Letters on the cholera asphyxia, as it has appeared in the city of New York : addressed to John C. Warren, M.D., of Boston, and originally published in that city. Together with other letters, not before published

Front matter

LETTERS

ON THE

THE

Letter I

New. York, August IQlh, 1832,

Deau Sir,

I HAD intended to have earlier acknowledged your very flattering attentions, and to have expressed the interest and instruction with which I perused the Report of the Massachusetts Medical Society ; which, although purporting to express the opinions of others, is undoubtedly one of the best original essays which has appeared on the subject of Cholera Asphyxia. This delay, however, enables me to add a few words in relation to the disease as it has appeared in this city, which I do, not from their novelty, but to show you how Nature and Art have still travelled the beaten path.

The Cholera Asphyxia has presented to our observation the same combination of phenomena that has distinguished the Epidemic in other quarters of the globe ; and when the varieties of constitutions, the differences in habits, sex, age, &c. are duly considered, the symptoms are remarkably uniform, particularly after asphyxia has supervened. The disease has been less malignant here than at Montreal and at Paris, which is probably to be ascribed to the better ventilation and greater cleanliness of our city ; for your own observation will yet assure you, that the disease, at least in cities, requires for its production the co-operation of local miasmata with the general epidemic poison ; and doubtless the same local developements give intensity to the poison wherever it prevails. Well favoured cities, therefore, with spacious streets, and especially where a proper attention is paid to the cleanliness of yards, houses, &c., and in which a crowded population is not permitted during the visitation of the Epidemic, may expect to reap a rich reward from measures that are so clearly dictated by experience and philosophy. In New- York we may be said rather to have suffered several endemics than a general epidemic. The epidemic poison has not been sufficiently active to produce a full predisposition to the disease, without the co-operation of local causes. It has been confined to the malarious part of the town, and generally to such houses as are small and crowded with inhabitants,— in some instances not less than a dozen in one house having died in rapid succession.

Although we may recognise in a very striking degree the phenomena of the Asiatic disease, they are more or less distinct in different subjects ; each case, however, presenting nearly the same combination. The symptoms most liable to modification, are lividness and collapse of the features, these being more frequently absent than has been remarked in other countries. Asphyxia, or nearly so, is a uniform symptom of the stage of collapse ; so also are the unequal distribution of heat, vomiting and purging, — almost invariably of a fluid resembling rice water, — very generally spasms, cold sweat, corrugated skin and bluenesa of the fingers, cold tongue, cold breath, suppression of the glandular secretions, &c.

The morbid appearances on dissection have been less uniform than the symptoms, and our pathology has been consequently much embarrassed. The small intestines commonly exhibit some appearances of congestion either of the mucous or serous coat, generally of the former ; the large intestines commonly blanched, especially if the diarrhoea has been profuse ; the stomach nearly natural ; liver sometimes greatly injected, but often very natural ; kidneys, spleen, and pancreas natural ; bladder empty and generally contracted. The gall bladder contains from one to two ounces of black, green or yellow bile. There is generally, though not always, an absence of this fluid in the intestines, which usually contain a substance similar to that evacuated during life. It has been well compared to rice water, with flocculent matter, which is soon deposited. The texture of the small intestines, particularly, is often softened, which has induced some physicians to ascribe this result to a violent inflammation of these organs, and to regard this action as the proximate cause of the disease. But so far as symptoms and appearances, that usually denote inflammation, are necessary to this theory, they are certainly nearly wanting in Cholera Asphyxia,— venous congestion being almost the only sensible condition of the blood-vessels. Both cavities of the heart are sometimes filled with black blood, and they are sometimes empty, —appearances which also attend the lungs. The brain is more uniformly injected than any other orgai^, and usually contains, either in the ventricles, or within its membranes, a preternatural quantity of serum ; yet the integrity of the mind is not much impaired; The veins of the spinal sheath are also commonly full.

Here, as every where else, the disease was most malignant at its irruption, and has become milder as the epidemic air has abated. Most of the subjects perished, at first ; and our greater success, now, arises from the milder condition of the disease, from a longer duration of the premonitory symptoms, and from the more susceptible class having been swept away. The nature and treatment of the epidemic are probably no better understood than when it first invaded Europe; The Asiatic physicians appear to have exhausted the subject, and the more we have departed from their modes of treatment, the less successful have been the results. It is certain that the disease was less fatal in Asia, where it is supposed to have been most malignant ; and it has been destructive in an increasing ratio ever since it appeared in Europe. At Quebec and at Montreal scarcely any recover, at this late period, after the accession of Asphyxia. Here the disease having been milder, the recoveries, after that stage, have probably been about one in six. If the habits of the patient have been regular and temperate, perhaps it is one to four or five that he will recover, if asphyxia have not existed more than one hour ; but no such good fortune awaits the intemperate. The noise which he hears is his funeral knell.

I have not remarked that changes of temperature or atmospheric phenomena, have exerted much influence on the character of the epidemic. It seems to have been governed by its peculiar laws, which have been scarcely modified by accident. The irruption took place when the weather was delightfully serene, and the city most remarkably exempt from disease. Diarrhoea had not even preceded it ; and it was an astonishing spectacle to witness the work of the destroyer without the usual admonitions of his approach. It was then that we had Death and not disease in our city. His march was rapid, under a cloudless sky and a most genial temperature ; and the mortality acquired its maximum during this seemingly auspicious state of the atmosphere. There then began a decreasing ratio, the weather and temperature becoming more variable, and the present storm, which has continued a week, seems not to have retarded its decline in the city; while in the neighbouring country the disease is appearing most malignantly under the same conditions of the atmosphere.

What are the exciting causes ? It has been very rare, if it has ever happened in this city, that the epidemic poison has done more than predispose the system. Other causes have been necessary to the developement of the disease, and perhaps none have acted with greater intensity than the exhalations which arise from filth and decaying materials. Indeed, the agency of these causes appears to have been almost indispensable, for few have suffered the disease who have lived temperately and prudently without the malarious districts. Consequently the disease has chiefly prevailed, and deaths have principally occurred, among the most abject of the lower orders,— attacking constitutions that have been rendered susceptible by vicious habits or broken down by disease. Still we have lost some valuable citizens, whose habits were temperate, and whose lives were exemplary ; but let us convert their loss to at least one good purpose ; let us avoid those exciting causes which, in almost every instance, have sent them prematurely to the grave. These causes have generally consisted in some kinds of indigestible food ; what in ordinary conditions of the atmosphere are inoffensive, but which are death to a subject predisposed to cholera. Garden vegetables, and almost every species of fruit, have been known to develope the disease ; and the prudent part of our population now restrict themselves to lean fresh meat, potatoes, boiled rice, stale bread, eggs, milk, butter, tea and coffee, and it is considered hazardous to extend the variety. Fatigue, imperfect clothing, currents of air, exposure to the rain, and depressing passions of the mind, have been known to create the cholera.

We have not been able to add any thing new to what has been long known, or rather unknown, respecting the proximate cause of the malady. Most of us are well satisfied that it possesses nothing in common with the ordinary cholera morbus, but that the diseases are essentially distinct. The hypotheses are very various ; some regarding it as a local aftection, and others as constitutional ; some referring it to a primary inflammation, congestion, or some unknown modification of the action of the alimentary canal ; others to congestion of the brain, or of the spinal marrow and ganglia ; while others look alone at the diminished glandular secretions, — and still another places the whole mischief in the carbonization of the blood, — and yet another regards the absence of the saline principles as the sine qua non. To me, however, the disease is just as obviously a constitutional one. We have frequently witnessed the invasion of asphyxia, without any premonitory symptoms, when it has been sufliciently apparent that all the functions and all the powers have been simultaneously affected. If this hypothesis be true, we shall understand why one important organ is at one time apparently sustaining much of the burthen of morbid action, and at another none at all. From so great a diversity of opinion respecting the proximate cause of cholera there would necessarily result a great diversity of treatment; but the variety of means employed very evidently arises, in part, from the want of success which attends every method.

We have no difficulty with the disease in its preliminary stages ; but after asphyxia has fairly supervened, I do not believe that one patient in six is restored by any process, whatever may have been asserted on this subject. I have seen much of the disease, and have looked at it impartially ; and I express a solemn conviction on the subject of its fatality. I have seen every method tried, and in some I have no confidence at all. I have none in what has been denominated the camphor treatment, exclusively ; none in the exclusive use of ice internally. I have seen the best results from powerful external stimulants ; — calomel more or less modified by small quantities of opium, according to the irritability of the mucous membrane, and camphor is a useful addition if spasms be present; friction with camphor, or applications of ice for the relief of spasm ; stimulants moderately to sustain the sinking powers, of which ammonia seems the best. The irritability of the mucous membrane is easily allayed, and is very rarely an obstinate symptom, — the most prominent, during the stage of asphyxia, being the absence of pulse, unequal distribution of heat, restlessness and altered expression of countenance. We have nearly abandoned transfusion, from its almost uniform failure. The recoveries I do not think have been in the ratio of two to fifty. The temporary eff"ect is very encouraging, but the patients soon die. Our best practitioners employ calomel in large and small doses, some preferring 15 to 25 grains once in three or four hours, and others five grains every hour. I have seen no good'effect from blood-letting in any instance after asphyxia; but this may have arisen from the quantity having been small, and the difficulty with which it is invariably abstracted. From the pathology of the disease, and the experience of the Asiatic physicians, I have been in favour of the remedy.

I regret that my time will not permit me to add more at present. Your citizens ought to be well informed of the fatality of the disease after the stage of asphyxia, and of its mildness before that stage supervenes, that they may be early induced to attend to the premonitory symptoms.

Very respectfully, &c.

LETTER II. New- York, August I8t/i, 1832

Dkar Sir,

I HAD yesterday the pleasure of receiving your favour of the 15th inst., and I was certainly agreeably surprised, that my remarks on the subject of Cholera Asphyxia should have afforded you the interest you do me the honour to express, and more particularly that you considered them worthy of publication. In relation to your inquiries respecting the symptoms vi^hich have marked the accession of the Cholera in this city, there exists here, as in other countries, the remarkable fact, that the earliest manifestations of disease are almost uniformly mild, and bear no corresponding ratio to the tremendous developeraent which suddenly succeeds after a certain duration of that premonitory stage. This introductory stage is very rarely wanting, and its duration and symptoms depend much on temperament and habits. The symptoms generally denote some impaired function of the digestive organs, and usually consist of diarrhoea, frequently connected with nausea and vomiting. This condition in many instances is preceded by constipation, which, however, is not so uniform as has been imagined, but which, if neglected, is very liable to result in diarrha3a. There is, indeed, a general tendency to looseness of the bowels, and they, who have been habitually compelled to employ some laxative medicine, find now an ample substitute in the epidemic influence. This is a fact, which, I think, cannot be too well understood ; for it is this impaired state of the digestive organs, this tendency in all to looseness and diarrhoea, which have rendered our precautions in relation to food so indispensable, and which, when disregarded, have taught a lesson of prudence that few would have heeded, but for the terrible penalty so evidently connected with the indulgence. If the habits of the patient have been prudent, especially in respect to food, the diarrhoea is moderate, continuing, if it terminate in malignant cholera, for many days without vomiting, and not productive of much prostration or distress, till collapse suddenly supervenes. If indigestible food be the exciting cause in a temperate subject strongly predisposed, vomiting is an early symptom ; which, however subsides, and there only remains for. a while, the diarrhoea, afterwards maintained by slighter errors in diet, till it sooner results in Asphyxia than in more abstemious subjects. I have not observed that constitutions impaired by disease, where great prudence has been practised, are more obnoxious to cholera, or that collapse sooner succeeds the premonitory stage than in the robust. Particular circumstances have led me to attend closely to this fact, and my observations on this subject do not concur with book authority. But it is equally true that constitutions.

impaired by intemperance and prostitution, are peculiarly the subjects of this pestilence ; and I cannot agree with Mr. Fife of Gateshead, "that drunkenness is not a powerful predisposing cause," though doubtless very much is to be ascribed to the influence of other accidental causes, — particularly excesses in food, and the filth in which they riot. The succession of primary symptoms is more rapid in such instances ; but still there is commonly a period for the successful intervention of art, but which is generally neglected. The aged sink quickly under the diarrhoea, if the choleric predisposition exist ; and children, though not often attacked, pass rapidly through the several stages of the disease to a fatal termination. Diarrhoea and vomiting do not always distinguish the premonitory stage ; but it is sometimes denoted only by headach, loss of appetite, oppression at the chest, &c. and again spasms are known to have been the earliest symptom, and at first the only prominent one, and susceptible of relief During the existence of diarrhoea, the appetite often remains unimpaired, and I have frequently known it to have been morbidly increased just before the occurrence of that symptom, and the paticfents have sunken rapidly into an incurable asphyxia. Something, no doubt, is to be ascribed in such instances, in explaining the accelerated march of the disease, to the morbid indulgence.

Much may be said on this very interesting subject of premonitory sy mptoms, on which are suspended the life of the patient and the happiness of friends, and which may determine the fate of both, as they may be duly noticed or disregarded. It is certain, however, that it is not one of the least attendant phenomena, that the patient, whose fears had been before sensitive on the subject of the epidemic, becomes seemingly indifferent after the invasion of the earliest stage, and is wholly regardless of life when he approaches the more alarming crisis. This apparent apathy has been ascribed, you are aware, to a disinclination to avow the apprehension, that the king of terrors has at length made his approach where most dreaded ; but I cannot think that the true cause has been assigned. It is a symptom belonging to the disease, and I have frequently experienced a great difficulty in exciting the fears of intelligent patients so far as to induce them to submit to the necessary remedies and a proper abstinence from food. It is a condition of the mind, also, which is progressive with the disease, and I have rarely heard of the least solicitude being manifested, after the formidable stage has supervened.

The premonitory symptoms, here as elsewhere, were of comparatively short duration at the irruption of the epidemic, at which time death ensued in a few hours after the attack.

The treatment of this epidemic, in its incipient stage, must, of course, be determined by the particular symptoms of the case, the probable strength of the predisposition, general circumstances of the patient, &c. From the impaired condition of the digestive functions, it is indispensable in all cases to discontinue solid food, and to limit the quantity of farinaceous fluids.

1st. If the subject be of temperate habits, the tongue clean or slightly coated, the evacuations not particularly morbid nor frequent, and no vomiting, it vp'illbe generally sufficient to stop the solid food ; or a small dose of castor oil, or of rhubarb and magnesia, will be all the medicine that will be indicated. If the diarrhoea be more urgent, denoting a more irritable state of the mucous membrane, probably two teaspoonsful of paregoric should be at once given, and another after each subsequent evacuation. A continued abstinence from solid food for a short time will supersede the necessity of a cathartic, where the bowels have been so thoroughly evacuated as a consequence of disease. The irritability of the mucous membrane is easily allayed at almost every period, and vo'miting and purging arrested without much difficulty ; and I have found paregoric the best remedy for that purpose when these symptoms are not violent.

2d. The next most simple combination of premonitory symptoms proceeds from some error in food, the most common of all exciting causes. If there exist much nausea, or imperfect vomiiing, and the food have not evidently passed from the stomach, the patient will be immediately relieved by a mild emetic of ipecacuanha, associated with calomel enough to act as a cathartic. The organs of digestion are thus unloaded, and the predisposition to disease at once subdued. The patient should be afterwards restricted to broth or gruel, till the symptoms shall have been absent for a day or two.

If a patient, who has thus erred, be not seen till the contents of the stomach have been ejected, or have passed into the bowels, emetics are not indicated, for we have seen no benefit arising from them, except at the very invasion, and for the purpose of evacuating the stomach. At later periods they are nearly sure to kill. If the diarrhcea be now only moderate, and the evacuations not presenting the characteristic appearance of malignancy, and the vomiting have ceased, a dose of rhubarb and magnesia will probably suffice. But if vomiting continue with obstinacy, a stronger predisposition is shown, and calomel modified by a grain or less of opium and one or two grains of camphor, is indicated ; and if the discharges be not soon arrested, more opium should be given, and the calomel repeated once or twice if the secretions have appeared morbid, till the bowels are again moved. Or, when 1 think I have obtained a sufficient advantage from the specific action of that remedy, and it has not produced a cathartic effect, I suspend its exhibition and await that result for some hours ; or, if there be any motive for an early movement of the bowels, I exhibit a dose of castor oil. It frequently happens that the direct operation of a cathartic, at the very invasion of the disease, will alone arrest its progress ; but after a delay of a few hours, the mucous membrane may have acquired a degree of irritability that must essentially modify the practice.

The quantity of calomel which I exhibit at a dose in the premonitory stages varies from 10 to 25 grains, — generally about 20 grains. But I have observed a great difference in the action of calomel and other cathartics in the diseases of Boston and Montreal and those of this climate. Here we are more subject to congestive affections of the liver and the abdominal viscera, and more active doses are more advantageously employed than at the former places.

3d. If diarrhoea suddenly invade, and be soon followed by vomiting, without any obvious cause, and if the evacuations be serous, and resembling or approaching in appearance to rice water, the attack has arisen from the activity of the predisposing cause, and constitutes a formidable case. Here there has probably been a gradual accession of disease, but not denoted by any remarkable symptoms, till this sudden developement of diarrhoea and vomiting. In such a case the tongue may be clean, and scarcely any other morbid phenomena than the intestinal commotion and the serous evacuations to admonish us of the impending danger. If the pulse be not much depressed, this is a case for blood-letting, and perhaps for its repetition. At the same moment a grain of opium should be given, and repeated once in 20 to 60 minutes, till the irritability of the mucous membrane be subdued. A large mustard cataplasm should be also applied over the region of the stomach and liver, and as soon as the skin is irritated by that means, a large blister should be substituted. Among the early remedies, calomel should not be neglected, and conjoined with opium and camphor if the vomiting and purging continue ; and it will be commonly found expedient to repeat the calomel for two or three large and successive doses. The evacuations will become very dark as the disease subsides. His convalescence will be gradual.

4th. If the patient exhibit a white tongue, and diarrhoea be almost the only other attendant symptom, he will probably be relieved by calomel alone. He will require particular prudence, however, in regard to food. If a sense of oppression at the chest exist, or pain in the head, or soreness at the region of the stomach, blood-letting will be indicated ; and if tenderness of the stomach remain, a blister or leeches applied there will accelerate his cure.

5th. It sometimes happens that the earliest symptoms consist of headach, oppression of the prsecordia, impaired appetite, and coated tongue. Blood-letting and cathartics of calomel are then required, and a blister over the region of the stomach. In these cases, where there has been no diarrhcEa, the first evacuation will be very dark.

6th. If there be a yellow coating of the tongue, and purging of bilious fluid, with or without vomiting, the case is a favourable one, whatever the exciting cause, and requires cathartics of calomel and oil. I have, however, seen such cases result in asphyxia, and terminate in death, the patient purging and vomiting a deep yellow or a deep greenish-yellow bile to the last moment.

7th. Spasms sometimes introduce the disease, and may exist for some hours, unattended by any other prominent symptom. They have not, however, I believe, constituted a difficult case, but have soon yielded to blood-letting and cathartics. They sometimes also occur in connexion with the premonitory symptoms of diarrhoea, and require, with other means I have indicated, stimulating embrocations, friction, &c. The topical application of ice is also excellent for the relief of spasm, whether in the premonitory or the subsequent stages of the disease.

8th. There is occasionally, from the access of the disease, a very obstinate determination of blood to the head, and palpable inflammation of the brain. In such instances the evacuations in the primary stage are very light, or do not occur at all. These cases require decision with the lancet, leeches to the hoad, removal of the hair, and cathartics of calomel and castor oil. The dejections become, at once, very dark, and frequent cathartics will be necessary in the progress of the cure. These casee almost always yield to this treatment. When they do not, or are neglected, vomiting and purging of the characteristic rice water takes place, and the patient passes through the stage of collapse into a state of delirium.

Whenever vomiting occurs as a premonitory symptom, all fluids should be denied the patient. If it do not readily yield to the treatment suggested, ice held in the mouth will be found a useful auxiliary, and it affords the advantage, also, of allaying the intolerable thirst which is sometimes early attendant on that symptom.

If the symptoms denote a severe grade of disease, salivation will hasten convalescence, and obviate the necessity of some other remedies.

Although the predisposition to this epidemic is generally developed by some of the premonitory symptoms which I have indicated, it occasionally happens that the attack is very insidious. The tongue may be clean, and of a healthy appearance : the evacuations at first bilious, and unattended with pain ; perhaps little or no vomiting and no evidence of danger in the countenance ;^ yet I have known a sudden transition of these auspicious appearances to an array of the most malignant symptoms.

I have said but little in respect to the state of the tongue as an index of the disease, and still less of the pulse, and skin, and secretion of urine. They are so variously affected, under apparently the same circumstances, that they cannot be assumed as criteria. The tact of the physician, therefore, must convert them to the best advantage in each individual case.

The patient will require particular instructions in regard to food during his convalescence, as he will be very likely to yield to his propensities.

I regret that my time will not allow me to reply fully to your letter, but I will drop you another line this evening, and communicate, also, the results of some analyses of the blood.

In reply to your inquiry, I have had no symptoms of the Cholera, and the physicians here have been generally equally exempt. The few that have died perished in the good cause of humanity, and were the victims of a generous ambition, that prompted them to exposures which no constitution can resist.

Very respectfully, &c.

LETTER III.* New-York, August 19th, 1832

Dear Sir,

In my letter to you yesterday, explaining the results of my experience in the treatment of the premonitory symptoms of Cholera Asphyxia, I had not the time to say what I could have desired on the no less important subject of the exciting causes of the disease. Having, however, adverted in a former communication to the ge-

* This letter was introduced by the original publisher with the following remarks, and which are retained for obvious reasons. I need not say that T entirely concur in the opinion expressed on the subject of food.

" The author of this and two other able letters on the same subject appears to disapprove the use of fruits and vegetables during the Cholera season.

" On this opinion it may be remarked, that a distinction should be made between a place where Cholera is epidemic, and one where it is expected to be epidemic.

" Where the epidemic exists no one should eat fruit and vegetables, unless the state of the digestive organs require these articles, and then with all possible precaution as to quantity and observation of the effect produced.

" Where the Cholera docs not prevail, the constitution of the atmosphere, although predisposing to the epidemic, need not prevent a prudent tibe of ripe fruits and good vegetables."

ncral facts, relating to this inquiry, which have occurred under my observation, I shall now con - fine my remarks to the most common of all the exciting causes of Cholera. It is an argument, d priori, that the varieties of food and the moderate stimulants, which are well adapted to the healthy system in ordinary conditions of the atmosphere, can scarcely endanger the health of the being they were destined to nourish, under any vicissitudes of the natural phenomena of the elements. This very plausible induction has operated in most places that have been visited by Cholera, and the general sentiment has been in favour of a moderate indulgence in the fruits of the earth, and the luxuries of the culinary art. The irruption of the Epidemic, however, soon proved to us the fallacy of this philosophy, and the experience of the majority has been conclusive against many species of food, which they had hitherto eaten with advantage. The fact has been even appalling to the most incredulous epicure, who has been compelled to drop his accustomed varieties, as they have been returned, one after another, from his stomach undigested ; or if perchance this organ have borne the indulgence with its wonted forbearance, an unusual tormina of his bowels has startled his confidence in the vigour of his digestive powers. Theory and experience all give way to the overwhelming argument of a choleric atmosphere. The constipated dyspeptic abandons his bolus of soap and aloes, and condemns unbolted flour as a purgative diet ; and even the shampooing of Halsted threatens him with hyper-catharsis.