Part 1 (1/2)

Letters on the Cholera Morbus.

by James Gillkrest and William Fergusson.

LETTER I.

If we view the progress of this terrific malady, as it tends to disorganise society wherever it shows itself, as it causes the destruction of human life on an extensive scale, or as it cramps commerce, and causes vast expense in the maintenance of quarantine and cordon establishments, no subject can surely be, at this moment, of deeper interest. It is to be regretted, indeed, that, in this country, political questions (of great magnitude certainly), should have prevented the legislature, and society at large, from examining, with due severity, all the data connected with cholera, in order to avert, should we unhappily be afflicted with an epidemic visitation of this disease, that state of confusion, bordering on anarchy, which we find has occurred in some of those countries where it has this year appeared.

Were this letter intended for the eyes of medical men only, it would be unnecessary to say that, during epidemics, the safety of thousands rests upon the solution of these simple questions:--Is the disease communicable to a healthy person, from the body of another person labouring under it, either _directly_, by touching him, or _indirectly_, by touching any substance (as clothes, &c.) which might have been in contact with him, or by inhaling the air about his person, either during his illness or after death?--Or is it, on the other hand, a disease with the appearance and progress of which sick persons, individually or collectively, have no influence, the sole cause of its presence depending on unknown states of the atmosphere, or on terrestrial emanations, or on a principle, _aura_, or whatever else it may be called, elicited under certain circ.u.mstances, from both the earth and air?--In the one case we have what the French, very generally I believe, term _mediate_ and _immediate_ contagion, while the term _infection_ would seem to be reserved by some of the most distinguished of their physicians for the production of diseases by a deteriorated atmosphere:--much confusion would certainly be avoided by this adoption of terms.[1] Now it is evident, that incalculable mischief must arise when a community acts upon erroneous decisions on the above questions; for, if we proceed in our measures on the principle of the disease not being either directly or indirectly transmissible, and that it should, nevertheless, be so in fact, we shall consign many to the grave, by not advising measures of separation between those in health, and the persons, clothes, &c., of the sick. On the other hand, should governments and the heads of families, act on the principle of the disease being transmissible from person to person, while the fact may be, that the disease is produced in each person by his breathing the deteriorated atmosphere of a certain limited surface, the calamity in this case must be very great; for, as has happened on the Continent lately, cordons may be established to prevent flight, _when flight, in certain cases, would seem to be the only means of safety to many_; and families, under a false impression, may be induced to shut themselves up in localities, where ”every breeze is bane.”

[Footnote 1: As medical men in this Country employ the word _infection_ and _contagion_ in various senses, I shall, generally subst.i.tute _transmissible_ or _communicable_, to avoid obscurity.]

Hence then the importance, to the state and to individuals, of a rigid investigation of these subjects. It is matter of general regret, I believe, among medical men, that hitherto the question of cholera has not always been handled in this country with due impartiality. Even some honest men, from erroneous views as to what they consider ”the safe side” of the question, and forgetting that the safe side can only be that on which truth lies (for then the people will know _what_ to do in the event of an epidemic), openly favour the side of _communicability_, contrary to their inward conviction; while the good people of the quarantine have been stoutly at work in making out that precautions are as necessary in the cholera as in plague. Meantime our merchants, and indeed the whole nation, are filled with astonishment, on discovering that neighbouring states enforce a quarantine against s.h.i.+ps from the British dominions, when those states find that cases of disease are reported to them as occurring among us, resembling more or less those which we have so loudly, and I must add prematurely, declared to be transmissible. It is quite true that, however decidedly the question may be set at rest in this country, our commerce, should we act upon the principle, of the disease not being transmissible, would be subject to vexatious measures, at least for a time, on the part of other states; but let England take the lead in inst.i.tuting a full inquiry into the whole subject, by a Committee of the House of Commons; and if the question be decided against quarantines and cordons by that body, other countries will quickly follow the example, and explode them as being much worse than useless, as far as their application to cholera may be concerned. It is very remarkable how, in these matters, one country shapes its course by what seems to be the rule in others; and, as far as the point merely affects commerce, without regard to ulterior considerations, it is not very surprising that this should be the case; but it is not till an epidemic shall have actually made its appearance among us, that the consequences of the temporising, or the precipitation, of medical men can appear in all their horrors. Let no man hesitate to retract an opinion already declared, on a question of the highest importance to society, if he should see good reason for doing so, after a patient and unbia.s.sed reconsideration of all the facts. We are bound, in every way, to act with good faith towards the public, and erroneous views, in which that public is concerned, ought to be declared as soon as discovered.

To show how erroneous some of the data are from which people are likely to have drawn conclusions, is the main cause of my wish to occupy the attention of the public; and in doing this, it is certainly not my wish to give offence to respectable persons, though I may have occasion to notice their errors or omissions.

Previous to proceeding to the consideration of other points, it may be observed, that all doubt is at an end as to the ident.i.ty of the Indian, Russian, Prussian, and Austrian epidemic cholera; no greater difference being observed in the grades of the disease in any two of those countries, than is to be found at different times, or in different places, in each of them respectively. At the risk of being considered a very incompetent judge, if nothing worse, I shall not hesitate to say, that if the same a.s.semblage, or grouping of symptoms be admitted as const.i.tuting the same disease, it may at any time be established, to the entire satisfaction of an unprejudiced tribunal, that cases of cholera, not unfrequently proving fatal, and corresponding in every particular to the average of cases as they have appeared in the above countries, have been frequently remarked as occurring in other countries including England; and yet no cordon or quarantine regulations, on the presumption of the disease spreading by ”contagion.” For my own part, without referring to events out of Europe, I have been long quite familiar, and I know several others who are equally so, with cholera, in which a perfect similarity to the symptoms of the Indian or Russian cholera has existed: the collapse--the deadly coldness with a clammy skin--the irritability of the stomach, and prodigious discharge from the bowels of an opaque serous fluid (untinged with bile in the slightest degree)--with a corresponding shrinking of flesh and integuments--the pulseless and livid extremities--the ghastly aspect of countenance and sinking of the eyes--the restlessness so great, that the patient has not been able to remain for a moment in any one position--yet, with all this, n.o.body dreamt of the disease being communicable; no precautions were taken on those occasions ”to prevent the spreading of the disease,”

and no epidemics followed. In the _Glasgow Herald_ of the 5th ult., will be found a paper by Mr. Marshall, (a gentleman who seems to reason with great acuteness), which ill.u.s.trates this part of our subject. This gentleman appears to have had a good deal of experience in Ceylon when the disease raged there, and I shall have occasion to refer hereafter to his statements, which I consider of great value. n.o.body can be so absurd as to expect, that in the instances to which I refer, _all_ the symptoms which have ever been enumerated, should have occurred in each case; for neither in India nor any-where else could all the grave symptoms be possibly united in any one case; for instance, great retching, and a profuse serous discharge from the bowels, have very commonly occurred where the disease has terminated fatally: yet it is not less certain, that even in the epidemics of the same year, death has often taken place in India more speedily where the stomach and bowels have been but little affected, or not at all. To those who give the subject of cholera all the attention which it merits, the consideration of some of those cases which have, within the last few weeks, appeared in the journals of this country, cannot fail to prove of high interest, and must inspire the public with confidence, inasmuch as they show, _beyond all doubt_, that the disease called cholera, as it has appeared in this country, and however perfectly its symptoms may resemble the epidemic cholera of other countries, _is not_ communicable. On some of those cases so properly placed before the public, I shall perhaps be soon able to offer a few remarks: meanwhile, I shall here give the abstract of a case, the details of which have not as yet, I believe, appeared, and which must greatly strengthen people in their opinion, that these cholera cases, however formidable the symptoms, and though they sometimes end rapidly in death, still do not possess the property of communicating the disease to others. I do not mean to state that I have myself seen the case, the details of which I am about to give, but aware of the accuracy of the gentleman who has forwarded them to me, I can say, that although the communication was not made by the medical gentleman in charge of the patient, the utmost reliance may be placed on the fidelity of those details:--

Thursday, August 11th, 1831, Martin M'Neal, aged 42, of the 7th Fusileers, stationed at Hull, was attacked at a little before four A.M., with severe purging and vomiting--when seen by his surgeon at about four o'clock, was labouring under spasms of the abdominal muscles, and of the calves of the legs. What he had vomited was considered as being merely the contents of the stomach, and, as the tongue was not observed to be stained of a yellow colour, it was inferred that no bile had been thrown up. He took seventy drops of laudanum, and diluents were ordered.

Half-past six, seen again by the surgeon, who was informed that he had vomited the tea which he had taken; no appearance of bile in what he had thrown up; watery stools, with a small quant.i.ty of feculent matter; thirst; the spasms in abdomen and legs continued; countenance not expressive of anxiety; skin temperate; pulse 68 and soft; the forehead covered with moisture. Ordered ten grains of calomel, with two of opium, which were rejected by the stomach, though not immediately.

Eight o'clock A.M. The features sinking, the temperature of the body now below the natural standard, especially the extremities; pulse small; tongue cold and moist; a great deal of retching, and a fluid vomited resembling barley-water, but more viscid; constant inclination to go to stool, but pa.s.sed nothing; the spasms more violent and continued; a state of collapse the most terrific succeeded. At nine o'clock, only a very feeble action of the heart could be ascertained as going on, even with the aid of the stethoscope; the body cold, and covered with a clammy sweat, the features greatly sunk; the face discoloured; the lips blue; the tongue moist, and very cold; the hands and feet blue, cold, and shrivelled, as if they had been soaked in water, like washerwomen's hands; no pulsation to be detected throughout the whole extent of the upper or lower extremities; the voice changed, and power of utterance diminished. He replied to questions with reluctance, and in monosyllables; the spasms became more violent, the abdomen being, to the feel, as hard as a board, and the legs drawn up; cold as the body was, he could not bear the application of heat, and he threw off the bed-clothes; pa.s.sed no urine since first seen; the eyes became gla.s.sy and fixed; the spasms like those of teta.n.u.s or hydrophobia; the restlessness so great, that it required restraint to keep him for ever so short a time in any one position. A vein having been opened in one of his arms, from 16 to 20 ounces of blood were drawn with the greatest difficulty. During the flowing of the blood, there was great writhing of the body, and the spasms were very severe--friction had been arduously employed, and at ten A.M. he took a draught containing two and a half drachms of laudanum, and the vomiting having ceased, he fell asleep. At two P.M. re-action took place, so as to give hopes of recovery. At four P.M. the coldness of the body, discoloration, &c., returned, but without a return of the vomiting or spasms. At about half-past eight he died, after a few convulsive sobs.

On a post-mortem examination, polypi were found in the ventricles of the heart, and the cavae were filled with dark blood. Some red patches were noticed on the mucuous membrane; but the communication forwarded to me does not specify on what precise part of the stomach or intestinal ca.n.a.l; and my friend does not appear to attach much importance to them, from their common occurrence in a variety of other diseases. It remains to be noticed, that the above man had been at a fair in the neighbourhood on the 9th (two days preceding his attack), where, as is stated, he ate freely of fruit, and got intoxicated. On the 10th he also went to the fair, but was seen to go to bed sober that night. The disease did not spread to others, either by direct or indirect contact with this patient.

Now let us be frank, and instead of temporising with the question, take up in one hand the paper on ”cholera spasmodica” just issued, for our guidance, from the College of Physicians by the London Board of Health, and in the other, this case of Martin M'Neal (far from being a singular case this year, in most of the important symptoms),--let the symptoms be compared by those who are desirous that the truth should be ascertained, or by those who are not, and if distinctions can be made out, I must ever after follow the philosophy of the man who doubted his own existence. The case, as it bears on certain questions connected with cholera, _is worth volumes of what has been said on the same subject_.

Let it be examined by the most fastidious, and the complete ident.i.ty cannot be got rid of, even to the _blue_ skin, the _shrivelled fingers_, the _cold tongue_, the _change in voice_, and the _suppression of urine_, considered in some of the descriptions to be found in the pamphlet issued by the Board of Health, as so characteristic of the ”Indian” cholera; and this, too, under a ”const.i.tution of the atmosphere” so remarkably disposed to favour the production of cholera of one kind or other, that Dr. Gooch, were he alive, or any close reasoner like him, must be satisfied, that were this remarkable form of the disease communicable, no circ.u.mstance was absent which can at all be considered essential to its propagation. As the symptoms in the case of M'Neal, were, perhaps, more characteristically grouped than in any other case which has been recorded in this country, so it has also in all probability occurred, that more individuals had been in contact with him during his illness and after his death, as the facility in obtaining persons to attend the sick, rub their bodies, &c., must be vastly greater in the army than in ordinary life; so that in such cases it is not a question of one or two escaping, but of _many_, which is always the great test.

Of the College of Physicians we are all bound to speak with every feeling of respect, but had the doc.u.ment transmitted by that learned body to our government, on the 9th of June last, expressed only a ”philosophic doubt,” instead of making an a.s.sertion, the question relative to the contagion or non-contagion of the disease, now making ravages in various parts of Europe, would be less shackled among us.

People are naturally little disposed to place themselves, with the knowledge they may have obtained from experience and other sources, in opposition to such a body as the College: but as, in their letter to government of the 18th of June, they profess their readiness, should it be necessary, to ”re-consider” their opinion, we, who see reason to differ from them, may be excused for publis.h.i.+ng our remarks. It seems surprising enough that, in their letter to government of the 9th of June, the College should have given as a reason for their decision as to the disease being infectious (meaning, evidently, what some call contagious, or transmissible from _persons_)--”having no other means of judging of the nature and symptoms of the cholera than those furnished by the doc.u.ments submitted to us.” Now, according to the printed parliamentary papers, among the doc.u.ments here referred to as having been sent by the Council to the College, was one from Sir William Crichton, Physician in Ordinary to the Emperor of Russia, in which a clear account is given of the symptoms as they presented themselves in that country; and, if the College had previously doubted of the ident.i.ty of the Russian and Indian cholera, a comparison of the symptoms, as they were detailed by Sir William, with those described in various places in the _three volumes_ of printed Reports on the cholera of India, in the college library, must at once have established the point in the affirmative. In fact, we know, that the evidence of Dr. Russell, given before the College, when he heard Sir William's description of the disease read, fully proved this ident.i.ty to the satisfaction of the College. Had the vast ma.s.s of information contained in the India Reports, together with the information since acc.u.mulated by our Army Medical Department, been consulted, all which are highly creditable to those concerned in drawing them up, and contain incomparably better evidence, that is, evidence more to be relied on, than any which can be procured from Russia or any other part of the world--had these sources of information been consulted, as many think they should in all fairness have been, the College would probably have spoken more doubtingly as to cholera, in any form, possessing the property of propagating itself from person to person. Much of what pa.s.ses current in favour of the communication of cholera rests, I perceive, on statements the most vague, a.s.sertions in a general way, as to the security of those who shut themselves up, &c. To show how little reliance is to be placed on such statements, even when they come from what ought to be good authority, let us take an instance which happened in the case of yellow fever.

Doctor, now Sir William Pym, superintendent of the quarantine department, published a book on this disease in 1815, in which he stated, that the people shut up in a dock-yard, during the epidemic of 1814, in Gibraltar, escaped the disease, and Mr. William Fraser, also of the quarantine, and who was on the spot, made a similar statement. Now, we all believed this in England for several years, when a publication appeared from Dr. O'Halloran, of the medical department of Gibraltar garrison, in which he stated that he had made inquiries from the authorities at that place, and that he discovered the whole statement to have been without the smallest foundation, and furnishes the particulars of cases which occurred in the dock-yard, among which were some deaths; this has never since been replied to--so much as a caution in the selection of proofs.

To show, further, how absurdly statements respecting the efficacy of cordons will sometimes be made, it may be mentioned that M. D'Argout, French minister of public works, standing up in his place in the chamber, _on the 3rd instant_ (_Septr._), and producing his estimates for additional cordons, &c., stated, by way of proving the efficacy of such establishments, that in Prussia, where, according to him, cordon precautions had been pre-eminently rigorous, and where ”_le territoire a ete defendu pied a pied_,” such special enforcement of the regulations was attended with ”_a.s.sez de succes_:” in the meantime the next mail brings us the official announcement (_dated Berlin, Sept. 1_) of the disease having made its appearance there!

To conclude, for the present: if there be one reason more than another why the question of cholera should be scrutinized by the highest tribunal--a parliamentary committee--it is, that in the ”papers” just issued by the Board of Health, the following pa.s.sage occurs (page 36):--”But in the event of such removal not being practicable, on account of extreme illness or otherwise, the prevention of all intercourse with the sick, even of the family of the person attacked, must be rigidly observed, unless,” &c. There are some who can duly appreciate all the consequences of this; but let us hope that the question is still open to further evidence, in order to ascertain whether it be really necessary that, in the event of a cholera epidemic,

”The living shall fly from The sick they should cherish.”

LETTER II.

In my last letter I adverted to the opinion forwarded to his Majesty's Council on the 9th of June last from the College of Physicians, in which the cholera, now so prevalent in many parts of Europe, was declared to be communicable from person to person. We saw that they admitted in that letter (see page 16 of the Parliamentary Papers on Cholera) the limited nature of the proofs upon which their opinion was formed; but I had not the reasons which I supposed I had for concluding, that because they used the words ”ready to reconsider,” in their communication of the 18th of same month to the Council, they intended to _reconsider_ the whole question. Indeed this seems now obvious enough, as one of the Fellows of the College who signed the Report from that body on the 9th of June (Dr. Macmichael) has published a pamphlet in support of the opinion already given, in the shape of a letter addressed to the President of the College, whose views, Dr. Macmichael tells us, _entirely coincide_ with his own; so that there is now too much reason to apprehend that in this quarter the door is closed. Contagionist as I am, in regard to those diseases where there is evidence of contagion, I find nothing in Dr.

Macmichael's letter which can make an impression on those who are at all in the habit of investigating such subjects,[2] and who, dismissing such inductions as those which he seems to consider legitimate, rely solely on facts rigorously examined. He must surely be aware that most of the points which he seems to think ought to have such influence in leading the public to believe in the contagion of cholera, might equally apply to the influenza which this year prevailed in Europe, and last year in China, &c.; or to the influenza of 1803, which traversed over continents and oceans, _sometimes in the wind's eye, sometimes not_, as frequently mentioned by the late Professor Gregory of Edinburgh. Who will now stand up and try to maintain that the disease in those epidemics was propagated from person to person? Could more have been made of so bad a cause as contagion in cholera, few perhaps could have succeeded better than Dr. Macmichael, and no discourtesy shall be offered him by me, though he does sometimes loose his temper, and say, among other things not over civil, nor quite _comme il faut_, from a Fellow of the College, that all who do not agree with him as to contagion ”will fully abandon all the ordinary maxims of prudence, and remain obstinately blind to the dictates of common sense!”--_fort, mais peu philosophique Monsieur le Docteur_. The time has gone by when ingenious men of the profession, like Dr. Macmichael, might argue common sense out of us; it will not even serve any purpose now that other names are so studiously introduced as _entirely coinciding_ with Dr. Macmichael; for, in these days of reform in every thing, _opinions_, will only be set down at their just value by those who pay attention to the subject.

[Footnote 2: I presume that I shall not be misunderstood when I say, _Would that the cholera were contagious_--for then we might have every reasonable hope of staying the progress of the calamity by those cordon and quarantine regulations which are now not merely useless, but the bane of society, when applied to cholera or other non-contagious diseases.]

Referring once more to the Report of the 9th of June, made by the College to the Council, and signed by the President as well as by Dr. Macmichael, the cholera was there p.r.o.nounced to be a communicable disease, when they had, as they freely admit, ”no other means of judging of the nature and symptoms of the cholera than those furnished by the doc.u.ments submitted to them.” The doc.u.ments submitted were the following, as appears from the collection of papers published by order of Parliament:--Two reports made to our government by Dr. Walker, from Russia; a report from Petersburgh by Dr. Albers, a Prussian physician; and a report, with inclosures, regarding Russian quarantine regulations, from St. Petersburg, by Sir W. Creighton. Dr. Walker, who was sent from St. Petersburg to Moscow, by our amba.s.sador at the former place; states, in his first report, dated in March, that the medical men seemed to differ on the subject of contagion, but adds, ”I may so far state, that by far the greater number of medical men are disposed to think it not contagious.” He says, that on his arrival at Moscow, the cholera was almost extinct there; that in twelve days he had been able to see only twenty-four cases, and that he had no means of forming an opinion of his own as to contagion. In a second report, dated in April from St.

Petersburg, this gentleman repeats his former statement as to the majority of the Moscow medical men not believing the disease to be contagious (or, as the College prefer terming it, infectious), and gives the grounds on which their belief is formed, on which he makes some observations. He seems extremely fair, for while he states that, according to his information, a peculiar state of the atmosphere ”was proved by almost every person in the city (Moscow), feeling, during the time, some inconvenience or other, which wanted only the exciting cause of catching cold, or of some irregularity in diet, to bring on cholera;”

that ”very few of those immediately about the patients were taken ill;”

that he ”did not learn that the contagionists in Moscow had any strong particular instances to prove the communication of the disease from one individual to another;” and that he had ”heard of several instances brought forward in support of the opinion (contagion), but they are not fair ones:” he yet mentions where exceptions seem to have taken place as to hospital attendants not being attacked, but he has neglected to tell us (a very common omission in similar statements), whether or not the hospitals in which attendants were attacked were situated in or near places where the atmosphere seemed _equally productive of the disease in those not employed in attending on sick_. This clearly makes all the difference, for there is no earthly reason why people about the sick should not be attacked, if they breathe the same atmosphere which would seem to have so particular an effect in producing the disease in others; indeed there are good reasons why, during an epidemic, attendants should be attacked in greater proportion; for the constant fatigue, night-work, &c., must greatly predispose them to disease of any kind, while the great additional number always required on those occasions, precludes the supposition of the majority so employed being _seasoned_ hospital attendants, having const.i.tutions impenetrable to contagion. Those questions are _now_ well understood as to yellow fever, about which so much misconception had once existed. The proofs by disinterested authors (by which I mean those unconnected with quarantine establishments, or who are not governed by the _expediency_ of the case) in the West Indies, America, and other places, show this in a clear light; but the proofs which have for some time past appeared in various journals respecting the occurrences at Gibraltar, during the epidemic of 1828, are particularly ill.u.s.trative. By the testimony of three or four writers, we find that _within certain points_, those in attendance on sick, in houses as well as hospitals, were attacked with the fever, in common with those who were not in attendance on sick; but that, where people remained at ever so short a distance beyond those points, during the epidemic influence, _not a single instance_ occurred of their being attacked, though great numbers had been in the closest contact with the sick, and frequently too, it would appear, under circ.u.mstances when contagion, had it existed, was not impeded in its usual course by a very free atmosphere:--_sick individuals, for instance, lying in a small house, hut, or tent, surrounded, during a longer or shorter s.p.a.ce of time, by their relatives, &c._ A full exposure of some very curious mis-statements on these points, made by our medical chief of the quarantine, will be found from the pen of the surgeon of the 23d regiment, in the _Edinburgh Medical and Surgical Journal_, No. 106.[3]