ASIATIC CHOLERA, ITS ETIOLOGY and TREATMENT.* By Adolphus Green, M. D., of St. Louis Mo. Reprinted from the St. Louis Medical and Surgical Journal, April, 1885. Synonyms. Cholera Asiatica sive indica, s. orientalis, s. epi- demica; in contradistinction to cholera nostras, s. indigena, s. eholera morbus. History. Asiatic Cholera was, uptil 1830, entirely unknown in Europe. Its native home is in East India, especially at the mouth of the Ganges and Bramaputra. After some scattered minor epidemics in 1816, a powerful outbreak of epidemic chol- era took place in 1817, at the mouth of the former mentioned large rivers, which soon invited the attention of other countries on account of its evident tendency to spread. Pursuing its way along these rivers, which were at that time the principal if not the only means of commercial intercourse, it gradually extended over the whole peninsula, and towards the close of the year 1818 it had already wandered through all East India. But it did not stop here ; forward was its motto. After visiting first the islands of the Indo-Chinese Archipelago and causing great havoc there it turned to China, carrying horror and devastation. It then per- sued its way westward, and arrived about the year 1821 at the coast of the Persian Gulf. About the year 1823, it, for the first time, paid its visit to Europe and established a cholera epidemic in Astracan, at the mouth of the Wolga. Here it stopped with- out penetrating further into Europe, but it was only a kind of temporary rest, to appear again after sometime. In 1829 the Cholera again made its appearance upon Euro- pean soil, in Orenburg, and in 1830 in Astracan. From there, it *Kend before the St. Louis Medical Society, March 14th, 18S5. 2 spread with astonishing rapidity, up stream, along the river Wolga, and within two months arrived at Moskow, in Sept. 1830.. Its further march, to the other countries of Europe, could per- haps have been successfully checked, had it not been for the .Russian Polish War in 1831, which afforded very favorable op- portunities for the further propagation of the disease. In future cholera epidemics it was also very evident, that in time of war the best opportunities were offered for the spreading of this dis- ease. At present it is also war, the Franco-Chinese War, that imported it into France, and from there to other countries. In April 1831, the cholera was imported by the Russian Army into Poland, and in a short time afterwards, in May 1831, the epidemic cholera was already in Danzig, and in spite of the most stringent quarantine regulations, it was impossible to check the further spread of the devastating disease. In August 1831,. it reaped a rich harvest in Berlin, and in Sept, of the same year,, in Vienna, while at the same time it was brought from Persia to Constantinople. Cholera raged in England in 1831, in France in 1832, Spain in 1833, Sweden in 1834, Italy in 1836, Tyrol in 1836, Bavaria 1837. From England the disease was imported, in 1832 by emigrant ships, to America. From Persia, where the disease raged in 1846, it made a fresh start and visited Germany and from there was carried to the greater portion of Europe. In 1849, the cholera was imported to our country by the Swan- ton and the New York. When these vessels left Havre in the autumn of 1848-Oct. 31 and Nov. 9 respectively-not only was there no cholera at that port, but there had not been any in all France. It did, however, exist in middle Europe, whence came the migrants who embarked on board these vessels and was car- ried by them to the ports of New York and New Orleans respec- tively. Similar cases occurred in 1854 and in 1866. In the lat- ter year, the disease broke out on the steamer England five days and on the steamer Virginia eight days after leaving a healthy port. In 1873, three distinct outbreaks of the disease occurred at widely remote points in the United States by similar means. Thus it is quite evident, that the history of Asiatic Cholera is a history of the travels of a powerful enemy of mankind, or bet- ter, a history of transportation by land and by sea, a description of how we carried that awful scourge in ourselves, in our clothes, in our ships, to our country, to our relations, and to our families. 3 But what is that which we could bring from one place to another? Is it a material something ? Has it a bodily nature ? In the present light of science we can satisfactorily answer these questions. Etiology. Asiatic cholera is a specific infectious disease, and like other infectious diseases can only be produced by infection. The word infection, from inficio, to put into, to mix, to stain, to taint, conveys the thought of bringing the disease, or the cause of the disease into the human body. Hence by infection we mean, a morbid material producing a disease, imported into the human body from without. But infection in the sense of modern science, means something more than mere importation from without, it in- volves that essential signification, though not implied in the word itself, namely, the reproduction of the morbific material, the cause of the disease. This property of reproduction, involves the accep- tation of a bodily nature of the sicknessproducing material. Bodies endowed with the ability of reproduction, we call organized or organic bodies. Bodies capable of reproduction must possess life, hence they are a living contagion, a contagium vivum. These are low vegetable organisms, complexes of atoms, which are continually undergoing disintegration, but by taking up proper material for their nutrition, they repair the loss, and thus con- stantly retain their chemical composition as well as their form. The various vegetable poisons, as Aconite, Belladonna, Strychnia, etc, introduced into the animal economy, by one way or other, will call forth various morbid phenomena, according to their nature. But as these vegetable poisons do not possess that in- comprehensible something, that we call life, there is a great difference between them and those vegetable organisms, disease germs, that possess life. (1.) The most virulent poison, either of the vegetable or min- eral kingdom, will only then produce its noxious influences, when given in a certain quantity and in a certain state of concentration, a very minute quantity and largely diluted of any of these poi- sons introduced into the human body, would fail to produce any morbid symptoms whatever, and sooner or later would be entire- ly eliminated from the system. On the contrary, the least, hardly imaginable minute quantity, of that living infectious ma- terial, disease germs, once introduced into the animal body, susceptible of the specific disease, which that specific living germ 4 is capable of producing, will sooner or later call forth all the mor- bid phenomena belonging to that specific disease. (2.) Poisons, properly so-called, i. e. not possessing vitality, display theii' morbid actions as soon as they have entered the circulation of the blood ; whereas, those living disease germs, those micro-organisms, do not display immediately their morbid action, but a period elapses between the introduction of the mor- bific principal into the animal economy, and the invasion of the disease, which we call incubation, brooding, hatching, an appella- tion justifiable only in infectious diseases. The micro-organisms, the parasites producing the disease, need more or less time for their development and multiplication, before they can display their morbid actions, and the phenomena depending upon them. This period of comparatively good health, enjoyed by the person infected, between the introduction of the infectious principal and the acute display of the morbid phenomena, the period of Incuba- tion , varies in the different infectious diseases. For instance, in vaccinia from two or three days, in scarlatina from four to seven, measles from nine to eleven days, in typhus abdominalis from twelve to sixteen, in asiatic cholera it is variable, while in some -cases a few hours suffice for the infectious material to develope its morbid action, in others two weeks and even more may elapse, before the first phenomena of infection are displayed. In hy- drophobia, incubation can last until sixty days, and in some cases from eighteen to twenty-four months. This difference in the period of incubation, even in one and the same disease, depends partly upon the quantity of micro-organisms introduced into the system, and partly upon the susceptibility of the person infected. (3.) In poisons there is no such thing as perfect immunity with some, and strong susceptibility with others. Aconite, atro- pia and strychnia, for instance, will injuriously effect any one, with the only difference in the quantity of the poison necessary for the one or the other. Whereas, in some of the infectious dis- eases, there is such a thing as perfect immunity and high suscep- tibility. There are some children who will not contract scarlet fever, even by the strongest exposure to the contagion, others again will do so by the least exposure. Some people, though not many, will not be infected by small pox and can not be success- fully vaccinated. Some will not get the cholera even if they be evei' so much exposed. This immunity and susceptibility depends upon the composition of the fluids of the body. The different 5 parasites require different elements of nutrition necessary for their development and multiplication. In the one human body there is an abundance of that unknown material, and that body is therefore very highly susceptible; in another there is very little or none at all of that unknown material, the necessary nutrition for a certain specific germ, and such a person possesses comparative or entire immunity from a certain specific disease. This explains why some infectious diseases, as measles, scarlet fever, variola and whooping cough, etc., as a rule (of course with some exceptions) affect a person only once in a lifetime, or in other words are self protecting diseases, because those germs have taken up that certain unknown material from that person once infected, and the body of such a person offers no more a favorable soil for the development and multiplication of that specific vegetable parasite. Such a person remains from thence perfectly and entirely insusceptible to that particular specific dis- ease for the remainder of his life. But, should such a person, either by some kind of diet or by some means or other which science has not as yet discovered, regain that certain unknown material, from that time his immu- nity ceases, and he is more or less susceptible to that certain specific infectious disease. But no matter how strongly suscep- tible a certain person may be to a certain specific infectious disease, even if he should be as susceptible of a certain infection as dry gun powder is of exploding by the least spark of fire, nevertheless he will never become infected, unless his organism comes in close contact with that infectious material, as the dry gun powder, when properly preserved, will never explode unless coming in contact with that spark of fire. Thus, a child, however susceptible of scarlet fever, measles, variola or whooping cough, would never become affected with one of these diseases unless the specific germ, the cause of one of these diseases, be intro- duced into its animal economy. A person, however feeble he may be, however affected be may be. with chronic bronchitis, or however suffering from poverty or privation, will not become tuberculous, unless the specific germ producing tuberculosis be, by some means or other, introduced into his animal economy. He may die from general debility, from chronic bronchitis, or as a result of poverty and privation, but he will never die of con- sumption or tuberculosis if tubercle bacilli have never been in- troduced into his system. Asiatic cholera would never make 6 its appearance here, unless the cholera germ, the cholera bacillus^ be imported here irom some other place. But, on the other hand, in an epidemic of cholera, though a person would not die from asiatic cholera, as a result of drinking impure water, so long as this water be not impregnated with the cholera germ, or as a result of uncleanliness, so long as the cholera germ has not been transplanted into this unclean locality and established there a fruitful centre of infection, or as a result of a slight catarrh of the stomach and bowels, so long as the cholera germ has not been introduced into his alimentary canal; nevertheless, as it is true that a feeble person with a diminished degree of resistance,, that one affected with bronchial catarrh, or one suffering from want and privation, may contract tuberculosis even on a slight exposure to the causes of the disease; that is, either by coming in contact with a consumptive person, or by some other means getting only a very small dose of contagion, which under other circumstances the normal power of resistance of the healthy or- ganism could easily withstand. So it is likewise true, that one whose alimentary canal has been irritated by the use of impure water or by the emanation of filth and uncleanness, or has become vulnerable by the catarrh of his stomach and bowels, will con- tract a most severe attack of asiatic cholera even by only a very small dose of the cholera poison, which, under opposite circum- stances, would not have affected him at all. (4.) Common poison not possessing vitality, if introduced into the animal economy in a quantity sufficient to produce its morbific effects, can not reproduce itself. Other animals, in close contact with it, will not become affected by it. If you give a dog the one-sixth of a grain of strychnia, which is sufficient to kill him, and while the dog is yet alive and the poison is equally diffused in his blood, you introduce a drop of his blood into the cellular tissue of a healthy dog, the latter will not become affec- ted, because the quantity of strychnia contained in that drop of blood is not sufficient to produce an effect. Still less would there be any if you introduce several drops of blood from that second into the third dog. But if you introduce a minute, hardly visible, quantity of vaccine lymph, from the vaccine vesicle of one child into the skin of another child, susceptible of vaccina, you will produce another vesicle, from which you can success- fully vaccinate ten other children, and from each of these ten children, ten again, and so on, literally without an end, so long as 7 you have enough individuals susceptible of vaccina, you could vaccinate thousands of thousands from the first minute, hardly visible quantity of lymph. If you should bring a child sick with scat let fever into a healthy locality, and allow other children to have free communication with it, you would produce an epidemic of scarlatina in that locality from that single child. Import one case of asiatic cholera into a locality free from it, without taking any precautionary measures to prevent its further spread, you will, under circumstances favorable for the spread of that disease,, that is for the development and multiplication of the cholera germ,, as a certain degree of heat, moisture, impure water, filthy locality,, etc, have an epidemic of asiatic cholera from that single cholera case. Again, if you take a grain of corn, wheat or any other seed,, and deprive it, by one process or an other, of its vitality, of its la- tent life, and place it under the most favorable circumstances for growth, as a rich soil, moisture, sunlight, etc., that seed would not grow, but decompose. The same is the case with that vegetable pa- rasite, in order to infect, i. e. to reproduce itself and multiply in an animal body susceptible of that specific infection, that parasite must possess vitality. Hence, by disinfectants, which presupposes infection, we mean such agents as are capable of depriving the disease germ of its vitality. Then, and only then, that germ ceases to be infectious. This points to a very plain and easy method of preventing the extension of any epidemic, which is a very important part of treatment. But before we can speak of the effective means for the prevention of its extension, we must first consider the manner of its infection ; how and when it be- comes contagious. It is very important to know that there are contagious materials, disease germs, which obtain their develop- ment, i. e. become ripe for activity, only inside the animal organ- ism, and others which acquire this development outside of the animal body. The former, Pettenkoffer designates as endogenous, the lat- ter as exogenous contagious materials. There are, however, certain conditions necessary for the exogenous germs to undergo,, in order to become effective. These are the life conditions of the germ. What these conditions are we do not know. In the one case these conditions are found in the ground, in another' in the air, in a third in, or upon, a vegetable or animal organism, even in the chamber, upon the linen of the patient or upon the floor of the sick room. The cholera germ, or cholera bacillus, as the- 8 celebrated Dr. Koch calls it, belongs to the latter class, to the exorgenous ones. When cholera bacilli have been introduced into the alimentary canal of a person susceptible to this disease, this person experiences a longer or shorter period of incubation, according to his lesser or greater susceptibility and the quantity of the poison received. During this period of incubation, these germs multiply and reproduce themselves in the alimentary canal. The period of incubation once ovex* and the morbid phenomena displayed, each and every diarrhoeal discharge of the cholera patient, contains a new crop of pestilential poison, which has only to undergo certain conditions necessary to its development and maturity in ordei* to become ripe for contagion. The period nec- essary for the development of the germ, outside of the human body, varies from a few hours to several days, according to the stage of the germ at the time when discharged from the human body. These discharges containing a new crop of cholera bacilli, are, immediately after having left the alimentary canal, entirely devoid of any contagious properties whatever. Hence the body of the sick person cannot infect others, either by contact or by his expiratory movements. Cholera, therefore, is not contagious in the same sense as small pox, scarlatina or measles. A healthy person, even if he be susceptible of cholera, might sit a whole day at the bedside of a cholera patient, and not become infected. Nevertheless cholera is contagious in another way. As the germs may find those conditions necessary for their development upon the human body, upon the linen or upon the floor of the sick room, when even a minute portion of his discharges have been deposited either by accident, neglect or helplessness of the patient, then the nurse who touches with her hands that part of the body of the patient upon which may have adhered even a very min- ute portion of his discharges, the- woman who washes the linen soiled with them, or persons visiting the sickroom and inhaling the germs liberated from the dried up and pulverized portion of his discharges left upon the flooi' of the sickroom and floating fn its atmosphere, would become more or less infected, according as they are more or less susceptible to this disease. Conse- quently, the effective means to prevent the extension of cholera within a certain locality are self suggesting. The source and fountain of infection as well as of the propagation of asiatic chol- era, namely, the discharges of the cholera patient, ought to be thoroughly and effectually mixed with a powerful disinfectant. 9 as a solution of carbolic acid, from 5 per cent, to 10 per cent., or one part of bichloride of mercury to one or two thousands parts of water. I, for good reasons, prefer the former. The nurse should wash her hands in a solution of 5 per cent, carbolic acid after touching the soiled part of the patients body, and each time before handling any food. The linen of the patient should first be immersed in a strong solution of carbolic acid before washing them, and the flooi* of the sickroom should be sprinkled over with the same strong disinfectant. These remarks apply as well to those that have only a slight and seemingly insignifi- cant diarrhoea, which may or may not be incipient cholera, as well as to those that lay prostrated from a malignant attack of the same disease. Treatment. There are a good many remedies recommended in this disease, of which opium ranks foremost, for instance, opi- um and camphor; opium, campor and ipecac ; opium, camphor and acetate of lead; and opium and calomel, etc. We can not deny that opium judiciously applied, judiciously as regards the stage of the disease and the quantity of the drug, is a power- ful agent for doing good, namely before collapse has set in, or even before a tendency to collapse shows itself, for then it would undoubtedly do harm and hasten the fatal issue. Even when there should not be any tendency to collapse displayed, but we see that opium does no good, that in spite of its liberal use, with or without other remedies, it does not arrest the inordinate dis- charges, we must be careful not to push it too far, else it might accumulate in the body and display at once its injurious effects. Other remedies, as subnitrate of bismuth, tannic acid, liquor ferri sesquichlorati and other astringents, strychnia, etc. are likewise recommended. The so-called Russian drops : Tr. Valerian Aether 3ij. Vin. Ipecac 3j. Tr. Opii Crocat 9j. 01. Menth. Pip gtt v. M. Sig. Twenty to seventy-five drops every one or two hours. Calomel is also recommended and does some times very good service, especially when opium is contraindicated. Prof. Le- bert recommended one-third of a grain of argent, nitras. com- bined with one-sixth of a grain of opium, made into a pill, and of such pills, one or two or even three may be given several times a day, according to the extent and frequency of the choleraic discharges. He, as well as other writers upon this subject, ack- 10 nowledge that these remedies may do good, only when ad- ministered at the beginning of the disease, or at least before a state of collapse is setting in. Although, sometimes the most desperate case gets well, yet, atother times the above mentioned remedies, even judiciously applied and at the beginning of the disease, will have no effect whatever. And this does not take place where the disease is ushered in by storm, where violent vomiting and purging alternate in quick succession, where there are severe muscular cramps, burning sensation in the epigastric region, unquenchable desire for cold drinks, that are quickly thrown up again, hardly perceptable radial pulse, skin turning -cold, hurried and oppressed breathing, and a rapid progressing exhaustion, but even sometimes in cases where the disease is in- sinuating itself, by a seemingly insignificant choleraic diarrhoea, and is gradually progressing to that fearful state of collapse which our well directed and judiciously applied remedies ought to prevent. This ought not to appear strange, when we consider that the above mentioned remedies, good and efficacious as they are in many cases, can not remove the cause of the disease, i. e. they can not deprive the cholera germ of its vitality. Hence it is self suggesting, that if we could find a remedy capable of kill- ing that living parasite in the alimentary canal, which is the cause of all the mischief, without at the same time injuring our patient we would have the remedy. Dr. Herman Eichhorst, Prof, of practice of medicine in Goet- tingen writes : a Starting from the idea, that in cholera we have to deal with Schistomycetes (cleftfungi) antiparasitic remedies might be tried. In an epidemic, in Koenigsburg in 1871, where I acted under the directions of Leyden, extensive use was made of the internal application of carbolic acid. It was given in a one percent, solution, in combination with spiritus aetheris nitrosi and aquamenth. pip. I must sincerely acknowledge that the thorough employment of this treatment could not show any spe- cial favorable result. To-day (he writes this in 1880) we might, perhaps, for good reasons, employ salicylic acid or salicylate of sodse, especially as these two drugs, under certain circumstances, possess costive properties. Benzoate of sodse might also be tried. The difficulty in the employment of such and the like remedies, consists that by the continuous vomiting and unrestrainable looseness of the bowels, the medicines cannot be absorbed from the intestinal canal. Perhaps it were not irrational to introduce 11 these remedies by means of some funnel arrangement, through the anus into the intestine." The same author when speaking of narcotics, says: "But a few years ago, they recommended in Russia, as a specific in cholera, the subcutaneous injection of hydrate of chloral, according to my observations there is nothing to hope from it." Allow me to make a few remarks upon the above statements of Dr. Eichhorst. (1.) We can not expect any result from one per cent, solutions of carbolic acid. For, aside from the fact that a one per cent. solution of carbolic acid is a very weak germicide, and after hav- ing been introduced into the stomach and mixed with the fluids there, ready for expulsion by the act of vomiting, it becomes more diluted; even this weak germicide, cannot be employed in sufficient quantity, for fear it might accumulate and poison the system, having in this disease more or less suppression of urine, and we cannot therefore expect it to be eliminated by the kid- neys. (2.) Salicylic acid and salicylate of sodae, besides being very unpalatable and therefore quickly thrown up, are dangerous on account of their depressing action upon the heart. (3.) Benzoate, does not possess a depressing but rather a strengthening influence upon the hearts action, and might, there- fore, be tried, though it is not palatable and is not a general germicide and, therefore, unreliable. (4.) The use of chloral hydrat in subcutaneous injections I consider irrational, from the difficult circulation of a cholera patient we cannot expect much of hypodermic injections, it might do good, given internally in small doses, not as a narcotic but as an antiparasitic. After several trials and experiments, 1 feel happy in being able to present to the Profession, what I think to be an efficient and comparatively harmless remedy in -cholera. This remedy is characterized by its antiparasitic, anti- fermentative, antiseptic, antiemetic and anodyne properties, and last but not least by its very pleasant odor. Benzol 4 per cent., Carbolic acid 1 per cent., Chloral Hydrat 2 per cent., Oleum Carui 1 per cent. H Benzol 3ij. Mucil.. Gum arab Sued liquirit. clep. aa gj. Addes Carbolic Acid 3ss. Chloral Hydrat 3j- 01. Carui 3ss. Aq. dest §iv. M. Sig. Well shaken up. One tablespoonful every one or two hours. 12 Of these drugs only benzol will need perhaps a little expla- nation. It is a hydro carbon, containing six atoms of carbon and six atoms of hydrogen, it is a colorless oleaginous liquid, posses- sing an agreeable odor, very inflamable, and as it is not soluble in water it must be prescribed with mucilage of gum arabic. Its antiparasitic properties (animal parasites) being very great, it has been given with success in trichinosis. Dr. Naunyn has es- tablished its antifermentativo properties as well. A few drops arrested formentation in a one per cent, solution of grape sugar, to which has been added yeast plant. By reason of the above named experiments, benzol has been given by Nau- nyn and others for abnormal fermentative processes in the stomach with the best results. In cases where, in spite of a long medication with creosot assisted by a diet free from starch and sugar, no improvement could be obtained, the gastric symptoms, namely: vomiting, pain in the epigastric region with loss of ap- petite, disappeared after a few doses of benzol, i. e. twenty drops two times a day. Experiments of Drs. Snow, Simpson and Nun- nely prove, that it possesses anaesthetic properties also. For this reason it has been recommended for inhalation in whooping cough. This mixture is by no means incompatable, but they rather assist one another in their germicide properties. Of course, a few drops of tinct. opii may be added if necessary and if cir- cumstances require it, the carbolic acid or the chloral may be left out. 2605 Wash Street.