Letters on the Cholera Morbus.

LETTER III

Having given, in my last letter, Dr. Davy's views as to the cause of cholera, I may so far remark just now regarding them, that they are not new, or peculiar to him; and that it may be well, before Dr. Macmichael or others pronounce them vague, that they should inquire whether some of those causes have not been assigned for the production of certain epidemics, by one of the soundest heads of Dr. Macmichael's college – Dr. Prout, who seems, if we have not greatly mistaken him, to have been led to the opinion by some experiments of Herschell, detailed in the Philosophical Transactions of the year 1824. They should recollect that other competent persons devoted to researches on such subjects (Sir R. Phillips among the number) admit specific local atmospheres (not at all malaria in the usual sense of the term), produced by irregular streams of specific atoms from the interior of the earth, and "arising from the action and re-action of so heterogeneous a mass." For my part I feel no greater difficulty in understanding how our bodies, "fearfully and wonderfully made" as we are, should be influenced by those actions, re-actions, and combinations, to which Sir Richard refers, and of "whose origin and progress the life and observation of man can have no cognizance," than how they are influenced by other invisible agents, the existence of which I am compelled to admit. – If the writer of the article on cholera in the Westminster Review, for October, 1831, do not find all his objections met by these observations, I must only refer him to the quid divinum of Hippocrates: – but I must protest against logic such has been employed by certain members of our Board of Health, who lately, on the examination of gentlemen of the profession who had served in India, and who had declared the disease not to be communicable, came to the conclusion that it must, nevertheless, be so, as those gentlemen could not show what it was owing to.

Most extraordinary certainly it does appear, that while Dr. Macmichael goes to the trouble of giving us (p. 27) the views of a captain (!) as to the progress of cholera at a certain place in India, he should have refrained altogether from referring, on the point of contagion or non-contagion, to the report of such a person as Dr. Davy, or to the reports of this gentleman's colleagues at Ceylon, Drs. Farrell and Marshall. Had Dr. Macmichael added a little to his extract from Capt. Sykes, by informing us of what that gentleman states as to the great mortality ("350 in one day") in the town of Punderpoor, "when the disease first commenced its ravages there," people would have means of judging how unlike this was to a contagious disease creeping from person to person in its commencement.

It is painful to be obliged to comment on the manner in which Dr. Bisset Hawkins has handled the questions relative to the Ceylon epidemic, which seems far from being impartial; for, while he quotes (p. 172) Dr. Davy, "a medical officer well known in the scientific world," as stating that the cause of the disease is not in any sensible changes in the state of the atmosphere, he breaks off suddenly at the word atmosphere, proceeds to talk of the changes in the muscles and blood of persons who die of the disease, and passing over the part quoted from Dr. Davy, near the close of my last letter, Dr. Hawkins leaves his readers to draw a very natural conclusion – that, as Dr. Davy admitted that there were no prevalent sensible states of the atmosphere to which the cholera could be attributed, he, therefore, believed it to have been propagated by contagion, an inference which we now see must be quite wide of the mark. Dr. Hawkins had, it appears, like many other medical gentlemen, access to the reports from Ceylon, &c., in the office of the chief of the army medical department in London, and it is to be regretted I think that, with respect to one of the Ceylon reports, he only tells us (p. 174) that "Mr. Staff-Surgeon Marshall reports from Candy, that of fifty cases which had occurred, forty died." Why more had not been quoted from a gentleman who had such ample means of witnessing the disease in its very worst form, I must leave to others to say; but, referring again to the highly interesting letter from Mr. Marshall on cholera, which appeared in the Glasgow Herald, of the 5th of August last, and in which, from many important observations which every body interested in cholera should read and study, the following remarks will be found: – "In no one instance did it seem to prevail among people residing in the same house or barracks, so as to excite a suspicion that the contact of the sick with the healthy contributed to its propagation." "The Indian Cholera, as it is sometimes called, appears not to be essentially different from cholera as it occurs in this and all other countries." "I consider it, therefore, impossible for a medical practitioner to speak decisively from having seen one, or even a few cases of cholera in this country, and to say whether they are precursors of 'the epidemic cholera' or not. That the disease is ever propagated by means of personal contact, or by the clothes of the sick, has not, as far as I know, been satisfactorily proved. The quality of contagion was never attributed to the disease in Ceylon, and I believe no-where did it occur in greater severity. I am aware that an attempt has been made to distinguish the ordinary cholera of this country from the 'epidemic cholera,' by means of the colour or quality of the discharges from the bowels. In the former it is said the discharge is chiefly bile, while in the latter it is said to bear no traces of bile, but to be colourless and watery. How far is this alleged diagnosis well founded? I am disposed to believe that, in all severe cases of cholera, whether it be the cholera of this country, or the epidemic cholera, the secretion of bile is either suppressed, or the fluid is retained in the gall-bladder." Mr. Marshall, it may be observed, is the gentleman who was selected by the late Secretary at War, in consequence of his known intelligence, to remodel the regulations relative to military pensioners; and I understand that, in consequence of the manner in which he executed that very important duty, he has since been promoted. After what appears from the above quotations, how perfectly unwarrantable must the assertion of Dr. Bisset Hawkins seem, that "from the Coromandel coast it seems to have been transported by sea to Ceylon!"

We shall, I think, be able to see that the assumption of Drs. Macmichael and Hawkins, as to the importation of the disease into the Mauritius from Ceylon, is equally groundless with that of its alledged importation into the latter island; and here we have to notice the same want of candour on the part of those gentlemen, in not having furnished that public, which they professed to enlighten on the subject of cholera, with those proofs within their reach best calculated to display the truth; be it a part of my duty to supply the omissions of these gentlemen in this respect. The following is a copy of a letter accompanying the medical commission report at that island forwarded to General Darling, the then commanding officer, by the senior medical gentleman there.

"I have the honour of transmitting the reports of the French and English medical gentlemen on the prevalent disease; both classes of the profession seem to be unanimous in not supposing it contagious, or of foreign introduction. From the disease pervading classes who have nothing in common but the air they breathe, it can be believed that the cause may exist in the atmosphere. A similar disease prevailed in this island in 1775, after a long dry season."

In the reports referred to in the above letter, there is the most ample evidence of the true cholera having appeared at different points in the colony before the arrival of the Topaze frigate, the ship accused by contagionists par métier, of having introduced the disease; so that, contrary to what Dr. Macmichael supposes, those who disbelieve the communicability of cholera, have no necessity whatever in this case for pleading a coinsidency between the breaking out of the disease, and the arrival of the frigate; indeed, his friend Dr. Hawkins seems to be aware of this, when he is obliged to have recourse to such an argument as that "it is, at all events, clear that the disease had not been epidemic at the Mauritius before the arrival from Ceylon;" so that the beginning of an epidemic is to be excluded from forming a part or parcel of the epidemic! Why is it that in medicine alone such modes of reasoning are ever ventured upon!

We know, from the history of cholera in India, that not only ships lying in certain harbours have had the disease appear on board, but even vessels sailing down one coast have suffered from it, while sailing up another has freed them from it, without the nonsense of going into harbour to "expurgate." Now, with respect to the Topaze, it appears that while lying in harbour in Ceylon, the disease broke out on board her; that after she got into "clene air" at sea, the disease disappeared, seventeen cases only having occurred from the time she left the island, and she arrived at the Mauritius, as Dr. Hawkins admits, without any appearance whatever of the cholera on board. On the day after her arrival, she sent several cases ("chronic dysentry, hepatitis, and general debility") to hospital, but not one of cholera; neither did any case occur on board during her stay there, at anchor a mile and a half from shore, and constantly communicating with shore,5 while a considerable number of deaths took place from cholera in the merchant vessels anchored near shore.

As to the introduction of cholera from the Mauritius into Bourbon, where it appeared but very partially, Dr. Macmichael very properly does not say one word. There was abundance of "precaution" work, it is said, and those who choose, are at liberty to give credit to the story of its having been smuggled on shore by some negro slaves landed from a Mauritius vessel. As to the precautions to which the writer in The Westminster Review attributes the non-extension of the disease in this island, hundreds of instances are recorded, in addition to those which we have already quoted, of the disease stopping short, without cordons or precautions of any kind – one remarkable instance is mentioned by Dr. Annesley, where, without seclusion, the disease did not reach the ground occupied by two cavalry regiments, although it made ravages in all the other regiments in the same camp.

We have, perhaps, a right to demand from those gentlemen who display such peculiar tact in the discovery of ships by which the cholera has, at divers times, been imported into continents and islands, the names of those ships which brought to this country, in the course of the present year, the "contagion" which has produced, at so many different points, cases of severe cholera, causing death in some instances, and in which the identity with the "Indian cholera," the "Russian cholera," &c., has been so perfect, that all the "perverse ingenuity" of man cannot point out a difference. If it cannot be shown that in this, we non-contagionists in cholera are in error, people will surely see reason for abandoning the cause of cordons, &c., in this disease, – a cause which, in truth, now rests mainly for support upon a sort of conventional understanding, unconnected altogether, it would appear, with the facts of the case, and entered into, we are bound to suppose, before the full extent of the mischief likely to arise from it had been taken into consideration. Admitting for a moment that a case of cholera possessing contagious properties could be imported into this country this year, will anybody say that a "constitution of the atmosphere" favourable to its communicability to healthy individuals, has not existed in a very high degree: – can a spot be named in which cholera, generally of a mild grade, has not prevailed? And if contagionists cannot point out a difference between some of the severe cases to which public attention has been drawn, and the most marked cases of the Indian or Russian cholera, I think that now there should be an end to all argument in support of their cause. Without at all going to the extent which might be warranted, I would beg to be informed of the names of the ships by which the contagion was brought, which caused the illness of the following individuals; or if they be allowed, as I presume must be the case, not to have been infected at all in this way, all that has been said regarding the identity of the foreign and severe form of the home disease, must be shown to be without foundation: – the detailed case of Patrick Geary, which occurred in the Westminster Hospital, – the fatal case of Mr. Wright, surgeon, 29, Berwick-street, – the cases, some of them fatal, which occurred at Port Glasgow, and regarding which, a special inquiry was instituted, – a case in Guy's Hospital, which caused some anxiety about the middle of July last, – a case reported in a medical periodical in August last, as having occurred in Ireland, – the fatal case, as reported in my first letter, of Martin M'Neal,6– a second case reported in a medical periodical in August, – a fatal case on the 12th of August last at Sunderland, reported upon to the Home Secretary by the mayor of that town, – three cases reported in No. 421 of The Lancet, – a very remarkable case duly reported upon in September, from the Military Hospital at Stoke, near Davenport, and a case with thorough "congee stools," spasms, &c. (the details of which I may hereafter forward), which occurred at Winchester on the 22d of September, in the 19th Foot, in a man of regular habits, and of the nature of which case the medical gentleman in charge had no doubt.

I quite agree with those who are of opinion, that in this and most other countries, cases may be every year met with exhibiting symptoms similar to those which have presented themselves in any one of the above. Instead of amusing us, when next writing upon cholera, with a quotation about small-pox from Rhazes, bearing nonsense upon the face of it, some of those who maintain the contagious property of Indian or any other cholera, may probably take the trouble to give the information on the above cases, so greatly required for the purpose of enlightening the public.

I must now beg to return to an examination of one or two more of the very select quotations made by Dr. Macmichael, with the view, as he is pleased to tell us, of placing the statements on both sides in juxtaposition. He is well pleased to give us from Dr. Taylor, assistant-surgeon, – what indeed never amounted to more than report, and of the truth or falsehood of which this gentleman does not pretend to say he had any knowlege himself, – that a traveller passing from the Deacan to Bombay, found the disease prevailing at Panwell, through which he passed, and so took it on with him to Bombay; but whether the man had the disease, or whether he took its germs with him in some very susceptible article of dress, is not stated by Dr. Taylor; however, he states (what we are only surprised does not happen oftener in those cases, when we consider similarity of constitution – of habits – of site or aspect of their dwellings, &c.) that several members of a family, and neighbours "were attacked within a very short period of each other;" but when Dr. Taylor goes on to say, "In bringing forward these facts, however, it may be proper at the same time to state, that of the forty-four assistants employed under me, only three were seized with the complaint;" he gets out of favour at once, and his observation is called "unlucky," being but a negative proof, and Dr. Macmichael adds, what everybody must agree with him in, that positive instances of contagion must outweigh all negative proofs: – to be sure: – but Dr. Macmichael's saying this, does not show that positive proofs exist. Give us but positive proofs, give even but a few, which surely may be done, if the disease be really communicable, and where contagion has been so ardently sought after by all sorts of attachés and employés of the cordon and quarantine systems in the different countries on the Continent. We could produce no mean authority to show, that a long succession of negative proofs must be received as amounting to a moral certainty; and what greater proof can we have of non-contagion in any disease, than we have in the fact regarding epidemic cholera, as well as yellow fever, that attendants on the sick are not more liable than others to be attacked? Regard should, of course, always be paid, in taking this point into consideration, to what has been already noticed in my second letter, or the inferences must be most erroneous. Dr. Macmichael quotes the statement of Dr. Burrell, 65th regiment (and takes care to put the quotation in italics too), that at Seroor, in 1818, "almost every attendant in hospital had had the disease. There are about thirty attendants in hospitals." Now, along with hundreds of other instances, what does Dr. French, of the 49th regiment, say, in his Report of 1829? That no medical man, servant, or individual of any kind, in attendance on the sick, was taken ill at Berhampore, when the cholera prevailed there that year, and refers, to his Report for 1825, in which he remarked the same thing in the hospital of the 67th regiment at Poonah; contrary, as he observes, to what occurred some years before in the 65th regiment at Seroor, about forty miles distant. In the two instances quoted by Dr. French, and in that by Dr. Burrell, all those about the sick stood in the same relation towards them, and all the difference will be found probably to have been, that the hospital of the 65th was within the limit of the deteriorated atmosphere, where the cause existed equally (as in the case of ague and yellow fever) whether persons were present or not.

In Egypt there is not, it is true, a "cruel and inhuman desertion" of the unfortunate plague patients; for, among other reasons, being predestinarians, they think it makes no sort of difference whether they attend on the sick or not. Those who act upon the principle of cholera being a highly contagious disease, may perhaps consider it necessary to recommend, among their precautions, that the medical men and attendants should be enveloped in those hideous dresses used in some countries by those who approach plague patients7– fancy, in the case of a sick female, or even of a man of pretty good nerves, the effect of but half the precautions one hears of, as proper to be observed. It is quite a mistake to suppose that the sick have not been sometimes abandoned during the prevalence of epidemics; and that too in cases where medical men had very erroneously voted the disease contagious: – among other horrid things arising out of mistaken views, who that has ever read it, can forget the account given by Dr. Halloran, of the wretched yellow-fever patient in Spain, who, with a rope tied round him, was dragged along for some distance by a guard, when he was put into a shed, where he was suffered to die, without even water to quench his thirst? I admit that, even with the views of non-contagionists, difficulties obviously present themselves in regard to the safety of those about the sick, when the latter are in such a state as will not admit of their removal to a more auspicious spot from that in which there is reason to believe they inhaled the noxious atmosphere. From what has been observed in India and other places, however, there is often sufficient warning in a feeling of malaise, &c., and the distance to favoured spots, where people may be observed not to be attacked, may be very short, – sometimes, as we have seen, but a few yards, so that a removal of the patient, with his friends, may be practicable, in a vast number of cases, previous to the setting in of the more serious symptoms.

I shall conclude this by cursorily referring to two circumstances which have within a short time occurred on the Continent, and which seem to me to be of no small importance in regard to cholera questions. It appears that the committee appointed by the French Chamber of Deputies to inquire into the questions connected with voting an additional sum to meet cordon and quarantine expenses, in the event of the cholera making its appearance in or near France, have made their report to the Chamber. They declare that in India the cholera was proved not to have been transmissible; and that in regard to Russia, it was not introduced, as always contended for by some persons: – they refer to the city of Thorn as exempt from the disease, though free from cordons, and in the midst of a country where it prevails, while the disease appeared in St. Petersburg and Moscow, notwithstanding their cordons, and even in Prussia, where sanatory laws where executed "avec une punctualité et une rigeur ailleurs inconnues." The money is nevertheless granted; it is always a good thing to have, but they have set one curious condition upon its being granted, which displays consummate tact, for it is to be employed solely in disbursements of a particular nature (dépenses materielles), including, it may be presumed, temporary hospitals, &c.; and that it is by no means ("nullement") to go into the pockets of individuals.

The other circumstance to which I allude is that, like Russia and Austria, Prussia has found that quarantines and cordons do not check the progress of cholera. The king declares that the appearance of the disease in his provinces, has thrown new light on the question; he specifies certain restrictions as to intercourse, which were forthwith to be removed, and declares his intention to modify the whole. In short, it is quite plain that, as Dr. Johnson has it in his last journal, – those regulations will, "in more countries than Russia, be useless to all but those employed in executing them."

LETTER IV

It need scarcely be said how much it behooves all medical men to keep in view the subject of the wide-spreading cholera, and not to suffer themselves to be led from an attentive consideration of all that appertains to it, by the great political questions which at present convulse the whole kingdom.

I totally disagree with Dr. Macmichael, as I believe most people will, that the notion of contagion in many diseases is "far from being natural and obvious to the mind;" for, since the time that contagious properties have been generally allowed to belong to certain diseases, there has been a strong disposition to consider this as the most natural and obvious mode of explaining the spreading of other diseases. A person sees evidence of the transmission, mediate as well as immediate, of small-pox, from one person to another; and, in other diseases, the origin of which may be involved in obscurity, he is greatly prone to assign a similar cause which may seem to reconcile things so satisfactorily to his mind. Indeed there seems, in many parts of the world, a degree of popularity as to quarantine regulations, which is well understood and turned to proper account by the initiated in the mysteries of that department: – for what more common than the expression – "we cannot be too careful in our attempts to keep out such or such a disease?" For my part, I admit that I can more easily comprehend the propagation of certain epidemics by contagion, than I can by any other means, when unaccompanied by sensible atmospheric changes; and if I reject contagion in cholera, it is because whatever we have in the shape of fair evidence, is quite conclusive as to the non-existence of any such principle. Indeed abundance of evidence now lies before the public, from various sources, in proof of the saying of Fontenelle being fully applicable to the question of cholera – "When a thing is accounted for in two ways, the truth is usually on the side most opposed to appearances." How well mistaken opinions as to contagion in cholera are illustrated in a pamphlet which has just appeared from Dr. Zoubkoff of Moscow! This gentleman, it appears, has been a firm believer in contagion, until the experience afforded him during the prevalence of the disease in that city proved the contrary. He tells us (p. 10), that in the hospital (Yakimanka) he saw "to his great astonishment, that all the attendants, all the soldiers, handled the sick, supported their heads while they vomited, placed them in the bath, and buried the dead; always without precaution, and always without being attacked by cholera." He saw that even the breath of cholera patients was inhaled by others with impunity; he saw, that throughout the district of which he had charge, the disease did not spread through the crowded buildings, or in families where some had been attacked, and that exposure to exciting causes determined the attack in many instances. He saw all this, gives the public the benefit of the copious notes which he made of details as to persons, places, &c., and now ridicules the idea of contagion in cholera. Grant to the advocates of contagion in cholera but all the data they require, and they will afterwards prove every disease which can be mentioned to be contagious. Hundreds of people, we will say, for instance, come daily from a sickly district to a healthy one, and yet no disease for some time appears; but at last an "inexplicable condition of the air," and "not appreciable by any of our senses" (admitted by Dr. Macmichael and others as liable to occur, but only in aid of contagion), take place; cases begin to appear about a particular day, and nothing is now more easy than to make out details of arrivals, there being a wide field for selection; and even how individuals had spoken to persons subsequently attacked – had stopped at their doors – had passed their houses, &c.8 Causation is at once connected with antecedence, at least for a time, by the people at large, who see their government putting on cordons and quarantines, and the most vague public rumour becomes an assumed fact. We even find, as may be seen in the quotation given from Dr. Walker's report, that contagionists are driven to the "somehow or other" mode of the introduction of cholera by individuals; so that it may be deplored, with respect to this disease, in the words of Bacon, that "men of learning are too frequently led, from ignorance or credulity, to avail themselves of mere rumours or whispers of experience as confirmation, and sometimes as the very ground-work, of their philosophy, ascribing to them the same authority as if they rested upon legitimate testimony. Like to a government which should regulate its measures, not by official information of its accredited ambassadors, but by the gossipings of newsmongers in the streets. Such, in truth, is the manner in which the interests of philosophy, as far as experience is concerned, have hitherto been administered. Nothing is to be found which has been duly investigated, – nothing which has been verified by a careful examination of proof."