CHAPTER III.. Section I.--Unsuccessful Modes of Treatment--Venous Transfusion

SECTION I.--UNSUCCESSFUL MODES OF TREATMENT--VENOUS TRANSFUSION EXPLAINED.

In this discussion we shall avail ourselves of the researches and investigations of eminent Professors, whose observations, experience, and position give their views the highest authority. The latest and most deserving record on this subject is from the pen of Professor Aiken, of Edinburgh, who observes, "There are few diseases for the cure of which so many different remedies and modes of treatment have been employed as in Cholera, and, unfortunately, without our discovering an antidote to the poison. In Moscow it is said that the mortality was not greater among the destitute of medical aid than among those who had every care and attention shown them. It may be fairly inferred, therefore, that in the severer forms of the disease, the action of this poison is so potent as to render the constitution insensible to the influence of our most powerful remedial agents. When, however, the disease is mild, or on the decline, much may be done by obviating symptoms to promote the recovery of the patient."

"The heroic remedies that have been employed in Cholera are bleeding, and calomel and opium, either separately or conjointly. With respect to bleeding, it may be stated, that in every country the patients bore bleeding badly in any stage, and that the practice in Europe was at length limited to a few leeches occasionally to the head. As to calomel, that medicine was used to the greater part of an ounce in the twenty-four hours, but with so little success that many patients have been seized and have died under the full influence of mercury. On the appearance of cholera in Europe, opium was administered in the doses recommended by the Indian practitioners to the greater part even of an ounce of laudanum; but it was soon seen that in the cold stage it was inefficient in controlling the vomiting or purging; that it did not allay the spasms, and, moreover, hardly produced any narcotic effect. The action of the accumulated doses of opium, however, though suspended during the cold stage, was often fully developed in the last stage, and occasioned so much affection of the head that most practitioners either abandoned its use or limited it to a mere fractional dose of that usually given in India, namely, from three to twelve minims of the tincture of opium, or half a grain to a grain of solid opium every four or six hours."

Let us now turn to a paper by the justly celebrated Professor Maclean, whose observations and experiences have been more extensive than perhaps those of any other professional gentleman either in Europe or America. Unlike many of his brethren, he holds on this subject the safer doctrines of practice, and very frankly and earnestly expresses the same in the following language: "Opium in cholera should be given only in the premonitory diarrhoea. At this stage, in combination with a stimulant, it is of the highest value. If persevered in, particularly in the strong doses (justly reprobated), it is a dangerous remedy, inducing fatal narcotism, or, at the least, interfering with the functions of the kidneys, and so leading directly to uræmic poisoning."

"Urgent thirst is one of the most distressing symptoms in cholera; there is incessant craving for cold water, doubtless instinctive, to correct the inspissated condition of the blood, due to the rapid escape of the liquor sanguinis. It was formerly the practice to withhold water--a practice as cruel as it is mischievous. Water in abundance, pure and cold, should be given to the patient, and he should be encouraged to drink it, even should a large portion of it be rejected by the stomach; and when the purging has ceased, some may, with much advantage, be thrown into the bowel from time to time.

In the stage of reaction, the fever may be moderated by cold sponging, or by the wet sheet; the secretion of urine may be promoted by dry cupping over the loins by the use of chlorate of potash, and the like. But suppression of this secretion is most to be dreaded where opium has been too freely used in the treatment. In men of intemperate habits, we often see, during the stage of reaction, obstinate vomiting of thick, tenacious, green, paint-looking matter, probably bile pigment, acted on by some acid in the stomach or alimentary canal. It is a symptom of evil omen, and often goes on uncontrolled until the patient dies exhausted, and this although all other symptoms may promise a favorable issue. I have known it last for a week, resisting all remedies, and proving fatal when the urinary secretion had been restored and all cerebral symptoms had subsided. Alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses offer the best hope of relief. The patient should be nourished more by the bowel than the stomach when vomiting is present. Ice should be not only to dissolve in the mouth, but to swallow in pieces of convenient size."

"Another heroic plan," says Dr. Aiken, "peculiar, perhaps, to this country, which was practiced when the inefficiency of medicines was generally admitted, was an injection of a solution of half an ounce of muriate of soda, and four scruples of sesquicarbonate of soda in ten pints of water, of a temperature varying from 105 to 120 Fah., into the veins of the suffering patient. The solution was injected slowly; half an hour being spent in the gradual introduction of the ten pints, and the immediate effects of this treatment were very striking. The good effects were rapid in proportion to the heat of the solution, but a higher temperature than what is stated could not be borne. After the introduction of a few ounces, the pulse, which had ceased to be felt at the wrist, became perceptible, and the heat of the body returned. By the time three or four pints had been injected the pulse was good, the cramps had ceased, the body, that could not be heated, had become warm, and instead of cold exudation on the surface, there was a general moisture; the voice, before hoarse and almost extinct, was now natural, the hollowness of the eye, the shrunken state of the features, the leaden hue of the face and body had disappeared, the expression had become animated, the mind cheerful, the restlessness and uneasy feelings had vanished, the vertigo and noises of the ear, the sense of oppression at the precordia had given way to comfortable feelings; the thirst, however urgent before the operation, was assuaged, and the secretion of urine restored, though by no means constantly so. But these promising appearances were not lasting; the vomiting continued, the evacuations became more profuse, and the patient soon relapsed into his former state, from which he might again be aroused by a repetition of the injections; but the amendment was transient, and the fatal period not long deferred. Of 156 patients thus treated at Drummond Street Hospital, Edinburgh, under the direction of Dr. Macintosh, only 25 recovered; a lamentably small proportion; and, small as it is, it seems doubtful if the recoveries were final or complete."

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But let us turn to another page, whose beauty is especially marred by unreasonable expedients: "The warm bath," says the writer, "was at first tried, but discontinued from the uncontrollable nature of the vomiting and purging, and the oppressive sensation of heat it produced on the patient's feelings. Mr. Dalton's vapor bath and Turkish baths in the Hospital at Scutari have been used, but without benefit, and to the disappointment of the hopes which had been entertained of them."

"Other methods of restoring warmth were had recourse to, such as frictions with the hand or by the flesh-brush, or rubbing the body with some strong stimulant embrocation, compounded of garlic, capsicum, camphor, cantharides, or other powerful irritants. Mustard poultices also were often applied to the feet and abdomen, blisters with or without an addition of oil of turpentine, the part having been previously rubbed with hot sand; and in cases supposed to be urgent, the mineral acids, and even boiling water, were employed for the purpose of producing instant vesication."

"And, again, we read of those who tried to stimulate the waning powers of life by galvanism, acupuncture of the heart, issues, setons, moxas, actual cautery along the spine, and, lastly, by small pieces of linen dipped in alcohol distributed over the body and then set fire to!!!" Such are some of the means which have been used in the treatment and cure of cholera.

"The failure of such powerful means at length caused most practitioners to confine themselves to checking the diarrhoea, which so frequently precedes cholera, and subsequently, to obviating symptoms as they arose," and for this purpose, returned to and adopted a very simple stimulating mixture, recommended by the Board of Health:

Rx. Pulveris Aromat., dram iij. Tinc. Catechu, " x. Tinc. Cardamom, C., " vj. Tinc. Opii, " j. Mixt. Cretæ Preparat., ounce xx. M.----S., j ounce, as necessary.

Tinc. Kino, or the decoctum Hæmatoxyli, were sometimes added.

These remedies, it is said, frequently arrested the attack altogether. If, however, the disease proceeded and the cold stage of cholera formed, the same remedies were prescribed in an effervescing draught. "To promote reaction in cholera and diarrhoea, the following formula has met with most universal approval in this country and in India. So highly is it valued, indeed, that it is ordered to be always in store, and in readiness in the Medical Field Companion of the army when on the march:

Rx. Ol. Anisi, } Ol. Cajeput, } [=a][=a]. dram ss. Ol. Juniper, } Æther, ounce ss. Liquor Acid. Haleri,[I.] dram ss. Tinc. Cinnam., ounce ij.

M.----S.: ten drops every fifteen minutes, in a table-spoonful of water. An opiate may be given with the first and second dose, but should not be continued."

The learned author to whom we have referred, after detailing some of the various expedients employed in the treatment and cure of cholera, sums up the whole under the common term--failure--and, in effect, declares the most powerful remedial agents ineffective and useless in controlling and subduing this disease.

This declaration is made in reference to the general result of the remedies and the various expedients adopted mainly by one class of physicians, to which special reference has been made. It is therefore partial, and confined solely to what is erroneously termed the regular practice. In declaring all remedial agents a failure, does not the author himself commit a greater failure in omitting to survey the whole subject of treatment, and to trace out and to show from the application of the pathology of the disease the probable cause of such failure?

However formidable this disease may appear, on account of its rapidity and its firm, unyielding grasp upon the vital powers, the forbidding and almost hopeless prospect of relief, and the lamentable results which have attended some modes of treatment, it seems particularly unfortunate for the profession that there should have been a disposition on the part of this learned author to abandon all remedial agents as comparatively useless, without a more thorough investigation into the cause of failure. On this point no effort or inquiry even is made. This is the more remarkable and surprising after dwelling at length on the pathology of the disease. It would seem as if all the light and science derived from this source for nearly half a century had been overlooked, or the pathology of the disease, from some cause not satisfactorily explained, had been deemed unworthy at least in this instance to dictate the course of treatment. This should govern in cases of cholera as in all other forms of disease, or else all our efforts and remedies will prove abortive. Now, had the doctor carefully investigated the various modes of treatment and compared the results of each, he might have come to a different conclusion. But, being confined and limited in his investigations, he is unable to discover anything reliable or worthy his commendation, except the formulas above and the recommendation of Dr. Maclean. Among all the remedies and expedients named, there is only one tending to fulfil, the indications required, and that one, though prompt and magical in its effects, has been unequivocally condemned, without looking beyond the transient result for any light it might shed upon the subject. How it should have escaped his notice and passed so long unobserved by the numerous professional gentlemen who had often witnessed the effect, and were anxiously searching for light and the means of affording relief to the suffering patient, is a most singular circumstance which can only be accounted for on the principle that they all were anticipating some strange phenomenon, or development of cure as mysterious as the disease itself, which led them to overlook the simple and effective means of relief so clearly represented and shown in their numerous experiments for something more heroic and powerful than as yet the imagination ever conceived.

If we trace the action of calomel, the use of opium, the effect of cupping, bleeding, blistering, etc., etc., we shall obtain no very desirable information; nothing valuable tending to indicate a correct principle of practice. If we go still further, and examine the tendency and effects of the various baths exhibited at Scutari, the use of the flesh-brush, the bare hand, the heated sand, the embrocations, the turpentine and other irritants, the boiling water, or the burning alcohol, skinning and cooking the patient alive, we shall be shocked at the enormous cruelty and barbarity that have been pursued, and turn from the repulsive exhibition, without discovering one ray of light to guide us in the right direction. Disappointed and baffled in our inquiries, shall we here abandon our investigations and dismiss the whole subject, because our course is involved in difficulties? Would intelligence and reason justify the neglect to improve the means at command? We think not; but rather induce us to advance in search of truth if the elements of success are not quite exhausted. Let us be encouraged and stimulated to untiring perseverance so long as there remains any experiment untraced and uninvestigated in its bearing upon the direct action of the disease. Had Dr. Aiken, or those other eminent surgeons who took part in those numberless experiments, instituted on the Continent and in England, especially those who initiated the process of injecting into the veins a solution of soda raised to a temperature from 105° to 120° Fahr., continued their investigations patiently and assiduously, they might probably have discovered long ago the correct theory of practice for the treatment and cure of cholera.

But they failed to see, or, if they saw at all, rejected the feeble ray of light struck out by the experiments in which they had themselves participated, and like the celebrated Dr. Hunter, who refused to listen to the discoveries made by his pupil, the indefatigable Jenner, who traced the identity of the variola with the common disease affecting the kine; and thence extracted the vaccine lymph and established a principle by which that loathsome disease and often recurring epidemic has been nearly banished from the earth. Though they have thus failed, they have nevertheless left on record, in unmistakable language, the result of their bold experiments, which we may investigate, and appropriate the instruction drawn thence for our own and the advantage of our fellow-men.

What, then, are these results, regarded as shedding light on this intricate subject? We refer only to one the most obvious which we have already cited above. Let us repeat and analyze, and, if practicable, show the principle evolved. There was, on various occasions, the solution of soda injected into the veins at the temperature from 105° to 120° Fahr.: a higher temperature could not be borne. This process was performed slowly, thirty minutes being occupied in injecting the ten pints. Now mark the result as the operation proceeds. Says Dr. Aiken, "After the introduction of a few ounces, the pulse, which had ceased to be felt at the wrist, became perceptible, and the heat of the body returned." Mark the language: "only a few ounces" were required to arrest for the time being, the progress of the disease and restore warmth to the body; a very remarkable fact, replete with instruction, as will appear as we proceed. Again says the Dr., "by the time three or four pints had been injected the pulse was good, the cramps had ceased, the body, that could not be heated, had become warm, and instead of cold exudation on the surface, there was a general moisture. The voice, before hoarse and almost extinct, was now natural; the hollowness of the eye, the shrunken state of the features, the leaden hue of the face and body had disappeared; the expression had become animated, the mind cheerful, the restlessness and uneasy feelings had vanished; the vertigo and noises of the ear, the sense of oppression at the precordia, had given way to comfortable feelings; the thirst, however urgent before the operation, was assuaged, and the secretion of urine restored, though by no means constantly so." Such is the astonishing result obtained by this experiment, and this, too, when only three or four ounces had been injected--all the urgent symptoms mitigated and relieved. What, we ask, could have been more satisfactory, or better calculated to aid the discovery of an important truth? Every distinctive and fatal symptom for the time is relieved, and the normal condition and functions of the system restored; a result which could only have been obtained by the evolution of a principle of sufficient promptness and power and diffusibility to arrest and utterly suspend for a time the force of this disease.

What, then, was the principle evolved in this experiment, which gave immediate relief? Did it consist in the half ounce of muriate of soda alone, or in the four scruples of sesquicarbonate of soda alone, or in the ten pints of water alone, or in the whole combined, or more especially in the high temperature to which the solution was raised? It is a well-established fact that, in order to raise the temperature of cold water to blood heat and above, a large amount of free caloric must necessarily be absorbed, and exist mechanically in the fluid; and, in this condition, the solution was introduced into the veins, and there evolved its vast amount of free caloric, which immediately permeated every organ of the system, arresting disease, raising the temperature of the body, and restoring its normal functions. Of this there can be little doubt. For free caloric is one of the most prompt, effective and diffusive stimulants known, and was evidently in this case the remedial agent which produced the result. True, it may be said the effect was transitory, and passed off as soon as the caloric became eliminated. This, however, cannot alter the nature, character, or influence of the principle on which it was produced. It is usually admitted that a remedy that has power to control disease, will, by its continued action and influence, restore the normal condition of the system permanently, or at least aid Nature to repair her own work. By this we would not be understood as advising a repetition of the experiment under consideration, even under the most urgent circumstances; far otherwise would be our advice. We are arguing for the purpose of evolving and establishing a general principle of practice.

The great question, then, is, Did the principle evolved fulfill the indications required? and if so, is it available and consistent with the pathology and the peculiar phenomena, or symptoms of the disease? To settle this point, we need only turn to the law and the testimony, the very highest authority on the subject. The doctrine now universally accepted and prevailing regarding its pathology is, that a poison, virulent, and subtle, and unknown, has been absorbed and infects the blood, so that, after a longer or shorter time, a primary disease of this vital fluid is produced, by which the vital energy is impaired, and all other morbific changes induced. The term "Algide," first used by the French Pathologists, very accurately describes one of the most remarkable and constant symptoms, viz., the diminution of animal heat. On this depend the altered condition of the blood, the depression of the nervous power, the impaired functions of the respiratory and all the vital organs which are essentially involved by the disease. The icy coldness of the surface, the breath, the extremities and general loss of temperature, all show the character of the disease and the wants of the system.

Did, then, the principle evolved accord with the pathology and phenomena of disease? And did it fulfill the indications required? If not, we ask by what means was the disease arrested, and all the urgent symptoms mitigated and relieved, or by what were the good effects produced, and the normal action for a time restored? Can the result be reasonably accounted for on any other principle than the one assigned--the stimulating power of the free caloric? We think not; for it accords most perfectly with the pathology and the peculiar phenomena of the disease. It assuaged the more urgent symptoms, answered the imperious demand of the waning powers, revivified and reinvigorated the vital energies, and restored for the time the normal tone of the system. What more could be desired in any single agent than the result here obtained? That it accomplished all this, there can be no question, according to the statement of the learned professors who have repeatedly witnessed and described the results.

The question, however, will arise, Can this principle be rendered available? Most certainly it can; and though it may not be convenient to introduce free caloric into the stomach, we can, by combination, introduce a stimulant of equal potency which shall be equally as prompt, effective and diffusive in its action, similar in its influence, and similar in its results. It is the principle--not the precise element for which we contend.

It is universally admitted that in many instances we may learn much from observing the manner of death which, in a majority of these cases of cholera, may be described by the term asthenia--a death similar to that which occurs in congestive fevers, and in some cases of accidental poisoning. Perhaps the most striking fact observed in these cases is the perfect exhaustion attending the last moments of existence, and the quiet, undisturbed manner in which life terminates. This very clearly shows the exhausting nature and congestive character of the disease, and gives us an idea of the course of treatment necessary to be pursued. If, then, there is anything to be learned from this source relative to its treatment, it does most certainly corroborate and strengthen the position we have here taken.

Another feature of the case in aid of our position consists in its entire accordance with the modes of treatment which have been most successful in the cure of cholera. The two formulas cited above, and now most universally adopted in Europe and India, are based on a similar principle. So in this country 1832,-33 and 34, the successful modes of treatment consisted in the adoption of a principle essentially similar. Hence we infer from the teachings of this experiment, and from all the collateral facts on the subject, that the general principle to be observed in the treatment of this disease is a prompt and diffusive stimulant; and hence we deduce the doctrine already apparent, that every form of treatment, to be successful, must be based on a prompt and effective stimulant of sufficient power to meet as speedily the indications required, as did the free caloric in the experiment to which we have referred.

Here we might pause for a moment and examine the suggestion and doctrines advanced by the learned Drs. Bell, Johnson, and many other eminent practitioners in India and Europe. We might further investigate the principles and trace the practical philosophy of such eminent surgeons, as Drs. Mackintosh, Thompson, Wallis Maxwell, Massy, Hill and Brady, all of whom have had opportunity of investigating the nature and character of the disease and extensive experience in its treatment.

We might also, in a further examination of the subject, embrace a host of American authors whose works teem with every shade of doctrine, and almost every variety and description of practice, some evincing a degree of skepticism on the subject more wonderful and marvelous than is becoming the great apostles of medicine. It would seem as if the guiding light of science and experience had forsaken them in this, the hour of their need; that facts and arguments had failed to illumine their minds, or direct their inquiries in the proper course for the discovery of "the truth." Their conclusions on this subject are, therefore, marvelously inconsistent and conflicting. Over this mass of specious and conflicting testimony we might long ponder, without deriving any very valuable information worthy an elaborate effort, or making any discovery to aid in the establishment of a general principle of practice for the cure of cholera. But this investigation must be deferred to another occasion, when time may permit a more thorough and critical examination of their doctrines and practice than can be presented in this brief essay. We would, however, remark in passing, that in some instances their philosophy, doctrines, and results may lead us to the same conclusion to which we have arrived from other sources as above, and from our regard and belief in the progress of science, feel compelled to advocate the same, as offering the best hope of success in the treatment of this disease.

In the employment of an anti-miasmatic principle and remedial agent, we feel ourselves abundantly sustained, by the concurrent testimony, of those English surgeons connected with the Medical Bureau in the department of India, whose numerous experiments and carefully detailed clinic cases occurring in the recent irruption and prevalence of the disease in that section, exhibit its utility in such a striking contrast with all former practice, as to leave no doubt as to its direct and specific action in the cure of cholera. It is in allusion to these experiments, and in answer to the question, what is deemed the most successful mode of treatment, that the learned Professor Maclean unhesitatingly observes, "Alkalies in the effervescing form, free stimulation of the surface, and chloroform in small doses, offer the best hope of relief." As this opinion comes from such high authority, and is compatible with the pathology of the disease, we may, without fear of controversy, add in conclusion, in any and every form of medication for the cure of cholera, we must not forget that chloroform is our sheet-anchor; and must be so combined and administered as to meet promptly the indications required.