grain of morphia was injected hypodermically. The bromides of potassium or ammonium in 15 to 30 grain doses, were used in several cases where there was a good deal of nervous excitement. 5. Imperfect Reaction was combated by assiduous care particularly in keeping up the external heat and in small
giving these
cases
of food repeatedly. It was in that alcoholic stimulants in the form of
quantities
were used, but never to any great the circulation being the test by on the effect extent, which the amount was regulated. A general idea
brandy
and arrack
appeared to be held that they increased poisoning that might exist.
any
tendency
to
urtemic
Urcemic poisoning did not appear to be so common the epidemic as it sometimes is, though there were several severe cases of it varying very much in degree. It is met with generally in cases in which the collapse stage had been prolonged. In such cases the importance of watching closely the quantity of urine, the amount of solid matters and albumen passed was often shown. When the uraemia appeared to depend on congestion of the kidneys every attempt was made to get the skin and bowels to act freely by the use of hot blanket baths, diaphoretics and purgatives; the use of dry cupping when thoroughly and properly applied seemed often beneficial in stimulating the action of the G.
during
I do not remember a case in which uraemic convulsions set in that recovered. Ice bags to the scalp, or the cold douche to the head, or the inhalation of chloroform generally relieved the more severe symptoms. 7. Secondary fever caused often a great deal of anxiety, but nothing can be done for it beyond trying
kidneys.
9.
Constipation
was
and then
troublesome best treated by until the bowels had time to
now
symptom during convalescence, and the
use
regain
of simple their tone.
enemas
l7l
a
was
Ulceration of the Cornea, though not very comrequires to be closely watched, especially in patients who have passed through a prolonged collapse ; to save the sight in many of these cases will call for the most careful general and local treatment. Locally cleanliness, the free use of atropine, extract of Belladonna or some preparation of dhatura, a pad and bandage, with as good a diet as the patient can digest, are the principal points to attend to. In one very bad case good results were obtained after the administration of 60 grain doses of 10.
mon,
the confection of turpentine B. P. three times a day. 11. Debility.?It is very remarkable how a number of patients go through a very severe attack of cholera and appear shortly afterwards to be very little the worse for it. The debility that does follow it is best treated by the judicious administration of as good food as the
patient can get, with some stimulants. Decoction of bark with carbonate of ammonia was given in a few cases. Small doses of quinine, 1 to 2 grains, was given in others. Administration. It is a recognised fact that to give a patient attacked with cholera a fair chance of recovery, he must be thoroughly well looked after during the whole time that the disease is in an active stage ; this cannot be done in such hospitals as one ordinarily sees organised during a cholera epidemic. If hospitals are to be anything better than lazarettos, they must cost money. The advantages of careful looking after patients are well illustrated by the statistics quoted ; when we consider that amongst the natives treated during a season of famine only 479 died out of 999 admissions, and of these 291 died before they had been 24 hours in hospital, the results are not bad. Every medical officer knows how much easier it is at such times to get European and East Indian patients nursed ; of these classes there were only 42 deaths out of 106 admissions, 14 of whom died within 24 hours of their admission. When cholera first broke out severely in Madras towards the end of 1876 all the cases that were admitted
into the General
pitched
on
the
Hospital were treated in sepoys' pals grounds, and scarcely anything could be
unsatisfactory. The Madras sepoys' pSl is extremely badly ventilated, and there is no means of lighting it except by the door. The cases treated in them did not do well, and very soon the air inside the tents became more
they were unpleasant to enter : when this represented, one large and three smaller temporary kidneys to act properly and to sheds were put up. They were erected on mud platforms keep down the hyperpyrexia by the use of wet packing one foot high, the walls being made of split bamboos and quinine, though this latter drug is often worse than (tatty or chettai work), and the roof of Palmyra leaves.
patient's
up the tered food, to get the to
keep
strength by judiciously adminis-
useless when there is renal congestion. 8. Retention of urine.?It is important to remember that retention of urine from atony of the bladder occasionally occurs after cholera; it is not an uncommon liiug to see a distended bladder which requires relief by the use of the catheter.
so
foul that
was
These sheds
well ventilated, lightsome and allowed each cot. They for a store room and a separate shed as bath-room and latrine, another as a cook-room and another as a disinfecting-room for the private clothing of the patients and the hospital were
ample room, viz. 90 superficial feet for were provided with a partitioned place
THE INDTAN MEDICAL GAZETTE.
172
and clothing. The large hut was devoted to natives males, one of the smaller to native females, another to European males, and the other for European females. Altogether there was accommodation for 48
bedding
following medicines and huts for immediate use :?
Medical attendance and nursing.?The treatment of the was under the orders of different medical officers. The Apothecary on duty in the hospital was required to visit the sheds constantly both by day From and night, and to see each case on admission. seven at night one of the clinical clerks was detailed for a tour of three hours' duty to administer medicines and keep the ward attendants up to their work. The male and female ward attendants were the great stand-by in the ward work ; of these there were plenty, the departmental order being that one should be employed for each patient admitted : this was never
Turpentine.
patients
On duty there was always about patients, they were divided into two classes, one for day and one for night duty, being relieved regularly at roll call ; the tour of duty was long, but did not appear to be injurious,?only two out of the whole number were attacked with cholera during the one
caste
At first these
men
had to be
ordinary coolies (as many as possible being men) from the bazaar, but they were soon trained, as
and several of them are the hospital.
the permanent establishBesides the ward attendants there was a toty or sweeper on day and another on night duty. A special dhobee was employed to work in the hospital grounds ; a special water-man and a cook were also entertained. The cook was required to keep hot conjee and broth ready at all hours of the day and night. now on
ment of
The diet of convalescents was sent over from the general kitchen. Drinking water for the caste patients and others was kept in separate chatties in the different huts. The huts were lit at night by kerosine oil?a point of no small importance when such a class of patients have to be looked after. A tent was pitched at the enbed and stretcher kept until admitted, in order to prevent the necessity of their entering the main building. Each native patient on admission was supplied with an open earthen chatty and an earthen pot for water. The natives were supplied with a large red hospital cloth and the Europeans with the ordinary trance to the
placed,
in which
hospital
to which all
suspicious
was
a
cases were
hospital clothing, viz., a pair of pyjamas, a shirt, a pair of slippers, &c. The bedding for both consisted of blankets, chintz quilts and pillows. The huts for Europeans were supplied with knives, forks, plates, bowls, tin pots, towels, &c., with a small box for their safe custody. The furniture in each hut consisted of the cots, a teapoy to each cot, one screen, a tin bed head ticket for each patient, a number of close stools, spitting pots, large open chatties to receive vomited matters, a hanging kerosine lantern, a basin, soap and towel for the use of the medical officer and
cines. There
was one
to hut at
night
subordinates,
and
a
table for medi-
hand lantern to carry about from hut and another for the cook-room. The
in the
>-
Condy's disinfecting fluid Carbolic lotion 1 to 40. MacDougal's powder. An enema syringe. A set of
cupping glasses.
male and female. Measure glasses for medicines. A hypodermic syringe A clinical thermometer. A urinometer with spirit lamp.
Catheters,
to be necessary.
prevalence of the disease.
kept
were
Chloroform liniment.
Test
tubes, nitric and acetic Bed pans, pewter.
to three
taken
1880.
Stevens' cholera saline. Sulphuric acid and opium mixture. Acetate of lead and opium pill.
beds.
found
appliances
[,Tuly 1,
acids,
&e.
Urinals, pewter. Feeding cups. Empty bottles for hot water. All regular prescriptions were made up in the General Dispensary. The cots were simple inexpensive wooden frames on wooden legs with canvas laced over it, the canvas being pierced in the centre so that one of the night stools or a large chatty might be placed under it in cases of violent purging : these holes were easily covered over The by means o? a draw sheet when not required. night stools were simple wooden boxes with a round hole cut in them, in which was placed a metal pan ; these the natives used without any difficulty, as they were large enough for them to sit upon native fashion. Bedding and clothing were supplied in ample quantities from the hospital stores, and at all times there was sufficient to keep the patients clean. There was a
partitioned off in
one of the huts, in which box for the clean clothing which had been returned from the dhobee.
store room was
kept
a
large
The disinfection of clothing.? As soon as clothing was removed from a patient it was placed to steep in a large tub full of carbolic acid and water 1 to 100 for twentyfour hours, then boiled for four hours in large open
chatties, then exposed for six hours to the fumes of sulphurous acid gas in the hut before referred to, and was
then handed
over
to the dhobee to be washed.
All the excreta was buried in deep trenches. A cuthing about this occurred when the motions were kept to be shown to the Visiting Medical Officers, they were always placed outside the hut in the chattiest rious
until these were provided with covers, the crows, of which there are thousands about the hospital, over and over again drank the contents apparently with impunity. March
26th,
1880,
