Cholera.

By this term is designated not the so-called cholera morbus
which may occur at any time in almost every community, but the
epidemic disease which we usually consider to be of Oriental origin,
and designate by the name of Asiatic cholera. Volumes might be
written upon the history of this disease and upon its relations to the
political history of the world. It seems highly probable that this
disease was one of the plagues known to the ancients, yet we are
able to trace it definitely and exactly only about three hundred
years back. Since this date it has at irregular intervals swept the
entire civilized world, so that the very name inspires dread in the face
of all that science has as yet accomplished. In 1817, 36,000 people
were attacked by the disease in three months in Calcutta; in No­
vember of the same year an English army marching through India
was decimated by it, 9,000 out of 90,000 men dying in twelve days.
From India the cholera proceeded that year toward the west, and
in the succeeding fifteen years had traversed nearly all of the known
world. At the end of this time (in 1832) it arrived for the first time
in America. In 1818 it raged again in India, spread thence into
different parts of Asia with frightful results. In the following year
150,000 persons died of it in one district of India alone. In 1823
it had reached China ; in 1831 it had spread to the north of Europe.
During this year 100,000 Hungarians died of the disease. The
Austrians surrounded their capital, Vienna, with a double military
guard to protect themselves against their neighbors of Hungary, but
in vain. In 1831 it had reached England, whence it spread through
the British Isles. It first appeared on our continent, at Quebec, in
June, 1832; within three months it had spread over twelve States.
The following year the West Indies and Mexico were visited. In
1834 it returned to Southern Europe, where it remained with more
or less intensity for three years. In 1837 it had entirely disap­
peared from Europe and America, and was not seen again for ten
years. In 1847 the cholera started again from India, which seems
to harbor it constantly, toward the west, and reached the United
States in 1849. During this epidemic there was noticed a phenome­
non, at that time new in the history of cholera, though the same
fact has been since repeatedly observed. The disease germs seemed
to traverse the ocean without human agency, for the cholera ap­
peared upon two emigrant ships a thousand miles apart, one of
which had been at sea sixteen days and the other twenty-seven
days, no cholera having occurred at the ports from which those
vessels had sailed. From this time onward the disease seemed to
linger in various parts of Europe and America for five years, when
another severe epidemic occurred. In 1865 the disease appeared
again in Arabia and Egypt, crossed to Constantinople in July, and
reached England by the autumn. In the following year the disease
broke out in America again. At the time of the writing of this
book it has once more appeared in Eastern Europe, and may be
expected again in our midst within a year or two.

Symptoms.—The disease is usually developed without serious
premonitory symptoms. In the majority of cases there is no further
warning than simple diarrhea, the stools being numerous and pro­
fuse, but not attended with pain. Vomiting may also occur,
although this is not a constant symptom. Aside from these indis­
positions, which may of course be induced by other causes than
cholera, there is nothing to indicate the onset of this dread disease.
Unless the patient be already fearful of infection, it may be difficult
to persuade him that the diarrhea can have any particular import­
ance; but the discharges suddenly increase in quantity; or if there
have been no previous diarrhea, the onset of the disease is marked
by sudden and profuse discharges from the bowels. This is the
beginning of the disease, and in many cases occurs during the
night. From the first the stools possess the characteristic features
by which the cholera is especially distinguished—they resemble rice
water, and are ordinarily designated as “ rice-water stools. “ The
liquid will be found to contain numerous small white, solid particles,
resembling grains of rice; it possesses little or none of the usual
character of intestinal discharges, but emits a peculiar offensive
odor. Not less characteristic than the discharge itself is the action
of the patient. He suffers none of the pain usually incident to
diarrhea, but is simply impelled by a sense of distention to evacuate
the bowels, a proceeding which gives him no pain nor uneasiness.
If vomiting occur, as it usually does at some period of the disease,
the matter ejected from the stomach is a watery fluid, somewhat
similar to that constituting the stools. The vomiting is not usually
accompanied with much nausea or pain, the act occurring in con­
sequence of a sudden impulse, just as is the case in the evacuation
of the bowels.

These symptoms mark the beginning of the disease ; mean­
while there is a sense of profound exhaustion and debility. The
pulse is usually rapid and weak, the skin cool, or covered with
clammy perspiration, the face pinched, and the muscles may undergo
the most painful cramps. If the attack be not severe, these symp­
toms begin to improve within a few hours ; in fact the patient may
be convalescent in half a day. In the majority of instances, how­
ever, the outcome is not so rapid nor so favorable ; the patient
passes into what is called the stage of collapse.
In this condition the pulse is extremely rapid and feeble, beat­
ing even 140 times per minute; it may be extremely difficult to
distinguish the beat of the heart when the ear is applied to the
chest. The failure of the circulation is indicated also by the stag­
nation of blood in the veins, in consequence of which the face and
surface of the body generally become dark blue or livid ; this con­
dition is especially marked in the lips and at the roots of the nails.
If the patient be bled from the arm, as was formerly often done,
the blood oozes from the wound and does not flow in a continuous
stream; leech bites, too, are not followed by the usual amount of
bleeding; all these things indicate that the blood is materially
changed from its natural condition.

The breathing, too, presents certain characteristic features.
The patient complains of want of air, and sometimes even gasps
for breath; the respiration is irregular and sighing. The expired
breath feels cold to the hand held before the mouth. The mind
seems usually overwhelmed; the patient does not realize the situ­
ation, has no fears for the result, even though previous to the attack
he may have harbored a profound dread of the disease. In some
instances he lies quiet and content, at other times is very restless,
though more from physical than from mental distress. The mus­
cular cramps usually appear at some stage of the disease; they
affect especially the feet, calves and arms. To relieve himself the
patient sometimes walks about even a few minutes before death.
As the disease approaches a fatal termination, the patient’s
body becomes intensely cold; he is usually unconscious, though if
so he usually complains of a sense of heat, and insists upon being
uncovered. The body temperature is sometimes decreased from
ninety-nine—the standard of health—to ninety, or even eighty; the
skin is wrinkled and shriveled ; the face pinched. The general
appearance is extremely characteristic ; one derives the impression
that the entire body has been diminished in size. The patient
appears to have grown old in a few hours, and the countenance
may be so changed as to be unrecognizable even by friends. Such,
indeed, is the result of the excessive drainage of water from the
body; for the constant discharges from intestines, stomach, and skin
result in a very material decrease in the weight of the body. This
loss of weight consists largely of the watery parts of the blood,
whence results the shrivelled appearance of the skin and body gen­
erally. Death often occurs in the state of collapse, though there
are instances in which a fatal result ensues before this stage of the
disease is reached.

If the patient recovers from the stage of collapse, he does not
as a rule begin convalescence at once, but passes into what is called
the stage of reaction. In this period there is considerable fever;
the diarrhea continues, but the discharges lose the rice-water
appearance and become green. Vomiting is frequently a trouble­
some complication during this period, thevomited matter also being
green. Death may also occur during this stage of reaction, the
patient being exhausted by the long continued vomiting and diar­
rhea. Even if recovery ultimately ensue, the individual’s powers
are apt to be impaired for a considerable time.

Cause.—There is, undoubtedly, a specific cause, a virus, v/hich
is essential for the production of Asiatic cholera. This is evident
from the history of the epidemics which have from time to time
spread over the world. The fact that the disease is at home, so to
speak, in certain parts of Asia, that only under peculiar conditions
it invades other countries; but especially the fact that its spread is
a continuous one from the original site of the disease — these all in­
dicate that there is a particular infectious material, without which
the disease does not exist. Quite otherwise is it, however, with
the question whether cholera is communicated bypersonal contagion.
Such method of communication is certainly not necessary; many
instances such as that to which reference has been already made —
the occurrence of the disease on vessels which had been at sea for
several weeks — demonstrate that cholera can arise in a locality
without any importation of individuals already suffering­ from the
disease. Yet it might be also possible that cholera could be com­
municated by personal contact as well as, by distribution through
the atmosphere. Yet many facts, positive as well as negative, in­
dicate that such transmission from person to person occurs either
not at all or extremely seldom; for it seems that among those who
are brought into contact with cholera patients, the disease is not
more frequent than among those who are not thus exposed. In
the report on cholera published by the French Government in 1831,
it is affirmed that among 55,000 persons attacked by the disease,
only 164 were individuals whose duties called them to associate
with the sick. These 164 persons had been employed as physicians
or nurses in the hospitals, where nearly 2,000 others, likewise em­
ployed, had escaped entirely. Among 58 persons employed in the
hospital at St. Petersburg, only one contracted the disease.
Similar observations have been made in great numbers, and show
that if cholera be contagious, its contagion is far less active than
that of other diseases, such as typhus fever. Then, again, cases of
the disease have been repeatedly imported into cities without
causing the multiplication of the disease in those localities; and,
finally, efforts have been made to induce the disease in healthy per­
sons by direct inoculation from cholera patients, but always without
success.

From these facts we may make the important practical deduc­
tion that there is but little, if any, personal danger in the presence
of a cholera patient; that nursing or attendance upon such a patient
does not increase the danger of contracting the disease. This is,
of course, quite contrary to the popular impression. We are
accustomed to see and hear of people fleeing in dread from the
vicinity of such patients; and it is even affirmed that physicians
have been known to evade attendance upon such patients, out of
fear of personal contagion. It is, of course, true that the locality
in which cholera is epidemic is more dangerous than one out of the
usual path of the disease; yet this danger arises, not from the pres­
ence of cholera patients, but from the atmospheric conditions
(whatever they may be) which make cholera possible.

While we are thus ignorant of the essential origin of cholera,
we are quite familiar with the circumstances which promote its
spread and render personal liability to the disease greater. It is
the universal experience that cholera appears first, is most destruc­
tive, and stays longest in those parts of a city in which sanitary regu­
lations are poorest. The densest and filthiest cities, and parts of
cities, have always been the home and breeding-place of epidemic
cholera. Several apt illustrations of these facts were observed in
London during the epidemic of 1849 ; in those districts of the city
supplied with drinking water from the Thames above the entrance
of the sewers the mortality was less than one-half of one per cent.; in
those districts which were supplied from the river below the entrance
of the sewers the mortality was from four to eight times as great. Evi­
dently the best protection against cholera in a locality where the
disease is epidemic consists in the greatest attention to sanitary reg­
ulations, the avoidance especially of decomposing animal matter.
Defective sewerage, accumulations of filth, crowding of people in
unventilated tenement houses — these are active causes in promoting
the establishment of epidemic cholera.

Measures for individual protection rest upon the same general
principles. There can be and need be no set of rules to be observed
as personal protection against the disease, for every person living
in a district infected by epidemic cholera is liable to the disease,
his chances of escape being proportioned simply to the excellence
of his general health and sanitary surroundings. The only salva­
tion from danger is flight to a locality unaffected and not likely to
be affected by the epidemic. Yet one measure of precaution may
become necessary, and should never be neglected during the preva­
lence of a cholera epidemic ; and that is prompt attention and
treatment of even the slightest diarrhea, for it is the universal tes­
timony that the attack of cholera is usually preceded by diarrhea,
and that the attack rarely occurs if this diarrhea be promptly
checked.

Every diarrhea, therefore, during the prevalence of cholera,
should be promptly treated by an astringent. A good mixture for
that purpose is the following :
Opium, -                                   One-half grain.
Camphor, -                                   Two grains.
A pill containing these ingredients may be taken every four
hours ; or half a teaspoonful of paregoric may be taken every two
hours during the day. No laxatives or cathartics should be admin­
istered.

Whether or not the access of country, or to a particular local­
ity of that country, can be prevented in the least by quarantine
regulations is still a debated question, though the evidence is over­
whelmingly in the negative. Yet it may be advisable to obtain the
benefit of the doubt and employ quarantine regulations, since even
a small degree of success in checking this formidable disease would
be a sufficient reward for the effort. It is scarcely necessary to
correct certain popular practices and impressions in regard to the
prevention of the disease. One of these is the idea that the adop­
tion of a light diet, such as rice, and the avoidance of fruits and
vegetables, diminishes the chances of infection, while others seem
to believe that the frequent indulgence in alcoholic stimulants will
accomplish the same result. Both these ideas are fallacies ; the one
object, as already indicated, consists merely in keeping the health
at the best possible standard. For feeble persons are not only less
able to resist an attack, but are also more susceptible to the disease,
although no age in life exempts from danger. Yet the largest
proportion of fatal cases is invariably among the aged, and the
next largest in early infancy. Thus the statistics of Duchesne, col­
lected from the Paris epidemic of 1849, show that the largest ratio
of deaths occurred between the ages of sixty and eighty-five years,
the next largest under five years. The actual mortality from
cholera is ordinarily not so great as the popular impression sup­
poses. During the epidemic of 1832 there occurred in London
one death among 1,228 inhabitants ; in Edinburgh one death to
2,033 inhabitants. In the United States the ratio was much
larger. Thus, in New York there was one death to every one hun­
dred persons, in Albany one to seventy-seven, and in Quebec one
death to twelve.

Treatment.—In the treatment of cholera, nearly all the rem­
edies known to medicine have been at various times employed, and
a great number of these have received warm commendation from
various observers. Yet the fact is, that medicine knows to­day
no means which guarantee success, or even a probability of success,
in saving life under the formidable attack of epidemic cholera. In
this, as in most of the infectious diseases, the effort must be to sup­
port the patient until the disease has expended its fury; for cholera
lb a self-limited affection, which leaves the patient in comparatively
few days, if he but live so long. To outline a treatment, therefore,
is merely to give the experience of one or more men, an experience
which may be at variance with that of other physicians. All agree
that there is nothing by which the duration of the disease can be
shortened, nor its most dangerous symptoms controlled. Dr.
Austin Flint, of New York, states his own practice, based upon a
long and extensive experience, as follows : “ The treatment is to
be considered as applicable to the different stages before collapse,
during the collapsed stage, and after the reaction. Prior to col­
lapse the paramount object is the arrest of the intestinal discharge.
This discharge into the intestine is the first appreciable link in the
chain of unnatural events, and if promptly arrested before it has
proceeded so far as to affect seriously the blood and circulation,
the patient is usually safe. The remedy on which most dependence
is to be placed in affecting this object is opium. Some form of
opiate is to be given promptly, in doses sufficient to effect the object.
The form of opiate is to be chosen with reference to promptness of
action and the probability of its being retained. Laudanum is to
be preferred. In the endeavor to effect the object of treatment in
this stage, moments are precious, for there is always danger that if
the object be not promptly effected, the patient will fall into the
collapsed state. The opiate should, therefore, be given in a full
dose. A grain of morphine (thirty or forty drops of laudanum)
is rarely, if ever, too large a dose for an adult. If the first dose
be quickly rejected by the stomach, a second should be instantly
given. The doses are to be repeated at intervals of from half to
three-quarters of an hour, until the discharges from the bowels
cease. If, owing to the occurrence of vomiting, the administration
of the drug by the mouth be ineffectual, it should be given by the
rectum, and in cases in which the symptoms are urgent, both modes
of administration should be resorted to. The system, even in this
stage of the disease, is not readily affected by opiates thus given.
If the administration be in the hands of the physician, and the
effects of the doses watched with care, danger from this source
(the opiate) may generally be avoided. The practical point is to
employ the remedy freely and promptly, so as to effect the object,
bearing in mind the fact that the delay of half an hour or an hour
is often fatal. Relying upon the opiate, it is best not to add other
remedies, lest by increasing the bulk of the doses they will be more
likely to be rejected. The patient in this stage should be restricted
to a very small quantity of water, or to small pieces of ice. Perfect
quiet is important. He should not be permitted to get up to go to
stools, and he should be urged to resist as much as possible the
desire to evacuate the bowels.

“I have repeatedly succeeded in arresting the disease by this plan
of treatment, and when arrested before proceeding to the stage of
collapse, the recovery is usually speedy. Regulated diet, rest, with
perhaps a tonic remedy, suffice for the cure. I believe no other plan
of treatment promises more than this, but it is not to be expected
that it will always prove successful. It will fail, or rather is not
available when, owing to the persistent vomiting and frequent purg­
ing, the remedy is not retained sufficiently long to exert its effect ;
and it is not available when the state of collapse occurs so quickly
that there is not time enough to obtain a remedial effect. These
difficulties are equally in the way of success from any remedies.
“ In the stage of collapse the plan of treatment indicated prior to
this stage may prove not only ineffectual but hurtful. It is still an
object to arrest the discharge into the intestine if it continues ; but
to employ opiates very largely for this object may not be judicious
in this stage. The symptoms in this stage of collapse are due mainly
to the damage which the blood has sustained in the loss of its con­
stituents from the discharges which have already taken place.
Opiates should be given, but much care should be observed not to
induce narcotism. Astringent remedies, if the stomach will retain
them, may be added, such as tannic acid, etc. If, however, these
or other remedies provoke vomiting, they will be likely to do more
harm than good.

“ In a large proportion of cases after collapse has taken place,
little can be done with much hope of success. Even if the vomiting
and purging cease, recovery may not follow. The blood may have
been damaged irremediably. Under these circumstances it is plain
that active treatment can effect nothing. Recovery, however, takes
place in a certain proportion of cases, and under a great variety of
treatment. It may take place when no treatment is pursued. My
first case of cholera, in 1849, illustrated the fact just stated. The
patient was brought into the hospital completely collapsed. I
remained with him several hours, and resorted to various measures
of treatment. At length all remedies were discontinued ; he was
allowed to drink abundantly of cold water, under the impression
that the case was utterly hopeless. Much to my surprise, after an
absence of several hours, I found the vomiting referred to had ceased
and reaction was coming on; he recovered rapidly. I had been led
to doubt whether, in general, active treatment effects much for the
advantage of the patient in the collapsed stage of cholera, and I
cannot doubt that it is often prejudicial. The object of treatment
in this stage, aside from the arrest of vomiting and purging, is to
excite and aid the efforts of nature in restoring the circulation. The
measures to be employed for this object are external heat, stimulat­
ing applications to the surface, stimulants, and food.

“ The application of heat may be made by means of warm blank­
ets or bottles of hot water placed near the body. Stimulants, in
the form of spirits and water, should be given as freely as the
stomach will bear, always recollecting the risk and the evils of
inducing vomiting. They will be most apt to be retained if given in
small quantities at a time, and often repeated, If vomiting be pro­
voked, either by drinks, remedies, or food, more or less injury is
done. Concentrated nourishment—essence of meat, chicken broth
and milk—is to be given in small quantities at a time, provided the
stomach will retain it. It is doubtless desirable to introduce liquid
into the system as far as possible. The only objection to drinking
water freely is the risk of promoting vomiting. Small lumps of ice
should be freely allowed. “

This description represents one of the chief lines of treatment
pursued in America. Another, which has also many advocates in
the medical profession, may be summarized as follows : During
the premonitory stage, including the diarrhea, reliance must be
placed upon rest, warmth, and mild but gently stimulating draughts,
paregoric, aromatic spirits of ammonia, tincture of ginger, with a
mustard plaster over the abdomen, and a hot mustard foot-bath if
coldness of the body increase and vomiting begin.

During the second, or rice-water stage, aromatics should be
given. A prescription much used and approved in India, is the
following :
Oil of anise, -                                Half a teaspoonful.
Oil of cajeput, -
Oil of juniper, -
Ether, ----- One teaspoonful.
Tincture of cinnamon, - - Two ounces.

Mix, and give ten drops in a tablespoonful of water every fifteen
minutes.

Another formula, much used in this country, is as follows :
Chloroform, - - - A teaspoonful and a half.
Tincture of opium,
Spirits of camphor,
Aromatic spirit of ammonia,                               “
Creosote, -                       Three drops.
Oil of cinnamon, -        - Eight drops.
Brandy,          -                      Two drachms.
Mix. Dissolve a teaspoonful of this in a wineglassful of ice-water,
and give two teaspoonfuls out of this glass every five minutes, fol­
lowed each time by a lump of ice.—Hartshorn.

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