Every disease in which exhaustion and coldness occur is sure to be treated more or less actively with alcohol, but in the collapse of cholera, as in the cold stage of fevers, it is generally useless, and sometimes hurtful. We believe that the following protest of Macnamara is sustained by almost universal experience: "I would here enter an earnest protest against the use of brandy or any alcoholic stimulant in this [the second] stage of cholera. I believe these, both theoretically and practically, to be the cause of unmitigated evil. I simply, therefore, mention brandy, champagne, and the like in order to condemn their use most emphatically in cholera; according to my ideas and experience, it is almost impossible to hit on a more detrimental plan of treatment than that usually known as 'the stimulant' in this form of disease."67 It is true that apparent dissidents from this judgment may be found, like Playfair, a deputy inspector of hospitals in Bengal, who even circulated printed directions for the treatment of the first stage of the disease by means of brandy or strong rum, cayenne pepper, and laudanum, and had entire confidence in the efficacy of the method.68 Dr. Macpherson, inspector-general of hospitals, also, after comparing the results of a stimulant treatment with those of other methods, reaches the conclusion that the mortality-rate of cholera is affected neither by the moderate nor by the excessive use of alcohol.69
67 Op. cit., p. 456.
68 Edinburgh Med. Jour., xix. 471.
69 Med. Times and Gaz., Jan., 1870, p. 62.
Upon no other point in the treatment of cholera is the agreement of physicians more complete than upon the use of opiates in the early stage of the disease. The premonitory diarrhoea has always been treated by opiates alone or associated with astringents. Probably the best rule is to give from twenty to thirty drops of laudanum, or an equivalent dose of some other liquid preparation of opium, in a little brandy and water, and repeat the dose as often as a stool is voided. Opiates have also been generally employed to mitigate the symptoms of the fully-developed disease. But, like all other medicines introduced into the stomach or rectum, they are apt to be rejected, and even if they are not, their absorption is very doubtful, so that at the height of the attack they must be considered as nearly if not quite useless. When the vomiting and purging begin to subside and reaction is about to commence, small and repeated doses of opiates undoubtedly tend to lessen the evacuations; but great caution must be observed not to exceed the due degree of stimulation, lest a dangerous state of narcotism or collapse be induced. It might be supposed that the hypodermic use of morphia would be less open to objection than its administration by the stomach; but it is to be remembered that the suspension of gastric absorption is only a part of the similar condition affecting the whole circulatory system, and that the stagnation of the blood in the systemic veins prevents the absorption of medicines administered subcutaneously perhaps as completely as the state of the gastric blood-vessels interferes with their absorption from the stomach itself. In point of fact, the utility of opiates at any stage of cholera after the first is not easily determined, for nearly always they are associated with other medicines, and especially with astringents. In this disease, as in others that involve life, we are seldom at liberty to test the powers of individual medicines, but are bound to endeavor to save life by associating those which seem to be required for the purpose. Opiates, then, are nearly always given in conjunction with astringents or stimulants during the first (or diarrhoeal) stage of the attack, but after vomiting is added to diarrhoea and a tendency to collapse is manifested they are at least useless.
The patient, it has already been said, should be disturbed as little as possible, and hence, if he becomes restless, and especially if he is rendered so by pain, he should be tranquilized by means of anæsthetics. Chloroform has generally been employed, and is best administered on the first accession of cramps. Much pain, with muscular fatigue and depression, is thus saved, and the inhalation of the medicine may be repeated as often as the pain threatens to return. No doubt other anæsthetics, and especially ether, would answer the same purpose.
Camphor has been claimed to be a valuable medicine in cholera, but there is no clinical evidence that it is so. Indeed, the only series of cases in which it was mainly depended upon gave a large mortality.
Acids have been employed in cholera, but chiefly on theoretical grounds, "in the hope of destroying the specific cholera process going on in the intestinal canal" (Macnamara). It is hardly necessary to discuss so vague a reason. What specific process is going on? What relation to it has the administration of acids? And, after all, only the hope is held out of destroying the hypothetical morbid process. The reaction of normal stools is usually acid, but sometimes it is neutral or even alkaline. In other acute bowel complaints with profuse diarrhoea they are acid, as in cholera infantum, but in epidemic cholera they are alkaline, because they consist chiefly of the water of the blood. It is far from proven that mineral acids can be useful merely by reversing the reaction of the stools. Far more probable is it that, in so far as they are of use, it is because they act as astringents upon the digestive mucous membrane. This may be inferred from the fact that, according to the advocates of these medicines, it is always difficult, and is often impossible, to acidify the stools in cholera. Moreover, it must be remembered that, like other medicines, the greater part of them are rejected by vomiting. If, then, mineral acids tend to lessen the diarrhoea of cholera, they act by their astringency and not by their acidity. Diluted or aromatic sulphuric acid may be given in the dose of from two to thirty minims, at intervals of an hour, in acid water or carbonated water, or diluted nitric acid, in doses of from twenty to fifty minims, at the same or somewhat longer intervals.
Intravenous injections were used in England during the first epidemic of cholera in 1832-33, but their results were regarded as unfavorable; subsequently, in 1849, they were tried with somewhat better success, and in 1867 the effects were still more encouraging. The liquid employed on the last-mentioned trial consisted of chloride of sodium 60 gr., chloride of potassium 6 gr., phosphate of sodium 3 gr., carbonate of sodium 20 gr., alcohol 2 drachms, and distilled water 20 ounces. The alcohol was added only when the liquid was about to be used, and the temperature of the latter was not allowed to exceed 110° F. or fall below 100° F. The liquid was contained in a zinc vessel holding about eighty ounces, with a lamp underneath, a thermometer hanging within, and a tap near the bottom, from which proceeded an india-rubber tube four feet long, with a silver nozzle at its end. The fluid was allowed to enter the vein by the force of gravity. If difficulty was experienced in introducing the nozzle, the vein was freely exposed, supported on a probe, and incised longitudinally. It was found that the success of the operation depended greatly upon having an ample supply of the solution prepared, so as to repeat the injection as often as might be found necessary. Mr. Little, who practised this method in numerous cases, stated as follows: "When a patient has been long pulseless clots form in the heart, and, as I have seen, extend into the larger veins. In one case the fluid would not flow in, and only distended the veins of the arm injected. After death clots were found extending from the heart into the axillary vein."70 Five out of twenty apparently hopeless cases recovered under this treatment. The first effect of the injection was to revive the pulse, which had ceased to be felt; the voice also was restored, the color and expression improved, the cramps were relieved, the temperature rose, and the patients became convinced that their recovery was assured. A profuse perspiration and a severe rigor accompanied these symptoms. The rigor was evidently a nervous phenomenon, and not a chill, for it occurred when the temperature was rising. Other cases might be cited which unquestionably owed their recovery to this mode of treatment. It is true, however, that much more frequently it failed of success; and probably not only because the injection could not reach the heart, but because, having permeated the blood-vessels of the whole body, it escaped, as the serum of the blood had done, from the damaged intestine. Nevertheless, it would seem that an expedient which in a certain proportion of cases has been quite successful might yet be rendered more certain in its results if the operative procedure were perfected.
70 London Hosp. Reports, iii. 470.