Title: Treatment of the Cholera in the Royal Hospital, Haslar - during the months of July and August, 1849
Author: Wilson, John Lyde
Language: English
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ROYAL HOSPITAL, HASLAR***


Transcribed from the 1849 Simpkin, Marshall, and Co. edition by David
Price.  Many thanks to the British Library for making their copy
available.



                                TREATMENT
                                    OF
                                 CHOLERA
                                    IN
                       The Royal Hospital, Haslar,
               DURING THE MONTHS OF JULY AND AUGUST, 1849,
                                   WITH
                      REMARKS ON THE NAME AND ORIGIN
                             OF THE DISEASE.


                                * * * * *

                                    BY

                        JOHN WILSON, M.D., F.R.S.,

                 INSPECTOR OF NAVAL HOSPITALS AND FLEETS.

                                * * * * *

                   SIMPKIN, MARSHALL, AND CO., LONDON;
                              LEGG, GOSPORT.

                                  1849.

                                * * * * *



TREATMENT OF CHOLERA.


ON admission the patient was immediately placed in a hot bath, from 104°
to 112° of Fahrenheit, in relation to the reduction of circulatory power,
and of superficial heat; diligent friction of the abdomen and
extremities, according to the place and violence of the spasms, being at
the same time practiced.  The measure seldom failed, except in cases of
extreme collapse, to excite some warmth, abate cramps, and lessen
suffering, at least, for a time.

While in the bath, or as soon as carried from it, a drachm of tincture of
opium, in aromatic water, was administered.  If, as almost invariably
happened, the draught was instantly rejected, the proper practice of the
hospital was forthwith commenced and steadily pursued.  It consisted of
the following means:—

Two grains of calomel, in bolus, every hour, or every half hour.

Half a drachm of oil of turpentine, in two ounces of mucilage, repeated
every hour, or every second hour; most frequently the last.  In one
instance it was given every half hour.

An enema, consisting of two ounces of oil of turpentine, two drachms of
tincture of opium, three ounces of mucilage, and three ounces of camphor
mixture, repeated according to circumstances.

Friction applied to cramped parts assiduously, and as forcibly as could
be borne, with turpentine and olive oil.

Such, in brief, was the treatment adopted and relied on, though various
auxiliaries were, from time to time, and in different cases, employed.

Occasionally, but chiefly when the patient represented the vomited fluid
as being sour, a solution of carbonate of soda in water was substituted
for plain water, as a portion of drink.  Sinapisms were sometimes
applied; aromatics were now and then, though seldom, prescribed; and in
two cases, where with moderately firm pulse, spasms were universal and
excessively severe, blood was taken from the arm.  Pans with hot water
were often applied to various parts of the body, but could seldom be long
borne, or kept in place, from spasms or other causes of restlessness in
the patient.

One remarkable and gratifying effect of the turpentine draughts consisted
in what may be called their acceptability to the stomach.  While aromatic
and cordial mixtures were instantly rejected, they were generally
retained for considerable periods.  The turpentine injection had similar
effects on the intestines, allaying irritation and checking discharges.
With few exceptions they arrested the flux for a time, in most instances
for a considerable time.  So powerful, in fact, was their restraining
power, that they did not require to be often repeated.  Their controlling
influence was unquestionably great.

Many years ago, while serving in the West Indies, and often looking
anxiously but in vain, for the constitutional effects of mercury in the
precipitous fever of that region, the writer was led to inquire whether
some accessory agent might not be found to accelerate and determine the
action of the mineral; and turpentine, from its penetrating properties,
rapidly entering the circulation, exciting the capillaries, and
stimulating the kidnies, presented itself as probably possessing the
desired qualities.  It was tried, and did not altogether disappoint
expectation.  It was thought afterwards that it did not only precipitate
mercurial action, but increased its remedial power.  A paper on the
subject was printed in the “London Medical and Physical Journal,”
especially in reference to the treatment of neuralgic affections, in
1830.

Calomel in some shape, in various quantities, after various intervals,
alone or combined, has long been the most popular remedy for cholera;
and, from the concurrent testimony of many witnesses, it has properly
gained its reputation.  The practitioner has not always, perhaps,
considered very carefully the grounds on which he prescribed, nor the
channel through which he expected its remedial agency, being satisfied
with the result.  It is certain, however, that the result from it—as from
other things—has been too often the reverse of satisfactory.  It is
equally certain, that if an auxiliary accelerating agent is a desideratum
in the precipitous fevers of the West Indies, it is much more so in
dealing with the yet more precipitous disease under consideration.
Looking at the matter in this light; believing that calomel, as it is
commonly administered, in the worst and most suddenly fatal cases of
cholera, seldom passes beyond the stomach; and being satisfied that to
act as a remedy it must enter the circulation, and reach secreting
extremities, the method of treatment specified above was adopted.

The results on the whole were satisfactory.  Though not such as were
desired or even hoped for, they at least exhibited a full average amount
of success, inspired confidence, and tended to support the belief, that
the practice was founded on right principles.

Of 37 cases admitted 12 terminated in death, the remainder in complete
recovery. {9}

All the cases in the above number were considered to belong strictly to
the epidemic cholera of the season, characterized chiefly by depression
of vital power, suppression of biliary and urinary secretion, and great
tendency to death.  Pains were taken to exclude from it allied
affections, especially bilious, or as it is sometimes called, English
cholera, of which there were many, and some grave cases.  Want of care in
this respect renders useless comparisons of the respective value of
different modes of treatment; and it is suspected that it is more to such
carelessness, to use no strange word, than to superior skill in the
practitioner, that the high proportion of cures claimed in some instances
should be ascribed.  This is said without meaning to insinuate that one
method of management is not better than another, or wishing to damp the
inquiry in which so many men are now anxiously engaged, as to how more
may be done than has yet been effected for choleral patients.  In
attempting to balance the respective merits of different lines of
practice, it is also necessary, in order to render the comparison fair or
instructive, to know whether as a whole, the cases treated by each were
equally severe.

Of the 12 fatal cases which occurred here, eight of the subjects were in
a state of complete collapse—cold livid and pulseless—on admission; in
another collapse was nearly complete, and death speedily followed in all,
without the slightest sign of re-action.  In one of the remaining three
cases, there were slight and transient periods of re-action, alternations
of promise and discouragement for fifty hours, when fatal sinking came
on.  In the other two, the first danger was past, but severe re-actionary
fever followed.  In one there was restoration of the biliary secretion;
in the other, during the last eighteen hours the subject had the complete
appearance of a patient in West Indian fever, discharging largely from
the stomach, and more sparingly from the bowels, a fluid exactly
resembling _black vomit_.

In the cases, which terminated in recovery, the impression was severe,
though not equally so; and in each the symptoms, as already stated, were
considered clearly characteristic of the prevailing epidemic.  In some of
them no hope was entertained for a time; especially in two cases, where
there was in excess, lividity of surface, cold sweats, corrugated skin,
bent fingers and toes, and failure of pulse.

In considering the probability of recovery from cholera, there is reason
to think that the manner of attack should be taken into account, jointly
with the severity of subsequent symptoms.  From what was observed here,
it appeared that when there had been precedent diarrhœa, or when there
had been—though sudden—a gradual progress to the collapsed state, there
was a much better chance for the patient than when the disease, in
overwhelming force, fell upon him at once.  When, soon after eating a
hearty meal, in perfect health, the subject is obliged to be relieved
from duty in the ranks, or on deck, becoming in an instant faint and
giddy, with a rush of fluid from the stomach and bowels, shrinking of
features, fluttering pulse, coldness of surface tongue and breath—struck
down, as it were, by electricity—to which soon followed the up-turned
ecchymosed eye and whispering voice—when the disease thus sets in, it is
doubtful whether art has any power to arrest, or materially modify its
fatal career.  Such, at least, is the impression from what was observed
here; and such, without questioning what has been alleged to have been
done by others, or disparaging the means they employed, it is apprehended
will be the conclusion of most observers elsewhere.

The practice pursued in Haslar Hospital is submitted to the profession,
not because it had any very eminent success, nor on account of its
including new remedies, but because the proportion of recoveries was at
least fully as large as that which has followed other modes of treatment;
because there was some novelty in the combination of the means employed;
and because it is thought that any contribution to the therapeutics of
cholera will be acceptable.

Among the diseases allied to cholera which have been treated in Hospital
during the last two months, should, it is believed, be included grave
cases of fever, with striking predominance of gastric symptoms, and
excessive discharges from the alimentary mucous surface, as well as the
following:—

Forty-three cases of febrile diarrhœa, with rice water digestions, and
strong choleral tendency.

Ten cases of colic, with spasms of extremities.

Twenty cases of bilious cholera, making a total, exclusive of fever, of
73 cases of allied affections, all of which have ended in cure, or are
making favorable progress.  Some consideration of these cases, and of the
various appellations applied to cholera, have led to the following
remarks on



THE NAME OF THE DISEASE.


Although the term cholera, when applied to the disease under notice, is
derivatively erroneous, it has been so long adopted, and universally
employed, that it would be vain, perhaps useless, to attempt to alter it;
but the adjective appellatives coupled with it are so numerous and
inappropriate, so confusing, and so likely to lead to unjust conclusions,
that it is desirable to substitute for them a single significant epithet.

Asiatic cholera is the most common designation, and appears to be the
most incorrect, inasmuch as it assumes that the disease is an import from
Asia, while there is strong reason to conclude that it has no more claim
to be called Asiatic than American.  There is reason to conclude that the
cholera now widely diffused over the United Kingdom, is not an imported
product of any foreign country, near or remote, but is as much the
product of the places and the circumstances of the subjects where it
exists, as is ague, or bronchocele.

Spasm is not peculiar nor essential to it; for severe spasms often
accompany bilious cholera; and in the worst forms of this disease cramps
are not violent nor continued.  Spasmodic cholera, consequently, is not a
proper designation.

The terms “malignant,” “pestilential,” &c., which have been joined with
it, convey no idea but that of destructive force, and are destitute of
discriminative meaning.

With a view to getting rid of these, and such erroneous or unmeaning
terms, it is proposed to couple with the substantive _cholera_ the
adjective _abiliosa_, the prefixed privative being intended to denote the
suppression of the biliary secretion, so constant and important an
element in the diseased actions constituting cholera.  It is true that
other secretions essential to health, as that of urine, are suspended, or
materially lessened; but the total want of bile in the fluid discharged
from the stomach and bowels, is one of the most striking and unequivocal
characteristics of the disease; and the term suggested would serve to
separate it from the form of cholera in which the biliary secretion is
excessively augmented, and with which it is perhaps sometimes confounded.
It would, at any rate, have the merit of giving one distinctive idea, and
leading to no false conclusion.  There would then be two intelligible
names for the two forms of the disease, namely, _cholera abiliosa_ and
_cholera biliosa_.



CAUSE OF THE DISEASE.


It is not intended in this place to discuss at length the question of the
contagious power, or personal communicability of cholera, but in support
of the opinion given above, that it is a domestic, not a foreign malady,
with which we have to deal, a few incontrovertible facts will be cited.

The disease broke out at the same time in Gosport, and in Portsea
Portsmouth and Southsea, situated on opposite sides of the harbour, and
affected numbers in different parts of those towns at once.

At the same time—almost to an hour in some of the places—it appeared in
Southampton, Salisbury, Bristol, and Plymouth.  Such simultaneous
eruptions of disease, in different distant places, appear incompatible
with the hypothesis of contagion—irreconcileable with the belief that it
arises from, and is communicated by one body to another, either directly
or indirectly, either by recent emanations from a diseased body acting
speedily on proximate healthy bodies, or by the same emanations, in a
concrete form—called formites—acting on distant healthy bodies, after
uncertain lapses of time.

In the Minden, hospital ship at Hong Kong, in 1843, when periodic fever
and flux were prevalent and highly fatal, a man, convalescing from an
attack of the latter, was suddenly seized with unquestionable symptoms of
cholera, which ran its destructive course in a few hours.  The case is
noticed in the “Medical Notes on China,” as curious from its isolation;
and a conjecture was hazarded at the time as to some affinity between its
cause and that of fever and fluxes, then rife at that place.  No other
case of cholera appeared before or after it, though the subject was
affected and died in the midst of a mass of men, accumulated between the
decks of a ship.

A similar case occurred in the Rattlesnake, while employed in the West
Indies, in 1826, with this difference, that it happened in a healthy ship
to a healthy man.  With incessant rice water vomiting and purging, rapid
failure of circulatory power, lividity of surface, cold sweats, cold
breath and tongue, the subject sunk in eighteen hours.  No other case
occurred in the ship, nor was another heard of on the station.

Whatever difficulty there may be in accounting for the occurrence of
those cases of cholera, it can scarcely be imagined that they arose from
human contagion.  It is certain that the disease was not propagated by
them.

In the year 1832, the north of Ayrshire generally suffered severely from
cholera, while the south part of the county entirely escaped.  The
disease was excessively fatal in the county town—Ayr—situate about a mile
north of the river Doon.  It approached close to the north bank of the
stream, but did not cross it.  From that river to the river Stinchar, a
distance of about 30 miles south, no case but one was known to exist; and
that one occurred in a letter carrier who had been in Ayr, when, or
immediately before he was attacked.  He returned to his residence in
Girvan, where he soon died with unequivocal symptoms of the disease which
was raging in the town from which he came, but had not till then appeared
in the town to which he returned.  Yet with him the disease not only
began, but terminated in Girvan—a poor place, in which the inhabitants
are not remarkable for cleanly or orderly habits.  Here then was a
district extending 30 miles in one direction, by about 20 in the other,
bounded on the north by the river Doon, on the west by the sea, on the
south by the river Stinchar, and on the east by a chain of hills, where
there was but one case of cholera, and that one carried into it, from a
deeply affected place 20 miles distant. {17}

How was its immunity to be accounted for, if the disease which was
destroying so many in Ayr was endowed with a contagious property?  The
intercourse was uninterrupted, and the district in question populous,
containing many villages and considerable towns, including Girvan, with a
population of about 5,000, mostly hand-loom weavers, a great majority of
whom lived in crowded, ill-ventilated, ill-kept rooms.  Cholera was
carried there: the place and persons seemed especially fitted to foster
and extend a contagious disease; yet the disease made no way there.

These instances, and hundreds of similar import which might be cited,
seem to show that cholera is not primarily and necessarily a
self-propagating disease.  The question, as to whether, when, and how it
has contagious power grafted on it, is one of more difficult solution, in
which it is not meant now to enter; but reference may be made briefly to
some circumstances which have been alleged in proof of the contagious
property of cholera—of power possessed by it, either originally belonging
to, or engendered by it.

In the autumn of 1833, Beith, a considerable town in the north of
Ayrshire, was suddenly affected by cholera, which, in a few days extended
to many persons, and in a few weeks cut off a large proportion of its
inhabitants.  About the time that the disease broke out, a poor family
had arrived from Glasgow, where cholera still lingered, where it had
existed more than twelve months, and where during the previous year it
had been prevalent and destructive.  The poor family that went thence to
Beith were not affected by cholera, nor was it shown that they had been
in communication with choleral patients in Glasgow.  All that was proved
against them was the fact that they had lived in that city, and yet on
them was charged the introduction of cholera into Beith, and indirectly
the mortality which followed.

It is worthy of remark, in illustration, with many such cases, of the
mysterious movements of the cause of cholera, that Beith in the preceding
year had wholly escaped its power, while adjacent towns and villages with
which it had constant intercourse were suffering severely from it.  That
Beith should evade the contagious power of cholera in 1832, when the
disease was rife in its near neighbourhood, and fall under it in 1833,
when there is no evidence of its being nearer than Glasgow in mitigated
force and occurring rarely, is, to say the least, difficult to
understand.

In the spring of this year a custom house officer who had been on board a
foreign vessel in the Thames, in which were cases of cholera, was soon
after attacked by the disease, and died at Gravesend.  A little later, a
nurse who had attended a choleral patient in the Dreadnought Hospital
ship was attacked by the disease and died. {19}

These two cases have been considered by some as all but decisive of the
question; they have been looked on as furnishing cumulative proof of the
self-propagating power of cholera.  But to satisfy others, especially
those gifted with only a moderate share of credulity, it would be
necessary to show that there was not at the time an endemic cause of
cholera on the banks of the Thames, which, though then but sparingly
developed, was capable of exciting the disease in persons strongly
disposed to it, by previous disease, destitution, or other debilitating
agents.  It would be necessary to show that one of the laws of other
febrile endemics, such as yellow fever, does not influence this, namely
that when the _essential_ cause is in much force it attacks persons,
though with a certain relation to individual susceptibility, with various
degrees, up to the least conceivable degree of it; while reversely, when
the cause is little diffused or concentrated, only those who are
especially disposed to it—only those who have excessive susceptibility,
natural or acquired—constitutional disposition, or disposition from
circumstances of life—suffer from it.  It can scarcely be denied, that on
such difference mainly, if not entirely depends the difference in the
prevalence of many febrile endemics; in one instance causing many, in
another few attacks; now leading to a sweeping epidemic, and then giving
rise to a few cases, or to one case.  It would, in short, be necessary to
show that while we are trying to trace the disease from one person to
another, its cause is not springing from under our feet, and mingling
with the air we breathe; which in the cases in question would not be an
easy task, seeing that the disease had much endemic extension both before
and after their occurrence, and that for years sporadic cases have been
reported in the same or neighbouring localities.  Nor will the doubts
left in the minds of some enquirers, after full consideration of those
cases, and allowing them all the weight they deserve, be lessened by
reflecting on those which happened in the Minden and Rattlesnake
respectively.

But the case of the nurse in the “Dreadnought,” suggests questions
respecting the fate of nurses attending choleral patients in other
places.  If it be true, as it is believed to be, that they are affected
by cholera in a degree scarcely, if at all, exceeding that of persons in
the same social condition otherwise employed, the fact would appear to
furnish a strong general argument against the contagious nature of the
disease.  How does it happen that persons living in the same room with,
and constantly handling and helping patients in all stages of the
disease, so constantly escape its power, if it be not only readily
communicable by the person to healthy persons, who are in juxtaposition
with its subjects for a short time, but capable of being propagated by
their clothes, in distant places, after undefined periods?

Five fresh nurses were brought into Haslar Hospital to attend the
choleral patients.  They passed at least half their time, night and day,
in the ward, and slept there in their turn.  They were much employed in
rubbing the patients, and consequently leaning over them, administering
injections, removing ejections, &c., in short performing all the duties
of their place, which were at once trying, laborious, and likely to
excite apprehension,—yet none of them was affected.

These, and such facts, of which a multitude might be accumulated, may be
objected to, on the ground that they afford negative evidence only, and
that one positive proof of contagion would outweigh them all.  Be it so.
But where is the positive proof to be obtained, and by what
distinguishing mark is it to be recognised?  Suppose one of the five new
nurses brought into Haslar to attend on the subjects of cholera had been
attacked by the disease, during, or soon after that service, must it be
admitted that the disease was communicated by the patient to his nurse?
It is submitted that it should not.  Before such admission can be held
necessary, it must be shown that the disease which attacked the nurse was
not derived from places outside the Hospital, which he was allowed to
visit, or from the cause diffused in the air of the neighbourhood, in
less or greater concentration, and manifesting its powers relatively to
the degree of concentration, and the force of pre-disposing co-operating
agents.

It would be unsafe to assert that cholera can never, under any
circumstances become contagious; but if the conditions which lead to its
acquiring that property, the crisis by which it is effected, and the
period of its accomplishment cannot be ascertained, the policy of
searching for it may be questioned.  Truth is desirable on its own
account certainly, but the truth or falsehood of a position is relatively
important according to its bearing on the business of life; and if the
position that cholera may become contagious could be demonstrated, to
what practical purpose could it be turned?  It does not appear how it
could be used to stay the progress or mitigate the power of the disease.
It would not likely be proposed as a reason for separating the sick from
the healthy, or enforcing quarantine regulations of any kind.  He must be
a very ardent believer in the self-propagating power of cholera who would
urge authority to shut up, and surround with guards, houses standing in
many different parts of Gosport, Portsea, Portsmouth, and Southsea, and
half the towns and villages of England.  There is little danger of such
measures being adopted now, although they were seriously put forth by the
General Board of Health, under sanction of an order in Council, in
October, 1831; but, if they were put in force, it would not be rash to
assert that they would aggravate the evil immensely.  They would turn
fear into terror, and interfere with, or prevent the ordinary offices of
humanity; thus, at the same time, supplying one of the most powerful
predisposing causes of the disease, and fearfully augmenting the misery
and danger of the affected.  In such a state of things it would be
impossible to persuade persons of character, like those who, without
hesitation, undertook the duty of nursing the choleral patients in
Haslar, to enter on similar service for eighteen-pence a day; nay, it
might be impossible to persuade men to enter on such a forlorn hope by
any consideration.

Although the pro-contagionist might not be moved by facts and inferences
like these, he would perhaps be disposed to ask the man propounding them,
some such question as the following.—As you do not admit that contagion
is the cause of cholera, what in your opinion is the cause?  In return it
would not be impertinent to say to the querist, what is the cause of
ague?  Something emanating from the surface of the earth, on the spot, or
not far from the place where its subjects are resident?—something so
subtle as to be imperceptible by the senses, and hitherto beyond the
scrutiny of chemists and meteorologists.  He would, it is presumed,
answer in some such terms, or if he attempted any much more precise and
instructive, he would proceed without the warrant of fact and experience.
Such at least would be the general reply of the profession, and a more
complete and unconditional confession of ignorance of every thing
respecting the essence of a most powerful and wide spread cause of
disease cannot be made.  Though we know a good deal of the places most
prolific in its production, as well as of the agents which co-operatively
increase its force, we know it solely by its effects.

In very similar, if not precisely the same terms, it seems to the writer,
should the question, what is the cause of cholera, be answered.  Little,
if anything more can be affirmed respecting its origin, but almost every
thing authentic in its history, progress, and phenomena, testify to its
having a local source, and generally very limited scope of operation.
Thus it appears simultaneously in different, distant places, leaving
intermediate places untouched.  It attacks in one town a particular
district, street, or portion of street, beyond which it does not travel.
In another town it shows itself among distant portions of the
inhabitants, leaving long spaces unscathed.  Again, while one town
suffers severely from it, another in the neighbourhood has not a single
case then, or thereafter; or the town which escapes this season, falls
fatally under its sway the next, when all the rest of the country is
clear.  These and such circumstances as these, point as clearly as it is
possible to point at the endemic source of cholera, although the
_essential_ cause of the disease cannot be ascertained.

But although we cannot in cholera, more than in periodic fever, ascertain
the _essential_ cause, there is no difficulty in showing the accidental
auxiliary agents, which both in disposing to, and co-operating with it,
give it much of its prevalence, and most of its fatal power.  They
consist in whatever deranges healthy action, and impairs constitutional
vigour—such as unwholesome insufficient or irregular supplies of
food—over labour—crowded and defective ventilation—dissolute habits,
including vicious indulgences in intoxicating drink, and want of personal
and domestic cleanliness—apprehension, anxiety, and inordinate emotions
of the mind; and defective drainage, including sewerage, with resulting
accumulation of organic matters.  For the last, at least, the State and
the authorities acting under it ought to be held responsible.

Whether the last named agent—defective drainage and its
consequences—constitutes any thing positive to the _essential_ cause of
the disease, or is necessarily connected with it, or whether it only
co-operates with those specified before it, in lowering the standard of
health, by the production in excess of hydrogen and other gases,
injurious to life, and thereby predisposes the body, through augmented
susceptibility, for the action of the _essential_ cause cannot be
determined.  It is pretty certain, however, that neither it in any
quantity, nor any amount of the other agents classed with it, as
disposing and co-operating powers, in the production and extension of
cholera, can of themselves create it.  If they could, not only part of
Ireland, but of places nearer home, must have been decimated, some of
them depopulated.

Whether excess or deficiency in the electric element, or disturbance in
its ordinary relations, in the place where cholera appears, acts any part
in the production of the disease, is not known.  It seems probable that
there is something abnormal in its distribution and movements; but that
is all that can ever be reasonably conjectured, at least for the present,
respecting it.

Whether there is any affinity between the _essential_ cause of cholera
and periodic fever, and, if any, of what kind, are questions that
naturally suggest themselves in investigating the etiology of the former.
That the question, as far as it relates to a certain affinity in the two
cases, should be answered affirmatively, the following considerations
seem to shew.

Swampy undrained soils, the banks of rivers, the margins of harbours, and
other low lying localities, with places where organic remains are
artificially accumulated, or allowed to accumulate, prove the most
prolific positions in the production of cholera, as well as of periodic
fever.

Both before the outbreak of cholera, and on its subsidence, fever of
type, more or less distinctly marked, with predominance of gastric
symptoms, are more frequent than usual.

Some remarks, as already stated, were made on this subject in the
“Medical Notes on China;” it may be added that many circumstances might
be cited, tending to show that there is a close connection, not only
between the causes of cholera and periodic fever, but also between it and
endemic fever generally.

All this is very vague and unsatisfactory, but with such generalities,
negatives and probabilities, it is feared we must for the present at
least, be as content as we can, unless we are disposed to leap to
conclusions, without finding the steps of evidence by which alone they
can be safely reached; or are willing to subscribe the creed, that
cholera, however first produced, is reproduced only through the
instrumentality of the human body—that, by whatever acts, combination of
acts, or of accidents it began, it is continued solely by contagion.

The essential cause of cholera—the _causa sine qua non est_—as well as of
other things in nature with what are more familiar, is, and perhaps ever
will be, beyond the reach of human penetration; and were its nature and
properties ascertained, such knowledge might contribute little or nothing
to our means of resisting its effects.  But while this ignorance exists,
and candour requires its confession, there is none respecting the
associated concurrent agents, through whose influence it acquires
extended prevalence and augmented fatal force.  They have been already
alluded to, and are so palpable as to be beyond question; and as they are
on the surface, and susceptible of abatement or removal, it becomes us to
deal with them promptly, vigorously, and perseveringly.

They divide themselves into two classes, the first of which concern
private citizens, both as individuals, and as forming families; the
second are subjects for legislative enactments, and consequent executive
interference, constructive and restrictive.

Respecting the first, it may appear superfluous to reiterate what has
been so often repeated, and universally admitted, namely the paramount
importance of sobriety, cleanliness, and industry, in conjunction with
sufficiency of nutritious food; nor to aver that if the former were more
sedulously practised, there would be much less ground for complaint of
the last than unhappily there is.  It would be out of place to enlarge on
such a subject here, but it may be allowable in passing to observe, that
it behoves the more intelligent and wealthy members of the community, lay
as well as clerical, to unite and help the more ignorant and needy in the
great—vast as to results—reform, which it contemplates and embraces.  A
good deal has been attempted, and something has been done, but much is
wanting.  The work is great, requires many labourers, and gives scope for
the combined exertions of enlightened philanthropists of all kinds.  Yet
we may say of it, without profanation or levity, and in the literal
meaning of the words—truly the harvest is great but the labourers are
few.

The second class of reformatory measures required for the object in view
must devolve on the legislature, and on authorities constituted by it, as
all experience shows they cannot be entrusted to the voluntary efforts of
individuals, or to those of municipal, or other local self-acting bodies.
The enlarged and disinterested consideration of men having authority,
independent of the conflicting interests, and removed from the prejudiced
opinions, affecting particular places, who look to the welfare of the
whole, must do the work, if it be ever done effectually.  Enlightened and
benevolent men in parliament and out of it have not been scared from the
undertaking by the obstacles real and fictitious in the way.  Let them
however, especially those in parliament persevere, leading others to join
them as they assuredly will, disregarding the selfish and ignorant
objections raised against their truly patriotic efforts, and they cannot
fail of their reward.

The measures especially required comprise the form and situation of
houses, width of streets, complete underground drainage, and the instant
removal or destruction of refuse organic substances from and on the
surface, by strict enactments, rigidly enforced.  This like the former,
is a hacknied theme, but it not the less important on that account, and
its interest can never be exhausted till the objects which it embraces
are accomplished.

If it were objected that such interference by the state in the ordinary
affairs of life would trench injuriously on the liberty of the subject,
it should be answered that the functions of government are not merely
repressive of public outrage, and punitive of offences against the
person, that improvements of the people’s condition at large ought to be
its great aim, and that it can no more be justified in permitting the
lieges, by omission of what is right or commission of what is wrong, to
poison themselves on a great scale, than it would be in looking
complacently on at the suicide of individuals.

It is true that the measures in question cannot be completed without much
labour, and opposition, extending over uncertain periods of time, but
they must ultimately become part of the hygienic economy of the land, if
we would avoid the imputation of being criminally accessory to the death
of thousands, and do our duty honestly to our neighbours.  Unlike the
other, which as they must be effected by individuals and families will
depend on improvements in the intellectual and moral condition of the
persons themselves, these can be achieved authoratively by the
Magistrates.  Both classes of reformatory measures are required to show
what may yet be done for the welfare of the people, and how incalculably
the people can contribute to it themselves, especially in respect of
health; but while only one of them is at the command of power, that one
should no longer be neglected.  Had all been done which might have been
done in this way, it may be asserted fearlessly that cholera would not
have exerted the fatal power which it did in 1832, and which it is
exerting in 1849; and that other epidemics which have prevailed in the
period would have had fewer victims.

Unsatisfactory and reproachful however as the sanitary condition of the
country is, when it appears how much it might be improved by the moral,
social and physical reforms alluded to above, it is excellent when
compared with what it was at former periods of our history.  On looking
back to the terrible epidemics, which in the thirteenth, fourteenth,
fifteenth, sixteenth, and even so late as the seventeenth century, under
the names of pestilence, black death, sweating sickness, and plague
ravaged this, and other portions of Europe, we find such was the
destructive power of disease then, that the most sickly seasons recorded
for nearly two-hundred years have been, in comparison with them, seasons
of health and enjoyment.  The questions which suggest themselves as to
the cause of difference will be variously answered.  Amid the obscurity
which involves the subject, one thing however is evident, and seems to
offer a sufficient explanation of the difference, namely, the miserable
condition of the people in those remote periods relatively to the
present, the results of ignorance, apathy, licence and
oppression—periodical recurrence of famine—wretched habitations,
wretchedly kept—and the total want of sewerage, with accumulations of
filthy decomposing substances, producing corruption in every corner and
at every turning, sufficient to poison every living thing in their
neighbourhood.

Since those disastrous times much, especially of late, has been done to
preserve the health of the people, but much remains to be done, and,
looking at the spirit in which the subject is taken up, and the arguments
furnished from without to illustrate and enforce it, especially the
urgent ones supplied by the daily lists of death from cholera, much more
it is hoped, will be done speedily.  If the legislature executive, and
people at large would co-operate heartily and systematically, each doing
their proper part to further the work—if stagnant fluids on and near the
surface, and poisonous exhalations from decomposing vegetable and animal
matter were prevented—if the dwelling places of the poor were
sufficiently large, properly ventilated and cleansed, while the
inhabitants conducted themselves industriously and morally, the effect,
though it might not realize expectation, would unquestionably be great.
The sanitary state of the people might then as far surpass that of the
present time, as it does that of the fourteenth and fifteenth centuries:
and this age in respect of health, would occupy a middle station between
the dark ages which are past, and the practically enlightened age which
is to come, and ought to come speedily.  The _essential_ cause of
cholera, and of other febrile endemics might be brought into existence,
but without indulging in idle visions, it may be predicted that they
would be comparatively harmless, in as much as they would be deprived of
the concurrent, fostering agencies, from which they derive their
prevalence, and chief instruments of destruction.  And not only would
cholera and other endemic diseases, whether prevailing epedemically, or
occurring rarely, be checked and mitigated, but other forms of disease
would be lessened, while constitutional health would be invigorated.
Such great ends are surely worthy of great means zealously employed.



POSTSCRIPT.


                        14_th_ _September_, 1849.

IN addition to the 12 fatal cases of cholera recorded in the text, one
occurred late on the 3lst of August.  The subject was received at 6 P.M.
of that day, in a state of complete collapse, and died six hours after
admission.

During the currency of the month there have been admitted 12 cases of
cholera, two of which, being in a state of profound collapse, terminated
speedily in death; 5 cases of bilious cholera which are doing well; 10
cases of febrile diarrhœa which are doing well; and one case of colic
with spasms of the extremities.

The number of cases of cholera, and of allied affections, excluding
fevers, and adopting the nomenclature proposed above, between the 4th
July and this date, are as under.

                         CHOLERA ABILIOSA.
  Cases.      Cured      Dead.    Remain, covalescent or improving.
        49         26         15                                   8
                          CHOLERA BILIOSA.
        25         19          0                                   6
                         FEBRILE DIARRHŒA.
        53         44          0                                   9
                         CONVULSIVE COLIC.
        11         10          0                                   1

Further experience has confirmed the opinion that the means specified at
the commencement of this paper constitute fit and remedial treatment in
the formidable division of cholera to which they especially refer; and
established the conviction that when the impression is not overpoweringly
severe at the onset, and when sinking has not made great progress, a
large proportion of patients will pass safely through the disease, under
their use, if perseveringly and unswervingly employed.  Latterly the
opiate draught administered on admission has been omitted, the treatment
consisting almost exclusively of calomel, turpentine draughts, and
turpentine enemata, with friction when required.  A rubefacient,
consisting of strong mercurial, and cantharides ointment, each one ounce,
with half-an-ounce of oil of turpentine, well mixed, has been used with
effect.  The calomel, and turpentine draughts have generally been given
every half hour, at first, in violent cases, and less frequently as the
symptoms subsided, being suspended when tendency to collapse was
overcome, or when bilious vomiting set in.

The practice in bilious cholera, febrile diarrhœa, and convulsive cholic,
was simple, and similar in all, consisting of a bolus containing three
grains of calomel, and one of crude opium, repeated every second, third,
or fourth hour, according to the force of symptoms.  Cathartics were
often required in the colicy affections, as was occasionally abstraction
of blood by venesection, or leeches.  The remedies were extremely
uniform, and have been uniformly successful.

It may be observed in conclusion that, up to this date, none of the
nurses, medical attendants, or other persons associated with the sick of
cholera have been affected by the disease, although one or more of the
medical officers of the Establishment have been almost constantly in the
ward, and one or other of the juniors has slept in an apartment close to
it; and further that no case of cholera has arisen within the walls of
the Hospital, while it has been frequently brought in, and had continual
existence within them, upwards of ten weeks, amid a population of
patients, servants, including the women who washed the foul linen, and
officers with their families, of nearly 600 souls.

                                * * * * *

                                * * * * *

                         LEGG, PRINTER, GOSPORT.



FOOTNOTES.


{9}  See postscript.

{17}  An anonymous writer in the _Times_ of the 11th August, states that
Birmingham had like immunity in 1832, and up to that date of the present
year.

{19}  Paper by Dr. Mc William in the Medical Gazette of 15th June of this
year.





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