the treatment of cholera. By Chables It.
Francis, M.B.
Considerable advance has been made in the treatment of cholera during the past twenty years, notably in withholding opium, and in not withholding water. I wish now to speak of the collapsed stage especially. Opium is admissible and beneficial in the earlier stages, but these are comparatively manageable ; in collapse it is poison. Still there is a great want of uniforto mity of action in the treatment of cholera, doubtless the absence of uniform
owing
in any of the thousand and one which have been given to the world. I do not
efficacy
vaunted plans pretend to say that my plan is infallible ; at the same time, my sphere of observation has been a very wide one, and the class of cases which have
come
under treatment have been most
unpromising, nearly all being in a state of extreme collapse; and the mortality has been so uniformly low under this treatment, considering the condition of the patients, that it seems, primd facie, to be worthy of a trial. But, with the treatment must be associated an amount of care, nursing, and watching, that will test the patience of the most assiduous. Yet it is essential, for without it no treatment will avail. I would premise by saying that I do not offer to the profession what has not been tried by others; on the contrary, sceptical members of the profession in India have had recourse to it, and can testify to the efficacy of the system. Nor do I pretend to much originality in it. I am indebted for the calomel part of the treatment to my friend, Dr. D. B. Smith, late Officiating Professor of Midwifery at the Medical College in Calcutta, who had himself become a convert to it after witnessing its success in the hands of Surgeon Lithgow, of the 75th Highlanders ; and to Mr. F. Webber, late Civil Surgeon in Assam, for his view3 on the subject of
cantharides, the successful administration of which first drew of a diuretic in the treatment of my attention to the value cholera. The principles of treatment which I venture to advocate in this disease are as follows :? 1, Keep up the flagging action of the heart by diffusible stimulants. This I believe to be best effected by twenty minims of sp. sether. nitrosi, combined with the same quantity of sp. This draught should be ammon. arom. and a little water.
frequently repeated an
every
half-hour,
dr even every
hour, until the pulse is felt at the wrist.
quarter
of
Then it may be
the INDIAN MEDICAL GAZETTE.
100
given at longer intervals. Brandy I object to, as it leaves a narcotising effect behind, which the diffusible stimulants do not. Opium is quite out of the question in collapse, as it complicates matters, and helps to induce urcemia; and I am inclined to believe that brandy has the same effect. Some practitioners give carb. ammoniae, but it must be avoided when prescribing the acetate of lead as an astringent, on account of the carbonate of lead which would be formed. It is astonishing how large a quantity of the ether and ammonia mixture can be borne. I have known several ounces given in the course
of thirty-six hours, with decidedly beneficial effect. 2.
ing
Water must be
nausea.
The
given freely object of this is
;
short,
obvious.
of course, of producThe watery consti-
drained away, leaving only a thick tarry fluid, which, on account of its viscosity, cannot circulate through the different organs, which hence become gorged with blood, are unable to perform their ordinary functions, and so constitute the serious secondary lesions from which patients die quite as frequently as they do from the original disease. It is marvellous to think of our forefathers withholding water in
tuents of the blood have
Nature?the vis medicatrix nalurce?is
cholera.
the effects of the
prepared
to
may be, and to re-establish the human machine in its integrity ; and nothing will facilitate her efforts more than restoring the vital fluid to
destroy
poison
as
soon
as
its natural consistence, to begin with. So much is undoubtedly due to good pure water in this respect, that we cease to wonder at the marvellous cures effected by those who declare, and no doubt
they
are
right,
that
they give nothing else. the benefit resulting from astringents is by no means uniform, still, as the patient's very lifeblood is being hurried out of his system in the form of proteine compounds, salts, etc., common sense surely teaches us to endeavour to arrest the discharge. As to whether the severity of the attack and the extent of the discharge stand in an inverse ratio to each other; in other words, that the more evacuations a patient has, the more poison will be eliminated, and so much the less severe will the attack become, is a disputed question; but all, who have had large experience in cholera, can entertain but one opinion, vis., that such an idea is not borne out by facts. On the contrary, so far as my own experience goes, (and I have treated some 2,000 cases,) although I have certainly met with some which appear to bear out the above view, I will venture to assert that the greater the purging the worse for the patient. The best astringents, I think, are diluted sulphuric acid and sugar of lead. I would give one or the other. If sulphuric acid be prescribed, thirty minims every lialf-hour, with some warm tincture, should be the dose.* It is a common practice to give an astringent after each purging. I prefer giving it before, so as to anticipate miscliief. If sugar of lead be preferred, give it in doses of from two to five grains in vinegar and water. The sugar of lead and opium" pill, which acquired so much celebrity when first introduced to the profession by Dr. Graves, is not admissible in the collapse of cholera, i. e., the lead may be given, but not the opium. Before collapse this combination 3.
Astringents.?Although
"
is invaluable.
For the natives of India I would add to it two
asafoetida, one of cayenne, and one grain of black pepper. And, as a prophylactic measure, such a pill is regarded for them quite a panacea. It is admirable, in this sense, for Europeans also. I confess I have les9 confidence in astringents grains
of
than in other parts of the treatment. Calom, I ?Together with stimulation and cold water, I look upon calomel and cantharides as the staple upon which most reliance can be placed. We hear it continually said by sceptics, *
Six doses may be given in one series. After the lapse of an hour or so, if purging continue, another six doses may be administered. Large of this quantities remedy will, like large quantities of Other remedies,
icadily be borne in the sollapse of cholera,
with
regard
to calomel,
[Mat 1,
"
one
might
as
well
give
so
18G8.
much white-
wash." True, a great deal of the calomel remains unabsorbed, but some is taken into the system during the period of absorption, and
nothing so surely equalizes the circulation (which are suspended in cholera)
secretions
and promotes the as this mineral.
green or bilious evacuation appears, the patient, as Over and over again have I sat by the bedside of one supposed to be dying from cholera.?no pulse at the wrist, features cadaveric, that frightful restlessness so characteristic of
When a
once a
rule, is safe.
the disease, all noting the apparent rapid approach of death? and, seeing the bilious stool appear, have felt that the danger was
Others will say that they have done the same, but with I do not say that all my patients have recovered, but more than half have, which, bearing in mind that the unfortunate victims are such as are usually given up and abandoned to their fate, tells forcibly in favor of the treat-
past.
different results.
I
quite inclined to believe, however, that calomel produce the same satisfactory issue that calomel plus cantharides will do. I prefer giving calomel in large doses, at longer intervals, in preference to the plan advocated by Dr. Ay re, of Hull, viz., grain doses at much shorter intervals, I give as much as 30 grains or 40 grains, to begin with, and repeat it every two, three, or more hours up to 150, 200, or 250 grains. In only one case, out of hundreds, have I seen salivation follow; and it yielded readily to treatment. Dysentery is to be watched for with all this calomel in the intestinal canal, and therefore it will be well to give castor oil in small quantities for two or I do net advocate castor three days after the attack is over. oil on Dr. Johnson's principle. One great benefit which, humanly speaking, is almost sure to follow its exhibition, is that there will be no urcemia. With the returning secretion of bile comes that of urine, slight at first, but soon very plentiful.* The calomel should be given in powder. It is easily ment.
am
alone will not
retained in most cases. A curious fact is mentioned by Dr. Parkes in his work on " cholera, and by Dr. Joseph Ewart in his Yital Statistics of the Army in India," which shows that the mortality from cholera, in the earlier days of our acquaintance with the disease, Neither of these was much less than in succeeding years. authorities accounts f for the fact, but when it is remembered that in those we
days
calomel
shall have, I think,
much more used than it is now, clue to the mystery. Epidemics
was
some
of cholera were, occasionally, surely quite as severe then as now, and yet the mortality was as low as from 25 to 35 per cent.
Diuretics.?I question whether sufficient attention has been drawn to this class of remedies. The prevailing idea is that, there being no absorption, to give medicine with a view to increasing or promoting the secretion from any organ is next to
useless,
as
it will
only
act
as a
foreign body,
of mischief rather than of benefit.
comparatively
harmless
remedies,
and
be
a
source
And if this be said of
how much the more of such
cantharides! Will not the irritated ? is asked. Already congested, to act upon it thus will surely produce violent inflammation, or some very serious mischief. What will be said when I state that I have given the tincture of cantharides in five-drop
violent measures
as
prescribing
kidney be excessively
doses, till between two and three drachms have been taken in thirty-six to forty-eight hours, without a bad symptom ?
from
early secretion of urine has followed its use, without any kidney whatever. And in fatal cases I have never met with any condition, in this organ, different to what is ordinarily seen in it in death from cholera. I observe that, An
affection of the
* It is very essential that the secretion should be plentiful: and the diuretic must not, therefore, be intermitted until it is; though it may bo administered at longer intervals. t Dr. Parkes is inclined to think that the epidemics of cholera were less severe in those days,
Mat
1,1868.]
FIELD SURGERY "WITH OUR FRONTIER FORCE.?BY B. "W. SWITZER.
within the last year or two, diuretics have been advocated by more than one author, and I conceive that this is a step in the right direction. Few would venture upon so powerful a diuretic as this ; but let me assure those who pause that they may Mr. Webber, Civil Surgeon in do it with
perfect safety. Assam, has used it for a longer period than experience of its efficacy and liarmlessness is
his
I have, and even
than
greater
mine. It is well to combine a warm tincture with the tincture of cantharides, and a little tinct. lavand- co. and sp. ammon. arom. and ether: and, looking upon cholera as a disease of malarious
origin,
I have
always
added
a
few
drops
of
liq. potass,
arsenitis to each dose, following it up, in convalescence, with quinine, with a view to avoiding all chance of a relapse; for
relapses
are
not uncommon.
occasionally
Frictions.?With regard to frictions, if agreeable to the patient, (and they often are in spasm), I would encourage them. As I said before, good nursing is a sine qua 11011. So much may be expected from this, that a professional friend, well known in medical literature, once said to me that, if he were ill with cholera, he should like to be put under the care of some maniac
(some
one
would be
with
chamber,
peculiar
views of his
own),
because such
surround him with all the comforts of and himself see that his instructions were
sure
to
a
one
a
sick
fully
carried out!
frequently happens that patients, at these merely made the receptacles for drugs In the crisis of an epidemic, incoherent therapeutical experiments" are made with no result. We learn in sanitary science, but in the treatment?the medical treatment?of cholera we learn nothing. Some there are who deliberately do nothing when a patient is in extreme collapse. They say?" Oh, why worry him ? let him die in peace!" Dr. Balfour, when advocating the use of strychnine in cholera, says:?"God help those who fall Now it is just in this very condiinto the state of collapse ! Remarks.?It too
times,
are
"
"
tion that I have found the treatment above defined so successful. It may be presumed that, in the course of a long residence in
India,
I have had
opportunities
of
testing
the
efficacy of
It is so ; and I may safely I have found nothing equal to
various so-called cures for cholera
say that, in collapse in cholera, this plan of stimulants, water, calomel, and cantharides, and unwearied watching. Cholera, before collapse has set in, may be combated in various ways, according to the nature of the
of the case, or of the constitution of the individual. would add, in conclusion, that great care must be taken, in these collapsed cases, to ascertain the condition of
epidemic, I
internal organs. Patients, when dying, it may be, of
be
apparently recovering,
will
pneumonia, without any external manifestation of the latent mischief. Natives are very fond ot lying prostrate on their backs. This should be preveuted ;
and attendants must be told to move them from side to side
occasionally. Dysentery is a very common secondary disease, requiring early detection. llecovery from collapse will depend very much upon the normal condition of the heart.
diseased, it may be
unequal
If this organ be in any way to the occasion. Collapse in
patients, or in those suffering from any constituaffection, is rarely, or with great difficulty, recovered from. But where there is nothing of this kind, and where all the organs are healthy, the chances are favorable. As this communication (which appeared, in part, in the Medical Times and Gazette of the 8th February last) is passing through the press, a professional friend,* in practice in Calcutta, is testing the efficacy of the treatment advocated, and informs me that he is abundantly satisfied with it. Will others follow his example, and favor the profession with the result in these coluimvi ? scrofulous
tional
*
Ten very bad eases were admitted into his under the ?alomel plan.?Ed., I. M. &.
recovered
hospital,
and nine have
101
Francis, M.B.
Considerable advance has been made in the treatment of cholera during the past twenty years, notably in withholding opium, and in not withholding water. I wish now to speak of the collapsed stage especially. Opium is admissible and beneficial in the earlier stages, but these are comparatively manageable ; in collapse it is poison. Still there is a great want of uniforto mity of action in the treatment of cholera, doubtless the absence of uniform
owing
in any of the thousand and one which have been given to the world. I do not
efficacy
vaunted plans pretend to say that my plan is infallible ; at the same time, my sphere of observation has been a very wide one, and the class of cases which have
come
under treatment have been most
unpromising, nearly all being in a state of extreme collapse; and the mortality has been so uniformly low under this treatment, considering the condition of the patients, that it seems, primd facie, to be worthy of a trial. But, with the treatment must be associated an amount of care, nursing, and watching, that will test the patience of the most assiduous. Yet it is essential, for without it no treatment will avail. I would premise by saying that I do not offer to the profession what has not been tried by others; on the contrary, sceptical members of the profession in India have had recourse to it, and can testify to the efficacy of the system. Nor do I pretend to much originality in it. I am indebted for the calomel part of the treatment to my friend, Dr. D. B. Smith, late Officiating Professor of Midwifery at the Medical College in Calcutta, who had himself become a convert to it after witnessing its success in the hands of Surgeon Lithgow, of the 75th Highlanders ; and to Mr. F. Webber, late Civil Surgeon in Assam, for his view3 on the subject of
cantharides, the successful administration of which first drew of a diuretic in the treatment of my attention to the value cholera. The principles of treatment which I venture to advocate in this disease are as follows :? 1, Keep up the flagging action of the heart by diffusible stimulants. This I believe to be best effected by twenty minims of sp. sether. nitrosi, combined with the same quantity of sp. This draught should be ammon. arom. and a little water.
frequently repeated an
every
half-hour,
dr even every
hour, until the pulse is felt at the wrist.
quarter
of
Then it may be
the INDIAN MEDICAL GAZETTE.
100
given at longer intervals. Brandy I object to, as it leaves a narcotising effect behind, which the diffusible stimulants do not. Opium is quite out of the question in collapse, as it complicates matters, and helps to induce urcemia; and I am inclined to believe that brandy has the same effect. Some practitioners give carb. ammoniae, but it must be avoided when prescribing the acetate of lead as an astringent, on account of the carbonate of lead which would be formed. It is astonishing how large a quantity of the ether and ammonia mixture can be borne. I have known several ounces given in the course
of thirty-six hours, with decidedly beneficial effect. 2.
ing
Water must be
nausea.
The
given freely object of this is
;
short,
obvious.
of course, of producThe watery consti-
drained away, leaving only a thick tarry fluid, which, on account of its viscosity, cannot circulate through the different organs, which hence become gorged with blood, are unable to perform their ordinary functions, and so constitute the serious secondary lesions from which patients die quite as frequently as they do from the original disease. It is marvellous to think of our forefathers withholding water in
tuents of the blood have
Nature?the vis medicatrix nalurce?is
cholera.
the effects of the
prepared
to
may be, and to re-establish the human machine in its integrity ; and nothing will facilitate her efforts more than restoring the vital fluid to
destroy
poison
as
soon
as
its natural consistence, to begin with. So much is undoubtedly due to good pure water in this respect, that we cease to wonder at the marvellous cures effected by those who declare, and no doubt
they
are
right,
that
they give nothing else. the benefit resulting from astringents is by no means uniform, still, as the patient's very lifeblood is being hurried out of his system in the form of proteine compounds, salts, etc., common sense surely teaches us to endeavour to arrest the discharge. As to whether the severity of the attack and the extent of the discharge stand in an inverse ratio to each other; in other words, that the more evacuations a patient has, the more poison will be eliminated, and so much the less severe will the attack become, is a disputed question; but all, who have had large experience in cholera, can entertain but one opinion, vis., that such an idea is not borne out by facts. On the contrary, so far as my own experience goes, (and I have treated some 2,000 cases,) although I have certainly met with some which appear to bear out the above view, I will venture to assert that the greater the purging the worse for the patient. The best astringents, I think, are diluted sulphuric acid and sugar of lead. I would give one or the other. If sulphuric acid be prescribed, thirty minims every lialf-hour, with some warm tincture, should be the dose.* It is a common practice to give an astringent after each purging. I prefer giving it before, so as to anticipate miscliief. If sugar of lead be preferred, give it in doses of from two to five grains in vinegar and water. The sugar of lead and opium" pill, which acquired so much celebrity when first introduced to the profession by Dr. Graves, is not admissible in the collapse of cholera, i. e., the lead may be given, but not the opium. Before collapse this combination 3.
Astringents.?Although
"
is invaluable.
For the natives of India I would add to it two
asafoetida, one of cayenne, and one grain of black pepper. And, as a prophylactic measure, such a pill is regarded for them quite a panacea. It is admirable, in this sense, for Europeans also. I confess I have les9 confidence in astringents grains
of
than in other parts of the treatment. Calom, I ?Together with stimulation and cold water, I look upon calomel and cantharides as the staple upon which most reliance can be placed. We hear it continually said by sceptics, *
Six doses may be given in one series. After the lapse of an hour or so, if purging continue, another six doses may be administered. Large of this quantities remedy will, like large quantities of Other remedies,
icadily be borne in the sollapse of cholera,
with
regard
to calomel,
[Mat 1,
"
one
might
as
well
give
so
18G8.
much white-
wash." True, a great deal of the calomel remains unabsorbed, but some is taken into the system during the period of absorption, and
nothing so surely equalizes the circulation (which are suspended in cholera)
secretions
and promotes the as this mineral.
green or bilious evacuation appears, the patient, as Over and over again have I sat by the bedside of one supposed to be dying from cholera.?no pulse at the wrist, features cadaveric, that frightful restlessness so characteristic of
When a
once a
rule, is safe.
the disease, all noting the apparent rapid approach of death? and, seeing the bilious stool appear, have felt that the danger was
Others will say that they have done the same, but with I do not say that all my patients have recovered, but more than half have, which, bearing in mind that the unfortunate victims are such as are usually given up and abandoned to their fate, tells forcibly in favor of the treat-
past.
different results.
I
quite inclined to believe, however, that calomel produce the same satisfactory issue that calomel plus cantharides will do. I prefer giving calomel in large doses, at longer intervals, in preference to the plan advocated by Dr. Ay re, of Hull, viz., grain doses at much shorter intervals, I give as much as 30 grains or 40 grains, to begin with, and repeat it every two, three, or more hours up to 150, 200, or 250 grains. In only one case, out of hundreds, have I seen salivation follow; and it yielded readily to treatment. Dysentery is to be watched for with all this calomel in the intestinal canal, and therefore it will be well to give castor oil in small quantities for two or I do net advocate castor three days after the attack is over. oil on Dr. Johnson's principle. One great benefit which, humanly speaking, is almost sure to follow its exhibition, is that there will be no urcemia. With the returning secretion of bile comes that of urine, slight at first, but soon very plentiful.* The calomel should be given in powder. It is easily ment.
am
alone will not
retained in most cases. A curious fact is mentioned by Dr. Parkes in his work on " cholera, and by Dr. Joseph Ewart in his Yital Statistics of the Army in India," which shows that the mortality from cholera, in the earlier days of our acquaintance with the disease, Neither of these was much less than in succeeding years. authorities accounts f for the fact, but when it is remembered that in those we
days
calomel
shall have, I think,
much more used than it is now, clue to the mystery. Epidemics
was
some
of cholera were, occasionally, surely quite as severe then as now, and yet the mortality was as low as from 25 to 35 per cent.
Diuretics.?I question whether sufficient attention has been drawn to this class of remedies. The prevailing idea is that, there being no absorption, to give medicine with a view to increasing or promoting the secretion from any organ is next to
useless,
as
it will
only
act
as a
foreign body,
of mischief rather than of benefit.
comparatively
harmless
remedies,
and
be
a
source
And if this be said of
how much the more of such
cantharides! Will not the irritated ? is asked. Already congested, to act upon it thus will surely produce violent inflammation, or some very serious mischief. What will be said when I state that I have given the tincture of cantharides in five-drop
violent measures
as
prescribing
kidney be excessively
doses, till between two and three drachms have been taken in thirty-six to forty-eight hours, without a bad symptom ?
from
early secretion of urine has followed its use, without any kidney whatever. And in fatal cases I have never met with any condition, in this organ, different to what is ordinarily seen in it in death from cholera. I observe that, An
affection of the
* It is very essential that the secretion should be plentiful: and the diuretic must not, therefore, be intermitted until it is; though it may bo administered at longer intervals. t Dr. Parkes is inclined to think that the epidemics of cholera were less severe in those days,
Mat
1,1868.]
FIELD SURGERY "WITH OUR FRONTIER FORCE.?BY B. "W. SWITZER.
within the last year or two, diuretics have been advocated by more than one author, and I conceive that this is a step in the right direction. Few would venture upon so powerful a diuretic as this ; but let me assure those who pause that they may Mr. Webber, Civil Surgeon in do it with
perfect safety. Assam, has used it for a longer period than experience of its efficacy and liarmlessness is
his
I have, and even
than
greater
mine. It is well to combine a warm tincture with the tincture of cantharides, and a little tinct. lavand- co. and sp. ammon. arom. and ether: and, looking upon cholera as a disease of malarious
origin,
I have
always
added
a
few
drops
of
liq. potass,
arsenitis to each dose, following it up, in convalescence, with quinine, with a view to avoiding all chance of a relapse; for
relapses
are
not uncommon.
occasionally
Frictions.?With regard to frictions, if agreeable to the patient, (and they often are in spasm), I would encourage them. As I said before, good nursing is a sine qua 11011. So much may be expected from this, that a professional friend, well known in medical literature, once said to me that, if he were ill with cholera, he should like to be put under the care of some maniac
(some
one
would be
with
chamber,
peculiar
views of his
own),
because such
surround him with all the comforts of and himself see that his instructions were
sure
to
a
one
a
sick
fully
carried out!
frequently happens that patients, at these merely made the receptacles for drugs In the crisis of an epidemic, incoherent therapeutical experiments" are made with no result. We learn in sanitary science, but in the treatment?the medical treatment?of cholera we learn nothing. Some there are who deliberately do nothing when a patient is in extreme collapse. They say?" Oh, why worry him ? let him die in peace!" Dr. Balfour, when advocating the use of strychnine in cholera, says:?"God help those who fall Now it is just in this very condiinto the state of collapse ! Remarks.?It too
times,
are
"
"
tion that I have found the treatment above defined so successful. It may be presumed that, in the course of a long residence in
India,
I have had
opportunities
of
testing
the
efficacy of
It is so ; and I may safely I have found nothing equal to
various so-called cures for cholera
say that, in collapse in cholera, this plan of stimulants, water, calomel, and cantharides, and unwearied watching. Cholera, before collapse has set in, may be combated in various ways, according to the nature of the
of the case, or of the constitution of the individual. would add, in conclusion, that great care must be taken, in these collapsed cases, to ascertain the condition of
epidemic, I
internal organs. Patients, when dying, it may be, of
be
apparently recovering,
will
pneumonia, without any external manifestation of the latent mischief. Natives are very fond ot lying prostrate on their backs. This should be preveuted ;
and attendants must be told to move them from side to side
occasionally. Dysentery is a very common secondary disease, requiring early detection. llecovery from collapse will depend very much upon the normal condition of the heart.
diseased, it may be
unequal
If this organ be in any way to the occasion. Collapse in
patients, or in those suffering from any constituaffection, is rarely, or with great difficulty, recovered from. But where there is nothing of this kind, and where all the organs are healthy, the chances are favorable. As this communication (which appeared, in part, in the Medical Times and Gazette of the 8th February last) is passing through the press, a professional friend,* in practice in Calcutta, is testing the efficacy of the treatment advocated, and informs me that he is abundantly satisfied with it. Will others follow his example, and favor the profession with the result in these coluimvi ? scrofulous
tional
*
Ten very bad eases were admitted into his under the ?alomel plan.?Ed., I. M. &.
recovered
hospital,
and nine have
101
