Transcribed from the 1849 Simpkin, Marshall, and Co. edition by David Price. Many thanks to the British Library for making their copy available.
TREATMENT
OF
CHOLERA
IN
The Royal Hospital, Haslar,
DURING THE MONTHS OF JULY AND AUGUST, 1849,
WITH
REMARKS ON THE NAME AND ORIGIN
OF THE DISEASE.
BY
JOHN WILSON, M.D., F.R.S.,
INSPECTOR OF NAVAL HOSPITALS AND FLEETS.
SIMPKIN, MARSHALL, AND CO., LONDON;
LEGG, GOSPORT.
1849.
TREATMENT OF CHOLERA.
On admission the patient was immediately placed in a hot bath, from 104° to 112° of Fahrenheit, in relation to the reduction of circulatory power, and of superficial heat; diligent friction of the abdomen and extremities, according to the place and violence of the spasms, being at the same time practiced. The measure seldom failed, except in cases of extreme collapse, to excite some warmth, abate cramps, and lessen suffering, at least, for a time.
While in the bath, or as soon as carried from it, a drachm of tincture of opium, in aromatic water, was administered. If, as almost invariably happened, the draught was instantly rejected, the proper practice of the hospital was forthwith commenced and steadily pursued. It consisted of the following means:—
Two grains of calomel, in bolus, every hour, or every half hour.
Half a drachm of oil of turpentine, in two ounces of mucilage, repeated every hour, or every second hour; most frequently the last. In one instance it was given every half hour.
An enema, consisting of two ounces of oil of turpentine, two drachms of tincture of opium, three ounces of mucilage, and three ounces of camphor mixture, repeated according to circumstances.
Friction applied to cramped parts assiduously, and as forcibly as could be borne, with turpentine and olive oil.
Such, in brief, was the treatment adopted and relied on, though various auxiliaries were, from time to time, and in different cases, employed.
Occasionally, but chiefly when the patient represented the vomited fluid as being sour, a solution of carbonate of soda in water was substituted for plain water, as a portion of drink. Sinapisms were sometimes applied; aromatics were now and then, though seldom, prescribed; and in two cases, where with moderately firm pulse, spasms were universal and excessively severe, blood was taken from the arm. Pans with hot water were often applied to various parts of the body, but could seldom be long borne, or kept in place, from spasms or other causes of restlessness in the patient.
One remarkable and gratifying effect of the turpentine draughts consisted in what may be called their acceptability to the stomach. While aromatic and cordial mixtures were instantly rejected, they were generally retained for considerable periods. The turpentine injection had similar effects on the intestines, allaying irritation and checking discharges. With few exceptions they arrested the flux for a time, in most instances for a considerable time. So powerful, in fact, was their restraining power, that they did not require to be often repeated. Their controlling influence was unquestionably great.
Many years ago, while serving in the West Indies, and often looking anxiously but in vain, for the constitutional effects of mercury in the precipitous fever of that region, the writer was led to inquire whether some accessory agent might not be found to accelerate and determine the action of the mineral; and turpentine, from its penetrating properties, rapidly entering the circulation, exciting the capillaries, and stimulating the kidnies, presented itself as probably possessing the desired qualities. It was tried, and did not altogether disappoint expectation. It was thought afterwards that it did not only precipitate mercurial action, but increased its remedial power. A paper on the subject was printed in the “London Medical and Physical Journal,” especially in reference to the treatment of neuralgic affections, in 1830.
Calomel in some shape, in various quantities, after various intervals, alone or combined, has long been the most popular remedy for cholera; and, from the concurrent testimony of many witnesses, it has properly gained its reputation. The practitioner has not always, perhaps, considered very carefully the grounds on which he prescribed, nor the channel through which he expected its remedial agency, being satisfied with the result. It is certain, however, that the result from it—as from other things—has been too often the reverse of satisfactory. It is equally certain, that if an auxiliary accelerating agent is a desideratum in the precipitous fevers of the West Indies, it is much more so in dealing with the yet more precipitous disease under consideration. Looking at the matter in this light; believing that calomel, as it is commonly administered, in the worst and most suddenly fatal cases of cholera, seldom passes beyond the stomach; and being satisfied that to act as a remedy it must enter the circulation, and reach secreting extremities, the method of treatment specified above was adopted.
The results on the whole were satisfactory. Though not such as were desired or even hoped for, they at least exhibited a full average amount of success, inspired confidence, and tended to support the belief, that the practice was founded on right principles.
Of 37 cases admitted 12 terminated in death, the remainder in complete recovery. [9]
All the cases in the above number were considered to belong strictly to the epidemic cholera of the season, characterized chiefly by depression of vital power, suppression of biliary and urinary secretion, and great tendency to death. Pains were taken to exclude from it allied affections, especially bilious, or as it is sometimes called, English cholera, of which there were many, and some grave cases. Want of care in this respect renders useless comparisons of the respective value of different modes of treatment; and it is suspected that it is more to such carelessness, to use no strange word, than to superior skill in the practitioner, that the high proportion of cures claimed in some instances should be ascribed. This is said without meaning to insinuate that one method of management is not better than another, or wishing to damp the inquiry in which so many men are now anxiously engaged, as to how more may be done than has yet been effected for choleral patients. In attempting to balance the respective merits of different lines of practice, it is also necessary, in order to render the comparison fair or instructive, to know whether as a whole, the cases treated by each were equally severe.
Of the 12 fatal cases which occurred here, eight of the subjects were in a state of complete collapse—cold livid and pulseless—on admission; in another collapse was nearly complete, and death speedily followed in all, without the slightest sign of re-action. In one of the remaining three cases, there were slight and transient periods of re-action, alternations of promise and discouragement for fifty hours, when fatal sinking came on. In the other two, the first danger was past, but severe re-actionary fever followed. In one there was restoration of the biliary secretion; in the other, during the last eighteen hours the subject had the complete appearance of a patient in West Indian fever, discharging largely from the stomach, and more sparingly from the bowels, a fluid exactly resembling black vomit.
In the cases, which terminated in recovery, the impression was severe, though not equally so; and in each the symptoms, as already stated, were considered clearly characteristic of the prevailing epidemic. In some of them no hope was entertained for a time; especially in two cases, where there was in excess, lividity of surface, cold sweats, corrugated skin, bent fingers and toes, and failure of pulse.
In considering the probability of recovery from cholera, there is reason to think that the manner of attack should be taken into account, jointly with the severity of subsequent symptoms. From what was observed here, it appeared that when there had been precedent diarrhœa, or when there had been—though sudden—a gradual progress to the collapsed state, there was a much better chance for the patient than when the disease, in overwhelming force, fell upon him at once. When, soon after eating a hearty meal, in perfect health, the subject is obliged to be relieved from duty in the ranks, or on deck, becoming in an instant faint and giddy, with a rush of fluid from the stomach and bowels, shrinking of features, fluttering pulse, coldness of surface tongue and breath—struck down, as it were, by electricity—to which soon followed the up-turned ecchymosed eye and whispering voice—when the disease thus sets in, it is doubtful whether art has any power to arrest, or materially modify its fatal career. Such, at least, is the impression from what was observed here; and such, without questioning what has been alleged to have been done by others, or disparaging the means they employed, it is apprehended will be the conclusion of most observers elsewhere.
The practice pursued in Haslar Hospital is submitted to the profession, not because it had any very eminent success, nor on account of its including new remedies, but because the proportion of recoveries was at least fully as large as that which has followed other modes of treatment; because there was some novelty in the combination of the means employed; and because it is thought that any contribution to the therapeutics of cholera will be acceptable.
Among the diseases allied to cholera which have been treated in Hospital during the last two months, should, it is believed, be included grave cases of fever, with striking predominance of gastric symptoms, and excessive discharges from the alimentary mucous surface, as well as the following:—
Forty-three cases of febrile diarrhœa, with rice water digestions, and strong choleral tendency.
Ten cases of colic, with spasms of extremities.
Twenty cases of bilious cholera, making a total, exclusive of fever, of 73 cases of allied affections, all of which have ended in cure, or are making favorable progress. Some consideration of these cases, and of the various appellations applied to cholera, have led to the following remarks on