moderate degree, consists simply in strictly enforcing the rules for
the patient's repose; that is to say, in intelligent nursing. Mental
excitement must be forbidden, and neither medicine nor food allowed
that is likely to interfere with the gradual and steady progress of
convalescence. Of all articles of food, cool water is not only the
most urgently desired, but is the most imperatively necessary for
replenishing the emptied blood-vessels and restoring the normal
functions. But unless great caution is observed it will be taken too
freely and provoke a renewal of the discharges. If any food besides
water is allowed, it should be of the simplest sort--of whey first,
and then of milk in small quantities at a time, with lime-water if it
provokes nausea or retching. Afterward thin broths may be given, also
in great moderation, and by degrees farinacea in milk and in animal
broths. Only when the strength is much improved should even the most
{764} digestible meats be permitted. In proportion as convalescence is
marked or interrupted by symptoms of undue reaction is it necessary to
prolong and render stringent this regimen; and if those symptoms
unfortunately arise which oftener, perhaps, depend upon an
over-zealous stimulant treatment than upon the natural reaction of the
system, they must be combated by measures which will lessen the local
congestions, especially of the brain and the lungs, and also by such
as will tend to prevent the system from falling into a typhoid state.
For the former dry cups applied to the back of the neck, and cold
lotions and affusions upon the scalp, are to be recommended, and for
the latter dry cups and warm stimulating poultices upon the chest near
the affected region. It is probable that the general warm bath, with
cold affusion upon the head at the same time, would prove as efficient
as it does in analogous states of typhoid affections. If the urinary
secretion is suspended or remains scanty, there is not usually an
urgent need of using means for its restoration; for that will
generally occur when the blood-vessels become replenished. It should,
however, be mentioned that, according to Macnamara, if the patient
does not pass any urine within thirty-six hours of reaction coming on,
ten minims of the tincture of cantharides in an ounce of water should
be given every half hour until six doses have been taken, and the
patient encouraged to drink freely of water. If this treatment does
not cause urine to pass, we must, after the sixth dose, discontinue
the medicine for twelve hours, and then repeat it in precisely the
same way. The dose here referred to is of the British preparation, and
if the use of it were not recommended by so competent an authority its
propriety might very properly be challenged.
After the cholera patient has become convalescent his restoration is
very apt to be retarded by dyspeptic disorders, for which, perhaps,
the best remedy is a judicious use of condiments with the food and of
bitter tonics, especially quinine, colombo, quassia, etc., before
meals. If there is constipation, it should be corrected by the
cautious use of fruits, and, if these prove insufficient, of mild
saline laxatives or small doses of castor oil or rhubarb. On the other
hand, if there is a tendency to diarrhoea, it should be met by the use
of a mild laxative, such as castor oil, magnesia, or rhubarb, followed
by chalk or bismuth, and the use for a time of simpler food and in
less than the usual quantities.
Having thus furnished a sketch of the plan of treatment of cholera
which we regard as dictated by experience, it may be not without some
interest to consider certain elements of the method a little more
fully, and criticise, in passing, some other remedies which have from
time to time been proposed. The first of these is venesection. There
was a time when certain physicians, carried away by conceptions of the
disease evolved from their inner consciousness, maintained that it
consisted essentially of a spasm of the blood-vessels, and that the
natural and legitimate cure for it was to be found in bleeding. No
theory is so gratuitous or absurd but cases may be found which appear
to justify it, and in this instance also examples were not wanting to
illustrate at once the truth of the theory and its successful
application. Longer experience, however, and a more correct conception
of the disease, have long since condemned this method, which was
almost as dangerous as it was irrational. If any additional argument
against it were required, it would be found in the condition of the
lungs after death. These organs, we have seen, are not {765} only not
engorged, but they are empty of blood, and death is due not to
asphyxia, but to apnoea, when it takes place in collapse.
If ever there existed any reason for the administration of an
emetic--and ipecacuanha has generally been used at the commencement of
an attack of cholera--it must be looked for, not in any clinical
experience of its virtues, but simply in the deplorable routine that
required the administration of an emetic at the commencement of nearly
all acute diseases, so that, whatever else was prescribed, the lancet
and an emetic seldom failed to be so. In this case also the proofs of
the successful administration of ipecacuanha were not wanting, and one
might be tempted to suppose, in view of the alleged facts in its
favor, that it was useful by causing an evacuation of the material
cause of the disease. Physicians were even to be found, of high
station and character, who contended that cholera is a species of
fever, and to be treated by an emeto-cathartic composed of tartar
emetic and epsom salts. If the treatment had been efficient, the
absurdity of the reasons for it might have been overlooked; but the
one was as disastrous as the other was false. But, as usual, the facts
had been misstated or misinterpreted, and emetics ceased to form a
part of the systematic treatment of cholera. The idea which possessed
those who advocated the use of evacuants was that there was either a
poison to be eliminated from the blood or one to be expelled from the
bowels. Apparently, the method was not efficacious, for the latest
phase of it, the use of castor oil in acute stage of cholera, was of
short duration.
When cholera first appeared in Europe the tendency naturally arose to
follow in its treatment the example of the British practitioners in
India. It then appeared that one of the most eminent among them,
Annesley, gave a scruple of calomel, with two grains of opium, at the
commencement of the attack, and repeated the dose in six or eight
hours, and again upon the following day. In the decline of the disease
he ordered scruple doses of calomel for the removal of a
"cream-colored, thick, viscid, and tenacious matter exactly like old
cream cheese, which glues the gut together and obstructs its passage."
Three, four, and even five, scruples of calomel were usually taken
before this effect was produced. When it is added that this
practitioner held depletion to be the capital element of the
treatment, and that he was equally lavish of his patient's blood and
of his own drugs, we can only wonder that any subjects of his heroic
method survived. It is now conceded by all enlightened physicians that
mercurials in large or in ordinary doses are worse than worthless in
epidemic cholera. In 1832, Dr. Ayre of Hull, Eng., proposed another
method of using calomel, to which he adhered in treating this disease.
It consisted in the administration of very small doses of calomel at
short intervals, and with each of the first doses a few drops of
laudanum. Such a method, if not carried too far, certainly has the
merit of sparing the patient a great deal of the perturbative
treatment against which we have, in the preceding pages, protested.
But that was not at all the notion of its proposer. He claimed for it
positive and active virtues. He stated, as the fundamental ground of
his plan, that "the primary and leading object of the treatment must
be to restore the secretion of the liver." He did not in the least
doubt that he was able to do this by the administration of
mercury--not, indeed, by a direct action upon the liver {766} itself,
but indirectly and sympathetically through the stomach, and by the
healthy and specific stimulus imparted to it, by which the due
secretion of the bile is promoted. It is, indeed, difficult to
conceive of any stimulus that calomel could impart to the stomach that
would not be equally given by any other non-irritant and insoluble
powder--subnitrate of bismuth, for example. Indeed, Ayre himself
relates the case of a man who in an attack of cholera took during
three days no less than five hundred and eighty grains of calomel, and
recovered without any soreness of the mouth. But the plan which he
finally elaborated was different. It was to give small doses of
calomel repeatedly--in the premonitory stage one grain every half hour
or hour for six or eight successive times, or, if this failed, every
five or ten minutes--and in the stage of collapse one grain and a half
every five minutes. In a few cases of extreme severity two grains of
calomel were given every five minutes for an hour or two, and then the
ordinary dose of one grain was resumed. But this was not all: with
every dose of calomel was associated one, two, or three drops of
laudanum, so that if these doses were repeated frequently the patient
received a very efficient amount of the narcotic during the attack.
Indeed, Ayre attributed to it the virtue of sustaining the vital
powers under the depressing influence of the disease, and of removing
or abating the cramps, as well as of detaining the calomel in the
stomach.[64] From the preceding account it follows that the treatment
of cholera by small doses of calomel with laudanum is founded on an
erroneous assumption of the mode of action of calomel, and that
whatever efficacy the plan of treatment may possess may with more
justice be attributed to the opium, whose effects we know, than to the
calomel, whose action, so far as it is known at all, has no
conceivable relation to the disease for which it was given. However
this may be, if the results of Ayre's treatment are compared with
those of other plans, it exhibits very little if any superiority. In
the report of the cholera committee of the College of Physicians,
London, made in 1853, we find the statement that in 725 unequivocal
cases treated on Ayre's plan the deaths were 365, or about 50 per
cent., and also the following commentary: "In general, no appreciable
effects followed the administration of calomel, even after a large
amount in small and frequently-repeated doses had been administered.
For the most part, it was quickly evacuated by vomiting or purging,
or, when retained for a longer period, was passed from the bowels
unchanged. Salivation but very rarely occurred, and then only in the
milder cases. We conclude that calomel was inert when administered in
collapse, and that the cases of recovery following its employment at
this period were due to the natural course of the disease, as they did
not surpass the ordinary average obtained when the treatment consisted
in the use of cold water only."[65] It is of interest to compare the
mortality of 50 per cent. above stated to have occurred under this
sort of calomel treatment with the mortality noted at the London
Hospital under various kinds of treatment, including the
administration of calomel in doses varying "from five to ten and
twenty grains every quarter, half, one hour, two, four, etc." Out of
509 cases, 281 were fatal, or 54.9 per cent.[66]
[Footnote 64: _A Report on the Treatment of the Malignant Cholera_,
Lond., 1833.]
[Footnote 65: Dr. Gull's _Report_, p. 177.]
[Footnote 66: _Lond. Hosp. Reports_, iii. 437, 441.]
Every disease in which exhaustion and coldness occur is sure to be
{767} treated more or less actively with alcohol, but in the collapse
of cholera, as in the cold stage of fevers, it is generally useless,
and sometimes hurtful. We believe that the following protest of
Macnamara is sustained by almost universal experience: "I would here
enter an earnest protest against the use of brandy or any alcoholic
stimulant in this [the second] stage of cholera. I believe these, both
theoretically and practically, to be the cause of unmitigated evil. I
simply, therefore, mention brandy, champagne, and the like in order to
condemn their use most emphatically in cholera; according to my ideas
and experience, it is almost impossible to hit on a more detrimental
plan of treatment than that usually known as 'the stimulant' in this
form of disease."[67] It is true that apparent dissidents from this
judgment may be found, like Playfair, a deputy inspector of hospitals
in Bengal, who even circulated printed directions for the treatment of
the first stage of the disease by means of brandy or strong rum,
cayenne pepper, and laudanum, and had entire confidence in the
efficacy of the method.[68] Dr. Macpherson, inspector-general of
hospitals, also, after comparing the results of a stimulant treatment
with those of other methods, reaches the conclusion that the
mortality-rate of cholera is affected neither by the moderate nor by
the excessive use of alcohol.[69]
[Footnote 67: _Op. cit._, p. 456.]
[Footnote 68: _Edinburgh Med. Jour._, xix. 471.]
[Footnote 69: _Med. Times and Gaz._, Jan., 1870, p. 62.]
Upon no other point in the treatment of cholera is the agreement of
physicians more complete than upon the use of opiates in the early
stage of the disease. The premonitory diarrhoea has always been
treated by opiates alone or associated with astringents. Probably the
best rule is to give from twenty to thirty drops of laudanum, or an
equivalent dose of some other liquid preparation of opium, in a little
brandy and water, and repeat the dose as often as a stool is voided.
Opiates have also been generally employed to mitigate the symptoms of
the fully-developed disease. But, like all other medicines introduced
into the stomach or rectum, they are apt to be rejected, and even if
they are not, their absorption is very doubtful, so that at the height
of the attack they must be considered as nearly if not quite useless.
When the vomiting and purging begin to subside and reaction is about
to commence, small and repeated doses of opiates undoubtedly tend to
lessen the evacuations; but great caution must be observed not to
exceed the due degree of stimulation, lest a dangerous state of
narcotism or collapse be induced. It might be supposed that the
hypodermic use of morphia would be less open to objection than its
administration by the stomach; but it is to be remembered that the
suspension of gastric absorption is only a part of the similar
condition affecting the whole circulatory system, and that the
stagnation of the blood in the systemic veins prevents the absorption
of medicines administered subcutaneously perhaps as completely as the
state of the gastric blood-vessels interferes with their absorption
from the stomach itself. In point of fact, the utility of opiates at
any stage of cholera after the first is not easily determined, for
nearly always they are associated with other medicines, and especially
with astringents. In this disease, as in others that involve life, we
are seldom at liberty to test the powers of individual medicines, but
are bound to endeavor to save life by associating those which seem to
be required for the purpose. Opiates, then, are nearly always given in
conjunction with astringents or stimulants {768} during the first (or
diarrhoeal) stage of the attack, but after vomiting is added to
diarrhoea and a tendency to collapse is manifested they are at least
useless.
The patient, it has already been said, should be disturbed as little
as possible, and hence, if he becomes restless, and especially if he
is rendered so by pain, he should be tranquilized by means of
anæsthetics. Chloroform has generally been employed, and is best
administered on the first accession of cramps. Much pain, with
muscular fatigue and depression, is thus saved, and the inhalation of
the medicine may be repeated as often as the pain threatens to return.
No doubt other anæsthetics, and especially ether, would answer the
same purpose.
Camphor has been claimed to be a valuable medicine in cholera, but
there is no clinical evidence that it is so. Indeed, the only series
of cases in which it was mainly depended upon gave a large mortality.
Acids have been employed in cholera, but chiefly on theoretical
grounds, "in the hope of destroying the specific cholera process going
on in the intestinal canal" (Macnamara). It is hardly necessary to
discuss so vague a reason. What specific process is going on? What
relation to it has the administration of acids? And, after all, only
the hope is held out of destroying the hypothetical morbid process.
The reaction of normal stools is usually acid, but sometimes it is
neutral or even alkaline. In other acute bowel complaints with profuse
diarrhoea they are acid, as in cholera infantum, but in epidemic
cholera they are alkaline, because they consist chiefly of the water
of the blood. It is far from proven that mineral acids can be useful
merely by reversing the reaction of the stools. Far more probable is
it that, in so far as they are of use, it is because they act as
astringents upon the digestive mucous membrane. This may be inferred
from the fact that, according to the advocates of these medicines, it
is always difficult, and is often impossible, to acidify the stools in
cholera. Moreover, it must be remembered that, like other medicines,
the greater part of them are rejected by vomiting. If, then, mineral
acids tend to lessen the diarrhoea of cholera, they act by their
astringency and not by their acidity. Diluted or aromatic sulphuric
acid may be given in the dose of from two to thirty minims, at
intervals of an hour, in acid water or carbonated water, or diluted
nitric acid, in doses of from twenty to fifty minims, at the same or
somewhat longer intervals.
Intravenous injections were used in England during the first epidemic
of cholera in 1832-33, but their results were regarded as unfavorable;
subsequently, in 1849, they were tried with somewhat better success,
and in 1867 the effects were still more encouraging. The liquid
employed on the last-mentioned trial consisted of chloride of sodium
60 gr., chloride of potassium 6 gr., phosphate of sodium 3 gr.,
carbonate of sodium 20 gr., alcohol 2 drachms, and distilled water 20
ounces. The alcohol was added only when the liquid was about to be
used, and the temperature of the latter was not allowed to exceed 110°
F. or fall below 100° F. The liquid was contained in a zinc vessel
holding about eighty ounces, with a lamp underneath, a thermometer
hanging within, and a tap near the bottom, from which proceeded an
india-rubber tube four feet long, with a silver nozzle at its end. The
fluid was allowed to enter the vein by the force of gravity. If
difficulty was experienced in introducing the nozzle, the vein was
freely exposed, supported on a probe, and incised longitudinally. It
was found that the success of the operation depended greatly {769}
upon having an ample supply of the solution prepared, so as to repeat
the injection as often as might be found necessary. Mr. Little, who
practised this method in numerous cases, stated as follows: "When a
patient has been long pulseless clots form in the heart, and, as I
have seen, extend into the larger veins. In one case the fluid would
not flow in, and only distended the veins of the arm injected. After
death clots were found extending from the heart into the axillary
vein."[70] Five out of twenty apparently hopeless cases recovered
under this treatment. The first effect of the injection was to revive
the pulse, which had ceased to be felt; the voice also was restored,
the color and expression improved, the cramps were relieved, the
temperature rose, and the patients became convinced that their
recovery was assured. A profuse perspiration and a severe rigor
accompanied these symptoms. The rigor was evidently a nervous
phenomenon, and not a chill, for it occurred when the temperature was
rising. Other cases might be cited which unquestionably owed their
recovery to this mode of treatment. It is true, however, that much
more frequently it failed of success; and probably not only because
the injection could not reach the heart, but because, having permeated
the blood-vessels of the whole body, it escaped, as the serum of the
blood had done, from the damaged intestine. Nevertheless, it would
seem that an expedient which in a certain proportion of cases has been
quite successful might yet be rendered more certain in its results if
the operative procedure were perfected.
[Footnote 70: _London Hosp. Reports_, iii. 470.]
Cramps in the limbs may be lessened by active friction and shampooing,
but there is no clinical reason for believing that these measures tend
to restore the circulation. Equally ineffectual are other means used
for communicating heat to the algid body and thereby reviving its
functions. It is true that some physicians found that warm baths, at
from 90° to 104° F., gave relief to the cramps and restored the
failing pulse. In most cases the calming influence of the bath was
noted, but it does not seem to have been curative or to have
diminished the mortality-rate.[71] It should not be forgotten that the
patient has no perception of his coldness. In all analogous
conditions, as has already been remarked, such as frostbite and the
cold stage of periodical fevers, cold, and not heat, promotes
reaction. Still more injurious, if possible, than hot applications are
irritants and stimulants after the stage of collapse has set in. Not
only are they absolutely futile for restoring the animal temperature,
but they are liable, unless very cautiously used, to produce
intractable sores upon the skin if recovery ensues. It should also be
remembered that the cholera patient's exhaustion is exceptionally
great, and is apt to be increased by the officiousness implied in the
use of many stimulating agents.
[Footnote 71: _Ibid._, iii. 445; _St. Bartholomew's Reports_, iii.
190.]
As early as 1832 a marked advantage was ascribed to the use of cold
affusions in cholera.[72] One of the physicians of the cholera
hospital of Berlin said: "In these living corpses which are struck
with asphyxia, lying cold and powerless, external and internal
medicines cease to stimulate; no steam apparatus, no warm bathing, no
friction, no irritant, avails." The condition is comparable to that in
approaching death by cold, in which friction with snow is well known
to be the proper remedy. Cold affusions were employed in the second
stage of the disease. If the pulse revived, the affusions were
continued in a tepid bath, after which the patient was {770} put to
bed and gently rubbed with cold flannels. Internally, ice-water was
freely administered. Labadie-Lagrave[73] refers to forty cases treated
in this manner, with only seven deaths. Yet the cold-water treatment
does not appear to have commended itself to physicians generally.
Evidently it does not meet the prime indication, which is to restore
the wasted waters of the blood and retain it in the blood-vessels.
[Footnote 72: Ainsworth, _Pestilential Cholera_, 1832.]
[Footnote 73: _Du Froid en Thérapeutique_, 1878.]
Cold water ought to be given as freely as possible to assuage the
thirst that exists in every stage of cholera, and especially in
collapse. Nor should it be withheld because it will presently be
rejected, for not only does it produce a grateful sensation in the
mouth and throat, but it renders the act of vomiting easier. Yet, to
some extent at least, the thirst may be allayed by rinsing the mouth
and throat with cold water. Iced water is preferable to ice used for
the same purpose, for the latter, by its relatively intense coldness,
irritates and dries the mouth. Fragments of ice swallowed whole allay
the burning heat in the stomach.