F553« 1871 FITZGERALD EPIDEMIC CHOLERA WC 262 F553e 1871 34632030R NLN 0511_77(_2 D NATIONAL LIBRARY OF MEDICINE ARMY MEDICAL LIBRARY FOUNDED 1536 WASHINGTON, D.C. RETURN TO NATIONAL LIBRARY OF MEDICINE BEFORE LAST DATE SHOWN V _-___f^_t J _«t"_te'___'- EPIDEMIC CHOLERA. BY L^ EDWARD AMBROSE FITZGERALD, SURGEON BENGAL MEDICAL SERVICE. LONDON: J. AND A. CHURCHILL, NEW BURLINGTON STREET. 1871. we/ LONDON : PARDON AND BON, PRINTERS, PATERNOSTER ROW. PREFACE. At a time like the present, when cholera is spreading over the continent of Europe, and when there is danger of tjiis unwelcome guest once more visiting the British Isles, I have some hope that this little production will not be allowed to pass altogether unnoticed. The opio-stimulant plan of treating cholera, based as it is on false theories, and so productive of disheartening results, has too long held sway. I myself was once a believer in it, but was compelled to give it up in sheer despair. The last time I tried it was in 1862. I was then at Gwalior, in medical charge of the 41st Native Infantry. Four cases of cholera occurred in the regiment. I treated them in good orthodox fashion, and all four died. Happily, no more men were attacked at the time, as I fear I should have gone on treating them in the same manner, innocently believing that I was doing the best that was possible for them. If these a 2 4 pages contribute in any degree to bring about the conviction that opium, astringents, and stimulants are not, and cannot be, remedies for cholera, they will not have been written in vain. I take this opportunity of thankfully acknowledging my indebtedness in an especial manner to Dr. George Johnson, of King's College, the perusal of whose works on cholera first shook my belief in the theories prevalent as to the nature of the disease, and served to develop the ideas I now hold in regard of the line of treatment that should be followed. London, 31st August, 1871. EPIDEMIC CHOLERA. HISTORY OF CHOLERA. Although the early history of cholera is enveloped in obscurity, it is now, after much investigation of the subject, generally considered to be no new disease developed in modern times. Some believe they can trace it in the writings of Hippocrates, Gralen, and other ancient medical authors. Allusions are made to it in the works of some Portuguese practitioners at Groa published in the sixteenth and seventeenth centuries ; and it is even said that it raged in London in the year 1676, in the days of Sydenham. From the simple fact that the epithet haizah, the name by which the disease is known in India at the present day, was current in the country more than three hundred years ago, we have a strong proof that it is nothing new to the people of the land. Prior to 1817, it would appear that very vague ideas were entertained as to what place this remarkable disease should hold in medical literature. It is therefore unsafe, because of the general absence of the term " Cholera" in hospital returns previous to that year, to infer that the disease was unknown, or little noticed. There is evidence of its having raged at Madras in 1770 and 1774, and of its having appeared at Granjam in 1781. In 1814, an outbreak occurred in Fort ETIOLOGY OF CHOLERA. William among a body of recruits recently landed ; yet the term " Cholera " does not appear in the returns submitted from the hospital in which the cases were treated. Many years afterwards, when cholera had begun to attract the attention of the faculty in India, Doctor Cruickshanks, the medical officer in charge of the recruits in Fort "William at the time of the outbreak, explained that he had classed all cases of cholera under the head of bowel complaint. In the same way, when the Secretary to the Government of India, in August, 1817, intimated to the Bengal Medical Board that there was a serious outbreak of disease at Jessore, having all the symptoms which we now know belong to cholera, and solicited advice as to the institution of remedial measures for its alleviation, their reply was, " The disease is the usual epidemic of the year, increased perhaps in violence by the peculiarities of the present season, and not improbably by certain local causes, affecting the health of the inhabitants of Jessore ;" thus showing that the matter was nothing strange to them. But although these and other instances might be quoted in proof of the disease having been known both before the coming of the British to India, as well as in the early days of their rule, yet it must be conceded that up to the year 1817 cholera had not been studied by the European faculty as a special disease, nor an appropriate position assigned to it in the medical world. ETIOLOGY OF CHOLERA. In its diffusion and propagation, cholera has often presented so many difficulties and such apparent eccentricities, that, while some observers have been led to believe it to be of a contagious nature, others have contended that it is essentially epidemic, and not spread through the agency of human intercourse. The doctrine of contagion has gained ground of late years, having received serious encouragement from the dictum of the Constantinople conference, and the 6 ETIOLOGY OP CHOLERA. misinterpretation of recent occurrences in India. It is particularly fortunate at such a time, when opinions are so divided, that the able work of Dr. J. L. Bryden, Statistical Officer attached to the Sanitary Commissioner with the Government of India, entitled " Epidemic Cholera in the Bengal Presidency," should have appeared. This work is one of so much research, is based on such a continued series of observations in divers localities, and after a careful survey of known facts so just in the conclusions arrived at, that it must long continue to hold its place as an authority on the subject of which it treats. Bryden states that whatever may be the secondary agencies at work, cholera, out of its home in the swamps and low alluvial lands of Bengal proper, is essentially epidemic, and dependent for its spread on meteorological phenomena, so much so, that if there were not a single human being in existence, it would still play out its destined part. For the production of an epidemic three things are required — viz. (1) the special miasm of cholera ; (2) moisture to vitalize it ; (3) a wind to transport it. The miasm is generated in the swamps of Bengal, and when the monsoon sets in, is vitalized by moisture and wafted along by the prevailing winds to TTpper India, and other distant regions. The miasm is a vital object, having a defined period of existence, which, unless shortened from some cause or other, may be set down at from three to four years, and it is subject to alternating periods of activity and dormancy. The moist weather of the monsoon is its season of activity ; the cold dry weather, that of its dormancy. If the breeding grounds ceased to send forth their deadly supplies, epidemic cholera would disappear not only in Upper India, but all over the world. The cholera that results from an influx of fresh miasmata may be termed a cholera of invasion, as distinguished from a cholera arising from revitalization, after a period of dormancy, of the miasm already spread over tracts of country. Epidemic cholera never advances against the wind. When it appears to do so, it is simply a cholera of revitalization, and not one of primary invasion. These and many other interesting details are discussed at length in 7 ETIOLOGY OE CHOLERA. Dr. Bryden's elaborate work, which those interested in the subject might read with advantage. After an experience of more than fifty years in the large hospitals of Calcutta, not a single medical officer who has had to deal with the disease, save Mr. C. Macnamara, has ventured to assert it to be of a contagious nature. Patients stricken with the disease have been treated in the same wards with other patients, and yet the sick in their immediate neighbourhood, as well as the hospital servants and attendants, have enjoyed a remarkable immunity. In the General Hospital of Calcutta, during the thirteen years ending July, 1868, about 24,000 European patients had been treated, including 1,100 cases of cholera. Of this large number, eight only had been actually seized with the disease in the hospital, and of these eight, seven had been admitted with diarrhoea. Dr. Edward Goodeve, a physician of known ability, in his article on Epidemic Cholera, published in vol. i. of Reynolds's "System of Medicine," says: "The majority of medical men in India, accustomed to see cholera year after year, to be in constant intercourse with the cholera sick, and to see the general immunity of hospital attendants and of themselves, doubt the contagiousness. The disease seldom spreads from bed to bed in a ward ; on the contrary, when people are attacked in hospital they lie generally in a distant corner, or in another ward. I have notioed this over and over again, and though I have been oonnected with the large hospital of the Medical College at Calcutta for many years, I do not recollect any spreading to the nearest or neighbouring patients." Dr. Bruce, speaking of his experience at Cawnpore, says : "In 1848, I had cholera in the Fusiliers from May till September. During the whole of that time I may say the hospital was never free of some cases, and at times it was crowded. The whole establishment may be said to have lived in the wards, the coolies for hours together never left the beds of the patients, and the medical officers did nothing but minister to their wants, and yet not one man, European 8 ETIOLOGY OE CHOLERA. or native, ever showed the least symptom of cholera. I took most particular care to have them mustered and looked at, but in that year there was not even a case of bowel complaint among them. I had often not less than 100 men thus exposed. In 1849, the result was the same ; not one man of the hospital establishment was attacked." Dr. Walker, -who was officiating Inspector-General of Prisons in the North- Western Provinces of India in 1864, writes : "I have taken advantage of my position to ascertain how far the choleraic influence in the atmosphere was felt among the population of the North -Western Provinces during the week 7th to 15th June, when cholera so heavily visited the jail of Allahabad. The choleraic influence was confined to a continuous tract of country. The Humeerpore, Banda, Allahabad, Mirzapore, Benares, Azimgurh, and Goruckpore districts suffered most. The sudden appearance of the disease put it out of the question that the affection moved with slow treads along human highways. Simultaneously at Goruckpore, Allahabad, and Banda, on the Bth June, the affection showed itself, indicating beyond a question that it had its origin in wide-spread atmospherical conditions." The advocates of the contagion theory have endeavoured to make much capital from the great outbreak among the pilgrims assembled at Hurdwar in April, 1867, and from which point they assert cholera radiated and spread over India as from a common centre or focus. This assertion is not in accordance with ascertained facts. On the 18th February, 1867, it was reported that cholera was prevalent at the foot of the hills. On the 22nd March, a sudden outbreak occurred in the Allahabad jail, causing fourteen deaths out of twenty-seven attacked. On the 23rd March, the disease appeared in the city of Benares, and on the 27th at Lucknow. On the 6th April it was at Bhurtpore, and on the 15th at Jeypore. Thus, without any reference to Hurdwar and the pilgrims, cholera was in full play at Benares, Allahabad, Lucknow, Bhurtpore, Jeypore, and the foot of the hills. These places, which represent a wide tract of country, 9 ETIOLOGY OE CHOLERA. could not possibly have derived the disease from that supposed central focus. Apart from these circumstances, a general epidemic of cholera had been actually anticipated by Bryden, not because of the large assemblage of pilgrims at Hurdwar, but because the seed of cholera being already sown, the disease was certain to appear, irrespective of any gathering, when the time favourable to -its development would arrive. On the 25th February, 1867, he addressed an important letter on the subject to the Sanitary Commissioner with the Government of India, some paragraphs of which, as given at page 30 in his work on Epidemic Cholera, are here quoted : — " I think it right to suggest to you the chance of an outbreak of cholera at Hurdwar and over the adjoining districts, in April and May. The invading cholera of November was, I think, spread over the whole area of Rohilcund, &c, even up to the hills ; and if this was the case, we are bound to expect its reappearance from all parallel history. The cholera of the years 1783, 1852, 1857, and 1862, teaches the same lesson throughout, that a cholera of this distribution will reappear in April. To me the cholera of November and December, 1866, is indicated in five deaths of the 36th Native Infantry at Ghazeeabad, and one in the Bth Native Infantry at Moradabad ; a sepoy of the 3rd Ghoorkas died on December 17th, while on detachment at Rampore, and another man of the Sappers was attacked while returning to Roorkee from his home in the Putteealah district. Dr. Walker also notices two fatal cases in the Roorkee bazaar on the 4th and 23rd December, and we know generally the fact of the appearance of cholera in Delhi and the neighbourhood at the same time. I do not know the strength of the body of cholera so distributed, but I dread universality of spread as much as the strength of special outbreaks, for we never know what the main body may be, of which these trifling indications are the mere index." So clear a prognostication of what subsequently did take place speaks loudly in favour of the views advanced and advocated by Dr. Bryden. Dr. Cutcliffe, the Sanitary Medical 10 ETIOLOGY OF CHOLERA. Officer at Hurdwar, gives the following account of the meteorology preceding the outbreak at that place in 1867 : — " The cold wind, locally known as the 'Dadoo/ blows from the snowy regions down to the heated plains below. It blows at night, and its direction is steadily from north-east to south-west. In April it commenced to blow about 9 p.m., and it ceased about 10 a.m. By day, the current of air is chiefly upwards towards the hills. The 11th April was a cloudy, close day, with the usual wind blowing upwards to the hills. In the afternoon, a heavy storm of thunder and very vivid lightning coming from the west broke over Hurdwar, when two men were killed, and four others severely burnt by the electric fluid. Heavy rain fell, and continued all night. The 12th was the great day for bathing, and the pilgrims, who had been wet for twelve hours, began before the dawn of day to stream off in thousands to the sacred ghaut. The rain still continued to fall, though now only lightly ; nor did it cease until the evening, when just before sunset the clouds broke, and the sun for a short time came out. A vast number must have waited in a state of fatigue for twenty-four hours, till the sun came out, ere they could have got any dry clothes on their bodies. On the following day (April 13th), eight cases of cholera were sent to hospital." On this Bryden observes : "We have the same evidence that cholera had passed over Roorkee into the Terai beyond Hurdwar in the last months of 1866 that we have of its having swept over Moradabad and Rampore into the Terai west of the Gogra at the same time. Everything required for epidemic manifestation among a population assembled at Hurdwar was present. The cholera had been introduced into a breeding- ground, well adapted for revitalization, and known from past experience to be a certain breeding-field. The vehicle of moisture, and the wind to bring it down on the assembled mass, were opportunely provided, and previous fatigue and exposure rendered the body of pilgrims eminently fitted for the reception of the miasm ; and when it did come, the assemblage succumbed to cholera as a body, just as it would have been prostrated as a body by the malaria poison, had it spent the 11 ETIOLOGY OF CHOLERA. same number of days in the same locality at the season when malarious influences are predominant. In the many epidemics I myself have witnessed, I have never been able to trace a symptom of contagious propagation. While I was at Jounpore there were two outbreaks of cholera in the jail ; the first in August, 1869, the second in February, 1870. During the first outbreak, although cholera was raging all over the district, only seven cases occurred. The second outbreak was remarkable for its severity, its complete localization, and the unusual period of the year at which it took place. The first man was attacked on the 3rd of February, the second on the 6th, "and a third on the Bth ; but it was not till the 9th of February that it declared itself in its intensity. On that day ten prisoners were attacked, and during the five subsequent days sixty-five other cases were admitted. On the 15th there was a lull. On the 16th, three more were attacked. After that date the disease declined remarkably, a few additional cases occurring now and then during the remainder of February and early part of March. There were ninety-nine cases in all. A more localized and severe outbreak is probably not on record. While twenty-five per cent, of the prisoners were attacked, not a case was reported beyond the jail premises. The outbreak could in no way be attributed to contagion. No man suffering from the disease, by whom it might have been communicated to others, had been admitted into the prison. In fact, outside the prison precincts there were no cases for communicating contagion. The first person attacked was a strong, healthy young man, a sweeper, who had been in the jail upwards of five months; the second, nineteen days ; the third, two months and twenty-two days- ; the fourth, one month and four days, and so on. It is quite as impossible to attribute the outbreak to the use of water from wells into which the poison of choleraic excreta had filtered through the soil. During the six years ending 31st December, 1869, only seven cases of cholera had occurred among the prisoners in the Jounpore jail, and these in August, 1869. Each of them, as soon as the disease de- 12 ETIOLOGY OF CHOLERA. clared itself, was brought to a separate barrack (No. 8) for treatment. If there were any accumulation of choleraic excreta awaiting infiltration, it must have been in the compound of that barrack, and the water in the well attached to it must have been most impure. Yet but a solitary individual was attacked in this part of the jail, and he only after thirty-two cases had already occurred elsewhere. This localized outbreak was in all probability due to the revitalization, under favouring meteorological influences, of a dormant cholera, which had given unmistakeable indications of its presence in August, 1869. The appearance of cholera in ships five or six weeks after sailing from infected ports, which has hitherto appeared so paradoxical, may be accounted for in the same way. Indeed, it is a matter for thankfulness, considering the large number of vessels that sail from various ports during the prevalence of cholera, to think how very few suffer from the disease after they have once fairly got to sea. Both before and during the outbreak in the Jounpore jail, the weather had been unusual. In the second week of February the leaves of the trees were falling fast ; the corn was yellowing in the fields, the days were sultry, and the thermometer often showed a temperature ten degrees higher than at the same time in previous years. After a continued prevalence of westerly breezes, the wind veered to the east on the 9th February. At half-past four that afternoon clouds gathered in the east. There was loud distant thundering, and every appearance of a storm. The storm did not come, but a few drops of rain fell. There was heavy rain and a fall of hail four miles off. "On that very day cholera began to rage in the jail. On the night of the 10th there was again some distant thundering. On the 11th, heavy clouds came up from the eastward, and at 1 p.m. there was a sharp downpour of rain. The wind continued easterly, without intermission, from the 9th till noon on the 13th February, and all this time the disease was at its height. At mid-day on the 13th the wind resumed a westerly direction, and within thirty-six hours afterwards the intensity of 13 ETIOLOGY OF CHOLERA. the disease had passed away. Although there was but little rain at Jounpore during the winter of 1869-70, it does not follow that there was a want of moisture in the atmosphere preceding the time of the outbreak. Dr. Murray Thompson, in his meteorological report of the North- Western Provinces for the five years ending 31st December, 1867, shows that, although October, 1866, was almost rainless, o*B of an inch only having been registered, yet that in this month the highest mean humidity of the five years, 1863-67, was found ; the consequence of which was, that cholera showed itself in the camps of the various regiments, European and native, assembled at Agra for the great Durbar of November, 1866, and gave an unequivocal foreshadowing of the general epidemic of 1867. Briefly summarized, the arguments against the spread of cholera as an epidemic by human intercourse may be thus stated :— I. Epidemic cholera in Upper India has, like plants, its appropriate season. It comes with the monsoon, and disappears with the dry cold weather. When it occurs in the cold weather, as in November, 1866, among the troops assembled at Agra for the Governor-General's Durbar, it is simply owing to the prevalence of exceptional meteorological phenomena. During the monsoon, cholera is at its minimum in Lower Bengal. If the disease were dependent for its spread on human intercourse, how comes it that at the very time that it is least prevalent in Lower Bengal, and when intercourse through travel with other parts of India is much reduced, it should invariably at such a time rage epidemically in the North- Western Provinces, "the Punjab, and elsewhere ? 11. It often breaks out simultaneously in places widely remote from each other, and where intercourse with affected parts was impossible. 111. Epidemic cholera never radiates from a central focus of so-called contagion, nor does it necessarily follow the highways of human intercourse. IV. Hill stations enjoy great immunity from cholera, notwithstanding uninterrupted intercourse with affected localities. 14 ETIOLOGY OF CHOLERA. V. Strict quarantine is not capable of impeding the spread and progress of cholera. The contrary has sometimes been asserted, but it has not taken long to disprove the assertion. Persia was said to have preserved herself, in 1865, by shutting up her ports against vessels from the Arabian coast. Why did she not escape on previous and subsequent occasions, by using the same means ? Italy boasted in 1865 that she had saved herself from cholera by strict attention to quarantine ; but how did she fare in 1867, when she resorted to similar measures ? Probably no country in Europe ever suffered more sorely from the disease than she did during that year. In India, neither movements of troops into camp, nor sanitary cordons to prevent the ingress of affected individuals, have proved an effective barrier against the disease. When it has been, asserted that such measures have arrested the progress of the disease, the assertion has been made in consequence of incomplete observations. In 1861, the institution of quarantine was believed to have saved the Punjab beyond the Jhelum from cholera. If this were true, how is it that, notwithstanding the employment of the same measures, the disease found its way in the subsequent year, and again in 1867, to Eawul Pindee, Peshawur, and other places across the Jhelum? On this point Dr. Bryden draws attention to a curious fact. It would appear that in the first year of an epidemic invasion, cholera, for some reason or other, comes to a stand at the Jhelum, and only appears across its banks in the following year as a cholera of reproduction. VI. More than fifty years' observation in the large hospitals of Calcutta and elsewhere has failed to show that cholera is spread from bed to bed in the wards. It stands as a remarkable fact, that hospital establishments, who are most exposed to such supposed foci of contagion, have almost invariably been exempt from the disease. Difference of race appears to exercise a remarkable influence in determining susceptibility to attack. It is a noteworthy fact that the British soldier, in almost every cantonment, exposed to the same epidemic influences, suffers in an infinitely 15 ETIOLOGY OF CHOLERA. greater proportion than the sepoy. The tabulated experience of twenty-five years proves this, so that it is not a matter of chance nor a thing casual or exceptional. In the epidemics of 1856 and 1861 at Meean Meer, while from the European portion of the garrison hundreds were swept away, the native portion, equally if not more numerous, lost only thirty-nine men in the former, and eleven in the latter year. No doubt the excessive predisposition of the British soldier to succumb to choleraic influences may in part be justly attributable to other causes than mere difference of race. Among these we may enumerate the frequent presence of venereal taint in his system ; the excessive use of spirituous liquors, at times followed by periods of depression from inability either through impecuniosity or through the stringency of military rules to obtain further supplies to keep up the stimulus ; debility arising from malarious fevers, and sometimes from the excessive use of tobacco ; the effects of a barrack atmosphere tainted from overcrowding, and the leading too sedentary a, life during the hot and wet weather. But after making allowances for all these drawbacks, the question of race seems to be a serious one, for it is not only the British soldier who shows a marked susceptibility to cholera, but the Ghoorka also, though in a less degree. In the epidemic of 1861, the losses at the various stations were — Europeans . . . . . . 78*92 per thousand. Grhoorkas . T . . . . 35*94 „ Sepoys s*lB „ This statement demonstrates, that while the disease is little more than twice as fatal to the British soldier as to the Ghoorka, the ordinary sepoy enjoys an immunity from its ravages thirteen times greater than his European comrade. Of all the causes that predispose to an attack of cholera, none, perhaps, exercise a more potent influence than fear and mental depression. There are numerous facts on record in proof of this statement. The Commission appointed by Lord Canning to report on the epidemic of 1861, ascertained that at Meean Meer, out of hospital, the cases to strength 16 ETIOLOGY OF CHOLERA. were 4*7, deaths to strength 2*9, deaths to treated 62*7. In hospital the cases to strength were 14*7, deaths to strength 11*6, and deaths to cases 79*2, on which they remark that "the virulence of the disease among hospital patients was clearly more than twice as great as it was among the healthy." The Commission noted, at the same time, that the medical officers, medical subordinates, and hospital servants who must have been in almost constant communion with the sick, enjoyed a remarkable immunity from the disease. How is such a phenomenon to be accounted for ? One set of men casually exposed is more than decimated, while another set perpetually in contact with the same agencies escapes marvellously ! To me there appears to be no difficulty in the explanation. There can be little doubt but that mental depression, arising from grief at witnessing the sufferings and rapid deaths in succession of friends and acquaintances, as well as fears lest they themselves might likewise become victims of the disease, were the chief, if not the sole causes of the excessive mortality among the men, who were either actually patients themselves, or in attendance on their comrades in hospital. In a cholera-tainted atmosphere the highest play of functional activity is required to maintain the balance of health, and the emotions of grief and fear so often fruitful in mischief, beyond doubt deprived them of that high functional activity they were so much in need of, and rendered them easily susceptible of the evil influences that were abroad. Dr. Bruce, surgeon of the lst European Bengal Fusiliers, noticed this fact many years ago. Writing of cholera in the " Indian Annals," of October, 1856, he says, " Mental depression predisposes as much to the disease as anything I know. So confirmed was I of this fact, that I latterly objected to let any soldier be attended by his comrade in hospital. I always caused his attendant to be selected from men who knew nothing, and cared as little about him. It was a curious fact, too, that the disease did not seem to attack the attendant till the excitement was over. It always followed after the death and funeral of the person he was anxious about." b B 17 ETIOLOGY OF CHOLERA. A remarkable case, illustrative of the baneful effects of fear, occurred in a native regiment at Deolee during the outbreak of 1867. " Two sepoys lived in the same hut, the one died of cholera on the 11th July. The second man, on going into his hut on the 1 6th July, fancied that the dead man was sitting on his bed; he rushed out in a state of great alarm, declaring that Umur Singh's ghost was sitting on his bed, and had asked him to smoke. A white cloth was found on the bed. The man was taken ill soon afterwards, and died next day." It is impossible for those who have not witnessed it, to conceive what amount of gloom and despondency the British soldier sometimes becomes a prey to on the occurrence of an outbreak of cholera. I have seen a detachment, 200 strong, almost demoralized from fear because the disease had appeared among them. Yet these were men not otherwise wanting in courage. They would have been as ready to face danger and death as British soldiers elsewhere. I have little doubt but that during the outbreak in the Jounpore jail, in February, 1870, fear predisposed many of the prisoners to attack. Few of the men were willing to attend on their sick comrades. They all seemed to be in a state of alarm. Many attributed the outbreak to supernatural agency. Somehow or other, a belief had sprung up that it was due to the spirit of a prisoner named Bullum, who had committed suicide on the eve of the sentence for his execution being carried out, prowling about the premises ; and they were thoroughly impressed that, unless some peculiar votive worship were gone through, it would continue to be a source of constant annoyance. From details recorded in Mr. C. Macnamara's treatise on Asiatic cholera (vide pages 196 and 197), it would appear that the virus of the disease is contained in the dejecta, and that such dejecta, if swallowed, may give rise to cholera. " I may mention," says he, " the circumstances of a case which occurred in another part of the country, but in which the most positive evidence exists as to the fact of fresh cholera dejecta having found their way into a vessel of drinking 18 ETIOLOGY OF CHOLERA. water, the mixture being exposed to the heat of the sun during the day. Early the following morning, a small quantity of this water was swallowed by nineteen persons (when partaken of, the liquid attracted no attention, either by its appearance, taste, or smell). They all remained perfectly well during the day; ate, drank, went to bed and slept as usual. One of them, on waking next morning, was seized with cholera; the remainder of the party passed through the second day perfectly well, but two more of them were attacked with cholera the next morning ; all the others continued in good health till sunrise of the third day, when two more cases of cholera occurred. This was the last of the disease ; the other fourteen men escaped absolutely free from diarrhoea, cholera, or the slightest malaise. " In this case, it is certain that the contaminated water was once, and once only, partaken of. Its effects were that out of a party of nineteen healthy men who swallowed it, five were attacked with cholera within seventy-two hours ; the remaining fourteen individuals were absolutely unaffected by the poison. These details leave us no reason to doubt that water, contaminated by the fresh dejecta of a patient suffering from cholera, produced the disease in five out of nineteen people who swallowed it, and that independently of either the season, nature of the soil, or any other appreciable circumstances, all of which were remarkably in favour of the persons attacked by the disease. Nor was cholera prevalent in the place ; I am assured it had not visited the locality for several years, nor has it, as far as I am aware, appeared there since." Unfortunately, experiments of this kind cannot be legitimately repeated, so that it is well-nigh impossible to refute or confirm the assertions made in the preceding extract. Until evidence to the contrary be obtained, it is incumbent on all, for the sake of safety, to accept Mr. Macnamara's statement, unsupported though it be, and in the institution of preventive measures to act upon it. But although the dejecta may contain the virus of the disease, it does not follow as a necessary consequence that cholera is usually B 2 19 SYMPTOMS OF CHOLERA. propagated through this medium. A gonorrhoea has been occasionally contracted in a water-closet, yet no one would, on that account, assert that water-closets are the channels by which the disease is ordinarily diffused. Again, the smallpox pustule undoubtedly contains the virus of the disease; but the spread of small-pox is not, for all that, due either to swallowing matter from pustules, or to direct inoculation. So, too, whether the virus of cholera be present or not in the dejecta, it is quite impossible, for reasons already given, to attribute the spread of the disease epidemically to the introduction of choleraic ordure, either with food or drink, into the alimentary canal. SYMPTOMS OF CHOLERA. A well-developed case of epidemic cholera may be described as having three stages ; the first, for want of a better term, may be styled the stage of development ; the second, the stage of collapse ; the third, that of reaction. In Calcutta, and various parts of Lower Bengal, f where cholera is endemic, the disease is often preceded by diarrhoea, which may continue for several days ; but in epidemic outbreaks such warning is usually of short duration. In fact, the severer the epidemic, the greater the absence of foreshadowings. So much stress has been laid by some writers on this " premonitory diarrhoea," that it has in the minds of many come to be considered almost synonymous with cholera itself. It is owing to this confusion of ideas that the boasted efficacy of opium, chlorodyne, and kindred remedies in cholera, has been so persistently reiterated. As long as diarrhoea is unaccompanied by other symptoms, it must be looked upon simply as diarrhoea and treated as such, though during epidemic outbreaks the contingency of cholera must not be forgotten. Diarrhoea should on no account be confounded with, or magnified into a disease of far more serious import. In epidemic seasons simple diarrhoea may sometimes lead to cholera, not in consequence of its being a part 20 SYMPTOMS OF CHOLERA. of the disease, but because it lowers the system, andrby so weakening its powers of resistance, renders it more easily susceptible of the evil influences prevailing. Though there is a proneness to diarrhoea during epidemic outbreaks, it is well known that many such cases are perfectly harmless, and would not, even if left to unaided nature, result in cholera. It is a great mistake to consider the more developed stages of cholera as a result of previous diarrhoea, and still more incorrect to argue that because diarrhoea has been checked, cholera has been cured. The occurrence of diarrhoea when epidemic cholera is rife is sufficiently serious of itself, without attempting to give it a fictitious importance. Stage of Development. — In the first stage of cholera, or that of development, the patient is seized with vomiting and purging, accompanied by restlessness, thirst, inward heat, and weakening of pulse. After the first evacuations of the contents of the intestine, the stools soon take on the characteristic rice-water appearance, and are passed in great quantity. The skin assumes a dusky leaden hue, and loses its elasticity. The temperature of the surface lowers, the urine becomes albuminous, and there is a general appearance of anxiety. If the disease progress unchecked, it passes into the second or algide stage, commonly known as the state of collapse. The duration of the stage of development is subject to much variation. Sometimes it may last only three or four hours, at others it may continue for two or three days. The average may be set down at from twelve to twenty-four hours. Collapse. — The second stage of cholera, or that of collapse, is characterized by coldness of the body, blueness of the skin, profuse clammy sweats, painful cramps in the extremities, hurriedness and difficulty of breathing, absence of pulse at the wrist, flagging action of the heart, suppression of bile and urine, continued vomiting and purging of fluid resembling rice-water, and a husky, whispering voice. The patient is restless, and tries sometimes to throw off the bed-clothes. The features are shrunken and pinched, the tongue is icy to the touch, the eyes sunk far back in their 21 SYMPTOMS OF CHOLERA, sockets, and in consequence of the lower lid drooping, the eye keeps half open. There is a sense of heat in the epigastrium, and the patient is tormented with an agonizing thirst. He has an incessant longing for water, and drinks it with avidity when it is brought to him. The water so drunk is frequently ejected from the stomach soon afterwards. The absence of pulse at the wrist denotes actual emptiness of the arterial vessels. The temporal, and even at times the brachial artery may be cut, without obtaining any blood. If a vein be opened, blood will not flow unless the part is fomented and perseveringly squeezed. After much difficulty a few spoonfuls of a dark tarry nature may come away. The absence of syncope is remarkable, and while the glandular secretions generally are much impaired or suppressed, the mammae are uninterfered with, and continue to produce milk. Though muscular strength is of necessity greatly reduced, a pulseless patient with a death-like countenance, will often sit up in bed, and even walk a little without any apparent inconvenience. Drowsiness is usually present, but without delirium, the patient retaining his senses to the last. In collapse, even with the aid of the stethoscope, the sounds of the heart are occasionally but indistinctly heard. Most cases that do not prove fatal, rally from collapse within thirty hours. The sooner reaction sets in, the better, as a rule, is the promise of recovery. The state of collapse, may, however, be sometimes very prolonged. A few patients under my care, who eventually did well, showed no signs of rallying until after the lapse of seventy hours. Reaction. — As collapse passes off, a remarkable change takes place. The pulse reappears at the wrist, and gradually increases in volume and regularity of beat ; the respiration, from having been hurried and shallow, becomes deeper and less frequent ; the general coldness of the surface gives place to more genial warmth ; the cramps, clammy sweats, and blueness of skin disappear, the shrunken eyes regain their natural fulness, the vomiting and purging subside, the secretion of urine and bile recommences, and the patient, 22 PATHOLOGY of cholera. wearied from the trying ordeal he has just passed through, falls into a slumber from which he awakes considerably refreshed. The progress to recovery now generally goes on unimpeded, and most patients are well enough in less than a week after rallying from collapse to do some light work. Medical writers of the present day are wont to dilate largely on dangerous sequelae as being almost a necessary consequence of collapse. I believe such sequelae are often the result of the improper treatment adopted. If cholera patients were not dosed with stimulants, opium and other noxious drugs in the stages of development and collapse, far less would be heard of the formidable array of secondary symptoms now so common when reaction sets in. Within the last four years I have witnessed three outbreaks of cholera, the first in 1867 among the troops at Dera Ghazee Khan, a post on the Punjab frontier ; the second and third in 1869 and 1870 among the prisoners in the jail at Jounpore, a station in the North- Western Provinces of India. In treating the patients that came under my charge during these three outbreaks, I used no opium, astringents, or stimulants, and out of seventy-two cases which rallied from collapse, only three suffered from secondary symptoms. Such a result contrasts strikingly with the recorded experience of numerous Indian practitioners, who look upon recovery from collapse without the intervention of secondary fever and other dangerous symptoms as rare, and a thing not to be generally expected. Without a more extended experience it may perhaps be premature to draw sweeping conclusions on this point, yet I must confess to having a strong belief that the difference in the results arrived at is to be attributed to the difference in the plan of treatment pursued. PATHOLOGY OF CHOLERA. No disease has probably enlisted more attention and continued observation than cholera, yet perhaps none has been more mistaken as to its real nature. However much this is 23 PATHOLOGY OF CHOLERA. to be regretted on every account, there is, considering the difficulties surrounding the subject, little reason for surprise. When we remember that great intellects, after watching and studying the revolutions of the heavenly bodies, were content for ages to teach exactly the opposite of what was true, we need not be astonished that in a similar way eminent medical men have, during the more limited period of fifty years, allowed themselves to be carried away by appearances, and to attach a signification to certain prominent symptoms in cholera which in no wise appertains to them. British practitioners, when first brought in contact with the disease, formed no distinct ideas as to its nature. They gave opium to allay cramps, purgatives to remove morbid secretions from the intestinal canal, calomel to restore the secretion of bile, and they drew blood to relieve venous turgescence. It was not till after cholera had swept over Europe in 1831-32 that the theory of collapse being mainly a result of drain of fluid from the body was propounded, and that, as a consequence of this drain, the blood thickens to a treacly consistence, and is incapable of passing freely through the smaller vessels. If this were true, there ought always to be a relation between the profoundness of collapse and the amount of fluid discharged from the stomach and bowels, whereas the reverse is frequently met with in practice. Some of the worst and most rapidly fatal cases are those in which collapse comes on with little previous vomiting and purging. It should be borne in mind that dark treacly blood is not peculiar to cholera. The same condition exists in the cold stage of a severe fit of intermittent fever. Dr. E. Goodeve,. referring to this matter, says, " I have seen people under the influence of malarious poison in Calcutta, lie for hours as cold and pulseless and as embarrassed in the breathing as in cholera ;" and many practitioners who have had opportunities of treating malarious fever will confirm this statement. In the suffocative stages of diphtheria, and inflammatory croup also, the blood thickens and is slow in its movement. Now in these diseases there is no drain of fluid from the body, to which the thickness and dark colour of the blood might be 24 PATHOLOGY OF CHOLERA. attributed. It is well-known to arise solely from impeded circulation. Stagnant blood has a tendency to coagulate, and slowly-moving blood to become dark, thick, and treacly. Unfortunately, the theory that thickening of the blood and collapse depend on drain of fluid from the body soon gained almost universal acceptance, and practice based on its mischievous and erroneous teachings was established, and has too generally prevailed up to the present time, with what melancholy results we well know. To Dr. George Johnson, of King's College, belongs the high honour of demonstrating not only the falsity of this theory, but also of explaining the real nature of the disease. At first sight nothing is more natural than to look upon the condition of a collapsed patient as one of advanced asthenia, and to treat him accordingly. The absence of pulse, coldness of the extremities and surface, the livid countenance and cadaverous appearance, at once suggest such an idea. But a little reflection will serve to show the incorrectness of this opinion. That there is no affinity between the state of collapse and that of ordinary asthenia, is proved in various ways. In asthenia syncope, or a tendency to it, is invariably present. A very slight exertion may be sufficient to endanger the life of a patient. Such is not the case in collapse. Patients in this condition will, as has been already remarked, sit up, and even walk about without apparently suffering therefrom. No case of advanced asthenia could possibly do so without incurring imminent risk of life. Again, the same remedies in collapse and asthenia act very differently. If, to a person fainting from loss of blood, or exhausted by purging, stimulants be given, the benefit is palpable in the pulse and the improvement of other symptoms. In collapse, on the contrary, not only is there no improvement, but the patient is often worse after a dose of brandy. A pulse which was perceptible before, is sometimes extinguished, after it has been drunk. And while stimulants are so mischievous, blood-letting, which would be almost certain to cause death in asthenia, has on many occasions brought marvellous relief to a collapsed patient. Indian 25 PATHOLOGY OF CHOLERA. physicians of former days were loud in their praises of venesection in collapse. Scot, who was a keen observer, and one of the most distinguished men in the Indian medical service of his time, says, — " The abstraction' of blood, unless as an antispasmodic, is a remedy so little indicated by the usual symptoms of cholera, that its employment in the cure of this fatal disease has afforded a signal triumph to the medical art. It requires no common effort of reasoning or reflection to arrive at the conclusion that when the powers of life appear to be depressed to the lowest degree, the pulsation of the heart all but extinct, the natural heat of the body gone, and the functions of the system suspended, and incapable of being revived by the strongest stimulants, the abstraction of blood might yet prove a remedy against a train of symptoms so desperate." Bell, another Indian practitioner of great experience, wrote many years ago to the following effect : — " All who restrict their attention in the treatment of cholera to the discharges and spasms, are in danger of losing sight of the true nature of the disease. They are prescribing for symptons, which it will generally be found at once disappear when the power of circulation is recovered. In fact, the removal of blood to the necessary extent has invariably, so far as the author's experience goes, put an immediate stop not only to spasms and oppression, but to vomiting and purging, and has relieved the prostration of strength. And in no situation has the physician more reason to be proud of his art than when in the course of a few minutes, a patient, from the agonies of cholera and from the jaws of death, is placed in safety, and not only restored to a sensation of health, but to one of positive bliss. The effect of blood-letting would indeed sometimes appear almost miraculous. A patient will be brought in on a cot, unable to move a limb, and but that he can speak and breathe, having the character (both to touch and sight) of a corpse, yet will he, by free venesection alone, be rendered, in the course of half-an-hour, able to walk home with his friends." Similar testimony of the good effects of bleeding in collapse is borne by Annesley, Martin, 26 PATHOLOGY OF CHOLERA. and many others. Indeed, it is a remarkable fact that when the treatment of cholera was other than the stereotyped opiostimulant plan, the mortality was far less than at present. The state of collapse apparently so similar to asthenia, and yet in reality so different from it, has been so lucidly explained by Johnson, that its phenomena from having once been so perplexing, may now be said to form one of the clearest and most interesting chapters in pathological history. The poison of cholera whatever its nature, enters the blood generally through the lungs, being derived from the atmosphere inhaled. Sometimes it may find its way into the circulation from the alimentary canal, having been originally introduced into the stomach either with food or drink swallowed by the patient. The blood so poisoned becomes irritant, and according to Johnson, "excites contraction of the muscular walls of the minute pulmonary arteries, the effect of which is to diminish, and in fatal cases to arrest the flow of blood through the lungs." It is a wellestablished fact that the walls of the minutest arteries contain muscular fibres, and that these fibres are as capable of contracting under the influence of a stimulus, as muscular fibre in any other portion of the body. Experiments have been performed which demonstrate that solutions of certain salts injected into the veins speedily impede the circulation, and that such arrest of the circulation is due to the power possessed by arteries of contracting on their contents. The poison of cholera appears to act similarly. That the pulmonary circulation is impeded, is evident from the appearances presented by the lungs, heart, and large vessels when death occurs during collapse. The right side of the heart and pulmonary arteries are almost invariably gorged with blood, while the left cavities are empty, the auricle being partially, and the ventricle fully and firmly contracted. The tissue of the lungs is pale and dense in texture, indicating the arrest of blood in the branches of the pulmonary artery before it has reached the pulmonary capillaries. Contrasted with this anaemia of the lungs, is the hyperaemia in most of the other viscera. 27 PATHOLOGY OF CHOLERA. As a result of this impeded circulation in the lungs there is a deficient supply of aerated blood to the left side of the heart, and the arteries of the body in consequence become more and more emptied, till at last the current flowing in them is so slow, and so scanty that the pulse becomes altogether imperceptible. That this emptiness prevails is established beyond a doubt, for the temporal, radial and even larger arteries may at times be cut without any blood flowing. To this emptying of the systemic arteries is due, not only the failure of the pulse, but also the shrinking of the integuments, the collapse of the features, and sinking of the eyeballs. The arrest of blood in the lungs, of which there is proof both before and after death, accounts very satisfactorily for the other remarkable phenomena met with in choleraic collapse, viz., the fall of temperature, the dark and thick appearance of the blood, the suppression of bile and urine, and huskiness of the voice. In ordinary health the purification of the blood is effected in the lungs. The venous and highly carbonized blood returned from the body to the right side of the heart is sent from thence through the pulmonary artery into the lungs, where it parts with its impurities by the process of expiration. At the same time, oxygen is introduced into the blood by inspiration, and the blood so oxygenized is returned to the left side of the heart, to be distributed through the systemic arteries to the whole body for the purposes of combustion and oxidation. In choleraic collapse, the circulation being impeded in the pulmonary capillaries, the supply of blood presented for oxygenation becomes reduced, the more so as collapse deepens ; and even this reduced supply is but imperfectly aerated. The quantity of oxygen becoming more and more limited, combustion in the body is proportionately reduced, and animal heat, which is dependent on combustion, fails. Hence the coldness of tongue, breath and surface generally. The secretion of urine and bile too, which are products of oxidation, are necessarily diminished or entirely suppressed, and the blood itself, simply from imperfect aeration, and not from the drain of its fluid part, becomes thick, dark and tarry. 28 PATHOLOGY OF CHOLERA. There are other diseases, such as diarrhoea and dysentery, in which, though the discharges from the intestinal canal are often very profuse, we never meet with the same state of blood as in collapse. If, then, in ague, croup, and diphtheria we have a dark, thickened state of the blood without any discharge of fluid from the body, and in diarrhoea and dysentery, where the discharges are frequently excessive, we never witness such a condition, surely it is not merely illogical, but actually perverse, to persist in maintaining that the thickening of the blood in choleraic collapse is mainly due to the drain of fluid from the body, and in the face of sound argument and a powerful array of facts to deny that it may result from some other cause. " Again, the husky, whispering voice of collapse is owing, not to muscular weakness, but to the small volume of tidal air in the respiratory currents. As but little venous blood reaches the lung tissue proper, there is but little demand for air to meet and decarbonize it. The respiration accordingly becomes shallow, and the vocal pipe feebly blown through refuses to speak." That the suppression of the chief constituents of urine and bile is due to the want of oxygen, and the consequent suspension of oxidation acquires confirmation from the circumstance of a nursing mother not losing her milk in cholera. The milk is principally composed of casein, sugar, oil, and water, and all these may be obtained from the blood without the aid of oxygen. The choleraic poison, when in the blood, probably undergoes an enormous amount of multiplication, just as the poisons of small-pox and scarlatina ; and having injured certain of the constituents of that fluid, Nature endeavours to ease herself of the incubus through the alimentary canal. The copious discharges that take place both in the first and second stages, instead of being harmful, are simply Nature's efforts at eliminating noxious materials from the system, and are a necessary part of the process of cure. The danger in cholera is not from the vomiting and purging, but from impeded circulation and consequent suppression of bile and urine. As long as a patient is pulseless, the cessation of 29 PATHOLOGY OF CHOLERA. vomiting and purging, instead of being in any way advantageous, unerringly denotes the ebbing of vitality, and is of the worst omen. In all the collapse cases that proved fatal in the Jounpore jail during the outbreak of 1870, vomiting and purging had invariably ceased without the pulse being restored, and the sooner under such circumstances the vomiting and purging ceased, the more rapidly did the cases proceed to a fatal issue. In many instances, even repeated doses of castor-oil, though retained on the stomach, failed to recall the action of the bowel. The poison had done its fatal work. Death soon followed the cessation of these curative processes. But the beneficial effect of the extraordinary action of the intestinal canal is not confined to the ejection merely of a special poison from the body. I believe it also exercises a compensating influence for the functions of the liver and kidneys, which are in abeyance. There can be little doubt that the elements which under ordinary circumstances would be carried off from the system through the agency of the bile and urine, are by this means in part, if not wholly, removed. Some of my patients who recovered were in collapse, and passed no urine for seventy hours ; but in all of them the vomiting and purging steadily continued. Reaction on these occasions was unaccompanied by febrile disturbance or other secondary symptoms, which I fancy would not have happened, had the constituents that form urine and bile not been eliminated ; and there was no other means of elimination but through the discharges from the stomach and bowels. In fact, I am of opinion that if the vomiting and purging were suppressed at the outset, no patient could survive collapse for twenty-four hours, much less for seventy. Interference, then, with these processes not only checks the expulsion of the special poison of cholera, but also prevents the elimination of the constituents usually entering into the formation of bile and urine. I have noticed it over and over again that, in proportion as the pulse and urine returned, so did the vomiting and purging cease. No medicine was, as a general rule, required to check these processes when the proper time for their cessation had come. When once the pulse and urine were restored, the vomiting and purging did not fail to 30 DIAGNOSIS OF CHOLERA. subside. At first I had some difficulty in persuading the native doctors and hospital attendants that the vomiting and purging in cholera were not only not dangerous, but actually good for the patient, and that the real source of apprehension was from failure of the circulation and suppression of urine. When, however, they saw all those cases turn out badly in which the vomiting and purging ceased, without return of the pulse and urine, they grew more reconciled to this doctrine. Even the patients themselves caught the idea after two or three days. Frequently, when I have asked a man whether he had passed any urine, his answer was, " No ; but lam being purged freely," seemingly satisfied that while that process was going on he was comparatively safe, and that there was hope of ultimate recovery. The mystery which has hitherto enveloped cholera, and the difficulties that have presented themselves in the interpretation of its remarkable phenomena are by Johnson's theory completely cleared away. Indeed, it is wrong to consider it a mere theory. It is really an explanation of an intricate state of things, by the force of facts observed and demonstrated during life and after death, and, what is of more importance, treatment based on this explanation yields better results than those plans more generally in favour. Speaking of Johnson's theory, well might Sir Thomas Watson say : — " Surely it seems a reasonable one ; it is founded on a true analogy ; it is consistent with the symptoms noticed during life, and with the conditions discovered after death. We may therefore legitimately regard it until fairly refuted as a sound, as well as a most ingenious and important theory. In truth, it derives a strong confirmation from the fact that it unlocks, like the right key, the whole of the pathological intricacies of the disease." DIAGNOSIS OF CHOLERA. Little difficulty presents itself in the diagnosis of cholera. Everything is so striking that there is but small chance of falling into error. In the stage of development, the vomiting 31 PROGNOSIS OF CHOLERA. and purging of rice-water fluid, the cramps, and the anxious leaden-coloured face, showing a tendency to pointedness and shrinking, are characteristic enough. The state of collapse is still more marked. After seeing a few cases, the physician will have no need of even asking a question. Before actually reaching the bedside of the patient, the peculiar corpse-like visage, blue skin covered with clammy sweat, and the husky, whispering voice, will too plainly have told their tale. Should reaction set in before the patient is seen, the history of the case will be a sufficiently safe guide for a correct diagnosis. PROGNOSIS OF CHOLERA. The first stage, or that of development, is not in itself dangerous. Patients seldom die at this period of the disease. If checked before the circulation has been much impeded, the return to health is speedy and effectual. The great cause for apprehension in the first stage is, that the disease may continue its progress to collapse. The state of collapse is one of serious danger to life. As long as there are no signs of reaction, the hopes of recovery rest entirely on the continuance of vomiting and purging. If these processes cease before the pulse is restored, and the kidneys resume their functions, the prospect is most gloomy. The case may, indeed, be looked upon as hopeless. The extraordinary action of the alimentary canal in cholera, as has been already explained, not only serves to eliminate a poison from the blood, but also acts as a substitute for the functions of the liver and kidneys, which are in abeyance. If, unfortunately, before the glandular organs are in a position to resume their regular functions, the wholesome work of the substitute be brought to an untimely end, there can be no other result than the extinction of life. . Should the treatment pursued in the first and second stages have been judicious, reaction from collapse will generally be of a healthy kind. The secondary fever, and other 32 TREATMENT OF CHOLERA. sequelae, dwelt on by so many medical writers as an almost necessary sequence of collapse, would be far less frequently met with if nature were assisted, and not thwarted, in the work of recovery. TREATMENT OF CHOLERA. In the treatment of cholera, two leading facts should always be borne in mind ; the first, that the vomiting and purging are not only not dangerous to the patient, but really a necessary part of the process of cure ; the second, that the absence of pulse, and other symptoms of collapse, do not imply a state of ordinary asthenia, but of impeded circulation. With these two facts before our eyes, it is needless to remark, how forcibly the use of opium and stimulants is contra-indicated. I believe a good deal of the mortality in cholera is to be laid at the door of these much- vaunted remedies. Opium not only checks the elimination of what is harmful, but, by so doing, also tends to store up a formidable hoard of secondary symptoms and sequelae, full of danger to the life of the patient. It is not uncommon for men to indulge in extravagant laudation of the very soothing effects of opium in this disease. But is mere temporary soothing of itself always desirable, or when produced of the best omen ? A patient labouring under strangulated hernia is soothed when mortification of the bowel has taken place ! But the sense of comfort so pleasing to him for the moment, is merely the fore-runner of death ! And methinks the soothing influence of opium, so often commended in cholera, has but lulled many a patient to sleep the sleep from which there is no waking. Stimulants, too, whether alcoholic or otherwise, are quite as injurious as opium, more especially from the time the slightest signs of collapse show themselves. What practitioner would think of giving brandy or wine freely to a patient labouring under spasmodic stricture of the urethra, and hope that by so doing the spasm would relax and the c 33 TREATMENT OF CHOLERA. urine flow ? Yet this is what is constantly being done in cholera. Although there is stricture of the minute pulmonary arteries, and the circulation impeded in consequence, the unhappy patient is dosed with brandy in unlimited quantity, in the vain hope of thereby restoring his vanishing pulse, and of rousing his vital energies, so sadly on the wane. And notwithstanding the fact that patients are often worse after taking the stimulant than before, this line of treatment has been adhered to and persevered in with a determination worthy a better cause. In sooth, those subjected to this course would have no chance whatsoever of recovery, were it not that nature often generously comes to the rescue, and by the agency of timely vomiting and purging, neutralizes the mischief that well-meaning, though very misguided friends would inflict. Many years ago, Dr. Stevens, of Jamaica, believing that cholera depended on a loss of the watery and saline constituents of the blood, suggested as a remedy the injection of warm water, mixed with various salts, into the veins. Although the injection of hot saline fluid into the veins during collapse was often followed by great temporary relief, the ultimate results obtained from this practice were so discouraging, that it fell into disrepute. Out of a hundred and twenty-five cases so treated by Dr. Mackintosh, only twenty- five recovered. Johnson surmises that the marvellous temporary relief arising from warm saline injections, as evidenced in the improvement of the pulse, rise in temperature, and disappearance of all the bad symptoms, is due to the hot fluid rapidly mixing with the blood in the right side of the heart and in the pulmonary artery, diluting it, and rendering it less irritating, just as diluents render the urine less irritating to an inflamed bladder or urethra. Besides this, the injection by its high temperature serves to relax the spasm of the minute arteries. " Thus, the impediment to the circulation being overcome, the blood rapidly flows on to the left side of the heart and the arteries, and the phenomena of collapse pass away with marvellous rapidity. The benefit, however, is of but short duration ; for the primary cause of 34 ** TREATMENT OF CHOLERA. the impeded circulation, namely, the poisoned condition of the blood being still in operation, and the originally hot solution being cooled down by its diffusion through the •entire mass of the circulating blood, the stream of blood through the lungs will soon again be obstructed, and the patient thus passes into a state of collapse as profound as before, and yet more hopeless. It appears, therefore, that the hot saline injection into the veins, and the operation of venesection, when it rapidly relieves, as it often has done, the symptoms of collapse, have this effect in common, that they facilitate the passage of the blood through the lungs, and thus lessen that embarrassment of the pulmonary circulation which is the essential cause of choleraic collapse. But whereas the hot injections act by removing the impediment which results from spasmodic contraction of the arteries, venesection acts by relieving over- distention of the right cavities of the heart, and thus increasing the contractile power of their walls." Elimination is the method proposed and recommended by Dr. Johnson. He argues, that as there is a poison in the system, and as nature endeavours, through the agencies of vomiting and purging, to throw it off, those efforts should be encouraged by the use of emetics and purgatives. If there were a definite amount of poison to be expelled, and that it was accumulated in the stomach or intestine, awaiting only the stimulus of an emetic or purgative to ensure its ejection from the body, this plan would be little short of perfect ; but it should not be forgotten that the cholera poison, as a result of the morbid process established, undergoes multiplication in the living body of a patient, so that when one crop of poisonous matter has been got rid of, it is soon replaced by another. This being the case, it is not at all likely that simple elimination can answer the purposes of cure. Reasoning from analogy also, the plan appears objectionable. In cholera the mucous membrane of the alimentary canal is made the channel by which the poison is eliminated from the body, just as the skin is the medium through which the system is purified in small-pox and scarlatina. In the c 2 35 TREATMENT OF CHOLERA. latter diseases one would scarcely hope, that by producing increased action of the skin with sudorifics, the cause of elimination would be served, and the process of cure accelerated. The patient so sweated would not only not be quit of the poison any quicker, but his after-recovery would, in consequence of the debility resulting from such treatment, be retarded, if not actually imperilled. In the exanthemata nature is as little interfered with as possible in the task of elimination. The same plan might be wisely followed in cholera. No small amount of risk may be incurred from over-doing matters. Neither emetics nor purgatives have any power in themselves of separating a poison from the blood. All they can do, is to cause the expulsion of what may be in the stomach or bowels. But if the stomach and intestines are of themselves exercising their expulsive efforts, surely the indication is powerful enough, that emetics and purgatives are not called for. Under such circumstances they are not only useless, but calculated to do mischief, by unnecessarily irritating and weakening the patient at a time when he needs the careful husbanding of all his strength for successfully encountering the severe ordeal he must pass through. The great object in treatment should be, to endeavour to counteract the effects of the poison working so prejudicially in the organism, and to keep up the tone of the system as much as possible, so as to enable it to battle against all baneful influences. The poison is probably of a miasmatic nature. This opinion gains strength, not merely from the history of epidemics, but from the fact that there is frequently a marked resemblance between cholera and malarious fever at the beginning ; so much so, that some have been led to believe that cholera is an exaggerated form of the cold stage of an intermittent. The poison deranges the constitution of the blood, and renders it irritant. One of the consequences of this morbid condition is, that the nervous system, particularly the ganglionic portion, becomes seriously affected. In the absence of a specific remedy wherewith to 36 TREATMENT OF CHOLERA. combat the evil at work, the use of strong nervine tonics possessing anti-miasmatic properties, appears peculiarly appropriate. During the outbreaks of 1867 at Dera Ghazee Khan, and of 1869 in the jail at Jounpore, I used quinine in five-grain doses, repeated every twenty minutes or half an hour, till twenty or thirty grains were taken. The quinine was always mixed up in an effervescing draught of thirty grains of bicarbonate of soda, and the same quantity of tartaric acid. After the administration of half a drachm of quinine, the draught was continued every second or third hour. The quantity of quinine might be increased in the case of European adults, who are not so easily affected by it as the natives of India. In the outbreak of 1870, the limited supply of quinine at my disposal was soon exhausted, and after the first six or seven cases I resorted to strychnia. I gave one-twelfth of a grain in solution every twenty minutes or so, from" the time cholera first declared itself until half a grain was taken. A dose was then given every hour, or every second or third hour, according to the urgency of the case. In cholera there would appear to be a remarkable tolerance of strychnia. Some of the patients had as much as a grain and a half given them in the four and twenty hours, without presenting any untoward symptom. Undoubtedly some of the strychnia must have passed out of the system with the dejecta soon after being swallowed; still for all that, considerably more must often have been absorbed than would be deemed safe or desirable under other circumstances. One grain of strychnia was dissolved in three drachms of dilute sulphuric acid, and then mixed with twenty-four ounces of water. Two ounces of this mixture constituted a dose. Where a plentiful supply of quinine is available, it might be advantageously combined with the strychnia. Such a mixture would, I fancy, act more decidedly than either remedy singly. Had I had a proper syringe at the time of the last outbreak, I would have tried the effect of strychnia hypodermically, and of strychnia and quinine combined. In 37 TREATMENT OF CHOLERA. this way the real amount of tolerance of the former drug, as well as the effect it exercises on the progress of the disease may be more exactly ascertained. As the entrance into the circulation would be more direct through hypodermic injection than through the stomach, the syringe ought to be used with great care. One-eighth of a grain might be tried on the first occasion. After that, the injection should be repeated with extreme caution, and not until an interval of at least four hours had passed. To ensure absorption, the mixture should be injected before the beat of the pulse at the wrist becomes imperceptible. Besides giving strychnia and quinine, I am in the habit of using acids largely, and consider them an essential part of the treatment to be followed. What may be their precise action in this dread disease I am unable to say, but I have no doubt of the beneficial effect exercised by them. The acid mixtures used were made up of vinegar, lime-juice, or sulphuric acid. Each was separately mixed with water in such quantity as to give the water a decidedly acid taste. The patients preferred the vinegar and limejuice mixtures, and often craved for them. A couple of drachms of nitrate of potash and a little bitartrate of potash were added to every bottle of acid mixture. Each patient had an ounce given him every fifteen or twenty minutes. Camphorated water was the ordinary drink allowed in the hospital. Every man took as much of it as he wished. When the suppression of urine was prolonged, fomentation of the loins and dry cupping were resorted to. The same was done to the chest, when there was any great sense of oppression and the respiration became laboured. On such occasions, where practicable, I would prefer giving the patient a full warm bath, with a view to allaying spasms and nervous irritation. In three cases of collapse, I tried leeching and the cupping lancets, but was only able to obtain a few drops of blood. Venesection, by lessening the over-distention of the right cavities of the heart, and so increasing the contractile power of their muscular walls, might sometimes be practised with 38 TREATMENT OF CHOLERA. advantage. It would probably be better not to delay resorting to this remedy till the circulation was too much impeded, and all traces of the pulse lost. Sir Ranald Martin relates the following striking instance of the beneficial effects of blood-letting in a case of advanced collapse, in his work on " The Influence of Tropical Climates on European Constitutions" (vide 6th edition, page 349): — "On visiting my hospital in the morning, the European farrier-major was reported to be dying of cholera. I found that during the night he had been drained of all the fluid portion of his blood. His appearance was surprisingly altered; his respiration was oppressed ; the countenance sunk and livid ; the circulation flagging in the extremities. I opened a vein in each arm, but it was long ere I could obtain anything but trickling of dark, treacly matter. At length the blood flowed, and by degrees its darkness was exchanged for more of the hue of nature. The farrier was not of robust health ; but I bled him largely, when he, whom but a moment before I thought a dying man, stood up, and exclaimed, ' Sir, you have made a new man of me.' He is still alive and well." When cramps were present, the parts were rubbed with ginger powder. If the diarrhoea stopped without the pulse and urine being restored, castor oil in half-ounce doses was always given, every hour, until the purging returned. In a few cases, the castor oil had not the slightest effect, and these invariably proved fatal. I have never used emetics in cholera, as I believe they can scarcely serve any good purpose ; the nausea and prostration they are likely to create are not at all desirable in the treatment of the disease. Out of seventy-two cases which rallied from collapse under the treatment above indicated, three only suffered subsequently from secondary symptoms. »Of these, two men (one named Khoobun, the other Elahee) were well enough on the 14th February, 1870, to be discharged from the cholera list, and placed among the convalescents. On the 16th February, they had to be re-admitted for secondary symptoms. They were both labouring under delirium, accompanied by congestion of the eyes, though there was an 39 TREATMENT OF CHOLERA. absence of heat of skin. I had their heads shaved, and blisters applied to the scalp and temples. The blisters produced no effect on Khoobun. The skin appeared to be insensible to the action of cantharides. He died by halfpast five in the evening. In Elahee's case, the blister had some effect ; but he continued delirious, and had a distressing hiccup for several days, after which he gradually regained his health and strength. The third case was that of a lad named Gokool. He was attacked with cholera on the 12th March, and by the 16th had completely rallied. A couple of days afterwards secondary symptoms set in. At first there was delirium, with congestion of the eyes ; then a very painful rash appeared on the greater part of the body. Finally, an erysipelatous inflammation broke out on his face, and the left parotid gland became highly inflamed. The patient, worn out by a constant succession of untoward sequelae, succumbed on the 31st March. Diet. — While choleraic symptoms are present, nourishment in the liquid form Only — such as sago, arrowroot, and strong soups — should be allowed. Liebig's extractum carnis, prepared according to the usual directions, would be a capital substitute for fresh soup. Solids should not be attempted, as they would be certain to encumber the stomach in an undigested form, or be immediately rejected. When the disease has been overcome, any debility or other symptom that may remain should be treated in the usual way. If diarrhoea be present, which happens but seldom, there is then no objection to the use of opium or other astringents ; and if the vital energies require rousing, stimulants, alcoholic or otherwise, may be employed. It is not advisable to be too hasty in the use of opium ; as a rule, the safest plan would be not to give it until about forty-eight hours after collapse had passed off, and no doubt remained that the cholera poison was still lurking in the system. One of the most serious difficulties in an epidemic outbreak of cholera, is to secure efficient attendance on each individual attacked. When so many and such urgent calls spring up so suddenly, it is no easy matter to bring into 40 TREATMENT OF CHOLERA. existence in a moment all the arrangements desirable. The uninitiated and ignorant cannot be turned into good hospital attendants in a day. I did the best I could with the material at my disposal. Unfortunately, during the outbreak in the Jounpore jail in 1870, there was a great unwillingness on the part of the prisoners to attend on any of their companions smitten with the disease. This was in a great measure owing to the belief prevalent that the outbreak was due to supernatural agency. The attendance being thus unwillingly given, was often performed in a faint-hearted way. The diarrhoea that frequently prevails during epidemics, and which may sometimes lead to an attack of cholera, should on no account be neglected. In such cases a couple of ordinary cholera pills composed of assafcetida, black pepper, camphor, and opium ; or a dose of chlorodyne, or a draught made up of three grains of quinine, twenty drops of laudanum, fifteen drops of dilute sulphuric acid, and two ounces of water should be given without delay. The dose may be repeated in four or five hours if needed. Other astringents may answer equally well. Should the diarrhoea continue in spite of these repressive measures, it will indicate the presence of some offending matter in the bowel requiring removal. In this case half an ounce or six drachms of castor oil with ten drops of laudanum, will .probably do what is needful. The patient should be kept quiet, and he will sometimes be all the better for a little hot brandy or whisky punch. Plomceopaths have always boasted that their treatment of cholera is more successful than that of ordinary practitioners. There is, I believe, much truth in the statement, not that their globules do any good, but because the -vis medicatrix naturae being uninterfered with, has a better chance of success in the conflict, than when as under ordinary practitioners, it has not only to fight against the disease, but also to combat the deleterious effects of opium and brandy. In giving the history of an epidemic, and recording the 41 TREATMENT OF CHOLERA. results obtained from treatment, it should never be forgotten that a careful distinction is to be made between the number of cases running to collapse, and those not advancing beyond the first stage. The first stage is seldom fatal, and when many or most cases do not go beyond it, the indication is clear that the outbreak is mild. Had cholera prevailed in England, and been as destructive to life, year after year as it has been in India, there can be little doubt that scores of special hospitals would long since have been established. No such movement has as yet been initiated in the East. In Calcutta and Bombay the disease is constantly present, and carries off thousands of the population annually. Can it be doubted that a special hospital in each of these great cities, with an efficient medical staff attached, would be a great benefit to all classes ? The success of any plan in cholera must mainly depend on the early treatment of cases. While the poison is limited in quantity, the likelihood of overcoming its influence is greater than when it has multiplied itself to an indefinite extent in the living body, and vitiated the. entire system. As regards a population such as we have to deal with in India, who look upon disease and the ills of life generally, as heaven-sent, and carry their ideas of fate to an insane extent, cholera will, I fear, for a long time to come be a grave difficulty. The patients brought to city hospitals and dispensaries are, as a rule, in a state of profound collapse — in fact, moribund. If inquiry be made, it will invariably be found that opium has been largely administered to them. Such cases do not, therefore, offer a fair field for the plan of treatment I propose. But among our soldiers, whether European or native, among the sailors employed on board the fleets of merchant ships in the harbours of Calcutta and Bombay, and among the prisoners who throng the jails all over the country, it is otherwise. Here we can secure the cases from the outset, and I am inclined to believe that in these instances if a more rational treatment, founded on that better knowledge of the pathology of the disease so clearly explained by Johnson, were adopted, the results 42 TREATMENT OF CHOLERA. would not be quite so ghastly as those now too generally chronicled. TABULAR STATEMENT SHOWING THE NUMBER OF CASES TREATED IN THE THREE OUTBREAKS, AND THE RESULTS OBTAINED. Number of Number T>l _. . , ,-..__ cases not of cases Year. P Peef cc , at whlch , C n lass of persons among advano i ng advancing Total. Recovered. Died, outbreak occurred. whom outbreak occurred. b by 0e y 0n d. first to stage. collapse. /2nd Sikh Infantry ) . . 1 1 1 4th Sikh Infantry j 1 2 3 3 1867 Dera Ghazee Khan < Camp followers of ) a -, ¦- \ above regiments j 1869 Jounpore.. .. | Prisoners in Station | _ 7 7 g . g 1870 Ditto . . . . Ditto .... 8 91 99 69 30 Total 13 102 115 83 32 Percentage of recoveries from collapse . . . . . . . . . . 68*63 Percentage of recoveries from first and second stages included . . . . 72*17 N.B. — All the cases (thirteen in number) that did not advance beyond the first stage recovered. 43 PREVENTION OF CHOLERA. PREVENTION OF CHOLERA. In the institution of measures for preventing the spread of cholera, it is necessary to discriminate between the disease dependent on primary, and that arising from secondary causes. To hope for similarly good results from sanitary precautions in both cases, would be to ensure disappointment. True epidemic cholera being dependent on a miasm generated in the soil, and borne along by the atmosphere, is unfortunately beyond our control. The miasm is a natural object, having a defined period of existence, and would probably play out its part unnoticed, but for the accident that, in contact with the human body, it acts as a poison. Cholera arising from this cause must be accepted as an inevitable evil, until perhaps in a far off future the ingenuity of man may devise some measure for preventing the breedinggrounds in Lower Bengal from sending forth their deadly exhalations year after year. It is possible, nay, it may be even deemed probable, that, just as when a flight of locusts passes over a tract of country, certain of its members descend continuously in its track and devour everything green, not even sparing huge trees in their destructive mood, so from a cholera-tainted atmosphere, whether stationary or in motion, a portion of the poisonous miasm may be detached and settle on the clothes of individuals, on articles of food, in fact on everything the air comes in contact with, even descending into wells and becoming mixed with the water. In this way food, water, and clothes, deriving their infection from the atmosphere, may become sources of the disease, and thus in all likelihood, while the primary cause will pass unnoticed, quite secondary ones will be magnified in importance. The cholera arising from true secondary causes, as from the swallowing of dejecta, or from the exhalations of infected latrines or contaminated clothes, is more amenable to pre- 44 PREVENTION OF CHOLERA. ventive measures. As the dejecta appear to contain the poison, the necessity for neutralizing them with chemical reagents, and burying them in unfrequented spots, far away from wells used for drinking purposes, is manifest. People coming from infected localities in India, should be stopped, especially on the banks of rivers, made to strip, bathe themselves in the stream, and their clothes after being well dried and sunned, might be subjected to a higher heat before large fires. But however imperative the establishment of quarantine, sanitary cordons, and other protective measures may be, and however successful they may prove in arresting cholera arising from secondary causes, they are powerless to prevent the ingress of an air-borne epidemic. Such barriers are not sufficient to check its progress, and it would be well for the public of the British Isles to bear this in mind, for should such an epidemic unhappily visit these shores during the autumn, the cause might be sought where it did not exist, and blame meted out where it was undeserved. Overcrowding men in a ward or barracks, and imperfect ventilation are sources of danger. The sepoys probably owe something of the immunity they enjoy to being housed in separate huts, for at times when massed in boats, they have suffered quite as much as the European soldier. Movements into camp have occasionally been attended with some benefit. But such a measure must be of very limited advantage so long as troops ' or other bodies of men are not placed beyond the influence of a cholera-tainted atmosphere. Now that the progress of railways in India affords increased facilities for locomotion, this remedy might in the case of European troops be made most effectual, by conveying them on the first sign of epidemic cholera manifesting itself, far away from the affected locality, say a hundred miles, or even more if necessary, and not attempting to bring them back until every symptom of the disease had disappeared. Any barrack in which a case of cholera may have occurred should be fumigated and white-washed without delay. To keep water free from impurity by the possible deposit of the miasm from the atmosphere, wells used for drinking purposes 45 PREVENTION OF CHOLERA. should be covered during the prevalence of an epidemic, and all articles of food carefully washed and cooked before being eaten. . Considerable protection might be afforded to individuals compelled to remain in infected localities, by giving each one a few grains of quinine morning and evening. Quinine probably possesses some amount of prophylactic power in cholera. This belief is shared in by others as well as myself. Hygienic measures, generally, such as proper ventilation, rigid cleanliness, wholesome food, &c, important as they are at all times, are eminently so in epidemic seasons. It is of the utmost moment to maintain the highest standard of health, the better to befit the body for resisting the insidious inroads of the disease. The habitations of European soldiers in India demand serious attention. There are certain cantonments, such as Agra, Allahabad, Cawnpore, Lucknow, Meean Meer, and Peshawur, where the men suffer severely every year from malarious fever, and where epidemics of cholera are sometimes very fatal. The fever might be almost eradicated, and the measures that would bring about this benefit would, I believe, prove a powerful check to cholera likewise. Malaria possesses three well-known properties — (a) It is heavy, and does not, as a rule, rise higher than eighteen or twenty feet above the level of the ground. (b) It is most powerful at night. (c) It is absorbed by the leaves of trees. Knowing these points, the remedies are clear. In feverish cantonments, all barracks for European soldiers should have upper stories, and the men should be made to sleep in them, and not on the ground floors ; for, in addition to malaria being more powerful at night, the body itself during sleep has far less power for resisting its baneful influences than in waking moments. The ground floors might be partitioned into dining and reading-rooms, workshops, and even used as places of amusement during the wet weather. If the men had upper floors for sleeping apartments, fever, which consti- 46 PREVENTION OF CHOLERA. tutes one of the principal diseases of military hospitals, and which sometimes incapacitates an entire regiment for carrying on its most ordinary duties, would be pretty well banished from the European army. Epidemic cholera, too, which has a miasmatic origin, would undoubtedly by this measure be considerably diminished, if not wholly prevented. In support of this opinion, I may adduce the improved health of the European soldiers in Fort William since the Dalhousie barracks were built. lam not aware of any epidemic outbreak having appeared among the men from the time they first occupied those buildings, now some fifteen years ago. If such good results have been obtained in a place like Calcutta, we may reasonably infer that the effects would be still more marked, if similar steps were taken in the Punjab and North- Western Provinces. It is worthy of note that the well-to-do portion of the community in Calcutta, which is numerous, and the members of which invariably sleep on upper floors, seldom have a case of cholera among them, although the disease is constantly present in their neighbourhood, and they suffer but little from fever ; while sailors and poor Europeans who are badly housed and occupy low apartments are frequent victims of either malady. Large, handsome trees should be planted in the neighbourhood of each barrack. They would not only serve for the absorption of malaria, but would also make a cantonment more sightly, and by their shade afford opportunity to the men for taking out-door amusement in the heat of the day during the warm season, according as they might feel so inclined. lam persuaded that the present practice of confining soldiers to their barracks for six months of the year, from a little after sunrise, to within a short time of sunset, thereby making them breathe a close, confined atmosphere for eleven or twelve hours consecutively, and pass their days in constrained idleness, acts most prejudicially on their health, and renders them easy victims of any evil influences to which they may happen to be exposed. Of late, the Government of India has, at a large cost 47 PREVENTION OF CHOLERA. to the State, done much to improve the habitations of European soldiers, but many years are likely to elapse before the improvements now happily in progress will be completed. When complete, there will be much reason for congratulation. Malarious fever is the cause of such wide-spread enervation among the men, and the risks to life from an attack of cholera are so great, that in no case could the maxim " prevention is better than cure " be more appropriately practised than in these instances. PARDON AND RON, PRINTERS, PATERNOSTER ROW, LONDON. 48 1 PRESSBOARD j 1 PAMPHLET BINDER i -^ Manufactured by i 1 6AYLORD BROS. Inc. j Syracuse, N. Y. ( l Stockton, Calif. I WC 262 F553e 1871 34632030R NLH Ds_i_-.77_,2 D NATIONAL LIBRARY OF MEDICINE