BRIEF SUGGESTIONS AS TO THE PREVENTION, 
RECOGNITION, AND TREATMENT OF 
CHOLERA. 
BY 
ROLAND G. CURTIN, 
OF PHILADELPHIA. 
FROM 
THE MEDICAL NEWS, 
September io 1892. [Reprinted from THE MEDICAL News, September io, 1892.] 
BRIEF SUGGESTIONS AS TO THE PREVENTION, 
RECOGNITION, AND TREATMENT OF 
CHOLERA. 
By ROLAND G. CURTIN, 
OF PHILADELPHIA. 
In view of the probable visitation of the Asiatic 
scourge, it may not be amiss, at this time, to call 
attention to some of the more practical features of 
the disease. 
First, as to prophylaxis. The prevention is better 
than the cure. After the germ has obtained a foot- 
hold, what is the proper course to pursue to guard 
again-t the disease ? 
The first important step is to keep the body and 
its surroundings perfectly clean. The body should 
be frequently bathed and the clothing changed. 
See that all cellars are free from contaminating sub- 
stances, and all privies and gutters properly disin- 
fected. Avoid crowding, as this favors the propa- 
gation of the disease. Eat moderately of good, 
nutritious food (don't 'starve yourself). Avoid 
fatigue, exposure, intemperance, and all excesses or 
anything that has a tendency to depress the vital 
energies. Take a full amount of sleep at regular 
intervals. Regularity and temperance in all things 
are of the utmost importance. 
All drinking-water and milk should be boiled- 2 
this being especially important in Philadelphia, 
owing to the danger of the water being contami- 
nated in its passage through the Schuylkill valley 
above the city. Avoidance of all saline laxatives 
is a safe rule during an epidemic. 
I will quote from an article of mine entitled 
"Sulphuric Acid as a Prophylactic in Cholera," 
published in the Philadelphia Medical Times, July 
12, 1873: 
During this last visitation (1866-67) I was resident- 
physician in the Insane Department of the Philadelphia 
Hospital. The disease had almost entirely disappeared 
from the city and from all parts of the Philadelphia Alms- 
house and Hospital, except from the women's wards in 
the insane department, where it still continued in a very 
virulent form. Strange to say, it was almost entirely con- 
fined to three of the seven wards on the female side of 
the hospital. It was so persistent that the Board of 
Health paid the hospital an official visit, but were unable 
to account for the presence of the disease in particular 
wards. It is true that the women's apartments were very 
much crowded, there being three hundred and fifty in- 
mates, but the wards in which it was so prevalent had 
proportionately fewer inmates than others which almost 
entirely escaped. During the whole epidemic only two 
cases occured in the male wards, while among the 
females one in every nine was attacked. Sex would not 
account for this difference, for statistics at large show that 
male and female lunatics are equally liable to the disease. 
After having concluded to use sulphuric acid, the next 
thing was to administer it to all the patients, many 
of whom were so suspicious that they refused at all 
times to take medicine, for fear of being poisoned. 
Knowing that it would be impossible to conceal it in 
their-food or usual drinks, I concluded to administer it 
disguised as lemonade, and announced through the 
nurses to the patients that I intended to " treat " the 
whole institution to lemonade every day, which an- 
nouncement was well received in general, and by some 3 
of them with enthusiasm. The drink was made in this 
way. About twenty drops of the dilute sulphuric acid 
were mixed with four ounces of water and sweetened 
with white sugar. Some oil of lemon and a few cut 
lemons greatly assisted in the disguise. What followed 
the administration of the sulphuric acid can best be 
shown by the notes taken at the time. The diary was 
begun on August 20, 1866, before which time seventeen 
cases had occurred in the insane department. 
August 20.-Four new cases. 
August 21.-Four new cases. 
August 22.-Four new cases. 
August 23.-Two new cases. Board of Health visited 
the hospital. 
August 24.-Five new cases. 
August 25.-One new case. Acid given for the first 
time, in the afternoon. 
August 26.-Four new cases during the early morning 
hours within twelve hours after the first administration 
of the acid. 
August 27.-No new cases. 
August 28.-One new case-a woman who refused to 
take the acid. 
August 29.-No new cases. 
August 30.-No new cases. 
August 31.-No new cases. The acid was discon- 
tinued. 
September 1.-No new cases. 
September 2.-Two new cases-two days after the 
suspension of the acid. 
September 3 -No new cases. Acid resumed. 
The acid was continued for some time, and no more 
cases occurred. 
It will be seen by the above diary that up to the time 
of administering sulphuric acid the disease was pursuing 
a steady course in the female department. It is true, 
and should be here stated, that every means had been 
tried to banish the disease, such as ventilating and 
cleansing the wards, spreading disinfectants, scattering 
the patients by using a large sewing-room for a sleeping 
ward, attention to diet, etc., but without apparent effect. 
The acid was first given on the 25th of August and con- 
tinued until the 31st. Four cases occurred within twelve 4 
hours of the time when the acid was first given. After 
this only one case occurred while the acid was being 
used, viz., on the 28th. This was a poor ignorant (?) 
lunatic, who, upon tasting it, spit it out, and surprised 
me very much by saying, with great vehemence, '' Doc- 
ther, ye call this limonade ; but ye can't desave me ; it's 
nothing but ile of vitriol." On the 31st of August it will 
be seen that the " lemonade" was stopped, on account 
of the exhaustion of the supply of white sugar in the 
drug store, as without this sugar it would have been im- 
possible to prepare the acid in such a manner as to insure 
the patients' taking it. On the 2d of September, two 
days after the suspension of the use of the acid, two new 
cases occurred, both of which proved fatal. The pro- 
phylactic was then resumed, and no new cases after- 
wards occurred in the insane department; but cases 
continued to arrive from the city until the 1st of No- 
vember. The use of the acid was continued uninter- 
ruptedly for several weeks. My friend Dr. J. F. Wilson 
gave it to the patients in the surgical wards during the 
epidemic, and he informs me that cholera visited every 
department of the almshouse and hospital except the 
surgical wards. 
The question naturally arises, was it the sulphuric acid 
that arrested the march of the disease ? I think it was, 
for the following reasons : 
1. The prompt disappearance of the disease within 
twelve hours of the time when the acid was first admin- 
istered, the only case arising during its use being that of 
a patient who refused to receive it. The acid was stopped 
on the 31st of August, and two days after this two cases 
occurred. The acid was then immediately resumed, and 
not a single case occurred afterwards. 
2. The fatality attending the disease. When an epi- 
demic declines from natural causes, it generally becomes 
less fatal. Of the four patients attacked on the 26th of 
August, three died, of whom one was a young, robust 
epileptic, who lived but five hours after the first symp- 
toms ; another was a strong lunatic, who succumbed in 
nine hours. The two cases which occurred on the 2d of 
September, after the suspension of the use of the acid, 
bothdied, thus showing that the type was none the less 
fatal. 5 
How did the sulphuric acid act ? According to Dr. G. 
B. Wood, it has the following effect upon the system, 
viz., tonic, astringent, refrigerant, and diuretic. It has 
been largely used in the treatment of the first and second 
stages of cholera. Dr. Macnamara, in his work on 
Asiatic Cholera, recommends the use of dilute sulphuric 
acid, in doses of fifteen minims, in the second stage. 
The celebrated " Austrian Specific " was composed of 
sulphuric and nitric acids. Nitric acid had been used in 
India in the treatment of cholera with considerable suc- 
cess. It was tried in England and found to be of no 
avail, when further investigation proved that the nitric 
acid of India contained a considerable amount of sul- 
phuric acid. The latter was an accidental product of 
the manufacture of the nitric acid in India. Hence the 
use of the combination of these two acids in the treat- 
ment of cholera. Elixir Hallerii, or liquor acidi Hallerii, 
has been much used in India, and is ordered as part of 
the medical stores of the British army there. It consists 
of sulphuric acid and alcohol. Drs. Buxton, Sansom, 
and Fuller, of England, used sulphuric acid with suc- 
cess in the first stages of cholera, especially in the 
choleraic diarrhea. From the above statements it 
would appear that sulphuric acid itself has some effect 
upon the disease, and now we will proceed to discuss its 
influence as a prophylactic. 
It had been noticed that workers in copper were re- 
markably exempt from cholera, and upon investigation 
it was found that the air surrounding them was consid- 
erably charged with sulphuric acid, which gave rise to 
the supposition that this was the active preventive agent. 
This led to the use of sulphuric acid in cholera districts 
and hospitals, but with what results I have not been able 
to learn. 
It has already been stated that sulphuric acid miyact 
beneficially independent of any specific action upon the 
cholera germ. 
I have said that it is a tonic, astringent, refrigerant, 
and diuretic. The vital energies are often very much 
reduced, digestion is poor, and the intestines and the 
system at large are in a relaxed condition, the result of 
the high temperature of summer. Here we find the 
condition favorable to an attack of cholera. The tonic, 
* 6 
astringent, and refrigerant effects of the sulphuric acid 
would all be eminently indicated by the conditions, and 
its administration might tide the patient over the period 
of danger. It may also act beneficially in another w ly. 
We all know the depressing effect of fear, which un- 
doubtedly predisposes to cholera. A prophylactic given 
in such cases would allay the fear and thus ward off the 
disease. 
It would seem that the article is of more import- 
ance since the comparatively recent discovery of the 
comma-bacillus, which cannot live in an acid me- 
dium. May this fact not account for the efficacy of 
sulphuric acid as a prophylactic ? The germ is, 
perhaps, destroyed in the alimentary canal before 
the products of its activity are taken up by the 
system. The remedy is in any case well worth a 
trial; for, if it should only allay the fears of the 
timid, the otherwise resulting depression might be 
avoided. 
Diagnosis and Treatment. It is most important 
to recognize the disease in its earlier stages; for at 
this period simple treatment is usually attended with 
success. Later on, in the cold stage, or in that of 
collapse, about 50 per cent, die, even under the 
most skilful management of the physician and nurse. 
What are the first symptoms of cholera ? The first 
stage is the forming stage or stage of invasion, some- 
times called cholerine, or the diarrheal stage. The 
intestines are in an irritable condition. The dis- 
charges are at first yellow and fetid ; later on be- 
coming whitish or grayish, and being composed of 
serum and epithelium. Fibrinous flakes are some- 
times present and the stools are blood-stained. 
This is the stage of invasion. It may come on 7 
abruptly, or gradually. Death may, in some rare 
cases, take place without vomiting or diarrhea. I 
had an opportunity of observing two such cases at 
the Philadelphia Hospital in 1866. At the autopsy 
the stomach and intestines were found filled with 
the so-called "rice-water" material, which usually 
constitutes the discharge in cholera. 
Sometimes the first stage is abruptly ushered in 
with restlessness, wakefulness, noises in the ears, 
languor, depression, headache, muscular weakness, 
and a weak, small pulse. 
In the cases of insidious onset the earliest symptom 
is a mild diarrhea. The stools are at first yellow, 
afterward watery, copious, and frequent, with 
abdominal pain, slight tympany, borborygmi and 
nausea. The extremities, especially the lower, 
become painfully cramped. 
This stage may last several days, or only for a 
short time, and may escape observation altogether. 
Prompt measures at this stage may stay the disease; 
hence the importance of recognizing the earliest 
symptoms. 
Thoughtless persons and children are usually the 
ones that allow this stage to pass by without atten- 
tion. Such persons should be carefully watched by 
those having charge of them. 
During an epidemic, any tendency to looseness of 
the bowels, even if seemingly innocent, should be 
promptly attended to by sending the patient to 
bed, and carefully regulating his diet. Chilling 
draughts should be avoided, and under no circum- 
stances should patients be allowed to rise-a bed- 8 
pan being used when the bladder or bowels are to 
be evacuated: 
The prognosis is especially grave when the attack 
is ushered in abruptly, with great irritability of the 
stomach and bowels, profuse depression, with pain- 
ful cramps in the muscles of the legsand abdominal 
walls. 
Dr. A. Herman1 states that the detection of al- 
bumin, cylinders, and epithelium in the urine 
during the time of the precursory diarrhea is a sure 
sign that the case is one of cholera; otherwise the 
diarrhea is of other origin. The discovery of the 
comma-bacillus in the dejt ctions will afford positive 
proof. 
The treatment for this stage is usually as follows : 
If the case is tardy in onset, simple remedies are 
usually efficacious, together with the directions al- 
ready given as to rest and nursing. A combination of 
general and local stimulants, local sedatives, astrin- 
gents, and stomachics has proved of benefit in the 
majority of cases. 
A formula that has heretofore been much used 
and extolled is the so-called Asiatic tincture: 
R.-Chloroformi f^j. 
Camphorae 3ij. 
Ft. sol. et adde 
Sp. aetheris. co f^ij. 
Tr. opii 
Tr. capsici 
01. caryophylli 
. aa f^ss.-M. 
S.-From five to fifty drops in water. 
' Allgem. Wien. med. Zeitschr., 1873. 9 
The following combination has been recom- 
mended by Dr. E. R. Squibb : 
R.-Tr. opii 
Tr. camphorae 
Tr. capsici 
. . aa f^j. 
Chloroformi (purified) . . . f^iij. 
Alcoholis (strong) . . q. s. ad f^i.-M. 
S.-A teaspoonful in water. 
Dr. Alfred Stille recommended for the precur- 
sory diarrhea a formula containing tincture of 
catechu, chalk mixture, and a small quantity of 
laudanum. Chlorodyne has been much used in this 
stage of the disease. Small doses of brandy with 
lime-water, frequently repeated, or, better, plain 
soda-water, sometimes control the vomiting. In 
this stage opium, with calomel or blue pill, has been 
recommended by many writers, to stimulate the 
biliary secretions. For local application, mustard 
plaster or mustard and chloroform sometimes allay 
the abdominal pains. 
The second, or cold stage, or that of collapse. In 
this stage the patient is in great danger. The most 
prominent symptom is the constant discharge of 
sero-epithelial material from the stomach and bowels. 
This fluid is of a grayish or whitish color, serous, 
intermixed with fibrinous flakes, and is usually 
passed without effort, being sometimes ejected from 
the bowels and stomach simultaneously. In some 
cases there is a persistent hiccough and painful 
cramps in the muscles of the legs, arms, fingers and 
toes, and abdominal walls. The cramps are often 
attended with contraction of the extremities. The 
patient is weak, stupid, heavy; the eyes are dark 10 
and sunken; the conjunctivae are dull, dry, and 
covered with a film; the tongue is dry and covered 
with a light, pasty film, and the nose is sharp and 
pinched. 
The breath is icy cold, the respiration shallow, 
while the voice is husky and whispering. The skin 
is cold, blue, shrivelled, and bathed in a cold, 
clammy sweat. The extremities first become cold, 
and afterward the trunk. The urine is scanty or 
suppressed. The blood is deprived of its water, 
thereby becoming greatly decreased in bulk and 
thickened, so that the poor, weak heart cannot 
propel it to supply the thirsty and famished tissues. 
The patient grows weaker and passes into a state of 
unconsciousness, and death ensues. Treatment at 
this stage is usually followed by little apparent 
benefit. 
The skin and mucous membranes are pouring out 
the fluid from the blood and tissues, so that they are 
in no condition to absorb medicines brought in con- 
tact with them. Medicines injected subcutaneously 
are scarcely absorbed, for osmosis is reversed. 
Intravenous and rectal injection of saline fluids has 
been used with varying results. The bowel would 
not be likely to absorb and the fluid would prob- 
ably be rejected. The object of the saline injections 
is to make good the loss caused by the general leak- 
age from the body. Transfusion of milk has been 
tried to the same end. 
Dr. David B. Smith has proposed the injection 
into the veins of amyl nitrite, to overcome arterial 
muscular spasm. He injected into the veins of a 11 
patient two drams in thirty-five minutes without 
appreciable benefit. 
A physician in India has recently published his 
experience with corrosive sublimate, which he em- 
ployed in doses of grain. 
Artificial heat and cutaneous stimulants have been 
used over and over again, with but little effect. If 
the patient survives the second stage, reaction slowly 
takes place. The treatment of the second stage is 
eminently unsatisfactory. The ability of the patient 
to tide over the crisis seems of more importance 
than the administration of medicaments. 
The third stage, or stage of reaction, or stage oj 
secondary fever. The conditions demanding treat- 
ment are extreme prostration, fever, and an alimen- 
tary canal deprived of its epithelium. The secretory 
activity of the kidneys is greatly impaired. The 
condition is decidedly typhoid. The plan of treat- 
ment will be expectant. One important point to 
be borne in mind is that the stomach and bowels 
will tolerate but little nourishment, for even after 
the patient has been convalescing for days a slight 
error in diet may induce a relapse. 
I append a list of the medicines that have been 
employed in the treatment of cholera- 
Mercury-Calomel, blue pill, and corrosive sub- 
limate in small and frequently repeated doses. The 
first two are often combined with opium. These 
are given for the purpose of quieting the stomach 
and stimulating the natural secretions. 
Tincture of camphor-Used as a systemic as well 
as a local sedative. 12 
Tincture of capsicum-A stomachic and stimu- 
lant to the gastro-intestinal canal. 
Opium-Tincture and deodorized tincture as 
local and general sedatives. To be given in small 
doses. Morphine has been used hypodermatically. 
Chloroform-Both as a stimulant and sedative, to 
allay gastric irritability. 
Sulphuric Acid-A tonic, refrigerant, and astrin- 
gent to the gastro-intestinal mucous membrane (and 
a germicide). 
Nitric Acid has been employed by itself and in 
the form of Hope's mixture, a combination with 
tincture of opium and camphor-water. 
Creasote-As an antiseptic, as well as to allay irri- 
tability of the gastro-intestinal mucous membrane. 
Brandy is the favorite alcoholic remedy, used 
early in small doses, in combination with lime-water 
or plain soda-w^ater. Champagne has been largely 
used to allay gastric irritability. 
Turpentine has been administered as a stimulant. 
Atropine acts as a stimulant to the respiratory and 
cardiac centers and diminishes secretion. 
Amyl Nitrite has been tried in the hope that 
it would dilate the arterioles and subdue muscular 
spasm. 
Arsenic has been extensively used to check the 
vomiting, small doses being used. 
Phosphorus, copper salts, lead salts, strychnine, 
have also been administered. 
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