Cholera.

Synonyms.—Cholera Algida; Cholera Asiatica; Cholera Maligna.

Definition.—Cholera is an acute, specific, infectious disease, occurring endemically and epidemically, and characterized by severe vomiting and copious watery stools, violent cramping of the muscles, and collapse.

Cholerine is a term which has come into use in recent years, and is applied to mild cases of cholera and the fatal cases of diarrhea attending an epidemic of cholera.

History.—On the right bank of the Ganges, one thousand feet above the sea-level, at the foot of the Himalaya Mountains, beautifully situated, lies the little town of Hurdwar. Here every year more than one hundred thousand people come to bathe in the sacred waters of the Ganges, while every twelfth year, a sacred year, two million devotees make the pilgrimage.

During the yearly visits thousands of sheep and cattle are slaughtered for ceremonial rites, and the waste portions rot in the burning sun to become centers for the propagation of infectious diseases. This little city of five thousand people is the home and great focus from which cholera radiates throughout India. Mecca and Medina, other holy cities, are also the places of vast pilgrimages, and one can readily understand why cholera is endemic in India, where sanitation is unknown.

For centuries cholera has occurred in epidemic form in India, Persia, Egypt, and those provinces of Russia bordering the Black Sea. As the Eastern countries were opened to intercourse with European nations, avenues of communication were offered for the transmission of this dread disease, and in 1832 cholera made its first appearance in Europe, one hundred thousand dying in France alone. During this year it was brought by emigrant ships to Quebec, where it rapidly spread along the lines of travel up the great lakes, until it reached the Upper Mississippi.

During this same year it entered the United States by the way of New York, where over three thousand died. It traveled along the great thoroughfares, leaving death in its wake. In 1849 another epidemic occurred, this time entering by way of New Orleans, and, as before, visiting the larger cities, carrying off its victims by the thousands. In 1854 it again appeared in New York, though the loss of life was not so great as in 1849. In 1866 and 1867 it also visited America, but was more mild, and there were less fatalities than in any previous epidemic. In 1873 it made its last appearance in the United States, but owing to greatly improved sanitation it did not prevail over a wide field.

Cholera is of more interest to the American from a historical standpoint than from a practical one; for, in all probability, the United States has seen its last epidemic, for the quarantine system becomes more rigorous each year. so that the fatal disease will hardly be able to find entrance into our country.

Etiology.—Predisposing causes are such as lower the vitality and resisting power of the body; viz., overwork and-lack of proper nourishment, enfeebled condition of the system from previous diseases, dissipation and poor food, especially food where decomposition has already begun, as in tainted meat and vegetables.

Season also influences the spread of the disease. In hot, moist weather the conditions are all favorable for the rapid development of the infectious poison; hence it reaches its maximum intensity at this time, while with the appearance of cold weather it entirely disappears. Social position is also a factor in predisposing to cholera; for this is essentially a filth disease, and consequently occurs more frequently among the poorer and more ignorant classes. During an epidemic the disease rages most fatally in the slums, where filth abounds, and is not so severe in the cleaner sections of the city.

The exciting cause is now generally recognized as the comma bacillus of Koch, which is not found in any other disease. This is about one-half the length of the tubercle bacillus, thicker and slightly curved, resembling a comma, hence the name. Some of them are corkscrew-like in shape, resembling the letter s. In fact it is not a true bacillus, but should be classed as a spirocheta.

They can be readily cultivated in various media, but desiccation destroys their vitality, differing greatly from the tubercle bacillus. They are found in the intestine very early in the disease, in the dejecta, and, when the rice-water discharges appear, are to be found in enormous quantities. They are rarely found in the vomitus, but may be found in large quantities in the intestines, post mortem.

In those cases which die within twenty-four or forty-eight hours from the attack, the bacilli are not found in the walls of the intestine; but where the disease is more protracted they invade the glands and deeper tissues. During an epidemic they are found often in the stools of well persons, such being immune owing to their vigorous health and resisting power. Koch, failing to find the spirilla in any of the internal organs, concluded that the systematic infection was due to ptomains or toxins generated from the spirilla, since dead cultures are always toxic.

The infection is usually introduced into the system through the medium of water, either directly by drinking, or from food which has been washed in infected water or has been diluted with the same. It does not enter by inhalation, since drying destroys their vitality. It may, however, be conveyed by meat or bread on which the germs live for from six to eight days. They may also be conveyed to the mouth by the hands of those who wash the linen of cholera patients.

The virulence of an epidemic, then, depends upon the degree of contamination of the water supply. The Hamburg epidemic of 1892 is a striking example of this fact. The water supply was taken unfiltered from the Elbe; the mortality in the epidemic that prevailed was forty-two and two-tenths per cent, while the filtered water supplied from the same stream to a neighboring citv resulted in a very low death rate. The safeguard of a city, then, lies largely in a pure water supply, and even this should be filtered.

Pathology.—The tissues after death are shrunken and drawn, and the extremities are inclined to be mottled; in some cases there is a post-mortem rise in temperature. Rigor mortis sets in very early. Spasmodic contractions sometimes occur for some moments after death; hence the eyes and jaws have been seen to move after life was extinct. Owing to this marked contraction, the limbs have been distorted and the partial fuming of the body is thus accounted for, and is not, as many have supposed, the result of being buried alive.

The tissues are dry, having been drained of their fluids before death; hence some time elapses before decomposition begins after death.

The chief visceral lesion is that of the intestinal canal. The mucous membrane is swollen, hyperemic, and softened. The solitary glands and Peyer's patches are congested and sometimes ulcerated. The peritoneum is either dry or covered with a viscid, sticky fluid. The intestine contains a more or less quantity of rice-water, fluid rich in the comma bacillus. The denuding of the peritoneum is now supposed to be due to post-mortem changes. The kidneys and liver show cloudy swelling, and occasionally degeneration; the spleen, however, is generally found to be reduced in size. The heart is flabby, dry, and anemic-looking, while the blood is very dark, but slightly coagulable and robbed of its salts and fluids.

Symptoms.—The disease may be divided into three stages: (1) A choleraic diarrhea; (2) Cold stage, or stage of asphyxia or collapse; (3) Stage of reaction. Dr. Scudder, having passed through the epidemic of 1866-67, graphically describes cholera in the following words:

"Incubation.—Diarrheal Stage.—The stage of incubation varies greatly in length, from but a few hours to days. It may be attended from the first with diarrhea, or it may precede this for some time. In the latter case, the patient will complain of a feeling of prostration, with relaxed skin, scanty urine, or urine of low specific gravity, a pallid tongue with a pasty white fur at its center; the pulse is invariably smaller, and increased in frequency; the appetite is poor, and the digestion imperfect, with occasionally a sensation of weight and uneasiness in the bowels. I have seen symptoms continue for from two to eight days before a choleraic diarrhea appeared, and I do not know that I have ever witnessed these symptoms where cholera did not fully develop itself, unless appropriate treatment was adopted.

"During an epidemic of cholera, diarrheas are very prevalent; and though it must be admitted that any form of gastro-intestinal irritation or disease predisposes to an attack, yet these are not to be regarded as choleraic. To place the matter in a different light, any diarrhea may become choleraic, but only by those persons being influenced by the peculiar epidemic poison.

"It is of importance, then, that we be able to distinguish between an ordinary and a choleraic diarrhea; for the first will require but the ordinary treatment (though it should always be arrested), while the second requires rest in the recumbent position, and a very careful treatment by specific remedies. We need not mention the symptoms of the ordinary diarrhea; it will be sufficient to specify those peculiar to the diarrhea of cholera.

"With the first choleraic discharge, the patient will feel unnatural prostration that is characteristic. It is not fear, or a nervous sensation, but a real exhaustion and loss of strength. An examination of the pulse will show an enfeebled circulation; the pulse being markedly small, easily compressed, and increased in frequency. The tongue will present a pallid appearance, with a white or pasty-white coat in its center. These symptoms are, as I believe, pathognomonic, and may be relied upon, whatever may be the character of the discharges. And I have seen them well marked, when there was but the inclination to go to stool, and where death resulted from cholera asphyxia within twenty-four hours.

"The discharges at first were fecal, though usually thin; as they continue they gradually lose color (dirty water) until at last they present the characteristic rice-water appearance.

"The duration of this choleraic diarrhea varies in different cases; rarely of two or three days continuance, frequently not more than six to eight discharges in less than as many hours. It is observed that the prostration increases with each discharge, and the pulse is more affected; the amount discharged by the stool, as a general rule, determining the extent of the prostration, and the development of the second stage.

"Thirst is a marked feature of cholera, developing in the first stage, and increasing as the disease progresses, until it becomes one of the most intolerable features of the disease. In the second stage, whatever the patient may take as a drink is immediately rejected.

"Cholera asphyxia is ushered in by increased frequency in the discharges, which have ceased to be feculent, and, in a majority of cases, are characteristic,—rice-water. Great prostration attends them, and the pulse becomes very small and feeble.

"As a general rule, nausea is developed with the choleraic diarrhea, and with the development of the second stage vomiting is frequent and persistent. The vomiting, as well as the diarrhea, persists until the stage of collapse, when it ceases of its own accord.

"The surface now presents a peculiar appearance; the first tissues are shrunken, and the skin covering the extremities is contracted and shriveled, and of a bluish, leaden color. The extremities are also cold, and as the disease progresses it extends upward to the trunk. There is a want of elasticity in the skin; when pinched up it does not readily assume its position. As the disease progresses, the loss of tonicity is indicated by a free but unnatural clammy perspiration, sometimes as sticky and of the consistence of glue water.

"A very marked feature of this stage of cholera is the spasmodic contraction of the muscles, known as cramps. These usually make their appearance in the second stage, and, increasing in severity as the disease progresses, continue to the period of collapse. Sometimes they do not cease until death is far advanced. They commence in the muscles of the legs and thighs, in which they are most severe. Sometimes they extend upward and involve the psoas and the muscles of the abdomen, and occasionally the muscles of the upper extremities and back. In one case I witnessed, these cramps assumed the form of true tetanic spasms, involving all the voluntary muscles.

"The last part of the second stage has been known as the stage of collapse. The pulse has now left the wrist. The extremities are cold to the trunk, and the skin presents the peculiar purplish. shriveled appearance heretofore named. The features are shrunken and pinched, the eyes set back in the head, the lips livid, the ears and nose itching", the forehead cold and clammy, respiration difficult and irregular, the cutaneous veins distended and dark, and the mind evidently clouded and not appreciating the condition. Even with such symptoms, life may be prolonged for several hours, the patient finally dying from asphyxia.

"It will be noticed as characteristic of cholera, that no urine is passed in the second stage of the disease; indeed, none is secreted, and the bladder is usually found empty on post-mortem examination.

"Stage of Reaction.—The pulse comes back to the wrist, the surface becomes warm, the patient breathes with more ease, and is inclined to sleep. As we have noticed above, it may not go further than this. When it does, we will find the skin becoming dry and harsh; the pulse increased in frequency to 100° or even 120°; the mouth is dry, and the coating of the tongue assumes a shade of brown, with brownish sordes on the teeth. The urine is scanty and very highly colored, if passed at all. As a general rule, there is marked irritation of the nervous system, the patient being restless and irritable, and unable to sleep.

"These symptoms may give way in a few hours, secretion being established, and the patient convalescing without trouble. Or they may continue for several days, presenting Ae features of the nervous stage of a typhus fever. Or, increasing, the disease may run rapidly to a fatal termination."

Complications.—Cholera Typhoid.—Following reaction, there may be relapse, the patient becoming delirious, the tongue dry and brown, sordes appear on the teeth and lips, and the patient passes into a comatose condition, which finally ends in death.

Kidneys.—Various kidney lesions have followed convalescence, and death from uremic poisoning is not an uncommon result of this complication.

Cholerine.—There are cases where the diarrhea is attended with severe griping pains, vomiting, liquid copious stools, in which there is some fecal matter, and finally a slight collapse, followed by reaction and return to health; this, in recent years, has been termed cholerine.

Diagnosis.—In the early stages, before the epidemic is fully established, there may be some confusion between this and cholera morbus, cholera nostras. Later the diagnosis is readily made, the symptoms being so marked as to be readily recognized. The rapid prostration, following the copious rice-water discharges, the vomiting and finally collapse, the patient becoming cold, blue, and almost pulseless, can not readily be mistaken.

Prognosis.—Like all infectious diseases, epidemics vary in intensity in different seasons and in different places. However, cholera is always a grave disease, and our prognosis should therefore be guarded. The mortality is always great among the aged and young children, among the intemperate and those poorly nourished, and where treatment is not vigorous in the early stage of the disease. We may say that the mortality varies from twenty to eighty per cent.

Treatment.—Prophylaxis.—Since cholera thrives where filth abounds, strict hygienic measures should be adopted to prevent further spread of the disease. Cleanliness should be the message communicated to every ear. Cess-pools, vaults, drains, catch-basins, etc., should be thoroughly cleaned and as thoroughly disinfected.

A vigorous quarantine should be established, and the excreta from a cholera patient, as well as the clothing and room, should be thoroughly disinfected. Regular habits should be insisted upon; for intemperance, overwork, and all influences which tend to depress the nervous system, predispose to cholera. Overeating should be discouraged, though the ordinary diet need not be changed; fresh vegetables and fruits should be encouraged, but, above and beyond all, are cleanliness and a pure water supply.

Medical Treatment.—Never having passed through an epidemic of cholera, I submit the treatment as practiced by Eclectics as given in Dr. Scudder's last edition of his work on practice, and also add the treatment recommended by Cantani, of Naples. The latter treatment, as you will see, was anticipated by Dr. Scudder; but no opportunity offered for trial after his attention had been directed to this line of treatment. We may therefore lay some claim to this new method.

Dr. Scudder says: "The treatment for the forming stage of the disease, diarrhea not being developed, will vary in different cases. When the circulation is feeble, and the skin relaxed, I prefer aconite with ipecacuanha in the usual doses, alternated with tincture of nux vomica in the proportion of ten drops to four ounces of water, a teaspoonful every two or three hours.

"If the tongue is pallid, and coated with a pasty-white coat, the sulphite of sodium may be given in doses of ten grains every two hours, or, in place of this, the bicarbonate of sodium, or common salt, may be used; but if the tongue is red, somewhat dusky, or there is a tinge of brown in the coating, the mineral acids will be preferable.

"A choleraic diarrhea requires to be promptly arrested. The patient should assume the recumbent position, and keep entirely quiet until the diarrhea is arrested, and the sense of prostration has passed away. This is imperative. The local application to the abdomen may be either a large sinapism or a cold pack, as the physician may prefer, or, in many, commence with the first, and then follow with the cold application.

"The remedies will vary in different cases, and with different practitioners. There is a very large list to select from, and we may employ the different classes of stimulants, astringents, narcotics, or special remedies.

"Among the first we have the essential oils, all of which have been employed, in the form of a compound tincture, in cholera. The compound tincture of cajeput is preferred by our school, and is probably as good as any combination that can be made. Whatever stimulant is selected, it is freely used, and continued until the diarrhea is arrested. In some cases it is combined with an astringent; in others, with a preparation of opium.

"Chloroform has been employed in this disease with advantage, in doses of from ten to forty drops. Chlorodyne has also been extensively used, and is probably as good a remedy as can be placed in the family. Camphor has been thought by some to be a specific; the tincture is given in doses of from ten to fifteen drops.

"The majority of the vegetable astringents have been employed to arrest the diarrhea of cholera. Some combine them with stimulants, others with narcotics; but the results have not been very flattering.

"Opium has been extensively employed for this purpose, and sometimes with excellent results. A pill of opium and camphor, half grain to one grain each, will probably be the best form of the remedy, and may be given as often as every hour. It has been recommended to add one grain of leptandrin to each dose, though I doubt the advantage of it. I have never used opium by mouth, in cholera, preferring its action by hypodermic injection of morphia.

"Of the many remedies I have employed for this diarrhea, nothing has given so much satisfaction as strychnia. I prescribe it in the following form:

"When the stomach is very sensitive to medicine, or there is a tendency to nausea and vomiting, we will have to employ remedies by mouth with great care. Indeed, in these cases I would never run any risks of exciting vomiting, preferring that the diarrhea should continue until it could be arrested by other means. I have had excellent success in these cases by administering salt water in moderate quantities, and the use of opium with a stimulant as an enema. The form that I prefer for the last is—

"In place of the salt water, when it is distasteful, especially when the mucous membranes were reddened, I here use the white liquid physic , in doses of a teaspoonful every fifteen to thirty minutes, until the patient is relieved. Afterwards, less frequently. The tincture of nux vomica may also be employed in this case with advantage, using it in small doses, frequently repeated.

"In the treatment of cholera asphyxia, the first object is evidently the relief of gastric irritation; for so long as nausea and vomiting continue, no other remedies can be of any use, as they will be ejected. For this purpose I employ cold salt-water packs over the abdomen, though some use the large sinapism in preference. The patient should be kept in a recumbent position, and not be allowed to get up to stool, a bed-pan or cloths being employed. Dry heat should be applied to the extremities to as great an extent as possible, the patient being covered with blankets. In some of the milder cases, stimulants or aromatics may be used to arrest the nausea. Thus, as we have already seen, the compound tincture of cajeput will stop the vomiting in cholera morbus, and, continued, will arrest the diarrhea. Some have depended upon the aromatic waters, but I do not think much of them.

"The remedies that I have employed to best advantage are the following: A teaspoonful of salt in a glass of water, and given m small quantities frequently, has served the best purpose. The white liquid physic has proven valuable in the class of cases heretofore named. The tincture of nux vomica, or a solution of strychnia, will also accomplish the object in many cases, and may be used alone or in combination with either of the other means.

"I do not attempt to give remedies for the arrest of the diarrhea so long as the vomiting continues, unless it is a stimulant which answers this purpose, or strychnia. I have found it better to use enemas for this purpose, the preparation of opium and xanthoxylum, heretofore named, being preferred.

"Soda in its various preparations stands first in the list of curative means, and we will generally employ common salt in preference to any other. Strychnia undoubtedly stands second in the list of remedies, being the most powerful stimulant and tonic we ever employ.

"Cramps of the muscles may be relieved by brisk rubbing, but this should always be done under cover. A local application of chloroform, or compound tincture of cajeput, to the affected part, will frequently give great relief. The simplest, as well as the most effectual plan, is to give the great toe a sudden twist with the hand.

"Let it be recollected that the patient must keep the recumbent position, must not get up to stool, and must be warmly covered in bed with the application of dry heat.

"Though the thirst is excessive, yet water can not be given with safety. Even after the vomiting is checked, we will find that but a small portion of fluid will cause it to recur. Small portions of salt water, frequently repeated, is the best means of supplying fluid to the blood.

"I feel confident that the loss of fluids might be replaced to some extent by subcutaneous injection, and for this purpose had prepared a four-ounce hypodermic syringe, had cholera reappeared in 1867. It was tried to some extent in 1866, with good results.. Absorption from the cellular tissue is very rapid, even in an advanced stage of cholera, and a weak solution of salt water would be readily taken up. It might be used at several points, and as much as eight to twelve ounces introduced in the course of an hour.

"The stage of collapse will be treated by the administration of salt water in such quantities as can be borne by the stomach, by the assiduous use of dry heat, and such stimulants as may be deemed applicable, and by the hypodermic use of strychnia in large doses. Other than these three means, I know of none that is likely to prove of any use. Persons will, in rare cases, recover from this stage without medicine, as I have seen in two instances.

"Convalescence must be managed with great care. Quiet in bed is the only course of safety. The desire for drink must be supplied gradually and in small quantity, whilst the food should be of the most bland description, and taken sparingly. I have generally put the patient upon the use of aconite in small doses, with belladonna if there was any tendency to congestion. If the tongue becomes dry, and the mucous membranes be dusky red, as is frequently the case in the third stage, we give the dilute muriatic acid.

"Small doses of strychnia may be continued internally, or in its stead we may give the tincture of nux vomica. Quinine, when needed, is best used in the form of inunction, or applied in solution in brandy, with brisk friction.

"In some cases, small portions of brandy may be given with the drink, to keep up the strength and aid convalescence. We are governed here by the same rules that governed its administration in fever. If the pulse increases in volume, with a better circulation of blood, better secretion, and better innervation, let it be continued; but if the influence is the reverse, let it be stopped."

Enteroclysis.—Professor Cantani, of Naples, used with great success, according to report, the following solution introduced high into the bowel:

This solution should be introduced through a Langdon rectal tube, introduced as high as possible, and at a temperature of 105°. These injections should be used with the first appearance of diarrhea. The bowel should be thoroughly irrigated several times in twenty-four hours.

Hypodermoclysis.—This is the introduction into the system of a saline solution to counteract the loss by the copious dejections, the solution:

The region selected is the mammary or ileo-costal; a large canula furnished with a stopcock is attached to the hose of a fountain syringe, which is elevated sufficiently high for the force of gravity to force the fluid into the system. A fold of loose tissue is raised, and the needle introduced quite a distance, and the current turned on; in a few moments quite a large tumor is formed; with a turn of the stopcock the solution ceases flowing; gentle friction over the seat of the swelling will hasten absorption, when more can be introduced. A warm bath greatly facilitates the absorption of the solution. At the same time a hypodermic of strychnia should be given, and hot applications made to the feet and extremities, while brisk friction of the surface with dry mustard will favor the reaction. This part of the treatment is begun with the first symptom of asphyxia. From the response I have received in the cold stage of cholera morbus from the introduction of saline solution, I am satisfied that it will prove of benefit in cholera.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.