On Asiatic Cholera Morbus. By Paul M. Eve, M. D. of Augusta, Georgia.
Believing it criminal to withhold from the medical profession anything on the Cholera Morbus at this moment, and conceiving it a duty to comply with the request of the editor of the American Journal of the Medical Sciences, I send the following observations which were made last summer while I was in Europe. I had felt a reluctance to make a further communication to the public on this engrossing subject, which was warranted and justified from my late situation in the Polish army; my time and attention having been almost exclusively devoted to surgical cases, and opportunities of investigating this disease having been comparatively limited. If it is thought, however, that my observations, imperfect as they are, and that my opinion, humble as it is, can in any way serve my fellow-labourers in the treatment of this modern plague, I most willingly and cheerfully present them my views on the subject.
As I have neither time nor inclination to write a long article, I will briefly state the principal symptoms of the Asiatic Cholera Morbus, the appearances on dissection, and then deduce from them the treatment. An attack is usually preceded by diarrhœa or by uneasiness in the stomach and bowels for some days, or is suddenly announced by vomiting and purging, commencing about three o’clock in the morning, when the temperature is lowest of the twenty-four hours; and is followed and accompanied by cramps or spasmodic contractions of the abdomen. There is great prostration of the animal powers; shrinking of the external parts, particularly of the features, which assume in many places as well as the fingers and toes, a leaden or purple appearance; a cold and moist or even a wet skin, conveying when felt, the sensation of touching a frog; great thirst; the tongue is blue and cold, or moist and partly covered with a white fur; the pulse is either imperceptible at the wrist or is quick, frequent, feeble and intermitting; respiration is slow and very difficult; the voice is much altered, questions and answers being made in a low whisper; the secretions, particularly of the kidneys, are diminished, except into the alimentary canal, where they are altered and augmented, without however any bile; purging and vomiting, sometimes one only, but generally both; first the contents of the stomach and intestines are discharged, and then a peculiar whitish fluid resembling rice-gruel or sero-albuminous matter; and lastly, cramps of the extremities, most frequently of the legs, and which may be compared to a bayonet piercing the calf or most muscular part.
The appearances after death, were almost constantly the same. The external parts were very much diminished in size; the extremities, the nose, lips, eyelids, cheeks, &c. were of a bluish or livid colour, and the skin was wrinkled upon the hands and feet. The vessels of the brain in some subjects contained black blood, but generally there was nothing peculiar in the contents of the cranium. There was more blood in the spine, probably arising from position. The heart, lungs and large vessels were filled with a fluid resembling tar in colour and consistency. Two hours after death it was liquid and appeared like venous blood; but at twenty-four hours it seemed deprived of serosity and of the property of coagulation, and albuminous concretions were found in the heart. The stomach and intestines were either empty or contained matter similar to the vomitings and purgings; their coats were contracted and paler than in a natural state, or as was most frequently the case, presented all the varieties from congestion to sub-inflammation. The liver and vena portæ were distended with black blood, and the gall-bladder with tenacious, dark yellow, or green bile. In almost every case the bladder was found empty and contracted.
From the above symptoms and results of post mortem examinations, it would seem that the pathology of the cholera morbus may be explained by a want of oxegenation of the blood, which becoming surcharged with carbon is unfit to stimulate the heart to contraction, and hence the congestion upon the internal and vital organs at the expense of the surface and extremities. With this pathological view of the disease, and from the positive fact of there being a centripetal action of the blood, is easily deduced the principle of conducting its treatment—the equilibrium of the circulation must be restored or death will ensue. Now, mechanically speaking, there are two ways of affecting this object, either by introducing a power which will give the blood a centrifugal direction, or calling it back to the surface, by direct external applications. But the animal economy is governed by other as well as mechanical laws; the vital properties of the heart are oppressed, its energy is diminished, and its power of reäction impaired by an accumulation of blood, and this is peculiarly the case when the blood is black or not oxegenated; the stimuli or powers introduced to rouse its action would therefore be worse than useless; besides, we usually address the heart through the stomach, which is in such an irritable state as to reject even the mildest article. Upon the surface, on the contrary, there is a want of action, and stimuli are called for to excite the skin; to restore its lost or increase its feeble circulation, and thus draw the blood and heat from the internal parts of the extremities.
The plan of treatment which I have found most successful, consisted in varying the following means according to circumstances. Within the first four hours after an attack, bleeding will generally be necessary; but when prostration has ensued and when the surface is covered with cold sweat, leeches to the epigastric region, or cupping followed by warm fomentations or mustard plaster or blister, together with frictions and heat to the extremities, will afford the greatest and most speedy relief. Notwithstanding the various and multiplied articles of the materia medica which have been recommended, as opium, calomel, oxide of bismuth, cajuput oil, spirits, &c. to allay vomiting and purging and calm spasms, I must give my decided preference to dermoid applications, which invite the blood from the heart, lungs, liver, stomach, &c. the congestion of which produces these symptoms. I do not deny that there are cases which can be, and are relieved by medicines; but, since we possess no remedy which can drive the blood from the centre to the surface—since all internal medicines are apt to excite vomiting, one of the most painful, distressing and fatal symptoms of cholera—and moreover, since we possess means which can be easily managed and varied to suit circumstances, and whose action is plain and evident to the senses—I cannot forsake them to launch upon the sea of experiment and conjecture, in the treatment of this rapid disease. The language of those who advocate the administration of internal remedies, is to give so much of a mixture or so many pills, and if they produce vomiting, repeat the dose; but if a cure is to be effected by relieving the symptoms, why give those medicines which excite or aggravate them? An infusion of peppermint, or the oil or essence of this plant, with a few drops of laudanum, in a little warm brandy and water, is what I have found best adapted for internal use; and even this should be prohibited when it produces vomiting. This symptom is often so distressing and so easily excited, that the stomach will reject whatever is presented to it. In such cases, I rely upon the horizontal position, perfect rest, and heat and frictions to the abdomen and extremities, without administering any thing internally. The warm bath I have known to be of great service, but the time necessary to prepare it and the exposure of the body to the air, are serious objections to its general employment. The same will not hold good in relation to the vapour bath, where the patient can be kept continually warm. Excessive thirst is best relieved by cold gum water, or by a piece of ice dissolved in the mouth.
Having enjoyed an opportunity of comparing the practice of the English, French, German and Poles, while stationed at Warsaw, in the months of May, June, July, and August, of the past year, and having experienced personally the disease, I feel some confidence in recommending the above treatment of the Cholera, to the American practitioner of medicine: and in support of its correctness and superiority, I will state that at Wisnia, a town of Gallacia, out of two hundred and forty persons attacked with it who were subjected to cutaneous frictions, and to the internal use of only an infusion of chamomile and peppermint two alone died.
To prevent an attack of cholera, cleanliness and sobriety ought to be most rigidly observed. All sudden or great impressions upon the system, as changes in the temperature of the air, cold and moisture, or emotions of the mind, excessive joy, fear, and the depressing passions, should be carefully avoided. The body to be kept moderately warm, a belt of flannel is recommended to be worn; and the mind calm, and confiding in a protecting Providence. The diet should be regular, and without any material change in the accustomed repasts. Emetics and purgatives are to be avoided, and certain articles of nourishment which are known to predispose to colic, or cholera affections; these are bad beer, sour-crout, cabbage, salad, beans or peas, spinage, cucumbers, pickles, unripe sour fruit, musk and water melons, cold meats, sour milk, &c. Good soups, beef, mutton, veal, fowls, eggs, Irish potatoes, bread, and tea in preference to coffee, should constitute the principal food of those who inhabit an infected district.
After all that has happened to admonish us, we can still hope that the cholera may not reach the Southern States. Its general course has been north-westwardly; from Calcutta it reached the Russian Empire; from Constantinople it passed to Great Britain. Although it existed in Hungary and in Vienna, still Lombardy, Switzerland, and Italy, have escaped; and the same thing is applicable to France and Paris, in relation to Spain and Portugal. It has not even existed in cities of the South of France, and Quebec and Montreal are nearly in the latitude of Paris; besides, these two Canadian cities are remarkable as being the most filthy and ill-ventilated of America. If it has progressed in a north-westwardly direction, and if it has avoided a southern latitude in Europe, why may we not escape its dreadful ravages? Let us, however, be prepared to meet it, that if it ever does come, we may be ready to cure the distressed, to relieve the afflicted, and to lessen the sufferings of the dying victim.
Augusta, June 30th, 1832.