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Dr. Johnson's book, therefore, comes opportunely. It will lead us to ask ourselves whether we are prepared to do battle with this fearful disease; whether we have any fixed method of encountering it; whether the experience of former epidemics has taught us lessons which may help us now; whether (as heretofore) we are still to proceed in treatment by the rules of the barest empiricism; or whether theory has anything to offer us as a guide amidst so much darkness. He who has followed the dealings of our French and Italian brethren in the treatment of cholera during the past six months, and has read the suggestions of our countrymen on the subject, will, we think, agree with us that, in the all important matter of treatment, we are very much where we were when the disease first visited Europe. But more than this. If we have attained to no positive knowledge of a treatment of the disease, it would appear that neither are we able to decide whether our remedies are simply negative or actually injurious in their effects. Is it not indeed true that our present dealing with the cholera-our search for a remedy for it—is very much of the same kind as are the proceedings of a chemist who indiscriminately throws into his crucible any variety of substances which first come to hand, and hopes, therefore, by some happy accident to tumble on a great discovery? Let any one read the divers methodsthe in some cases opposing methods of cure adopted by estimable practitioners; let them reflect upon the thousands of different remedies, the infinite number of cures, boasted of by legitimate members of the profession; let any one conscientiously make himself master of what the abundant pages of medicine can tell him on this score, and we are sure he will agree with us, that our preparedness to meet another advent of cholera is not a thing to boast of. We are proud of being a practical people, not over given to theory; but we are sadly apt to forget that in the application of medicine to the cure of the disease, no one of the helps on which we rely is more likely to deceive us than the one on which we rest ourselves so lovingly and so firmly, the prop experience. We forget that the wise Father of Medicine taught how fallacious in medicine experience is experientia fallax; how difficult a right judgment of things; how easy to draw false conclusions, and to make the post stand for the propter. We are apt to laugh at theories in medicine; but we believe it would not be hard to show that the very greatest advances in the practice of medicine have arisen not from the lessons of mere empiricism, but have followed upon a change of theory. Buckle has a very remarkable observation on this point. He tells us:

"There is no well authenticated case on record of any theory having been abandoned because it produced dangerous results. As long as a

theory is believed, men will ascribe its evil comsequences to any cause except the right one............ Every practical change may, by careful analysis, be shown to depend in the first instance on some change of speculative opinions."

Every one who has read the history of medicine, must admit that there is at all events great truth in Buckle's remark which is quoted by Dr. Johnson; and, doubtless, as an illustration of his own exposition of the pathology of cholera.

Dr. Johnson comes before us with a new theory of cholera; and, if his theory be right, it follows that the generally accepted practice-what we might call the "orthodox " treatment of cholera-is founded on a completely erroneous basis, and is therefore itself completely wrong. Dr. Johnson has a right to be heard in this matter. No man more so; for he has long and carefully studied the question upon which he writes; and he is an accomplished observer; and has put his theory to the test of a large practical experience, and still finds it a good theory.

Dr. Johnson, first of all, clears the ground by proving the fallacy of the ordinarily accepted theory of cholera; viz., that the collapse attending it is the result of purging and vomiting. Loss of blood-serum (as it is argued) produces collapse. Arrest the flow of serum by opium, etc., and you will prevent the collapse. Now this Dr. Johnson utterly denies; and his statements require refutation at the hands of those who adopt the serum-arresting and astringent practice. If he be right, their practice is assuredly prejudicial to life.

He proves his case in this way. In the first place (he argues), there is no direct relation between the loss of fluids and the degree of collapse in cholera; rather do they stand in an inverse ratio to each other: for experience shows that the most rapid and fatal collapse is attended with little or no purging or vomiting. Then, again, the symptoms attending the collapse are not such as mere loss of the fluids of the body would produce: blueness of skin and other signs of obstructed breathing; absence of syncope; remaining muscular power; and remarkable rapidity of recovery, as if from suspended animation by drowning, are not the signs of loss of blood or of its equivalent. Neither is the influence of treatment such as we should expect of it, if the popular theory of collapse were true. Alcoholic stimulants, Dr. Johnson asserts, increase the symptoms of collapse. "They have been given," he says, " freely and boldly; and the result has been that, in the stage of collapse, they are not only useless, but positively injurious."

No doubt the striking temporary benefit produced by injections of hot water into the veins of cholera-patients has gone far to confirm the theory

that the collapse results from loss of water. But this explanation, Dr. Johnson says, is erroneous. The benefits attending the water-injections result from this-that the heat relaxes the spasm (above spoken of) of the small pulmonary arteries, and so allows a freer temporary circulation of blood through the lungs,; and confirmatory of this is the fact, that no such good effect is produced by merely tepid water injections. Thus, in truth, the results of this mode of treatment, which seem, at first glance, to upset Dr. Johnson's theory, are, in reality, confirmatory of it.

Again, the effects of venesection in the hands of those who have employed it in cholera, are exactly the reverse of what they should be if the popular theory were true. Instead of producing syncope, it strengthens the pulse, and removes the faintness and debility. The experience of the highest medical authorities in India attests this fact. As to purgatives, indisputable records show that recoveries from collapse have occurred when both purging and vomiting have been encouraged by emetics and 'purgatives. And on this point, Dr. Johnson throws out a challenge which requires an answer from those who oppose his theory:

"I defy you to shew me," he says, a single case of recovery from collapse, in which the intestinal discharges have not continued, in a greater or less degree, while the symptoms of collapse were passing off."

Now, if the popular theory and practice were correct, surely the very opposite of Dr. Johnson's assertion should be the case.

The issue is here clearly stated. If Dr. Johnson be right, the popular practice the astringent and alcoholic treatment of collapse of cholerais founded on a false theory, and is a deadly and destructive treatment.

But, if the collapse be not the consequence of loss of serum (as popular error teaches), what is its true cause? Now here, in the answer to this vital question-vital truly to the patient, because of its direct bearing on practice-comes the theory of Dr. Johnson. It is this. The best observers of the bodies of cholera patients who died during collapse have noted, as uniformly and constantly present, those appearances which indicate arrest of the pulmonary circulation, that is, arrest of the blood in the small branches of the pulmonary artery before it reaches the capillaries the left cavities of the heart empty; the right cavities and pulmonary artery distended; the minute tissue of the lung anæmic, pale, and dry.

Moreover, it is a fact, that the symptoms which we should naturally expect to represent such an abnormal condition of organs are the very symptoms which actually attend the collapse of cholera-viz., little or no pulse; the blood sometimes not even flowing from a cut artery; shrinking of the features; sinking of eyeballs; etc.

We may, therefore, start from this point, that the partial arrest of the blood in the lungs in the collapse of cholera is a demonstrated fact. That this arrest does not result from the thickening of the blood through the loss of its water, is proved by this, that the collapse is a sudden event; that it passes off whilst the loss of water is still going on; and that the worst cases of collapse are those in which there is neither purging nor vomiting-i. e., where there is but little loss of blood-serum.

But what then causes the arrest of pulmonary circulation? Dr. Johnson maintains that the cause is to be sought in the contraction of the muscular coats of the pulmonary arteries, induced by the irritative action of morbid matter in the blood. And he adds, that the thickened condition of the blood is the consequence, not the cause, of the arrest of the pulmonary circulation; and argues it out in the following way. The stream of blood through the lungs being greatly lessened, the supply of oxygen is also necessarily lessened, and in a corresponding degree. Hence, in the collapse of cholera, there is defective oxygenation of blood and tissues; and we note its obvious results in coldness and blueness of the surface of the body, diminished amount of expired carbonic acid, and almost (though never complete) suppression of bile and urine.

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To this last statement, touching the cause of the suppression of bile and urine, we would call special attention. We believe it is entirely Dr. Johnson's own; and certainly his explanation seems conclusive. argues Bile, urine, and carbonic acid are products of oxygenation; therefore, suppress oxygenation, and, pro tanto, you suppress the formation of these compounds. And he explains the fact which has been noticed, of the secretion of milk continuing in nursing mothers when suffering from cholera, by a simple chemical theory: that the constituents of milk-oil, sugar, caseine-require no oxygen for their formation.

The thickening of blood, therefore, is a consequence of defective aëration. It always occurs when respiration is impeded, as in pulmonary and cardiac diseases, and during the cold stage of ague. Dr. Dundas Thomson found the blood of a patient suffering from some affection of the bronchial mucous membrane thicker with excess of solids than any cholera-blood he had ever examined. Moreover, whenever reaction sets in, the blood becomes rapidly thinner; or, in other words, whenever the blood begins to flow freely through the lungs-i. e., when its due oxyge nation is re-established. And it is worthy of note, that this thinning of the blood under improved aëration will go on even though the diarrhoea may continue. Bile also then appears in the stools, as the result of the oxygenation of blood-constituents which have accumulated during the collapse.

Purging and vomiting, Dr. Johnson not unreasonably concludes, are the natural cure of cholera. They are efforts of nature to be rid of the blood-poison. The worst and most deadly cases of cholera collapse are those in which neither vomiting nor purging occurs. Nature attempts to throw off this poison through the intestinal mucous membrane, just as she attempts to throw off the poison of small pox by the skin. To interfere with the purging, therefore, is to interfere with the process of cure— to assist in retaining the poisonous element within the body, or within the digestive tube, and thereby probably to produce diarrhoea, excite fever, and increase the risk of collapse. Moreover, experience approves this view, by showing that the astringent practice is an injurious practice. Dr. Johnson affirms statistically that, under the astringent treatment, fewer patients recover from cholera than they do under that treatment which has for its object the elimination from the bowels of the poisonous secretions poured out into them.

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Now it is to the consideration of the value of the theory of Dr. Johnson of cholera collapse that we would call the attention of the profession, because we verily believe, with Mr. Buckle, that no failure in treatment will ever bring men to see the error of any treatment, so long as they have full belief in the theory on which that treatment is founded. Dr. Johnson proves the error of the "orthodox" theory of collapse; and he substitutes for it another theory, which, to say the least of it, has undoubtedly remarkable claims, upon scientific grounds, to the consideration of the profession. We may truly say this of it, that there is perhaps no instance is which the theory of a disease, founded on physiological and pathological facts, more strikingly explains the symptoms and dictates the course of treatment. We therefore think that the profession is greatly indebted to Dr. Johnson for thus enforcing upon their attention at this moment so vital a question. He offers us a pathological theory which suggests a truly scientific treatment of cholera. To oppose the excretory efforts, he asserts, is the same thing as applying cold to the burning skin of scarlatina. Recovery, on the contrary, is favoured by the use of means which facilitate the escape of the morbid secretions. Emetics, mild purgatives, and diluents are the means suggested by this theory, which knows nothing of specific cures or chemical antidotes. By this means Nature is aided in her efforts at cure; and we, at all events, if we do not cure the patient, do not impede his chance of cure. Dr. Johnson argues: The old heating method of treating small-pox, which compelled the patient to breathe an atmosphere charged with the poisonous exhalations from his own skin, was suggested by an erroneous theory. The treatment of epidemic diarrhoea and cholera by opiates and

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