OBSERVATIONS ON A LETTER PROM DR. N. CHAPMAN, OF PHILADELPHIA, To DR. W. B. TYLER, OF FREDERICK (MD.} ON THE SUBJECT OF '"* V AS APPEARING IN PHILADELPHIA, AUGUST, 1832. " Is it not strange that medical men should for the first time have abandoned all their principles of practice, and throwing aside reason, catch at any shadow that was passing by, in the gloom of deficient or erroneous pathology" ?!! " Remarks on the pathology and treatment of the disease termed Malignant Cholera." Jim. Jour, of Med. Set. for Aug. 18:12. p. 533-. 183:5, -~ 1 TO DR. TYLER. SIR, To no one can these pages be so properly addressed, as to you, to whom we are indebted for the appearance of the letter, which is the subject of the following remarks.— It is to be lamented, that you have not yourself (having seen the disease as I have heard) given us your sentiments on it, and thereby have enabled us to form an opinion as to your agreement or disagreement with the views of your cor- respondent.----After having waited nearly six months, in the hopes of seeing some observations on a publication so widely disseminated, from some practitioner to whom the disease had become familiar by the (i lights of actual obser- vation and experience," I have thought it expedient to an- alyze the views therein expressed; and I have taken the same opportunity to point out various apparent inconsisten- cies, when tested by the former printed opinions of the wri- ter of the letter; but which seem incontestibly to flow, from a due comparison of them. I remain, Sir, very respectfully? AN INQUIRER. COPY OF A LETTER FROM DR. N. CHAPMAN, OF PHILADELPHIA, TO DR. WAI. BRADLEV TYLER, OF FREDERICK, (MD.) [J\'ole. This copy is from the Frederick Herald of August 25,1832. The correc- tions, as appearing in the National Gazette of September 4, 1832, are given in ital- ic, and between brackets, at the places thus corrected.] My dear sir: I have delayed to answer your letter, till I had formed some decision as to the nature and treatment of the Pesti- lential Cholera which is now prevailing. These are points on which so much difference of opinion existed, that I found it impossible to make up my mind as to them, without the lights of actual observa- tion and experience. I have now seen the disease sufficiently 1q enable me to arrive at satisfactory, and I trust, just conclusions on the subject. - JBut I can present in the narrow compass of a letter, only a very concise and imperfect exhibition of my views, and in- deed, such are my incessant occupations, that I have scarcely leisure to execute even this slight sketch. The disease, luholly independent of contagion, is caused by an epidemic agency, of which we know nothing with certainty. It is not improbable, however, that it is owing to an aeriform poison, which acting through the medium of the stomach on the ganglionic nerves, so impairs that system, that its functions are in a greater or less degree suspended. As always happens, where sensorial or ner- vous influence is withheld, there is in this case, a recession of blood from the periphery [of the body], and correspondent accumulations of it in the deep seated vessels, subversive of the proper distribu- tion of it in the circulation, attended by a vitiation or suppression of the secretions. This, in a word, is my theory of the disease, the truth qf which, I think, is sustained by the symptoms, the phe- nomena on dissection, and the mode of cure. It is generally held here, that Cholera is pretty [almost] uniform- ly preceded by considerable disturbances of the alimentary canal, by nausea or purging, or the two united.—That affections of this sort, are very common in the city and elsewhere, cannot be denied. But whether they constitute the preliminary stage of the disease is, very doubtful. It seems to me, they ought rather to be considered as a condition, arising from distinct sources qf irritation prcilispo- V sing to the disease. Can it he credited, Hint a cause ultimately ope- rating so powerfully as that of Cholera, should endure for three or four or five days, merely teazing in this slight manner, the stomach or bowels ? The transition from these mild and lingering affections, to the explosion of Cholera in its fullest force, is far too*stidden and violent, to suppose that they are one and the same disease, varied only by stages. I know not the analogies by which the hypothesis can be supported. Nor is this preclusive [prelusive] indisposition mentioned by any of the writers on Asiatic Cholera whom I have consulted. It is scarcely to be presumed, that so prominent and im- portant a fact, had it an existence, could have possibly escaped the attention of these very able and experienced historians of the dis- ease. Being attached to armies, and more particularly from their position in hospitals, they enjoyed the best, and peculiar advantages, for accurate and discriminating observations. It was first noticed and promulgated by some of the British publications, though not sanctioned by all, and from a similar coincidence [of such derange- ments] *of gastric and entiretic derangement with the epidemic in this country, the notion has been espoused by us. Be it as it may, such [these] disorders should at once be removed, as they are apt at all events, to invite an attack of Cholera. They do not differ from the ordinary complaints of the season, and require no peculiar management. Genuine Cholera, for the most part, comes on with little or no premonition. The earliest symptoms are complaints of load, and oppression, and anxiety about the praecordia, with an internal sense of heat, referrible to the stomach or bowels, with great thirst and a whitish tongue, and at the same time, the head is confused, the ex- pression of countenance haggard, accompanied by slight nervous tremors, muscular weakness, cool skin, and either a quick and some- what feeble, or a full and struggling pulse. Copious evacuations upwards and downwards, of [a] fluid resembling dirty or turbid rice water, with flocculi mixed in it, soon occur, followed by cramps or spasms of the muscles of the extremities and abdomen. These are seldom so violent as has been represented, and never extend to the alimentary canal. An aggravation of the preceding symptoms rap- idly takes place, and in half t an hour or more, the tongue becomes icy cold, the skin more chilled and sodden, though feeling hot to the patient, covered with a dewy viscid perspiration, the hands shrivelled or wilted, as if mascerated, the nails of the fingers blue, the pulse scarcely or not at all perceptible, the face sunken, especi- ally the eyes, around which is a dark circle. This colour gradually diffuses itself [more or less] over the entire surface, partaking olUhe ' " Of gastric and entiretic derangement," omitted in the corrected copy. f "Jlc'f," omitted in the corrected copy. VI various shades of lividness, from a saturnine to a blueish or black- ish hue. During this period, the thirst is intense, the heat of the stomach in some instances is increased to a burning sensation, the respiration greatly embarrassed, the air expired cold, the voice low, or whispering and plaintive, the diaphragm convulsed, and there is a total suppression of the urinary and other secretions. Discharges from the alimentary canal, and the spasms, likewise cease or are much diminished. [The intellectual faculties, though obtuse, are seldom otherwise affected, and in some instances, their entire integrity is throughout preserved.] Death ultimately takes place in a sort of tranquil stupor, or with indescribable jactitation and distress, the latter state being by far the most [more] common. As I have briefly described the disease, such is the tenor of its character and progress, though occasionally diversified in some re- spects. Thus I have seen its accession as sudden as the electric shock, and have met with cases without spasms, or vomiting or pur- ging. Many other anomalies might be mentioned, could I indulge in such details.—The disease may be properly divided in most in- stances, into two stages,—that of aggression, and collapse. Called at the commencement of an attack, unless there is extreme depression, I blee;l very* freely from the arm, and uniformly cup the epigastrium, and give calomel largely, combined or not with opium, according to the severity of the spasms. The case will al- most invariably yield to these remedies, and we have no further trouble concerning it. But where the attack is confirmed, or in oth- er words, the state of collapse exists, the difficulties of management are vastly increased, and the practice is somewhat different. The first step, under such circumstances, is to puke actively with tepid salt and water, a tumbler full at a time. This usually settles the stomach, allays thirst, produces some degree of reaction, a stronger pulse, increased warmth of surface, and a resolution of the spasms. Co-operating in the same design of arousing the vital forces, and ex- citing the skin particularly, the body and extremities may be rub- bed with warm flannels. Let a vein be then opened, and if the blood flows freely, take a large quantity, and especially should the pulse rise and the blood become florid. But where the reverse happens, or you have slowly to coax out the blood, or the pulse is sensibly weakened by the loss of it, stop the operation, and apply twenty or thirty cups to the abdomen, including the epigastrium, which, though they may not draw much blood, are eminently serviceable as revellents. The cups are to be succeeded by a blister to the same parts. Calomel is next to be given in the dose of five, ten or twen- ty grains, frequently repeated, till the aggregate amounts to about a drachm, and then worked off with a table spoonful of castor oil. • '• Very," omitted in the corrected c.i-pv. VII As the result of these means, there are commonly bilious evacua- tions, discharges of urine, and other proofs of the restoration of secretory power. Little more is demanded than what has been mentioned. 1 have, however, sometimes known, though rarely, that at this point of the case, irritability of the stomach to return, with the appearance of approaching exhaustion, in which event, stimuli are to be resorted to ; the best of which are, a strong infu- sion of cayenne pepper, or clove tea, or the spirits of camphor, or the aromatic spirits of ammonia, or mint julep.—But they are cau- tiously to be administered, and in small portions, or they are instant- ly rejected, or they overwhelm the energies of life, or more slowly induce typhoid prostration. Drink is sometimes vehemently solicited, particularly in the height of the attack, and the instinctive desire for cold water, or even for ice, may be gratified in moderation. The proper nourish- ment in convalescence, the only time when any is wanted or to he allowed, is chicken water or beef tea, rendered agreeably pungent with cayenne pepper. Thus I have hastily laid before you an out- line of my mode of managing this terrible* disease. It may be ob- served that, with scarcely an exception, it is depletory or evacuant. Deluded by false appearances of debility in the disease, and still more by the weight of authority, I adopted when it first broke out among us, in common with my medical friends, a course of practice in conformity with such an impression—and most disastrous was the issue. Nearly every patient, amounting to five or six, [in the dif- ferent hospitals,] died. The prominent indications seemed to call for heat to the surface, and the internal exhibition of the diffusible excitants. Every variety of bath, hot [warm] water, vapour, heat- ed air and topical applications of hot sand, or oats, or salt, &c. were used, and also frictions with the spirits of turpentine alone, or united with camphorated mercurial ointment, and other articles. Brandy, ether, camphor, vol alkali, &c. &c. were in succession tried, and the whole of these means with no other effect,than an inconceivable exasperation. The suffering indeed, induced, was as great as I have ever witnessed from the application of any remedial process. No practical lesson is more important than that in the cure of this dis- ease, all such appliances and medicines are mischievous, till evacu- ations are premised, and then to be most discreetly directed. [ The system previously is utterly intolerant of them, and I have found it better to expose the patient naked to cool air, than lit cover him, even ivith a blanket.] It were easy to acquaint you with divers other methods of treat- ing this epidemic, or to enumerate a number of special remedies that have been proposed. Dismayed, as it were, by the fearful charac- * " T-rril>;c" omitted in the corrected copy Vlll fer of the disease, practitioners have been too prone in its treatment, fo abandon their principles and well tried remedies, in analogous eases, to seek a resource in specifics and nostrums. I do not mean to vaunt of my success, but on a fair comparison of all that I have seen attempted, I am led to an unqualified prefer- ence of my own plan [of this plan.] It cannot be charged with being tentative or empirical—is deduced [on the contrary] from established views of pathology and therapeutics, and is sanctioned in most of its features by the lengthened and concurrent experience of the distinguished and authoritative writers on the disease in In- dia. Many may be cured by it, and some will sink under the force of the attack in despite of your efforts. The case not being too far advanced, a triumph over the disease is pretty certain. Cholera is, on the whole, more tractable than yellow fever, or the winter pes tilence, which devastated our country during the late war. Ever, my dear sir, Yours, most truly, N. CHAPMAN. Philadelphia, August 18, 1832. To Dr. Wm. Bradley Tyler, Frederick, (Md.) [P. S. I have omitted to mention that this very practice, by emetics, calomel, bleeding, fyc. is the one which I have for twen- ty years taught in my lectures, as most appropriate to the ivorst forms of the ordinary cholera of our own country. You will find a tolerable synopsis of it in my work on the Materia Medicu. I will only add, that there is considerable difference of opinion among us as to the best means of puking, some preferring ipe- cacuanha or the sulphate of zinc, $*c. In Britain, the mustard emetic seems chiefly to have been used, while in France the ipe- cacuanha, and in Russia, and other countries of the north of Europe, the salt and water. The latter, on the whole, I think is most appropriate, though I have in some instances resorted to the ipecacuanha, very advantageously. ] [To face page viii.] Hosmtal Reports to the Boahu of Health, for the month of August, \83.\ of the Cases admitted, and Deaths from Cholera,-—also, the reports ofprivate practice for the same time. *>.£ o H H CQ to , S <= - % I. 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Some errors in Mms House and Prison teports. July 27 --- — to Aug. 4 1 i i I 2 2 8 4 1 1 1 0 3 2 4 4 6 5 3 1 11 7 7 3 I 7 4 26 6 69 18 5 to 11 7 3 1 7 9 2 1 12 6 3 1 9 9 6 10 2 22 7 13 3 L4 5 74 42 ] L5 2 28 12 26 18 8 2 78 49 47 31 323 65 11 to 18 1 L0 3 3 3 10 3 0 4 0 1 5 8 11 3 10 4 9 4 13 10 7 2 46 25 6 5 16 8 17 5 6 2 23 23| i 4 430 90 19 to 25 9 0 1 7 7 2 0 2 0 1 2 2 2 1 8 0 7 3 2 0 6 1 27 7 9 0 13 2 15 2 7 2J 9 6! 1 144 32 26 to 31 5 1 1 3 1 11 2 10 1 0 0 21 4 5 1 8 0 6 2 42 10 Two or three hospitals are not included, being open, but for a very short time TO DR. N. CHAPMAN. SIR—A considerable period has elapsed since the appearance of your letter to Dr. Tyler, on the subject of Cholera.—Published first in the Frederick-town Herald, and having with various encomiastic remarks, been transplanted into most of the papers of the union; it has consequently become public property, liable to be remarked on by any individual who may deem it worthy of consideration; either, as relating to the disease of which it professes to treat, or to those discrepances which it displays with other parts of your accredited writings. I have awaited, Sir, to see from some professional pen, either in Philadelphia or elsewhere, such observations, which it appears to me, flow naturally from the perusal of your letter, and from a com- parison of its sentiments, with your well known opinions elsewhere given. None such having appeared, either from an acquiescence in its contents, or from some other motive, I have at last concluded to give your letter that examination, which the importance of the subject demands; emanating as it does, from authority deemed so high, and rendered still more important, when it is remembered that you fill the responsible situation of Professor of the theory and practice of Medicine, &c in the oldest of the Medical Institutions of our country. I trust Sir, to your love of medical science, and of your encour- agement to a free inquiry in every department thereof; together with your liberal promotion of every investigation, even into your own particular views, to obtain my excuse for the remarks I may be called on to make, and the inductions to be drawn, in the course of my investigation into the merits and bearings of your letter. Placed in the elevated station above adverted to, the medical profession naturally looked for your views respecting that wide- spreading disease, which, within the short period of six months has carried, and still is carrying desolation and dismay throughout our continent, after fifteen years' ravage of the European and Asia- tic world.—Such a length of time would apppear sufficient for any common observer to have studied fully, the character, peculiarities and nature of this disease, from the numerous works printed on the subject, in every place where it has found a footing.—Embracing nearly half the time of your professional career, how is it, that, (unaccompanied by the terrors of its actual presence,) its visitation 2 had not been prepared for; nor its investigation pursued, so far as I have been able to learn, by any of the practical professors in our numerous schools of medicine?—For, considering its ravages else- where ; seeing that \t had surmounted rivers, seas, deserts, moun- tains, forests, &c.—that it had been equally fatal in the coldest and hottest climates; we surely, had every reasonable ground to antici- pate a closer connexion with it; and consequently, had both time and interest to engage in its pursuit, and prepare for its visitation. —But, when it actually reached our shores, how were we prepar- ed ? Until its sudden explosion in Canada, (however originating there,) we scarcely knew it except by name. All were in the dark, since even the experience of others seems to have been but little thought of.—Nay, its rapid strides in Canada, and even its advance to the city of New York, seem scarcely to have awakened the members of the profession in Philadelphia, to the full danger that pressed upon them, beyond that which was felt by the affright- ed community at large; and which looked to the profession in the day of trial and distress, but found it nearly as uninformed and unsettled as itself, in a concern of such vital importance.—The Medical Committee, after a three weeks' absence, and a close ob- servance of the disease in Canada, brought back but little consola- tion; nor was their promised pledge of further information with- drawn, until the pestilence had nearly left your city. Such too, was precisely the fact as to your letter, which it seems indeed, was intended merely for the private information of your correspondent. —The disease brushed by you with rapidity; and by the time your letter did appear, Philadelphia had sunk into a stale of com- parative tranquillity. Certainly, this did not arise from medical acu- men or professional skill; for all were paralized, and scarcely knew what direction to pursue, amid the conflicting tides of opposing no- lions, both in theory and in practice, that were continually promul- gated.—In private and in hospital practice, it would seem, so far as I can learn, as if no uniformity prevailed; and the mortality, pro- portioned to those attacked, was, it is believed, nearly as great as in other places. The letter I am about to analyze, is dated on the 18th of August 1832, three weeks after the full breaking out of the disease, and the opening of the hospitals in your city, on the 27th July, according to the newspapers.—It appeared in the Frederick-town Herald on the 25th of August, and in the National Gazette of Philadelphia, on the 1st of September, at which time your hospitals were closed— so that, in fact, it was absolutely useless to the community'—Whv it was not directly addressed as a circular to the profession in Phil- adelphia, the jmmediate seat of ihe disease, and of discordant prac- r.C?'h^ir/ A0^' 1>',,er» (hl a re-i0n not th*n affected but to whieh it would have duly arrived,) containing, it would scorn 3 matter deemed of high importance, and oi immediate utility to your fellow citizens, I cannot learn or comprehend. If the common saying, of charity begins at home, ever could be properly applied, it would indeed seem connected with the then existing state of Philadelphia—and the benefit of your lucubrations might have been profitably exhibited, where it was urgently required; and nearly ■two weeks of desolation and woe might have thus been prevented! At the actual time of its circuitously reaching your city, its im- portance was nugatory; the disease had nearly subsided, the hos- pitals were closed, and death had obviously sheathed his sword of destruction. The loss, no doubt, was great, in thus being preclud- ed from testing at the time, the validity and perfection of your "own plan" of treatment; and we must remain satisfied (unless a not-improbable recurrence of the disease takes place) with the state- ment you have thus so concisely and indirectly afforded. It has been reported, that you do not assume to yourself the credit of the treatment you so warmly recommend. I cannot well reconcile this report, I confess, to the general tenor of your letter, in which we find the expressions, " the outline of my mode of manage- ing this terrible disease," &c.—"my own plan," &c.—which, altho' modified slightly in the connected copy, as it is called in the Na- tional Gazette, yet we cannot doubt your maintaining it absolutely as your own;—for how otherwise could you venture to speak of not ii vaunting of their success"? It is indeed true, that very numer- ous are the writers who have preceded you in the details of the the- ory, symptomatology, treatment, &c. of this disease, not only on the shores of Hindostan, but in every part of Europe in which it pro- gressively appeared; as well as before and since it reached theCana- das and the United States.—Should it be affirmed, that five hundred treatises have appeared upon it, it would probably be within due bounds. Still however, since your conclusions as to the nature and treatment of the disease, are founded on the "lights of (your own) actual observation and experience," presenting at the same time on- ly a very concise and imperfect exhibition of your views, it seems conclusively to follow, that all that is thus imperfectly detailed, is considered as your own, and as such, promulgated, for the consid- eration of your correspondent, if not for that of the public at large. __Fearful nevertheless, of misapprehending your real views in these particulars, I have thought it expedient to give an accurate copy of your letter as it first appeared in the Frederick Herald, and also, to mark the corrections and additions of that which appeared in the National Gazette; in order to enable every one to judge of the im- portance of those corrections, and how far they really help to modi- fy or alter the conclusions which the first would naturally elicit. In the subsequent remarks, I shall endeavour to demonstrate, that the depletory system was most accordant with the principles you 4 at first abandoned; for it had been recommended by a large propor- tion of the writers on the subject: if therefore, it was your misfor- tune to have been led astray by circumstances to be adverted to; and if your good genius happily led you back to well tried principles and remedies, they were the "principles and remedies" of other writers of at least fifteen years' notoriety. In adverting to Cholera as an Epidemic, allow me to call your attention to the writings of the venerable and illustrious Rush, whose pages at present too greatly neglected, will hereafter attract that (renewed) notice for which they were formerly unrivalled in this country, whilst others of present notoriety will sink into ob- livion.—As you have written largely on Epidemics, I would sug- gest for consideration the following remarks, and whether they have not been amply verified by the Epidemic that you describe in your letter to Dr. Tyler? "From a short review of these facts, (says Dr. R. p. 174, &c.*) reason and humanity awake from their long repose in medicine, and unite in proclaiming, that it is time to take the cure of pestilential epidemics out of the hands of physicians, and place it in the hands of the people."----"I would as soon believe, (p. 177) that ratafia was intended by the author of nature to be the only drink of man instead of water, as believe that the knowledge of what relates to the health and lives of a whole city or nation, should be confined to one, and that, a small or privileged order of men. But, what have physicians, what have Universities or Medical Societies done, after the labours and studies of many centuries, towards lessening the mortality of pestilential fevers ? They have either copied or contradicted each other in all their publications." I would also further recommend the following judicious remarks of the same enlightened physician, as to the precursory or premoni- tory symptoms, which, says he, it will be necessary to publish an account of, to prevent the formation and mortality of this (yellow) fever : and " to exhort the people, as soon as they feel those symp- toms, to have immediate recourse to the remedies of purging or bleeding. The danger of delay in using one, or both these* reme- dies, should be inculcated in the strongest terms; for the disease, like lime, has a lock on its forehead, but is bald behind "(p 177) It is true, Sir, Dr. Rush is speaking of the Yellow Fever-—but were he now living, his towering and expanded mind would have «f rilile \ 0,"f monger evidences of the premonitory symptoms ol Cholera, and of the absolute importance of attending to them. Very respectfully, 1 remain, Sir, AN INQUIRER. •Med. Inq. & Obs. Vol. HI, 4th edition, 1815. OBSERVATIONS ON A LETTER ADDRESSED TO DR. TYLER, ON THE SUBJECT OF THE AS APPEARING IN PHILADELPHIA, IN AUGUST, 1832. "Mi dkaii Sin:—I have delayed to answer your letter, till I had formed some decision as to the nature and treatment of the Pestilential Cholera which is now prevailing." It is to be regretted that we have not a copy, and the date of Dr. Tyler's letter, to which this of August 18th, is an answer.—When it is remembered that the disease of which it treats, had scarcelv been three weeks in Philadelphia; a knowledge of these dates might have enabled us to judge of the rapid decision of the writer as to its nature and appropriate treatment, founded on his own experience, between the 27th July and the time of writing; during which peri- od, by the returns of the Board of Health,* 37 patients had been received in the Locust st. hospital, and 16 had died; that is, about 45 per cent, admitting the whole number received to be actually and bona fide Cholera patients; for, it is remarkable, that a gen- tleman who gives some account of the disease, and speculates deep- ly on it, has stated returns of a somewhat different nature—"Before concluding these remarks, I will insert from the Day Book the com- parative results oi the practice pursued, under the direction of the physician-in-chief, in the hospital, prior to the adoption of my practice, and of that which I introduced, upon the principles be- fore explained. From July 27th to August 6th, 14 cholera patients were received into the hospital; of these, five were cured,! and nine died. From August 7th inclusively, to August 21st, twenty-eight cases occurred; of these, twenty were cured, and eight died. Both computations have been made, by excluding all cases not choleric; and in each, some of the cases were moribund, when received."— By the report of the Board of Health, however, it would appear, * See Tables, from the Plulada. Daily Chronicle of Novem. 29, 1832. f •« Including," says the writer in a note, "too cured hy my treatment, being my two first cases."----This practice then, must differ from that of Dr. Chapman, for both speak respectively, and positively of their particular practice. This is indeed rendered certain, from the previous part of the sentence itself, as above quoted. It is to be regretted, that we are not told, how many were not cholera, and how many were actually moribund when received, as well as ho-w /owg such moribund cases lived, after reception. Vide Am. Jour, of Med. Sci. August, 1812, p. 541. c OBSERVATIONS ON that from the 27th July to August 6th, only twelve patients were admitted, and seven died: and from the 7th inclusive to the 21st, of twenty-eight received, nine died.----There is some descrepancy, it will be perceived, in the reports of the Board of Health and of the gentleman alluded to, which it might be useful to reconcile. Per- haps no place is more appropriate than this, to refer to the conden- sed tabular view * of all the cases received and the deaths noticed during the month of August, in the different hospitals, as drawn up from the reports of the Board of Health: and which are derived from the daily reports afforded from each hospital respectively. If in this, any mistake occurs, now is the time effectually to remedy it—We may here be permitted to enquire the reasons for preferring the name of "pestilential Cholera," to any other of the numerous synonymes that have been given to the disease?—As we must have a name, it may be as well to be able to assign some reason for our nomenclatural distinction. " These are points on which so much difference of opinion existed, that I found it impossible to make up my mind as to them, without the lights of actual observa- tion and experience." This is all well enough, and will be adequately comprehended by the profession, so far as it is calculated to lead to a due convic- tion, of the earnest endeavours by "actual observation and experi- ence" to come to "just conclusions"! But, admit for an instant, the conclusions drawn to be fully legitimate, and decisive to the mind of the writer; do we not perceive, that as these present views are different from those at first acted on, but which were doubtless, then, considered as conclusive; do we not perceive, I repeat, that, as you ask for yourself, personal observation and experience, (inde- pendently of all, who have preceded in their inquiries during fif- teen years, on the subject of Cholera;) and that you have required only fifteen days, to bring you to the very antipodes of treatment and of theory; it is highly probable, every other man not disposed to swear in verba magistri, will claim an equal privilege of delay- ing to make up his mind, until equally sharing in the "lights of ac- tual observation and experience."—In thus rejecting a decision on the opinions of others, especially when guarded by long establish- ed principles, taught so long, and constantly practised on; we per- ceive a determination, to acquire information, only from the narrow boundaries of our own limited comprehensions! The experience of others, even when abetting our own long tried principles and remedies, are inadequate to enable us to "make up" our minds * See Tables. A LETTER TO DR. TYLER. 7 without being fortified by self-experience!---Let us suppose, ns must be admitted to be sometimes the case, such asserted self-expe- rience, to lead to a false judgment or conclusion ; or, that the judg- ment, though correct, has been founded on a false experience, or incorrect observation! What then? Have persons never been known to think differently of diseases and remedies at different times? and yet found such diversity of conclusions on an affirmed experience in both cases; one of which, if not both, obviously must be the result of error in judgment from hasty and incorrect observation? Now, which of the two shall the profession admit, on the recom- mendation of the same person? the opinion primarily maintained, and ultimately disavowed; or a later one, which has no stronger foundation than an experience thus admitted to be vacillating; and acknowledged as too nastily adopted, and considered as eorrect?— Experience then, may mean any thing or nothing; for if one day's experience is set.at nought by that of the succeeding, who can be sure, that the judgment or conclusions drawn from this, shall not in a short time be found to be equally incorrect!—Certainly then, if we pay no respect to the experience of others; or at least, find " it impossible to make up our minds" when they differ, we must be under a strange delusion, should we reckon on the confidence of the medical profession in our own; and more especially when that is acknowledged to have been at first led astray, by a departure from old established principles, and practice ! «I have now seen the disease sufficiently to enable me to arrive at satisfactory, and T trust, just conclusions on the subject. But I can present in the narrow com- pass of a letter, only a very concise and imperfect exhibition ot my vie-.vs, and in- deed, such are my incessant occupations, that I have scarcely leisure to execute even this slight sketch." How Sir, will it be withjothers ? Will they have no scruples on the subject of "satisfactory'conclusions"? May they not possibly doubt their being "just," when they are so diametrically the re- verse of those you set off with ? Is the last conclusion so absolute, that no one shall venture to adhere to the first? Conclusions drawn by others, were to themselves, doubtless, as satisfactory and just, as yours have appeared to you.—These have been opposed, and oppo- site indications drawn from the same train of symptoms! Now, as the evacuant plan met with opposition, even from yourself at first; this present testimony in its favour, will probably not alter the opinions of those who are waiting to test it by "actual observation and experience," from seeing such difference of opinion maintained, not only by different individuals, but by the same person at differ- ent times! And if, by a comparison of the mortality at the differ- 8 OBSERVATIONS ON ent hospitals, it is found that this was not very different by any particular plan, or by a change of practice from the stimulating to the evacuating plan; no great reason will be perceived from the facts, why each individual should not, in justice to himself, await his own self-experience and observation, therefrom to draw conclu- sions. Unacquainted with the particular circumstances of.the prac- tice, &c. of the different hospitals, I can of course, say nothing, ex- cept that I trust, the able physicians placed at their heads, will, respectively afford us information and explanation, on many parti- culars of high importance and interest; on which the profession are altogether undecided. Indeed, they seem absolutely called upon to vindicate themselves, from the implied want of success, which your words convey, at a later part of your letter; and thus enable us to estimate accurately the claims of superiority therein maintained! You tell your correspondent, that you can present in the narrow compass of a letter, only a ''concise and imperfect exhibition of your [my] views;" and afford subject of sympathy under those la- bours, and those incessant occupations, which left you "scarcely leisure to execute even this slight sketch."—Concise indeed, and imperfect, we will agree to call it with you ; trusting, that hereafter we shall have the full benefit of your experience, derived from ample, extensive and accurate clinical observations on the disease, in all its various forms and stages. Let us no longer have the in- vidious questions proposed, " In the four quarters of the globe, who reads an American book ?—or what does the world owe to American Physicians or Surgeons?"—Let us have a work deserving of im- mortality, on a disease that has rendered so many immortal; but which yet wants the finish of satisfactory and just conclusions ! Let us here be permitted to advert to the labours of Dr. Rush, during the eventful period of the Yellow Fever of 1793, in the months of July, August, September and October, and compare them with the "incessant occupations" which surrounded you from the 27th July to the date of your letter.—In this disastrous period of three weeks, we see by the table, aboift three dozen patients had exercised your skill, or nearly two a day; of which, if all were real Cholera cases, 16 died, or about 1 in every 2\ cases !—A compari- son of the other hospitals, either collectively, individually, or by weekly estimate, will show an average mortality scarcely superior. —But the labours of Dr. Rush also, are not the less deserving of recollection in the minds of Philadelphians ; nor the account of his avocations, and his occupations, to which he devoted himself, in that afflictive and heart-rending period oi four months ! "Between the 8th and 15thof September,"' says this admirable man, " I visited and prescribed for between one hundred and 120 patients a day ! Several of my pupils visited one-fourth or one- * Account of the Bil. Yellow lever of 1793, p. 18 J, Med. Inqu. "H Ob*. A LETTDR TO DR. TYLER. 9 fifth part of that number. In the short intervals of business, spent at my meals, my house was filled with patients,'' &c.—" I went to bed in conformity to habit only, for it ceased to afford me rest or re- freshment. When it was evening I wished for morning; and when it was morning, the prospect of the labours of the day, at which I often shuddered, caused me to wish for the return of evening." On the evening of the 14th of September, Dr. Rush was attacked with the disease, requiring bleeding and other evacuations; yet he admitted persons to his chamber next morning for advice; and on the 16th prescribed in his parlour " for not less than 100 persons." —On the 19th, resuming his labours abroad, though so weak, as with difficulty to ascend a pair of stairs. For 5 or 6 weeks, not less than from 50 to 150 received advice at his house, independently of his external duties; and "the evening did not bring with it the least relaxation from my labours. I received letters every day from the country, and from distant parts of the union, containing inqui- ries into the mode of treating the disease, and after the health and lives of persons who had remained in the city. The business of every evening was to answer these letters, also, to write to my family," &c. &c. ! I forbear!—I should but transcribe the whole of Dr. Rush's interesting and important treatise on the Yellow Fever of 1793, were I to give a full and adequate idea of his incessant labours and occupation, both of mind and body; and that, in relation to a disease, then, as little, or perhaps less known to us, than the Cholera here treated of.----It will be allowed, that it was a period to try men's souls", beyond all other epidemics that have appeared amongst usj—a perfect acquiescence at that time in its absolute contagious character, among medical men, both here and elsewhere, rendered it doubly dangerous.—A doubt of the contagious character of Chole- ra, stripped it of half its terrors; so that I may venture to say, com- pared with the Yellow Fever of 1793, the Cholera of this season sinks into insignificance ! Perhaps, it may be permitted me to ap- ply to the deeds of your most illustrious predecessor in the practical chair, the words of the poet, "Hie Labor, hoc opus est." Before I conclude, my observations on this sentence of the letter, allow me to ask, as you use the expression, "my views," whether they are claimed as exclusively your own; and as such, indicated now, for the first time?—for I perceive them, both in the original, and in the corrected copy. « The disease, -wholly independent of contagion, is caused by an epidemic agency, of which we know nothing with certainty. It is not improbable, however, that it is owing to an xriform poison, which acting through the medium of the stomach on the ganglionic nerves so impairs that system, that its functions are in a greater or less degree suspended." 3 10 OBSERVATIONS ON How wonderful must be the tact that could, in the short perim? of three weeks, and by the attendance on three dozen cases, by self-experience and observation, thus rapidly attained, (for alf others are rejected) be qualified so decisively to cut the gordian knot, that has, for fifteen years, divided the writers onChoIera, and on which they are not yet agreed; that, even in italics the certainty is proclaimed, that "the disease is wholly independent of conta- gion" !—Certain now, of this important fact, the greater disap- pointment we must feel, by the confession made, that although caus- ed by an epidemic agency, "we know nothing with certainty" of that agency!—"Hinc Hide lachrymse!—At least we have here a truism, not very consoling to the march of intellect in our profes- sion ; that during a lapse of twenty-two centuries since the aera of Hippocrates, we have attained so little light upon the subject!— If this be truly the case, why hazard so dogmatically, the affirma- tion of its non-contagious nature ?—For my own part, I mean not to contest the point, which, like yourself, I do not credit; yet, with the numerous facts, &c. as yet not fully elucidated and explain- ed, which strongly favour the doctrine of contagion, I should deem it at least prudent, merely to state it as an opinion, but would not chuse to affirm that opinion as absolute and certain.—Individual opinion is of little importance; and will probably be received on- ly for what it is worth: it is certain, that neither your assertion nor mine, would satisfy the minds of those who hold an opposite opin- ion. They call for facts, and not opinions, to verify a circumstance of such primary importance! and in the assertion thus unhesita- tingly advanced, I see nothing either demonstrative df, or nega- tiving the contested point.—I await, in common with your medical brethren, your full elucidation of the subject; which your extensive observations will enable you to demonstrate. Admitting however,that we know nothing about this agency; it may perhaps be conceded, that a few facts connected with the sub- ject of Epidemics, are to be found dispersed throughout the works on Medicine, from the time of Hippocrates to the present date ; which, if accurately collected together, would probably, form a body of doctrine of infinite value. I am sure I need not point them out to you, who have written so learnedly on the causes, phenomena and laws of Epidemics!—You will agree with me nev- ertheless, that if we know but little as to epidemic agency, we are not much more advanced or decided on the subject of contagion. The precise distinction between it and infection, if any, is inade- quately comprehended; and terms are employed perpetually, at variance with the apparent intentions of their authors: the conta- gious or non-contagious nature of Yellow Fever, is not even yet universally agreed on, amongst us; and with all these, and other particulars that will probably occur to your mind, perhaps you wilt A LETTER TO DR. TYLER. 11 excuse me for saying, a less authoritative tone would have been more becoming. Whatever promptitude of opinion or decision you assume, on the doubtful poi?it of contagion above noticed; and admitting at the same time, that we know nothing of the epidemic agency pro- ducing Cholera, with certainty; in the succeeding clause of the sentence, we find a recurrence to mere probability as to its nature! I would have here preferred the words, not impossible.—If it is probably an "aeriform poison," as suggested, (though this sug- gestion is European,) do you not, from your chemical knowledge, think it also probable, that, as an aeriform, and consequently a tan- gible substance, some idea would, ere this, have been acquired re- specting it? You are well acquainted, no doubt, both with the simple and the compound gaseous fluids, that have within your own time, been successively discovered; you know the mode of procu- ring them for chemical research; their analytical detection and all the minutiae, by which they are distinguished from each other.—Which of all these, do you imagine the probability will rest on, in proof of your supposition? You also know that some appear poisonous pos- itively, whilst others seem destructive, only negatively. But with all we do actually know, permit me to ask, if your probable case is strengthened in the slightest degree, by all the eudiometric experi- ments and observations that have been so numerous, both here and elsewhere ? Have they pointed out any positive fact in any way fitted to elucidate the mysteries of miasmata? What, in short, has the Science of Medicine acquired in this respect from Chemistry? —If, however, you suppose this aeriform poison to be sui generis, why did you not institute a series of experiments to determine it? How is it, that Dr. John Davy, so many years back, discovered (in the E. Indies) that the air expired in this disease, was not only cold, but greatly deficient in the amount of carbonic acid, which should have accompanied it; indicating a source of undue spissitude (ex- cuse this old Boerhaavian term, which will probably be renewed in its application,) to the blood ; how is it, that this ingenious chemist, neither saw, nor supposed it probable from his personal experience, and chemical experiments, that an triform poison, untangible, and unknown, was the cause of Cholera ? He was probably too consid- erate, to think of placing self-speculation, where fact only should be seen.__I fear Sir, the omission to verify by chemical experiment, this aeriform poison, will preclude that immortality which so splen- did a discovery would have insured:—and, that it will but lead us to regret, lest it should have been seen merely as a deceitful vision, oi which we may say, with Macbeth— " I have thee not, and yet T sec thee still," .------"a fal.se creation, Proceeding from the heat-oppressed brain," &c. 12 OBSERVATIONS ON At all events, as you are not certain of the fact, but merely regard it as probable, we shall pass its further consideration—indeed, we might the balance of the sentence; inasmuch as its.probability rests entirely on that of its precursory cause, the aeriform poison above mentioned. Admitting this unknown poison however to be actually conveyed to that great centrum sympathiae, the stomach, and then to act through its intermedium on the ganglionic nerves, as several preceding writers have also asserted; I would be gratified to know, on which of these, or if on all? Perhaps, even a brief account of them, would aid us in this hypothetical description; especially, as a definition or description of terms, will very often prevent misappre- hension.—Now, I am of opinion, that a want of this precision as to terms, has led to infinite confusion in every branch of medical sci- ence! and I would fain see it obviated, in the further inquiries that may be made as to this pestilential Cholera. Permit me to observe, that I find the sentence rather obscure; and that I cannot determine, what system is referred to, as being sus- pended in its functions: whether it is the system of the stomach, or of the ganglionic nerves.—I should be gratified in learning also, whether this aeriform poison is direct, and prompt; or rather slow and chronic, if I may say so, in its action ? the former, I presume, by sympathy, will better explain some of those cases which we are informed are as sudden as the electric shock;—the latter view may harmonize better with those that are preceded by premonitory symptoms.—As in a path so little unravelled as is that of Cholera, we need every probable and possible means to reach our destination; so these ideas, like those in the letter, being estimated for no more than their worth, may very properly be regarded as more allied to hypothesis than to fact. *« As always happens, where sensorial or nervous influence is withheld, there is in this case, a recession of blood from the periphery, and correspondent accumulation of it in the deep seated vessels, subversive of the proper distribution of it in the circulation, attended by a vitiation or suppression of the secretions. This, in a word, is my theory of the disease, the truth of which, I think, is sustained by the symptoms, the phenomena on dissection, and the mode of cure." Admitting the truth of the proposition of the first part of this sen- tence, viz. that it "always happens, where," &c. &c. we cannot Sir, surely forget, that the premises are, as yet, altogether unsettled, and dependent on your assertion alone! You recollect no doubt, that you have ventured to maintain, only the probability of the cause by which this nervous influence is withheld: its certainty therefore is problematical, even by your own admission!—Yet on so treacherous a basis, is erected a towering hypothesis; which, A LETTER TO DK. TYLER. 13 in the succeeding sentence you pronounce "in a word" tobe your theory "of the disease"!—How this problematical, aeriform poi- sonous cause acts; at what point of time after reception, the "reces- sion of blood from the periphery" ensues; with its corresponding accumulation in the deep seated vessels; all this, and more that seems intimately associated, is left unexplained. Although you thus give it to the profession as your theory (par excellence), you do not favour us with the smallest insight as to the catenation of cause and effect.—If we wish to comprehend it, here it stands, to be un- riddled by any one who can'dive deep enough to reach its aforesaid basis. But, as the onus probandi rests with the author, we may hope that in due time we shall be favoured with a complete devel- opement of your views, both on this especial point, and on the viti- ation of the secretions; which, as I understand it, has a slight ap- proximation to humoralism ; and into the boundaries of which, you have hitherto opposed so determined a resistance. In tacitly admitting this, for the present, as your theory of the disease; we reserve nevertheless the right of shewing, when you further advance your claim, that others have preceded you in the same opinion; nay, that it even seems to be unhesitatingly advanced as his also, by one of the subordinate attendants on your own hos- pital ! It would embrace too much space at present, and besides, I would rather await the due presentation oiyour claim in its behalf, strengthened as it will be, by every possible proof!—I will barely ask in the interim, to what class are we to refer it ? to solidism, or humoralism; or to a combination of both ?—It will be time enough hereafter to examine whether it is fully "sustained by the symp- toms, the phenomena on dissection, and the mode of cure." "It is generally held here, that Cholera is pretty uniformly preceded by consid- erable disturbances of the alimentary canal, by nausea or purging, or the two uni- ted. That affections of this sort, are very common in the city and elsewhere cannot be denied. But whether they constitute the preliminary stage of die disease is very doubtful." ' Tis well! That such affections were common, you seem une- quivocally to admit; though you hesitate to call them premonitory symptoms; nor will you even allow them to be the preliminary stage of the disease; at least, to you, it is very doubtful.—Never- theless, all must be aware, that those who have had more ample experience, do affirm the fact to be so; of which we may find the most ample proof in the excellent compend of Boisseau, and in the Report of the Massachusetts Medical Society, both of them print- ed anterior to the Cholera, appearing in Philadelphia. In short, there is scarcely a writer on Epidemics, including yourself, that 11 OBSERVATIONS ON docs not confirm the fact, that they invariably make all concurrent diseases assume their livery; and evince thereby, in these prelimi- nary symptoms or premonitions, the necessity of regarding them as giving a powerful tendency to the complaint—Thus, says Hil- lary in his "Inquiry into the means of improving medical know- ledge," Ed. 1761, p. 34S, (a work by the bye, well deserving of recommendation,) " Thus, when a catarrhous fever is epidemical, how many people are affected with coughs, and a slight catarrh, yet go about their business, and are tolerably well. And, when a Di- arrhoea febrilis, or a dysentery, are epfdemical, how several people will have a loose belly, or a few loose stools, or a little griping, yet go about business and are well," &c. It is true, you admit the fact, but endeavour to disprove the connexion which the so called pre- monitory symptoms, unquestionably have with the full formed dis- ease. *'lt seems to me, they ought rather to be considered as a condition, arising from distinct sources of irritation predisposing to the disease. Can it be credited, that a cause ultimately operating so powerfully as that of Cholera, should endure for three or four or five days, merely teazing in this slight manner, the stomach or bowels." We will admit the fact to be as you here affirm, for argument sake; yet, if they were so universal "a condition"* as we are led to believe, both here, as well as in Europe and Asia, during the prev- alence of the Epidemic; it seems difficult to deny some intimate connexion with it; or not to see in them, those premonitions, which, if unattended to, will soon run into the actual disease; and hence the strict propriety of forewarning the public, of the danger they incur, of lightly regarding them on any occasion.—As for the proposi- tion of "Can it be credited," &c. It may be asked, Why not?— Because one cannot, is his credence really so overwhelming, as to * We are very glad to find you are not singular in this opinion, as the following extract may shew, and which, considering the works on Asiatic Cholera consulted, it seems extraordinary should have been overlooked. You will find it in the Mad- ras Report on Cholera—or in Johnson's Medico-Chirurgical Review, p. 609 of his No. for April last. The language, it will be perceived, has a great analogy with yours.— "This most formidable disease does not appear to be attended by any premoni- tory symptoms which can be regarded as being at all peculiar to it; on the contra- ry, we may safely assert, that it is of sudden invasion: for though a slight nausea, a laxity of the bowels, and a general feeling of indisposition are often found to pre- cede Cholera, yet these symptoms are evidently common to many acute diseases; and they are especially frequent in this climate without being followed by any gra- ver ailment. When such symptoms are found to precede Cholera, they might with more truth, be regarded as indicating merely a certain deranged state of the ali- mentary organs, a condition of the body which certainly predisposes a person to an attack of Cholera." A LETTER TO DR. TYLER. 15 be the sole rule of faith with every one else, without previously attending as you have done, to self-experience and observation ? If, as on a preceding occasion, the word here used had been "improba- ble," it might have passed; but, by the present formula, whoever ventures to admit the position combated by you, must inevitably be delivered up, as heretical in his opinions !—But what is meant precisely, by the sentence itself? You here appear to speak of Chol- era, as if you absolutely knew its cause, but which you have explicit- ly disavowed. If then, "a cause operating so powerfully as that of Cholera," is positively unknown, why will you undertake to lim- it, and thereby undervalue its powers of action ?—Surely, the great- er action involves the lesser; and, if this cause, whatever it be, can thus promote the higher grade of the disease, it must, a fortiori, be able to promote all those preceding slighter "teazings" of the stomach and bowels ! I wonder that any difficulty should present itself in this particular; when we know so well the power oi sym- pathetic action in the stomach and bowels, in promoting good or evil in the highest degree! At all events, whatever may be individ- ual credence, it will not alter the matter of fact, so ably and so ex- tensively affirmed by hundreds of persons, conversant with the dis- ease in every place, not for weeks only, but for months and years. "The transition from these mild and lingering affections, to the explosion of Cholera in its fullest force, is far too sudden and violent, to suppose that they are one and the same disease, varied only by stages. I know not the analogies by which the hypothesis can be supported." Admitting an unknown " aeriform poison" as the cause of Chole- ra, must it not, in its action on the stomach, &c. take some time (varying in different constitutions, &c.) to produce a train of effects from the lowest degree, to the "fullest explosion"? or is it in all cases as rapid as electricity?—Will not its action probably be re- solved by most persons, (whatever it may be in itself,) into some- thing like that which governs, or is produced by the miasmatic causes of intermittent and other febrile affections? Surely, little as we know of these miasmata, we may find strong "analogies" be- tween them and the causes of Cholera.—Nay, so closely are they united, that the Intermittent Choleras * reported by Hoffman, arc amongst the most interesting cases in his instructive writings. Tor- ti has also favoured us' with some of equal interest in his Therapeu- tice specialis, (p. 250) and they are spread in sufficient amount through the writings of many of the older authors, to repay the * Op: om: v. 3, p. 358—v. 6, p. 487. 16 OBSERVATIONS ON trouble of research, to all, who think those ancient writers deserv- ing of investigation. It is apparently this " teazing" of the stomach and bowels, which (by sympathy) must call into action the ganglionic nerves. "Can it be credited," that unless the stomach and bowels were thus teaz- ed, these organs would, nay could, sympathetically call into action the ganglionic nerves, and so impair the system, as to suspend its functions in a greater or less degree ? Now, if this broad assertion of yours be correct, I would ask, whether this impairing of the sys- stem, must not necessarily be accompanied by some symptoms, in- dicating a change of organic functions, as preparatory (and happily therefore premonitory) to this "explosion of Cholera in its fullest force" ? Are not the gastro-enteritic affections of Broussais, in their highest state of explosion, essentially connected with all those little trifling sensations or premonitions, which, if duly attended to, would have precluded the accession of the higher grade of symptoms ? Why should there be greater difficulty in considering the so called premonitory symptoms, a part of Cholera, than in looking to, and acknowledging as such, the early, mild and almost imperceptible symptoms of every disease, when compared with those more violent ones, which are to follow in succession, if not prevented by atten- tion to the former?—All are in due order and rotation; and may be regarded as merely links of one common chain. "Nor is this preclusive indisposition mentioned by any of the writers on Asiatic Cholera whom I have consulted. It is scarcely to be presumed, that so prominent and important a fact, had it an existence, could have possibly escaped the attention of these very able and experienced historians of the disease. Being attached to ar- mies, and more particularly from their position in Hospitals, they enjoyed the best, and peculiar advantages, for accurate and discriminating observations." Whom of the " writers on Asiatic Cholera," that do not mention it, have been then consulted?—I believe I do not mistake the in- tention of altogether denying, (in the preceding, the present and succeeding sentences,) all premonitory symptoms, or preliminary stage, here called "disturbances of the alimentary canal by nausea or purging, or the two united." If I do not misrepresent the mean- ing, which is remote from my intention, I cannot but think that its correctness is sufficiently disproved: nevertheless, to prevent all cavil, I will notice a few in particular, in order to shew, that if the fact of "this preclusive indisposition" has not been met with in any of the writers on Asiatic Cholera whom you have consulted, your reading must have been limited on one of the most interesting subjects of many years' standing ! To say nothing of the numerous papers in the English periodicals of 1S20, LS21 and 1822, and sub- A LETTER TO DR TYLER. 17 sequently up to the present moment, I need only mention the early Reports of Bombay, &c. in 1819, in most of which the fact of pre- monition is very generally adopted.—At a later period, when ob- servation "and personal experience" had been more extended, and when those, who deem it right to confide in the reports of others, collected the reports in this particular ; we find amongst others, in the " Practical Observations on Cholera Asphyxia," by J. B. Kirk, that he not only accredited these premonitory symptoms himself, but obtained the testimony of numerous practitioners in favour of the same. To mention the whole would be unnecessary; I shall on- ly state, that he has enumerated nearly 40, in which scarcely a dif- ference of sentiment prevails;—one practitioner returns 78 cases of Cholera, all preceded by Diarrhoea;—another, gives 579, in which it obtained invariably, and adds, that by stopping it you save your patient—one of 600—of 500—and several of 100—of 50 and less. All unite in their opinion as to the premonition arising from Di- arrhoea.—To come nearer home, the New York Special Medical Committee, in a paper dated August 1st, 1S32, make use of the following language in relation to this subject. "The Members of the Special Medical Council have been very careful to make the most extensive inquiries of the Physicians un- der their direction, and generally among their medical friends, con- cerning the premonitory symptoms of the disease; and thus far the important fact is confirmed, that the invasion of Cholera is, with very few exceptions, preceded by some notice of its approach—un- less it had been brought on by a gross violation of the rules of liv- ing, as dictated by prudence and laid down by this council; intima- tion of its approach is most frequently given by uneasiness or loose- ness of the bowels. The results of our inquiries go likewise to prove, that in this stage of the disease it is very much under the con- trol of medicine judiciously adapted to the particular circumstances of the case. A want of due attention to the premonitory symptoms, especially to a looseness in the bowels, is followed by aggravated Cholera, and too frequently by death. The certainty of great dan- ger when this warning is neglected, and the equally strong assur- ance of safety when these symptoms have been removed by proper remedies, should induce every one to be watchful of the first appear- ance of diseases, and prompt in meeting them." To extend these authorities, seems almost useless; yet it may be well to advert to the state of opinion amongst the Medical men of Philadelphia, your cotemporaries;—perhaps it might be allowed to say of many of them, co-equals! The Commission to visit Can- ada from Philadelphia, both in the short report made at their re- turn in the newspapers, and in the more extended one of a later 4 IS OBSERVATIONS ON period, insist upon it; especially in p. 22. Facts of a like import are largely disseminated in the pages of the Cholera Gazette of Phil- adelphia. Such, and so numerous are the facts on this head, that did we not know the diffidence with which some writers view their own opinions, it might be imagined that this difference arose from a desire of singularity! Even the ancients have in this, as in many other particulars of consequence, pointed out to us those facts, which we ought to bear in remembrance; Cozlius Jlurelianus, a writer well known, and of infinite merit, and who lived about two hun- dred years after the death of our Saviour, in his book entitled "De Morbis acutis and chronicis," p. 255, lib. 3, cap. 20, expressly men- tions the Signa Cholerae fulurse—"Prsecedit frequenter choleri- cos stomachi gravedo at que tensio: anxietas: jactatio: vigilise: tormentum intestinorum cum sonitu, quern Graeci borborismon vocant. Ventris dolor: atque per podicem venti fluor nihil relev- ans," &c.—His full description of the disease is graphic as any of the present day; and for the benefit of those who do not possess his (oft-quoted but little perused) work, I might here give it, did time permit.—What makes me think he is actually describing the disease in an epidemic character, is the observation made by him, that it was so acute and rapid as described by the ancients, as never to reach the second day. Now the common Cholera, wherever it exists, though sometimes fatal at a very early period, can scarcely be as- serted never to reach the second day. It may be worthy of notice, and perhaps may lead to a closer investigation, by those who ve- hemently cry up sympathy, as if before unknown, to look at the antiquity of the doctrine of the consent of parts, as applied to this disease. " Magis autem patiuntur in ista passione stomachus et venter, et intestina : cxtera vero membra omnia corporis consen- tiunt."----How nearly has he forestalled the views connected with the ganglionic nerves !—Not to break in, by further reference to him, I will merely remark, that he made great use of cups to al- lay the spasms, and for other purposes, to the limbs and epigastri- um. They were not however accompanied with the scarifications and discharge of blood.—Let me now again repeat, that whoever has not met with all the authorities I have noticed, and many more on the subject of premonitory symptoms, must admit that their reading has been limited and imperfect; and consequently, inade- quate to authorize so decided a denial, as is here done, by calling it merely "a condition," and deriving it from "distinct sources of irritation." But I observe moreover, that in denying it to the writers that have been consulted on Asiatic Cholera, it is thought to be scarcely presumable, that so "prominent and important a fact," (meaning premonitory symptoms) could have escaped them, if it had exist- ence; and especially, since " being attached to armies" and "hospi- A LETTER TO DR. TYLER. 19 tals, they enjoyed the best and peculiar advantages for accurate and discriminating observations."----1 cannot doubt this to be your candid opinion; and consequently, as a just inference, that you would have much greater confidence in the observations made in the Locust street hospital, than in any derived from private practice.— But are we not all aware, that the fleeting and insidious symptoms, whether regarded as premonitory, or as a " condition," were for the most part disregarded; and that it was rarely, until the disease was fully formed, and vomiting, &c. had made their appearance, that the patient was conveyed to the hospital ? Was it not, in fact, a source of complaint in the publie papers, that many, and especially in the beginning of the epidemic, were brought thither in a moribund state? And is it not generally admitted, that it is chiefly in the forming stage, and "not too far advanced," that medical agency will prove beneficial? 41 It was first noticed, and promulgated by some of the British publications, though not sanctioned by all, and from a similar coincidence of gastric and entiretic de- rangement with the epidemic in this country, the notion has been espoused by us. Be it as it may, such disorders should at once be removed, as they are apt at all events, to invite an attack of Cholera. They do not differ from the ordinary com- plaints of the season, and require no peculiar management. By most authorities deserving of consideration, on Ihe subject of Epidemics, the ideas of precursory symptoms are no wise obscurely taught; and by attending to which symptoms, the full formed dis- ease may often be prevented ; and the old medical axiom be fully appreciated, of " venienti occurrite morbo." It may, as is here sta- ted, have been some British publications that first noticed the "hyp- othesis" in question; and if confined to this individual epidemic, there can be little doubt of the fact. Now the reason of this is con- spicuous, in those publications being the fruits of English physicians, who first saw and wrote upon it, almost at the instant of its break- ing out in India, in 1817; and the fact of their having noticed it thus early, is a strong presumption of its truth; whilst the similar- ity of those premonitory " gastric and entiretic derangements," wherever the Cholera has appeared, is another fact of equal corrob- oration. It will, I trust, be granted, that such "similar coincidence" in every part of the world, looks very much like the close connex- ion of cause and effect; in the opinion of most persons, it will prob- ably be considered to be the truth, and not a mere " notion," as it is here denominated. Nor would it be difficult to shew from your own writings, whether on your own authority, or, as pointed out by Webster in his work on Pestilence, (a book of infinite conveni- ence for reference, and proof of the energy and laborious investiga- 20 OBSERVATIONS ON tion of its author among the old writers) that an opinion of this kind was common in former periods, and has been deemed orthodox by you.—May I not indeed affirm, that the assumed connexion of the prior symptoms (ordinary complaints of the season) with the Chol- era, is not imaginary, but truly founded, since you admit that "they are apt to invite at all events an attack." Now this is all that is con- tended for; and is that which is to be sedulously guarded against;— if successful in arresting the further progress of this "condition," Cholera is effectually prevented. Nevertheless, if this " coinci- dence" is common, and if apt to invite an attack, must we not think the term premonitory, at least judicious, as a beacon to light up the approach of the enemy; and thus aid in frustrating his attack? It leads to nothing injurious, either theoretically or practically, and I would therefore suggest a re-consideration of this " notion." " Genuine Cholera, for the most part, comes on with little or no premonition. The earliest symptoms are complaints of load, and oppression, and anxiety about the prcecordia, with an internal sense of heat, referrible to the stomach or bowels, with great thirst and a whitish tongue, and at the same time the head is confused, the expression of countenance haggard, accompanied by slight nervous tremors, muscular weakness, cold skin, and either a quick and somewhat feeble, or a full and struggling pulse. Copious evacuations upwards and downwards, of fluid re- sembling dirty or turbid rice water, with flocculi mixed in it, soon occur, followed by cramps or spasms of the muscles of the extremities and abdomen. These are sel- dom so violent as has been represented, and never extend to the alimentarycanal." By "genuine Cholera," in the sentence, I presume is meant the violent, spasmodic, asphyxial, Indian, or pestilential disease; which is thus indirectly admitted occasionally to come on with premoni- tion. Whichever of these names is adopted, the term may be re- garded as incorrect, inasmuch as it is not always accompanied with spasms, asphyxia, or pestilential symptoms; nay even the term Cholera is improper; since so far from bile being generally dischar- ged, it is, both upwards and downwards a fluid altogether different; and sometimes, as is mentioned, (confirming thereby the Ion"- line of authorities from Hippocrates downwards,) there is an absolute ab- sence of vomiting or purging. What shall we call this variety? a cholera sicca, as the older writers have done? for we cannot well do without some kind of name. As however, none of the symptoms are uniformly present, we cannot well tell on which to fix as pathogr nomonic of the complaint, and by which our nomenclature should be framed. "The earliest symptoms of load," &c. are in truth, those very premonitory symptoms which you decry; but which every prudent person, medical or otherwise, will instantly attack, before the higher range of symptoms follow; and in so doing, collapse, congestion, &c. are all annulled. They are the very symptoms which' A LETTER TO DR. TYLER. 21 you tell us "do not differ from the ordinary complaints of the sea- son," and which "should at once be removed," because "they are apt to invite an attack of Cholera.—Had you attended sufficiently in drawing a line of demarcation, it would have probably been found, that even these "earliest symptoms" came on progressively, or con- secutively; the earliest being the first link of the chain; and therefore necessarily the earliest to be arrested by remedial measures; whilst the later named symptoms of the catalogue, indicate the approxima- tion to, or the full formed disease. All, it may be affirmed, is in strict order; and is reasonably deducible from the harmony of na- ture, even in her state of morbid action upon the animal economy. The expression of " either a quick and somewhat feeble, or a full and struggling pulse" amongst the earliest symptoms, would appear to indicate much diversity of disease; or, that this part of the picture is really drawn from different periods of this early stage itself; at any rate, they would seem to prove, that much difference of treat- ment may be called for, to meet their respective indications. Is not "the somewhat feeble pulse" rather in opposition to "very free bleeding"? Perhaps this "somewhat feeble," falls within the limits hereafter adverted to of "false appearances of debility," by which you say you were "deluded;"—and probably, when the de- lusion ceased, that apparent state of debility resolved itself into one of oppression or congestion; relievable by the evacuant and deple- tory plan, rather than by the " course of practice" you at first adopt- ed.—For it is well known, that congestion is more readily removed by depletion, than by super-addition to the causes producing it: hence the high importance of blood-letting, which would seem to be claimed as your discovery, in the postscript to your amended copy; but which I shall endeavour to shew, in its proper place, that even if this practice has been taught " for twenty years in your lectures," yet, that having abandoned those principles, an exclusive claim upon them, could not be correctly sustained.—Let me here ask, what is meant exactly by a struggling pulse? I have looked in vain, into several writers who have nearly exhausted the subject, but find none under this descriptive title. Whatever may have been meant by struggling, I suppose the "fall" means a strong pulse, in contra- distinction to the quick and feeble one. All this will doubtless be explained hereafter. I have already adverted to the occasional absence of the " copious evacuations," &c. chiefly with a view to attaining a name for the disease, that shall be free of ambiguity or contradiction! The "Lucus, a non lucendo" might be a fair premonitory plea, for Chol- era sine xo-hrj. Not only they are occasionally absent, one, or both — but they never or rarely are coeval with the preliminary stage. It is said in the sentence under notice, that the spasms never extend to the alimentary canal. Perhaps it is rarely the case; but surely, °2 OBSERVATIONS ON an attendance on a few patients, can scarcely authorize a decision so unqualified ! If I am not mistaken, others have found evidence of it, in the irregular contraction of the intestines, continuing even after death. These spasms of the extremities, &c. are very curious, and will no doubt receive attention. May we be allowed to ask your opinion as to those highly singular cases that are noticed, in which the muscles continued to act, a long time after death? Is this sympathy, or what? Perhaps, as you do not mention them, you did not meet with any such cases; some therefore may possibly deem it incredible: I think it proper to give one case, at least, from Mr. Finlayson, in the Medico-Chirurgical Transactions for 1820. One would almost suppose that Galvani had located himself within the individual, and was performing some of his electro-chemical experiments.* "An aggravation <»f the preceding symptoms rapidly takes place, and in half an hour or more, the tongue becomes icy cold, the skin more chilled and sodden, tho' feeling hot to the patient, covered with a dewy viscid perspiration, the hands shriv- elled or wilted, as if mascerated, the nails of the fingers blue, the pulse scarcely or not at all perceptible, the face sunken, especially the eyes, around which is a dark circle. This colour gradually diffuses itself over the entire surface, partaking of the various shades of hvidness, from a saturnine to a blueish or blackish hue." As no two authors probably, in the description of this disease, give it uniformly in the same manner; and, as infinite diversity must be produced by the different constitutions on which the aeriform poison acts; so we may, perhaps, consider the statement and train of symp- toms here given to be as good as any. I must however request at- tention to one or two particulars, in which I apprehend, you have employed rather a figure of speech, than given us the actual fact. It is well known, the temperature of the body is about 98°; and, that during the month of August, the thermometer rarely sinks be- low (say) 70°.—Now, icy-cold, as applied to the tongue, would im- * "The other died 14 hours after seizure, the most powerful remedies having been employed without effect. About 15 minutes after he expired, the toes began to move in various directions, and the feet were made to approach each other. Mus- cular contractions were speedily propagated upwards, along the inside of the legs and thighs. The thighs were turned slowly inwards, so as to approach each other, and again oiitvvards, the whole of the lower extremities moving on the heels as on pivots. These motions proceeded upwards, producing a quivering in the muscles. In 5 minutes the upper extremities began to be similarly affected, the fingers were extended, and often rigidly bent inwards; pronation and supination of the hand were steadily though slowly performed. The same quiverings were observable as in the lower extremities, and extended to the pectoralis major muscles, and the su- perior margin of the latissimus dorsi. The muscles of the face moved, and the head was observed to shake. The total duration of these appearances was half an hour. By moving or pricking the arms or limbs, these contractions were rendered strong- er, uad again renewed when they had ceased." A LETTER TO DR. TYLER. 23 ply 32° at least. Did you ever try the thermometer to determine the fact? or did you, without duly attending thereto, feel it, just at the time, or immediately after the patient had taken into his mouth a piece of ice for which he had an " instinctive" desire ? I am, I con- fess, doubtful of the tongue having ever fallen in temperature to the freezing point; for I have no where found that it becomes quite rigid and frozen from this diminished temperature; but which would be the case very certainly, in a short time, if the fact was as your words imply.*—The chilled sensation of the skin, (to the physician we presume) whilst feeling hot to the patient, is one of the most singular facts of false perception that we find in the annals of medi- cine, and extremely difficult to explain by any of the hypotheses that have exploded on the subject.—What renders it more curious, is, that it is nearly the reverse of what we find to be the case, in the cold or congestive state of Intermittent; and i,n which bleeding has also been so strongly commended, though not generally adopted! —It is probable analogies will be found between them; especially if we refer to the intermittent Cholera of Hoffman, Torti, and others already alluded to. In this state of chilliness, whilst the patient is shaking universally—his teeth chattering, and the sense of warmth is scarcely appreciable by him, though covered with blankets ; yet to the attendants, the temperature of the body is greater by several degrees than the natural, t In saying the nails are blue, we peiceive merely an echo of the ♦ It is the more to be regretted, that, (so far as I have heard,) the thermometer was not tried in the above cases; from the circumstance that Mi1. Keir in his treatise on Cholera, as it appeared at Moscow, speaking of the diminished temperature of the tongue, p. 57 and 58, adverts to two cases, in which he measuscd the tempera- ture under the tongue, by the bulb of Keaumer's thermometer placed there for two minutes. In one of them it was at 20° or 77° Fah.—In the other, at 25° or 88° of j/ah.—Whilst under his own tongue it reached to 30° or 95° of Fahrenheit. These cases were amongst the worst, and yet no i'r//-coldness seems to have been present. __We ought to have had a comparative experiment here, especially, since Ken's treatise, or at least Boisseau's, who refers to this experiment, were in the city of Philadelphia at that juncture. + Something of an analogous character, and therefore deserving of association in this place, is to be found in an account of an operation for Aneurism in the ham, by Mr. Brodie, at St. George's Hospital in 1827. The operation performed in the usu- al manner on the 9th of August, seemed to progress favorably until the 6th of Sep- tember, when a 2dary hemorrhage appeared, and augmented from time to time, su that on the 8th, Mr. B. tied up the artery in the groin. On the I lth Oct. hemorrhage ensued, and was restrained by pressure, but "at 4 A.M. of the 19th, 12 oz. of Mood were lost from the groin, and on the morning of the 20th, a pint and a half"— " From the 20th to the 50th, the patient went on very well. No hemorrhage oc- curred; the pain in the foot was relieved, and he was recovering from the state of depression into which he had been thrown. On the morning of the 30th, however, a slight bleeding occurred, with occasional rigors; and, what is curious, although he •was shivering, and complained of excessive cold, the temperature of the skin was up to 103° by the Thermometer." This man died on the 2nd Novem.; and the whole ease is extremely interesting, not only in itself, but from the subsequent severe critique of the Lancet; in which it appears, in the No. for Feb. 23. 1827-8, p. 791, &c. 2-1 OBSERVATIONS OS mistake of every writer. The semi-transparency of the nails, as horn, permits the blood congested below them, of a dark or livid hue, to be seen :—but the nail, as such, is certainly untinged. It is perhaps of little importance, further than that it is well to under- stand as far as possible, the real character of every symptom ; and hence, we find in fact, a lividity around the nails, some time before it is distinctly marked upon the nail itself.-----The affirmation here given, of the pulse becoming "scarcely or not at all perceptible" in "half an hour," is properly qualified, by the super-addition of the words "or more":—meaning thereby, we presume, an inde- finite and unlimited period, which any one may fill up,pro re nata; and therefore, as well calculated to apply to those cases, in which the accession "was as sudden as the electric shock," as for those of a more protracted character.—This colour, we are told, gradually diffused itself over the entire surface." It may be doubted if this expression is quite correct: wherever the remora of the blood exists on the "periphery," there it will be seen; and exactly in intensity to the degree of that remora, or congestive state. " During this period, the thirst is intense, the heat of the stomach in some m- stances is increased to a burning sensation, the respiration greatly embarrassed, the air expired cold, the voice low, or whispering and plaintive, the diaphragm convul- sed, and there is a total suppression of the urinary and other secretions. Discharges from the alimentary canal, and the spasms, likewise cease or are much diminished. Death ultimately takes place in a sort of tranquil stupor, or with indescribable jac- titatiou and distress, the latter state being by far the most common." The intense thirst which is here spoken of, appears to be one of the most prominent, and permanent symptoms; and for the most part comes on, earlier than this sentence would seem to imply; contin- uing with almost unabated importunity to the very instant of death. This is doubtless, in some way sympathetically associated with the burning sensation of the stomach ; but more so, we apprehend, with the exhausted state of the blood vessels, and consequent diminished secretion of the saliva and other arterial discharges. The instinct- ive desire for fluids, to supply the watery discharges xata et two, points loudly to the proud practitioner, that, after all, he is but the handmaid of Nature; and happy will he feel, if not too desirous of obstructing the measures she not obscurely points to! We are here not favoured with the slightest explanation of the "embarrassed" state of respiration.—Do you suppose Sir, that it always depends on one and the same cause, through all the various stadia of the disease? Too much stress is probably laid by writers on congestion alone; since many dissections seem to shew, that the lungs are not always, perhaps not commonly, in such a state.__ In the cold stage of Intermittent, attended with congestion, the air. A LETTDR TO DR. TYLER. 25 returned in expiration, is not cold, as is found to be the case in Cholera;—not even in engorgement, or apoplexy of the lungs.*— Now, is it not plain, that when the embarrassment, in respiration is accompanied with cold breath, that such embarrassment must de- pend on something else than mere congestion, at least of the luns contested hv vour Aid: and it remains to see how this claim can be settled to J j .• r .•_..! a/.... .im'nrlopil. in snme measure decline your our Aid: and it remains iu sec ..«.» -...., —------------—- - mutual satisfaction! You do indeed, in some measure decline 4(» OBSERVATIONS ON the honour of paternity to the plan, by immediately stating, that it (your plan) "cannot be charged with being tentative or empirical;" it being "deduced from established views of pathology and thera- peutics, and is sanctioned in most of its features by the length- ened and concurrent experience of the authoritative writers on the disease in India."—I should have presumed you were satisfied in giving it to the writers you notice; had you not restricted it to "most of its features," thereby giving us to understand, that all but " the most" of its features, belong to you.—Now, I would desire you to present any individual feature, which they have not announ- ced ! Of their experience, you may well say " lengthened," for it extends to at least 15 years, so far as it relates to the Indian wri- ters; whilst yours, is embraced in the period from about the 1st to the ISth of August!—Concurrent therefore, will scarcely ap- ply ! "now, the first portion of this prolonged period of nearly three weeks was obviously taken up by those plans of treatment that were found so fatal, and which you so happily abandoned !—With the ad- mission made throughout your letter, we must be allowed to add, that, if not empirical, it was assuredly tentative; at least I appre- hend it will be so considered by 99 of 100 of your medical readers. If you ask me why I think so, in opposition to your self-assurances, I shall very candidly reply, that admitting as you have done, the "fearful character of the disease," unless it is absolutely demonstra- ted that you were not among those practitioners, who, from dismay, abandoned principles and well tried remedies in its treatment; I cannot for my life view it in any other way !—Although I should be glad to find that you could divert from yourself, this obvious deduction from your own words; yet I must add, that the post- script to your amended copy, positively strengthens the presump- tion; since you there tell us, that you had taught "this very prac- tice, by emetics, calomel, bleeding, &c." for 20 years in your lec- tures?—Why, if then most appropriate, did you doubt at all of their absolute necessity in the cases before you?—Why leave that prac- tice for one you soon discovered to be so fatal?—You refer us to a "tolerable synopsis" in your work on the Materia Medica; which synopsis I have in vain looked for!—for, your reference is altogeth- er general, and does not point to any particular part. Few proba- bly will take the trouble that I have done to hunt it up; but will be satisfied to take it upon trust, on the authority of your assertion • and will credit you for a synopsis which I have not been able to discover. To be sure, I may not have looked in the right place • but, since in your postscript you particularly make emetics, calo- mel and bleeding precede the fyc, so I have limited my researches lo those points, and have left the $c. for further investigation —I shall merely add, that I, of choice selected your first edition as be- ing nearer to the actual period you advert to;' although 20 ye-u- A LETTER TO DR. TYLER. 47 are not yet fully accomplished, since you were raised to a chair, that you appear now to think of little importance in a medical school. As regards emetics, Sir, I find no notice of their use in Cholera, when you are treating of the "bowel affections," p. S8, vol. I. This disease is not even mentioned when treating of Ipeca- cuanha, and its particular employment in bowel complaints.—In short, so far as I can see, this disease is unnoticed in the whole dis- cussion of emetics; except as incidentally excited artificially, by tartar emetic, to remove poison from the stomach.----In speaking of calomel, p. 311, vol. II., and mentioning it expressly in the "bowel affections"—and its employment in the E. Indies by Yates and Maclean in Dysentery; yet you are not led to notice its use in Cholera !—Where Sir, is it then to be found ?----As for bleeding, important as it is, in a remedial point of view, it finds no particular notice from you. Cursorily indeed, it appears in your pages; but I have not found any especial connexion of it with Cholera; and hence, I must very earnestly request you to point out the part, which I may have unfortunately overlooked; and which may also be the case with others.—We shall thus be able to compare the re- spective claims of yourself and of the E. India practitioners: for al- though you seem to take precedence of them by your remarks, I cannot find that any of them have looked to your writings as the source of their treatment during the period of 15 years. " Many may be cured with it, and some will sink under the force of the attack in despite of your efforts. The case not being too far advanced, a triumph over the disease is pretty certain.— Cholera is, on the whole, more tractable than yellow fever, or the winter pestilence, which devastated our country during the late war. " Ever, my dear Sir, yours most truly. "N. CHAPMAN. "Philadelphia, August 18, 1832. "To Dr. Wm. Bbadley Tyieh, Frederick, MJ." This sir, is precisely the amount of information we derive from the admirable writings of the E. India and other practical men, during a period of 15 years—or 780 weeks;—to which, your portion of three weeks' hospital practice is as the 260th part, whilst your 37 patients to the millions recorded must now appear as a drop in the bucket! __It is probable Dr. Tyler was well acquainted with the writers adverted to, if not directly, at least from the periodicals which have annually recorded them. How truly happy must it have made you, and what a source of felicitation from your correspondent, that you so fortunately discovered the important fact announced in the antipenult sentence of your letter! viz. that if "not too far ad- vanced, a triumph over the disease is pretty certain" !! My dear 48 OBSERVATIONS ON Sir pray inform your readers, if it is the triumph of Nature or of Art—of principles re-adopted, or what?----1 think I see Dr. Tyler proclaiming this important truism, as one, with which the writings he had perused, had made him familiar! Nay, with which his dai- ly experience in every other disease, must have informed him! We entreat you to acquaint the profession, whereby we may exactly distinguish the line by which we reasonably mark a triumph, if triumph we can call it, when "not too far advanced."—Can you inform us also how to triumph over the disease when it is "too far advanced"—or is this beyond the reach of all scientific principles and practice?—In which of these two different stages of Cholera is it that it may be deemed " on the whole, more tractable than yellow fever, or the winter pestilence?—for if this is really true, why was Dr. Tyler and the public, to be terrified by the appalling influence of your descriptive pen? * And now Sir, in bidding you farewell, allow me to ask, with the utmost respect, and with absolute sincerity of intention, wherein has your letter been calculated to be useful, either in theory or prac- tice, beyond what has long been known to every one who kept pace with medical science; and had not thought it necessary from undue dismay, to depart from long established principles, and plunge into a sea of doubt and despondency. I should not have deemed it necessary to remark on the letter at all, had it not been, for the very general and prevalent report at the time, that Dr. Chap- man had discovered a new method of treating-the disease, which had divested it of much of its hazard;—and I was therefore led to examine it with a greater attention, than I should otherwise have considered it entitled to.— With great respect, your well wisher— AN INQUIRER. * May we be permitted to ask, if the mortality of yellow fever or winter pesti- lence, has ever equalled in any hands, that of Cholera? we will not say at the fatal period of the first few days; but at and after the happy period of more felicitous practice. THE END. ERRATUM. Page 18, line 12. for "and" read et.