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           CHOLERA.




TWO  CLINICAL  LECTURES
UPON
THE NATURE, TREATMENT, AND SYMPTOMS,
SPASMODIC  CHOLERA,
J. F. V. BR.OMSAIS.
DELIVERED DURING THE PREVALENCE OP THE DISEASE IN PARIS.
                NEW-YORK :



PUBLISHED BY WILLIAM STODART, NO. 6 CORTLANDT-ST.





                   1832. 
 
PREFACE.
  The two following Lectures were translated nearly verbatim from
the language of M. Broussais, in their clinical delivery at the hospital
of the Val de Grace, during the continuance of the epidemic in Paris,
by a medical gentleman ; who, in the expectation that  the Cholera
would obey the same law  upon the American Continent as it ob-
served in Europe, under similar circumstances, in succeeding to the
Influenza or Epidemic Catarrh, transmitted them to this country for
publication, with a view to their  general dissemination.   The name
of Broussais is sufficiently attractive to the scientific world, as attached
to several admirable productions, illustrative of the most celebrated
doctrines in the French school of medicine.  To the public, generally,
who may not be so well aware of his eminence as a physician, it  is
sufficient to observe, that he stands in the highest rank as a Patholo-
gist, and has deservedly won the respect of the savans of Europe.
  It has evidently been the intention of the translator to preserve the
sense of the Lecturer, and hence the  nice  propriety  of language
has been considered a secondary object; but it may be confidently
stated, that the  matter has been carefully preserved, and even many
of the descriptive phrases as scrupulously adhered to, as a translation
would admit.
  An eager  desire, on the part of the undersigned, to add to the in-
formation of the Medical Profession on a topic so vitally important at
this time, prompted him to submit these Lectures  to the Public  as
early as they could be prepared for the press.

                                JOHN S.  BARTLETT, M. D.
  New-York, June 23, 1832.        Albion Office,  Cedar-street.
Entered, according to the Act of Congress, in the year 1832, by  John S-
  Bartlett, in the Clerk's Office of the District Court of the United States
  for the Southern District of New-York. 
 
DR. BROUSSAIS' FIRST  LECTURE
                    ON THE


CHOLERA  MORBUS.
   Gentlemen,
                  The disease, the nature of which we are now to
investigate, is called the Cholera Morbus.   The name comes from
another malady, so called, because those affected with it vomit a
a great deal of bile.   The denomination was given to it in the times
when the humoral  doctrines  were in  vogue ; at which period, dis-
eases were  attributed to humors  when their evacuation was  most
apparent, or seemed to explain the nature of the disease.  Thus, in
the sporadic cholera,  there is  always a large  secretion of  bile;
and thence  the name of Cholera Morbus,  from the  Greek word
cholos, bile, and the Latin word morbus, disease ; so that the etymolo-
gical  signification of the word is, disease of the bile.   This name
has been applied on account of  the number of symptoms belonging
to an epidemic which has long  been known in the equatorial regions,
and which now rages within our walls.
   This epidemic has doubtless prevailed at several different epochs,
and probably is the same as the  frightful pestilence which made its
appearance in the year 1348,  and carried off nearly a third part of
the existing population; and it has in effect a very great affinity to what
is  told us of the black pest.  But  whatever may have been its nature,
it  was forgotten in our region.   We read, from time to time, numer-
ous articles in the papers, upon the ravages which the cholera morbus
had made at Calcutta and other cities of India or the Levant, but it was
still nothing more than a matter of curiosity.  The English, who
have considerable establishments in the East Indies, had never intro-
duced the disease into their own country, and the small number of
French who have visited those places, never spread its contagion at
home.  Whether this  was owing to the  circumstance that the com-
munications between these countries have always been by sea, to the
kind of food taken during the voyage, or to the fresh winds which blow
over the water, and thus destroy the causes of the malady whatever
they may be, I cannot say; but certain it  is, that the disease  had
never left the place of its origin.
   The Russians first introduced  the cholera into Europe, by means
of their communications over land with Persia, India, and countries 
6
of the east, where the English have  settlements, the disease having
followed, their armies.   They brought it to Warsaw,  and thence it
has spread over various parts of the  continent.  It has appeared in
different districts of Germany, in the provinces bordering upon Tur-
key, in Hungria,  and Austria ; in short, it has been propagated to a
great extent in the north and east of Europe, and has manifested the
same violence as in the tropics.   This  circumstance  constitutes an
essential difference between the cholera and the yellow fever, which
never appears, or at least,  never prevails to much extent in  cold
climates.  In  fact, the  yellow fever is supported by heat, and by
emanations from low and marshy grounds ; but the cholera needs no
such aliment; it respects neither country nor season.
  The cholera morbus,  arriving  in our latitude, manifested itself first
in England, and hence  it appears that an intervening sea  cannot  ar-
rest its progress, though the  distance, it is true, from the continent to
England is very trifling in comparison with that  to India.  I only
allude to the  circumstances  as  important considerations  in our re-
searches, and not as tending to establish, with any certainty, the man-
ner by which the disease may be propagated.
  The malady was preceded in many of the  cities in the north and
east of Germany by a sort of convulsive catarrh, which was called
grip ;* the year following this scourge appeared in all the places which
had been previously visited with  the grip, and persons who had made
accurate observations and calculations of its progress, predicted from
the appearance of the grip here last year, that the cholera would fol-
low it the next.   In this hospital we certainly discovered the fore-
runners of this event, (not the grip, for I acknowedge that during the
last year we  had very few cases of the convulsive  catarrh, and I
hardly believed in the existence of the  grip, so rare were its instan-
ces,) but we observed some weeks before the appearance of the cholera,
a great susceptibility in the digestive organs, so that we were obliged
to reduce the aliment of many of our convalescent patients, and to
renounce some means of internal revulsions which we were employ-
ing in cases of catarrh and peripneumony.  Some experiments which
we made of the use of tartar emetic in cases of inflammation of the
lungs, were attended with remarkable success in the winter • but we
observed, all  at once, that it  had become impossible to introduce this
medicine into the digestive canal of certain of our patients without
producing the most disagreeable  effects.  Many threw up the tartar
emetic and experienced violent convulsions of  the stomach.  In two
cases, which  I particularly remember, the pulse was scarcely percep-
tible for the space of sixteen days ; the patients were in  the same
situation as those who are now affected with the cholera, except that
the pulse  was not quite extinct; they  were  in a  state  of extreme
stupor; the eyes  red ;  the extremities  cold, and the pulse at times
imperceptible; their evacuations  and  vomitings  frequent.   This
malady, treated upon  the system of antiphlogistics, yielded to  the
                        * See Appendix  (a). 
7
  medicine, but the patients were for a long time cold;  but I confess
  that this observation was not of sufficient importance  to decide me
  upon following the same system in cases of the cholera when it ap-
  peared with such violence in this hospital at first.   Some time after a
  patient was brought, whose pulse  had nearly ceased; he  was bled
  profusely, and we then discovered that he had an inflammation of the
  lungs, which nothing would have led us to suspect when his pulse was
  nearly extinct.  Here, then, are symptoms which seem  to indicate an
  increased irritability of the organs of digestion.   Under the influence
  of what causes, then, has this increased irritability taken place 1 A
  question by no means easy to determine.   Let  us proceed to  the de-
  velopment of the actual epidemic.   It broke out  all at once among
  the poorest and most miserable classes of the  people  in Paris,  and
  those first attacked were carried to the Hotel Dieu ;  three days after
  we had cases of it at the Val de Grace ;  it had  also made its appear-
  ance at the Gros Caillou, nearly at  the same time as at the Hotel
  Dieu.  The precise epoch of its appearance, was,  I believe, the 26th
  of March : we had no case of it at this hospital, however, till the 29th.
     Let us now recal what has been said of the  manner in which it is
  propagated.   The disease had scarcely any  appearance of being
  contagious, since the persons who were first attacked, certainly had no
  communication with those who might have been in England; at least,
  this was  the most probable supposition.  However this may be, I will
  proceed to lay before  you whatever facts I am in possession of, re-
  garding the manner of propagation.   Doubtless the disease  showed
  itself first in persons who had  never been in contact with those af-
  fected by it.   It is too strongly marked to have been brought in any
  vessel coming to France, for this would have immediately been dis-
•  covered.  Some person attacked with the  cholera,  arriving at Calais,
  or some  other sea-port, would have communicated it  to those about
  him.  Nothing of the kind, however, is known to have happened.
  But, although those first seized did not appear to  have taken the in-
  fection from any one else, it is a well established fact,  that when the
  malady had once declared itself in a house, it almost always happen-
  ed that a number of persons were attacked in the  same house, and I
  know of no instance where it has been confined to  a single individual
  under one roof; I have no doubt  there may be such instances, but I
  know many to the contrary; and in general,  upon being called  to
  visit a patient seized with  the  cholera, I have noticed that  several
  cases ensued the following two or three days. This fact gives rise to
  the suspicion that there is a species  of infection by which the patient
  communicates the disease to those who have charge of him.   But, on
  the other hand, the inmates of the  same house may be regarded as
  exposed  to the same influences, and thus contracting the disease inde-
  pendently of  all contagion.    This is possible ;  but  still cases  of
  the cholera are known to occur in different stories, and different fa-
  milies living in the same house, with various modes and habits of life ;
  so that it would seem that in these houses there is some  peculiar cause
  which multiplies its ravages. 
8
   We must, however, make a great  allowance for the moral affec-
tions ; those  persons  who are  struck  with terror  at the  sight  of
choleric  patients,  are doubtless very  strongly  predisposed to the
disease.   I will mention to you  the example of a very distin-
guished person, an eminent foreigner, whose  name, however, I am
not at liberty to make public.  This gentleman had  traced upon the
map the whole progress of the cholera ; he conversed with his phy-
sician several times a week upon the route it had already taken, and
was continually occupied in calculating the time  when it  would ap-
pear in such and such a place, and finally when it would reach France.
The cholera having broken out here, " Behold," said  he, " the disease
is now at Paris ; there is no doubt  I shall feel its effects."   He took
pains  to be informed every day of the number  taken, and the num.
ber dead, but at first discovered no symptom of the disease in himself.
He at length however experienced the diarrhoea which usually precedes
the cholera, and though it was carefully treated from the first, nothing
could  arrest its  progress.   This is a case under my  own eyes, for I
was called to the patient  by his attending physician.  I could mention
several similar cases.  I found one yesterday of the  same nature. A
patient whom I  had cured of an extremely obstinate inflammation of
the stomach and bowels,  was in great fear of the cholera.   He went
to pay a visit  to one of his friends, who was attacked, but did not ven-
ture into the chamber, as  he found the whole family in  tears  and
deeply afflicted  ; he had hardly entered the house when he was seized
with the cholera ; and I think he will die this day.   Thus it appears
that the disease is propagated by the most extraordinary means.
  From some circumstances, it would appear that the disease is car-
ried in the air ;  but this supposition is contradicted by the fact, that
the cholera thus regularly  distributed over the same  plain, attacks •
one village while it spares another;  that  it is not communicated by the
inhabitants who are continually passing from one to the other ; and
that the same persons who had ventured with impunity into the midst of
the sick, were attacked when the scourge  at length arrived to their own
place  of residence.  There  is something  so extraordinary  in  the
manner in which the malady advances, that it merits the attention of
physicians.  After all the facts I have cited, I am in  doubt if I ought
to admit the idea of infection  as it is  generally understood.  It is
certainly impossible to allow that the  disease is contagious, at least
in the same way as the small  pox  or the itch ; for this epidemic is
not communicated by inoculation.  Persons have inoculated them-
selves with the  blood of choleric patients;  others have even swal-
lowed it; and others have impregnated their garments with it • some
have had the courage to sleep in the same bed with the sick • and in
short, every experiment of the kind has been made, and the disease
has in no instance been thus contracted.  These  experiments were
doubtless made  by men of courage  ; for, had timid persons been for-
cibly  inoculated, I have  no  doubt  that they would  have  taken the 
9
 disease.  1 am of opinion that courageous and devoted men could alone
 have made these experiments with impunity ;  a circumstance well
 worthy of notice.  The author of a recent work on the subject, speaks
 of a choleric atmosphere which is confined to a city, a village, or to a
 single house even: but the existence of this  atmosphere cannot be
 demonstrated.   It is certain, however, that there exists a strong pre-
 disposition to cholera, and it is to this point that our researches must
 be directed at present.
   It is proved by the reports of French physicians, who have visited
 other countries to study the nature of cholera, that every remarkable de-
 rangement of the gastric system may be followed by this malady when
 it prevails in the country.  There are instances, however, of persons be-
 ing seized with it, who were in good health, and with no other previous
 symptoms than those of the disease itself; but these cases are very rare.
 The malady is generally first announced by a slight relax, unattended
 by any disagreeable symptoms ; when this ordinary  relax  already
 exists, that produced by the cholera discovers itself in a manner not
 to be mistaken.  Thus, the first predisposing causes are diarrhcea and
 indigestion, and chronic irritations of the gastric system, which  may
 have existed for a longer or  shorter period ;  but, above all, a dispo-
 sition to  diarrhoea.   Another predisposition to cholera is terror, one
 of the most powerful  causes undoubtedly. I have already mentioned
 one of the numerous instances I have met  with of this.   Intoxica-
 tion.   Men who were in good health, having been intoxicated, have
 been seized the day  following with cholera, though they had expe-
 rienced no previous indigestion :  with  the  last exception, this  case
 would be ranked among the first class of predisposing causes. Another
 predisposition is the intercourse between  the two sexes.  One of my col-
leagues, a professor in this institution, has mentioned to me numerous
 examples of students who were seized with the cholera after having
 visited a brothel. And those who have studied the disease at Warsaw,
 in Russia,  and other places, have  observed the same fact.   Conva-
 lescence  is another predisposing cause ;  persons convalescent  from
 disorders pertaining to the gastric system, or on the point of becom-
 ing convalescent, are always exposed  to the cholera: but  we have
 not observed that this was one of the most powerful predispositions,
 or, at least, we have  been  able to elude it, by subjecting our patients
 to a severe regimen.   I think, therefore, that such persons are not in
 danger  unless they  commit some  excess which causes indigestion ;
 a thing,  indeed, which happens too often.  To these predispositions,
 I will add that of patients who have for a long  time  been suffering
 from some severe malady.  I am led  to  this  conclusion,  because
 numbers of my old patients who had been completely cured of inter-
 mittent fevers or of inflammation of the bowels, have been returned to
 me now.  I have taken particular pains to  ascertain with what
 diseases they had been afflicted  before, and  ascertained almost uni-
  formly that they were affections of the gastric  system.  I have also
  remarked, that numerous persons who had been attached to the army 
10
 of the north, having passed some time in the hospitals, where they took
 sulphate of quinine, some of them in very large doses, easily became
 victims to the cholera : but I have not been able to ascertain whether
 these cases were attended with the previous diarrhoea or with acciden-
 tal indigestions.   These are the principal predisposing causes.  I will
 add, that persons in apparently good health, and who had experienced
 none of these predisposing causes, having  been attacked suddenly, I
 have endeavoured to investigate the matter thoroughly, without con-
 tenting myself with the first details given me by the patients.   I ob-
 served that they voided worms,  and I discovered a great quantity  in
 those who died.   I believe we have had seven or eight cases of those
 attacked by cholera when they believed themselves perfectly well;
 but I cannot consider a person, who is troubled with worms, as enjoy-
 ing good health.
   Manner of attack. I here divide the malady into primary and second-
 ary.  There are, as  you know,  three great sections of the digestive
 canal ;  the upper consisting of the stomach, which contains the duode-
 num ; the middle containing the small intestines; and the lower section,
 in which are found the colon, the coecum, and the rectum.  You know
 that all inflammations of the intestines predominate sometimes in one,
 sometimes in another of these sections.   The cholera,  then, is not
 exempted from these laws : we  have observed the commencement of
 the malady in one or the other of these  three  sections of the diges-
 tive canal.   I shall  speak first of the attack  in the lower section,
 these being the most frequent. The patients experience slight attacks
 of colic, or sometimes nothing more than  a slight pain in the abdo-
 men which precedes an evacuation : many  are seized all at once
 with an inclination to go to the privy, and there discharges are made
 promptly and without pain.  The canal  empties itself at once ; and •
 some persons, habitually  constipated, are much pleased to find their
 passage open.   As soon as the intestine becomes empty, the charac-
teristic results of the cholera take place.  The matter voided has a
 milky appearance, and somewhat  resembles a decoction of rice or
oatmeal: it is often tinged with bile, and  I have constantly noticed
 that  it contains particles  of mucus.  After this, all the symptoms
 and characteristics peculiar to the malady which I have just described,
make their appearance.   The patients are seized with cramp ; the
extremities become cold ; nausea succeeds, and is rapidly followed
by vomiting, as we  recently observed  in the case of a  patient
 who,  though he  experienced only a slight  nausea at  the   com-
mencement of our visit, vomited  abundantly  before  we left  him.
I proceed now to the attacks  of the disease in the middle section
 and the small intestines.  The patients experience flatulence,  violent
 workings and heat in the intestines for several days ; they have also
 slight colic and a sort of uneasiness which they  find it difficult to
 describe.  They, however, preserve their appetite.  Sooner or later
 the diarrhoea ensues, and the symptoms already noticed as occurring
 in the lower section, manifest themselves here.  The attack of the 
11
malady commences least frequently in the upper section : in this case
the patients are constipated ; they experience some nausea and irri-
tation of the stomach ; they  are  forced to vomit, which they do at
first without pain, unless there have been previous predispositions;
after this vomiting becomes painful; cramp takes place in the upper
extremities ; the throat becomes dry, hot, and sore ;  the  muscles of
the jaw are also affected with cramp ; and after this the other symp-
toms of cholera appear.
  There is still another way in which the disease attacks the patient;
this is by the nervous system.  In this case there  is no derangement
of the digestive canal: the persons thus seized, experience a dizziness
and fall senseless.*   Many soldiers have been attacked in this way;
and there have been cases of it  also among the citizens.  Persons
thus taken with the cholera, fall as if struck  by lightning, and in
numerous instances have died immediately.   A  question here arises.
Does the disease, in these  cases, really commence in the nervous
system 1  Was there not previously a general irritation in the diges-
tive canal, which produced a reaction on the  nervous system 1  I am
inclined to this last opinion.   It is certain, at  any rate, that numbers
who are  seized at  first with dizziness, sudden  loss of strength,
relaxation  of  the muscles,  and fall, recovering from these attacks,
are taken with vomiting, the first  sign of the malady, and then expe-
rience severe  colic.  These are the facts I have been able to gather
respecting the manner in which the disease first declares itself.
  When the malady is secondary, it appears  towards the close of a
violent inflammation, or even in a convalescent person.  In a patient
suffering from some acute disease, the cholera commences ordinarily
by diarrhoea, and after that the other symptoms appear.  The pulse
is feeble, and  the remains of fever, which would probably have dis-
appeared in two or three days, are at once extinct; the patient becomes
cold, and the symptoms of cholera declare themselves in a manner too
evident to  be mistaken.  Convalescent persons  are usually attacked
in the lower section ; and, by looseness of the bowels, and having no
fever, slowness of the pulse and coldness of the extremities  take
place the sooner.  Inflammatory  diseases of the lungs seem to be a
preservative ;  and it has been remarked, that persons troubled with
asthma escape the cholera : this must not, however, be entirely trusted
in, as there are phthisical patients who have  a sort of diarrhoea, and
if they  had this  predisposition in the time of cholera, they would
doubtless be attacked.   Tims it appears, that  persons sufferings from
diseases of the stomach or bowels, are most strongly predisposed to
the cholera.
   Symptoms.  The better to  explain the symptoms and characteris-
tics of this malady, I shall make the following divisions of them :   1st,
Those which  come to our knowledge by the information of the pa-
tients themselves ; 2d,  Those inferred from the exterior aspect of the
patients j  3d,  Those  resulting from  the nature of the evacua-
                        See Appendix (b).
                               2 
12
 tions.   First series—Those  patients who  are able  to  describ*
 their condition, give  us an accurate detail of what passes within
 them.   They experience an inversion  or upturning of the  lower
 part of the  abdomen, with violent heat and burning concentrated
 near  the  epigastrium.   Those who are physicians,  say  that  they
 feel all their blood rushing to the interior .of the abdomen :  such
 are their expressions : others imagine that they feel electric sparks,
 which occasion much pain, and which are followed by uncommon
 heat; then  comes an extreme  heaviness, with a weakness of the
 muscles, so  that the  patients cannot move.   With the exception of
 complete apoplexy, there is no disease which renders the body so
 heavy and so lifeless as the cholera ;  the patients have no power of
 motion ; they seem to be a mass of lead or stone;  they can only stir
 the feet and hands, but cannot raise  the  trunk.   This is easily con-
 ceived,  for the  principal  point of irritation is in the digestive canal,
 and must react on the  spinal marrow  and muscles of the  body.
 Their discharges are not very painful, for they are not accompanied
 by tenesmus or  desire of going to stool, as in cases of ordinary dysen-
 tery, but are made  with ease, and almost without' the volition of the
 patient.  The colics exist, nevertheless, but do not seem to occasion
 the discharges  which  sometimes take place even when the colic is
not felt.  The discharges and colic  are generally  accompanied by
 cramp.   These cramps  are  always very  painful; and it  is  these
 which especially exhaust the patients, and are by them  the  most
 dreaded.  The  pain is  manifested by the shrieks of the sufferer.
 The cramps do not effect the members  alone ; they also manifest
 themselves in the  muscles of the back, which are placed along the
 vertebral column.  The  patient always feels a considerable irritation
 in the region of the stomach and the epigastrium, which is, perhaps,
 felt more  than  the colics ; it oppresses the patient, and prevents
 respiration ; and he seeks to be relieved from it by placing a cushion
 under him, so as to make the breast  prominent.   A strong contrac-
 tion appears in the face.  Vomiting  gives relief, and many of the
 patients desire  and provoke it.  The vomitings go on, continually
 increasing, with compression of the epigastrium,  and difficulty of
 breathing; and, with these symptoms, come cramps in the limbs and
jaws, and sometimes in the muscles of the eyes.   The knowledge of
 most of these symptoms is  due  to the declarations of the patients
themselves.   Let us proceed now to the symptoms entirely  exterior.
 You observe, in the first place, signs which  the  patients do not
speak of.  The  muscles  are strongly  marked under the skin • the
eyes are hollow, dry, and sunken; after some hours, the consist-
ence of the eyeball seems to be dissolved ;  and one would say the
 eyes were turned inward  by means  of a thread.  The aspect of
 the patient is hideous ; the face  very soon loses its fulness and is
 contracted in a manner  peculiar to these affections :  but  what
 causes the greatest astonishment, is the livid hue which spreads itself
 over the countenance as the disease  advances.  The extremities 
13
 are cold ; the tongue is usually pale, chill, broad, and flat ; the breath
 cold, and the pulse feeble ; the words are rather  breathed than pro-
 nounced.  The patient  remains  motionless  on  the back; if you
 force them to lay upon the side, they cannot  continue so long,  but
 beg to be laid  on  their  back, so that the breast may  be  raised.
 While the body thus  remains still, they move the feet  and hands,
 uncover the breast,  complain of a fire within,  and tear  off  the
 poultices and   other warm  applications placed  on  the stomach;
 they turn from one side to  the  other, but are not able to  rise  up.
 The  colour  becomes darker  and  darker, and  is soon livid.    It
 varies, however, according  to the  natural complexion of the  pa-
 tient.   Dark complexions become black or bluish ;  but those which
 are more transparent turn yellow, taking the colour of bad gilding.
 This is followed by cessation of the pulse, which I shall call asphyxy.
 The pulse grows weak rapidly, and  sometimes disappears in three
 hours, or even  less.   As soon as the pulse begins to grow  feeble, the
 patient falls into the heaviness I have referred to :  there  are cases,
 however, in  which he still preserves his strength when the pulse  is
 extinct, and  is  even able to raise himself up, and go from one place
 to another;  but this  strength  is soon lost, and the unhappy person
 falls powerless.  After the cessation  of the  pulse, the  black hue
 manifests itself with various rapidity, sometimes at the end of two or
 three  hours, sometimes even in less ; this depends upon the promp-
 titude  with which circulation ceases.  When a patient, thus affected,
 is examined with a stethoscope, a slight tremor is perceived similar to
 that in a dying  person, or a pregnant woman.  These are the cha-
 racteristics by which  this affection is discovered.  When the patient
 throws up nothing but the aliment he has taken, this vomiting cannot
 be said to be caused by cholera ;  neither is the voiding of local mat-
 ter any sign  of it;  but when these symptoms are followed by that
 kind  of matter  I mentioned before, there  can be no doubt of the
 existence of cholera, whatever pains the patients may  experience
 beside.  I insist upon  this point.  A more foetid  smell arises from
 this matter toward the last, than at the commencement of the malady.
 The matter changes its character during the progress of the disease :
 it grows thick when the sickness is long continued ; but is,  at first,
 extremely thin.   A noise is heard in the intestines, and the matter,
 tinged with bile, is rapidly voided.   In some cases, this appearance
of bile continues to the last.   It is important to pay attention to this
circumstance, in order not to be  deceived.   The cholera may be
always recognised by the  appearance of whitish gelatinous particles
in the evacuations.*  Attention must be paid rather to the affections
than the pains,  for  nothing is more variable generally and in parti-
ciilar  cases,  than the sensibility of our interior organs.   There are
persons who  suffer  much from  the  slightest  inflammation ;  others
undergo  severe diseases without suffering.   Among those attacked
 with cholera, some pass  through all the  different  stages without
pain ;  others are agitated, and suffer in the limbs, or have very dis-
                         See Appendix (c). 
                              14

tressing cramps.   The pain of the cramps varies according to the
sensibility of the  individual; some are attacked without moving a
muscle;  others utter horrible  shrieks.  Hence  the  importance of
attending to the  fundamental  characteristics  of the disease,  and
these cannot be inferred from the sensibility of the  patient.  Slowness
of circulation, extinction of the pulse,  coldness of the extremities,
livid colour of the face, are the characteristics which it is impossible
to mistake, and are the symptoms upon which we must fix our atten-
tion.  When called to a patient, if you find his evacuations white, and
a diminished circulation, be sure the cholera has commenced.   This
is the object of my first lecture.  In the second, I shall  occupy my-
self with the progress and treatment of the malady. 
DR. BROUSSAIS' SECOND LECTURE
                    ON THE


CHOLERA   MORBUS.
  Gentlemen,
                  In the lecture of yesterday, I imparted to you
some ideas, which I had collected, upon the cholera morbus.  I shall
recal, in a few words, the most important parts of that lecture.
   We have seen that the cholera is probably a very ancient malady,
since the name of sporadic cholera has been given to it, although it dif-
fers greatly from that disease in its  character of an epidemic ; for the
sporadic cholera is scarcely ever developed, except in the summer,
under the influence of irritating causes very easily averted, and is nei-
ther propagated by infection, nor contagion.   On the other hand the
cholera morbus is certainly propagated by a kind of infection which it
is difficult to characterise. Still it is proved to exist, as I showed you in
my first lecture, and we  are forced to admit  it.   I  mentioned next
the predispositions to cholera, which reduce themselves to an uncom-
mon irritability,  or a morbid irritation of the digestive canal.   I also
pointed out to you the determining causes, which are, all kinds of
violent stimuli that  cause any  considerable derangement in the act
of digestion.  I then directed your attention to the manner in which
the disease commences its attacks.   You undoubtedly remarked that
there was, almost always, as the patients themselves avowed, some
disorder of the digestive canal; but that the malady sometimes com-
mences in the nervous system by loss of the power of motion, or of
the intellectual faculties.  I added, however, that  I was by no means
convinced that those patients, in whom the  disease made its appear-
ance under the latter form, had not  already experienced  some de-
rangement of the digestive canal:  I  was therefore  obliged to leave
this point undecided.  I next  showed how the attacks  commenced
in the  three principal sections of the  digestive  canal.   There are,
then, four different ways in which the disease commences ;  by tbe
three principal sections of the digestive canal, or by  the nervous sys-
tem ;  which last, I am of opinion, may be the effect of some previous
but undiscovered affection of the digestive, canal.  After this, we ex-
amined the characteristic symptoms of the malady.  That you might
the better remember them, and to  avoid all mistake, I classed them
i« the following order:   let.  The symptoms, which came  to  our 
16
 knowledge by the declaration of the patient  of what he has  per-
 ceived in himself; for this malady always commences by some de-
 rangement, and  these are the affections of which the patient is able
 to give an account.  2d. The symptoms discovered upon examining
 the body of the  patient.   3d. The nature of the evacuations.   I
 fixed  your attention with care upon this point, because it is of great
 importance in recognising the disease.
   We will now proceed to the question, if in case the cholera be ar-
 rested in its  earliest stages by a proper  and well directed medical
 treatment, this can be considered according to the rules of good logic
 to constitute a particular disease in  every case ; I  am  of opinion it
 cannot be, and these are my reasons.   For example, if a man is
 running to throw  himself into a  river, and is  met by  a  friend  who
 removes the cause of his sorrow, would you say that  this man has
 been pulled out of the river 1   Certainly not.  Still it is not the less
 true that he would have been  drowned, but for the intervention of his
 friend.  This is precisely the case of those in whom the progress  of
 the cholera has been arrested; they were hurrying on  to death, and
 you have stopped them.  Still their progress had already commenced.
 We must consider, then, 1st.  The progress of these affections ;  2d.
 The examination after death ; 3d. The prognostics  ; 4th. The treat-
 ment.  These will form the subject  of the present lecture.
   Progress of the malady.  It is difficult to discover any absolute,
 independent, and unvarying progress in the cholera.  It is worthy of
 remark, in the first place, that the spontaneous cholera is always the
 most dangerous.   M. Gravier, physician of the King, at Pondicherry,
 having observed the disease at Calcutta, was the  first  person edu-
 cated at the physiological school, who applied the  principles of this
 school to the investigation of the  cholera.   M. Gravier lamented the
 bad result of a treatment by  stimuli, composed of pepper,  brandy
 cinnamon, musk,  and ginger, applied in such cases ; and  he  proved
 that a greater number of cures could be effected by keeping the pa-
 tients upon rice-water, after having bled them.    He  could  obtain
 neither leeches, nor ice, nor any  of the means which you have seen
 employed  here ; and  besides this,  the malady discovered  itself in
 thousands of individuals, so that he was only able to employ two or
 three  general means against this devastating scourge. The same em-
 barrassment  recurs in every  instance of a great epidemic.   It  is
evident, then, that by this anti-phlogistic treatment,  of which  the
 basis was copious  bleeding, and by adopting rice-water for the beve-
 rage  instead of  brandy and other  stimulating drinks, M. Gravier
 cured  more  than  half his  patients, while  scarcely one per cent
 was saved by the  method adopted before.   Still M.  Gravier has con-
 fessed, with  an  extremelylaudable  candor, that bad treatment  was
 better than to abandon the disease to itself; for there was no case on
 record of the cholera, thus abandoned, terminating otherwise than
 fatally.  This fact was noticed in a communication by M. Gravier
 on the subject, which was showed me in manuscript, for my opinion' 
17
in 1823 or 1824 ; I forget the precise epoch, but the article will be
found in the  archives of  the Faculty of Medicine.   M. Gravier
has, since then, sent me a great number of notices upon the cholera,
from which an article was formed, which appeared in the Annals of
Physiological Medicine, for the year  1827.  The observation of M.
Gravier, is  conformable to our experience; this terrible malady,
when abandoned to itself, is uniformly mortal, while it is  curable in
different degrees, according to the treatment, and the conditions by
which it may be modified.   There are. three different ways, then, in
which the disease may be treated ; 1st. By pure stimulus ; 2d.  By
a stimulating and debilitating treatment, employed simultaneously or
alternately ; 3d. The physiological treatment.   The disease, aban-
doned to itself, is always fatal, and appears with the following symp-
toms :  When the affection has discovered its peculiar characteristics,
the patients have  continual vomitings  and evacuations; the pulse
grows feeble by degrees, and finally disappears;  as soon as the pulse
has become extinct, the  blue colour appears, proceeding from the
extremities to the centre ; the evacuations cease, and the irritability
disappears  throughout; the intellectual faculties, which  had been
preserved in a wonderful manner for a long time, and in spite of the
sinking of the  patient, are now  lost.   Of these unhappy persons,
some die in a sort of agony of short duration, which is announced by
a strange respiration, which I should rather term  a laborious heaving
of the  stomach ; others expire suddenly  in endeavouring to move
themselves,  or in the moment of being placed upon a seat, or .raised
up to change the position.   Such is  the termination of the malady.
As to its duration,  the term varies a little, but not much, for the dis-
ease is circumscribed within very narrow limits: it is scarcely ever
known to last longer than three days  when left to itself; and often
terminates fatally in two or three hours; that is to say, the  pheno-
mena of vomiting,  evacuations, feebleness of the pulse, coldness of
the extremities, blackness,  and agony, advance sometimes with great
rapidity, sometimes with a  degree of slowness, which is  generally
confined to the space of three days.   The disease is modified in the
first place  by pure stimuli.   I mention this method first, because it
has been adopted in India, at Calcutta, and in the English settlements
generally, for the simple reason that  Brown's system  had absorbed
the whole English  practice, and the physicians who came from Eng.
land, were necessarily obliged to apply their theory to the patients in
every possible climate;  still this  method was more injurious  in  the
tropics than elsewhere.*  This method, purely stimulative, consists in
administering spirituous liquors, such as brandy, rum, gin, not only
pure, but impregnated, and  saturated with aromatics  and irritating
substances, such as cinnamon, nutmegs,  cloves, &c. Madeira wine is
every where employed, having been  brought by land, and being ex-
tremely powerful, as the chemists know, since its fermentation is not
finished ; and there remains a considerable quantity of sugar : besides
this, it is found in every part of the world.  Some narcotics are also
                        *  See Appendix  (d). 
18
used; but the Maderia wine and brandy are always impregnated with
aromatic substance, such as musk, pepper, ginger, and cloves.  The
mortality under the influence of this  treatment, is^ frightful.  There
are, however, a few instances of a happy termination of the malady;
such are the resources of human nature, that the patient sometimes
owes his safety to the very circumstance which seemed about to put
an end to his life, and this by means of revulsions.  It must  be con-
fessed, that our information respecting the phenomenon of revulsions,
is much too limited;  because these revulsions depend upon the sym-
pathies or co-operation  which exist between the organs; and this
study has been abandoned entirely in favour of experiment.  In this
there is  nothing astonishing; it is natural to the human mind.  When-
ever any new method comes greatly in vogue, it is easily seized upon
by men  of science and of high reputation, and they must be satiated
with it before they can  perceive the inconveniences  which results
from it.   Hence  great  numbers became victims to the system of
Brown,  before its dangers were discovered.
  It is then proved that  those  who are  treated by excessive stimuli
may experience a favorable  crisis  of their disease, and this crisis is
brought about by sweating, and it is particularly that kind of sweat-
ing which is induced by  wine, punch, spirituous liquors, and brandy,
which saves the life of the patient.
  These are the advantages  of this treatment.   I shall now mention
its inconveniences.  The first  is, that this method,  compared with
another  which I shall speak of, is infinitely more dangerons, since it
is attended with a much  greater number  of deaths.   Another is, that
those who are cured by the stimulating method, still  preserve a mor-
bid state of the digestive canal, and even of the whole system, which
continues through the rest of their life.
  The eclectic or mixed method of treatment, is advised by erudite,
but timid persons, and is adopted by the mass of physicians, because
their ideas upon the nature of the disease  are not well determined.
It consists in first bleeding the patients,  and after  that, in provoking
either upwards by ipecacuanha or tartar emetic, or downwards  by
calomel, or other purgatives  ; and in endeavouring to produce perspi-
ration by means of sudorifics,  baths externally applied, or heat ap-
plied internally.   Narcotics  are then administered  for the pain or
movement of the nerves; but they are given before the inflammatory
state has been sufficiently reduced.   This method is attended with
more favorable results than the former ;  and  it has prevailed in Paris
among those physicians  who were not educated at the physiological
school, and who  have not been accustomed, as we have in this school
to compare continually the effect of the modifications in the different
maladies with the progress of the symptoms,  and the results obtained
from examination after death.  I shall not enter into any farther de-
tails of this method ; it is much employed, and it is sufficient to refer
to it.  I ought to remark,  however, that its results are more favor-
able than those of the  first method.  I hardly know, indeed, if a 
19
 comparison can be drawn between the two; for the results of the first
 have been attended with hardly any success; none, indeed, unless
 in comparison with the  ravages of the  cholera  when  left to itself,
 which is known to be almost uniformly  fatal.  It is better, in effect,
 to expose the patient to extreme stimulus, than to  leave him to perish ;
 but it is better still to weaken him  by bleeding  before resorting to
 stimulus.
   The physiological  method, which consists in the use of emol-
 lients and relaxants,  and of  stimulus  applied  externally, in pro-
 portion to the  susceptibility of the patient, appears to us preferable
 to the  others ; and I  shall  proceed to  describe its  rules  of appli-
 cation.  I wish you to take particular notice  here, that I am  not
 speaking of the treatment of the disease, but only of its progress. I
 simply wish to explain to you, that there is a great variety in the pro-
 gress of the malady ; that it is subjected to modifying circumstances;
 that, when abandoned  to itself, it has not the same result as when
 treated medically ; and that its result differs according to the manner
 in which it is treated.   I wish to fix your attention upon these points
 without going into any further details ; for you have all the same op-
 portunity for  examining the disease as myself.
   Examination of the body after death.  When these attacks prove
 fatal to the patient, it is very natural to  open  the body in order to
 discover the first,  or, at least,  the  secondary cause of the disease,
 which has extinguished life.  I make a distinction here  between the
 examination of those who were not subjected to any treatment,  and
 those who  were treated in a manner to  delay death a little without
 finally preventing it.   When we examined the bodies of persons who
 died after having exhibited symptoms of the cholera morbus, it was ne-
 cessary to take account of their former maladies  and the traces they
 had  left upon the organs.   We have here, as  in all the  hospitals,
 many instances of patients  who are brought  in alive,  but who die
 before they can be subjected to any treatment.   These  patients are
 black when first presented to us—generally completely black.  The
 muscles are very prominent in the body after death, and in a state of
 contraction, like those of a wrestler who is making an effort to rise
 from the ground ; and they have been thus described with great accu-
 racy in  a work just published.   On opening the body, we find in the
 brain a  considerable injection in  the  menynges  or membrane.   The
 injection of the cerebral substance is not generally in proportion to
 that  of the menynges;  that is to say, the  membranes which envelope
 the brain.  This is nearly all that is worthy of remark in the brain;
 there is almost always a little wateriness in the cavity of this  mem-
 brane ;  but, in general, this is not abundant,  but,  on the contrary, a
 very considerable  quantity is found in those patients who have been
treated for a certain time, and who have been bled. We remark very dis-
 agreeable symptoms in the throat also, when these congestions of the
 blood in the head are formed ; there is a stiffness, dryness, and some-
 times a choaking  up of the  ganglions;  otherwise there is no in-
                              3 
20
creased softness, nor dissolution  of the mucous  membrane of
the mouth, or of the oesophagus.  The stomach is ordinarily very
much disordered, sometimes black, sometimes brown, and some-
times reddish.   Its vessels, extremely developed,  exhibit ramifi-
cations of a black colour; and between these vessels the mucous
membrane is  softened, and almost dissolved.  Meanwhile, it is
always necessary to take notice of the  previous  diseases.  We
have noticed that  habitual drinkers,  or those who have exposed
the stomach to any habitual excess, exhibit  frequently a softness
and even  a very considerable  destruction of the  mucous mem-
brane ; and this alteration does not exist in persons of sober ha-
bits.  The duodenum is rarely disordered  to any great degree,
unless the patient had been previously affected with complaints of
the stomach and bowels.   The small intestines are very much
filled up; but here occurs a very remarkable circumstance ;  for
we must  make  our  distinctions, and speak of the symptoms in
reference to the appearance of the  body after death.  Those pa-
tients who had very abundant evacuations, (and these take place to
a frightful degree both by vomiting, and going to  stool, in those
who have  no medical treatment, so  that their strength is exhaust-
ed and life passes away,) those patients exhibit the redness of the
mucous membrane of the intestines less apparently ; it exists,
however, from the  commencement to the end of the canal, but not
very distinct.   An immense quantity of the liquid which is eva-
cuated, is  found in  the interior of the digestive canal.  There is
an entire analogy between the  matter vomited and voided down-
wards, after the fecal matter and bile  have passed away, and  this
liquid which is found in  the cavities of the digestive canal.  We
have had an  opportunity of examining patients in whom these se-
cretions produced by cholera had not been repressed by the  ef-
forts of art, in  consequence of the physicians not  having disco-
vered, during the first moments  of the disease, the malignity of
certain evacuations, which might be  mistaken  from slight acci-
dents or from derangment of the gastric system ;  these patients ar-
rived here in the last extremities before they could receive any
treatment.  We were much surprised at feiese examinations, to
discover a sort of mucous formation, and a large quantity of fluid
resembling a fuliginous solution which filled the intestines.  The
mucous membrane  appeared a little paler than usual, a slight red-
ness merely pervading its whole extent.  From the upper orifice
of the stomach, down to the anus, no part  discovered this redness  •
and we have only been able to  ascertain that when the patient had
experienced a previous irritation of the digestive  canal, the sto-
mach and bowels had  the appearance of greater redness and al-
teration.  The bladder was contracted  and gathered into the pubis,
a circumstance  not at all surprising,  since the abundance of the
intestinal  evacuations must,  of necessity;  have  exhausted the
sourcee of urine : but there was no appearance of  inflammation. 
21
   Those subjects in whom the malady had been treated in such a
 manner as tc& prolong it without final success, exhibited appear-
 ances a little different.  These affections commonly cease,  or, at
 least, are modified when the patients are subjected to medical treat-
 ment.  When they are well treated, this cessation is followed by
 their cure, but when treated  less advantageously, they are some-
 times cured, sometimes not. When they are not cured, it is found
 that the inflammation is  more strongly  marked.  The redness,
 which was a slightly pale, and resembled in some degree the colour
 of the flower called hortensia, is here very bright: it is scarlet,
 or even bordering  upon black ; there are portions  even in the
 digestive  canal, which appears  gangrenous.  Thus,  when  the
 disease made its first attacks in  the  gastric  region, a frightful
 derangement is found in the  stomach, the  mucous membrane of
 this organ appearing entirely destroyed  and very  black.  When
 the disease  commenced in   the  small  intestines, the  mucous
 membrane is sometimes gangrenous ; in  other patients it is com-
 pletely destroyed.  The liquid contained in the digestive canal,
 is less fluid, less white, less opaque, adheres to the mucous mem-
 brane, and approaches the condition of a false membrane.   The
 intestines are less humid, less black, and more difficult to  sepa-
 rate from each other.  The glands of Peyer and  Brown, some-
 what more swollen, present the appearances of ileo colic.
   In a word the ordinary  symptoms  of  disease of the stomach
 and bowels appear.  The brain is crowded not with blood,  be-
 cause the patients have often lost much by bleeding.  It is more
 humid,  and fewer drops  of blood  are  discovered when its  sub-
 stance is  cut: the  ventricles  are more  moist,  and  sometimes
 abundantly supplied with watery  matter.   We have never
 found  it inflamed,  nor have  we  ever remarked any  arachnitis,
 properly so called.  We have seen  congestions  of  blood and
 watery  effusions, but never distinct inflammation. As to the heart,
 we found it in the first subjects, choaked  up with thick blood, its
 partitions  thickened,  and upon being cut, blood, less coagulated
 than we expected, followed the  knife in drops, and even  in a
 stream ; but  there  wjas  no marked inflammation in the internal
 membranes of the heart and  of the  large vessels.  When
 the  patients  lived  for  some  time after the  secretions of the
 digestive canal had  ceased to be so abundant, the bladder was not
so much contracted as in the case  of  those who had died during
the evacuations.  It was entirely filled with urine, without inflam-
mation, a circumstance which  throws much light upon the cause
of the cessation of urine, which must be attributed to the deviation
of the watery fluids  which go  to  the intestinal surface instead of
following their course as in the healthy condition.  The muscles
are sticky, dry, and emaciated.  The lungs present no remarkable
 appearance.  I repeat here, we must give attention to the previ-
 ous diseases.  What are we to conclude from all this ?   That the 
22
   cholera morbus is essentially an inflammatory affection. This is my
   conclusion.  This inflammatory affection  attacks the whole ex-
   tent of the digestive canal, from the throat to the anus. Whenever
   it is intense, when it is very red, as it commonly is when the ma-
   lady has lasted a long time and the evacuations have ceased, when
   it is less bright in colour, as  is the case when death takes place
   in the midst of abundant evacuations, it is always  general, and
   there is no part of the canal which is exempt from it.   I insist upon
   this proposition,  which is  in1 opposition  to many  reports upon
   the cholera.   I insist upon it, because it is true, and serves to ve-
   rify many important points.  Some persons maintain that there
   is no inflammation in the digestive canal,  and  they rest their po-
   sition  on the fact, that some  patients have died during abundant
   evacuations, in which case the external membrane of the digestive
   canal is not scarlet; but the inflammation does  not the less exist,
   and the abundance of the secretions and evacuations explain suf-
   ficiently its want of redness.   Do not conclude from this, how-
   ever, that I only consider the disease in relation to inflammation.
   I set aside here that unknown cause referred to in my first lecture,
   and which I compare with that of the small pox, which is equally
   unknown; what we see in the small pox, as in the  cholera, is
   the inflammation which these  maladies produce.   Thus, in a word,
   the cholera morbus, as we believe, is a general inflammation of
   the internal membrane of the digestive canal, of which the first
   determining cause is unknown, while the predominating and sub-
   sequent causes  may be comprehended.   And there is an advan-
   tage in this; for if the first causes cannot be discovered, we  can,
   at least, distinguish the secondary causes, a circumstance of great
   importance, and which ensues us much success.
    Prognostics.   These are 1st,  The previous health of the pa-
   tient.  Persons in good health are easily cured when the disease
^  is treated in time.  The age  of the patient—Young  persons  are
   cured  more easily than the aged.  The sex—Upon this point, it has
   been impossible  to make any positive or  satisfactory compari-
   sons.  The moral condition—I have already made some remarks
   on  this point, and all our observations tend to confirm them.  The
   prognostics depend, 2dly, upon the nature of the commencement
   of the disease.  If it begin in a downward direction, by a gentle
   diarrhoea, there is time to treat it, and arrest its  progress.   And at
   this moment a vast number of these affections are stopped at their
   commencement by  the skill of the physicians in Paris.  The dis-
   ease, when thus arrested, is called cholerine. Thus, some  trifling
   consolation is offered to the public.  The physician says to the
   patient,  "you have the cholerine; you have a slight  diarrhcea
   but you have not the cholera."   And when it is checked he  does
   not say, " you have had the cholera."  Thus he avoids terrifying
   the patients, who are satisfied without being made to understand
   that they were victims devoted to the cholera, had not the neces-
   sary succour been lavished upon them.  When the disease attacks 
23
the middle parts, the result is the same. If it be confined to a slight
relax and tension, it is easily checked. When the symptoms pre-
dominate in the upper parts, and the diarrhoea has ceased, I ven-
ture the opinion, that the disease is more easily cured.  When, on
the contrary, it has lasted a long time, and the cramps,  which are
a proof that the inflammation of the intestines has extended to the
spinal  marrow, have commenced, when the patients are seized
with great anxiety, agitation,  and uneasiness through the whole
extent  of the  abdomen, they are in much greater danger. When
these symptoms have disappeared, and there remains nothing more
than vomiting and distress of  mind, there is  much more hope  of
recovery.   All the symptoms have not  the same importance.   The
congestions of the brain scarcely ever manifest themselves during
the violence of the disease. The patients may appear to be in such
a state  of sinking and exhaustion as to cause the belief that there is
a congestion of the brain  ; but if you excite them, if you speak to
them, they answer very well: so that, if you have let fall any indis-
creet expressions, you may have cause to  repent  it when you
see that the patients have the full use of their faculties.  On the
contrary,  when the symptoms of the  attack  have  ceased, and the
moment when you flatter yourself that the cure is about to com-
mence, a very severe congestion of the brain may take  place, un-
less  measures are adopted to arrest its progress.  When the ma-
lady is  prolonged, when the patient is revived from the state  of
asphyxia, and the dark colour  has disappeared, the tongue red,
and the skin hot,  the disease has changed its nature ; the patients
exhibit all the  symptoms of  the diseases  of  the  stomach and
bowels, which we are called to treat every  day.  We here make
this distinction : it is always necessary in the treatment we adopt,
to have reference  to the modifications of the disease.   When the
patient has  been  revived from a state  of stupor, asphyxia, and
blackness, by means of stimulus, this disease of the stomach which
ensues, is severe, and resolves  itself into  typhus.   At this very
moment, indeed, it is said that the typhus reigns in Paris with the
cholera, and the same thing is repeated upon the subject that was
said in Germany,  Poland, Russia, and  the  Levant.  But if you
wish to appreciate justly this pretended typhus, this typhoid fever
which  succeeds the cholera, and of which  the most dangerous
symptoms have been suppressed, you  will perceive that this same
fever should be subjected to the same treatment as the ordinary
complaints of the stomach and bowels.  In our hospitals, for in-
stance, there is no typhus ;  there is nothing  else than slight com-
plaints of the stomach and bowels, which pass off in three or four
days, and the patients call for food.   In  those halls, on the  con-
trary,  Avhere the patients have  been revived by means of stimu-
lants, such as punch and  brandy, they perish in great numbers,
after having been  carried into an other hall as  cured of the cho-
lera.   They are reported  in the  bulletin as  cured  of cholera, and
placed in a separate room as affected with typhoid fever, and no- 
24
 thing farther is said about them ; the attention of the physicians is
 given to the new subjects of cholera who arrive, and the first are
 forgotten.  I now pass to the treatment which, for the sake of per-
 spicuity I  divide in the following  manner : The Ancient treat-
 ment, or treatment of the sporadic  cholera—Treatment after the
 manner of Brown—Mitigated treatment, or eclectic, or vacillat-
 ing treatment—Finally, Phisiological treatment, such as we em-
 ploy  here.   These are the four divisions we have made.
   Let us examine first the ancient treatment.  In all the standard
 treatises the following receipts, are found.  We  are  directed to
 administer abundantly to the patient  a decoction which favours
 vomiting, that the bile may pass off;  and after that, when  every
 thing that  was wrong in the digestive canal is evacuated, the
 cramps  and irritation must be allayed by narcotics.  This treat-
 ment has saved some individuals, but has not been so successful as
 to be generally adopted; besides this, the practice  of the middle
 ages has fallen into disrepute, and Brownism has taken its place,
 particularly in those countries where the cholera prevails, for the
 English physicians have carried there the ideas of Brown.
   Brownian treatment.  This  consists in  the  use of stimulus.
 I have little to say on this head, having already referred  to  it
 before.   I  shall only add, that it cures very few patients.  I will
 not say it kills them,  because, when the cholera is left to itself, no
 one escapes ; and this treatment, in a vast number of cases, is suc-
 ceeded  by  typhus or disease of the stomach and bowels, which
 extends  to a degree of typhus.   I do not wish  to accuse any
 one, but only to do justice to all.  As to the means  of treatment,
 I have pointed them  out.
   The mitigated treatment consists  of the following means.  The
 physician seeks to restore heat to the patient at the  period  of
 asphyxia, or if you wish to go  back to the diarrhoea, which pre-
 cedes, he seeks to remove it by means of rice-water, diascordium
 and opium.  Sometimes, indeed, the force is moderated, but it is
impossible  to prevent the  malady from breaking out.   After the
asphyxia and  the blackness  have made their  appearance, the
physician endeavours to warm the patient by external and internal
applications.  For exterior, hot baths  are used, and dry friction
 with aromatic and stimulating substances, hot bricks and flannel.
The skin is irritated  and stimulated continually, in the hope of re-
calling circulation.   For the same purpose,  hot drinks are inter-
nally  administered. Some practitioners have no fear of the drinks
being too strong.  Like the followers of Brown, they give brandy
and punch.   Others,  more timid, make use only of borage, or balm
and, above all, of camomile, which has lately obtained a great credit.
 After  that  they give something fortifying,  acetate  of ammonia,
 ether, or substances containing alcohol.  If the patient  experi-
 ence nausea, opium is sometimes added.  When a reaction is pro-
 duced by these means, which does not always happen, the patient 
25
grows warm ; some hours afterwards, he becomes cold again ;  the
same methods are again employed, but he grows cold continually.
But persons who manage well, hasten to profit by the first appear-
ance of warmth, and send  the patient into another hall.  Thus I
saw, at a boarding school, a number of scholars who had been at-
tacked, warmed again for the moment, and sent home to their pa-
rents, where the disease immediately returned.  It is possible,
however, to maintain this warmth :  and when a continued reaction
has been obtained,  an intense irritation occurs; less violent, how-
ever, than that produced by the hyper-stimulants of the Brownians.
Others think that evacuations should be promoted by emetics. As
soon as they see the quantity of liquid which inundates the digestive
canal, they say,  " evacuation must be aided,"  without reflecting
that they will arrive at the  absolute exhaustion of the strength,
and that the irritation will be augmented.   English and  Polish
physicians have been known to give, alternately, calomel to  pro-
mote evacuation, and brandy to stimulate.   Some cures have re-
sulted from  the treatment.
  I cannot say what is the proportion of cures effected by these
different methods;  it would require many years  of research to
ascertain.  It will  perhaps be known at some future day, but at
present I can only  state to you the most general facts. When, by
the means I have spoken of, the patient is revived from his stupor,
if these physicians discover  much fever, they bleed, either  with
the lancet or by leeches applied to the epigastrium :  then, if the
patient be too much weakened by loss  of blood, they give  him
ether or seltz water ; in a word, the medicine is suggested by the
symptom.
  These  results are more favourable than those of Brown's treat-
ment.  It is the prevalent method  in this capital, and to this we
owe a great advantage in the mortality over  other countries where
the disease has  appeared.
  We come  now to the physiological treatment, which we employ.
I wish to describe, and, if possible, to justify  it.  We  made, at first,
some experiments with hot drinks  and  stimulants, moved, as we
were, by the coldness of the patients : but as these means did not
succeed,  we abandoned  them, and have not recurred to them.  I
watched the patients carefully ; I gave  them, not camomile, for I
dared not go so far,  but mallows, and similar things.  They  said
to me,  " I beg you to give me something cold; I am tortured by
the hot drinks;  I have a terrible burning in the throat, and I beg
you to  cool it in some way."  Their countenance  brightened in
saying this,  but they afterwards fell into a still greater dejection.
I concluded, from examining the bodies, and from the confession
also of the patients, that stimulants were of  no  use.   I then admi-
nistered cold drinks; the patients drank freely, but the evacuation*
redoubled in consequence.   I recollected that ice had been  em-
ployed to advantage in Germany; but I only had a  vague  and 
26
 unsatisfactory idea of the manner in which it had been used.   It oc-
 curred to me to diminish the drinks and  give them ice.  When the
 patients had copious evacuations both ways, I caused ice to be given
 them to eat, with the injunction to swallow it.   They  took the ice
 with delight:  the tongue was cold, the pulse extinct, and the  body
 chilled.   When the tongue is observed to become red, the skin to
 resume its colour, and the blackness to disappear, the ice may be dis-
 continued and the  drinks given;  but while the  physician is endea-
 vouring to restore the moisture of the mouth and the interior of the
 body, the gastrite is developed, reaction is going  on, the nature of the
 inflammation is changed, and consists in a rapid congestion towards
 the digestive canal.  The vomitings and stools continue,  and the
 pulse is accelerated ; from being slight and hard, it becomes fuller and
 softer, the brown  colour of the skin passes gradually  away, and
 one is surprised, the next day, to see the  patient with  the signs  of
 commencing inflammation of the stomach and bowels.  In the mean,
 time, when he is troubled with thirst you may give him some drinks,
 which you may be sure he will absorb.  The danger is of filling the
 intestinal canal at the moment it is choaked up.   When the asphyxia
 and blackness have disappeared, and the  patient has recovered his
 strength, you conduct him slowly without stimulus, waiting till he has
 become slightly cold, and till the tongue, which  had become a  pale
 red, but not  more pale than when it first grew cold, has recovered its
 ordinary  colour.  This is the substance of the treatment for the in-
 terior.  For the exterior, heat may be applied ; it should be directed
 to the  lower extremities.  It is not well  to accumulate heat upon
 the breast; the patient cannot support it; they have, on the contrary,
 a desire to uncover themselves, which seems to aid their respiration,
 and they derive sensible benefit from it, and express their satisfaction.
 If, on the other hand, you force them to have the breast covered, if
 you place them under a blanket or down  covering, they appear to
 suffer extremely, and beg you to uncover  the breast a little.   The
 public is still the dupe, in this respect, to prejudices which have been
brought from Germany.  I will speak here of friction : it is certain
 that there are  establishments at Paris, where the persons employed in
 rubbing, sweat themselves before they excite any perspiration in the
 patients.   On  the contrary, this stimulus only increased the anguish
of the sick, and chilled them after the first  few moments, by leaving
them uncovered.  It is not enough to apply  cooling substances in-
 ternally, and heating ones without ; the inflammation must be com-
 bated ; and  for this  purpose we employ leeches.  Bleeding can be
 rarely resorted to, the blood being every thick and having somewhat
 the appearance of jelly. Its fluidity may be momentarily restored by
 rubbing the  arm of the patients, or by plunging  it into hot water ■
 but all this  produces no essential result.   In order that the bleed-
 ing may be of any use,  the  patient must  be taken in  the  earliest
 stages of the disease.  I then cause leeches to be applied to the  epi-
 gastrium and the lower part  of the  abdomen.   The leeches draw 
27
 nothing at first, but in proportion  as circulation is promoted  by the
 ice, and at the same time by emollient poultices placed upon  the ab-
 domen.   A quantity  of blood is taken by the leeches, so as to aid
 the cure.  You will  ask me, perhaps, how the want of ice  may be
 made  up ? I answer, that nothing is so good as ice.  Nevertheless,
 I think that small draughts  of cold water may be  of use.  Besides
 this, there are, in almost all  places, persons who understand  how to
 produce ice by artificial means, by using oxide of manganese, sulphuric
 acid, or muriate of soda.  Ice must be procured, if possible  ; but if
 it cannot  be obtained, the want of it must be supplied by taking small
 quantities of fresh water. Blisters and mustard-seed poultices should
 be  employed afterwards to prevent congestion of the brain. Leeches
 may be applied with advantage to  the temples,  and  upon the jugular
 vein;  poultices  and warm applications of mustard seed should  be
 placed upon the extremities;  and hot  vapour baths should be used,
 at the same time applying ice and  cold water.
   It may be said, perhaps, you are exclusive then. Will you allow us
 to give neither iEther nor Seltz-water to the  patients who fall into
 syncope after  bleeding ?  I beg pardon ; I think this  may be done ; I
 would have the  physician  use stimuli when he perceives the pulse
 of the  patient  growing weak, provided he has ice  in readiness to
 calm its  effect.   I have done this myself, and believe  it  advan-
 tageous,  and  I have done this, though  very seldom,  in this hospital,
 since I cannot be here at all moments of the day, nor can I  choose
 my attendants, to watch the patients without interruption.  But, in
 spite of this, I have obtained very remarkable success, since  at pre-
 sent we do not lose more than one patient out of thirty or forty,
 while at first we lost about one out of six.  The proportion of cures
 has been since augmented, because the  patients have been brought to
 us before  they had reached the last stages of the disease.   Thus, you
 observe, I do not absolutely reject  any  system  of treatment.  Some
 persons have proposed narcotic glysters with laudanum.   I will now
 express my opinion upon this.  In the commencement of the disease,
 if a stifled sound ensues when you touch the abdomen,  this  proves
 that it  is not air which prevails in its cavity, but that it is full of the
 mucous matter of which I have spoken.  If, in these circumstances,
 you administer glysters of rhatany, and other astringent substances,
 you will produce irritations;  the matter will not be detached, but
 will mount up again ; congestion of the brain will ensue, and you will
 be in danger of witnessing  very disagreeable  results :  this practice
must therefore be renounced.  But  when the patients have been bled,
and their evacuations have been abundant, if they continue to expe-
rience  pain in the lower  part of the abdomen ;  if they are affected
 with terror,  agitation  and  uneasiness,  it is time to  administer
narcotic glysters.  You will  then obtain remarkable success,  while,
if you administer the glysters prematurely, the result  will not be satis-
 factory.   As to the quantity of opium, this depends upon the system
adopted by the physician. There are some who reject opium and sti-
                               4 
28
mulants ; others administer them in large doses. I prescribe but from
five to ten drops of laudanum. I have given even forty drops when the
patients were very much convulsed,  but never any greater quantity.
This, then, is the substance of my  treatment.  I allow no kind of
warm drinks.  The only time that 1 think them admissible, is when the
patient begins to have an appetite.   1 then prescribe a  cup of soup
diluted with water, which revives the patient in an astonishing man-
ner, so that he fancies himself cured.  As to the length of time, we
have had patients in this hospital, who  have remained  four or  five
days in  a  state of asphyxia and blackness ; we expected,  every
moment, that they would  die, but still they have recovered to the
great astonishment of the assistants.   We have had instances of the
recovery of patients who had  become black or dark coloured,  and
this has been owing to the use of ice and cold drinks*
  I now proceed  to the  treatment at  the  time  of predisposition.
When a person,  affected  with irritability of the digestive canal, sees
that the cholera has broken out in the place where he lives, he should
commence by diminishing the quantity of his food at least one half.
This is called the prophylactic treatment.  Only a  small quantity of
vegetables must  be eaten : I do not  say  that they  should be entirely
given up, but used very sparingly.   You should eat eggs, veal,  and
poultry,  and not drink much between meals;  and not at all, unless
you  are thirsty.  Great  moderation must be  used in this respect.
All kinds of uncommon and violent  fatigue  must be avoided ;  and
also sexual intercourse, which easily fixes the disease in feeble sub-
jects ; the regular habits of life must be kept up, and not deserted for
any invitation, nor upon any occasion.  I have known many per-
sons, who, after  preserving themselves a long time from the malady,
fell into some excess, and were attacked the next day, and some
died in a few hours.   All persons,  or, at least those who have not
uncommon courage and firmness of character,  should  avoid the
sight of patients suffering with cholera, as there is something  very
frightful in the contortions of their  countenance ;  and one  must be
accustomed to attend patients, in order to behold, with  indifference
so terrible a spectacle.   Fruit and milk must  be given up; there are
persons, however, who digest milk perfectly,  and  these need not re-
nounce it.  There are others who are constantly disordered by milk
which occasions  in them an almost continual diarrhoea ;  besides this'
there are others who regard coffee and milk as  a daily  purgative
and such persons should abstain from it.  I know there are some who
say,  " If I do not take coffee with milk, I shall have no stool."  I an-
swer them, " Give up your coffee and milk, should nothing pass you
for a week." All passion must be avoided, as this gives  rise  to great
inconveniences.  Above all, a resource against terror must be sought
in the moral  powers ; for this malady, so terrible when suffered to
progress, can, by attacking it in the very commencement, be made
one of the least  injurious from which human  nature suffers.   The
cholera morbus, in fine, is one of these  diseases which best'proves 
29
the power of medicine.   Had  all the physicians  in Paris agreed  as
to the manner of treating it, you would have seen wonders perform-
ed, and France would have been distinguished among the nations for
effectually arresting the cholera ;  but this is  impossible ; the idea of
uniformity of thought is a chimera, an  Utopia, to which no reason-
able man  can yield himself up.
  When the  disease commences with some  precursory symptoms,
this is truly the  moment  of  triumph.   If a  man, who has com.
monly one stool a day, or every other day, perceive,  all at once,  a
relax  in  the  middle of  the night, without cause  or motive, and
that the evacuation of ordinary matter is  followed by a white mu-
cous substance, depend upon it this man is attacked  with  the first
degree of cholera.   In this situation, it is very easy to cure him, as
I have already ascertained.   There are physicians who are satis-
fied with prescribing brandy, astringents, diascordium, simarouba, and
rhatany, with glysters and other things of the kind.  They recom-
mend also a  diminution of nourishment.  But these are only half
means.   Go at once to your object, cut off the food, apply  leeches
to the anus if the pain be in the lower part of the abdomen, and to
the epigastrium if it  be in the stomach. Make free use of the leeches
and of ice, and you are sure of success,  unless  you have to deal
with patients whose viscera were previously disordered  ; and we must
always except such cases.  I repeat what I have already told you :
it is an eternal truth  : if your patients have organic affections of long
standing,  above all if they be aged, you must  not flatter yourselves
that a cure  will be so easily effected : but when success is possible,
you will obtain it.   It is much more prudent to impose this regimen
upon them, for two or three  days, than to give them chicken and
rice, with soup.  Be severe, and make no change  in your prescrip-
tions, for  if you authorise three mouthfuls, the patient  will be sure
to take five, and the whole fruit of your labours will be lost.
   This is all, gentlemen, that  the actual state of my knowledge, and
my ideas on  the  cholera morbus, allows me  to say to you, and I
shall be extremely happy if you can derive any advantage from my
remarks. 
APPENDIX.
  (a.) The convulsive catarrh, termed, in Germany, The Grip, is closely allied,
if not identified, in character with the Influenza ;  and the observation of M.
Broussais, that the Cholera appeared in all the places  that had been visited by
the  slighter Epidemic, has been strikingly confirmed  both in England and on
this Continent.  In France, likewise, although the instances were rare in the
hospitals of the Val de Grace, they were sufficiently frequent, in other situa-
tions, to establish a similar analogy with respect to the  cholera ; and thus it
may be  remarked,  in  the  history of this disease, that the Influenza was its
precursor in Europe and America.  The severity of the epidemic catarrh,
during the last winter, over a wide extent of the territory of the United States,
and the  presence and progress of malignant cholera at the present time, lend
additional force  to the  assumption, that some connexion, however remote,
exists between the two diseases, and that a similar condition of the atmosphere
is favourable to their respective developments.

  (6.) The mode of attack, through the direct agency of the nervous system,
was exemplified  in the  army of the Marquis of Hastings, at Jubbulpore, in
November, 1817.  The  Cholera appeared at the commencement of the Pin-
daree war, and destroyed nine thousand people (soldiers and followers of the
camp), in twelve days.  In innumerable instances, the attack, in its utmost
severity, was instantaneous ; the sufferers fell as though the nervous power
were exhausted at  one blow, and rose no more.  In Pekin, in the year 1821,
the  same suddenness of  attack was visible ; people, engaged in the pursuit of"
business, were seized without a premonitory symptom, and expired frequently
before they could be removed to their dwellings.

  (c.) It has been  laid down  by most of the writers on Cholera, that the ab.
sence of the slightest biliary tinge in the evacuations, is one of the strongest
proofs of the  presence  of the disease.  Such declarations must, however
according to M. Broussais, be  received with caution ; he has remarked the
colouring of bilious matter in the discharges to the last, and therefore refuses
to admit its want,  as  a  positive proof that cholera prevails : " The Whitish
gelatinous particles always recognised in the evacuations," afford a more cor-
rect test of its existence.

  (d.) The observations of M. Broussais are not calculated to explain the ra
tionale of the  practice by the English physicians in India, and we therefore"
refer to  the reports of the  Medical Boards in that country, for the following
statement:                                                            8
  " The grand objects, recommended by the Medical Boards in  India  are to
equalize the distribution  of the blood and nervous influence ; to counteractthfl
spastic action so common  to  the irritable diathesis of hot countries to truard
against the danger of congestion in the vital organs,  and to restore the natn
ral  secretions of the  system.  The great danger of congestion  is guarded
against by bleeding; spasm and irritability are opposed by powerful narrot;™ •
whilst full and repeated  doses of calomel are admirably calculated to act unon
the  secernents, and restore them to their proper functions, and especiallv when
united,  as is occasionally the  case, and, perhaps, always ought to be \£th
antimonials.  All  this is  accomplished rapidly,  and the disfase cease! n
a few hours.  But, if from the  violence of the  attacks, or from anv otbl^
cause, it cannot be accomplished, the violence of the  disease may not be  W
resisted, and the patient, in a few hours, or, at the  utmost, in  two or thref
days, falls a sacrifice to its fury."                                       ree 
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