which a strict quarantine has protected places to which cholera has
been carried by sea. In the United States numerous examples might be
given of seaports into which cholera was brought from foreign
countries, and within whose quarantine stations it was confined by
rigid sanitary regulations; but it is sufficient to cite the case of
New York, through whose quarantine at Staten Island nine-tenths of all
emigrants to America have passed. Writing in 1867, Dr. Peters said:
"There have been fourteen epidemics of cholera at Staten Island, and
only four have reached New York." A large number of illustrations has
been collected by Dr. Smart, Inspector-General, R. N.,[61] who sums up
the matter as follows: "Believing that cholera has frequently been
excluded from islands by quarantine, and as often introduced by its
non-observance, I regard it as a truly preventive measure; but,
recognizing the impracticability of exacting it under many
circumstances, I would insist on the most strict isolation of all the
first cases or units of disease, whether introduced from without or
originating from relationship to introduced cases, or persons or goods
imported from infected countries."
[Footnote 61: _Lancet_, April, 1873, pp. 555, 659; _Times and
Gazette_, April, 1874, p. 387. Compare also Colin, _Brit. and For.
Med.-Chir. Rev._, July, 1874, pp. 42-44.]
While experience demonstrates the efficacy, and therefore the
necessity, of quarantine against cholera in seaports, it has also
shown that the same agent of prevention need not be invariably and
rigidly applied. When quarantine meant literally a detention, and
almost an incarceration, for forty days, it often failed through its
very rigor at a time when proper methods of disinfecting ships,
cargoes, crews, and passengers were either unknown or inefficiently
applied. It is now certain that quarantine may be reduced to a
fraction of its original duration, and yet possess a much greater
degree of efficiency, its length depending upon the number and the
sanitary condition of the crew, etc., the nature of the cargo, etc. It
is evident that a ship carrying only cabin passengers is less open to
suspicion than one crowded with filthy emigrants, although both may
have sailed from the same cholera-infected port. A more liberal rule
may govern the one than the other; and in the second case a rigid
inspection and cleansing of luggage may be imperative which would be
superfluous as well as vexatious in the first case. The importance of
such a treatment of emigrants' effects has already been illustrated by
cases in which they caused an outbreak of cholera after having been
carried from a seaport into an interior town many hundreds of miles
distant.
In regard to the time during which a vessel that has had cholera on
board within a week or ten days should be detained under sanitary
inspection and treatment, including a thorough cleansing of the
passengers and their effects, no absolute rule can be laid down; but
it would appear that if no suspicious cases arise within a week, there
need be little apprehension that any will occur.
The sanitary measures which should be undertaken wherever there is
reason to fear an invasion of cholera are, in the first place, such as
are {758} equally appropriate in anticipation of any infectious and
contagious epidemic disease, and relate especially to the removal of
all sources of putrid emanations, whether in stagnant ponds, in
streets, markets, shambles, sewers, privies, cellars, or inhabited
rooms; for these influences, although they do not cause cholera, yet,
by lowering the vitality of persons exposed to them, create an
abnormal susceptibility to disease. Many instances in Europe might be
cited to prove that whole cities, which in the earlier epidemics were
devastated by cholera, were either spared entirely in the later ones
or suffered in a far less degree. The measures which proved most
efficient were an improved water-supply and a better system of
sewerage; and this fact strongly corroborates the belief that
contaminated water and fecal emanations are the principal agents in
propagating this disease. Cleanliness is the best disinfectant, but
during epidemics of cholera, as of other diseases, the popular faith
is very strong in numerous articles called by that name. The real
value of these preparations is commercial rather than sanitary, but,
indirectly, they are useful by prompting those who use them to be more
diligent in searching out and removing many sources of
air-contamination that perhaps invite and intensify attacks of
cholera.
The disinfectants in common use comprise chlorine gas, chlorinated
soda, chloride of zinc, sulphate of iron, permanganate of potassium,
carbolic acid, and the fumes of burning sulphur. Some of them--and
especially the chloride of zinc, sulphate of iron, the permanganate of
potassium, and carbolic acid--are supposed to be capable of destroying
the infectious principle of the vomit and stools. Another method is to
receive such matters in vessels containing saw-dust, which, after
being dried, is consumed by fire; and still another is to mix them
with dry earth and bury them. If they are thrown into water-closets or
privies, they should have added to them a portion of sulphate of iron.
Whatever has been used by cholera patients should be destroyed, unless
of value, and in that case it should be thoroughly purified by hot air
or boiling water and long exposure to the sun. The importance of
having large and well-ventilated rooms for cholera patients is very
great, but less, perhaps, for the patients themselves than for their
medical attendants and nurses. All persons should be excluded from
them who are not required by the duties of the sick chamber, and in
case of death funeral assemblages ought not to be allowed; nor, during
a cholera epidemic, ought crowded assemblies for any purpose to be
permitted.
During epidemics of cholera, as of some other diseases, the liability
to be attacked is greatest when the vital powers are depressed by
mental or by physical causes. Hence it is desirable that one's courage
and confidence should repose upon a consciousness of having done
whatever is recognized as proper to ward off the disease--not by a
minute, watchful, and anxious attention to rules at every step, but by
such a general care of the health as good sense and experience enjoin.
Undoubtedly, other things being equal, the weak, sickly, careless, and
imprudent are more liable to suffer than the strong and cautious, and
therefore it is incumbent upon all to maintain as high a degree of
health as possible, avoiding not only all probable sources of
contagion, direct or indirect, but excessive fatigue, catching cold,
depressing emotions, sexual excesses, etc. During the first cholera
epidemics in this country it was considered so dangerous {759} to eat
fruit and fresh vegetables that many persons lived entirely upon meat,
rice, and bread. Such a regimen intensified choleraphobia, and was
also an unsuitable midsummer diet. There is no reason to believe that
any intrinsically wholesome food need be prohibited during the
prevalence of cholera.
The one article of diet about which the greatest and most peculiar
care should be taken is water. It is the first duty of towns supplied
with water from a common source to be sure that it is, and continues
to be, uncontaminated. Well-water should be used as little as possible
after the disease has made its appearance, and, as an additional
precaution, no water should be drunken that has not previously been
boiled. Where ice can be procured it may be used to restore the boiled
water to an agreeable temperature for drinking. Filtered water,
provided that it be properly filtered, may likewise be regarded as
innocuous.
TREATMENT.--If regard be had to the various methods and particular
medicines which have been used in the treatment of cholera, it will
appear that in hardly any other acute disease has a greater number or
variety been employed. If, on the other hand, we endeavor to learn
what measures have been really and generally curative in cholera, and
what are they to which, on the occurrence of an epidemic of the
disease, we may turn with confidence in their power to cure, the
result of the investigation is disheartening, and adds to the
accumulated proofs that the power of medical art is exceedingly
restricted. To this conclusion we must assent at whatever cost to a
faith which is strong in proportion to the ignorance out of which it
grows. Nor, if we consider the matter rationally, ought we to be
surprised or humiliated on account of the comparative helplessness of
medicine in this disease, since, if we reflect upon it, the case is by
no means peculiar or exceptional. Every disease that may become mortal
occurs more or less frequently with phenomena which place it beyond
the resources of therapeutics as completely as cholera is in its most
malignant forms; and yet no one lays it to the charge of medicine that
the various fevers, for example, are at times utterly uninfluenced by
the most rational and judicious treatment. Nor does any one bring a
railing accusation against medicine when accident fatally damages a
part essential to life.
One accident of frequent occurrence presents a certain analogy to
cholera in its effects, and that is a burn or scald involving a very
large portion of the skin. In cases of this sort experience assures us
that death is almost inevitable, and that the duty of the physician is
to avoid officious and meddlesome treatment, and address himself to
soothe the patient's suffering and maintain his strength, if haply the
powers of nature may triumph over the effects of the injury. This,
too, is the lesson, substantially, which experience has taught
respecting cholera. It is certain that in this disease the function of
the whole gastro-intestinal mucous membrane is reversed, and that it
is no longer a secreting and absorbing organ, but one almost
exclusively exhaling, and that through it the liquid which is
essential to carrying on the functions is rapidly running away. If the
lesion on which this symptom depends is complete, if the
gastro-intestinal mucous membrane has entirely lost its natural
function, evidently it is quite futile to address any treatment to
this organ. But if, as probably happens in a great majority of the
cases, the {760} disorganization takes place gradually, it is evident
that there is more to hope from remedies when the disease is gradually
developed than when it reaches its acme at a single bound and leaves
no time for medical intervention. The one unmistakable lesson that
experience teaches respecting the treatment of cholera is, that its
success depends upon its prompt and early application. Almost as
distinctly does observation teach that subsequently to the first (or
diarrhoeal) stage the comparative value of different methods and
individual medicines is very uncertain. And, finally, it would seem
that in this, as in other acute diseases, intelligent and careful
nursing and regimen are quite as important as any medicinal treatment
whatever. However a false notion of the power of medicine may blind us
to the fact, it is none the less a fact, that if different methods of
treatment are compared, that method gives the best results which is
least perturbative. For example, in England, on board of a hospital
ship, were 85 cases, of which 19 treated by quinine gave 12 deaths, 12
by calomel gave 2 deaths, 12 by carbolic acid gave 3 deaths, and 37 by
"Nil" gave 1 death.[62] Or, again, in 1865, at the London Hospital,
159 patients were treated--48 with a mixture containing logwood,
ether, aromatic sulphuric acid, camphor, and capsicum, of whom 31
died; 56 with sweetened water, of whom 28 died; 21 with castor oil, of
whom 14 died; and 20 with "saline lemonade," of whom 6 died.[63] In
the last example the deaths during the use of the astringent mixture
were twice as great as under sugar and water, and under castor oil
twice as great as under "saline lemonade."
[Footnote 62: _Times and Gaz._, Dec., 1866, p. 590.]
[Footnote 63: _London Hosp. Reports_, iii. 444.]
We shall first give an account of the management of cholera in
general, and then consider some of the particular medicines used in
its treatment.
The essential elements of all plans of treatment for this disease, as
for so many others, are rest and abstinence. Whatever else may be
done, nothing avails without them. This remark applies emphatically to
the premonitory diarrhoea; if it is neglected it may readily be
converted into the full-formed disease. It is therefore essential,
during the prevalence of cholera, that whoever is attacked with
diarrhoea should at once give up all active occupation, and confine
himself to a recumbent posture and to the use of food of the blandest
quality, such as mucilages and similar preparations, especially of
rice, which, less than any other vegetable food, is liable to
fermentation during digestion. It is prudent to drink no water that
has not been boiled. If there is reason to believe that the bowels
retain feces from before the attack, it is generally thought advisable
to administer a laxative dose of castor oil, to procure the discharge
of matters which would act as irritants. Except for this purpose
purgatives are neither indicated nor expedient. In a large number of
cases nothing more is necessary than the use of means to check the
action of the bowels, and which should consist of absorbents or
antacids, astringents, and opiates as they are contained in the
officinal chalk mixture, with the addition of tincture of kino or
catechu and a small proportion of laudanum. This medicine should be
given in dessertspoonful doses at intervals of not more than an hour.
If, instead of a diarrhoea which differs from ordinary dyspeptic
diarrhoea chiefly by its watery character, there should also be colic
and profuse discharges, it is proper to add to the medicines just
suggested some which are of a decidedly stimulant character, such as
the essential oils of {761} cajeput, cloves, cinnamon, peppermint,
etc., with which chloroform, ether, or Hoffman's anodyne may be
associated. At the same time rubefacient embrocations may be applied
to the abdomen, which should also be compressed slightly with a broad
flannel bandage. Instead of these stimulants, and perhaps more
efficiently, may be used a simple epithem made by dipping a large
towel several times folded in cold or cool water, applying it so as to
cover the whole abdomen, and then enveloping it and the body with a
dry towel. This application is more soothing than any liniment and its
action is more constant. Instead of any of these agents dry heat may
be used, obtained from bags of hot salt or sand, or moist heat from
thick poultices of flaxseed meal or Indian corn meal or similar
substances enclosed in flannel bags and applied to the abdomen while
they are as hot as can be borne. It is difficult to determine which of
these applications is the most useful. But, on the whole, heat is
preferable to rubefacients, and moist to dry heat. The cold-water
dressing is probably best suited to young and robust persons.
It must be remembered that between choleraic diarrhoea and cholera in
its complete form there are several grades, in one of the most common
of which a tendency to vomit, and even a certain amount of vomiting,
accompanies the diarrhoea. Anti-emetic remedies are then indicated.
They may consist externally of rubefacient and aromatic applications
to the epigastrium (especially the spice poultice); and it is claimed
that a hypodermic injection of morphia in this part is very efficient.
Internally, the best remedies are ice swallowed in small pieces and
small but frequent draughts of iced carbonated water or iced
champagne. Where these liquids cannot be procured, effervescing
powders used in the same way form a very good substitute for them. If,
notwithstanding such remedies, the diarrhoea continues or if it tends
to increase, astringent and absorbent medicines may be substituted for
them; for example, bismuth may be given instead of chalk, and if this
also fails acetate of lead may be prescribed. The last may be used by
the rectum as well as by the mouth, but with very questionable
advantage. Meanwhile, especial care should be taken to avoid giving so
much of any opiate as will induce sopor or excite nausea.
Whoever has had the care of cholera patients has probably, at first,
felt sanguine of success in their treatment, even after the
characteristic discharges and the symptoms of collapse had set in; but
a little more experience has proved their hope to be deceptive, and
revealed the reason of it in the absolute suspension of the
sensibility and absorbent function of the digestive canal. Hence the
dismal unanimity of all medical authors, who from actual observation
of cholera have declared that no treatment avails to arrest the
fully-developed disease. And yet there is some encouragement in the
fact that recoveries sometimes occur from even the most desperate
state of collapse and under the most dissimilar methods of treatment;
so that the physician is warranted in not yielding to discouragement
and in cheering his patients with hope even to the end of life. The
popular dread of this, and indeed of all epidemics, is sure to be
exaggerated, and it therefore behooves the physician to combat the
fears of his patients, and by a cheerful manner as well as encouraging
words administer the cordial of hope, which often proves stronger than
pharmaceutic elixirs.
{762} It may be well to enumerate, as many do, the indications of
treatment in the active stage of cholera, but they really need no such
specification. It is evident that they consist in combating the
symptoms--the vomiting, the purging, the debility, the cyanosis, the
cramps, etc.; and the only means by which the carrying out of such
indications can even be attempted are neither more nor less than would
be used to relieve the same symptoms in other affections. If the
evacuations could be controlled, evidently the cramps and the collapse
would not occur; but this essential and preliminary step cannot be
secured. The medicines introduced into the stomach or rectum are not
absorbed, but are speedily rejected; those which are administered
subcutaneously are not taken up by the stagnant blood as freely as in
other diseases; the nervous system gives little or no response to the
mechanical and physiological stimulants applied to the skin. Yet, in
spite of these obstacles, the physician must persist in the use of
rational methods, in the hope, however faint it may be, that he may
succeed in restraining, and possibly in arresting, the fatal course of
the attack. For this end he has hardly any means at command except
those, or such as those, which were recommended in the first stage of
the disease--the anti-emetic and anti-diarrhoeal medicines, which he
is only too likely to see rejected as soon as administered. Yet he
must not cease to allay the thirst by the repeated administration of
small quantities of carbonated and cold liquids, water, or champagne
wine, or morsels of ice swallowed whole. The application of pounded
ice in a bladder to the epigastrium is a measure of an analogous sort,
and is sometimes as efficient as generally it is soothing. In other
cases the aromatic poultice seems to answer better. Of irritants
little can be said that is favorable, but the combined irritant and
anæsthetic action of chloroform is useful, and morphia should be
applied to the epigastrium as well as given hypodermically.
If the vomiting tends to become less frequent, acetate of lead may be
prescribed, in the hope that it will exert some constringing action
upon the gastro-intestinal mucous membrane. The distressing symptom,
hiccough, cannot with any certainty be controlled by medicine, but
perhaps the inhalation of chloroform is more efficient than any other
remedy, as it also is for the cramps in the limbs. For the latter
purpose it is preferable to the frictions with flannel or with
stimulating liniments which are generally employed. If such liniments
are used, care should be taken that they do not contain ingredients
that may disorganize the skin either immediately or subsequently. A
dangerous compound of the latter sort introduced during the first
epidemic of cholera in this country became officinal under the name of
liniment of cantharides.
The loss of the water and of the salts it holds in solution in the
blood is, as has now been frequently repeated, the chief pathological
element of the disease, next after the conjectural cause which injures
the mucous membrane of the stomach and bowels. It was rationally
indicated, and therefore a method was early practised, to supply this
loss by injecting into the veins a solution of sodium salts. The
method was seductive as well as rational, for its primary effects were
extremely encouraging; it nevertheless failed, and probably for the
very reason that suggested its use. Indeed, there is no more reason,
if there is as much, to suppose that a liquid artificially introduced
into the blood-vessels will be retained when {763} the natural liquor
sanguinis cannot be so. Necessarily, the one will escape where the
other has escaped.
Certain systematic writers prescribe a method intended, on the one
hand, for reviving the animal heat, and on the other for restoring the
movement of the circulation. It need hardly be remarked that the two
form essentially but one and the same indication. If the circulation
is restored the animal heat will revive, but not otherwise. The same
treatment leads to both ends, and it consists partly, as already
stated, in the use of stimulants, such as alcohol, camphor, coffee,
ether, etc.; but their efficacy depends upon their being taken into
the blood, and with it reaching the various nervous centres upon which
the renewal of functional activity depends. Little, therefore, can be
expected from them at the height of the disease--that is, in the stage
of collapse--but as soon as any signs of reaction are manifested they
tend to promote it, and hence may enable the functions to revive. For
this reason they are adapted to persons who are feeble by reason of
their tender or their advanced age, or who have previously suffered
from ill-health. But if they act at all, and the more they tend to
act, they must be employed with circumspection, lest they outrun the
purpose of their administration and produce a violent or excessive
reaction. Instead of, or in conjunction with, these internal remedies
the local stimulants of the skin, already enumerated, may be used with
the due precautions, and, in addition, baths at a temperature of 105°
F. of water alone or with the addition of salt or mustard; but all
such remedies are of little avail until reaction has commenced. Before
that event there is reason to believe that the cold bath is
preferable, or, still better, frictions of the whole body with cold
water, or even with ice, after which the patient should be wrapped in
dry and warm blankets. Yet the efficacy of this powerful agency is by
no means comparable to that which it produces in the algid forms of
malarial fever. The two conditions, although apparently analogous,
are, in reality, very different. In the cold stage of fever the
mechanism is indeed paralyzed, but none of its mechanical elements are
wanting; but in algid cholera there is an actual subtraction of water
from the blood, that turns it from a liquid capable of circulating
through the narrowest channels into one that stagnates even in the
largest vessels. In the one case force is wanting to circulate the
blood; in the other there is no normal blood to circulate.