Surgeon General's Office erection, Cs&?/. (Tktfjr.^.e/ No. lUniL cSI . : CLINICAL RESEARCHES CONCERNING THE HOMŒPATHIC TREATMENT OF ASIATIC CHOLERA. PRECEDED BY A REVIEW ON THE ABUSE OF THE NUMERICAL METHOD IN MEDICINE. BY J.-P. TESSIER, M.D., tri PHYSICIAN TO THE HOSPITAL SAINTE-M ARGUERITE IN PARIS. TRANSLATED BY CHARLES J. HEMPEL, M.D., FELLOW AND CORRESPONDING MEMBER OF THE HOMCEOPATIIIC COLLEGE OF PENNSYLVANIA; HONORARY MEMBER OF THE HAHNEMANN SOCIETY OK LONJJON, &G. &C. NEWiYORK: WILLIAM RADDE, 322 BROADWAY. Philadelphia: Rademacher & Sheek. — Boston: Otis Clapp. — Manchester, Eng. : Turner, 41 Picadilly. 18 5 5. Entered according to Act of Congress, in the year 1855, by William R adde, In the Clerk's Office of the District Court of the United States for the Southern District of New-York. Henry Ludwiq, Printer, 45 Vesey-st. ON THE ABUSE OF THE NUMERICAL METHOD IN MEDICINE. I have. stated in my " elementary principles" of homoeopathy, that Hahnemann's method is systematically rejected by certain physicians for no other reason than because it is a theory. In the eyes of these learned men, every doctrine, every theory, every system is an obstacle to the scientific progress and development of medicine : hence according to their logic, Hahnemann's theory must necessarily be false and dangerous. Indeed, if every theory is necessarily false, there is no reason why Hahnemann's doctrine should be true. The systematic opposition of these physicians to a philosophical reform of therapeutics, which seems to me fraught with great results, naturally leads me to examine this great question : Whence comes the truth in medicine ? Does it, as has been supposed, emanate from the men of genius who have successively produced their medical theories and systems ? or does it flow from the adoption of a certain logical method, as was proclaimed by Bacon, believed by Pinel, stated "by Chomel, and repeated by Louis 1 The theory of knowledge is one of those questions which no one treats who is not either an accomplished metaphysician or a presumptuous ignoramus. Ido not consider myself capable of judging between Aristoteles and Plato, Descartes and Bacon. In this respect I abide by the conclusions of the schools and of good sense ; this is sufficient for my purpose. Not being competent, Ido not wish to meddle with the question of the origin of knowledge in its generality. I shall content myself with examining whether the medical reformers who proscribe Hahnemann's ideas, because they did not come into the world as, according to their own infallible wisdom, they ought to have come, have or have not common sense on their side in what they themselves teach ; in one word whether the method by means of which our observers and statistical philosophers pretend to reconstruct the medical edifice upon a new basis, is a serious truth or a Utopia. I shall say a few words of Pinel's endeavor to base medical science upon analysis ; of Chomel's attempt to present a doctrine exempt from all theory ; and lastly, I shall arrive at the medical reform of Louis, and shall dwell upon it at some length. Pinel lived at a time when analysis was spoken of as we talk now-a days of progress, at a period when, in order to pass for a man of intellect, one had to be a friend of analysis as one has to be, in our time, a friend of progress. Pinel fell into the trap which the philosophical sophistry of his period laid to the simplicity of his genius. He imagined in good faith, but with a feeling of honest vanity, that, previous to his teachings, physicians had neglected analysis, because they made no more mention of it than they did of synthesis. He therefore betook himself to the task of basing medicine upon analysis, of declaiming without rhyme or reason against all theories, systems, flights of the imagination, premature conclusions, &c. But when he undertook to compose a book, the analysis remained outside on the cover, and the book was a synthesis or a nosological classification very much resembling that of Cullen. Moreover, Pinel believed in what he called the eternal principles of the healing force of nature which is as synthetical and hypothetical an idea as ever was. As a philosopher, Pinel is therefore without any merit, since he was unable, in the matter of method, to distinguish his right from his left hand. This does not take away his claim as a medical authority ; but we cannot admit that it was his mission to direct the intelligence of the medical profession in a new channel of philosophy. To conduct others we must in the first place be able to walk without leading-strings. The reform of medicine by analysis is therefore an illusion which the spirit of the age rendered excusable. iv ON THE ABUSE OF THE NUMERICAL METHOD IN MEDICINE. 5 Chomel who was an eminent practitioner and a distinguished pathologist, was frightened in his younger years by the impetuosity of Broussais, and this impression has clung to him all his life time. Seeing the pernicious influence which the theory of irritation had on the general science and practice of medicine, he conceived an aversion against all theories. He suspects every thing, which is not a simple isolated fact, or some direct inference from particular facts which it is easy to establish. The dread of an evil frequently leads us to a worse one. Chomel arranged his personal impressions into an absolute system ; this was an error. More than this ; since it is just as impossible to do without theories as it is to live without air, and since Chomel is subject to the common laws of humanity, it follows that he has theories, that he propounds theories without knowing it, and that, in this respect, he lives in a complete illusion. I will proceed to the proof of this. Chomel closes his '¦'¦Elements of general 'pathology' I with these words : " our object has been, we do not hesitate to to repeat it, to find the limits of our subject, to endeavor to reach them without going beyond them, and to present on an essentially abstract subject, a doctrine exempt from theories, and exclusively founded upon facts, and upon their immediate and rigorous consequences." Here we have an author who is well convinced that he is no theorizer, that he has presented a doctrine free from theories, and who would blush to have followed a theory. This author does not even inquire whether there can be doctrines without theories, or, which is the same thing, whether it is possible to think without ideas. Well, let us examine his preface : " I have spoken of disease in general as I should speak of a particular case of disease, if I intended to give as complete a history of this case as it is possible to give " Hence Chomel's pathology is the description of some fictitious malady, a malady that comprises every thing which belongs to pathology and therapeutics, an imaginary being, in one word, a fiction ; and this is no theory ! Chomel is mistaken : it is not only a theory, but it is the oldest theory that has ever been known in medicine ; it is the theory of the absolute unity of disease, of the unity of the pathological type. This theory is the opposite of that which teaches that every disease is an entity, and which therefore admits a plurality of types, and a radical distinction of these types in pathology. The theory of the absolute identity of all diseases, belongs both, to the followers of Hippocrates and those of Broussais : the only difference existing between these two classes of philosophers is this, that, according to the hippocratists, disease is something general, a reaction of the vital principle, whereas the Broussaisists consider it. as something Hippocrates teaches : fever is every thing ; Broussais : irritation is every thing in pathology. It is the application of the theory of the typical unity of all diseases to general pathology that Chomel calls a doctrine "without theory. The pretension of furnishing a doctrine without a theory, is therefore an illusion just as much as the pretension of basing the medical edifice upon analysis ; and, although excusable on account of the early impressions of the author, it is nevertheless an illusion, and not by any means a new guide to the activity of professional minds. So far then we do not see that there exists a new method of discovering truth in medicine. And, if this new method does not exist, is it right to avail ones-self of some supposed truth as the exclusive condition of the perfection of art, for the purpose of proscribing the therapeutic reform of Hahnemann and those who wish to ascertain the truth or falsehood of this theory, precisely because it is a theory 1 It seems to me that, if it were possible to mistake an illusion for a new method, a new truth might easily be mistaken for an illusion. I have now arrived at what I term the abuse of statistics in medicine, the so-called school of observation, the numerical method. I will at once explain why I look upon this method as an abuse of statistics. From time immemorial observations and numbers have existed in medicine. From time immemorial there have been VI ON THE ABUSE OF THE good and bad observers in medicine, and numbers have been resorted to for good and bad purposes ; and the defect of a method being charged upon the inadequacy of those who apply it, and not upon the method itself, it has been supposed that the first scientific duty of a physician at all tfmes was to observe, to observe unceasingly, and to meditate upon his observations rather than to count them. Indeed numbers will always be something secondary in medicine, but it would be wrong to reject them on this account, for they may be exceedingly useful in some cases. I have not the remotest thought of condemning numbers, no more than the exaggerated importance which is attached to them ; this sort of extravagance is inherent in the very character of the numerical method, and is scarcely deserving of being noticed. The abuse to which I am desirous of calling the attention of physicians, is not exactly the tiresome and extravagant display of useless figures ; but the fact, that the natural order of things has been inverted, and that the numerical method has been substituted in the place of the medical art. This substitution constitutes the greatest possible abuse of statistics. This abuse is a characteristic feature of the School of observation, of the numerical School, of the statistical physicians, in one word, of those observers who oppose with all their might every endeavor to verify by observation Hahnemann's theory, because it is a theory. If we succeed in showing that this new basis upon which they attempt to construct the medical edifice, is a Utopia, we shall be fully justified in pursuing other methods than those of our modern so-called observers ; we shall be fully justified in not having adopted the sterile errors which these innovators offer as the source of all truth ; in one word, in not having believed that it is possible in medicine to do without ideas, without theories, or doctrines, any more than without practical observation. vii NUMERICAL METHOD IN MEDICINE. FOS SALE BY WILLIAM RADDE, 322 BROADWAY, NEW-YORK, PUBLISHER OF HOMCEOPATHIC BOOKS AND SOLE AGENT FOR THE LEIPZIG CENTRAL HOMCEOPATHIC PHARMACY. HOMCEOPATHIC MEDICINES. Wm. Radde, 322 Broadway, New- York, respectfully informs the Homoeopathic Physicians, and the friends of the System, that he is the sole Agent for the Leipzig Central Homoeopathic Pharmacy, and that he has always on hand a good assortment of the best Homoeopathic Medicines, in complete sets or by single vials, in Tinctures, Dilutions and Triturations ; also, Pocket Cases of Medicines ; Physicians' and Families 1 Medicine Chests to Laurie's Domestic (60 to 82 Remedies) — EPP'S (60 Remedies)— HEίlNG'S (60 Remedies to 102).— Small Pocket Cases at $3, with Family Guide and 27 Remedies. — Cases containing 415 vials, with Tinctures and Triturations for Physicians. — Cases with 268 Vials of Tinctures and Triturations to Jahr's New Manual, or Symptomen-Codex. — Physicians' Pocket Cases, with 60 Vials of Tinctures and Triturations. — Cases from 200 to 300 Vials, with low and high dilutions of medicated pellets. — Cases from 50 to 80 Vials of low and high dilutions, &c, &c. Homoeopathic Chocolate. Refined Sugar of Milk, pure Globules, &c. Arnica Tincture, the best specific remedy for bruises, sprains, wounds, &c. Arnica Plaster, the best application for Corns. Arnica salve, Urtica urens tincture and salve and Dr. Reisig's Homoeopathic Pain Extractor are the best specific remedies for Burns. Canchilagua, a Specific in Fever and Ague. Also, Books, Pamphlets, and Standard Works on the System, in the English, French, Spanish and German languages. B3P Physicians ordering medicines will please mark after each one its strength and preparation, as : moth, tinct. for mother tincture. 1. trit. or 3. trit. for first or third trituration. 6 in liq. or 30 in liq. for sixth or thirthieth attenuation in liquid. 6. in glob, or 30 in glob, for sixth or thirthieth attenuation in globules. ASIATIC CHOLERA. Seventeen years ago I studied at the Hotel-Dieu, under Magendie, the Cholera, which then raged so fiercely in Paris. At that time I observed about seven hundred cases.* Another cholera-epidemic enabled us to make, new observations. The interval between the two epidemics gave us time to reflect on the character of the disease. It is the result of these investigations that we now publish for the purpose of proving two things, first : that Asiatic Cholera is as well known to physicians as any other malady ; secondly : that the treatment of this disease can be founded upon a truly scientific basis. These two propositions are opposed to the general opinion existing among laymen as well as among a large number of physicians. This seems to furnish an additional reason why these erroneous opinions, which are prejudicial to our art, should be removed. It is not, by any means, my intention, to give a complete history of the cholera epidemic, from its origin. I shall confine myself to the principal points in the physiological, pathological and therapeutic analysis of the epidemic. This plan will enable me to treat a few of the serious questions that have been raised, and which, it seems to me, have not yet been satisfactorily solved. We shall perhaps likewise be enabled to draw the line of demarcation between what can be and what cannot be cured at the present day. In this way we shall point * See Magendie, Lectures on Cholera at the College de France Paris, 1832, one vol. in 8. 1 2 PHYSIOLOGICAL ANALYSIS. out what has been done and what has yet to be done. It seems unnecessary to justify the plan of this work by any other reasons. § I. PHYSIOLOGICAL ANALYSIS. The question is not to give or to find a physiological definition of the Cholera that shall account for all its phenomena. Such an investigation, after straining our imagination to the utmost, would lead us where it has led all those that have given themselves up to it for the last twenty-four centuries, to a more or less ingenious methaphor. To my mind there is nothing less scientific than a metaphor, except the mind that contents itself with it. Let us send the physiological physicians, the organists, humoralists, chemiatrists, mechanical practitioners, &c., in search of the quintessence of Cholera ; we will limit ourselves to the study of the phenomena that it presents to us. Cholera assumes three different orders of symptoms, according as it attacks the animal, vital or natural functions.* The first manifest the invasion of the * Here is a description of this traditional division of the functions, taken from the Latin of Bcerhaave : "The functions are habitually distinguished into vital, natural and animal. " Vital functions are such as are indispensable to the preservation of life ; among these we number the muscular action of the heart, the secretory action of the brain, the pulmonary action, and the flow of the blood and of the vital sprits through those organs and their arteries, veins and nerves. " Natural functions are those whose business it is to assimilate the food to the organs ; these are the action of the viscera, vessels and humors, namely : the action of receiving, retaining, moving, changing, mixing, secreting, applying, excreting, consuming. "Animal functions are so related to man that the mind either derives corresponding ideas from their action, or the will is influenced, or, stimulated into manifestation by this action ; such functions are : tact, taste, smell, sight, hearing, perception, imagination, memory, judgment, reasoning, affections and voluntary motions. " (H. Bcerhaave, Institutiones medicse, Paris.. 1747, p. 361—362). 3 ASIATIC CHOLERA. disease by a sense of .malaise, anxiety, aphonia, cramps, spasms, delirium, coma ; the second by the thinness, frequency, smallness, irregularity, collapse of the pulse, the weakness of the beats of the heart, and the embarrassed respiration ; the third by diarrhoea and vomiting, derangement of the secretions, some of which are entirely suppressed, by a sudden emaciation, by a suspension of the phenomena of nutrition, by coldness, blueness of the skin, hippocratic or choleric face, and this external appearance of the body which has been characterised by the equally correct and energetic appellation of cadaverous. To this group of symptoms we have to add congestions and inflammations that develop themselves before or after the febrile reaction, in order to have a complete aggregate of the phenomena that succeed each other with more or less regularity and connection in an attack of cholera, and the progressive aggravation of which brings the patients so frequently and so rapidly into the grave. Whatever part of the body may be assaulted, the epidemic does not seem to confine itself to an alteration of the phenomena of sensibility and contractility. Its action is deeper; it taints the very sources of life, the essential, formative powers of the organism. When the fundamental conditions of life are attacked, it is not only particular functions that are disturbed, but their ' whole relation to each other, their whole mechanism becomes deranged. Animal functions. — It seldom happens that sensibility or contractility are the first functions that are attacked in cholera; it happens, however, in some cases. Thus, for instance, the disease has set in with cramps, pains, in various parts of the body, in the head, legs or in the extremities. More frequently, before experiencing any other pain, the patients experience a marked weariness and weakness in the muscles, a vague and general 4 PHYSIOLOGICAL ANALYSIS. malaise. All this, however, occurs irregularly, and alterations in the animal functions do not always usher in the epidemic. The seat of the cramps or pains varies ; in some cases the extremities alone are attacked, in others the lumbar muscles or the large muscles over the thorax; the face and nape of the neck, and other parts are likewise invaded. When unremitting, the pains may become agonizing. Then they extort cries from the patients, and may even cause convulsive spasms. Almost all the patients retain their consciousness ; the general sensibility is likewise preserved ; the senses are but little or not at all impaired. In very serious cases they are rather duller; the hearing is rather hard, and the patient complains of buzzing ; in almost every case there is loss of voice. At a later stage of the disease, delirium and coma set in. Admitting that all these phenomena proceed from an alteration of the nerves of the animal sphere, what would be the seat of this alteration? The brain, the spinal marrow or the nerves? or would it in one case be one of these parts, and in another case another ? And the muscles, are they affected directly or only indirectly in consequence of a counter-shock emanating from the alteration of the nerves that are ramified through their tissue ? The phenomena which we observe, are not sufficiently constant to be traced to the same portion of the nervous system. As regards the question whether the muscular irritability is affected primarily or secondarily, we are unable to affirm anything positive in this respect. Either of these two circumstances may occur. If we attempt to establish an order of succession in these modifications of the animal functions, two contrary opinions will likewise become apparent. Either the phenomena which seemed isolated at first, react, each in its way, upon the 5 ASIATIC CHOLERA. brain, and there become concentrated, or else the phenomena emanate from the cerebral mass as their focus, and localize themselves successively in the various elements of the animal functions. The specific mode of action as well as the unity of the nervous system, the double evolution of its phenomena from the centre to the periphery and from the periphery to the centre, do not permit any affirmation in this respect, for the positive demonstration of either of these mechanisms is impossible. Vital functions. In the history of the vital functions we have to examine the blood-vessels, the circulation, the blood and respiration. The tone of the vessels is sensibly affected by the cholera. It is well known that their tone depends upon the voluntary expansion and contraction of their tissue. These properties are entirely different from their elasticity, which is not spontaneous. The coats of the veins are flabby, although these vessels are not empty. If a vein is opened, and the blood pressed out, the coats of the vein do not contract, they remain what they were. Ido not know whether a similar phenomenon takes place in the arteries ; inductive reasoning would seem to lead us to think so. The beats of the heart are weaker ; its contractions seem without energy ; they are not unusually excited by the obstacle which the capillary circulation seems to oppose ; on the contrary, the action of the heart is just as depressed as that of the veins and arteries. It would seem as though the blood could not pass beyond the capillaries, for it accumulates in these vessels, especially in their terminal ramifications, and there produces these passive congestions, and this blueish color which are one of the characteristic signs of cholera. Generally however, when the blood does not flow to a part in sufficient quantity, without there existing any obstacle to the venous circulation, this part assumes a livid pallor. 6 PHYSIOLOGICAL ANALYSIS. The veins seem to swell, and the venous blood bears no proportion to the corresponding arterial blood.* In cholera a state of inertia prevails at the centre as well as at the periphery of the sanguineous system. The circulation is still going on even when the pulse has become imperceptible. This is evident from, the fact that camphor or ether which has been deposited in a mucous bursa, is absorbed ; but the circulatory movement is exceedingly depressed. The blood is visibly altered in epidemic cholera. This alteration affects the proportion of the fluid to the solid constituents of the blood. Becquerel has furnished an interesting description of these alterations. Beside the chemical alterations, the blood presents altered physical and physiological properties. The first alteration, which was pointed out by Magendie in 1832, is the extreme viscidity of the blood during the disease as well as after death. This viscous blood does not turn red when exposed to the air ; but if previously mixed with a certain quantity of water, it will then turn red when exposed to the air. This viscidity seems therefore to be owing to the absence of water, and to certain changes in the proportion of the solid constituents of the blood. As regards the physiological alteration of the blood, consisting in the fact that it is no longer coagulable, it remains even after the addition of water, or after the blood has turned red. This is a most important phenomenon. It shows that the blood has lost its only vital property, its plasticity. This loss of plasticity corresponds to the loss of tonicity in the organized tissues ; it is the cessation of the spontaneous molecular movement by means of which life becomes manifest according to * Before making any artificial injections in animals, it is even useful to tie the arteries of the part that is to be injected, a few moments previous to the operation. By this means the part through which the tied artery courses, becomes bloodless. 7 ASIATIC CHOLERA. its inherent quality. In severe cases of cholera this alteration develops itself progressively ; it indicates a disorder that is carried to its extreme limits, since it is, so to say, the commencement of death. Does this vital alteration of the blood take place directly, or is it the effect of the excessive alvine evacuations 1 If this latter supposition were true, the alteration of the blood could only take place after considerable discharges from the bowels had taken place. But it is seen even at the commencement of the disease, before the bowels had been much affected. lam therefore inclined to think that the alteration of the blood takes place directly, and that, on the other hand, the evacuations exercise a marked influence on the constitution of this fluid. In its mechanical phenomena the respiration does not seem disturbed ; but may we not suppose that the blood in the lungs remains unaltered ? It would seem so, to some extent at least, since the arterial blood, during the course of the malady, is as black as the venous blood. These extraordinarily rapid and deep alterations of the vital functions constitute one of the particular features of cholera ; they do not exist to the same extent in any other disease. Natural functions. — These functions are the first that become altered during an attack of cholera. This alteration exists in every stage and form of the disease. Erom the mouth to the anus, all the phenomena are modified ; it is not only the secretions that are altered ; the tissues are likewise changed by characteristic symptoms of inflammation. The most striking changes are excessive intestinal and gastric secretions, suppression of the bilious secretion after a few evacuations, and suppression of all the other secretions. The altered appearance of the secreted substance indicates the derangement in the natural functions. 8 PHYSIOLOGICAL ANALYSIS. The unitary relation of the secretions shows itself by the suppression of some, and the excess of the gastrointestinal discharges. If sweat appears, it is only a partial sweat, in the face, on the extremities ; the unity of the secretions is least perceived on the skin. The external changes of the body are exceedingly remarkable. The totality of these changes produces the well known cadaverous aspect of cholera-patients. They show a deep alteration in the nutrition of the solids. The skin is either the seat of partial congestions in the face and at the extremities, or else extending all over the body; these congestions have a livid appearance. Simultaneously with the appearance of the congestions, the mucous membrane collapses, and the skin loses its tonicity. This coincidence of the congestions with the loss of tonicity and the diminution of animal heat in the affected parts, is a sign of a most violent attack on the vital forces ; it is the sign of a death-struggle from the commencement of the disease. In order to complete this physiological analysis of the morbid phenomena of the cholera and group them into a unit, it remains for us to determine their order of succession or mutual relations. This can only be done imperfectly, but it may be useful to make the attempt. In cholera life is attacked to its very foundation, but not to the same extent in every case. The vital principle cannot be attacked in its very sources, in its formative powder, without vital products manifesting a corresponding alteration. Indeed, in all the affected parts, we not only notice a functional derangement, but a perceptible alteration of nutrition and of the properties of these parts themselves. I have already pointed out the diminished tonicity of the tissues, and the diminished plasticity of the blood. These, however, are not the only alterations in the phenomena of reproduction, since 9 ASIATIC CHOLERA. simple irritations may be succeeded by real inflammations, the signs of which become more marked in proportion as the disease develops itself beyond its cold stage. The phenomena of cholera are different from the socalled nervous phenomena, which simply affect the surface of the vital functions. In cholera the depths of life itself seem to be tainted. The phenomena of irritability depending upon those of reproduction, it clearly follows that these must be succeeded by an altered sensibility and contractility in each of the various apparatuses attacked by the cholera. Here follows the order of succession in the phenomena of cholera as manifested in each of these parts. The organs of the natural functions are always attacked, but they may be attacked alone. Tlie derangement of the natural functions is generally succeeded by a derangement of the vital functions ; in such a case the organs of the animal functions are scarcely ever left intact ; sometimes the derangement of the animal functions even precedes that of the vital functions. These alterations vary through a whole series of degrees ; they are either more marked in the natural, animal, or simultaneously in two of these three orders of functions. One may likewise cease whilst the other is just commencing, and the disease may thus attack one apparatus after the other, abandoning at least in a measure the former before it attacks the second, and the second before it passes to the third. In some cases these three classes of apparatuses are struck simultaneously by the disease from its very commencement, and with an extreme violence. Not only may the organs of the natural, vital and animal functions be deranged, but the central nervous system which maintains the normal relation of these organs to each other, may likewise be attacked. If this happens, we observe in the production, succession and relation of 1* 10 PHYSIOLOGICAL ANALYSIS. the morbid phenomena those strange irregularities which are designated under the name of ataxic cholera. Last question. How does death take place in cholera 1 ? We have seen that the phenomena of formation are intensely altered in an attack of cholera ; we may therefore, conclude, that death takes place in consequence of the immediate lesion of the vital principle. As to the mode of dying, it varies according as the patient dies at one or the other period of the disease. In the cold stage the vital spark becomes extinct gradually and progressively ; nevertheless death finally takes place when the irritability of the heart has become extinct, and its beats cease in consequence. The organs, in this case, present all the symptoms of death by syncope, as Bichat has described them, without, however, the characteristic cholera-changes being any the less on that account. After the reaction, death almost always takes place by the brain; but, since at the last moments, the alteration of the vital functions is combined with that of the central nervous system, and the coldness and blueness reappear with the cessation of the arterial pulsation's, it follows that death takes place both by the derangement of the cerebral functions and by the discontinuance of the heart's action. Indeed the signs of death by the brain, and those of death by the heart, in other words the signs of asphyxia and those of syncope are found combined.* I shall not carry the physiological analysis of cholera any farther. It may be said that this analysis does not shed any light on the inmost nature of cholera. This is true, but we ought not to ask of physiology what it cannot give us. Beyond analysis we have fancies, arbitrary hypotheses, illusions and deceptions. They * See Bichat's Investigations of life and death. (Recherches sur la vie et la mort.) 11 ASIATIC CHOLERA. all lead to extravagant conclusions, from which the cholera would not be an exception. §II- PATHOLOGICAL ANALYSIS. The term cholera is thus defined by Boerhaave : A violent evacuation from the stomach and bowels upwards and downwards* If applied to the disease, ¦whether epidemic or sporadic, of which we treat, the term morbus was originally added to it : cholera-disease, real cholera. The disease is, therefore, named, in accordance with its principal symptom. It is not my intention to describe it here in all its completeness, not having any thing to add which is not perfectly known to every body ; I shall limit my pathological analysis to the forms which the cholera presented in 1832 and 1849. These forms were the same in both epidemics ; the only difference consisted in the frequency of the cases or the intensity of the disease. But these differences which will be indicated when we come to speak of the particular varieties of the epidemic, are sufficiently marked to enable us to account for the general physiological difference between these two epidemics. By fgrm I mean what pathologists were in the habit of designating as varieties. A form is, therefore, not characterised by a single symptom, but by an essential change in the combination and order of succession of the morbid phenomena. f The cholera disease presents itself under the following four forms : 1. Cholerine. 2. Simple cholera. 3. Ataxic cholera. * See Boerhaave's Institutiones medicce, Paris, 1774, p. 401. t This does not seem an appropriate place of entering largely upon a discussion of this general pathological question ; I have said enough for every enlightened reader. 12 CHOLERINE. 4. Black or galloping cholera. I do not consider such general symptoms as an undefinable malaise, lassitude, more or less painful embarrassments of the bowels, and slight attacks of dyspepsia, which many individuals experience during an attack of cholera, as belonging to the disease. I shall simply point out the phenomena which belong to every epidemic, and which proceed in a measure from fear, chagrin, a pre-occupied state of mind, a change in diet and general habits, and from the precautionary measures which had been taken with more or less discretion against the disease. CHOLERINE. We frequently designate by this name the diarrhoea that precedes an attack of cholera. By cholerine we here mean the real cholera, also termed cholera diarrhoeica, which is the least dangerous variety of the disease. This form presents itself with various modifications. Sometimes the accompanying symptoms are so slight, that one hesitates, but improperly, in our judgment, to consider the disease an attack of cholera. These symptoms are a malaise, a sense of soreness and weariness, accompanied by a diarrhoea which is at times a mere serous discharge without colic, and at times a slightly dysenteric attack with acute colic and some nausea. After having lasted from one to three days, this condition disappears of itself, leaving behind it a more or less painful torpor of the digestive canal, which either ceases in a few days, or else continues for several weeks and even months. In another degree of cholerine we notice either a sudden or else slow and progressive invasion of a serous diarrhoea, which is at first colored and afterwards whitish, accompanied by a general sense of weariness, slight 13 ASIATIC CHOLERA. shudderings, followed by nausea and some slight vomiting, after which the sense of general coldness and weakness becomes more marked ; at this period some slight cramps are experienced in some part of the body, sometimes in the trunk, and at others in the extremities. This condition is generally transitory. A remission of the symptoms soon takes place, the colic and diarrhoea decrease, the vomiting ceases, the general temperature is restored, accompanied by a slight febrile motion of a day's or half a week's duration. The cramps generally disappear together with the nausea and vomiting ; at other times they continue, the patient experiences them several times in the course of twenty-four hours, or else a continuous and dull pain or a weakness, which remains unchanged for a long time, takes their place in the .region where the cramps were experienced. The least error in diet may bring back all these accidents, even after they had completely disappeared. A relapse may likewise set in in consequence of great bodily exertions, exposure to the cold air, an excessive repast, violent emotions. In such a case it is a more serious form of cholera that attacks the debilitated constitution. A relapse in this form of cholerine should be represented to the patients as something very dangerous. Another modification of cholerine consists in a derangement of the digestive functions and organs, accompanied with a moderate febrile motion. The coldness is only felt at the beginning of the disease, when bilious vomiting takes place, together with the bilious or serous diarrhoea, which constitutes a feature in this modification. The head is heavy and painful, the face is more or less flushed, the eyes are slightly injected ; the buccal cavity presents symptoms of a congestive irritation, and even of an inflammation, which is characterized by the swelling and redness of the free margin of the gums, the soft deposits on their convex surface, the redness 14 SIMPLE CHOLERA. of the tongue at its edges, the thick coating which covers its dorsal surface with more or less uniformity or irregularity, the dryness of the throat, and an intense thirst ; the epigastrium is sensitive and feels painful when pressed upon ; considerable heat is felt in the region of the stomach, which sometimes extends as high up as under the sternum ; in the abdomen the patient complains of seated pains around the navel, or of shifting pains in the hypogastrium or in the sides ; the urine is scanty, turbid, and the discharges are not frequent. Cramps occur but seldom ; but the soreness, weariness and pains in the extremities are habitual symptoms. This condition generally lasts seven days ; in some cases, however, the malady terminates critically by sweat, nosebleed, abundant or cloudy urine, an erythematous eruption on the skin ; generally the malady disappears gradually, leaving behind it, for a shorter or longer period, consecutive phenomena, such as a troublesome stomacace ; painfulness of the stomach and dyspepsia ; distention and torpor of the bowels, or an irregular diarrhoea ; either of these symptoms may occur when the patient exposes himself to the cold, or commits the least error in diet. Cholerine, which is almost always cured in young people, very often terminates fatally in old persons ; they sink gradually, and die after a series of slight^ relapses. In such cases the intestinal inflammations are generally accompanied by prostration and a comatose drowsiness. SIMPLE CHOLERA. This form is generally considered typical of epidemic cholera. 1 have seen many instances of it towards the close of summer, between the two epidemics of 1832 and 1849. Sauvages asserts, that in his time, some twenty 15 ASIATIC CHOLERA. cases of it were admitted every year into his hospital of St. Eloi of Montpellier, if lam not mistaken. This is, proportionally, a much larger number than occurs at Paris, when the disease is not epidemic. The simple cholera presents two well-marked periods : a frigid period, and a period of reaction, when a cure is about to take place, or else a period of collapse, when the disease terminates fatally. For the sake of more completeness we will divide the phases of the disease into a greater number of periods. Period of the precursory Symptoms. — The precursory symptoms vary. Sometimes they consist in a diarrhoea without colic, with increasing alvine discharges first of foecal matter, afterwards of a watery substance which is green or of a pale color, and finally assumes a whitish appearance. This phenomenon may be accompanied by others, but it is sometimes isolated until the actual invasion of the disease. The diarrhoea may be accompanied by colic, with an urging to stool as often as the colic is felt. In such a case the patient generally experiences an increasing feeling of weakness. In other cases the precursory symptoms consist of more general, and more vague phenomena; the head is slightly embarrassed ; slight attacks of vertigo take place every now and then ; sleep is disturbed ; the patient is tormented by an undefinable uneasiness. JThere is loss of appetite, anorexia, with or without thirst, a bitter or flat taste in the mouth, slight nausea, a certain fulness in the epigastrium, and a sensation as if the hypochondria were traversed by a bar that now rises and then descends again ; the abdomen is distended ; the patient is seized with urging to stool, after which the diarrhoea develops itself, consisting nearly of profuse serous discharges without any foecal odor. The patient complains alternately of heat and cold ; his face is pale, his complexion sometimes sallow, he looks sad and his voice is 16 SIMPLE CHOLERA. somewhat hoarse and thinner. These phenomena increase and decrease alternately. The nausea which accompanies the alvine evacuations, increases more and more ; and the nausea is accompanied by weakness, vertigo and coldness until the moment when the disease breaks forth. If the precursory symptoms do not exist in every case, the cases where they are wanting, are, at any rate, very few. The duration of the precursory period varies from a few hours to several days. During this period most of the patients attend to their business or pleasures. It is sometimes after a meal that the second period commences. Period of invasion.— This period has three principal symptoms, diarrhoea, vomiting and cramps. After a feeling of anxiety and malaise, the patient is suddenly seized with a copious vomiting of alimentary substances mixed with liquids and the gastric fluid ; he feels easier after the vomiting, but he, at the same time, experiences a sense of coldness, which runs through the trunk and extremities ; thirst sets in, but the introduction of beverages into the stomach excites fresh and easy vomitings of fluid substances, which look more or less bilious; the vomiting is speedily followed by a ligllt-colored and profuse diarrhoea, accompanied by borborygmi and soon after by sinking of the abdomen. The nausea which exists simultaneously with the diarrhoea, is soon followed in its turn by vomiting. In the bends of the knees, or in the knees, loins, hypochondria, and in the upper and lower limbs, the patient experiences simple pains, or distressing cramps. At this stage the patients generally take to their beds and try to get warm. But their rest is unceasingly disturbed by alvine or gastric evacuations, or by muscular pains, partial shuddering and coldness. The invasion of the disease is sometimes progressive and, except the vomiting, this period cannot be distinguished 17 ASIATIC CHOLERA. without difficulty from the preceding one. It sometimes lasts for some hours without any new symptoms supervening. At other times it sets in abruptly, and the disease develops itself at once as soon as it invades the organism. In some cases the diarrhoea ceases for a moment as soon as the vomiting takes place ; there are likewise cases where no cramps occur. On examining the condition of the organs at the time when the first attack takes place, we find a well-marked inflammatory congestion of the gums and tongue ; on its dorsal surface the tongue is covered with a uniform, characteristic, white coating, and at its edges and on its inferior surface, it exhibits a red, somewhat livid color, which contrasts very decidedly with the color of the coating. The throat is likewise irritated ; the oesophagus is sometimes painful in its whole extent, the epigastrium is painful to pressure, the abdomen is tormented by colic, which spreads from the navel to the neighboring parts. The urine, which had been scanty until then, ceases to flow ; the skin of the hands is cool, likewise that of the face. The aspect of the patient is not yet much altered ; but when the attack takes place with violence, the features of the patient alter at once. Period of increase. — This is termed the cold period, on account of the new symptom which is added to the former. After the vomiting a remarkable change takes place in the pulse, which becomes feeble, irregular, intermittent. The temperature of the extremities sinks, first of the lower, then of the upper. The skin of the extremities looks livid ; the face changes rapidly ; the eyes seem to retreat into their sockets in consequence of the collapse of the cellular tissue ; the nose becomes cold, the lips blueish, the general malaise and the anxiety increase ; cramps set in after the alvine discharges, which become more and more frequent, and look whitish, are mixed with grey or white flocks resembling the offal of 18 SIMPLE CHOLKRA. washed meat, or rice that had been boiled too long. The vomiting becomes more and more copious ; the patient is no longer relieved by the vomiting as at first ; on the contrary, it is preceded and followed by burning at the epigastrium, under the sternum, and by a painful pressure at the epigastrium. The patient is restless, complaining at times of coldness, at others of heat of the extremities ; the cramps become much more frequent ; the face and extremities exhibit signs of rapidly increasing emaciation; the livid color of these parts changes to a blueish violet color, which becomes more and more marked. The eyes are dull, dry, the nostrils are frequently covered with a dusty substance, the nose is pointed ; the blueish parts are covered with a cold sweat ; the pulse becomes smaller, feebler, more imperceptible, at times regular, at others unequal and intermittent, or slower or more frequent than in a normal state of the system. The voice becomes gradually extinct, and the patient speaks only in a low tone of voice ; and when he does speak, it is only to ask for drink, wherewith to quench his burning thirst. He is also heard to moan or to utter plaintive cries when the violent cramps seize him. The cramps become more and more painful, more and more general. Generally they decrease under the influence of heat and frictions. But all such relief does not last long. Sometimes the accidents seem to cease for some hours, and it seems as though a real remission of the symptoms were setting in ; but soon after, the diarrhoea, the vomiting, cramps, blueness and coldness reappear with an increased intensity. These illusory remissions may last a day or a night ; but then the symptoms return with increased violence at the hour when they had broken out the day before. These remissions have given rise to the belief that there is an intermittent cholera. The period of growth lasts from a few hours to twentyfour 19 ASIATIC CHOLERA. and even forty-eight hours, after which the symptoms seem to remain stationary for some time. Acme. — When the disease has reached its acme, the symptoms remain for some time the same ; they present a complete development of the cholera. The patient generally lies on his back ; the position of the patient varies according as he is quiet or restless. The features of the patient exhibit what is termed the hippocratic face. Its complexion is cyanotic, especially the ears, nose, eyelids, lips'^ this blueish color invades the upper part of the neck, and sometimes the whole neck. Generally the face is without any expression ; nevertheless the sensations and even the feelings of the patient are still depicted in it; it looks 'frightful when the patient is tormented by cramps. The skin of the trunk frequently preserves a certain warmth ; that of the extremities is cold, livid, blueish, wrinkled, dry or moist. The intellectual faculties are undisturbed, the senses preserve their respective faculties. However, the patient is troubled with vertigo, buzzing in the ears, and does not wish to talk. The pains are more or less violent and scattered; the most intolerable of the pains are the burning under the sternum, the bar across the epigastrium, and cramps in the muscles of the trunk. The muscular strength is considerably decreased; nevertheless the .patient is still able to sit up in bed either for the purpose of drinking or vomiting; the trunk and the extremities move with an astonishing ease. The breathing, which is frequently natural, is often embarassed by the constrictive cramp-pains of the thoracic muscles ; it is sometimes hurried. The voice has no resonance, or it is hoarse and feeble ; at the base of the thorax the patient experiences an anxiety which sometimes increases to a perfect agony, and makes the patient say that he is choking. 20 SIMPLE CHOLERA. The beats of the heart are weaker than in a normal state ; the pulse of the large arteries corresponds with the beats of the heart ; at the wrist the pulse sometimes differs, being either very small or completely extinct. Sometimes it is only felt on one side. The tongue and mouth are the seat of a well-marked stomacace ; in many cases the throat is similarly affected. The vomiting at this stage may be considered typical of the vomiting in cholera ; likewise the atonic discharges. In the discharge's from the stomach or bowels, the bile has entirely disappeared. The urinary secretion is completely suppressed ; the secretion of tears and nasal mucus likewise ceases. In some patients sweat breaks