4 lEx ICthrts SEYMOUR DURST When you leave, please leave this hook Because it has heen said " Ever'thing comes t' him who waits Except a loaned hook." Avery Architectural and Fine Arts Library Gift of Seymour B. Dlrst Old York Library Digitized by the Internet Archive in 2013 http://archive.org/details/lettersoncholeraOOpain THE CHOLERA ASPHYXIA OF NEW-YORK. \v VS-- ■ . LETTERS OX THE CHOLERA ASPHYXIA, AS IT HAS APPEARED IN THE CITY OF NEW-YORK : ADDRESSED TO JOHN C. WARREN, M. D., OF BOSTON, AND ORIGINALLY PUBLISHED IN THAT CITY. TOGETHER WITH OTHER LETTERS, NOT BEFORE PUBLISHED. BY MARTYN PAINE, M. D. PUBLISHED BY COLLINS & HANNAY. Clayton Van Norden, Printers. 1832. ExTERED according to the Act of Congress, in the year one thousand eight hundred and thirty-two, by Collins &, Hanxay, in the Clerk's Office of the District Court of the United States, for the Southern District of New- York. TO THE READER. When I addressed the first of the following Letters to the distinguished gentleman with whom I prepared for my profession, 1 was influenced principally by the de- sire, so natural and common to pupils, to repay by every means in their power, and if possible, however slightly, in kind, the unlimited debt which they owe to their in- structors. The early appearance of the Cholera in New- York, a disease before unknown in our country, afford- ed an opportunity for the humblest among us, to com- municate information which might be interesting, and perhaps useful, to the most skilful and learned and eminent in other cities. And I could not but appre- hend, that this inscrutable and relentless stranger would, in his arbitrary and fearful progress, visit Boston, where I have many friendships and near attachments. The lit- tle therefore that I could, by diligent observation, learn of the Cholera, I was irresistibly impelled to communicate to one to whom all in that city look for professional aid vi or instruction. But I had not the most distant expecta- tion, that my letters would meet the public eye, nor would my own judgment have led to their publication. I will not, however, deny the gratification I felt, at learn- ing that their publication had been deemed useful by one, whose approbation I have ever wished to deserve. The first four letters appeared originally in the Boston Daily Advertiser and Patriot, and in the Boston Weekly Messenger and Massachusetts Journal, and it was not until after they had been published in those papers, that the idea was suggested to me of offering them to the public in their present form. As soon as I had adopted this suggestion, I thought it would be better to reserve the remainder of the letters, until the whole should be published together, and the fifth and sixth letters are ac- cordingly now for the first time presented to the public. I am sensible that these letters can possess no other value than such as they derive from my means of ob- servation, and the diligence with which they have been improved. I ought, therefore, to say, that from the first appearance of the disease in this city I have sought it at all times and in all places, and indeed much more con- stantly than was consistent with my health, and ordinary engagements. In connexion with two medical friends, I made, on the second of July, a minute post mortem examination of two of the first who fell victims to the vii disease, and which were the two first dissections made in the United States. These examinations are fully described in the seventh letter, which was originally published in the New-England Medical and Surgical Journal. Since then, besides my own private practice, I have daily visited as many of the hospitals as my en- gagements would admit of, and have made and witness- ed numerous dissections. To have described these va- rious post mortem examinations would have been an un- necessary repetition of similar appearances. I have thought it worth while to preserve only such cases as would exhibit the several varieties of symptoms which have passed under my observation. These will be found in the eighth, ninth and tenth letters, which have also been published in the Medical Journal. One of these also announces the important discovery by Dr. Gale, a" scientific chemist of this city, of oil existing in a free state in the blood of Cholera subjects. The letters, except those describing the dissections, are printed in the order in which they were written. The parts of the subject of which they treat cannot, there- fore, be expected to be formally or methodically ar- ranged. Each letter was however designed to embrace a single topic. The first presents a general view of the disease ; the second relates to the nature and treatment of premonitory symptoms ; the third to the importance viii of attention to food, as a means of prevention ; the fourth to the treatment of Asphyxiated Cholera ; the fifth to the nature and philosophy of the disease ; and the sixth gives a circumstantial account of its symptoms as they appeared in this city. The other letters con- tain the dissections. I trust I need not apologize for those occasional repe- titions and other faults, vi^hich are almost incident to letter vi^riting. But I cannot but regret, that the more impaired condition of my health has unfitted me for the task of completing the letters as I wished to have done, and forbade any thing like the revisal and correction which they required. Less than this I could not, and more I need not say, to a candid public. New- York, September 14th, 1832. LETTER 1. New-Yokk, August lOi/i, 1832. Dear Sir, I HAD intended to have earlier acknowledged your very flattering attentions, and to have ex- pressed the interest and instruction with which I perused the Report of the Massachusetts Medical Society ; which, although purporting to express the opinions of others, is undoubtedly one of the best original essays which has appeared on the subject of Cholera Asphyxia. This delay, how- ever, enables me to add a few words in relation to the disease as it has appeared in this city, which I do, not from their novelty, but to show you how Nature and Art have still travelled the beaten path. Tho Cholera Asphyxia has presented to our observation the same combination of phenomena that has distinguished the Epidemic in other quar- ters of the globe ; and when the varieties of con- stitutions, the differences in habits, sex, age, &c. are duly considered, the symptoms are remarkably uniform, particularly after asphyxia has super- vened. The disease has been less malignant here than at Montreal and at Paris, which is probably to be ascribed to the better ventilation and greater cleanliness of our city ; for your own observation 2 10 will- yet assure you, that the disease, at least in cities, requires for its production the co-opera- tion of local miasmata with the general epidemic poison; and doubtless the same local dcvelope- ments give intensity to the poison wherever it prevails. Well favoured cities, therefore, with spacious streets, and especially where a proper attention is paid to the cleanliness of yards, houses, &c., and in which a crowded population is not permitted during the visitation of the Epi- demic, may expect to reap a rich reward from measures that are so clearly dictated by expe- rience and philosophy. In New-York we may be said rather to have suffered several endemics than a general epidemic. The epidemic poison has not been sufficiently active to produce a full predisposition to the disease, without the co-ope- ration of local causes. It has been confined to the malarious part of the town, and generally to such houses as are small and crowded with inha- bitants, — in some instances not less than a dozen in one house having died in rapid succession. Although we may recognise in a very striking degree the phenomena of the Asiatic disease, they are more or less distinct in different subjects ; each case, however, presenting nearly the same combination. The symptoms most liable to modi- fication, are lividness and collapse of the fea- tures, these being more frequently absent than has been remarked in other countries. Asphyxia, or nearly so, is a uniform symptom of the stage of collapse ; so also are the unequal distribution 11 of heat, vomiting and purging, — almost invariably of a fluid resembling rice water,- — very generally spasms, cold sweat, corrugated skin and blueness of the fingerS; cold tongue, cold breath, suppres- sion of the glandular secretions, &c. The morbid appearances on dissection have been less uniform than the symptoms, and our pathology has been consequently much embar- rassed. The small intestines commonly exhibit some appearances of congestion either of the mucous or serous coat, generally of the former ; the large intestines commonly blanched, especial- ly if the diarrhoea has been profuse ; the stomach nearly natural ; liver sometimes greatly injected, but often very natural ; kidneys, spleen, and pan- creas natural ; bladder empty and generally con- tracted. The gall bladder contains from one to two ounces of black, green or yellow bile. There is generally, though not always, an absence of this fluid in the intestines, which usually contain a substance similar to that evacuated during life. It has been well compared to rice water, with flocculent matter, -which is soon deposited. The texture of the small intestines, particularly, is often softened, which has induced some physi- cians to ascribe this result to a violent inflamma- tion of these organs, and to regard this action as the proximate cause of the disease. But so far as symptoms and appearances, that usually denote inflammation, are necessary to this theory, they are certainly nearly ^vanting in Cholera As- phyxia, — venous congestion being almost the 12 only sensible condition of the blood-vessels. Both cavities of the heart are sometimes filled with black blood, and they are sometimes empty, — appearances which also attend the lungs. The brain is more uniformly injected than any other organ, and usually contains, either in the ventri- cles, or w^ithin its membranes, a preternatural quantity of serum ; yet the integrity of the mind is not much impaired. The veins of the spinal sheath are also commonly full. Here, as every where else, the disease was most malignant at its irruption, and has become milder as the epidemic air has abated. Most of the subjects perished, at first ; and our greater success, now, arises from the milder condition of the disease, from a longer duration of the pre- monitory symptoms, and from the more suscepti- ble class having been swept away. The nature and treatment of the epidemic are probably no better understood than when it first invaded Europe: The Asiatic physicians appear to have exhausted the subject, and the more we have departed from their modes of treatment, the less successful have been the results. It is certain that the disease was less fatal in Asia, where it is supposed to have been most malignant ; and it has been de- structive in an increasing ratio ever since it ap- peared in Europe. At Quebec and at Montreal scarcely any recover, at this late period, after the accession of Asphyxia. Here the disease having been milder, the recoveries, after that stage, have probably been about one in six. If the habits of 13 the patient have been regular and temperate, perhaps it is one to four or five that he will re- cover, if asphyxia have not existed more than one hour ; but no such good fortune awaits the in- temperate. The noise which he hears is his fu- neral knell. I have not remarked that changes of tempera- ture or atmospheric phenomena, have exerted much influence on the character of the epidemic. It seems to have been governed by its peculiar laws, which have been scarcely modified by acci- dent. The irruption took place when the wea- ther was delightfully serene, and the city most re- markably exempt from disease. Diarrhoea had not even preceded it ; and it was an astonishing spectacle to witness the work of the destroyer without the usual admonitions of his approach. It was then that we had Death and not disease in our city. His march was rapid, under a cloudless sky and a most genial temperature ; and the mortality acquired its maximum during this seemingly auspicious state of the atmosphere. There then began a decreasing ratio, the wea- ther and temperature becoming more variable, and the present storm, which has continued a week, seems not to have retarded its decline in the city; while in the neighbouring country the disease is appearing most malignantly under the same con- ditions of the atmosphere. What are the exciting causes ? It has been very rare, if it has ever happened in this city, that the epidemic poison has done more than 14 predispose the system. Other causes have been necessary to the developement of the disease, and perhaps none have acted with greater intensity than the exhalations which arise from filth and decaying materials. Indeed, the agency of these causes appears to have been almost indispensa- ble, for few have suffered the disease who have lived temperately and prudently without the ma- larious districts. Consequently the disease has chiefly prevailed, and deaths have principally oc- curred, among the most abject of the lower or- ders, — attacking constitutions that have been rendered susceptible by vicious habits or broken down by disease. Still we have lost some valu- able citizens, whose habits were temperate, and whose lives were exemplary ; but let us convert their loss to at least one good purpose; let us avoid those exciting causes which, in almost every instance, have sent them prematurely to the grave. These causes have generally consisted in some kinds of indigestible food ; what in ordinary conditions of the atmosphere are inoffensive, but which are death to a subject predisposed to cho- lera. Garden vegetables, and almost every species of fruit, have been known to develope the disease ; and the prudent part of our population now restrict themselves to lean fresh meat, po- tatoes, boiled rice, stale bread, eggs, milk, butter, tea and coff'ee, and it is considered hazardous to extend the variety. Fatigue, imperfect clothing, currents of air, exposure to the rain, and depress- ing passions of the mind, have been known to create the cholera. 15 We have not been able to add any thing new to what has been long known, or rather unknown, respecting the proximate cause of the malady. Most of us are well satisfied that it possesses nothing in common with the ordinary cholera morbus, but that the diseases are essentially dis- tinct. The hypotheses are very various ; some regarding it as a local affection, and others as con- stitutional ; some referring it to a primary inflam- mation, congestion, or some unknown modifica- tion of the action of the alimentary canal ; others to congestion of the brain, or of the spinal marrow and ganglia ; while others look alone at the di- minished glandular secretions, — and still another places the whole mischief in the carbonization of the blood; — and yet another regards the ab- sence of the saline principles as the sine qua non. To me, however, the disease is just as obviously a constitutional one. We have frequently wit- nessed the invasion of asphyxia, without any premonitory symptoms, when it has been suffi- ciently apparent that all the functions and all the powers have been simultaneously affected. If this hypothesis be true, we shall understand why one important organ is at one time apparently sustaining much of the burthen of morbid action, and at another none at all. From so great a di- versity of opinion respecting the proximate cause of cholera there would necessarily result a great diversity of treatment; but the variety of means employed very evidently arises, in part, from the want of success which attends every method. We 16 have no difficulty with the disease in its prelimi- nary stages ; but after asphyxia has fairly super- vened, I do not believe that one patient in six is restored by any process, whatever may have been asserted on this subject. 1 have seen much of the disease, and have looked at it impartially ; and I express a solemn conviction on the subject of its fatality. I have seen every method tried, and in some I have no confidence at all. I have none in what has been denominated the camphor treat- ment^ exclusively ; none in the exclusive use of ice internally. I have seen the best results from powerful external stimulants ; — calomel more or less modified by small quantities of opium, accord- ing to the irritability of the mucous membrane, and camphor is a useful addition if spasms be present ; friction with camphor, or applications of ice for the relief of spasm ; stimulants mode- rately to sustain the sinking powers, of which ammonia seems the best. The irritability of the mucous membrane is easily allayed, and is very rarely an obstinate symptom, — the most promi- nent, during the stage of asphyxia, being the ab- sence of pulse, unequal distribution of heat, rest- lessness and altered expression of countenance. We have nearly abandoned transfusion, from its almost uniform failure. The recoveries I do not think have been in the ratio of two to fifty. The temporary eflTect is very encouraging, but the patients soon die. Our best practitioners employ calomel in large and small doses, some preferring 15 to 25 grains once in three or four hours, and 17 others five grains every hour. I have seen no good effect from blood-letting in any instance after asphyxia; but this may have arisen from the quan- tity having been small, and the difficulty with w^hich it is invariably abstracted. From the pa- thology of the disease, and the experience of the Asiatic physicians, I have been in favour of the remedy. I regret that my time will not permit me to add more at present. Your citizens ought to be well informed of the fatality of the disease after the stage of asphyxia, and of its mildness before that stage supervenes, that they may be early induced to attend to the premonitory symptoms. Very respectfully, &/C. 3 18 LETTER II. New- York, August IStli, 1833. Dkar Sik, I HAD yesterday the pleasure of receiving your favour of the 15th inst., and I was certainly agree- ably surprised, that my remarks on the subject of Cholera Asphyxia should have afforded you the interest you do me the honour to express, and more particularly that you considered them worthy of publication. In relation to your inquiries respect- ing the symptoms which have marked the acces- sion of the Cholera in this city, there exists here, as in other countries, the remarkable fact, that the earliest manifestations of disease are almost uni- formly mild, and bear no corresponding ratio to the tremendous developement which suddenly suc- ceeds after a certain duration of that premonitory stage. This introductory stage is very rarely wanting, and its duration and symptoms depend much on temperament and habits. The symp- toms generally denote some impaired function of the digestive organs, and usually consist of diar- rhoea, frequently connected with nausea and vomit- ing. This condition in many instances is pre- ceded by constipation, which, however, is not so uniform as has been imagined, but which, if ne- glected, is very liable to result in diarrhoea. There 19 is, indeed, a general tendency to looseness of the bowels, and they, who have been habitually com- pelled to employ some laxative medicine, find now an ample substitute in the epidemic influence. This is a fact, which, I think, cannot be too well understood ; for it is this impaired state of the digestive organs, this tendency in all to looseness and diarrhoea, which have rendered our precau- tions in relation to food so indispensable, and which, when disregarded, have taught a lesson of prudence that few would have heeded, but for the terrible penalty so evidently connected with the indulgence. If the habits of the patient have been prudent, especially in respect to food, the diarrhoea is moderate, continuing, if it terminate in malig- nant cholera, for many days without vomiting, and not productive of much prostration or distress, till collapse suddenly supervenes. If indigestible food be the exciting cause in a temperate subject strongly predisposed, vomiting is an early symp- tom ; which, however subsides, and there only remains for a while, the diarrhoea, afterwards maintained by slighter errors in diet, till it sooner results in Asphyxia than in more abstemious sub- jects. I have not observed that constitutions im- paired by disease, where great prudence has been practised, are more obnoxious to cholera, or that collapse sooner succeeds the premonitory stage than in the robust. Particular circumstances have led me to attend closely to this fact, and my ob- servations on this subject do not concur with book authority. But it is equally true that constitutions, 20 impaired by inlcmperance and prostitution, are peculiarly the subjects of this pestilence ; and I cannot agree with Mr. Fife of Gateshead, "that drunkenness is not a powerful predisposing cause," though doubtless very much is to be ascribed to the influence of other accidental causes, — particu- larly excesses in food, and the filth in which they riot. The succession of primary symptoms is more rapid in such instances ; but still there is commonly a period for the successful intervention of art, but which is generally neglected. The aged sink quickly under the diarrhoea, if the chole- ric predisposition exist; and children, though not often attacked, pass rapidly through the several stages of the disease to a fatal termination. Diar- rhoea and vomiting do not always distinguish the premonitory stage ; but it is sometimes denoted only by headacli, loss of appetite, oppression at the chest, &c. and again spasms are known to have been the earliest symptom, and at first the only prominent one, and susceptible of relief. During the existence of diarrhoea, the appetite often remains unimpaired, and I have frequently known it to have been morbidly increased just* before the occurrence of that symptom, and the pati(^nts have sunken rapidly into an incurable asphyxia. Something, no doubt, is to be ascribed in such instances, in explaining the accelerated march of the disease, to tlie morbid indulgence. Much may be said on this very interesting sub- ject of premonitory symptoms, on which are sus- pended the life of the patient and the happiness 21 of friends, and which may determine the fate of both, as they may be duly noticed or disregarded. It is certain, however, that it is not one of the least attendant phenomena, that the patient, whose fears had been before sensitive on the subject of the epidemic, becomes seemingly indifferent after the invasion of the earliest stage, and is wholly re- gardless of life when he approaches the more alarming crisis. This apparent apathy has been ascribed, you are aware, to a disinclination to avow the apprehension, that the king of terrors has at length made his approach where most dreaded ; but I cannot think that the true cause has been as- signed. It is a symptom hclongiiig to the disease, and I have frequently experienced a great difficulty in exciting the fears of intelligent patients so far as to induce them to submit to the necessary reme- dies and a proper abstinence from food. It is a condition of the mind, also, which is progressive with the disease, and I have rarely heard of the least solicitude being manifested, after the formi- dable stage has supervened. The premonitory symptoms, here as elsewhere, were of comparatively short duration at the irrup- tion of the epidemic, at which time death ensued in a few hours after the attack. The treatment of this epidemic, in its incipient stage, must, of course, be determined by the par- ticular symptoms of the case, the probable strength of the predisposition, general circumstances of the patient, &c. From the impaired condition of the digestive functions, it is indispensable in all cases 22 to discontinue solid food, and to limit the quantity of farinaceous fluids. 1st. If tlic subject be of temperate habits, the tongue clean or slightly coated, the evacuations not particularly morbid nor frequent, and no vomit- ing, it will be generally sufficient to stop the solid food ; or a small dose of castor oil, or of rhubarb and magnesia, will be all the medicine that will be indicated. If the diarrhoea be more urgent, deno- ting a more irritable state of the mucous mem- brane, probably two teaspoonsful of paregoric should be at once given, and another after each sub- sequent evacuation. A continued abstinence from solid food for a short time will supersede the ne- cessity of a cathartic, where the bowels have been so thoroughly evacuated as a consequence of dis- ease. The irritability of the mucous membrane is easily allayed at almost every period, and vomiting and purging arrested without much difficulty ; and I have found paregoric the best remedy for that purpose when these symptoms are not violent. 2d. The next most simple combination of pre- monitory symptoms proceeds from some error in Jood, the most common of all exciting causes. If there exist much nausea, or imperfect vomiting, and the food have not evidently passed from the sto- mach, the patient will be immediately relieved by a mild emetic of ipecacuanha, associated with calo- mel enough to act as a cathartic. The organs of digestion are thus unloaded, and the predisposition to disease at once subdued. The patient should be afterwards restricted to broth or gruel, till the symptoms shall have been absent for a day or two. 23 If a patient, who lias thus erred, be not seen till the contents of the stomach have been eject- ed, or have passed into the bowels, emetics are not indicated, for we have seen no benefit arising from them, except at the very invasion, and for the purpose of evacuating the stomach. At later periods they are nearly sure to kill. If the di- arrhoea be now only moderate, and the evacua- tions not presenting the characteristic appear- ance of malignancy, and the vomiting have ceas- ed, a dose of rhubarb and magnesia will proba- bly suffice. But if vomiting continue with obsti- nacy, a stronger predisposition is shown, and calomel modified by a grain or less of opium and one or two grains of camphor, is indicated ; and if the discharges be not soon arrested, more opium should be given, and the calomel repeat- ed once or twice if the secretions have ap- peared morbid, till the bowels are again moved. Or, when I think I have obtained a sufficient advantage from the specific action of that reme- dy, and it has not produced a cathartic effect, I suspend its exhibition and await that result for some hours ; or, if there be any motive for an early movement of the bowels, I exhibit a dose of castor oil. It frequently happens that the di- rect operation of a cathartic, at the very invasion of the disease, will alone arrest its progress ; but after a delay of a few hours, the mucous mem- brane may have acquired a degree of irritability that must essentially modify the practice. The quantity of calomel which I exhibit at a 24 dose in the premonitory stages varies from 10 to 25 grains, — generally about 20 grains. But I have observed a great difference in the action of calomel and other cathartics in the diseases of Boston and Montreal and those of this climate. Here we are more subject to congestive affections of the liver and the abdominal viscera, and more active doses are more advantageously employed than at the former places. 3d. If diarrhoea suddenly invade, and be soon followed by vomiting, without any obvious cause, and if the evacuations be serous, and resembling or approaching in appearance to rice water, the attack has arisen from the activity of the predis- posing cause, and constitutes a formidable case. Here there has probably been a gradual acces- sion of disease, but not denoted by any remark- able symptoms, till this sudden developement of diarrhoea and vomiting. In such a case the tongue may be clean, and scarcely any other morbid phenomena than the intestinal commo- tion and the serous evacuations to admonish us of the impending danger. If the pulse be not much depressed, this is a case for blood-letting, and perhaps for its repetition. At the same mo- ment a grain of opium should be given, and re- peated once in 20 to 60 minutes, till the irrita- bility of the mucous membrane be subdued. A large mustard cataplasm should be also applied over the region of the stomach and liver, and as soon as the skin is irritated by that means, a large blister should be substituted. Among the 25 early remedies, calomel should not be neglect- ed, and conjoined with opium and camphor if the vomiting and purging continue ; and it will be commonly found expedient to repeat the calo- mel*for two or three large and successive doses. The evacuations will become very dark as the disease subsides. His convalescence will be gradual. ^ 4th. Tf the patient exhibit a white tongue, and diarrhcea be almost the only other attendant symptom, he will probably be relieved by calomel alone. He will require particular prudence, how- ever, in regard to food. If a sense of oppres- sion at the chest exist, or pain in the head, or soreness at the region of the stomach, blood-let- ting will be indicated ; and if tenderness of the stomach remain, a blister or leeches applied there will accelerate his cure. 5th. It sometimes happens that the earliest symptoms consist of headach, oppression of the prsecordia, impaired appetite, and coated tongue. Blood-letting and cathartics of calomel are then required, and a blister over the region of the stomacli. In these cases, where there has been no diarrhoea, the first evacuation will be very dark. 6th. If there be a yellow coating of the tongue, and purging of bilious fluid, with or without vo- miting, the case is a favourable one, whatever the exciting cause, and requires cathartics of ca- lomel and oil. I have, however, seen such cases result in asphyxia, and terminate in death, the pa- 4 26 tient purging and vomiting a deep yellow or a deep greenish-yellow bile to the last moment. 7th. Spasms sometimes introduce the disease, and may exist for some hours, unattended by any other prominent symptom. They have not, How- ever, I believe, constituted a difficult case, but have soon yielded to blood-letting and cathar- tics. They sometimes also occur in connexion with the premonitory symptoms of diarrhoea, and require, with other means I have indicated, stimu- lating embrocations, friction, &.c. The topical application of ice is also excellent for the relief of spasm, whether in the premonitory or the subse- quent stages of the disease. 8th. There is occasionally, from the access of the disease, a very obstinate determination of blood to the head, and palpable inflammation of the brain. In such instances the evacuations in the primary stage are very light, or do not occur at all. These cases require decision with the lan- cet, leeches to the head, removal of the hair, and cathartics of calomel and castor oil. The dejec- tions become, at once, very dark, and frequent cathartics will be necessary in the progress of the cure. These casee almost always yield to this treatment. When they do not, or are neglected, vomiting and purging of the characteristic rice water takes place, and the patient passes through the stage of collapse into a state of delirium. Whenever vomiting occurs as a premonitory- symptom, all fluids should be denied the patient. If it do not readily yield to the treatment sug- 27 gested, ice held in the mouth will be found a use- ful auxiliary, and it affords the advantage, also, of allaying the intolerable thirst which is some- times early attendant on that symptom. If the symptoms denote a severe grade of dis - ease, salivation will hasten convalescence, and obviate the necessity of some other remedies. Although the predisposition to this epidemic is generally developed by some of the premonitory symptoms which I have indicated, it occasionally happens that the attack is very insidious. The tongue may be clean, and of a healthy appear- ance : the evacuations at first bilious, and unat- tended with pain ; perhaps little or no vomiting and no evidence of danger in the countenance ; yet I have known a sudden transition of these auspicious appearances to an array of the most malignant symptoms. I have said but little in respect to the state of the tongue as an index of the disease, and still less of the pulse, and skin, and secretion of urine. They are so variously affected, under apparently the same circumstances, that they cannot be as- sumed as criteria. The tact of the physician, therefore, must convert them to the best advan- tage in each individual case. The patient will require particular instructions in regard to food during his convalescence, as he will be very likely to yield to his propensities. I regret that my time will not allow me to reply fully to your letter, but I will drop you another line this evening, and communicate, also, the results of some analyses of the blood. 28 In reply to your inquiry, I have had no symp- toms of the Cholera, and the physicians here have been generally equally exempt. The few that have died perished in the good cause of humani- ty, and were the victims of a generous ambition, that prompted them to exposures which no consti- tution can resist. Very respectfully, &c. 29 LETTER 11 1.^ New- York, August I9th, 1832. Dear Sir, In my letter to you yesterday, explaining the results of my experience in the treatment of the premonitory symptoms of Cholera Asphyxia, I had not the time to say what I could have desi- red on the no less important subject of the ex- cittfig causes of the disease. Having, hovi^ever, adverted in a former communication to the ge- * This letter was introduced by the original publisher with tlie following remarks, and which are retained for obvious reasons. I need not say that T entirely concur in the opinion expressed on the subject of food. " The author of this and two other able letters on the same sub- ject appears to disapprove the use of fruits and vegetables during the Cholera season. " On this opinion it may be remarked, that a distinction should be made between a place where Cholera is epidemic, and one where it is expected to be epidemic. *' Where the epidemic exists no one should eat fruit and vegeta- bles, unless the state of the digestive organs require these articles, and then with all possible precaution as to quantity and observation of the effect produced. " Where the Cholera does not prevail, the constitution of the at- mosphere, although predisposing to the epidemic, need not, prevent a prudent tl^e of ripn fruits and good vegetables." 30 ncral facts, relating to this inquiry, which have occurred under my observation, I shall now con - fine my remarks to the most common of all the exciting causes of Cholera. It is an argument, d priori, that the varieties of food and the mode- rate stimulants, which are well adapted to the healthy system in ordinary conditions of the at- mosphere, can scarcely endanger the health of the being they were destined to nourish, under any vicissitudes of the natural phenomena of the ele- ments. This very plausible induction has ope- rated in most places that have been visited by Cholera, and the general sentiment has been in favour of a moderate indulgence in the fruits of the earth, and the luxuries of the culinary art. The irruption of the Epidemic, however, soon proved to us the fallacy of this philosophy, and the experience of the majority has been conclu- sive against many species of food, which they had hitherto eaten with advantage. The fact has been even appalling to the most incredulous epicure, who has been compelled to drop his ac- customed varieties, as they have been returned, one after another, from his stomach undigested ; or if perchance this organ have borne the indul- gence with its wonted forbearance, an unusual tormina of his bowels has startled his confidence in the vigour of his digestive powers. Theory and experience all give way to the overwhelming argument of a choleric atmosphere. The con- stipated dyspeptic abandons his bolus of soap and aloes, and condemns unbolted flour as a 31 purgative diet ; and even the shampooing of Halsted threatens him with hyper-catharsis. The doctors, who tickle the palates of their patients, are thrown into confusion, and some are alarmed lest it should lend a fact to ano- ther class, who regard the subject of food as an important part of the methodus medendi in diseases of the digestive organs. The epidemic influence, however, cannot be resisted, and there soon prevails a remarkable unanimity in regard to the impaired condition of the digestive func- tions, and the necessity of abstinence from many common articles of food. In short, there is an internal impression produced on every one, which admonishes him that he is more than usually vul- nerable. The epidemic poison creates, almost universally, an irritable state of the stomach and bowels, of which very few are aware without an experiment, but, which is, however, commonly made ; and the issue will depend on the extent of the indulgence. Even the habitual drunkard glides safely along by abstaining from his accus- tomed liquor, and observing a rigorous diet ; and it has been constantly observed that in those sub- jects, the immediate exciting cause has been rather some indigestible food, than the inebriating poison. It is undoubtedly important to obviate constipation ; but this is rarely a difiiculty in cho- lera times, and should be done by medicine rather than by food. The former, judiciously applied, is safe, the latter is attended with danger. The necessity of precaution in respect lo ingesta will 32 be more or less modified by the intensity of the predisposing causes. In this city it has extended, by common consent, to all garden vegetables and to ail ripe fruits ; to pastry, puddings, cheese, and all the et ceteras which are not included in the following bill of fare. A healthy, robust man sits down to a breakfast of stale bread, butter, boiled eggs, and tea or coffee, or milk. — His dinner is constituted of some fresh animal food, light mealy potatoes, boiled rice, stale bread, eggs and a glass of water — perhaps of wine. For tea, — he con- tents himself with toast and tea alone. This is technically called a cholera table," and prevails not only in private, but in many public houses. Not only, therefore, has it well been said that the Cholera is the " Apostle of Temperance," but it has taught mankind a lesson on sensual indul- gences, which will not be soon forgotten. The great objection to fruit arises from the direct irritation, produced by its constituent acid, and from its particular liability to fermentation during the epidemic. I have known whortle- berries to have simultaneously developed the cholera in five temperate and healthy members of one family, (the Bogart family,) who were all gathered to the tomb ere the setting of that sun which rose upon their sufferings. Dr. Gale, a very intelligent chemist in this city, is engaged in a series of experiments on the blood of Choleric patients. He has supplied me with the following facts which may interest you; In eight analyses of cholera blood," he says, 33 there has been a universal diminution of water, being, in some cases twenty per cent, and in one twenty below the ordinary standard, which is 9000. The salts, and especially the soluble ones, have been found from one fourth, to one half less than their usual proportions. The colouring matter has been found to have increased in som*e instances to eight or ten per cent. This blood, when drawn from the patient, appeared like the dregs taken from a cask of old port, of a muddy purple." A fact worthy of remark is, that those who have long suffered from the premonitory symptoms, have lost both the water and salts of the blood in proportion to the profuseness of the evacuation ; which renders it probable that the loss of water and salts from the fluids of the system would occur from any profuse evacuation. The principles of the blood which have been lost, have been found both in the evacuations and the perspirable matter. Very respectfully, (fee. P. S.* It has been contended, that a critical reference to food produces a morbid sensitiveness on that subject, and that this fearful apprehension is likely to impair still more the healthy tone of the stomach. The argument, however, is not sustained by the facts. It is fear which impels us to an observance of food and to avoid the exciting causes. When public attention is properly di- 5 34 reeled to this subject, and the exciting causes are well understood, the fears, which agitated the individual, are allayed, and he eats his food with a conviction of its inofFensiveness. This is con- clusively shown by the almost universal exemption from cholera of such as are properly abstemious ; and I have had the most ample demonstration that the victims to this disease, among the sober members of society, have been such as have dis- regarded the admonitions of experience in rela- tion to food. — An attempt at concealment is na- tural enough, where the sufferer has been in some measure the victim of his own imprudence ; but I think that society requires the benefit of every il- lustration of this subject, and I do not hesitate to declare my conviction, that in most instances the disease, in this city, has been the direct result or aome error on the part of the individual. 35 LETTER IV. New-Yobk, August 22, 1832. Dear Sir, A FEW days ago, in replying to your letter, I did myself the honour to state to you the re- sults of my own observation, and that of others in whom I have particular confidence, in the treatment of the " premonitory symptoms" of Cholera Asphyxia, These symptoms continue to announce the approach of the more malignant stage, with rare exceptions, and are still susceptible of easy removal. Positive injunctions must be given to the patient, to deter him from injurious indulgences during his convalescence, a propen- sity to which, I have had occasion to remark, is a characteristic symptom, and which frequently in- volves the sufferer in a most abrupt transition to the fatal stage of collapse. To effect an obser- vance of the proper objects of attention, it is not unfrequently necessary to excite the fears of the individual. I adverted in a former letter so very briefly to the treatment of the cholera in its advanced stages, and as the disease has not yet presented itself to your observation, I have determined to avail my- self of a few moments of leisure, to submit to you 36 the experience of the best physicians in this city. There was, at the irruption of the epidemic, a greater diversity of practice than prevails at the present time. The fatality of the disease, and the different views which were entertained of its proxi- mate ctiuse, necessarily suggested many remedial agents of conflicting principles, and every subor- dinate expedient that ingenuity could devise. I always commended this enterprise and resource of the profession, although it was sometimes op- posed to my own prepossessions. The experience of foreign practitioners was only conclusive as it related to the epidemic in their own climates. It had here invaded almost another world, and it was fair to presume, that its character would be modi- fied by the great physical differences of climate, and a thousand local accidents. It was a just presumption, that what was true of one remedy in Asia, and of another in Europe, might be found inapplicable to the modified disease in America. There was, and is, nothing settled in regard to the proximate cause, and, therefore, we could de- rive butlittle assistance from established principles. Our only guide was existing experience, and our only hope, in the favourable direction that might be given to experiment by modifying circum- stances. Each practitioner, therefore, met the destroyer with such weapons as experience had provided, or his own ingenuity suggested. Their incongruity was certainly indicative of the unde- termined nature of the disease and of its great fatality Each system of practice, and almost 37 every remedy employed, have been fully and fairly applied ; and after a careful observation of their results, I am prepared to say that we have gained nothing since the disease invaded Europe. It is the same disease here as it was in Asia, — but little modified by those great physical causes which dis- tinguish the different climates of the earth, and which not only generate peculiar diseases, but exert the most sensible influence on the moral and physical condition of man. If less distinguished as a specific disease than those of the great con- tagious family, it is certainly not less remarkable in the uniformity of its phenomena ; and it is almost equally characterized by pathognomonic symptoms. This identity, also, is further illus- trated by the coincidence in the results of our treatment, and that which has been applied in other parts of the globe. From this rule, how- ever, must be excepted the very important remedy of blood-letting, which was found so beneficial in the Indies ; but even to this we have not given that full opportunity, on which the Anglo-Asiatic physicians insisted — having either been bafiled in our attempt at its abstraction, or we have not car- ried its effect beyond that deliquium which results from the removal of some dozen or fourteen ounces, and beyond whichj we are told, we shall reach the great centre of the circulation, and re-action com- mences. Although the moderate depletion by this remedy, which has been often practised by judi- cious hands in this city, has seldom encouraged any hope of success, I am determined to employ 38 it, in extenso, when favourable opportunities may occur. I will confine it to those cases in which any experiment may be justified, and where the diarrhoea has not been profuse. The arteries will supply us with any quantity, — and I know not that 25 or 30 ounces of blood, so obtained, can more endanger the patient, than an exudation of 200 or 400 ounces of serum from the mucous membrane of the intestines. The disease, however, is now hap- pily passing from this city, and should you be so ill-fated as to sufier a visitation, I shall look to you for a decision of this most important inquiry. I entertain no doubt, that the greater suc- cess of this remedy in the hands of the Anglo- Asiatics is to be ascribed to the absence of pre- monitory diarrhoea in the East, and the retention of the fluids in the system when blood-letting was so usefully practised. It is equally apparent, also, that we may depend on a greater probability of success, should we be so fortunate as to meet with the blood not already deprived of its serum. In regard to calomel^ my own experience is sustained by that of our best physicians. From the particular irritability of the mucous mem- brane, and the profuseness of the discharges, the prepossessions of many physicians, who now re- gard it with a sense of dependence, were adverse to its exhibition. The little encouragement, however, which they derived from other remedial agents, directed their attention to the declaration of foreign physicians, that this medicine not only allays the irritability of the mucous membrane, 39 but induces that change of action which is neces- sary to the re-establishment of health. I may safely assure you, Sir, that our best practitioners now employ calomel in doses of 10 to 30 grains, with more confidence than they repose in all other remedies. Either with or without small quanti- ties of opium and camphor, according to the ex- isting state of the serous evacuations, it seldom fails to allay the irritability of the mucous mem- brane, and of the system generally ; to mitigate or remove the spasms ; and if the case be suscep- tible of relief, to convert the discharges from the appearance of rice water to that of the green con- fervae, or the not infrequent blackness and consist- ence of boiling tar. This transition is nearly a sure omen of a radical chancre throuorh the whole system. Then are we delighted with an almost simultaneous developement of the great functions of life. The action of the heart is no longer almost extinct; we press the arteries with a thrill- ing sense that Death himself is subdued ; we are warmed into hope and joy by the returning heat to the extremities ; the hand no longer burns on the region of the epigastrium, where the heat may have borne a contrast at 106 degrees; the features begin to expand, and the prophetic blueness to fade away into the flush of life or the vermilion of a less dangerous congestion ; and although a spectacle, rare in opposition to others that have baffled the same skill and the same physical means, we contemplate the result even with admiration, so great is the victory, and so obvious the triumph of art. 40 Although calomel thus transcends all other re- sources in the treatment of Asphyxiated Cholera, there are subordinate agents of indispensable im- portance. These consist chiefly of all those means, which, applied externally, stimulate the skin and excite the vascular action of that organ. Heat is the most important, and is commonly applied by accumulating around the patient bottles of boiling water, bags of hot sand, the air bath, &c. Hot chalk is an excellent application when the skin is wet with perspiration. Stimulants of every kind have been employed, and none more universally than mustard cataplasms to the extremities and abdomen. It is my practice to apply a very large blister over the abdominal region, as soon as there is the least probability of its making'any impression. An ointment has been introduced at the Green- wich Hospital by its intelligent and ingenious physician. Dr. Roe, and adopted with evident benefit at other hospitals and in private practice. It consists of one pound of strong mercurial oint- ment, seven ounces of Cayenne pepper and seven ounces of camphor, intimately blended. The whole surface of the patient is thoroughly rubbed* with this composition, by means of a brush, and the process frequently repeated till reaction en- sues, or salivation is effected. Another ointment has been compounded by Dr. Rhinelander, of the Crosby-street Hospital, and is prepared in the following manner : Take of red pepper and cam- phor each half a pound, simple ointment one pound, muriatic acid one ounce. Triturate to- 41 gether the powdered camphor and pepper, adding the acid. Pour the mixture into the melted oint- ment, carefully stirring it. The ointment is very freely applied to the whole surface, and the skin afterwards covered with hot chalk. In this pre- paration, the active principle of the pepper is evolved by the acid, and it possesses, therefore, the advantage of being more stimulating than the other, but it wants the specific property which is imparted by the mercury. Dr. Roe's prescription is found an excellent adjuvant, in co-operation with calomel, in producing the constitutional effect of that substance, and, with proper subsequent treatment, a patient is rarely lost after salivation is established. Various other stimulants, more or less compounded, are in use, and are all found preferable to dry friction. The hot hath has not been much employed, and has been considered inferior to the other means of applying heat. I once assisted some medical friends, in immersing a patient, whose case presented all the striking phenomena that are described by the oriental physicians, in a bath in which was diffused a pound of strong flour of mustard. I have seen no case since, terminating fatally in so short a time, in which reaction was more fully effected, and I have not since repeated the experiment. Time for action is short, and there has never been a tub or water at hand. From the result of that application, although the patient died soon after, I think the mustard bath is worthy of further triaL Dry heat by means of 6 42 burning alcohol has been fully applied, but with no very useful effect. I have been long in the habit of employing ice for the relief of vomiting, and it is found essen- tially useful for the same purpose in Cholera As- phyxia. It also allays the thirst, and thus removes one great cause of restlessness. How far it ex- erts an impression on the morbid action is a sub- ject of inquiry. An extraordinary degree of heat is evolved about the region of the stomach. In one case, in which I applied the thermometer to the surface, a temperature of about 106 degrees was denoted while the patient was expiring. I have imagined that these cases will be more gene- rally benefited by the external application of ice to the epigastric region, than by mustard cata- plasms. Ice, too, I have applied advantageously to the head in obvious congestions of the brain, which are frequently attendant on Cholera, or arise as one of its consecutive diseases. It is also very advantageously applied, for the relief of spasm, to the muscles affected. Stimulants, internally, have been almost unani- mously employed, and by some to a very great- extent. We have seen but little benefit arising from them, and least of all from opium given as a stimulant. I think the Cholera has conclusively shown that its mode of action is sui generis^ and not analogous to that of alcohol. In very mode- rate doses, it is useful in allaying the irritable state of the mucous membrane, particularly in restrain- ing the evacuation* ; but, beyond this purpose, I 43 believe it never fails to do harm. The best of the profession, and who have seen most of the disease employ alcoholic stimulants in great moderation, and generally prefer the more volatile and diffu- sible. Their use is clearly suggested by the fail- ing powers of life ; by the very languid state of the circulation, and other phenomena incident to approaching dissolution. But, in opposition to these symptoms, they are contradicted by the pathology of the disease, — at least by some of its local developements. We have seen no benefit from their liberal use, and it is even doubtful whe- ther they contribute much in any quantities. It requires the conviction of experience, however, to enable us to abstain from their use, and to resist the impulse to apply them to the dying spark. One of the best properties of these agents is that of allaying nausea and vomiting, particular- ly diluted brandy. Dr. Arnoldi, of Montreal, in- forms me that he employed with great success small quantities of brandy and strong coffee in combination ; but I have never tried it. Emetics have not been the subject of much ex- periment. Experience in the old world has ad- monished us of their danger ; pathology is op- posed to their exhibition ; and the alarming ir- ritability of the mucous membrane, and the ter- rific prostration of the vital powers, have de- terred us from their use. We have hastened to quiet the tumult by more sedative or by exciting means of another character. Where they have been employed in Asphyxiated Cholera, I think 44 I am warranted in saying they have hastened the fatal termination. Where they have been em- ployed with success, I have no doubt it has been in what is regarded as the forming stage of the disease. In the progress of convalescence, emetics are occasionally salutary, but it is only after an ab- solute impression has been made on the morbid action. It has been very judiciously observed by a committee deputed by the Kappa Lambda Association, in their publication on this disease, that, after the system begins to react, and the calomel to operate, there is a discharge of im- mense quantities of dark porraceous bile, like boiled spinage, and this often collects about the praecordia, creating great distress, even so as to prevent the patient from lying on either side. This very troublesome symptom has been found to yield immediately to the operation of an eme- tic of warm salt water, or of Seidlitz powders re- peated at intervals." The result of the observa- tion of the committee is of course correct, al- though I think the philosophy wrong. Cathartics. I have not placed calomel in con- nexion with this class of remedies, as its supe- rior advantages in Cholera depend on its speci- fic mode of action. Its ultimate operation as a cathartic is doubtless desirable, but not essential to the changes it exerts. When we have accom- plished all that we contemplated in the prelimi- nary treatment of Asphyxia by this remedy, and a cathartic is indicated, none answer so good a 45 purpose as castor oil. I have long been satisfied, though I do not recollect to have heard or to have seen the remark, that castor oil exerts a specific action on the liver, and sustains a rank, in that rela- tion, only subordinate to the mercurial prepara- tions. It manifestly co-operates with the latter in the production of bilious discharges, and will, in- dependently, produce that result more than any other cathartic. It possesses, also, the eminent advantage of generally irritating less the mucous membrane, or prostrating the strength. Dr. Caldwell, of JMontreal, informs me in a letter to Professor M'Naughton and myself, that he em- ployed as a cathartic, after the exhibition of calo- mel in the earlier stages of this disease, tart, potassse 3ij. in a little warm chicken broth, which he repeated every second hour until it operated freely. Nothing," says that eminent gentleman, seemed to allay the gastric irritation so well as the soluble tartar. In many instances it seemed to act as a charm, and I do not know a single instance of any one, who went through the influence of this treatment, that was subse- quently attacked with Cholera," In the progress of the case, rhubarb and magnesia, especially when combined with more than an equal quanti- ty of Rochelle salts, answers a good purpose. The salts, probably, by accelerating the opera- tion, prevents the rhubarb from irritating the mucous membrane. The common saline cathar- tics, uncombined, irritate the bowels, and are ge- nerally prejudicial. I know but little of the ac- 4G tion of the resinous, not having employed them from their irritating properties. I have seen As- phyxia produced by their severe operation. An- nesley often combined aloes v^^ith his scruple doses of calomel to effect more perfectly the eva- cuation of the pultaceous creamy matter, which often filled the intestines, and to the presence of which he ascribed so much evil. We do not find this an attendant symptom, to any great extent, of our choleric patients. I think also that an ob- jection applies to the irritating properties of sen- na, and I believe it is very rarely used. Char- coal is given by a few as an adjuvant to other cathartics. This class of remedies is clearly only indicated after a considerable change in the morbid action has been effected by other agents. Camphor has had in New York its few warm and respectable advocates ; but the great pro- portion of the profession have not the least confi- dence in its remedial properties. Its cause has not been sustained by any authenticated cases, and when employed alone, it has been perfectly abor- tive in my own hands. It is directed to be exhi- bited in doses of three to five drops of the saturated tincture, frequently repeated ; and to be employ- ed, at the same time and in larger quantities, in the form of enemata. It is very useful in allay- ing some of the symptoms of the " precursory stage," and is an excellent adjuvant in subduing the irritability of the stomach and bowels, and controlling the spasms in the advanced stage of Asphyxia. For this latter purpose, also, it exerts 47 a good effect when applied externally. It imparts to opium a more sedative effect, and forms with that substance and calomel an admirable combi- nation when vomiting and diarrhoea exist. It is liable in large doses to produce determination to the brain. When employed as a specific, its exhibition proceeds on the homopathic plan. Opium and its preparations. I have briefly ad- verted to this substance as employed by some physicians with a reference to its supposed stimu- lating properties, and have explained the general result in the use of it. When given in excess, it seldom fails to aggravate all the phenomena of congestion, and has done more mischief in the premonitory stages. It is valuable when cau- tiously employed, and it not unfrequently happens that one preparation is preferable to another. In a former letter, I indicated some of the conditions of the premonitory stage in which it was evident that the camphorated tincture was best. Dr. Tappan, of the Park Hospital, informs me that he exhibits with the first dose of calomel about ten grains of Dover's powder with a happy effect ; and I may here remark that it is frequently his practice, after the plan of some Anglo-Asiatics, to adminis- ter a full dose of opium immediately after blood- letting in the less advanced stages of the disease ; a practice which is sustained by the report of the Kappa Lambda Association. I have found in the sulphate of morphine, a preparation, least of all liable to objection. Its astringency is not suffi- ciently great to arrest any profuse diarrhoea ; but 48 where it is chiefly an object to allay the irritability of the stomach, to subdue the spasms, and to tran- quillize the system, its effect is admirable, and its tendency to increase congestion comparatively lit- tle. When purging and vomiting exist in connexion to any great extent, it is useful to give the sulphate of morphine, and to administer the tincture of opium by injections. The sulphate of quinine has been employed in a few cases at the Crosby-street Hospital, with and without calomel, in doses of ten grains, once in an hour or two. The effect has been uniformly rather bad, and the patients have died. Charcoal has been employed by a few physicians, and is in still greater repute as a popular remedy. By the latter class, it is of course only exhibited in the mild stages of the disease ; and when any apparent benefit has arisen from it, the subjects, I believe, in all instances, have only been affected with the premonitory symptoms. It certainly can exert no effect on the vital proper- ties, and, of course, does not reach the functions through the only media by which such a disease can be subverted. Its action is evidently merely chemical, as an absorbent, and laxative by its mechanical irritation. Injections are very subordinate remedies, and have been most advantageous when employed to impart heat to the intestines through the me- dium of water, or restrain evacuations by the agency of opium. Large quantities of hot water have been sometimes absorbed in an hour or two, after being injected. At other times it has been 49 removed, at a very reduced temperature, without any sensible diminution of its quantity. This is probably a better mode of administering alcoholic stimulants, than by the mouth. The weight of experience here is more in favour of this method. When vomiting does not exist in connexion with diarrhoea, it is also better to restrain the latter by injections of laudanum, than to introduce much opium into the stomach. Composed of warm water, they are useful auxiliaries in the progress of convalescence, to relieve the tormina which sometimes proceeds from the irritation of the acrid bile. An infusion of tobacco, according to the suggestions of Mr. Baird, was kindly injected at my request, in one or two cases at the Crosby- street Hospital, but evidently with a bad effect. Other gentlemen have informed me that they have derived no benefit from its use. A solution of the super sulphate of alumen was freely administered per anum et per orem, at the Bellevue Hospital, where it was used on the principle of its astrin- gency ; but I believe the very enterprising gentle- men of that institution were disappointed in its effect. Cupping and leeching have had a full propor- tion of our attention. They are less salutary than general blood-letting, when it is an object to produce an impression on the whole system, or for the relief of high vascular action, whether local or general. In Asphyxiated Cholera, where there exists more than the usual determination of blood to the head, they have been found use- ful, and contribute to the relief of oppression at • 7 50 the precordia, and some of the varieties of ab- dominal distress. Like general blood-letting, the local abstraction is often indispensable, in the treatment of some of the consecutive diseases. Transfusion, according to Dr. Latta's me- thod, has been tried, and found wanting. It has been employed in numerous instances at the hospitals, and in private practice. T have in- jected but one patient, who was surprisingly be- nefited for a short period, but who soon relapsed in- to his dying condition, and expired in three hours after the operation. The results of this experi- ment have been generally uniform. The circu- lation is re-established, and sometimes with con- siderable vigour ; the temperature of the body is universally augmented ; the cold perspiration is converted to an animating warmth ; the oppress- ed respiration is removed or relieved ; the livid hue of the features is changed to the flush of health ; the general restlessness is subdued ; and the patient exclaims that his cure is almost com- pleted. I witnessed an interesting exemplifica- tion of these phenomena, in a very robust sub- ject, at the Crosby-street Hospital, who was suf- fering the whole array of symptoms that distin- guish the collapsed Cholera. The operation was performed by Dr. Depeyre, and the solution injected stood at the temperature of 1 14 degrees. A thermometer was introduced within his mouth, and the temperature marked at93degrees. Three pounds were slowly transfused, and the thermo- meter had risen to lOlJ degrees. All the evi- dent improvement I have noticed above imme- 51 diately ensued, and the man laughed aloud from the ecstacy of relief. This man was a corpse an hour after. These results embarrass the hypothe- sis of the humoral pathologists, and supply ano- ther argument to those who assign the proximate cause to a modification of the properties and functions of organic life, and who regard the al- teration of the blood and the other fluids as con- secutive, and only one of the numerous symptoms which arise from morbid action. I can only learn that " Dr. Leo's Method" has been tried at the Greenwich Hospital, notwith- standing its claim of novelty, and the well-known properties of his remedy. It was found wholly inert. Electricity has received but an unsatisfactory trial, though I am informed that it has produced no sensible effect. The hypothetical treatment of Dr. Binaghi has been put to the test, especially at the Crosby- street Hospital, and has added another demon- stration of the inefficiency of remedies that are directed to the primary impression of a mor- bific poison, acting, by concession, through the medium of the nervous sy stein, but having in- volved every other tissue, and deranged the whole economy of organic life. The moxa, burning al- cohol, et id omne genus, having had their day, no longer torture our patients in vain. The sul- phate of quinine, I have said, has been also in- sufficient in the few instances in which it has been given ; but as to strychnine, brucine, &.c. commended by this writer and Haaz, I cannot 52 learn that they have received any notice ; nor do I know that hyosciamus and cicuta have been ap- plied as remedial agents. The oxygene and 7iitrous oxide gases have been tried at the Greenwich and other hospitals ; but I am informed by the gentlemen connected with three of those institutions, that they have obtained no benefit from their use, — and that the blueness of the skin was not even influenced. A negative part of the treatment, of very great importance, consists in the exclusion of all food, and even of water, — so necessary is it to subdue the irritability of the stomach, and so easily is that organ offended. I had intended, when I began this letter, to have illustrated our practice by its application to par- ticular modifications of the disease. There are very few who have any confidence in the specific action of any remedy ; and that treatment can only be successful which is determined by general principles, and the peculiarities of each individual case. Th^ best indications are frequently derived from idiosyncrasies, and where these are neglected the greatest advantages are lost. I have no doubt that it is owing much to this circumstance, that blood-letting has so constantly failed at our hos- pitals, where the subjects are broken down by intemperance, or by previous disease. Too much praise, however, cannot be given to those gentle- men who have employed a remedy so philosophi- cal, and yet so opposed to prejudice, when it was obvious that empyrical practice, or even the power 53 of calomel, must fail. Since my preceding ob- servations on the subject of blood-letting, I have been informed by Dr. Dekay, that, in his private practice he has adopted this remedy, with the best success in very advanced stages of the disease, when the constitution of the subject was adequate to a co-operation with art. This gentleman ex- hibits diffusible stimulants freely at the same time, with large doses of opium, which he regards as essential to the success of blood-letting. He has not observed any deleterious effect from the opium, and its tendency to produce congestion is counteracted by the impression from the ab- straction of blood. Very respectfully, &c. 54 LETTER V. New- York, August 26th, 1832. Dear Sir, Having hitherto restricted my letters to practical remarks on the Cholera of New- York, I shall venture to digress from experience to theory ; although I do not imagine that you can be much interested by any communication, which does not relate to the important facts that apper- tain to this subject. Still, the propensity to spe- culate on these facts becomes irresistible ; and however one may, at first, resolve not to entan- gle himself in the mazes of hypothesis, he un- avoidably arrives at principles which influence his judgment, and which finally become so im- portant to himself, that he cannot believe that they will not be interesting to others. The first opinion I intend to examine is that which places the proximate cause of the Spas- modic Cholera in the bowels, and which sup- poses injiammation of those organs to be the source of the whole mischief. This doctrine is insidious, and derives great plausibility from the frequency of the small intestines exhibiting a pinkish appearance, — from the occasional soften- 55 ing of their tunics, — from the vomiting and purg- ing, — and from its being capable of explaining many of the morbid changes that arise in other parts of the system, on the principle of sympathy. But inflammation, to produce such extensive sympathies, and such a rapid succession of phe- nomena, so soon resulting in death, must be severe. Its existence, however, is scarcely de- noted by many of its usual characteristics. There is never any hardness of the pulse, no cupping of the blood, and scarcely a pelicle of coagulable lymph, — abstracted with whatever care, — no ten- derness of the abdomen and no continued pain, no remarkable prostration of the muscular strength, no dryness and no redness of the tongue or fauces, and no symptomatic fever. Pathologi- cal anatomy is scarcely less conclusive against this theory. Our own necroscopic researches correspond with the observations that have been made in the other hemisphere. We look in vain for that florid redness which distinguishes acute inflammation. Its hue is dull, nor does it exist in those minute vessels which are the instruments of that mode of disease. It is evident, that this appearance exists in the venous and not in the arterial system. The larger arteries, leading to the intestines, are exhausted of blood; the veins are commonly full, and there is never presented any of that minute injection, which would be ne- cessary to the existing condition of the larger vessels, did the redness reside in the terminating series of the arterial vessels. But this redness 56 does not uniformly belong to the mucous, and may then be found to exist in the serous tissue ; as was observed in the case of the black female which I reported on the 2d of July, and which is noticed by others. The constitution of these tissues is so different, and the ordinary results of their morbid affections are so characteristic of their peculiarities, that striking modifications should at least arise, when inflammation of one or the other might happen to be the proximate cause of Asphyxiated Cholera. The almost constant pathognomonic symptoms of this disease, the very uniform combination of more accidental pheno- mena, and the analogies supplied by other tissues of the system, are certainly opposed to an hypo- thesis which ascribes the seat of the inflammation, indiscriminately, to the mucous or the serous organs. And here let me remark an important circumstance, which adds to the obscurity of the subject. Notwithstanding the redness be wholly confined to the serous tissue, the discharges of serum from the mucous membrane are as abun- dant, as when that organ is the seat of the vascular fulness. These are phenomena which require in- vestigation. This irregular developement of congestion, and sometimes of inflammation, in one or the other of these coats of the intestines, will doubtless account for the tenderness of the abdo- men in some instances, and for its absence in most. It has, however, happened in many in- stances, that the appearance of redness is wholly wanting, and we are then told that the nature of 57 inflammation is not understood, and that redness is not necessary to its existence. Thus driven from the most difficult entrenchment, the hyper- semia of Andral is preferred by some, for the still greater ambiguity of the term, and its more generic import. But, yet another sign. The mucous tissue is softened, — it is disorganized, — and therefore is denoted the most active inflam- mation. When v^as it proved, I would inquire, that no other mode of action is capable of pro- ducing such a change ? Who ever, before, wit- nessed the Cholera Asphyxia ? and may there not be something in that disease, differing even from inflammation, that may modify or derange the structure of organs 1 What action is that which precedes mortification of the lower ex- tremities in subjects of an advanced age, with- out any apparent exciting cause, or any sensible evidence of inflammation ^ The morbid action of Cholera sometimes tends to the disorganiza- tion of the whole body. We see it in the blood before life is extinct, — we recognise the wither- ing poison in the frequent flabbiness of the heart,- — and we are sure, from the rapid decom- position of the body, in some cases, that there had been almost a conflict between the vital pro- perties and the laws of chemistry. — I will not il- lustrate these phenomena by the operation of the electric fluid, — for I believe that they arise not alone from the absolute extinction of life, but owe much of their production to the elements of disease. This argument, however, like the last, 8 58 is deficient in the uniformity of facts. The soft- ening of the mucous tissue occurs without any other sensible mark of inflammation, or does not exist where inflammation may be obvious ; and in a majority of cases it does not occur. It is sometimes seen, and again is absent under the most similar circumstances. The most remark- able instance I have witnessed occurred in the black female to whose case I have alluded, and whose disease was of short duration. I accident- ally omitted the fact in my report of that case, but every tissue of the small intestines was so softened, that they were easily penetrated by my finger. It will be recollected that the appear- ance of congestion, in that case, was confined to the serous membrane. It is said that the glands of Brunner and Peyer are enlarged, and that thus this particular species of morbid action is denoted ; but this argument, like the others, must fall from want of the fact. I have known it to have been absent in at least an equal num- ber of the many cases which I have seen examin- ed, and the weight of the best authority is against it. I have seen these enlargements in some in- stances, the evident consequence of an antece- dent chronic diarrhoea. Perhaps the fallacy of this doctrine, which I have endeavoured to invalidate, may be illustra- ted by the recital of a single case, though others analogous are constantly occurring. But a few days since I was summoned in the morning to attend a young lady who had been attacked in 59 the night with malignant Cholera. She had been for a few years rather delicate, and suscep- tible of congestive diseases of the abdominal vis- cera. Since the irruption of the epidemic, she had been twice affected by diarrhoea, but which spontaneously subsided. The last attack was four or five days anterior to the catastrophe of which I am speaking ; and during the interve- ning period all was quiescent. I entered her chamber at fifteen minutes before seven o'clock, and her hyppocratic countenance expressed but too truly, that the destroyer had almost done his work. Her case, therefore, may be briefly told. She had felt entirely well on the pre- ceding day, and up to the hour of retiring at twelve o'clock. She had eaten for her dinner of hashed-beef, a few stringed beans, a light mealy potato and a small beet. The repast was finished with baked rice pudding and a sweet sauce. I believe, however, they were all taken in moderation. At her tea she took nothing more than toast. Between eleven and twelve, prompt- ed by a good appetite, she ate again of the cold pudding and sauce, and retired to obtain the sleep from which she was destined to awake in death. At four o'clock the invasion took place, and from the progress of dissolution, when I saw her, she must have begun to die at that hour. At half past 10 o'clock, life was perfectly extinct. Here is a violent, and a rapid case, and did the symptoms denote that aggravated inflammation of the bow- els, which should have existed, had such been the 60 source of the phenomena ? Nothing can be in- ferred from the pulse, for that was almost insensi- ble. — The tongue was as natural as in health. — The more important evidence of tenderness of the abdomen was totally wanting, — and the profuse discharges of serum were neither preceded, nor attended with pain. The patient protested against a cataplasm to the abdomen, as she had been much more severely affected before, and had re- covered w^ithout any remedy." I am far from believing that the pathologiac state of the stomach and intestines has not a very im- portant connexion with the disease, and exerts a most positive influence on the whole system ; aug- menting the violence of the constitutional symp- toms, and precipitating death. The common de- velopement of the earliest symptoms of disease occurring in those organs, — the profuse and mor- bid secretions which soon ensue, — and the very general redness of the mucous or serous tissue, — render it evident, that there is a particular deter- mination of the morbid action to those organs ; — and their well known properties, and important relations, can leave as little doubt, that the whole circle of sympathies is variously and extensively disturbed. The astonishinof discharore of serum from the mucous membrane cannot be the re- sult of a mechanical process. The vital proper- ties, and the modified functions of the ex- treme vessels, must be concerned in the pro- duction of this fluid ; but the secretion is so rapidly performed, that the component parts of 61 the blood are separated, without supplying that usual evidence of change, which marks the pro- ductions of analogous processes. With as much propriety may it be said, that the profuse dis- charge from the skin is a simple exudation from the blood, as the separation of the serum by the mucous membrane may be attributed to the same mechanical principle. Whether the mode of action be always the same, or what particu- lar modifications may arise, it will probably be difficult to determine. Dissections must be made w'lih an especial reference to this inquiry, which may yet reflect other light on the pathology of in- flammation; It may yet appear that the fluidity of the blood is so affected, that its red globules can no longer enter the extreme vessels ; or per- haps, that the depletion of the instruments of dis- ease has so modified their vital properties, that irritability is rendered more obtuse, and the red globules recede to the capillary system. Certain it is, that the blanched appearance of the large intestines is generally greatest as the disease has been protracted, and the discharges profuse. I know not whether it be true, that there exist more of the common evidences of inflammation in sub- jects that have not been aflfected with vomiting and purging, as such instances are rare, and I have not witnessed, nor can I learn that dissec- tions have been made where death has occurred under these circumstances. I very recently at- tended the examination of a robust subject at the Grosby-street Hospital, who died in a few hours 62 after transfusion with the common saline solution. His habits were intemperate, and the disease was severe and rapid. The examination was made about eight hours after death. In this case, the loss of serum had been partially supplied, and of course, the blood was more than usually dilute. The small intestines appeared to several ob- servers, who had witnessed numerous dissections at this and other hospitals, to exhibit a more vivid redness than was recollected in any other instance. The mucous tissue was very minutely injected, and presented, through its whole tract, a uniform blush of redness. It was studded with enlarged follicles, but its texture was firm as in health. There was nothing more observed that can illus- trate my subject; but it may be stated, that the large intestines were rather blanched, and its mu- cous follicles were not visible ; that the stomach was large and free from every vestige of disease ; that the liver and other viscera of the abdomen were natural; — the gall bladder full of greenish yellow bile, none of which had escaped into the intestines ; — the bladder perfectly contracted ; — the lungs partially inflated and entirely natural, and the heart soft and flabby ; — its cavities and the larger vessels were well filled with blood, nearly as dark, but rather more fluid, than in those who die without the saline transfusion. It is not improbable, also, that a contraction of the extreme vessels, may occur extensively through the system, by which the red globules would be further excluded. 63 Although I do not advance these conjectures as probable, and believe that the absence of the usual phenomena of acute inflammation is strong- ly indicative of some other mode of action, I could still desire, that further investigation may enable us to resolve this morbid state of the in- testinal canal into, a modified form of inflamma- tion. The treatment, not only as respects these organs, but also the influence of their diseased action on the whole system, would then be more within the reach of philosophy, and those princi- ples which experience has established. But whether inflammation, or some mode of action essentially diflerent, I cannot doubt that it is only a part of an original series of morbid actions as extensive as the numerous functions of the system. There is one analogical fact, in the view of the subject just taken, that may encourage the pre- sumption that the action is allied to the proximate cause of inflammation. It is now generally con- ceded that profuse haemorrhage from the mucous coat, whether of the stomach or intestines, is fre- quently the direct result of acute inflammation, and proceeding from the secretory organs of that mem- brane. It appears, therefore, to be a fair sugges- tion, whether the fluid evacuated, in a great pro- portion of choleric subjects, may not be the pro- duct of an action analogous to inflammation. We have all the constituent parts of the blood with the exception of its red globules ; and it may be far- ther remarked, that as in patients aflfected with 64 Cholera, the discharge is generally sudden and profuse, — so also in hsemorrhagic inflammation is the evacuation of blood surprisingly abundant ; — and under either circumstance, the system sustains the depletion, with less prostration of its powers, than would arise from any other mode of abstract- ing the vital fluid. Perhaps not the least remark- able incident attending this secretion of the com- ponent parts of the blood, is the great uniformity of its occurrence wherever the Cholera has pre- vailed. But opposed to these conjectures, which may be advanced by the advocates of inflamma- tion, is nearly the whole symptomatology of the disease ; and let it not be imagined, that in having thus given a fair representation to the subject, I am already becoming a convert to the doctrine which regards inflammation of the bowels as the proximate cause of Cholera. I am not only willing, but could even desire, for the reasons which I have assigned, that it may be yet determined that this mode of action is analogous to something with which we are familiar, and the treatment of which may be embraced under the settled principles of our science. We shall have accomplished much, if we can relieve the intestines of the weight of disease which they so generally sustain, and in doing which the constitutional derangement will be released from an overwhelming sympathy, — and the blood vessels will be no longer exhausted. Have the Humoral Pathologists supplied us with a better solution of the great problem of this disease ? I cannot believe that their philosophy 65 will bear the analysis which must ultimately sus- tain the conclusion at which reason aspires. The most critical examinations do not detect any foreign substance in the blood, nor have its ele- mentary or component principles formed any new combinations. If the due proportion of its con- stituent parts have been disturbed, and we find a diminution of the serum and the salts, by car- rying the same investigation a little further, we shall discover them in the form of secretions, and by that very circumstance, denoting the essential agency of the solids in their separation; But before this diminution takes place, and while yet there are ample phenomena to evince the malig- nancy of morbid action, we find the blood still constituted as in health, and only yielding up its physical characters to the organized parts of the system. It is only as disease advances, that this vital fluid succumbs to the influence of the modi- fied powers and functions; and at last when dis- solution begins, the changes have become quite apparent. If diarrhoea or vomiting have attended the case, we discover an absence of the serum or the salts in the ratio of those discharges. Hence we are told, that the problem is demon- strated, and that we have nothing to do but to replace the evacuations. It is then that the lungs refuse to perform their office, and respiration is almost at a stand. What is the unavoidable re- sult of the interruption of this function, no less remarkable than the impaired action of another organ, on which so much emphasis is laid ? It 9 66 is an imperfect oxygenation of the blood — and therefore " oxygen gas is a specific for the dis- ease." This failure of decarbonization can never be detected till evident lesions have occurred in some of the great organs of life. Does the blood sometimes refuse to separate into its component parts ? This is only so in the advanced stages of the disease, when other sensible changes have been the slow^ result of the morbid process, and may be regarded as a rare phenomenon if the blood be properly abstracted. Perhaps the most remarkable appearance at- tending this fluid, and which I announced in two cases lately reported to you, as the dis- covery of Dr. Gale of this city, is the extrica- tion of the oil of the blood, and its existence in a free state in every part of the vascular sys- tem. If any other accidental deviations in the sensible properties of the blood have been some- times observed, as its diminished fluidity where vomiting and purging had not existed, it has only been when the organic powers have suflfered in more than a corresponding ratio; and the com- plexity of that fluid, and its probable vitality, will afford modes of accounting for such deviations, and render the principle of explanation which I have adopted sufficiently comprehensive. Do we find in the fluids secreted any evidence of a mor- bid condition of the blood? Let us examine the results, as the extinction of life approaches. — We detect nothing more in the evacuations from the alimentary canal than the component parts 67 of the blood itself. The organs of secretion have scarcely produced any change in their pro- perties, or their relations to each other, and it is the fairest inference that there is nothing here to countenance the opinion of vitiated fluids. If Christie, Annesley and others, discovered in the intestines an opaque, pultaceous fluid, its exist- ence did not occur to other observers, and I be- lieve has been rarely noticed in this hemisphere. The acid of Hermaan is now forgotten, and with it his treatment is involved in the same oblivion. The analyses of the bile, which have been made in Europe, have detected nothing unusual in that fluid, and we discover no other remarkable changes in the other secretions of perspiration, urine, and saliva, than their increase or diminu- tion, or some variations in the proportion of their constituent parts. However this inquiry may be pursued, we shall find nothing to sustain the humoral pathologist. Even his very remedies discourage his philosophy. Does he endeavour to restore to the blood its flu- idity by the transfusion of water, or recombine its constituent salts ? He is, at most, elated only by the beam of hope, which for a moment animates the brow of his patient ; but who soon relapses into the apathy of death, and brings a chill over the enthusiast. — That these experiments may continue to be repeated will be less remarkable, than the blind zeal of Hermaan, wlio successfully promulgated an hypothesis in Russia, which Ains- lie had imagined and Annesley refuted in India. 68 The acid was fully demonstrated not to exist in the secretions, and it was no less shown that it could be only detected in its natural combinations in the blood. Has the saline treatment of Wil- liam Stevens been attended with better success ? There is good reason to believe, that even in tropi- cal fever, which he esteems a kindred of Cholera, the principal agents were blood-letting to an ex- tent of 30 or 60 ounces, calomel, emetics, sul- phate of quinine and Croton oil.* It is useless to multiply objections. I know of no remedy, suggested by this hypothesis, that experience has sanctioned, or that has not left the projector its Bolitary advocate. In conclusion of this subject, it is difficult to understand how the morbific poison can produce a direct influence on the blood, even if the vitality of that fluid be fully conceded. It is suf- ficiently difficult of apprehension, that the agency of the virus is originally through some part of the system, more material and more eminently en- dowed with the properties of life. That its pri- mary action is exerted on the great source of sympathy and sensibility is even hypothetical, and although from the susceptibility of this sys- tem of organs to external impressions this is the most intelligible solution, it is still so impossible * Vide Medico-Chirurgical Review, vol. xx. 280. — My friend Dr. Holmes, of Montreal, informs me that he has tried Dr. Stevens' method in a few instances unsuccessful]}'. I have not known any useful results from it in New York. 69 to comprehend the mode of action, that the mind involuntarily glances to other organs, or even to the unorganized blood, and seems to find repose in the greater darkness by which the subject be- comes enveloped. If the poison be introduced and combined with the blood, as maintained by Searle, Stevens, Desruelle and others, the fact must be shown, before the doctrine can be tenable. Is the supposition that the poison produces its first impression on the solids more encumbered with difficulty, than that which introduces it into the blood through the medium of an organized part, and then supposes that in the course of its dis- tribution, and thus diluted, it produces the physi- cal changes through the system ; or, than that which maintains that a direct and primary im- pression is made on the blood itself, by which the subject is not only embarrassed with the in- explicable mode in which that change is produced, but there is superadded an equal difficulty in ex- plaining the possible manner in which the blood, thus diseased, so suddenly and so fatally deranges every function of life ? The existence of the poison is absolutely hypothetical, and is only in- ferred from the necessity of supposing some uni- versal cause, and from a long series of analogies; not from our ability to detect its presence in any mode of its existence. I need not therefore say, that the difficulty increases as we attempt to in- troduce an imaginary substance into the circula- tion, and that the design becomes utterly vision- ary, when we afterwards direct its influence to 70 the organized system. Even the oxygen gas of the air, as stated by Stevens, is not attracted into the circulation," — nor even its azotic prin- ciple, — an assumption which was important to illustrate his doctrine.* If this negative fact prove any thing, it is opposed to the opinion of that gentleman. It will be an interesting inquiry to ascertain whether the polypyform lymph observed by M. Marcus and his associates, and which is frequent- ly noticed in this city, be sometimes produced before death, and how far it becomes a mechani- cal cause. I have witnessed it in subjects as ear- ly as five or six hours after dissolution, when the lymph was abundant and had acquired almost an organized appearance ; and others assert that they have found it within the short space of half an hour. Many enlightened pathologists ascribe the seat of Cholera to the nervous system, either without limitation, or restricting it to the nerves of the bas-ventre. Hence we have the doctrine of di- minished nervous energy, and of central ganglion- ite, and ganglionite neurilematic peripherique. But are there any uniform indications that ei- will afterwards," says Dr. Stevens, "bring forward some very strong facts to prove, that the aerial poisons which act as the remote cause of the essential fevers, do not produce their effect by any direct impression on the nervous system; on the contrary, they appear, like the oxygen of the air, to be attracted into the circula- tion, and produce their effects on the solids of the system, entirely through the medium of the blood." 71 ther system of nerves has sustained that impres- sion, which is subsequently developed in the other great organs of life ; or any lesions of that system, through the whole progress of the disease, that bear any correspondence with the morbid pheno- mena of other organs ; or are there any symptoms which denote even a primary invasion of the nerves ? We have so little to direct us in this in- vestigation, that the question will probably always remain undetermined, whether it be through the medium of this or some other tissue, that the poison deranges the general functions. But that the brain and nerves are not the primary seat of Cholera, — that they subsequently participate lees than some other organs in the morbid action, and at most, do but serve to transmit the impression they may receive from the morbific agent to other parts of the system, I think may be nearly demon- strated. If we look at the mind, we shall find it '^sitting unimpaired and serene amidst the ruins of organic life." Respiration is only performed by the voluntary muscles, — pulsation has long ceased in the extremities, — the heart has become inaudible to the stethoscope, — yet the integrity of the mind remains undisturbed ; and the indiffer- ence with which it contemplates the wreck over which it presides, proves that at least its peculiar and last abode in the body is still its own uninva- ded possession. The powers of the mind are fully exercised in respect to the voluntary muscles ; and it is not unusual to witness successful attempts at walk- 72 ing when the pulsations of the heart are only sensible to the ear. These phenomena are cer- tainly not coincident with the attendant symp- toms of other organs. The functions of the brain are wholly undisturbed, while the heart and the lungs, and all the viscera of organic life, are involved in a chaos of disordered action. Animal sensibility is not known to be particu- larly affected, till near the termination of life. It is scarcely augmented or diminished, or in any way modified, — a remarkable circumstance, if we regard the common influence of disease on that property, and which serves to demonstrate the little participation of the nervous system in the great conflict of nature. The sufferer is even conscious of the unequal distribution of heat, and feels as intensely as in health, the ac- tion of stimulants upon the cold, and shrivelled and livid surface of his body. He hears and sees with a natural acuteness. The functions of sen- sation, therefore, remain unimpaired, and the great office of the cerebral system goes on to the last moment. But these are facts with which all observers are familiar, and render the hypothesis of di- minished nervous energy entirely paradoxical. The vital properties, with which the different parts of the system are endowed, are certainly not derived from the cerebral nerves ; and the sympathetic system, as is imported by its very name, is chiefly destined to maintain a connexion between the complex parts of the most organized 7<^ o bodies. The various properties, by which the functions of organs are performed, exist in them independently. The analogies derived from vege- tables, and the inferior animals, in proof of this fact, are too familiar to be repeated, and illustrate the peculiar office of the sympathetic system. Irri- tability, mobility, &c. are implanted in the organs which they are designed to govern, and where we find them peculiarly modified and adapted to the purposes of each individual part ; and perhaps it is not improbable that the brain itself, in respect to its organic life, is sustained by properties quite independent of the nervous power. If the prin- ciples of life were imparted by the nerves, and there were really a diminution of nervous power, how does it happen that irritability, contractility,