Since the etiological study of patho logical bacteria with their ptomaines and toxins has come to engross the at tention of the profession, and especially since the discovery of the epidemic cholera bacillus by Koch, many writers have suggested that cholera morbus also depended for its essential cause on a specific bacillus or its toxins. But no such organism has as yet been identified as the essential cause.
Pathology.—The essential pathological conditions involved in cases of uncom plicated cholera morbus are a morbidly sensitive condition of the mucous mem brane of the alimentary canal, a general impairment of the tonicity of tissues with deficient oxygenation of the blood, and so decided an impairment of the vasomotor nervous influence over the vessels of the mucous membranes of the stomach and intestines as to allow copi ous exudation of the serous elements of the blood. The exudation constituting the cholera discharges results from these conditions and has no necessary connec tion with any grade of inflammation, catarrhal or otherwise. This is proved by the fact that, in the most rapidly fatal cases, post-mortem examinations re vealed no ordinary- traces of inflamma tion in the mucous membranes. It is only in the cases that run a more pro tracted course in which febrile reaction occurs, followed by more or less mucous discharges, that we find appearances of ordinary catarrhal inflammation.
Prognosis. — Cholera morbus, as it occurs in adults and in children over five years of age, runs a brief course and gen erally ends in recovery. Only a small percentage of such cases terminate fatally. It is very different, however, when the disease attacks infants or chil dren under three years of age. Only a small percentage of this mortality re sults from the violence of the first stage and direct collapse. :,1.1uch the larger part results from the occurrence of re action and the establishment of a per sistent grade enteritis and progressive exhaustion and emaciation.
Treatment.—In the beginning of at tacks of active cholera morbus the lead ing objects to be gained by treatment are to allay the morbid sensitiveness of the mucous membrane of the alimentary canal; to restore the general tonicity of the tissues and of the vasomotor nervous system; to promote the natural secre tions, especially of the liver and kidney-s; and to properly regulate the diet, drinks, and general sanitary surroundings of the patient. In the treatment of all this class of patients it is of the greatest im portance to secure for them a constant supply of fresh, pure air. The most complete ventilation possible and rigid cleanliness should be enforced day and night. To accomplish this is often a very difficult task among all the classes of people who occupy small or over crowded lodging-rooms on the narrower and less-cleanly streets of our large cities. But a firm insistance upon keep ing whatever doors and windows there are freely open during hot summer nights as well as during the day, and the prompt removal of all gastric and in testinal discharges from the room, will accomplish much in this direction. To overcome the morbid sensitiveness of the mucous membrane, restore the tonic ity of the nervous and vascular systems, and increase natural secretions, we need the combined or coincident use of ano dynes, antiseptics, and tonics. ln the
early- stage of active vomiting and diar rhoea the following formula has been used with the most satisfactory results:— Carbolic acid, 71/2 grains. Glycerin, 5 drachms.
Camphorated tincture of opium, 2 ounces.
Cinnamon-water, 21/2 ounces.-3/1.
To an adult one teaspoonful of this mixture is to be given immediately after each paroxysm of vomiting until the paroxysms cease to recur. Vomiting is never a continuous process, and if a dose of medicine is given as soon as possible after a paroxysm a few minutes will elapse before the patient can vomit, and thus some impression of the medicine is obtained. But if we follow the inclina tion of the patients and nurses and wait for the patient to "rest a little" and the stomach to become "settled," we simply allow time enongh for the stomach to regain ability to vomit with another supply of serous exudation, and now the dose of medicine is likely to be ejected as soon as swallowed. The teaspoonful of the mixture may be given in half a tablespoonful of water; and in treating young children the dose should be ap portioned to the age of the child. In addition to the above, small doses of calomel may be given every half-hour or hour until the discharges become less watery and show some indications of the presence of bile. Sinapisms of mustard may be applied over the epigastrium and to the back over the spine, but should be allowed to remain only long enough to redden the skin without vesicating it.
As soon as vomiting has ceased and the intestinal discharges show evidence of hepatic secretion, it is generally only necessary to continue the formula recom mended every two, three, or four hours until the diarrhoea also has ceased and the patient is inclined to sleep. In many cases no further use of the preparation is required, rest and a judicious regula tion of the diet for a few days being ficient to restore the patient to health.
Sometimes, however, the patient's mouth remains dry, the pulse more fre quent than natural, the palms of the hands and the surface of the abdomen warmer than natural, the urine scanty, and several diarrhceal discharges each day accompanied by pain and restless ness. In such cases a continuance of the carbolic-acid formula, already given, with a few drops of nitrous ether added to each dose, and giving, for nourish ment only, a thin gruel or porridge made of good milk and wheat-flour, or pure milk with a little fresh lime-water added, will often insure recovery.
A very great variety of other reme dies have been used with more or less benefit, nearly all of them, however, combining anodyne, antiseptic, and astringent or tonic properties with strict regulations of diet. The use of potas sium bromide in the cholera morbus of infants has recently been strongly rec ommended by M. L. Brown. Prepara tions of bismuth, generally given with small doses of codeine or other anodyne, have long been used with benefit in the protracted cases. In treating cases, espe cially in young children, much care should be exercised in giving opiates and astringents, lest they add to the tardiness of the kidneys in secreting urine, and thereby increase the danger of coma or convulsions. (See CHOLERA. INFANTIIM and INFANTILE DIARRIREA..)