Dull ' . ED we 262 8433t 1832 •£ ARMY MEDICAL LIBRARY FOUNDED 1836 WASHINGTON, D.C. TREATISE ON CHOLERA ASPHYXIA, OR EPIDEMIC CHOLERA, AS IT APPEARED IN ASIA, AND MORE RECENTLY IN EUROPE. WITH PRACTICAL REMARKS ON THE DISEASE IN EUROPE ; AN APPENDIX OF CASES ; AND THE REPORTS AND REGULATIONS OF THE BOARDS OF HEALTH OF LONDON AND EDINBURGH. 15Y GEORGE HAMILTON BELL, FELLOW OF THE ROYAL COLLEGE OF SURGEONS, EDINBURGH LATE RESIDENCY SURGEON, TANJORE ; ANB JOINT MEDICAL SECRETARY TO THE EDINBURGH BOARD OF HEALTH. SECOND EDITION, VERY GREATLY ENLARGED. WILLIAM BLACKWOOD, EDINBURGH: AND LONGMAN & CO., LONDON. MDCCCXXXII. /4-wvi.ex WC 8433t |83t PRINTED BY NEII.L & CO. OLD FISIIM ARKET. w/s TO SIR CHARLES BELL, F. R. S. CIVIL KNIGHT OF THE GTJELPHIC ORDER, ETC, My Dear Sir, The favourable reception tvhich the former Edition of this xoorh has met with from the profession and the public, affords me the pleasure of bringing the Second Edition in this manner under your notice. During the fourteen years which have elapsed since I ceased to be your pupil, it has been my constant aim to profit by the lessons which I was taught by you, and by your late brother, Mr John Bell ; and as there is no one to whom, both professionally and individually, I owe so many obligations, I have the sincerest gratification in inscribing this Volume to you, as a trifling, but most willing, tribute of respect and gratitude. I am, With great regard, Your obliged nepheio and faithful servant, G. HAMILTON BELL. ADVERTISEMENT. When the former edition of this work was published in June last, the disease of which it treats was comparatively remote from us. But those acquainted with its habits had at that time the greatest reason to fear, from the direction in which it seemed to be moving, that it would overcome every barrier, and within a short time make its appearance in Great Britain. This anticipation has been unfortunately verified; and now that Cholera may be said to be actually amongst us, it is still more to be regretted that both medical men and the public press, should have lent themselves so readily to the propagation of exaggerated and alarming accounts of the mortality, as well as of the supposed contagious nature, of the disease. Entertaining the opinions which I have formed on the subject of contagion, I have found it necessary in the present edition to treat the subject 6 ADVERTISEMENT. pretty fully ; but I hope that, in stating my views, I have shewn no want of the respect and deference which I owe to those distinguished medical men from whom I differ. Neither has it been my wish to undervalue the numerous unprofessional writers who, in various ways, have favoured the public with their sentiments on this question ; although it is impossible not to regret that, on a point of such momentous importance, some of those writers had not been a little more calm and dispassionate in their examination of the evidence ; and rather better informed as to the facts on which they profess to found their conclusions. Now, indeed, that the disease has gained a footing in this country, and that the chief effect of inculcating the doctrine of contagion must be, to excite panic and uneasiness at home, and to impose additional restrictions on our foreign commerce, it seems to me any thing but judicious to press this controversy in the manner in which the contagionists have done. If the disease be contagious, the contagion, to say the least of it, must be of a very peculiar and capricious character, and far from dangerous to every one who comes in contact with the sick. Hence we may hope, that in those towns in which Cholera may make its appearance, the 7 ADVERTISEMENT. medical men and others whose assistance is indispensable, will not allow their exertions to be paralyzed, by fear for their personal safety. On this subject I take the liberty of referring to the more extended discussion, which occupies a portion of the following work. In preparing this edition, I have availed myself of all the information concerning the disease, its symptoms and treatment, which its nearer approach has brought within my reach. I have also adverted to those peculiarities which have marked its progress through Europe, and particularly in England ; and, in the Appendix, I have arranged the Reports and the practical directions of the Boards of Health of London and Edinburgh, in a manner which I hope will be found useful. It is a fortunate circumstance, that, however much medical men may differ as to the mode in which Cholera is propagated, they are now pretty much agreed as to the course of treatment which has been found, on the whole, most successful ; and best deserving of their sanction, in the general directions given to the public. By the kindness of my friends Drs Meikle and .Stevenson, who saw much of the disease in India, I have been enabled to give, in the Appendix, ¦vm ADVERTISEMENT. several of the cases which they treated or saw at Haddington ; and Mr Steele has been so obliging as to allow me to add to those cases an exceedingly interesting case of the disease which occurred in the parish of Newton, and was successfully treated by him. Edikbuugh, No. 13. Castle Street, 17th January 1832. CONTENTS. Introductory observations, •...-.• • • Page 1 Sect. I. — Nature of the disease, .... 3 Names — Varieties — Premonitory Symptoms — Stages — Character of blood drawn during disease — Duration of disease — State of mind during disease — Muscular contractions after death. — Anomalies — Postmortem appearances — Venous congestion — General question of bloodletting — Collapse not necessarily the result of high arterial action, ... 3-23 Sect. II — Proximate cause of the disease, 24 General observations — Effect of misnomer — Difficulty of explaining the disease on admitted pathological doctrines — Not an inflammatory affection of the alimentary canal — Not depraved secretion of the gastro-enteric mucous membrane — Not from failure in pulmonary function — Not depraved secretion of every mucous surface — Venous congestion effect not cause — Secretion suspended — Classification of vital powers ; 1. Sensorial ; 2. Respiratory ; 3. Circulator — Case — Quotations — the bearing of them— Physiological points, &c. — Cholera secretion — Cholera discharges — Nervous sources of secretion Case — Conclusions and inferences, . . . . 24-60 10 CONTENTS. Sect. 111. — Remote cause of the disease, . . 61 General observations — History of the disease — Galvanism, . . . • • • . . 61-67 Sect. IV. — On the communicability of Cholera As 08 PHYXIA, BY MEANS OF CONTAGION OR INFECTION, Importance of question of contagion — Commencement of the disease — Its progress — Map — Eccentricities, and habits of the disease, in towns, in camps — Not carried from place to place by travellers or troops — Limited extent of fomes — Discussion of question of contagion, with reference to India — Map— Case of the Topaze frigate— Of H. M. S. Liffey, Captain Deare's letter — Muscat — Contagion with reference to Europe — Halts made by the disease, on confines of Russia — Course of disease in Europe — Map — Mission of Drs Barry and Russell — Their conclusions on the question of contagion — Inquiry into the evidence adduced by them — Immunity of hospital attendants in India and in Europ — Conclusions — Dr Becker, . . 68-132 Sect. V. Exciting Causes, . . . . . . 133 1. Whatever is likely to depress the general powers of the system— 2. Every thing producing chylopoetic derangements — 3. Whatever determines to abdominal viscera — Advantages of well built houses and comfortable abodes — Premonitory diarrhoea, 133-138 Sect. VI. Treatment of the Disease, , 139 Indications — 1. To relieve oppressed circulation — Rationale of bloodletting — Modus medendi — Rule as to extent — Topical depletion — 2, To stimulate the system — Medicines — Over-doses of narcotics frequent—Drink — Frictions — Rubefacients and vesicatories-—3. To restore heat of the body — baths — CONTENTS. 11 Best method of applying heat — General result of these steps of treatment — Empirical remedies — Case — Congestion — Oxygen — Galvanism — Prognosi — Case, with remarks — A surgeon's account of his own case and treatment — Prognosis — Case at Sunderland, remarks — 4. To guard against local congestion — Case at Haddington — 5. To guard against re-action — Uncommon in India — Fever in Europe — Treatment — 6. To produce healthy con- dition of the bowels— Treatment, . . . 139-174 APPENDIX, 177 Case illustrative op identity of Russian and Indian Cholera, . . .-..-. . . . 177 Case treated without bloodletting, . . 178 Case in which bleeding was resorted to, . . 188 Quotations in favour of venesection, . . 181 Case of severe (British) Cholera Morbus in Edinburgh, 188 Regulations proposed by Sir Henry Halford, 190 Author's Letter to Sir Henry Halford, . 198 Regulations of Central Board of London, . 212 Report of the Edinburgh Board of Health, . 223 Steps already taken by that Board, . . 229 Report on out break of disease at Haddington, 229 Dr Cruikshank's case, 232 Messrs Meikle and Stevenson's cases, . . 233 Mr Steele's case, ....... 240 ERRATA. Page 2, line 21, for his read my 69, 14, for delicate read deliberate ; 100, 4, for all read most CHOLERA ASPHYXIA. INTRODUCTORY OBSERVATIONS. From the year 1818 to 18217 the Author served as Assistant- Surgeon in the Honourable East India Company's Service within the Presidency of Madras ; and during that period the Epidemic Cholera prevailed, more or less generally, in the Peninsula. On his arrival in India, he had the advantage of being placed in the General Hospital at Madras under Mr Surgeon Annesley, who was then in charge of that establishment ; and as Cholera at that time prevailed to an alarming extent, and in a very destructive form, in that Presidency, every opportunity was afforded of observing and studying the disease ; and both duty and interest concurred in recommending the study of it to the Author's fullest attention. At Madras, and subsequently in various districts in the interior of India, I saw the disease under every possible aspect ; in all its stages ; in every variety of the patient's condition ; in the hospital, in the camp, and in private dwellings ; among the natives and A 2 INTRODUCTORY OBSERVATIONS. among Europeans ; among those newly arrived in India, and among those who had heen long inured to the climate. Patients of every class, native and European, are received into the Madras Hospital ; and, at the time when I was appointed to do duty under Mr Annesley, the King's 13th Regiment of Light Dragoons had just arrived from England, while the 84th Regiment of Infantry had, after a long residence in India, reached the coast for re-embarkation. There was, consequently, presented the most complete exhibition of the disease, on almost every imaginable condition of the human constitution. At that time Mr Annesley was prosecuting, with great care, his inquiries into the nature and treatment of the Epidemic Cholera, which was then very generally believed to be a new disease ; and 1 had not only an opportunity of partaking in those inquiries, and of seeing Mr Annesley's practice, but of assisting him in post-mortem examinations. In the course of his subsequent duties in various districts of India, I had much reason to congratulate myself, that my attention had been so early and so particularly called to this disease, and that I had become acquainted with it under such peculiar advantages. It is not therefore as a speculative inquirer that I now enter on the discussion of this subject; and in what I have now to say as to the nature and mode of treatment of Cholera, I hope it will be found, that I support my statements and views by direct appeals to facts, the result of my own observation and experience, acquired at the bedside of the sick, where alone accurate data are to be found on which rules of practice or theoretical opinions in medicine can safely rest. 3 SECTION I. NATURE OF THE DISEASE. It is of the utmost importance in the outset to counteract, if possible, the false inferences resulting from the inappropriate names which this disease has received. The epidemic of India has been called Cholera Morbus, Cholera Spasmodica, Cholera Indica, Cholera Epidemica, and, more lately and more appropriately, Cholera Asphyxia *. Of all these appellations, that of Cholera Morbus is the most unfortunate, though perhaps more likely to mislead the student than the practitioner. To the latter, the first case of the disease points out the inapplicability of the name ; whereas the student can never get rid of the idea that he is studying a disease which is seated in the abdominal viscera. It will be seen in the sequel, that it is of the utmost consequence to forget that the Indian disease has ever received a name, so likely to interfere with our attaining a correct acquaintance with its nature. * Mr Kennedy calls the disease Contagious Cholera. To say nothing of the reasoning on which he has arrived at the conclu- sion that Cholera is contagious, it is enough to observe, that while so many medical men deny contagion, in the sense in which Mr Kennedy uses it, there is neither courtesy nor propriety in giving the disease a name, which necessarily assumes the ques- tion of contagion to be determined. a 2 4 NATURE OF THE DISEASE. Cholera Spasmodica is not much more appropriate, as spasms not only occur in the common Cholera Morbus, but are far from being invariably an accompaniment of the Indian epidemic ; indeed, it often happens that in the most unmanageable cases there are no spasms Mr Scott, in the Madras Report on Cholera, has proposed the term Cholera Asphyxia. And though it would be an advantage to get rid of the word Cholera altogether, still it has become too commonly received a name for this disease to admit of our disusing it *. Asphyxia, in its original signification, is particularly appropriate and distinctive ; the disease never continuing for any length of time without producing a suspension of the pulse. In this treatise, therefore, the name which Mr Scott has proposed for the disease shall be used. Cholera Asphyxia, as it affects different individuals, and from variety, perhaps as to the state of concentration of its cause, varies so much, as to have induced some practitioners to propose that it should be divided into two species. There can be no doubt that the disease is sometimes much more unmanageable than at others : at such times, every patient seems to be immediately struck with death, and all the efforts of his medical attendants prove unavailing to arrest its fatal progress. This is often found to be the case on * Whether we derive Cholera from %oM, bile, or from #«A#s, intestine, it is equally inappropriate to this disease. Bile does not even appear to be secreted during its progress, and the ali- mentary discharges are merely symptoms ; but, as has been said in the text, it does not now appear advisable to alter a term which has been so long considered applicable to the disease. 5 NATURE OF THE DISEASE. the first breaking out of the disease ; and it is remarkable, that as the disease is disappsaring, it seems to become milder. The insidious nature of Cholera, to a certain extent, accounts for this ; for persons not aware of the disease, and unprepared for it, are often beyond recovery before they are known to be attacked ; whereas, after the alarm has spread, the first symptoms are watched, and the patient is immediately put under medical treatment. But whether mild or uncontrollable, the symptoms and course of the disease are always so well marked, that there appears no reason to encumber our nomenclature by subdividing it into species. Mr Kennedy, a late writer on Cholera, in order to meet some distinctions which have occurred to Doctors Barry and Russel in the progress of their inquiries in Russia, proposes to add Chronic Cholera to the classification. I see no good reason for this. During the prevalence of Cholera, affections of the chylopoetic organs are common, and these, whether the effect of alarm or of miasma, no doubt predispose to Cholera, just as a debauch or any other debilitating cause predisposes. But a looseness surely has no claim to be considered a chronic type of Cholera. The subsequent fever, which occurs more frequently in Europe than in Asia, is likewise regarded by some as a stage of the disease. This fever, however, appears to me to be rather the natural effect of re-action when the blood is in the unhealthy state to which Cholera reduces it ; and I should as soon think of calling an attack of fever, which sometimes follows suspended animation from immersion in water, chokedamp or the like, a stage in the accident, as of class- 2 6 NATURE OF THE DISEASE. ing this fever as a stage in the peculiar disease under consideration. The prominent symptoms of Cholera Asphyxia are very frequently the first intimation to the patient or his friends of the accession of the disease ; so that the pulse may be gone, and many of the peculiar serous evacuations have taken place, before the victim is aware of his having more than a slight indisposition. This insidious disease, like the marsh fevers of Rome, commences so frequently during sleep, that some have been inclined to consider this as one of its peculiarities. There has been naturally much anxiety to discover premonitory symptoms of a disease, which is thus often far advanced to its fatal termination before it is known to exist. But there is no reason to believe that there is any such stage in Cholera Asphyxia ; although no doubt, while Cholera prevails in a city or camp, peculiar feelings of indigestion, loss of appetite, and disordered bowels, are very general. So much indeed is this the case, that "false alarms are, at such times, of frequent occurrence. And it would even appear, that there is a tendency to chylopoetic derangements during the prevalence of Cholera, beyond what may naturally be supposed to result from the dread and horror excited by exposure to the hidden causes of so rapidly fatal a disease, having apparently its seat in the abdomen *. * I am informed, however, that in Sunderland and Newcastle a diarrhoea of one or more days' continuance generally precedes an attack of collapse. Such a premonitory symptom cannot but be regarded as fortunate, and ought never to be neglected where- ever the disease is prevalent. 7 NATURE OF THE DISEASE. In describing this disease, it may be useful to attend to what may be called four stages :—: — 1. The invasion of Cholera is so insidious, that the individual attacked may be quite unconscious of the presence of the first stage of it. Very often, indeed, it is only to be detected by those well acquainted with the disease, and by careful observation. Not only in this stage, but throughout the whole course of the disease, the appearance of the countenance is one of the most highly characteristic symptoms. An intimate friend perhaps, observes, that the person attacked has an expression of anxiety, that his complexion is unnaturally earthy, and that his eyes seem sunk in his head. In reply to inquiries, the patient will perhaps deny that he is unwell : he may say, however, that he is a little deaf; and if minutely questioned, he may admit that he has indescribable sensations of being out of order ; that he has oppression at the chest, and is unaccountably depressed and listless : he may have no nausea, but he has tormina of the bowels, and perhaps an uncomfortable sensation of heat at the pit of the stomach : his pulse is quick and weak (I have seen no case in which it had the febrile throb) ; the hands and feet feel cold ; the nails are blue, and he has had one or more unnatural alvine discharges. The first of these is generally characteristic ; there is a sudden call, and the whole intestines seem to be at once emptied, followed by a feeling of weakness. Thus, " while the servant (a Hindoo) of Captain H. was bringing in breakfast, his master was struck with his appearance, and asked him what ailed him ? he replied he had nothing to complain of but deafness, which he ascribed to sleeping in the cold night 8 NATUItE OF THE DISEASE. wind. His master, alarmed at his looks, sent him to the hospital tent (the epidemic was prevailing in the camp to which this gentleman belonged) : on minute examination the man was found to have had some suspicious stools, his pulse had sunk, his skin was cold : He had Cholera, and became rapidly worse ; and though he was put immediately under treatment, and was a man of good habits, and strong constitution, he had a hard struggle for his life *." It is unfortunate that the first stage of Cholera is to be discovered only by the most experienced eye ; and that even when the patient has a suspicion of his condition, the risk of exposing himself to ridicule, from its being a " false alarm," may keep him silent, while the acknowledgment of his fears might have been the means of saving his life. It is to this insidious approach of a malady at all times so mortal, that, in part at least, must be ascribed its being so alarmingly destructive on its first breaking out at an Indian station ; patients being extremely apt to allow it to go beyond remedial means before they seek assistance. 2. In the second stage Cholera is more easily recognised : The pathognomic character of the countenance, to those who have ever seen the disease, is no longer doubtful : the eyes are sunk in the head, the lips are blue, there is a ghastly look about the mouth, and the whole features are shrunk. The patient does not now deny being unwell ; he acknowledges having passed some peculiar stools, and probably has had vomiting ; these have been followed by great prostration of strength : there is tinnitus aurium, often slight * Author's Case- Book, and many similar instances might be mentioned. « 9 NATURE OF THE DISEASE. deafness and vertigo ; the pulse is more decidedly affected, it is weak and thready ; the skin is cold ; there is much thirst, and a burning pain at the pit of the stomach ; but the tongue is not dry — it is moist, white, and cold. When the ratio symptomatum of the disease is under consideration, it will be necessary to take particular notice of the fluid which is passed from the stomach and bowels ; at present it is sufficient to say, that it is not alimentary, or excrementitious ; it is either a homogeneous and almost limpid, or a turbid fluid ; or it is like water in which grain has been boiled, with pieces, more or less numerous, of opaque white or yellowish coagulated matter floating in it. The manner in which the discharges take place is characteristic — the desire is sudden, unaccompanied by griping or nausea, and the stomach or bowels are emptied at once, and with some violence : the gastric and intestinal evacuations are nearly similar in their appearance and nature. 3. In the third stage, the sinking of the countenance is still the most prominently characteristic symptom. The eyes, surrounded by a dark circle, are completely sunk in the sockets ; the whole countenance is collapsed; the skin is livid; and the expression is so altered, that the patient's most intimate friend can hardly recognise him. The surface is now generally covered with a cold sweat, the nails are a pearly blue, and the skin of the hands and feet is corrugated, as if they had been long steeped in water ; the sensibility of the whole surface is deficient, but it is by no means uncommon for patients to complain of a burning heat in their cold skin. Vesicatories do not act ; even boiling water does not raise a blister. If the case be attended with spasms, the suffering of the patient is 10 NATURE OF THE DISEASE. much aggravated, and is sometimes excruciating. The spasms commence in the hands and feet like cramp ; they stretch up the limbs to the trunk, which however they do not always reach. In some cases, again, the muscles of the abdomen are principally affected, and they are drawn towards the spine during the whole course of the disease. These spasms may have commenced early in the disease, being on some occasions the very first symptom. The discharges from the stomach and bowels are at this stage very irregular ; in some cases they are still very frequent, in others, after one or two evacuations, they wholly cease. The pulse at the wrist, if it have not ceased, is scarcely perceptible, and the heart beats feebly. When the spasms are severe, they frequently, even though the pulse be still quite distinct, stop it during the paroxysm — the same effect is produced by excessive vomiting. The breathing is slow and oppressed: this also sometimes occurs early in the disease ; the voice is low, and but few words can be spoken with one expiration ; the exhaled breath is cold ; and though the heat of the body is many degrees below the standard, the patient throws off the bed-clothes, and entreats the bystanders to allow him cool air and cold water. Hiccup is not uncommon, and is rather a favourable than an unfavourable symptom. 4. In the last stage the intestinal evacuations have most likely ceased ; the eyes, completely sunk in their orbits, are glazed and flaccid, turned upwards, and half- covered with the eyelids ; the spasms are now commonly at an end ; the extremities, indeed the whole body, is that of a corpse, and the impression communicated by the skin has been well likened to that of " a damp hide." Every artery has ceased to 11 NATURE OF THE DISEASE. pulsate, and the action of the heart, if perceptible, is a mere flutter ; the whole body is bathed in a cold and clammy sweat : it is painful to witness the oppression of respiration and jactitation of the sufferer. The dying man can still be roused, but when undisturbed, he generally appears in a state approaching to stupor ; and though perhaps in a humour which might almost be termed sulky, is in most cases coherent to the last. These symptoms are the immediate forerunners of death. If blood be drawn during the progress of the disease, it is found in the outset dark-coloured ; as the case advances, the blood becomes thick, there is a deficiency of serum, it coagulates quickly, and does not assume the buffy coat. In the latter stages of the disease the current in the veins has stopped, and the blood is so grumous that it can scarcely be forced out, in the smallest quantity, through a large orifice. The whole course of these stages, generally speaking, does not exceed sixteen hours, and, unluckily, the practitioner is seldom called in until the first, and part of the second, stage have passed. The period consumed by each of the above artificial divisions varies in every case. I have seen instances in which death ensued in less than four hours after the commencement of the disease ; and others, in which its latter stages, with the pulse quite imperceptible, had already lasted a whole day. The condition of the mind is remarkably collected during the whole progress of this terrible illness ; for, though patients, as the malady advances, are unwilling to be disturbed with questions, this appears rather to result from the want of physical energy than from any intellectual failure. Indeed, as the fatal event 12 NATUItE OF THE DISEASE. approaches, the only wish a patient seems to have is to be allowed cold water, and to be left to die in peace. It has been well said, that a patient, in the last stage of cholera, may be called " a living corpse." A curious phenomenon has been several times observed : — After a patient has been some time to all appearance dead, and when the attendants were dressing the corpse, spasmodic twitches have taken place in the limbs, having, in some instances, even extended to the muscles of the body, and general spasmodic contractions have supervened*. Cases often occur in which one or more of the above detailed symptoms do not appear. There may be no spasms ; the vomiting and purging may early cease, or there may have been only one large alvine discharge, followed by a mortal collapse, the patient seeming to be at once struck with death ; and though, on the very first appearance of the disease, he has walked to the Surgeon, his pulse is found to be gone, his heart has ceased to beat, blood can be got only in drops from the veins, he lays down his head, and dies without a complaint. These anomalies are not confined to individual instances, but are found to occur, as Mr Scott well expresses it, in " local epidemic visitations." Thus, he says, " when the disease appears epidemically in a town or district, or in the lines of a corps or the camp of a marching regiment, it may on one occasion be distinguished * This peculiarity has led to some very improper attempts to excite popular clamour, on the risk of being buried alive. After death, from failure in the circulation of the blood, as is the case in cholera, resuscitation is impossible, — insensibility, from senso- rial injury, leaves the system in a different condition, as I shall have occasion to show in a subsequent chapter. 13 NATURE OF THE DISEASE. throughout, by the absence of vomiting, and the prevalence of purging ; and on another, by the excess of vomiting, and, though more rarely, by the absence of purging. Spasm may be generally present in one instance of invasion ; in another, it may not be distinguishable * ." 1 was on one occasion called upon to send assistance to a district in which the disease was thus described — " It commences by attacking the sufferer with an agonizing heat in the stomach, vomiting and purging, and lock-jaw ; death ensues in two hours, and often more rapidly : it bids defiance to every remedy." Extract from letter of the Honourable Mr Harris, Principal Collector, Soonda. But in all cases in which the disease has established itself, there are the collapsed countenance, blue lips and nails, shrunken fingers, the total failure of the usual secretions, deficient animal heat, suspension of the pulse, and remora in the venous circulation. Post- Mortem Appearances. — The appearance of the body after death from Cholera Asphyxia, is always peculiar ; the whole surface is livid, the countenance collapsed, and the body shrunken, resembling rather the body of a patient who had suffered from a prolonged illness, than that of a victim to a disease of a few hours' duration. It must be borne in mind, however, that the present description is confined to dissections made on bodies in which death has proceeded immediately from an active attack of the disease, and that organic lesions are not included, which, * Madras Report, p. 21. 14 NATURE OF THE DISEASE. though evidently unconnected with the cause of death, have frequently heen particularly noted in descriptions of dissections of the bodies of persons who have died from Cholera. On opening the abdomen, the first peculiarity which presents itself is the gorged appearance of the veins, and semi-fluid state of the venous blood. The peritoneum and omentum have nothing unnatural in their appearance ; the characteristic colour of the viscera is a light pinky hue, shading to purple ; and the veins, wherever they are to be seen, appear loaded with black blood. The floating viscera generally feel more pulpy than usual, as if their coats were thickened ; the solid viscera look purple, or are mottled : the stomach may appear full ; in general, however, it is partially contracted : the small intestines, though full, are not always distended. And I have almost invariably found alternate portions of the great intestines contracted and dilated. The whole canal is sometimes distended with flatus. The mesenteric veins are in a state of great congestion. On a more minute examination, the contents of the alimentary canal are found to be a muddy fluid, resembling that which has been passed in such quantities, from the stomach and bowels, during the disease : there are no fasces, but always more or less flatus. The enteric mucous membrane, particularly at the upper portions of the canal, is often coated with a glary and tenacious matter, which would appear to be an accumulation of the coagulated opaque substance which is passed with the serous fluid. This is not unfrequently in such quantities, at particular parts of the canal, as almost to fill up the tube : its colour is not always opaque white ; it has been 5 15 NATURE OF THE DISEASE. described as a dark grey ; and I have seen it of a greenish tinge. It is said to be sometimes bloody. These slight variations in the colour of this matter, do not appear to affect the nature of the disease ; and from Mr Annesley's experiments they would appear often to be attributable to admixture with the medicines prescribed ; nor is this matter invariably present. The internal coat of the stomach, and sometimes of a portion of the duodenum, has very generally a peculiar appearance ; there are vascular patches, not of inflammation, but as if vessels had burst, and blood had been extravasated between the coats. These spots, though no dpubt commonly a congeries of congested veins, do certainly sometimes arise from extravasation. Patches also are described as having the character of inflammation, generally near the pylorus ; which are by some considered the result of local irritation, produced by portions of the remedies prescribed having adhered to these parts of the stomach ; and they must be taken as a proof that reaction had commenced before death. Worms are very frequently found in the intestinal canal. Having removed the alimentary canal, venous congestion is still found to be the most remarkable feature of the dissection. The large veins are gorged, and there is nowhere a trace of arterialized blood perceptible : indeed this has been found to be the case during life ; for one surgeon attempted in vain to get blood from the brachial artery*. The liver is in most cases dark-coloured, and mottled, being at its dependent parts usually gorged with black blood ; * Dr Davy on one occasion, in bleeding from the temporal ar- tery, in Cholera, found very little difference between the appear- ance of arterial and venous blood. 16 NATURE OF THE DISEASE. but it is said to have been found, in some dissections, perfectly natural in its appearance. The gall-bladder is generally, but not invariably, full of bile. I have always found marks of congestion in the spleen ; but the appearance of this organ seems to be very variable. Dr Christie mentions a case in which he found it empty, and, in the dissections made by the Ceylon practitioners, it seems to have been often found smaller than usual. ; The urinary bladder is always contracted and empty ; the kidneys are healthy, but partake of the character of venous congestion ; the substance of the liver, when cut into, is found gorged with black blood, not coagulated, but thicker than usual ; the colour of the bile in the gall-bladder is generally green, but I have seen it healthy in appearance ; the great veins of the trunk and liver are full of thick impure blood, as are the right auricle and ventricle of the heart. The lungs are black, and in appearance almost of a fleshy structure, and, when cut into, freely give out the same grumous black blood. In some instances this impure blood is even found in the left side of the heart, and to have reached the aorta ; and cases are mentioned in which black blood was found in the carotids. In the brain there is the same character of venous congestion ; but here there is generally some slight appearance of arterial blood : — there is often found a small quantity of serum in the ventricles, or at the base of the brain. The descriptions which have been given, as if portions of the brain had been in a state of high inflammation, are wholly at variance with the character of the disease in its course, and seem rather to belong to a disordered state of the circulation than NATURE OP THE DISEASE. 17 to this disease ; except indeed in cases in which death had not proceeded immediately from Cholera, and when reaction had taken place. Such is generally the condition of the body after death, arising from a 'pure case of Cholera. It may be remarked, however, that in particular dissections, some of the organs here described as being in a state of congestion, are found not perceptibly different from their healthy condition ; and instances are said to have been met with, in which the whole abdominal viscera presented nothing very peculiar in appearance. In such cases, (none of which have fallen within my experience), the lungs, or encephalon, will no doubt be found highly congested, and the external veins much loaded. The above description of the disease, and of the appearances on dissection, which are the result of observations made when I was unbiassed by theory or hypothesis, will be found, I am confident, to correspond with the descriptions given by all those who have treated of the disease under similar circumstances. But before attempting to .give the ratio symptomatum of Cholera, a sketch of the progress of an actual case of the disease will greatly assist this elucidation. Every one practically acquainted with the disease, must have met with such a case as the following : — A patient is brought into the hospital, in what I have called the third stage of the disease : his countenance is sunk ; he has vomiting and purging ; his skin is cold ; his nails are blue ; his pulse is scarcely perceptible ; his breathing is oppressed, and he has spasms in the extremities. He is immediately placed v> 18 NATURE OF THE DISEASE. in warm blankets ; stimulants, including a dose of calomel, are administered ; and a vein is opened in each arm, with the largest orifice. At first the blood flows very sluggishly, perhaps it is only procured by kneading the arms, but by-and-by the stream is more free, and as the blood flows it is improved in its colour ; the patient feels the greatest relief, the pulse rises, and the colour of the blood testifies that the lungs are restored to their function. Little else is necessary ; the patient has a second dose of calomel administered to him, is left in a warm bed, and falls asleep. In the course of a few hours a cathartic is prescribed, to remove the colluvies which the restored secretions are pouring into the intestinal canal. It only remains to guard against local congestion and reaction ; but it was generally found in India, that, in a case treated as above, there was no such interference with recovery. The suspended functions seemed to be at once restored : the blood was arterialized ; the animal heat returned ; the excrementitious secretions took place, and the kidneys resumed their function. And it is particularly worthy of notice, that even persons the most ignorant of the doctrine of diseases, who are at all accustomed to see cases of Cholera, are aware that the passing of urine by the patient, is an unerring test that the disease has been overcome. This summary of a successfully treated case of Cholera is given, not as an anticipation of the observations on the practice (which, of course, belong to a subsequent division of this Work), but because the rationale of treatment is often an important help in our endeavours to understand the nature of a disease. 19 NATURE OF THE DISEASE. And what has been said seems fully to warrant the conclusion, that Cholera is, early in its progress, a disease in which the due proportion Jbetween venous and arterial blood is destroyed. No stage of the disease has been hitherto discovered, in which venous blood does not preponderate in the system : let it be observed, too, that this is found to be the case so immediately after what must be considered the accession of the disease, that had the venous congestion been the consequence of high action, that stage must have been discovered. For instance, a man in high health and spirits accompanies his companions to bathe ; he is seized, while in the water, with vomiting and purging, or with spasm, is brought immediately to a surgeon, and is found in what I have called the second stage of the disease. This is not by any means an extraordinary example of the sudden and unlookedfor manner in which this remarkable disease makes its attacks. Or a man goes to bed perfectly well, and is roused at three o'clock in the morning by a call to stool; animal heat has already failed, and in three hours he is dying. In what to all appearance, therefore, is the very outset of the disease, the animal heat sinks, the action of the heart is lowered, arterial secretion has ceased ; and if death ensue, every vein is found congested, while the arteries are empty. But what is far more valuable in a practical point of view, this position may be illustrated by the effect of the medical treatment : We have a patient suffering under extreme prostration of strength, and the pulse is scarcely perceptible, perhaps is not to be felt; we remove blood, and as it flows the pulse rises, the powers of life return, and if we can sufficiently relieve 15 2 20 NATURE OF THE DISEASE. the oppressed system, nothing more is necessary to save the man's life. It may be said, that this point is unnecessarily pressed, as it is generally admitted that the disease is one of venous congestion ; but, though it is acknowledged by most practitioners that ultimately there is venous congestion, still they are so much trammelled by the opinions of the schools, that they find it difficult to admit this state sufficiently early in the disease. Bleeding is found a successful remedy in their own hands or by others ; but then bleeding is indicated only when there is increased action, and they are searching in vain, in the earlier stages of Cholera Asphyxia, for a period of high excitement. Nay, we find ingenious pathologists doing their utmost to prove, in their dissections, that inflammation has actually existed ; and, in the face of evidence which, to unprejudiced minds, would be demonstration, they persist in regarding the disease as one of excited vascular action throughout its whole course. Before proceeding farther, it is very important to say a few words on the general question of bloodletting, not only to satisfy such reasoners that the withdrawal of blood may remove prostration of strength, but to clear the way for the Author's explanation of the nature of Cholera Asphyxia. There are two opposite conditions of the system, in which it may be advisable to withdraw a portion of the circulating blood. The first, when high general arterial action exists, or when local inflammation has taken place : in such circumstances bleeding is called for, because it is necessary to lower the heart's action, or, it may be said, because arterial blood unduly preponderates in the system. Indeed this may be regarded 21 NATURE OF THE DISEASE. as the fact, for, in cases of highly excited action, the blood circulating in the veins will be found to retain the arterial hue. The second state of the system in which bloodletting is expedient, is when the balance of the circulation is depressed on the other side, and the venous blood is in excess. Fever, Peritonitis, and Acute Rheumatism, are examples of the first, and Cholera Asphyxia is the most remarkable example of the second which practice presents. The condition of the system in Cholera has been already spoken of ; but a case of more common occurrence, which affords an example of bleeding being indicated to remove an excess of venous blood, will supply a farther illustration. When there is a broken rib, the action of the chest being impeded, respiration is checked, the blood thrown into the lungs is not purified, the circulation is obstructed, and venous blood; soon preponderates in the system. In such a case, therefore, we bleed not merely to ward off inflammation, but in order to reduce the blood requiring the function of the lungs ; so that the quantity thrown into those organs being proportioned to their restricted capacity, they may be enabled to prepare it for arterial circulation. But, in the latter class of cases, it is not indifferent whether we draw blood from an artery or a vein — a practitioner who would open the temporal artery of a patient whose lungs were clogged with unarterialized blood, would increase the risk of suffocation. Yet we actually find Indian writers so completely mistaken in the rationale of bloodletting in Cholera, that they narrate their attempts to remove blood by the 22 NATURE OF THE DISEASE. temporal artery, when the surface is livid, and after the arteries have ceased to beat. There is another preliminary consideration, which has been lost sight of by many inquirers into the nature of Cholera, viz. That diseases of sudden collapse are not necessarily preceded by a state of high arterial action.— Where, it may be asked, is such a stage in the instantaneous debility produced by the poison of a viper ? But, in order to illustrate this fact, we need not leave the doctrine of diseases. Intermittent fever supplies an apposite illustration : On the approach of a fit of ague, the symptoms are those of great depression ; there is lassitude, and weariness of the limbs, followed by chilliness ; the nails and lips become blue, the countenance sinks, and shivering ensues ; and there are, in some cases, spasms of the extremities. In short, the condition of the system approaches to that which prevails in Cholera Asphyxia ; and there can hardly be a doubt, that in the cold stage of fever the balance of the circulation is interrupted, and that venous blood preponderates in the system. In 1825, when in India, and while maturing these opinions on the nature of Cholera, I was called to the capital of a native prince (Tondeman, Bahadur), to treat a very violent fever, which was committing great ravages ; and I had then an opportunity of seeing the occurrence of death, in what there was every reason to consider the cold stage of an intermittent. The first instance in which this happened was in the case of the principal minister of the Rajah. This patient had suffered from remittent fever for some days. When first visited, though much weakened, he was 23 NATURE OF THE DISEASE. free from feverish symptoms ; and on the following morning he continued convalescent : about mid-day, however, he was attacked with what had all the character of the commencement of an intermittent fever ; he had a severe fit of ague, but instead of the hot fit ensuing, the symptoms of collapse continued, the coldness of the extremities became death-like, the pulse failed, the countenance sank, and the man died in the evening. Two similar cases occurred at the same time. There was no epidemic Cholera in the district, — the prevailing disease at the place mentioned was a violent remittent fever, followed, as is very common in India, by an intermittent ; and such was the termination of many of the cases at that time under treatment, in all of which the primary fever was similar to that in the cases which proved fatal. Unfortunately, from the caste of the patients, it was impossible to obtain post-mortem examinations of those interesting cases ; but there can be little doubt that venous congestion would have been found the principal character of the dissection. Collapse, then, may occur without previous high action ; it is produced by many poisons ; we see it in Ague, and it occurs in Cholera. 24 SECTION 11. PROXIMATE CAUSE OF THE DISEASE. Most practitioners in India seem to have been impressed with the belief, that the disease which has obtained the name of Cholera is, if not a disease sui generis, a malady very peculiar in its character ; and many theories have consequently been proposed in explanation of its nature. Not one of these, however, will be found to account for all the phenomena of this very remarkable disease ; and some of the most intelligent medical men have not been able to satisfy themselves of the rationale of the line of practice, which, even in their own hands, has proved most successful ; for, while pouring in with one hand the most powerful stimulants, they were depleting their patients to the utmost with the other. Hence, the opinions on the nature and treatment of Cholera have become so conflicting, that the disease is very generally believed not to be understood ; and its treatment is considered to be mere guess-work. Early in the Author's practice in Cholera, he, like others, was impressed with the paramount importance of becoming acquainted with the true nature of the disease ; not merely to direct his practice, but also in the hope of being enabled to explain the rationale of what, by general consent, was admitted to be the most successful mode of treatment. 25 PItOXIxMATE CAUSE OF THE DISEASE. The first case he saw satisfied him, that the term Cholera Morbus was calculated to mislead all who had never seen the disease. No doubt, discharges upwards and downwards are common to this and to the disease which had already obtained the name of Cholera Morbus; but this fact may be said to be the full extent of the analogy — for even the nature of the evacuations in the two diseases is totally different ; and in no other symptom do they bear any resemblance to each other. But this misnomer has not only proved a stumblingblock to those practically unacquainted with the disease, it has been in the way at every turn — treatment is indicated and controlled by it, and the most elaborate hypotheses in explanation of the disease have been thereby shackled. The vomiting and purging of the Indian Cholera are in truth of very secondary importance in indicating the treatment of the disease ; every practitioner, not misled by a name, or blinded by a theory, being aware, that as soon as the balance of the circulation is restored, the symptoms which have thus led away the pathologist at once disappear. In the course of the Authors inquiry into the nature of Cholera, it became evident to him, that the symptoms, course, and effects of the disease, could not be explained on the received doctrines of Pathology. He found, that even had dissection afforded, as some imagined, evidence of high inflammatory action having existed, no hypothesis on the nature of inflammation would support the idea of this state being present, when every artery had ceased to beat, and when the action of the heart was no longer perceptible. He found, that pure nervous debility, in its usual acceptation, would not explain the disease ; for when the 26 PROXIMATE CAUSE OF THE DISEASE. body was like a corpse, asphyxiated and cold, the patient could walk, retaining his sensorial and voluntary powers. Neither was depraved secretion sufficient ; for the breath was cold, and the skin blue, so that arterialization must have been deficient ; and to all appearance every secretion was at an end. Nor did the respiratory system supply any means of removing the difficulty ; for .though, no doubt, when the lungs are as it were clogged up, the breathing becomes laborious ; yet this, to any extent, was not an unfailing symptom, and seemed always, when present, to be the result of the morbid condition, and not its cause. Here, then, was a disease in which, although there were great discharges of serous fluid from the alimentary canal, all the natural secretions were at an end, the animal heat had disappeared, the heart and arteries had almost ceased to act, and the blood in the veins was impeded or stopped ; yet the sensorial and respiratory powers were little, if at all impaired. The questions thence suggested are, — I. Is this a local or a general affection ? — and, 11. Is it vascular or nervous ? 1. Though, no doubt, a severe and extensive affection of the alimentary canal will produce serious interference with the circulation, still, under such circumstances, we should have no reason to expect so complete a state of Asphyxia as occurs in the disease under consideration. In an inflammatory condition of the gastro-enteric canal, the action of the heart may be affected, and the pulse become thready ; but the skin does not become livid, nor the body cold ;—; — and every one who has considered the post-mortem 27 PJROXIMATE CAUSE OF THE DISEASE. examinations of victims of Cholera is aware, that it is even questionable whether partial appearances of inflammatory action can be discovered, far less those of extensive inflammation. Besides the immediate and complete recovery from a state nearly of death, which so frequently follows successful treatment in Cholera, is wholly at variance with the doctrine that the disease is an extensive inflammation. If the symptoms were entirely restricted to depraved secretion into the stomach and intestines, we might be justified in considering the disease a local affection of the gastro-enteric mucous membrane. But, truly, the vomiting and purging are of very secondary consideration. The skin is blue, the surface cold, the arteries empty, the veins loaded, and the current of their blood stopped throughout the whole periphery ; and, in such a condition of the system, we cannot be justified in supposing that there is an increased, even though depraved, secretion going on within the alimentary canal. And if we are to consider the disease as the result of a local affection, the evil might with more propriety be ascribed to the pulmonary function. But that it is not the result of a failure in this important function, is proved by there being frequently no marked symptom referable to the chest, and by the disease being generally advanced in its course before the respiration becomes oppressed. This supposition is also irreconcilable with the known immediate effect which the suspended function of the lungs produces on the sensorium. Were the lungs to fail in their function, so far as to render the blood unfit for its purposes, it would follow, that wherever arterial blood was required, the defect would be apparent, and hence the brain would immediately feel the 28 PROXIMATE CAUSE OF THE DISEASE. injury. Accordingly we find this to be the case in circumstances in which the system suffers from the sudden decarbonization of the blood. For example, when a bed-room gradually fills with the fumes of charcoal, insensibility is the first symptom of the danger of the sufferer*. Cholera, therefore, cannot be referred to a topical affection of any of the great organs — the sensorial, respiratory, or alimentary. The difficulty of accounting for all the symptoms, on the supposition that the cause of Cholera is a local affection of some of the great viscera, has led to the hypothesis, that it is an affection of every mucous surface, and that it consists of a depraved condition of the secerning function of those surfaces. But this implies, that secretion is excited on the most extensive surface of the body, when that surface is nearly or entirely deprived of arterial blood ; for in Cholera the discharges continue after the circulation has to all appearance ceased. 2. Every dissection, after death from Cholera, proves, that this disease produces great venous congestion ; and there can be no doubt that such a state of the system invariably exists in Cholera. But this * While engaged in the preparation of this edition, I have had an opportunity of hearing a paper read by my friend Dr Adam Hunter of Edinburgh, in which he endeavours with much ingenuity to prove, that the immediate cause of Cholera is a failure in the function of the lungs. This he proposes to remedy by oxygenated gases, and for that purpose he has prepared a simple and ingenious apparatus. This invention ought certainly to be tried ; for although I believe the failure of the pulmonary function to be one of the effects, and not the cause of the disease, still when re-action commences, such steps as Dr Hunter recom- mends may prove very beneficial. 29 PROXIMATE CAUSE OF THE DISEASE. must be regarded as the effect, and not the cause, of the disease. Blood drawn from a patient labouring under Cholera, is not only much blacker than usual, but is generally grumous ; and, late in the disease, attains the consistence of tar. This must still be regarded as the effect, and not the cause, of the disease ; for, were the immediate cause of a disease such a morbid condition of the circulating blood, as to destroy those organic functions which are found to have failed in the very commencement of Cholera, the sensorium would likewise suffer, and insensibility would accompany the other symptoms. It is not therefore likely, that Cholera Asphyxia results from a morbid state of the circulating blood. When in the animal body we find a circle of actions performed, distant parts united in function, and the flow of fluids to particular organs determined, controlled, or suspended, as may be necessary for certain purposes ; whatever may be our notions with regard to contractility, we must attribute such combined actions to the power of the nervous system. And whatever may be our opinions as to the nature of those processes from which the various secretions immediately result — whether we consider them chemical, or mechanical, or ascribe them to an unknown vital principle — still the determination of the pabulum to the secreting surfaces, must be attributed to a general, and uot to a local agent. The nervous system stretches itself out to every point of the body, and we find it distributed most largely where we may expect the energy of such an agent to be most required ; demonstrating, as it were, that those actions on which the performance of the various organic functions depend, are traceable directly to this system. Hence 30 PROXIMATE CAUSE OF THE DISEASE. we seem to be justified in concluding, that if we find, by disease or accident, that an entire class of the functions of the living body is at once suspended, such suspension must be ascribed to an injury to that portion of the nervous system by which these functions are carried on. In Cholera, in the very outset of the disease, all secretions, properly so called, are found to have failed ; the alimentary ejecta are not gastric juice, pancreatic fluid, bile, mucus, or excrementitious matter. The kidneys cease to secrete urine ; saliva no longer flows into the mouth, nor are the eyes moistened with tears ; carbonic acid gas is not thrown off in its usual quantities from the lungs, and animal heat is not evolved in the body. Here, then, is a disease which suspends secretion in every part of the body. The functions of the parts which are thus rendered powerless, are unquestionably dependent on nervous energy, the involuntary nerves being the class which have failed ; and hence it seems to follow, that the immediate cause of this disease is to be sought in the nervous system. But here it may be asked, How can a disease be considered a nervous failure, in which we find the sensorium, the respiratory, and the voluntary powers unaffected ? The answer to this difficulty may be comprehended in the following propositions, which embody the conclusions on this subject at which the Author has arrived. 1. The great ganglionic or sympathetic system of nerves, is possessed of a power wholly unconnected with cerebral influence, which it may retain after the brain and spinal marrow are removed, and which may cease to exist while these retain the full exercise of their functions. ¦A 31 PROXIMATE CAUSE OF THE DISEASE. 2. To this system belongs the circulation and distribution of the blood ; and it consequently has a most important share in regulating secretion, and in carrying on the involuntary functions. And, 2. To the suspension of this power of the system, as I conceive, is to be ascribed the disease which has obtained the name of Cholera Asphyxia. These conclusions are the result of an intimate practical acquaintance with this disease, and an anxious study of all its phenomena; and they are supported by a careful and minute inquiry into the nervous system in all its bearings. A disquisition on the subject would be out of place here ; but still it is necessary to state some physiological distinctions, not generally received, but which appear to me to be well founded, and which, I think, may be rendered of much value in pathological inquiries. Physiologists have proposed various classifications of the powers of the system in the perfect animal. We have the animal and organic life of Bichat ; the sensorial, nervous, and muscular powers of Phillips ; the contractility and sensibility of Bostock, &c. — The classing of muscularity with the brain and nerves seems plainly objectionable ; for though Bostock considers contractility as a power independent of the brain, or of nervous, agency, it is difficult to detect its independent operation ; and such a separation seems worse than useless in a living organized body, in which we are in danger of losing sight of the true source of action, in. restricting our attention to contractility as a power independent of nervous agency. No doubt, a muscle, removed from the body, can, for a longer or shorter time, be excited to action, according to its nature; but this muscle is 32 PROXIMATE CAUSE OF THE DISEASE. still supplied by innumerable ramifications of nervous filaments, and we must destroy their vitality before it can be considered as proved, that the contractility of the muscle is independent of nervous agency. On the other hand, it is unquestionable, as is exemplified in death by electricity, and by the operation of certain poisons, that whatever destroys the excitability of the nervous system puts an end to muscular contractility*. It appears to me, that disease has not been sufficiently considered in the classifications of the powers of the system ; and that, by keeping the effects of various diseases, accidents, or poisons, in view, the agents carrying on life in the more perfect animal system, might be brought within a simple intelligible classification, regulated by the following proposition : — That we are to consider as belonging to a distinct power of the system, any set of complicated actions and functions which can exist independently of the other powers of the system, and which, when destroyed, leave the other powers entire. For example, a man gets a blow on the head, and is immediately deprived of his mental faculties, his senses, and all voluntary power of motion ; but though he has stertorous breathing, from the loss of control over the * The contraction which boiling produces, can scarcely be con- sidered similar to living contractility : besides, a muscle has also expansibility ;so here is another power. In fact, even in admit- ting that contractility has an independent existence, we advance little in the explanation of its excitement, control, continuance, regulation, and suspension, which the various motions and ac- tions of the system are constantly calling forth ; while the altered power which cerebral or nervous affections produce, proves how great the influence of the brain and nerves must be on muscular action. 1 33 PIIOXIMATE CAUSE OF. THE DISEASE. muscles connected with the air-passages, his respiration is little affected, and the circulation of the blood goes on regularly. In such circumstances, there is clearly a suspension, or destruction, of a source of faculties and actions, which, though necessary to the existence of a complicated system, is independent of other powers which are in operation for the preservation of life. Keeping this general proposition in view, then, the powers carrying on life in the more perfect animal may be divided into three : viz. the Sensorial ; Respiratory*; and the Sympathetic, Ganglionic, or Organic. I. The limits of this Essay do not admit of such a disquisition as would be necessary fully to illustrate the correctness of this classification. It is sufficient to observe, that the nature and extent of the sensorial power is exhibited in apoplexy — in injuries of the head — in acephalous children — and in experiments on animals after the brain has been removed — or with poisons which suspend the sensorial influence, without affecting the other powers of the system. 11. Respiration is so important to life, that neither disease nor accident can suspend it for more than a very short time, without the other powers being annihilated. But still its independence of the senso- * I limit this term to the mere mechanical operation by which inhalation and expiration are performed for pulmonary purpose?. The functions of the lungs belong, in part at least, to the circu- lating power. C 34 PROXIMATE CAUSE OF THE DISEASE. rial and sympathetic systems can be demonstrated. In apoplexy, and other causes of stupor, respiration continues after the sensorium has failed ; and the same thing can be proved, by removing the cerebrum and cerebellum of living animals. The following experiment of Mr Brodie proves, that respiration is also independent of the power which circulates the blood. Mr Brodie inoculated the thigh of a dog with the Upas Antiar. "In twelve minutes the dog was languid. In fifteen minutes the heart was beating very irregularly, with frequent intermissions, and there was a slight rigor. In twenty minutes, the heart was beating feebly and irregularly ; he was sick, and vomited ; but the respirations were as full as under natural circumstances, and he was perfectly sensible. At the end of twenty minutes he suddenly fell on one side, and was apparently dead. The thorax was immediately opened : the heart had ceased contracting, and was distended with blood ; there was one distinct full inspiration after the dissection commenced *." This was not a solitary experiment ; and, in a footnote, Mr Brodie mentions that M. de Lile had found that the Upas Tieutte entirely suspends the power of respiration, without immediately destroying the sensorium. It has been shown that Cholera Asphyxia affords a remarkable illustration of the fact, that respiration may continue free after the circulation to all appearance has ceased. Having thus shortly pointed out grounds for ascribing independent action to the powers which peculiarly * Philosophical Transactions, 1811. 35 PROXIMATE CAUSE OF THE DISEASE. belong to the more perfectly organized classes of animals, the purpose of introducing these speculations in this Essay renders it necessary that a fuller consideration should be given to what is considered a third power of the system. 111. The Circulating Power. The most important function of this power of the system being the circulation and distribution of the blood, the term Circulating Power, although not the most scientific which might be chosen, seems sufficiently expressive of the sense in which it is here employed. The seat of this power is, I conclude, in the ganglionic system of the great sympathetic nerve. But it would be out of place here to enter into a disquisition on the nature of this system, from its first appearance in organized life, to the condition in which it presents itself in the more perfect animal. The sympathetic nerve is said to arise from the sixth nerve of the skull. But really this derivation of the great system of abdominal ganglions and nerves is worse than useless, since it leads the inquirer astray from the true nature of this portion of the animal system. The branch of the sympathetic which joins the sixth, is no more to be regarded as the origin of the sympathetic system of nerves, than is the branch which joins the eighth, or fifth, or any one of the branches which join the spinal nerves. And if the Author's idea of the nature of the abdominal nervous system be correct, we must view these merely as nervous communications between the different powers of the system. c 2 36 PttOXIMATE CAUSE OF THE DISEASE. My opinions as to the nature of the sympathetic nerve are founded on pathology, and were originallyformed in my endeavours to discover the true nature of Cholera Asphyxia. They are further supported, and in truth established, by the experiments of others, I regard the semi- lunar ganglion and the solar plexus as the principal source of the energy of the sympathetic system. And it appears to me, that the integrity of this system is necessary to the completecirculation of the blood, and to the progress of inert fluids in non-muscular vessels. It has been proved by Sir Charles Bell, that, towards the perfection of voluntary muscular motion, not only is a nerve of motion requisite, but one of sensation. And I conceive, that, towards secretion, not only is a medullary nerve required, but a branch of the sympathetic system, which, without intending it as a perfect analogy, may be illustrated by the necessity of the presence of both the positive and negative wires towards galvanic operations. According to this notion, the sympathetic system must possess an important share in the function of secretion. It is difficult to say to what extent the sympathetic system has subservient to it contractility # . It * I think it is evident, that the current of venous blood can neither be maintained by the power of the left ventricle of the heart, nor by the " suction" of the right side of the heart, while the current in the lymphatics, lacteals, and all non-pulsating vessels, cannot be accounted for on the doctrine of contractility. Dr Sharpey has discovered, that certain animals have even a power of giving motion to fluids which are external to their own bodies, and which cannot be referred to muscular action. Seeing o that the tadpole and mussel possess such a control over foreign fluids, we surely shall not arrogate too much to the vessels of the 37 PIiOXIMATE CAUSE OF THE DISEASE. does not appear to have any power over voluntary muscles. To it may belong the expansile and contractile properties of the arteries, and the purely vermicular motions of the intestines *. But there is no occasion to pursue this farther, as it is not indispensably necessary for my present purpose. As already said, the classification of the powers of the system which I consider best adapted for pathological inquiries, is founded on the proposition, — that any circle of actions which can exist independent of the other powers of the system, and which can be destroyed without their immediately failing, is a power. The fact is best ascertained by disease, because experiments with the knife may destroy more than one class of actions. But there are some experiments which assume very much the character of disease, viz. those with poisons. One of Mr Brodie's very interesting series of experiments with poisons, has been cited above {vide p. 34), and is of importance, as proving that the circulation may be destroyed, leaving entire the other powers of the system. Another of those experiments is no less illustrative of my present view. Mr Brodie found, that certain poisons, while they destroyed the sensorium. and respiration, left the circulation unaffected ; and that the heart continued to act, and to circulate black blood, some minutes after voluntary motions were at an end ; and he concluded, that if he more perfect animal, if we conclude that they are enabled to pro- pel their contents independently of contractility. * When Dr W. Phillip divided the par vagum, he found rea- son to believe, that, though the animal lost the power of empty- ing its stomach by vomiting, still it possessed the ability of pass- ing slowly on the digested food. 38 PROXIMATE CAUSE OF THE DISEASE. could support the circulation sufficiently long, to overcome the injury done by the poison to the brain and respiratory system, he would resuscitate the animal. He describes the experiment as follows : " Some woorara was inserted into a wound in a young cat ; she became affected by it in a few minutes, and lay in a drowsy and half-sensible state, in which she continued at the end of an hour and fifteen minutes, when the application of the poison was repeated. In four minutes after the second application respiration entirely ceased, and the animal appeared to be dead ; but the heart was still felt acting about 140 times in the minute. She was placed in a temperature of 85° of Fahrenheit's thermometer, and the lungs were artificially inflated, about forty times in a minute. " The heart continued acting regularly. " When the artificial respiration had been kept up for forty minutes, the pupils of the eyes were observed to contract and dilate on the increase or diminution of light, saliva had flowed from the mouth, and a small quantity of tears was collected between the eye and the eye-lids. But the animal continued perfectly motionless and insensible. " At the end of one hour and forty minutes from the same period, there were slight involuntary contractions of the muscles, and every now and then there was an effort to breathe. The involuntary motions continued, and the efforts to breathe became more frequent. At the end of another hour the animal, for the first time, gave some signs of sensibility when roused, and made spontaneous efforts to breathe 22 times in a minute. The artificial respiration was discontinued. She lay as if in a state of profound sleep for forty minutes, when she suddenly awoke and 39 PROXIMATE CAUSE OF THE DISEASE. went away. On the following day she appeared slightly indisposed ; but she gradually recovered, and is at this time still alive, and in health *." In this experiment we have a proof that the power which circulates the blood may retain its energy for forty minutes after the perfect death of the sensorial and respiratory powers. But, at the same time, the fact that the various powers of the system are not wholly independent of each other, is proved by other experiments similar to this. Thus Mr Erodie found, " that the circulation of the blood may be maintained in an animal from whom the brain has been removed, for a considerable, but not for an unlimited time f ." The experiment cited at page 34. proves, that the power which supports the circulation may be destroyed, yet the sensorium and respiration remain, for a time, unaffected. The peculiar and remarkable symptom of Cholera Asphyxia is, that after the heart has ceased to beat, and when the blood appears no longer to be circulated, the respiratory and sensorial powers continue wonderfully entire, so that the condition of the patient is not very different from that described as produced by Upas Antiar. The following case, which occurred early in my practice in India, will serve to illustrate this peculiarity of the disease :—: — Arcot, 26th July 1819.— Ensign W. set. 18, had only been a few weeks in India — on his march to join his regiment. This young gentleman had a feverish attack, some stages back, but has been able to accompany the detachment in his palanquin, and had * Philosophical Transactions, 1812, p. 207- t Ibidem. 40 PROXIMATE CAUSE OF THE DISEASE. yesterday quite recovered. He, this morning, after breakfast, sent his servant for a dose of salts, without reporting himself sick. I saw him about ten o'clock a. m. He said he had not felt well after the morning's march, and as he required medicine, he had no doubt the salts, which he had just taken, would set all to rights. At three o'clock p. m., while in attendance on a sepoy who was dying of Cholera, it was reported to me that Ensign W. was attacked with the disease. On reaching his tent, I found him in the third stage of Cholera Asphyxia. The vomiting and purging had nearly ceased. His skin was cold — his pulse not perceptible — much thirst— spasms of the extremities — countenance sunk. He was perfectly collected. He said, that soon after I had seen him he had been purged, and that he had vomited up the salts. He had been then attacked with cramps, but he did not suspect Cholera. I immediately attempted to bleed him, but could not, even by kneading the arm, procure above a few drops of grumous blood. Calomel and opium, laudanum and ether draughts, and hot brandy and water, were administered. Bottles of hot water were applied to the extremities, frictions and shampooing, &c. resorted to. All was vain ; clammy and profuse perspiration broke out, jactitation came on, and he was a corpse by eleven o'clock p. m., retaining his mental faculties till the last ; having been able to give information relative to his friends in England, immediately before his death. But as it is important that this point should be established, the Author will here adopt the language of other practitioners in describing the condition of patients labouring under Cholera. Mr Marshall, 41 PROXIMATE CAUSE OF THE DISEASE. when staff-surgeon at Ceylon, (1819), says, " In a few instances the vital energies appeared to be rapidly depressed, and indeed almost extinguished ; and every endeavour to arrest the progress of the disease became unavailing. One man, a Caffree sergeant, whom I saw at half-past six P. m.. in apparent good health, was suddenly seized at half-past seven p. m. with a slight uneasiness in his bowels, which was followed by one watery evacuation, and once or twice he belched up a little watery fluid from his stomach. Warm water being in constant readiness at the hospital, he was in a warm bath by about ten or fifteen minutes after the griping pain came on. A scruple of calomel, with a stimulating draught, were instantly exhibited ; a vein was opened while he was in the warm bath, but very little blood flowed. All the means employed were of no avail ; the mortal symptoms became rapidly aggravated, and, by a quarter past nine, he had expired." Dr Davy, Physician to the Forces, Ceylon, (1819), in the report of a case, five hours after the accession of the disease, observes, " I could perceive no pulse of the heart cr arteries ; his extremities were cold, the whole surface of the body cool, and bathed in sweat ; even the axilla felt cool, the thermometer in it did not rise above 96° ; under the tongue, it was stationary at 97°. I asked if he felt any uneasiness about the chest, he replied, not the least ; his breathing was quick, about 34 in a minute, not laborious ; he said he had no fixed pain anywhere, nor was pain produced by pressure on the abdomen. Cramps occurred frequently in different muscles, particularly of the inferior and superior extremities, and in the abdomen ; and once, while I was present, the muscles of the face 42 PROXIMATE CAUSE OF THE DISEASE. were extremely affected, as in Trismus. The spasms were of short duration ; they were so painful, that under the agony they occasioned, the patient cried aloud. The tongue was clean ; he was rather thirsty, and often called for water. Whilst I was with him (about an hour) he had no vomiting, or retching, or evacuation from the bowels ; an enema that was prescribed was not retained. His expression of countenance was wild ; his eyes sunk a little ; his features not collapsed ; his expression was agitated ; his intellect clear." This man continued conscious to the last, and quietly expired after ten hours' illness. Mr Farrel, Deputy-inspector of Hospitals, Ceylon, (1819), in his observations on the reports on Cholera, made by the medical men in that island, says, " When the heart ceases to act ; when the countenance collapses, and the eyes sink deep in the orbits ; when the body becomes cold, and has a death-like appearance, the more frightful from the faculties of the mind and the power of speech remaining in the living corpse ;—; — when all this takes place in less than one hour from a state of perfect health, what can be said of it, but that it is the work of the hand of death * ?" According to Dr Christie, " Sometimes, when the pulse is scarcely perceptible at the wrist, the patient is still able to walk ; and long after the pulse has ceased at the wrist, (although perhaps not able to move about), he is often sufficiently strong to sit up, to use his arms and hands, to speak f," &c. * I have taken the liberty of making these quotations from the manuscript reports of the Ceylon Medical Officers, the use of which has been kindly afforded me by Sir George BallingalL in whose possession copies of them are. t Observations on Cholera, by Dr A. T. Christie. 43 PROXIMATE CAUSE OF THE DISEASE. These quotations (and similar passages occur in every work on Cholera) are sufficient to satisfy any unprejudiced mind, that after Cholera has put almost an entire stop to the circulation of the blood, the sensorial and respiratory powers retain their functions. My own observations of the phenomena of the disease, coincide in every particular with the reports just cited. Indeed, it was from finding this fact so prominent in this disease, that I was first led to draw the above physiological references. The indispensable necessity of arterial blood for the due performance of the functions of every part of the body, makes it a very remarkable feature of Cholera, that the mental faculties should be retained, apparently in such perfect preservation, after the heart must have ceased to send, in due quantity and quality, arterialized blood to the brain ; and that the sensorial power should frequently continue to exist after the circulation of the blood has, to all appearance, ceased. The circulation within the head has several peculiarities. The cerebral arteries have not a cellular coat ; they are reduced to extreme minuteness ; and they do not appear to be accompanied by nerves *. The communication between the veins and the sinuses of the dura mater is peculiar, and the sinuses themselves are widely different from veins. The direct course of the blood, however, from the heart to * Could it be demonstrated that the sympathetic system does not extend its branches to the circulating vessels of the brain, it would be a justifiable conclusion that the cerebral matter is capa- ble of communicating energy to the vessels imbedded in it j and it might in some degree support the idea which I have ventured to propose, that Cholera Asphyxia is to be attributed to a failure in the sympathetic system. 44 PROXIMATE CAUSE OF THE DISEASE. the head, will have considerable effect in preserving entire the cerebral circulation, after that of the trunk and extremities has ceased. But it is not necessary to speculate further on this point ; it is sufficient for the present purpose to state, that notwithstanding the cessation of circulation in the trunk, the sensorial and respiratory powers are nearly perfect. And the fact that, in this disease, the mental functions remain comparatively unimpaired till the last moment of life, is very valuable in one point of view. The symptoms of Cholera Asphyxia throughout its course, must be referred to the condition of the circulation. At whatever period of the disease the state of this important function is examined, it is found to be morbidly affected. Even before patients themselves are aware that they have been attacked, the arteries are beating feebly, and the venous circulation is perceptibly obstructed ; and at however early a period in the course of the disease venesection is performed, the current of the blood is found to be retarded, and the colour of the fluid is unnaturally dark. If, in such circumstances, we should find every function of the system suspended, we might conclude that the disease arose from a morbid change in the blood itself. But the continuance of the sensorial and respiratory powers, after the failure of the circulation in the trunk and extremities, and the suspension of all the organic functions, is a direct proof that the disease is not to be ascribed to " death of the blood." Every character of Cholera authorizes us in concluding, that it arises from failure of a portion of the nervous system. When, in consequence of a blow on the head, a man loses all sensorial and voluntary power, while the respiration and circulation remain 45 PROXIMATE CAUSE OF THE DISEASE. little affected, no one doubts that it is a systematic portion of his frame which has been suspended, and that the loss of perception and of motion has arisen from the source of nervous energy to which these belong having lost its controlling power. In Cholera, the animal heat sinks, secretion fails, and the circulation ceases. Whatever may be the ultimate means by which these important properties of the system are produced, whether chemical, mechanical, or vital, every one will admit, that the combinations which effect them must depend on the nervous system. It has been demonstrated, that, in this disease* the sensorial voluntary, and respiratory involuntary nerves, retain their functions. A man on the point of death from Cholera, breathes, and can give expression to his thoughts. We must, therefore, in endeavouring to ascertain the source of the disease, look to the sympathetic system of nerves, which we find perfect in those tribes of animals which have no brain, and which is proved by experiments to retain its independence in the higher classes of organized animals, where the brain is superadded. If we refer to the symptoms of Cholera we shall find, that the functions over which I have endeavoured to prove this system to have control, are those which the disease suspends ; and it is particularly worthy of notice, that wherever the branches of the sympathetic system are largely distributed, there the symptoms of the disease are most prominent. It would even appear that the sinking of the eye may be ascribed to the failure of the energy of the sympathetic system, for Dupuy found that the removal of the superior cervical ganglion of the sympathetic nerve in a horse, was immediately followed by sinking of the eye in its socket. 46 PROXIMATE CAUSE OF THE DISEASE. " Le 24 Juin, on lvi extirpa le ganglion guttural gauche. Aussitot apres l'operation, l'oeil de cc cote parut plus enfonce dans l'orbite." — Journal de Medecine, t. xxxvii. p. 343.* It now becomes necessary to endeavour to account for the discharges which so frequently become a principal feature in Cholera Asphyxia ; and with that view, it is proper to premise a few words on the general subject of secretion. Secretion, according to Bostock, is to be referred to chemical and mechanical agencies. He says, "If the substances produced are identical with any of the constituents of the primary fluid, or even very similar to them, it may appear probable that the operation is principally mechanical ; whereas, if the secondary substance differs considerably from any of the constituents of the primary fluid, we should naturally suppose that it has been produced by a chemical affinity, or by the combined effect of chemical and mechanical * Since the publication of the former edition of this Work, a writer in the Foreign Quarterly Review, without noticing my work, adopts and proposes my hypothesis, but in a reversed or- der. He supposes the nervous system, to a suspension of which I have ascribed the disease, to be affected by paralysis of the functional apparatus of the lungs, occasioned by a human miasm. This, he says, injures the blood, and the diseased blood injures " the vital energy of the nerves distributed to the respiratory, circulatory, and secreting organs."- — Foreign Quarterly Review for October 1831. In a previous page I have stated the reasons which induce me to think that the disease is not to be ascribed to the lungs. The able writer of the article in question has more recently adopted fehe name which 1 have selected as most appro- priate for this disease. — See Medical Gazette for November 1831, p. 223. 47 PROXIMATE CAUSE OF THE DISEASE. action*." And he is anxious to throw entirely out of view nervous agency, and to avoid using the term vital principle. In my mind, little is gained by referring this function, in the more perfect animal, to unknown chemical affinities, or incomprehensible mechanical actions ; and until we have some better authority than mere conjecture for ascribing these processes to such agents, I think it better to retain the use of an unknown (except by its effects) vital principle. And it is unquestionable, that whatever may be the nature of the ultimate actions from which secretion results, the circles of actions, which are called into operation by each secretion, must be ascribed to the nervous system. Neither mechanical action, nor chemical affinities, will account for the determination of blood to organs at the moment when it is required, or for the suspension of functions under particular circumstances. In truth, it would appear that the efforts of the vital energy are often rather to overcome mechanical actions and chemical affinities, than to appropriate them to its own purposes ; and so far at least as secretion is concerned, I should be inclined to lay it down as an axiom, that whenever these agents come prominently forward, it is to be ascribed to a failure of the principle of life in the system. There is another objection to Bostock's account of secretion. He has not, as it appears to me, sufficiently restricted the meaning of the term, but confounded processes, which are not only different when carried on in their proper organs, but which are different when they take place in the same viscus. He makes secretion and exhalation the same operation. But does it * Bostock, vol. ii. p. 495. 48 I'IIOXIMATE CAUSE (JF THE DISEASE. *? * not happen, that, from disease or accident, a secretion may be changed to a mere serous fluid ? It is most inconvenient to the pathologist, in such circumstances, to apply the term secretion to both processes. No doubt the word depraved is added, but this only adds to the objection ; for " depraved secretion" does not imply that there is a new action, which is the fact, but that the secerning apparatus is still acting, though disordered. The consequence is, that the pathologist is misled ; whereas, were it understood that secretion has ceased, and that a new action has taken place, inquiry would be made into the new condition of the system which had led to this change, This point cannot be better illustrated, than by the two diseases which have received the same name, Cholera Morbus and Cholera Asphyxia. In the common Cholera Morbus, secretion is not at an end : the matters discharged from the stomach and bowels are the gastro- enteric secretions in a vitiated state, and bilious and excrementitious colluvies ; the pulse rises, the skin becomes hot and dry, the tongue is furred and parched ;. every symptom of the disease is referrible to the secerning functions of the abdominal viscera, and to irritation, consequent on depraved secretions being thrown into the intestinal canal. How opposite is the condition in Cholera Asphyxia ! We have, in this, a disease in which there is a complete suspension of every organic function ; and although, as one of its symptoms, it is attended by great intestinal discharges, yet in these there is not a trace of any of the abdominal secretions. In the former disease there are depraved secretions, producing great constitutional derangement. In the latter there is suspension of secretion, result- 3 PROXIMATE CAUSE OF THE DISEASE. 49 j» ing from a general disorder. In the first case, the object of the physician is to evacuate crudities, and correct disordered actions. In the second, the curative indications are to relieve the system, and to restore the function. Secretion, according to the proper acceptation of the term, should be restricted to that change on the blood which is productive of a substance wholly different in its nature and character from the primary fluid, and which cannot previously be detected in it : Whereas I should denominate the disengagement of any of the component parts of the blood, in an unchanged state, as exudation or exhalation. When a disease fills the cellular membrane with the serous part of the blood, it is not a secretion : When a sac is filled with pus, it is by secretion. And on the same principle, a discharge of serum into the stomach or bowels is to be regarded, not as a secretion from the mucous membrane, but as an exudation from the capillary vessels. Besides, it will be found, that such exudations are not always to be ascribed to arterial action, but may on some occasions result from a remora in the venous circulation ; which, by forcing back the venous blood into the capillaries, the more attenuated parts of the blood are by these thrown off on the secreting surfaces. It is at least evident, that when the capillary vessels continue to throw off large quantities of fluid, after the left side of the heart has ceased to supply them with blood, the process can only be accounted for in this way. The above observations on secretion generally, appeared necessary to render the following explanation ,of the Cholera discharges intelligible. The fluids evacuated by the stomach and bowels 50 PROXIMATE CAUSE OF THE DISEASE. during Cholera Asphyxia, are found to be portions of the component parts of the blood. In health we never see such fluids discharged from the abdominal viscera. They are not gastric or duodenal juice*, — they are not bile, — they are not excrementitious matter, — nor are they the mucous secretion of the canal. The Cholera discharge consists of the serum and fibrin of the blood. But then evacuations go on, and the bowels are filled, after the heart has almost ceased to act, when the arteries are empty, and when the capillary vessels are no longer supplied with blood by the usual course. The great veins, however, the liver, and the right side of the heart, are gorged with blood ; the abdominal veins having no valves, regurgitation takes place, the capillaries are filled by a retrograde course of the blood, and are thus enabled to discharge the more attenuated parts of it. And although I believe that, in these circumstances, there is a deficiency of that nervous energy which is necessary towards secretion, still, as the medullary nerves retain their functions, the action by which this fluid is excreted will retain the character of life, and will consequently differ from the purely mechanical and chemical changes which take place after death. The source of nervous energy by which secretion is excited, gives rise to one of the most interesting questions in physiology. When a man has his spine dislocated, * I am aware that some recent chemical experiments seem to warrant the conclusion, that the Cholera discharge from the sto- mach partakes of the nature of gastric juice. But it would re- quire more faith than I have in chemical experiments on the vital fluids, to satisfy me that the secretion of one of the most import- ant fluids in the system, is inordinately excited in the state of the arterial circulation which exists during Cholera. PROXIMATE CAUSE OF THE DISEASE. 51 and loses power over the portion of his body below the injured part, if he continue to breathe, the secretions go on. When in apoplexy or concussion of the brain, the sensorial power only is suspended, secretion is not destroyed. In acephalous monsters, a very small portion apparently of the medulla oblongata suffices towards the performance of secretion ; and we find that some monstrous productions, in which there was not only no appearance of brain, but a very imperfect formation of the medulla oblongata*, have lived, even for some days, and secreted urine. In all Mr Brodie's experiments, in which the sources of the sensorial and respiratory powers were destroyed, although, by artificially inflating the lungs, he could maintain the circulation of the blood, and produce apparently all the changes on that fluid which usually take place within its own vessels, secretion was at an end f . * Much stress is laid by certain physiologists, who are anxious to lower the importance of the nervous system, on the fact of uterine monsters being formed, in which not only no brain or spinal marrow was found, but little appearance of a nervous sys- tem. Without stopping to inquire, whether due examination was made in these cases into the existence of the sympathetic system, I may observe, that, until the powers of the placenta be ascertained, little weight can be given to the evidence afforded by imperfect fetal productions. The reasoning in the text has reference to animals which can live by breathing. t As venous blood, after removal from the body, by exposure to atmospheric air, acquires the arterial hue, the changes on the blood, exhibited in Mr Brodie's experiments, may have been purely mechanical. I may observe, that while Mr Brodie found that the loss of the sensorial and respiratory powers put an end to all the usual -secretions, exudation went on, and the process of inflating the lungs was generally put a stop to, by the air-cells becoming ob- structed by the exuded fluid. D 2 52 PROXIMATE CAUSE OF THE DISEASE. The conclusion to which these facts lead is, that the medullary source of secretion lies between the pons Varolii and the beginning of the dorsal vertebras. In Cholera, where the failure appears to be in the sympathetic system, secretion is suspended ; as also happens in experiments with poisons, by which the power which circulates the blood is destroyed *. It is therefore evident, that the integrity of more than one of the powers of the system is necessary to the function of secretion ; and we are justified in concluding, that this process not only requires the preservation of the upper portion of the spinal column, but the vital energy of the sympathetic system. It is important, before concluding this branch of the subject, to attend to the effect produced by Cholera on the cuticular discharges. We have seen, that perspiration almost invariably makes its appearance in the latter stages of the disease. I have never seen a fatal case in which, sooner or later, this symptom has not been present. According to Dr Christie, " profuse perspiration is a very common symptom of Cholera. It is a curious fact, that there is sometimes profuse perspiration when the pulse at the wrist is extremely small, or altogether imperceptible. This has generally been considered as indicative of extreme debility of the cuticular perspiratory vessels. On the other hand, I am inclined to think, that these vessels have their action very much increased ; for were the * The destruction of the fifth nerve produces ulceration and sloughing of the eye, membrane of the nose 3 and in the gums of the side of the face supplied by the destroyed nerve. And Mr Dupuy found that the removal of the upper cervical ganglion of the sympathetic in the neck produces nearly similar results. — Lerouz's Journal de Medccine, t. xxxvii. 53 PROXIMATE CAUSE OF THE DISEASE. reverse the case, how does it happen that, when only a small quantity of blood flows sluggishly, or in drops, from a large orifice made in a vein, or even when no blood can be procured, the cuticular secretion forces its way through the minute pores of the skin ? It is easily conceivable how debility of the perspiratory vessels can occasion increased perspiration, when the superficial arteries which are immediately behind them act with vigour ; but when these arteries do not contain a sufficient quantity of blood to enable them to continue their own action, the only way in which perspiration can be thrown out, is evidently by an increased action of the perspiratory vessels # ." This explanation seems to me to refute itself. The pulse is altogether imperceptible, the heart is beating languidly, " and the arteries, immediately behind the secreting vessels, have not a sufficient quantity of blood to enable them to continue their action." When, in fact, all appearance of arterial blood, colour of the skin, animal heat, &c. are absent, this author supposes that the exhalant arteries have the power of throwing off profuse perspiration. Now to this I cannot assent. On what, in the first place, it may be asked, are the exhalant arteries to act ? Even admitting that the capillary arteries have an action independent of dilatation, their action surely must be useless when the arterial blood is no longer sent to themf. It has been found, that the fluid which exudes * Observations, pp. 80, 81. t The action in arteries would, I think, be much better ex- pressed by calling it simply contractility ; the term muscularity having led to much bad theory, and consequently, injurious prac- tice. A muscular power is not only uncalled for, but, with all its attendant liability to spasm, irregular action, &c would prove 54 PROXIMATE CAUSE OF THE DISEASE. from the inner surface of the intestinal canal, must be supplied by the veins ; and if it be admitted, that the capillary vessels in the periphery of the arterial system are filled at all, this also must be ascribed to regurgitation. And let it be kept in mind, thatj late in the disease, when the alarming symptom of profuse cold perspiration makes its appearance, the external veins are invariably gorged, so that their valves will be no hinderance to a retrograde course of any elected fluid portion of the blood. I may again notice the fact, that though the skin is thus throwing off profuse perspiration, vesication cannot be produced. This has been a subject of much wonder. But vesication is the result of inflammation, and inflammation belongs to the arterial system ; so that, under the view here given of Cholera, vesication is not to be looked for while the disease lasts. Before proceeding to a review of my inferences, I refer to the following case, extracted from the MS. Ceylon Reports, as illustrative, not only of the difficulties which are encountered in the treatment of this disease, but also as amounting, almost to a demonstration, of the correctness of my views ; while, at the same time, it shews how they may be rendered practically available. highly injurious, by interfering with the circulation in its course ; and a spasmodic local affection of an artery might irretrievably suspend a function on which the life, not merely of the body as a whole, but of each individual part, depends. It appears to me as absurd to attribute action to arteries independent of a supply of blood, as it would be to expect a mill-wheel to continue its gyrations after we had turned off the supply of water. PROXIMATE CAUSE OF THE DISEASE. 55 Extract. — " Private Thomas Lay ton, 19th Regiment. i£t. 22 ; 3 years in Ceylon. " Had not previously suffered from disease, when admitted into hospital labouring under epidemic Cholera. Says he has been affected with slight looseness for the last two days : at present, 10 o'clock a.m. 14th August (1819), complains of headach, vertigo and faintness, with violent vomiting and purging of watery fluid : the features are shrunk, and expressive of great anxiety ; pulse small and intermitting, profuse perspiration, skin moderately hot, tongue clean ; has had some spasmodic twitches in the fingers and toes. Although the state of collapse was fast coming on, I still considered that the circulation might be relieved by venesection ; Ib. iss. of blood was abstracted from two orifices before it ceased to flow. He was instantly placed on a spirituous vapour bath, took hydrargyri submuriatis gr. xxx. in powder, and several stimulant antispasmodic draughts, the second of which was combined with tinct. opii 3 i- " At 12 o'clock the vomiting and purging still continued ; took another dose of hydr. submur. gr. xxx. had his abdomen fomented, and rubbed with 01. terebinthinae. His head was also shaved, which, together with his legs and arms, was rubbed with a liniment composed of antimonii tartaris and 01. commune. At this time, the state of collapse was completely formed ; he tossed his body and limbs to and fro on the couch : the vomiting and purging was now relieved, but cold clammy sweats continued, with spasms in the extremities, for the space of ten hours, during which time blisters were applied to the 56 PROXIMATE CAUSE OF THE DISEASE. head and thorax ; he was kept warm by the vapour bath, had repeated stimulant glysters, and his limbs rubbed with various strong embrocations. " Ten o'clock p. m. — Was still in a cold perspiration ; continued 'perfectly collected ; pulse began to flutter, and both blisters had vesicated. From this period the pulse gradually rose, and by eight o'clock next morning the skin was moderately hot, pulse slow and steady, had not had a natural evacuation. 15th August, R, pulv. rhei B ij. aquae cinnam. 3j ii. Vespere, — Had not had a stool, but had made water several times, and slept two hours ; is extremely exhausted and torpid ; was allowed some wine, and such food as he fancied. R. enema purgan. " August 16. — Is still in a state of torpor and listlessness ; pulse steady ; no appetite. The enema brought away some foetid stools. R. hydrarg. submur. gr. x. ter in die. — Repet. enema cathart. " August 17- — The stupor and insanity, with obstinate costiveness, continue ; he also complained of pain and fulness of the left side, with oppression of the breathing. Thirty leeches were applied to the thorax, and four full dozes of cathartic pills were administered, which produced some bilious stools ; pulse and heat natural. " August 18. — The stupor and catching in breathing having increased, he was put into a warm bath ; the former blister being healed, another was applied to the thorax, and the catharsis kept up by a cordial rhubarb mixture." The case goes on till the 22& August, symptoms and treatment continuing much the same, on which day this is the report:—" Breathing more oppressed ; pulse still regular ; has not had a stool from 57 PROXIMATE CAUSE OF THE DISEASE. the medicine. R. enema purgan. c. 01. terebinthinse 5 ij. Vespere, — Low muttering delirium came on during this day. He gradually sunk, and died about three o'clock on the 23d instant. " Sectio Cadaveris Five Hours after Death. " On taking off the skull-cap nothing unnatural appeared on the surface of the dura mater, excepting a number of veins running over it being much distended with blood. A great proportion of the veins likewise on the surface of the brain were highly turgescent, and some of the smaller branches contained portions of air intermixed with blood. The cortical and medullary parts of the brain were natural in appearance and consistence, except the latter exhibiting, when cut across, numerous bloody points. The right lateral ventricles contained about two drachms of serous fluid, the left about one and a half drachms. The pineal gland was very firm in consistence, but natural in colour ; there was nothing remarkable about the other parts of the encephalon. There was about half an ounce of serum slightly tinged in the base of the brain. The medulla spinalis was so firm in texture as to approach to the consistence of ligament : the vertebral canal could not be examined in a manner sufficiently satisfactory, for want of proper instruments ; and the only circumstance which I was capable of noting, was part of the serous fluid oozing out, which no doubt ran along the sheath lining the canal from the base of the brain*." The appearances of the chest and abdomen are given. In the former there was evidence of the existence of inflammatory * Ceylon Manuscript Reports. 58 PROXIMATE CAUSE OF THE DISEASE. action ; in the latter, the viscera had the usual character of disordered circulation consequent on a partial recovery from Cholera. Now, the progress of this case is not only valuable, as illustrative of the nature of Cholera, but it assumes something of the shape of a prolonged experiment, confirmatory of the speculations which, with a view to pathology, I have offered on what appears to me the most useful subdivisions of the powers of the system. This case farther proves the practical value of the opinions which I have ventured to propound regarding the treatment of the disease. So long as the symptoms of the disease had their source in a suspension of the energy of the sympathetic system, the intellect was clear, and, as nothing is said of the respiration, we may conclude that the breathing was not more affected than it sometimes is in Cholera. When that disease was overcome, there was a period of exhaustion, followed next day by symptoms of cerebral congestion. Reaction then apparently took place within the skull, still complicated, however, with congestion ; but, although the pulse was natural, the breathing was now becoming affected. Next day the symptoms are more decidedly referrible to the origin of the respiratory nerves, and there is " catching in breathing." It may be added, that a correct notion of what was going on in such a case would have directed attention, in the first instance, to the sympathetic system, in the second to the brain, and, in the third, to the upper portion of the medulla spinalis. The conclusions and inferences at which I have arrived, therefore, are, — 1. That there are three powers in the system, viz. 59 PROXIMATE CAUSE OF THE DISEASE. the sensorial, respiratory, and sympathetic ; and that each of these, on all common occasions, is enabled to perform its functions without the active interference of the others. 2. That the destruction of any one of these powers does not immediately annihilate the other two. (1.) The sensorium may be suspended, and the circulation and respiration continue unimpaired. (2.) The circulation may be supported after the source of respiratory power and the brain have been removed. (3.) The circulation of the body may be stopped, and the sensorium and respiration remain unaffected. 3. That the source of the sensorial and voluntary power is in the cerebrum and cerebellum ; that of the respiratory power, in the upper portion of the medulla spinalis ; and that of the circulating power, in the ganglionic system of the great sympathetic nerves. 4. That secretion requires the integrity of the upper portion of the spinal column and of the sympathetic system ; and that when the power of either of these sources of nervous energy is suspended, any appearance of secretion is fallacious. 5. That secreting surfaces may throw off component parts of the blood, after their power of secretion is at an end. 6, That Cholera Asphyxia is a suspension of the power by which the circulation of the blood is carried on. 7. That the fluid which, during a fit of Cholera, is poured into the alimentary canal, and which exudes from the skin, mouth, eyes, and mucous lining of the bronchise, is excreted after secretion has ceased, when animal heat is no longer evolved, and when arterial action is at an end ; and therefore must be regarded PROXIMATE CAUSE OF THE DISEASE. 60 as an exudation from the venous capillaries, or if from the arterial capillaries, is occasioned by their being supplied with blood by regurgitation. I have thus brought to a conclusion my hypothesis as to the immediate cause of Cholera ; and have to return my professional brethren thanks for the indulgence with which they have received these physiological views in explanation of the Pathology of that disease. I could hardly have expected that a theory, promulgated for the first time, and differing so widely from any which has been heretofore suggested, should have been at once adopted ; but as many of those experienced in Cholera have expressed their assent, I have reason to hope, that, as European practitioners become acquainted with the disease, the correctness of my conclusions will be more generally admitted. 61 SECTION 111. REMOTE CAUSE OF THE DISEASE. The remote cause of any particular disease is frequently the most obscure question connected with its nature ; and I much fear that practically we should gain little by becoming acquainted with the remote cause of Cholera. The disease, to whatever origin it is to be traced, seems to be now gradually diffusing itself over the globe, — uninfluenced apparently by climate, — and hitherto setting at defiance all human means of retarding its progress, or of lessening to any considerable extent its average mortality. Were it of any importance to hazard conjectures as to its remote cause, I should be disposed to say that the theory most consonant with the phenomena of the disease, is that which ascribes it to certain galvanic changes on the earth's surface ; but really such speculations are of little value, nor is there any theory of the disease which has led to important practical results, except that which traces its origin and spread to contagion alone. Some writers go so far as to say, that even the question of contagion resolves into a mere splitting of straws ; but no one who looks around him can view this question in that light, and therefore I propose in the next Section, to discuss the subject very fully ; merely observing here, that the difficulty of accounting 62 REMOTE CAUSE OF THE DISEASE. for the rise and extraordinary progress of this disease has very naturally led speculative writers to seek its remote cause in contagion. In my apprehension these writers have failed in estaίlishhig their position ; but whether they have done so or not, lam sure that all my professional brethren will readily concede to me that, independently of contagion altogether, the extension of a disease, having its source in terrestrial or atmospheric causes, is no new phenomenon. Influenzas, it is well known, have on various occasions become universal ; so also a town or district has been frequently visited by a fever without apparent cause ; while other places have as frequently and as unaccountably become exempt from diseases, to which they had been formerly subject. I have seen intermittent fever become epidemic in an extensive district of India (the Southern Mahratta provinces), and prevail for a time over the whole face of that country. We are ignorant of the cause of ague. It is said to be marsh miasm ; but it prevails constantly in some of the highest and driest stations in India ; whereas other districts, which, during the hot season, are flooded over their whole surface, are peculiarly free from fever. The most interesting example of this is afforded by the kingdom of Tanjore, which is annually flooded during the dry season by rivers, having their flood-heads in the western Ghauts, which are filled during the rains on the op^ posite side of the peninsula ; and yet, in that country, which, during six months of the year, is kept in a constant state of irrigation and evaporation, intermittent fever is comparatively exceedingly rare. But if fever and ague can become epidemic, as I have seen it in the Southern Mahratta provinces, where the 63 REMOTE CAUSE OF THE DISEASE. Country is varied and far from marshy, there is no assignable or obvious reason why that disease may not, as Cholera is now doing, extend itself over the world. If, therefore, the hidden cause of a disease, which is admitted on all hands not to be contagious, can pervade many thousand square miles, as intermittent fever did, during the year 1819-20, in the district of India to which I have referred, we may wonder at, but have no right to deny the possibility of, such a disease as Cholera extending itself by means equally inscrutable. If we could point out the source of nervous energy, we might (on the explanatory hypothesis which I have attempted) hope to become acquainted with the remote cause of Cholera. But, in the present state of our information, it is much easier to prove what does not give rise to the disease, than to form any plausible conjecture as to its true source. There can be no serious doubt, however, that a disease similar to Cholera has been known in Asia from time immemorial. Bontius, upwards of two centuries ago, in treating of " Cholera Morbus," describes very correctly the prevailing disorder. " This disease," he says, ** is attended with a weak pulse 5 difficult respiration, and coldness of the extreme parts ; to which are joined great internal heat, insatiable thirst, perpetual retching, and restless and incessant tossing of the body. If, together with these symptoms, a cold and foetid sweat should break forth, it is certain that death is at hand." There is also frequent mention of what was undoubtedly this disease, by the medical officers of the East India Company's Service, in the latter portion of the last century ; and, in 1775, it seems to have assumed the character of an epidemic in India, 64 ItEMOTE CAUSE OF THE DISEASE. and to have extended itself to the Island of Mauritius. Hence we may almost conclude, that the tremendous pestilences which are so frequently mentioned by native historians, as having desolated Indian armies, were frequently no other than the modern epidemic or malignant Cholera. Nor does the disease appear to have been confined to India. Dr J. Johnson, in his Diseases of Tropical Climates, publishes a letter from Mr J. B. Shepherd, who met with a disease in the Brazils, which he calls Wlort de chien (fancifully corrupted from the Hindoo name of the disease, Mor deooim), which, from the success of bloodletting in the treatment of it, I have little doubt must have been Cholera Asphyxia ; and I think it by no means improbable that the English " sweating sickness" partook of the character of this epidemic. I have also very high authority for believing that a disease very like the Indian Cholera prevailed at the Havanah in the year 1810 # : and still more recently, in 1829, several cases resembling Cholera Asphyxia, in its most malignant form,' made their appearance in a public school at Clapham. On this subject I may refer to Mr Secretary Scott's able digest of what the Medical Board at Madras knew concerning Cholera prior to 1817f ; from all which it is evident that this disease was not unknown * The authority to which I refer here is that of Admiral Fle- ming, who informs me, that in 1810, on his arrival at the Havan- nah, some of the crew of his ship suffered from a disease strongly- resembling the disease now travelling through Europe. The dis- ease was at that time prevalent in the Island of Cuba ; and was called Pasma. The remedies were, warm-bath, antispasmodics, and bleeding. t Report on Epidemic Cholera, as it appeared at the Presi- dency of Fort St George. 65 REMOTE CAUSE OF THE DISEASE. before its appearance as an epidemic in 1817 ; although its appalling mortality at that time, and rapidly extended ravages, forced it on public attention with a character of novelty which led to the general belief that it was a new and unheard of disease ; and this opinion has been fostered and circulated by European writers who have not sufficiently attended to the evidence on the other side. Whether, in the more recent and wider spread of the disease over countries differing from each other so completely in climate, temperature, habits, and all the other predisposing or counteracting causes of an ordinary epidemic, it may not be guided by some element with the nature of which we are as yet unacquainted, is a speculation into which I have already said I will not enter. All that I would venture to suggest is, that possibly galvanism may present phenomena which might aid us in our inquiries into the remote cause of the disease. Ritter found that while positive electricity seemed to augment the vital powers, negative electricity diminished them ; the former increased the pulse, the latter lowered it ; the former caused the sensation of heat, the latter of cold. We again have seen that the distinctive character of Cholera Asphyxia is the sudden deprivation of the nervous energy of the sympathetic system ; and all the length to which I go is to suppose it not impossible that the source of the disease may be found in some sudden change of the electric or galvanic condition of the surface of the earth. I say this, however, with no intention of supporting the hypothesis that galvanism is identical with nervous energy ; but unquestionably that agent is so intimately connected with every portion of the creation, that any sudden withdrawal of it E 66 REMOTE CAUSE OF THE DISEASE. from the animal system might not improbably produce such a disease as Cholera ; — a conjecture which receives some countenance from the very extraordinary effects which thunder-storms are reported to have had on many occasions on the progress of this disease in India*. * A remarkable instance of the sudden cessation of Cholera after a thunder-storm is said to have occurred at Jassy. One of the most accurate observers of the peculiarities of the disease, also says, " several instances have been known of its (the Cholera) having suddenly ceased on the occurrence of a thunder-storm." And, in a foot-note, he adds, " I witnessed a remarkable instance of this at Kulladghee in 1824. After the disease had prevailed for several weeks in the troop of horse artillery, there was a vio- lent thunder-storm ; after which not a single case occurred." — Dr T. Christie's Observations on Cholera, pp. 97> 98. It is a circumstance calculated so far to give support to the theory which ascribes Cholera to some terrestrial influence, that, in In- dia, the lower animals, such as cattle, monkeys, and poultry, suf- fered from the disease ; and, if newspaper reports are to be cre- dited, a similar phenomenon has been observed in some of the European continental towns; and in Hamburgh in particular, it is said that the Jisk also in the rivers were affected. The latter circumstance is very remarkable, and, if well-founded, may lead to some interesting speculations. Some speculators on Cholera have also observed that, in India, mounted troops, as being farther removed from the earth's surface, suffered less from the disease than infantry ; while a distinguish- ed physician in this country has ascribed this immunity to the circumstance of the cavalry being generally picked men. See a review of several works on Cholera, in the Edinburgh Medical and Surgical Journal, for December 1831. My own opinion is, that there are not facts sufficient to support either hypothesis j for, Ist, The mounted troops in India, in proportion to their numbers, suffered as severely, or nearly so, as the infantry, as will be seen from the reports of the different presidencies, and also from Dr Turnbull Christie's work on Cholera ; many of his cases being taken from the horse artillery corps which was under his medical charge. 2dly, The native cavalry in the Company's 67 REMOTE CAUSE OF THE DISEASE. After all, however, the result at which we arrive is, that we know absolutely nothing of the remote cause of Cholera. This is the conclusion to which all practical writers have come ; and although the phenomena to which I have just alluded, and others in the history of the disease, may no doubt lead to much curious and interesting speculation, it is of infinitely greater consequence, in the present state of our knowledge, to confine ourselves to the practical questions which the actual presence of the disease suggests ; one of the most important of which is that which forms the subject of the following section. service are not, properly speaking, picked men; and, besides, whatever the troopers may be, it is well known that, in India, a cavalry regiment is always attended by a greater number of dis- mounted camp followers and native servants than an infantry re- giment ; all of whom are included in the returns made by the medical man in charge of the corps. ?>dly, Even were it true that mounted troops were not so liable to the disease as pedes- trians, I should be inclined to attribute their exemption to the circumstance of their being less exposed than infantry are, to fa- tigue and the other discomfits of an Indian march. In connexion with the remote cause of Cholera, I may mention that my friend Dr Meikle of Edinburgh,, who saw much of the disease in India, and who himself suffered no fewer than five at- tacks of it, is subject to a very peculiar sensation when exposed to the hidden source of the disease, which enabled him repeat- edly in India to announce its approach before any actual case had occurred. The sensation, as he describes it, is that of numbness in the fingers ; and it is singular that, the other day, in Hadding- ton, he had again the same feeling. 68 SECTION IV. ON THE COMM UN IC ABILITY OF CHOLERA ASPHYXIA, BY MEANS OF CONTAGION OR INFECTION. This disease is generally supposed to have commenced in 1817, at Jessore, a town within the Delta of the Ganges : but this is not the fact ; and it is important that it should be known, because much of the European speculation, on the subject of contagion, rests on that assumption. The Heport of the Medical Board of Bengal, on the Epidemic Cholera, puts this matter beyond dispute, and proves that the disease, instead of spreading from Jessore as a centre, broke out in Bengal Proper, in several places, many miles distant from each other, nearly about the same time ; and, consequently, that whether the disease be contagious or not, the conclusions which have been so confidently deduced from the localities of Jessore, and the habits of the natives of that place, must be laid out of view in determining that controversy. The question, as already remarked, is one of very high importance, whether we confine our view to the disease itself, and the means of arresting its progress, or look to the subject as involving the commercial relations of the country to an extent almost incalculable. It is, therefore, much to be regretted, that most of the writers who have taken part in the argument have yielded much too readily to their prejudices or preconceived 69 CONTAGION. opinions. They have not approached the inquiry with that caution which becomes persons, many of whom are very imperfectly informed as to the facts on which their reasoning is founded ; and almost all of whom are speculating on a disease, with the habits and peculiarities of which they have had little or no practical acquaintance. At the same time they reject at once, and without scruple, the testimony and the conclusions of a large and intelligent class of professional men, who arrogate no superior knowledge as to the hidden sources of this extraordinary disease ; but who, upon the particular question of contagion, have had opportunities of forming a delicate opinion, which has been somewhat rashly set at nought by a crowd of authors, both professional and unprofessional, who have committed themselves eagerly and conclusively on that question. It is not improbable that some of those gentlemen may, ere long, see reason to modify their opinions ; and, at any rate, the weight of their authority would not have been lessened, had they expressed themselves with less confidence on a point which, to say the least of it, is not yet determined. I am far from supposing myself exempt from bias or prejudice. But although my acquaintance with the disease in India has led me to the conclusion, that it is not contagious in the sense in which that term is used by European writers ; and although I will not presume to say, that in Europe changes may not have taken place in the nature of the disease, sufficient to render it, to a certain extent, communicable by one person to another ; I must on the other hand declare, that while I have seen no evidence that the disease was contagious in India, nothing has hitherto 70 CONTAGION. occurred in its progress through Europe, which may not, in my humble apprehension, be explained, without admitting it to be communicable in that manner: Under this impression I have spared no pains in my attempts to trace and to illustrate the progress of the disease on the Maps, which form part of this Work. Every thing likely to contribute to the dissemination of correct information is of vast importance ; and the following details, founded chiefly on the public records of the disease, or on my own personal experience, will not, I hope, be deemed uninteresting or trivial, at a time when so much injury has been done by the publication of theories and speculations, in which these historical facts are either entirely overlooked, or much misrepresented. Many of the writers on this subject, indeed, seem to me more eager to advocate and support particular opinions, than to engage in a dispassionate and impartial inquiry concerning a matter in which the community has so deep an interest*. * One of the most influential examples of hasty and partial generalization which 1 have met with on this subject, is to be found in an article in No. XCI. of the Quarterly Review. No- thing can be more specious than the argument in that article ; but, on reference to the details which I have given in the text, I think it will appear that the reviewer, like many other Euro- pean writers who have taken part in the same controversy, has been misled by erroneous information, particularly as regards the progress and spread of the disease in Asia. The facts, as he has arranged them, undoubtedly harmonize exceedingly well with the theory of contagion ; and a similar classification of facts may be made, with at least equal plausibility, in support of the opposite theory. Instead, however, of following that course, and, like other controversialists, passing over the facts of an opposite ten- dency, I have preferred a simple historical detail of the progress of the disease, leaving it to the contagionists to account for cer- tain well authenticated anomalies, which appear to me irrecon- cileable with their theory. 71 CONTAGION. According to the most authentic information which we have on this subject, Epidemic Cholera first appeared on the hanks of the river Barumpooter, at Mymensing, in Lat. 24° 40', and Long. 90° 15' E., in the end of May 1817, and during June and July of that year it prevailed over the whole of that district. On the 11th of July 1817, it broke out at Patna, in Lat. 25° 37", and Long. 85° 15", distant upwards of 300 miles from Mymensing. In the course of August 1817 it appeared at Calcutta, and on the 17th of that month we find it at Silbet, 325 miles north-east of Calcutta. On the 19th of August 1817 it broke out at Jessore, and by the middle of September it had extended over six degrees of latitude and eight degrees of longitude. .In six weeks more it was found to have stretched westward six additional degrees of longitude ; for by the beginning of November 1817 it had reached the river Sinde, in 25° Lat. and 78° Long. The yellow portion of the accompanying Map shows very nearly the extent to which the disease had spread during these seven months. During the next four months the disease did not extend itself; but on the 27th March 1818, it began to move to the north, west, and south, by regular stages at the rate of about two miles a-day, — stepping on from station to station, and apparently arriving at no place prematurely, or out of the regular progress. The dates on the accompanying Map exhibit this striking feature of the disease. Thus, take the centre of the space over which the disease so rapidly extended itself in the autumn of 1817, and let a circle be described from that centre, embracing any of the stations at which the disease broke out ; and its simultaneous 72 CONTAGION. appearance at all the points equidistant from this central point will be found very remarkable. Vizagapatam, on the coast, due south from the point which I have selected ; Nagpoor, south-west from the same point ; and Etawah, on the north-west, are each of them about seven and a half degrees distant from the centre point, and the disease will be found to have reached all of those places very nearly on the same day, viz. about the middle of May 1817. Take then a set of more distant stations. Thus Musalapatam, on the coast, to the south ; Hydrabad, in the interior, to the south-west ; Jaulnah, on the west ; and Delhi, on the north-west, are each of them about nine geographical degrees distant from the same centre point ; and it will be seen that the disease appeared at all of those places between the 10th and 25th of July 1817. The dates in this Map are taken from the Bengal Report on Cholera. Although the regularity of the progress of the disease to the north-west and west, is a matter as to which there is now unfortunately no doubt, the peculiarity becomes the more remarkable, from the time at which it reached the peninsula of India on its way to the south. Thus, it appeared at Ongole on the 14th of August 1818, in North Lat. 15° 30', and Long. 8° East ; and at Dharwar 15° 25' North Lat. and 75° of East Long, on the 13th of the same month (August). It appeared in Soonda, in 14° 50' N. and 74° E., in the beginning of September ; at Hurryhur in 14° 30' ~N. and 76° E., on the 12th September ; and at Nellore, 14° 20' N. and 80° 25' E. on the 20th September. It appeared at Madras, 13° 5' N. and 80° 25' E., on the Bth October ; and at Bangalore, which is 3000 73 CONTAGION. feet above the level of Madras, in Lat. 12° 5T N. and 77° 46' East, on the 22d of October. And as we approach Cape Comorin, on the extreme south point of India, we find it coming down one coast almost stage for stage with its progress on the other side *. We thus find the disease travelling from north to south, with unaccountable regularity ; appearing in the line of 20° of northern latitude in the beginning of 1818, and reaching 8° north latitude on the Ist of January 1819 ; holding its course, seemingly uninterrupted by winds, seasons, or climate ; appearing at Dharwar, in the interior, on the 1 3th of August, in the height of the rains, when the thermometer seldom rises above 75° of Fahrenheit in the hottest part of the day ; and at Ongole, on the coast, in the same latitude, but distant 5° of longitude, in the dry season, when the thermometer varies from 95° to 105°, within a few hours of the time at which it broke out at Dharwar. In the progress just referred to, far from being assisted by winds, the disease must have frequently travelled in direct opposition to their currents, and seems never to have been retarded or advanced by their direction. Though the general progress of the epidemic was thus regular from north to south, the disease did not appear regularly at every town in its course. It often seemed to pass over particular stations, breaking out at distant points to the south of them, and, perhaps after three weeks or a month, it would return on the place which had thus apparently escaped the scourge. The course of the disease through individual districts in India, was often, indeed, very eccentric. It * Vide Map affixed to Madras Report, and the Report. 74 CONTAGION. frequently happened, that, instead of advancing directly to populous places by the principal and most frequented roads, it would " take a complete circuit round the village, and, leaving it untouched, pass on as if it were about wholly to depart from the district, then, after a lapse of weeks, or even months, it would suddenly return, and, scarcely reappearing in the parts which had already undergone its ravages, would nearly depopulate the spot that had so lately congratulated itself on its escape *." Or, it would sometimes nearly depopulate small villages in the neighbourhood of a principal station, before it made its appearance there. Thus, during a period of upwards of five years, from 1819 to 1824, while I had medical charge of the civil and political establishment in the southern Mahratta provinces, Cholera, in an epidemic form, appeared annually in that district in the months of April, May, and June. The town of Dharwar is the principal civil station in these provinces, and, during a great part of the time referred to, I was also in medical charge of the garrison of Dharwar, yet the disease appeared in that town in the years 1820 and 1821 only. In the latter of these years, as stated in my official report, the disease had " prevailed for the last two weeks in several surrounding villages of from six to twelve miles distant, and has in some of them swept off many of the inhabitants," being thus, for many days, within sight of the capital of the district before it reached it. In 1824, although the disease again prevailed in the immediate neighbourhood, it did not appear at all either in the town, or jail of Dharwar, although no attempt to impose any restraint on the intercourse * Bombay Report, p. 6. 75 CONTAGION. with the villages in which the disease prevailed, was ever thought of. This peculiarity in the habits of the disease was still more strikingly illustrated on its first breaking out in the neighbourhood of Benares, the Brahminical metropolis, the facts connected with which, I shall immediately have occasion to refer to. A still more striking peculiarity in the history of the disease is, that when it made its appearance in a camp or city, instead of extending to every habitation, it was almost invariably confined to particular portions of even the most populous places. Sometimes, in an army for instance, one or two regiments encamped together, or separated by other corps, were the only sufferers in an attack of the epidemic. One division, or even one street only of a town, was sometimes the seat of the disease, — nay, its prevalence has been known to be limited to one side of a market-place, and, notwithstanding the most uninterrupted communication, the ravages of the disease would be for a time confined to these particular spots. What is still more remarkable, troops, carrying their sick along with them, could leave the source of the disease behind them ; an entire and immediate stop having been frequently put to its ravages by removing a camp a few miles *. So also it frequently happened, * This did not occur in single regiments only. The Marquis of Hastings, in 1817, moved ground with an army of nearly 100,000 men, including camp-followers, when the Cholera was at its height, — when tf all business had given way to solicitude for the suffering. Not a smile could be discerned, nor a sound heard, except the groans of the dying, and the wailing over the dead." — " It was clear that such a frightful state of things could not last long. It was therefore wisely determined by the Commander- in-chief, to move in search of a healthier soil and purer air." — 76 CONTAGIOX. that, when Cholera prevailed destructively in a village, the inhabitants got rid of it by deserting their houses for a time, although, in doing so, they necessarily exposed themselves to many discomforts, which we should be inclined to consider exciting causes of an infectious or contagious malady. On the other hand, however, the disease has been said to accompany troops in marching into a district where it had not previously prevailed, and into which it has been thus introduced. This is a fact so much at variance with the well ascertained habits of the disease, that, without contradicting it, I should not be inclined to admit it without a minute inquiry and unquestionable evidence. We have just seen that an army, by shifting its ground, has put an entire stop to the ravages of the disease ; and yet it is said that a detachment of troops have not only carried it with them for ten or twenty marches, but have communicated it to healthy persons at that distance. But this is not all ; for this very question has been largely Bengal Report, pp. 14, 15. The army moved upon the 13th November 1817, and after marching between forty and fifty miles, halted on the 19th. The description of the march is most ap- palling : " The road was strewed with the dead and the dying ; the ground of encampment and line of march presented the ap- pearance of a field of battle, and of the track of an army retreat- ing under every circumstance of discomfiture and distress." — Ibid. p. 17- " The army on the high and dry banks of the Bet- wah at Erich, soon got rid of the pestilence and met with re- turning health." The disease ceased to be epidemic on the 22d or 23d, so that this crowded camp, carrying thousands of sick along with it, by moving forty miles, and in less than ten days, shook off this disease, which some of the recent writers on con- tagion represent as having been carried from Nagpoor to Jaulnah, nearly 300 miles, by a small force ; and from Ceylon to the Isle of France, about 2000 miles, by a British frigate. 77 CONTAGION. discussed in the Bengal Report, and, amongst many others, the following remarkable instance to the contrary is given. " There is yet a still stronger instance " (the reporter observes) of a diseased body (of troops) " joining a healthy one, without thereby communicat" ing the infection to it. On the morning of the 11th " of May 1818, a detachment of ninety men, of the " Ist battalion 26th native infantry, marched from an " inferior post to join the main body of troops then " encamped at Sangor. After an ordinary march, it " halted in perfect health half way, under shelter of " a few trees on the banks of a small lake, situated in " the midst of an open space about three miles in cir" cuit, and surrounded by low woody hills. The whole " remained well until the fall of night, when Cholera " broke out amongst them. The first man was taken " ill at midnight, and died in half an hour. Several " others fell sick within the next few hours, and before '-* sunrise twenty out of the ninety were overtaken by " the disease. Although the Sangor camp was distant " only five or six miles, the detachment was too weak " to move without assistance. The sick of the Sepoys " and followers were, therefore, carried on in carts and " doolies sent from the main body; but before 11a.m. " when they got to their ground, five were already dead, " and two others moribund. Next morning a man of " the same party was seized in the act of scouring his " accoutrements, immediately became insensible, and " expired in a few minutes. During the three succeed" ing days, several others were taken ill, and before the " end of the week, of the whole detachment there was " not a single man but was sent to the hospital labour" ing under Cholera, or other modifications of bowel " complaints. The men of this party mixed promis" 78 CONTAGION. cuously with those of the Sa?igor troop, and yet, " of the latter, not one individual got the disease" —Bengal Report, p. 132-3-4. Similar instances are innumerable ; and, in my apprehension, the apparent exceptions, to what may be called the general rule, may be otherwise accounted for. When travelling on circuit, I have found the disease prevailing in a district before any report had been made of the fact, notwithstanding the most positive orders on the subject ; and lam persuaded, that, were the instances adduced in support of the statement now under consideration strictly inquired, into, it would be found that, instead of the troops carrying the disease along with them, the usual apathy of the natives of India had prevented its existence from being noticed, until the fact was brought prominently forward by the presence of Europeans. My own experience, if 1 may be permitted to mention it, presents a very extraordinary example of the general habits of the disease, so adverse to the notion of its being carried forward by troops, that I shall here abridge a portion of the journal of a march which I made in India. In July 1819 I marched from Madras in medical charge of a large party of young officers who had just arrived in India, and who were on their way to join regiments in the interior. There was also a detachment of Sepoys, and the usual numerous and miscellaneous attendants and camp-followers of such a party in India. Cholera prevailed at Madras when we left it. Until the fifth day's march (50 miles from Madras), no cases of the disease occurred. On that day several of the party were attacked on the line of march, and, during the next three stages, we continued to have additional cases. Cholera prevailed in 79 CONTAGION. the countries through which we were passing. In consultation with the commanding officer of the detachment, it was determined that we should endeavour to leave the disease behind us ; and, as we were informed that the country beyond the Ghauts was free of it, we marched without a halt until we reached the high table-land of Mysore. The consequence was, that we left the disease at Vellore, eighty-seven miles from Madras, and had not a case of it until we had marched seventy miles farther (seven stages), when we were informed that it prevailed at one of our appointed places of encampment. Our camp was, in consequence, pushed on a few miles, and only one case, a fatal one, occurred in the detachment. The man was attacked on the line of march. We again left the disease, and were free of it during the next 115 miles of travelling. We then entered a tainted district, and found many of the villages deserted by the inhabitants, who had fled in search of healthier ground. Here we had cases of the disease occurring for three stages. We once more got beyond its limits, and reached our journey's end, 260 miles farther on, without having a case. Thus, in a journey of 560 miles, this small detachment was exposed to, and left the disease behind it, four different times, and on none of those occasions did a single case occur after we had left the tainted districts. I have known the disease to prevail for several w T eeks at a village in the southern Mahratta country, within a few miles of the principal station in the district, and then leave that division of the country entirely ; or, perhaps, cases would occur at some distant point. In travelling in circuit with the Judge of that district, 1 have found the disease prevailing destruc- 5 80 CONTAGION. tively in a small and secluded village, while no cases were reported from any other part of the district. It happened oftener than once, when the disease attacked the battalion under my charge at Dharwar, in the southern Mahratta country, that it was confined to one particular subdivision of the lines of the regiment, from which only cases were brought into hospital during that particular round of the disease ; and a similar phenomenon took place in the town of Dharwar, certain streets only suffering from the disease at one time. Other instances of still a more limited prevalence of the disease occurred at particular places ; for example, in a camp, only one tent would appear to have been within the sphere of the remote cause of the disease, and almost every person who had slept in that tent would be attacked in the course of one night. An instance occurred to a friend of mine, in which the disease seemed to be caught in a very remarkable manner. The division of the army to which this gentleman was attached, had suffered severely from Cholera. One evening, when the disease appeared to have subsided, he, in a stroll with a friend, met a lady of their acquaintance on horseback, who stopped and conversed with them, and in the course of that night each of these individuals was attacked with Cholera. The great practical question suggested by these peculiarities in the history and progress of Cholera is that of contagion ; and in order that there may be no misunderstanding about terms, I think it proper to premise, that, by contagion, I mean that unknown quality in a disease whereby it is capable of being communicated from man to man without the presence of its original source. And if it be ascertained that, r> 81 CONTAGION. in this sense, Cholera is contagious, and still more if there be any foundation for the notion that contagion is the sole cause of the dissemination of this pestilence, neither individual risk, nor the sacrifice of a whole town or district, ought to prevent the shutting up of the disease in any place into which, by misfortune or negligence, it has been imported. If, on the other hand, the disease be non-contagious, or if something more than mere contact or communication be necessary in order to bring the virus into operation, no one can seriously doubt that rigorous quarantine regulations and sanitary cordons are worse than useless. The supporters of contagion in Cholera have invariably taken it for granted, that the disease commenced at Jessore, about seventy miles to the northeast of Calcutta ; and they trace it to the local unhealthiness of Jessore, and to the poverty and fish diet of the inhabitants. But we have seen that the disease truly did not commence at Jessore. No doubt when it broke out at that place, the poverty of the inhabitants, and the unhealthiness of the town, rendered it so fatal as to bring its existence prominently before the public, and thus led to the belief that it had been generated in this town, and carried by contagion from it as a centre. There is, however, no foundation for this hypothesis. On the contrary, the disease had commenced six weeks before, at the places already mentioned ; and it is not a little remarkable, that, on its first appearance in the summer of 1817, it broke out simultaneously at several places in the Bengal territory, at the distance of many hundred miles from each other, whereas, ever since, its march has been progressive; and, since 1817, I know of no instance on land in which the disease has made its F 82 CONTAGION. appearance at two points, at the distance of 800 miles from each other, without' occurring at any of the intervening stations. I am quite aware that this is a fact which may be adduced as proving the disease to be contagious, since it may be said that it is by contagion that it is carried forward in the particular direction in which it seems to be moving. But, on the other hand, it must be remembered, that it is not by great lines of road or other thoroughfares only, that the disease proceeds. Of course, where there are no inhabitants there can be no victims to the disease ; but again and again, in India, it has arrived in the course of its extraordinary progress at a town or village, without a trace of contact or communication with any place or person affected with the disease. Besides, a contagious disease never moves with the steady and undeviating progress so remarkable in Cholera. Its course is more erratic; and hence, if Cholera had been communicable by contagion alone, it must have been carried, times without number, by regiments on their march from infected to healthy quarters, whereas, it is matter of notoriety, that the very reverse has been the fact ; and that regiments, instead of propelling the disease in the line of their march, have at once suspended its ravages by changing their ground; the most remarkable instance of which is the well-known movement, just alluded to, of the grand army under the Marquis of Hastings, in the year 1817, whereby the most appalling mortality was arrested as if by a miracle *. These are * As an example of the rashness with which statements con- cerning the contagious character of the disease in India are made, I may refer to the article in the Quarterly Review just cited. In that article, it is said that the British army carried Cholera into 83 CONTAGION. facts which can neither be explained away nor dis~ puted. They are matter of public record, and the subject of reports by the most distinguished medical men in India ; and so far at least as regards Indian experience, nothing surely can be more unreasonable than the conduct of those medical writers and journalists in England, who, without the slightest practical acquaintance with the disease, set their own impressions and speculations against the authority of almost the whole medical profession in India, or at least of very nearly all the members of that profession who have had sufficient opportunities of making themselves acquainted with the habits of this disease *. The progress of this disease from town to town, and from country to country, has been very extraordinary. It has extended itself over countries differing entirely from each other in climate and in geographical position ; and it appears to have been little if at all affected by climate or temperature. Hence, it has been very naturally said, that a disease which has thus spread, must have been propagated by contagion ; and the conclusion would be a legitimate one, the Burman empire in 1823 ; whereas, it is an historical fact, that the army found the disease prevailing among the Burmese. * It is said, in a recent Number of the Foreign Quarterly- Review (Oct. 1831), that the majority of Indian practitioners are contagionists. This is so notoriously contrary to the fact, that the talented writer of the article to which I allude must have proceeded on erroneous information. The reports of the Medical Boards of Bengal and Madras are conclusive upon this subject ; and with the exception of one or two young men who had seen little or nothing of the disease, I have never met with an In- dian practitioner who believed Cholera to be contagious in that country. F2 84 CONTAGION. had Cholera advanced more rapidly on great thoroughfares, or along the sea-coast, where unrestricted intercourse prevailed, than in the interior of the country, where little or no communication existed ; but instead of having been there propelled in one direction, and retarded in another, the disease was found in India to travel with an equal pace over the whole country, extending in its course south over eight or ten degrees of longitude, and reaching the least frequented spots and most secluded villages no less than the most populous districts *. Much stress has been laid by writers on this subject, on the fact that Cholera has travelled along the banks of rivers. Undoubtedly it has done so ; but in so far as regards India, the writers who rely so confidently on this fact, have not adverted to the peculiarity, that the progress of the disease along the banks of rivers, has not been confined, as they seem to suppose, to navigable rivers. It has extended itself * I am aware it has been supposed, that the disease adhered to thoroughfares, and was only found in great cities. In answer to this, I may refer to the Reports of the Indian Boards, which conclusively negative that supposition. Besides, it must be borne in mind, that even these reports are prepared by Europeans, who are seldom, and only accidentally, in unfrequented towns and villages in India. But I ask, under correction of every man who has been in India, whether it has not again and again hap- pened that parties of officers and their servants have been fatally attacked with Cholera, on hunting excursions in the interior of the country ? How common was it also, during the war, for de- tachments of troops to meet the disease in the most unfrequented places. On great thoroughfares, there will always be fatigue, exposure to climate, unwholesome food, and other predisposing causes, sufficient to account for the occurrence of the disease, when it is prevalent in the country, without having recourse to the agency of contagion. 85 CONTAGION. along the banks of rivers, whether navigable or not, for a reason which will at once be satisfactory to everyone acquainted with India, viz. that in India, as in other hot climates, the inhabitants are almost always to be found on the banks of rivers ; and in absence of inhabitants, the disease of course cannot manifest itself. Besides, it is a well-known peculiarity of the disease, that it is apt to attach itself to low lying places, such as the banks of rivers usually are. But on the banks of rivers in India, as elsewhere, it has not happened that the disease has outstripped its regular march # . Even on navigable rivers, where the most uninterrupted intercourse has prevailed, it may be safely said, that there has been no instance in which the progress of the disease has been accelerated by the small trading vessels which go from port to port, and which, if the disease could have been so communicated, must, in innumerable instances, have carried with them the supposed pestilential virus, which nevertheless remained innocuous in every place where it had not been preceded by the unknown and hitherto inscrutable primary cause of the disease. It may be said, that we are not to expect that a disease, which, like Cholera, at once arrests the wayfaring traveller, is to pursue its course rapidly on land. But this remark does not apply either to navigable rivers or to the sea-coast. Hence, had Cholera been transmissible merely by contagion, instead of reaching * In the article in the Quarterly Review to which I have alluded, the progress of the disease is said to have been accele- rated along the banks of navigable rivers, and on the sea-coasts ; but this statement is made in the face of the facts established by the Indian Reports, and shown on the maps accompanying this work, and other works on Cholera. 86 CONTAGION. the sea-port of Madras simultaneously with its appearance in parallel latitudes in the interior, it must have been carried from the tainted districts in the north to the seat of the Presidency, by some of the many trading vessels, which, free of all quarantine regulations, maintained a constant intercourse between the districts where the disease prevailed and the ports along the coast which it had not yet reached, and to which those coasting-vessels in no instance expedited its advances. The progress of Cholera down the peninsula of India, when it visited that country in 1818, is so instructive on this point, that I have obtained an abridgment of the map published by Mr Scott in his report already referred to. The authenticity of this piece of evidence is indisputable ; and, notwithstanding all that has been written on the subject of contagion, I have met with no successful attempt to account for this phenomenon. This map shews that Cholera, as an epidemic, was in 19° N. on the 10th March 1818; that it travelled regularly at the rate of about one degree of latitude a-month ; and that it reached Madras on the Bth October 1818, in 13° N. This was its progress during the dry season, and when there was no interference with the constant commercial intercourse which prevails on the Coromandel coast. On the 15th October annually the port of Madras is closed ; and in consequence of the prevailing winds, and of the surf which, during the next two months, breaks upon the whole of that open coast, every vessel is forced to leave it, and the small trading vessels are drawn high and dry on land. Yet, on looking to the annexed map, it will be seen, that this interruption of intercourse had no effect in retarding the pro- f> S6 87 CONTAGION. gress of the disease. It reached Cuddalore on the 14th November, Madura on the 30th of the same month, and Cape Comorin by the Ist of January 1819- The disease is said to have been transported in vessels from Palamcotta to Ceylon. It first appeared in Ceylon, in the middle of December 1818, at Jafnapatam, but only when it had reached the latitude of that place on the peninsula of India ; whereas it did not prevail at Palamcotta until January 1819- But, on the supposition that Cholera may be carried in this manner, it certainly is not a little remarkable that it should not have been brought from Calcutta fifteen months earlier, by some of the many trading vessels constantly passing between Calcutta and Trincomalee, in the island of Ceylon. Such incontrovertible facts as these, seem to justify the conclusion, that this disease is regulated by laws of its own, and that contagion, strictly so called, will not account for its spread. But those writers who have so zealously maintained that the disease is purely contagious, adduce two instances of its supposed communication in that manner, which they represent as conclusive. They say, in the first place, That the disease was carried from Ceylon to Port Louis, in the Isle of France, by the Topaze frigate ; and, secondly, That it was carried by country vessels from Bombay to Muscat, at the entrance of the Persian Gulf. It may be observed in the outset, that, if this disease be of the highly contagious and communicable character contended for, it is not a little extraordinary, that, at the end of fourteen years, no more than two instances are to be found of the supposed conveyance of the disease by sea ; while it is notorious, that, during all that time, there have been no quarantine regulations 88 CONTAGION. in India, and while it must be obvious, that, if the disease could have been so transported, it must long ere this time have been carried by regular stages, from the Isle of France, for example, to the Cape of Good Hope # , thence to St Helena, and so onward to Europe, by some of the thousands of vessels which must have brought with them the seeds of the sup 1 posed contagion ; more particularly if it be of that subtle and extraordinary nature described by Drs Russell and Barry, who, in one of their communications to Government, talk of the virus of Cholera having remained latent for thirty days in an individual, and in another represent it as inherent in the cordage or seams of a vessel, although none of the passengers have suffered from it — a refinement in the doctrine of contagion, and a sublimation of pestilential virus, which I believe to be wholly unexampled. But this is not the only answer to the two instances alluded to. The evidence, so far as regards the Topaze frigate, is of this nature. That vessel left Trincomalee in Ceylon on the 9th of October ] 81 9, while Cholera prevailed there, for the Mauritius, and reached Port Louis on the 29th of October 1819. When the Topaze arrived at Port Louis, the crew appear to have been very unhealthy, for on the day after the arrival of the frigate, several patients were sent on * In the Quarterly Review (above cited) it is said, that the Cape has been protected by the old Dutch quarantine laws ! Does the Reviewer really suppose that ships from India are sub- jected to any quarantine at the Cape? The health officer comes on board, and requires the usual assurance of the health of the crew; but this is a mere ceremony, and would be wholly unavailing to arrest Cholera, if that disease be transmissible, as the contagion- ists maintain, by goods, and by passengers who are not themselves labouring under the disease, and who never had it. 89 CONTAGION. shore, suffering under dysentery, inflammation of the liver, and other complaints. There was no case of Cholera ; but, on the forenoon of the day of the vessels arrival at Port Louis, one man on board was attacked with severe spasms and vomiting. Three weeks after the arrival of the vessel, Cholera began to spread in the town of Port Louis. Such is the substance of Mr Kennedy's statement in his work on Contagious Cholera. At the same time, however, he admits, that cases of Cholera had occurred at Port Louis early in September, nearly two months before the arrival of the Topaze. This admission appears to me perfectly fatal to the whole of his theory, so far as it is founded on the Topaze frigate ; but this is not all, for it is well known that a Medical Board was appointed to inquire whether there was sufficient evidence that the disease had been introduced by this vessel, and that Board reported on the 4th December 1819, that the disease had prevailed before the arrival of the Topaze: — " That the first case occurred so early as the 6th " September 1819 ; and that they feel the strongest "persuasion that it is not of a contagious nature ; " and that it is not of foreign introduction. In " these conclusions the French medical gentlemen " unajiimously concurred, and both considered the " disorder promoted, if not produced, by the great " and sudden vicissitudes in the temperature *." It is not therefore altogether fair, either in Mr Kennedy, or in Sir Gilbert Blanc and the other contagionists, who rest so much upon this instance, to represent it as an incontestible proof of the transmission * Asiatic Journal, December 1831, p. 328. 90 CONTAGION. of the disease in this manner. Nor will it do for two home-bred physicians, one of whom never saw a case of the disease, and the other of whom had no very extended Indian experience, to set their conjectures and hypotheses, at the distance of fourteen years, against a report drawn up at the time, and on the spot, and unanimously concurred in both by the English and French medical officers. In truth, the case of the Topaze frigate, so far from supporting Mr Kennedy's conclusion, manifestly disproves it, as far as negative evidence can disprove any thing. But Mr Kennedy says that seventeen cases of Cholera occurred on the passage of the Topaze from Ceylon to the Mauritius. The precise place where, and the time when, these cases occurred, are not mentioned by Dr Kennedy; but it appears from the journal of Mr James Foy, the surgeon of the ship, that these seventeen were attacked immediately after the ship sailed from Trincomalee, and while of course they were within the tainted limits. It is not stated that any other cases of Cholera occurred on the passage, and it is almost certain that none would occur, or if so, they must have occurred within a few hours of each other, while the vessel was passing through, as it were, a tainted current, beyond the limits of which there could be no new case. On this point, I can confidently appeal to every medical man who has witnessed the disease ; for, while it has been proved repeatedly that a change of ground will relieve a detachment of troops on land from the ravages of the disease, it has been equally well ascertained, that a vessel, after leaving a tainted port, or passing through a tainted current, enjoys a similar exemption. It appears to me, therefore, that the evidence afforded CONTAGION. 91 by the Topaze frigate refutes itself ; and, for that reason, I have been at no pains to find evidence on the other side. But having accidentally met my friend Captain Deare, I have great satisfaction in quoting the following letter from him, in which it will be found, that his conclusion is precisely that to which his profession generally have come on this subject. His letter is as follows : — " Edinburgh, %Bth November 1831. — My Dear Sir, In compliance with your request, I have much pleasure in stating to you such particulars as came under my personal observation in his Majesty's ship Liffey, and now suggest themselves to my recollection. In the month of October 1823, that ship was lying in the Madras Roads. The wind for several days previous to the disease making its appearance had been light, and generally off shore ; the evening on which the malady did break out being unusually close and oppressive. In the course of twenty-four hours nearly fifty men were in their beds, twelve of whom I think died. At the expiration of this time the ship was ordered to sea ; the disease up to the hour of our sailing evidently gaining ground. We accordingly stood out from the Roads for forty or fifty leagues, and returned to the anchorage in forty-eight hours with the malady completely checked, and all of our sick convalescent. The inference to be drawn from this, in my opinion, is, that the Cholera Morbus is not contagious, and that it is communicated entirely by unknown local causes. The crew of the Liffey consisted of between 300 and 400 men, and had the disease been contagious, instead of merely local, it must have spread through the whole or greater part of the ship's crew, in place of yielding as it did immediately 92 CONTAGION. to change of air. It is perhaps as well to mention, that the officers and men generally were in constant communication and contact with the sick, nor am I induced to suppose that the slightest danger was incurred thereby. I remain, &c. (Signed) Charles Deare." The truth is, that the case of the Topaze, as stated by Mr Kennedy, would be perfectly unique in the history of the disease. Cholera has now been spreading epidemically for upwards of fourteen years, during the whole of which time it has constantly prevailed in numerous sea-ports. Had it, therefore, been capable of taking a sea voyage of 2000 miles, and of being propagated by a vessel six weeks after it left the diseased port, the solitary instance of the Topaze would not have been the only one in the British navy to which the contagionists could have appealed ; and we should not have remained up to the present day without examples of new cases of the disease at our quarantine stations. The second instance of the supposed transmission of the disease by sea, referred to by Mr Kennedy and others, is that of Muscat, to which, he says, that the disease was carried from Bombay. Muscat is about 1000 miles of clear sea-way from Bombay, and between these two ports there is an uninterrupted and extensive commercial intercourse. The Cholera reached Bombay in its regular course, and at what, according to the rate of its progress, may be looked upon as its appointed time, on the 10th August 1818 ; and Bombay continued to suffer severely in the years 1819, 1820, and 1821. During all this time, the intercourse with Muscat remained uninterrupted ; and the disease did not break out there until 93 CONTAGION. June 1821. On reference to the map, it will be seen that the disease appeared at Muscat, just as it had previously done at Bombay, in the regular course of its progress over that part of the world. Mr Kennedy's argument, in short, proves too much ; for if nothing more be requisite in order to propagate the disease than intercourse between an infected and a healthy port, and if it be also true (as it undoubtedly is), that the intercourse between Bombay and Muscat was as constant and uninterrupted in the years 1818, 1819, and in 1820, as in 1821, Muscat ought to have suffered nearly three years earlier than it did. If, indeed, a well-aired and well-cleaned British frigate carried the disease, and in three weeks, from Ceylon to the Mauritius, a distance of 2000 miles, it is incredible that three years should have been required to transport the same disease from Bombay to Muscat, between which two ports the intercourse is carried on by filthy Arab trading vessels, crowded with passengers of every description. In short, it must be obvious to every dispassionate inquirer, that the attempt to prove contagion by instances such as these is desperate. Had the disease been truly contagious in the East, the last fourteen years would have afforded thousands of instances ; and, as happens in other contagious diseases, the populace would have been familiar with the fact, and would have rejected any attempt on the part of medical speculators to satisfy them that the disease was not so communicable. But the contrary has happened ; and, in India, the natives, learned and unlearned, concurred with the medical profession, generally speaking, in regarding the disease as non-contagious. This is a fact of more value in the present argument, than all that 94 CONTAGION. the European contagionists have written or can write ; and, therefore, leaving the Indian question on the basis on which experience has placed it, let us next inquire whether there be any evidence that the character of the disease, as regards contagion, has been altered in the Temperate Zone. The points for inquiry here are similar to those which have been already considered, viz. first, the mode of progression of the disease on the great scale, and its habits where it has broken out ; and, secondly, the question as to whether or not there has been sufficient evidence advanced to support the theory of contagion. The most remarkable feature connected with the entry of the disease into Europe, is the length of time during which it seemed to hover on the frontiers. Thus the disease, approaching Europe apparently in a direct course, passed on from India to Persia, thence to Asiatic Turkey, and from Asiatic Turkey across the Caucasus to Astracan, which it reached in September 1823, — creeping on, as it had done in India, from country to country, at a pace so regulated, that, had no cause of detention occurred, it ought to have reached the western parts of Europe by the year 1825. Instead, however, of forcing its way into Russia in the winter of 1823, it did not reach the Don or the Wolga until the autumn of 1830. This is unquestionably a very remarkable circumstance, but such pauses are not new in the history of the disease. In Bengal it occasionally made halts, although not for years, yet for several months, which were equally unaccountable. For example, it is a well known fact, that it stopped in the neighbourhood of Benares, the Mecca of the Hindoos, soon after its first breaking out in India in 1817. At that time 2 95 CONTAGION. the alarm occasioned by its appearance and appalling mortality, excited a panic among the natives of India, who looked upon it as an immediate judgment from Heaven. It prevailed within a few miles of Benares, which, as being the holy city of the Hindoos, was inundated by crowds from all quarters, hastening to deprecate the wrath of Heaven by vows and sacrifices. Benares, as is well known, contains a population exceeding half a million. The site of the city is reckoned holy, but the holy precincts are of a very limited extent ; and in order to have the benefit of a residence within the sacred territory, the houses are piled upon each other in successive storeys, something in the style of the old town of Edinburgh. " The streets are so " extremely narrow, that it is difficult to penetrate them " even on horseback. The houses are built of stone, " some six storeys high, close to each other, with ex" tremely small windows to keep them cool," (to keep out the glare, and hot winds), " and prevent inspection. " The opposite sides of the streets, in some places, ap" proach so near each other as to be united by galleries. " The number of stone and brick houses from one to " six storeys high is upwards of 12,000, the mud houses " above 16,000 ; and, in 1823, the permanent inhabi" tants by enumeration exceeded 582,000. During the " festivals, the concourse is beyond all calculation *." Here, then, it may be said, was a city marked out almost for extermination by a contagious disease. In August and September 1817, it prevailed, as will be seen from the map, within a short distance of this city. The inhabitants of the tainted neighbourhood hastened in thousands into Benares; and strange, * Vide Hamilton's Gazetteer, voce Benares. 96 CONTAGION. and, on the theory of contagion, wholly unaccountahle, as it may appear, this city was not visited by the pestilence until eight months after it had come almost up to its gates. The Cholera was at Gazypore, Euxar, &c. in September 1817, yet it did not prevail at Benares until May 1818. It made one of its extraordinary and capricious halts in the immediate vicinity, and for the time, the inhabitants, who had never thought either of contagion or of sanitary cordons, entirely escaped. By some cause equally unaccountable, the epidemic was stayed for seven years on the confines of Russia and Turkey. The contagionists say that it was thus retarded by the Russian quarantine regulations. It is not pretended, however, that, during this interval, cases of the disease occurred at the quarantine stations, or that it came close up to the sanitary cordons which arrested its progress. Besides, even were it admitted that the Russian regulations stopped the progress of the disease, how came it not to advance into European Turkey ? We hear of no Turkish quarantine restrictions. The truth is, that no means, either restrictive or permissive, with which we are acquainted, will explain these anomalies. The disease did not pass into Turkey in 1824, although the road was open ; and since the autumn of 1830 it has pursued an undeviating course westward, in utter defiance of quarantine regulations and sanitary cordons, and every other means which the most vigilant and despotic sanitary police could devise. The disease entered Russia in a northerly course in the beginning of autumn 1880, and it reached Moscow in the course of two months, or little more ; prevailing over a large extent of territory during the l 97 CONTAGION. whole of the latter part of autumn 1830. The Russian winter seemed to have some effect on it ; for it did not proceed actively until the spring of 1831 # . It then began to advance on an extensive line, reaching Riga in May, St Petersburgh in June, in its north-westerly course, — and in its westerly course arriving at Warsaw in April. It appeared in Dantzic, Lemberg, and Brody, in May — Jassy in June — Pesth and Bucharest in July — Berlin and Vienna in Septembe — Hamburgh in the end of September — and Sunderland in the end of October. Compare this progress with what has been exhibited of the habits of the disease in India, and observe the result. The want of quarantine regulations, and the disbelief in contagion by the natives, and by the medical men in India, occasioned, as we are told, the spread of the disease in that quarter of the world. Admitting for a moment the justice of this implied censure on the British Government in India, How has the fact turned out in Europe? There, surely, it cannot be said that there has been any want of quarantine regulations and of sanitary cordons. On the contrary, these regulations have been most rigorously enforced, both by land and sea ; and yet a disease which, in absence of quarantine regulations, took thirteen years to reach Europe, has, within little more than twelve months, traversed the north of Europe, * A recent writer, of high professional attainments, ascribes this pause to non-intercourse ; assuming that, in Russia, the in- ternal communication is interrupted. This, however, is a mis- take. During the winter, the intercourse in the chief Russian thoroughfares is not only uninterrupted, but expedited by the Russian mode of winter-travelling. — See the Edinburgh Medical and Surgical Journal for December 1831. G 98 CONTAGION. and arrived in Britain, in defiance of such regulations, and with a progress similar in every respect to that by which it was characterized in the East. If this be not demonstration, at all events, it ought to be sufficient to beget some little distrust in the minds of those controversialists, who persist in applying rules founded on their acquaintance with the habits and peculiarities of known diseases, to a disease which, both in its nature and progress, is anomalous, and as to which there are as yet no grounds for coming to any certain conclusion. The next branch of this inquiry resolves properly into a question of evidence. The Eritish Government naturally, and most properly, anxious to have full and satisfactory information concerning the phenomena of this disease, despatched Doctors Barry and Russell to St Petersburgh, in summer 1831, to watch its progress. These gentlemen were necessarily placed in somewhat of a difficult and trying situation ; and it is perhaps to be regretted, that, in drawing their conclusions from the facts which came under their notice, or which were communicated to them, they did not proceed with a little more caution and circumspection. Most undoubtedly, the result of their mission has been, generally speaking, unsatisfactory to the profession to which these gentlemen belong, and to the public ; since both contagionists and anticontagionists, who have occasion to look to the materials collected by Doctors Barry and Russell, must at once perceive that there are many and most striking defects, both in their facts and in their conclusions ; and that, truly, that part of their inquiry which embraced the question of contagion, has been accidentally left incomplete, in consequence of the death of a gentleman, on 99 CONTAGION. whose information, in- answer to certain of their queries, they seem to have placed their chief reliance. We must take the papers of these gentlemen, however, as they have been laid before the public. It appears from that publication, that they arrived at St Petersburgh on the 29th of June 1831 ; and their first communication, at the distance of two days afterwards, settled the question as to the identity of the Asiatic and European diseases. Then, seven days after their arrival at St Petersburgh, they write to the following effect : — " Although we feel that the time since our arrival here, has been much too short to allow of a full investigation of the facts tending to illustrate the origin of the disease, yet, under all the circumstances of our position, we have resolved not to defer the expression of those conclusions on this subject to which we have already arrived with the most perfect unanimity"— Papers, p. 26. And they then go on to state their conclusion, viz. " that, from the manner in which the disease has now broken out in this city, we see no other mode of accounting for its sudden appearance here, than by concluding that the barks from places on the Wolga, where the disease prevails, have brought something with them, which, disseminated in this atmosphere, has been the immediate cause of the eruption of Cholera which has just occurred." — Papers, ibidem. When Doctors Russell and Barry wrote the preceding passage, they certainly must have forgotten that they were charged with an important public mission ; and that the question on which they had so speedily come to an unanimous conclusion, without " full investigation," was, in its practical consequences, one of the most important and difficult which they had to G2 100 CONTAGION. determine. It is understood that, when Dr Russell left this country for St Petersburgh, he, as having been an Indian practitioner, was an anticontagionist. Dr Barry, on the other hand, like all European medical men who had not seen the disease, entertained a strong prejudice in favour of contagion. However that may be, the question which they had to decide, was one involving commercial property to the amount of millions, and intended to lead to regulations in which the whole community of Great Britain had a vital interest. These two gentlemen knew, moreover, that the disease, the identity of which with the Indian disease they had ascertained within a day or two after their arrival, was not reckoned contagious by their professional brethren in India. On this subject they had reports from the Medical Boards of at least two Presidencies, stating that to be the result at which they had arrived, after patient and anxious inquiry, founded on their own experience, and on the reports regularly furnished by their medical establishments. It was further matter of notoriety, that some of the most distinguished European physicians, including, in particular, those who had treated the disease in Russia, concurred with the Indian practitioners. And yet, in this state of matters, we find Doctors Russell and Barry, within six days after the commencement of their inquiry, and, as they say themselves, before they had fully investigated, and on mere hearsay and conjecture, came to be unanimously and decidedly of opinion that the disease was contagious, and that its sudden appearance at St Petersburgh was to be accounted for by "- something " brought by barks from infected places on the Wolga. 101 CONTAGION. Had these gentlemen said, that the barks to which they allude had brought individuals with them suffering under the disease, by whom it was communicated to the inhabitants of St Petersburgh, their conclusion would have been intelligible ; or had they even explained the nature of the pestilent substance brought by the barks, there might have been less cause to complain ; but as their communication to Government stands at present, it is impossible to imagine any thing more vague and unsatisfactory. But it is not merely for drawing a hasty conclusion on such premises, that Drs Russell and Barry are responsible. On the contrary, one would be apt to suppose, that they had engaged in their inquiry without being historically acquainted with the habits and peculiarities of the disease, as it had exhibited itself elsewhere : since nothing is more certain than that the disease in its first appearance in a town or district, is not traceable to any visible or known origin. No doubt if it be taken for granted that the first victim of the disease in any particular town, must, as a matter of absolute necessity, have received it from having been placed in contact or juxtaposition with an infected person or substance, then, indeed, Drs Russell and Barry, finding no actual sufferer to whom they could trace the contagion, were driven perforce to look for an inanimate substitute, among the cordage, or in the cargoes of the barks on the Wolga. But if, on the other hand, the history of the disease has demonstrated, as far as a negative can be demonstrated, that it has broken out almost invariably as if it were indigenous, where is the necessity for finding some visible external cause ? This in truth is the capital mistake into which all inquirers after the origin 102 CONTAGION. of the disease have fallen. They must find " something," and yet what that something is, no man has been hitherto able to say. One thing, however, is quite certain, and that is, that a person actually suffering under the disease is not indispensable. There is no occasion to go to India in order to prove that fact ; for I believe it may be safely said, that (except in places where there was reason to look for the disease) there is no town in Europe to which Cholera has been conveyed by an actual patient, or even by a convalescent ; and what is more remarkable still, there is I believe but one authenticated case of a death from the disease at any of our numerous quarantine stations. Certainly there is no instance of a new case having occurred at any of those stations ; — the disease, in the only cases which have occurred, having been clearly brought on board by the sufferer, and not having spread in the ship after it left the diseased port. On the other hand, in Europe as in India, the first appearance of the disease in a town is generally speaking traceable to no external cause ; nor is it necessary to go out of this country in order to establish that fact, the first victims of the disease at Sunderland having been, as is well known, persons who were unable to trace the attack to any thing like contact or communication with either persons or vessels coming from any infected port. Drs Russell and Barry, therefore, would have more correctly represented the fact, had they stated that the disease had broken out at St Petersburgh, according to its usual habit in India, in a manner wholly unaccountable. A glance indeed at the accompanying map with reference to the established habits of the disease in its progress in any particular direction, 103 CONTAGION. will demonstrate that there was no occasion to look for its remote cause in the sails, cordage, or timber of barks coming from infected towns. It will be seen from this map, that Cholera reached Moscow and its neighbourhood in the autumn of 1830, that its progress was stayed during the winter, and that during the following spring we find it in February 1831 in Mohilew travelling westward ; in April at Warsaw, about &50 miles due west ; in May at Dantzic, about 400 miles west from Mohilew ; in the same month at Riga about 400 miles to the north, and Lemberg about 400 miles south-west of Mohilew. Then, on the 26th of June, it arrived at St Petersburgh, 7° due north from Mohilew, and Bucharest, 8° due south of Mohilew, in the beginning of July 1831. In short, let its progress to those places, or to any other at which it appeared, be looked to, and the same uniform system of dissemination will be found to prevail. Its arrival therefore at St Petersburgh, just like its arrival at every other place which it has visited, must be ascribed to some general cause, not to any local peculiarities in the trade of St Petersburgh ; more particularly when it is found that the date of its arrival at that city coincided with the period at which, without reference to any local peculiarities, it might have been expected. In Europe, recovery from the collapsed state of Cholera appears to have been very generally followed by a fever of typhoid character, of which I shall have occasion to treat more largely in the sequel. Doctors Russell and Barry regard this fever as a stage of European Cholera, and seem to think it likely that contagion from the fever will communicate not only typhus but the collapse stage of Cholera. They say, 104 CONTAGION. because the attendants of patients labouring under this fever are liable to take, not the fever, but Cholera, therefore the fever propagates Cholera. Here, also, these gentlemen overlook a very remarkable feature in Cholera, which is, that, during its prevalence, it seems to absorb or neutralize all other morbid affections. This is a well known peculiarity, to which I am myself able to bear testimony, for I have repeatedly seen the disease break out during the aguish season, in a district of India, where intermittent fever m endemic ; and while Cholera prevailed, that is, for fifteen or twenty days, not a single case of intermittent fever was reported or brought to the hospital, although both before the arrival and after the departure of Cholera, five or six fever cases a-day were the average. If such be the fact, and it is matter of notoriety, it is not at all remarkable that typhus fever should not be in activity at such a time, or that persons susceptible of disease within the tainted limits should suffer from the prevailing epidemic. In treating of the subject of contagion, Doctors Russell and Barry report it as a matter of fact, that the virus of the disease may be carried about in the human constitution without manifesting itself for upwards of thirty days. They announce this singular circumstance in the following passage, from which., it will be perceived, that here, as in other instances, they speak from mere hearsay. " About the month ef November last year (1830), when the Epidemic- Cholera was on the decline at Casan, and when the prisoners were assembling from different parts of the empire to be transported to Siberia, a party of them were dispatched from Casan to Perm, the principal town of the district or government of that name, which 105 CONTAGION. they reached in about twenty-five days. They were all healthy at the time of their setting out — no casualties occurred on the road — the Cholera was not prevalent on any part of the road through which they passed, and when they arrived at Perm, the disease was unknown there, never having reached it. They were conveyed to a jail out of the town by a detour, so that they might not pass through it at all. A very few days after their arrival the Cholera broke out among them, and spread to the other prisoners in the jail, and about fifteen died in all."— Papers, p. 42. In order to prove contagion by such an example as the preceding one, it is necessary to suppose, that, on this particular occasion, the disease had laid aside all its ordinary habits. In several instances mentioned in these papers, Doctors Russell and Barry represent the disease as seizing the patient within an hour or two after contact with the infected person. At p. 62. they use an argument to prove that contagion may be left behind by patients removed from their own houses to hospitals, and that after nine days all risk of contagion is over ; and, in addition to all this, the fact is indisputable, that Cholera has generally begun and ended its ravages at any one place within less time than that during which it must have remained latent in the persons of these prisoners. But this is not all, for, on the hypothesis on which Doctors Russell and Barry proceed, one or more of these prisoners who left Casan, to all appearance, in perfect health, must have marched for twenty-five days with the Virus of this mortal and extremely rapid disease in his system. Nothing can be more violent than such a supposition, while nothing is more in accordance with the ordinary habits of the disease than that it 106 CONTAGION. should have broken out spontaneously at Perm (which, as appears from the map, lay within its range) as it did at other places, and that some of its first victims should have been these poor prisoners, worn out with the fatigue of a long winter march, and dispirited by the dreary prospect of the exile to which they were proceeding. The next instance given by Drs Russell and Barry is intended to prove that Cholera may be conveyed to a village by an individual, and that in its progress it can be barricadoed out, or limited to a particular quarter. The evidence, however, on this point, is extremely loose. In the first place, the reporter of the fact is not only a contagionist, but one who is very eager to prove his own success in suspending the progress of the disease. He says that Cholera was brought by a coachman fifty versts, and propagated by him to a particular portion of the village, — that the diseased limits were ascertained, and a barricade formed, by means of which the rest of the village escaped attack. The only explanation which can be given of such an occurrence is, that, with a disease so capricious as Cholera, it is impossible to say whether the exemption enjoyed by the barricadoed quarter was owing to the precautions taken, or to the peculiarity frequently exemplified in the history of the disease, that it chooses its own limits, and does not transgress them. lam far from wishing to evade anomalies of this description, of which there are several in the course of the papers now under examination, the most remarkable of which certainly is that of Zarcozelo and Peterhoff, to which the Russian Court retired, while the epidemic prevailed at St Petersburgh. A similar instance of immunity, much relied on by contagionists 1 107 CONTAGION. as illustrative of the same fact, is that of the French Consul's garden in the neighbourhood of Aleppo ; and, I believe, there are similar instances to be found in most of the towns in which the disease has appeared. Now, in reference to the whole of these, all that can be said is, that they are in no way more unaccountable than many of the other anomalies by which this epidemic is distinguished. They prove nothing except that, in certain circumstances, the disease did not transgress certain limits, while, on the other hand, there are innumerable instances in which the most rigid sanitary precautions have proved unavailing, and in which the disease has broken out in persons who are admitted to have had no contact with any infected person or substance. In addition to this, there are facts connected with the disease as it appeared in India, still more extraordinary even than those in question. On what hypothesis, for example, can the following facts, which fell under my personal knowledge, be explained ? The military hospital at Dharwar, an oblong apartment of about 90 feet by SO, was within the fort, while the lines of the garrison were about a mile distant, beyond the spjls. On two different occasions, in 1820 and 1821, when the disease prevailed epidemically among the troops of that station, but while no case had occurred in the fort, within which the hospital was situated, I brought the patients at once from their quarters, into the hospital, which was crowded with sick labouring under other disorders. No attempt was made to separate the Cholera patients from the others. On one of those occasions no case of Cholera occurred within the hospital among the numerous patients or the hospital 108 CONTAGION. attendants ; on the other occasion, one of the sick was attacked, but he was a convalescent Sepoy, who was at liberty to leave the fort during the day. The disease on each of those occasions was confined to a particular subdivision of the lines, and none of those residing within the fort were attacked. Here, then, there were from twenty to thirty cases of Cholera admitted in the course of a few days into the same apartment with from forty to fifty patients, suffering from other ailments, and yet not a single instance to countenance the notion of contagion occurred. It is hardly fair in European writers to disregard facts such as thesej the authenticity of which is put beyond all question by the reports made at the time, corroborated by the testimony of almost every medical man in India. According to Mr Scott, " The most striking instances of immunity from the " disease, under the most intimate personal inter" course, will be found recorded in the original re" ports. In the hospital of the Royal Regiment on" ly one individual out of one hundred and one at" tendants was attacked with the disease. In that ** of the 11th Native Regiment, at Vizianagram, as " recited by Mr M'Andrew, p. 33, not one was " seized, although their numbers would seem to have " been great. In the hospitals at Trichinopoly no " attendants were taken ill. Many medical officers " appear to have slept in their hospitals, without suf.'•* fering any bad consequences. At St Thomas' " Mount, where a general receiving hospital for pa" tients with the Cholera was established, and where " the numerous attendants were people not at all ac" customed to hospitals, not one of them was taken " ill ; yet it was not uncommon to see them using 109 CONTAGION. " the bed-clothes of patients who had just recovered " or died. The same observation applies to the nu" merous receiving hospitals at Madras. Mr Acting" Surgeon Gibson, on reporting on a late attack ¦" (April 1823), experienced by the 69th Regiment "at Wallajabad, observes, I had ninety- two admis" sions, and increased the establishment of servants " to double : I lived in the hospital, amidst the sick, *' day and night, and yet neither 1 myself, nor any " of the servants, got the disease ; but the hospital" Serjeant's wife, living in a retired room, not near " any disease, had a severe attack *." In Bengal, likewise, the same phenomena were observed. " At Hutta, again, a healthy town on the " banks of the Sonar, in Bundlekund, the epidemic '" committed such ravages that the inhabitants fled, " and took refuge in the neighbouring villages ; and " so virulent was the poison, that three Sepoys and " seven camp-followers of the Sd Battalion Ist Re" giment, were seized, merely on that corps march" ing through the place. And yet, the disease ne" ver appeared amongst a company of Sepoys, or their ** followers, then in the fort, which was divided from " the town only by abroad street. What here served " to skreen these men from infection ? Certainly no " suspension of intercourse between the town and " fort ; for this always remained free ; much less su* perior salubrity of situation, for the fort was small, " and crowded with buildings, and the town high and " open. Thus, too, whilst the disease raged in Sau" gor, and in the lines of the Ist Battalion 26th Na•" tive Infantry, about a mile and a half distant, not * Report, p. 1. 110 CONTAGION. " a case occurred in the fort in the centre of the " town, which was then garrisoned by 200 men of " the 2d Battalion Ist Regiment. In like manner, " in Kotah, three companies stationed in the fort es'* caped entirely, whilst 100 persons were daily pc" rishing in the town. And at Muhadpore, where ** the epidemic prevailed in the vicinity, and was " daily attacking a detachment of Bengal troops, con" sisting of the Ist Battalion 6th Regiment Native " Infantry, two Rissalus of Skinner's Horse, and M 1500 camp-followers, it entirely spared a body of " 500 of Holkar's Reformed Horse, although the two " camps closely adjoined, and a man who had been " sent in from the Bengal Division, after getting the M disease, went through every period of it amongst " the healthy Mahrattas *." In dealing with a disease, whose ascertained habits are so extraordinary, and where the facts arrayed on the one side can always be neutralized by facts no less conclusive on the other, it is in vain to talk of jZarcozelo and Peterhoff, or of Aleppo, or of the Foundling Hospital at St Petersburgh, or, in short, of any instance of the kind, as proving any thing either one way or other f. The test which I would * Bengal Report, p. 136-7- t I observe'that a very able medical writer on this subject refers to the jails in India as illustrative of the same fact ; but the immu- nity from attack enjoyed by certain of these prisons, proves no- thing in favour of contagion. The prisoners in those jails are al- ways employed during the day in outdoor work ; there has never been any attempt at seclusion ; and their guards, like our police- men, reside, when relieved, in their own houses in the villages, so that the immunity of prisoners, when it occurred, must be re- ferred either to the caprice of the disease, or the locality of the jail. — See the Edinburgh Medical and Surgical Journal for De- cember 1831. 111 CONTAGION. apply is this. Is there any well authenticated case, in which, by means of contagion alone, the disease has been communicated to a town or district, in which there was not reason to expect its appearance, and therefore, when no unknown remote cause of the disease could have been present ? Do the contagionists go the length of saying, that if a patient, labouring under Cholera, were brought from Newcastle, where the disease now is, to Edinburgh, where it has not yet appeared, that individual would cause the disease to break out in Edinburgh ? Or, if this be said, is there any fact to support it ? Assuredly I have met with none ; for whether the disease can be barred out or not, nothing appears more certain than that, without some predisposing cause, atmospheric or terrestrial, the virus, whether apparently brought by persons or goods, never has manifested itself. But if that be the fact, and if, as seems now to be admitted by the most distinguished professional writers on the subject, something more than mere contagion be necessary towards the propagation of the disease, where is the occasion for resorting to contagion in order to explain its progress ? It is admitted that the disease does not require contagion for its propagation ; that a particular state of the atmosphere or of the earth will cause it to break out spontaneously. This seems now, indeed, to be the approved doctrine of some of the contagionists themselves. Nay, they go farther, and admit that the remote cause must cooperate with the contagion, in order to give it efficacy. Such at least seems to be the result at which some late writers, of great European experience, have arrived, and, if so, I am really at a loss to perceive on what sound principle the element of contagion has 112 CONTAGION. been superadded to a remote cause of the disease, which is admitted to act independently of contagion. It may be imagined, indeed, that when the disease has established itself in a town, personal communication with the sick may excite it in a person who might otherwise have resisted its remote cause ; but why should this hypothesis be resorted to, except on very sure grounds ? The theory of contagion is practically a very inconvenient one, and it seems really unnecessary to assume that it co-operates with the hidden cause of the disease. Mere contagion, according to this notion, is insufficient ; while it is admitted that the unknown cause will produce the disease without contagion ; but if contagion, in absence of this malignant influence, be harmless, and if the pestilence can advance and spread independently of contagion, I can see no use in embarrassing ourselves with two exciting causes of the same disease ; one of which is conceded not to be essential to its dissemination, and the other confessedly requires no such aid. But, on the contrary, I should rather say, that when the disease has once gained a footing it will run its course, — attacking all those who are susceptible of it within the limits to which it is confined ; nor do I believe that a susceptible person would be in more danger from contact with a person labouring under the disease, than he is from exposure to the supposed unknown influence. Besides, on the hypothesis now under consideration, it is taken for granted, that, without the aid of a remote cause, a susceptible person will receive no injury from being placed in juxtaposition with a Cholera patient, — so that at least it is quite clear that a sick person himself is innocuous after the pcs- :\ 113 CONTAGION. tilential miasm, or whatever else it may be, has exhausted itself in the particular town or district. We come now to a series of facts collected by Drs Russell and Barry, for the purpose of shewing that the disease is directly communicable by contagion. One general observation applicable to the whole of this class of facts is, that the persons who are supposed to have been thus infected, were one and all of them within the limits, where at the time the remote cause of the disease seemed to be in activity. But, in an inquiry of this kind, it is proper to look in detail to the particular instances which Drs Russell and Barry have adduced. The first is that of the city prison at St Petersburgh, where it is said that a woman was attacked with the disease a few hours after her arrival, and that several others in the same apartment suffered. Her husband (whom she is supposed to have infected before she was herself attacked) after a short time was likewise seized, and several in the same apartment with him " were also taken ill. In short, of twenty-seven attacked (fifteen dead) there is but one to whom communication cannot be traced. He was confined for a capital offence, and had less liberty than the others. There were about 400 prisoners and attendants." — Papers, p. 45. Had these cases been insulated, and had the disease never broken out without communication between a patient and the person attacked, they might have served to support the theory of contagion ; but, with reference to the numberless instances in which the disease has broken out, without any traceable contact, the passage just quoted proves no more than that the remote cause of the disease was in operation within this particular prison, and that those of the prisoners who 114 REMOTE CAUSE OF THE DISEASE. were susceptible were attacked ; and the fact that the prisoner confined for a capital offence, and separated from the others, did not escape, is, so far as it goes, a very important confirmation of that supposition. The next instance is that of Mr Baird's works. These are on the banks of the Neva, and are very extensive. " Three hundred and fifty men, and their families, the serfs or property of Mr 8., live and work with him in the inclosure." They are well fed. Seventeen were attacked with the disease, seven died. " First case, on 19th June O. S., a man of 80 ; second case, on 20th s a man of 19 ; not the slightest connexion could be traced between them." Mr Baird's proceedings are creditable and instructive. He improved the dormitories, attended to the feeding of his people, and erected a temporary cholera hospital: " There were, besides the above, about 100 men employed in a sugar refinery on the premises, not one of whom was attacked, though exposed to great heat and unrestricted communication with the world as before the Cholera : these were free men. Three hundred and fifty other freemen live ou^ide, and work within Mr B.s establishment, in the various manufactories carried on by him. Of these seventeen were attacked with the Cholera, ten died." — Papers, p. 45. If this instance prove any thing, I should rather say that it proves the disease not to be contagious, since otherwise it is difficult to account for its not having spread more extensively in Mr Baird's works ; more particularly, as he does not appear to have been himself a contagionist, or to have taken any steps for preventing communication between the sick and the 115 CONTAGION. healthy. The immediately following case in the papers is of the same description, and is an interesting example of the disease not crossing a river. It is that of the village of La Nouvelle Saratova, which is chiefly inhabited by Germans, with a population of about 1000.—" A servant belonging to one of the families who arrived on the 26th of June, O. S., complained of being cold, and being slightly indisposed that very day, but attended to her ordinary occupations until the 30th, when she was suddenly attacked with vomiting and purging towards evening. During the night violent cramps came on ; she had but three motions, and vomited but twice in all. Hands and feet very cold and blue, lips blue ; died in twenty hours from the first attack of purging. The above is the evidence of the woman of the house. The medical man who saw the sick maid about an hour before her death, stated that she had all the symptoms of Cholera. The woman of the house, the mother of the maid, and others, were about her in her illness ; none of them attacked." — Papers, p. 46. The bedding on which she lay and died was given to a beggar, and was afterwards carefully traced, and found to have been used with impunity. This case, therefore, so far from proving the disease to be contagious, strikingly illustrates the peculiarity to which I have already adverted, viz. that when a Cholera patient is carried beyond the tainted spot, the disease is not communicable to those about him. We are next told that Cholera was carried to the village of Colpina by a party of healthy marines, who left St Petersburgh on the 21st of June and arrived at Colpina on the 23d. " They had been all examined before they marched, and brought a certificate of good h 2 116 CONTAGION. health. On the day of their arrival they were also examined hy Dr Bowman, and found in good health." The first case occurred among one of these men on the 27th. "He had been drunk, and in company with the second case the day previous to his being taken ill ; the woman, No. 3. had nursed No. 2. while at home, so that there appears a strong case of communication which cannot be traced farther. From a plan which I made out, marking the houses in which the disease occurred, it appears that some rows remained free of Cholera, but there is a sprinkling in most of the streets." — General Wilson's Letter, Papers, p. 35. The simple account, then, of this outbreak of Cholera is, that it reached the village of Colpina in its progress over the face of the country ; that it made its appearance suddenly in one spot, among a set of dissipated, ill fed, and ill clad people, three of whom appear to have been attacked within a few hours of each other ; and that it then appeared simultaneously in other parts of the village, without any trace of communication between the sufferers and those originally attacked. Contagionists, such as Drs Russell and Barry, certainly involve themselves in strange contradictions and inconsistencies ; for while, on some occasions, they carry the virus in the cordage and sails of a ship, and in others suppose it to remain dormant in the human constitution for periods varying from seven to thirty days ; in others, such as that just mentioned, they make the contact and the development of the disease all but simultaneous. And my firm persuasion is, that all those reasoners who set out with a predetermination to account for every case of the disease on the theory of contagion, must unavoidably land themselves in similar difficulties. 117 CONTAGION. Accordingly, the papers now under consideration are full of these inconsistencies. Thus the hypothesis of Drs Russell and Barry is, that the disease was carried from St Petersburgh to the villages around by the fugitive work people, who fled on the first appearance of the disease. But see how their facts desert them. They refer to the case of " a German colony about one verst and a half from Colpina, on the Moscow road, that is the Moscow road used since the establishment of quarantine at Peterhoff and Zarcozelo," containing about 200 inhabitants. No precautions against contagion were taken ; " and yet " not a case of Cholera occurred in this village, aU " though the disease prevailed all around." Take then their next proof of the same fact, which is that of Alexandryski, containing nearly 4500 inhabitants, besides those in the villages and country houses near it. The first appearance of the disease here " was on the 23d of June, when a flax-dealer, who had arrived from Yaroslav on the Stk of June, and continued to enjoy good health till the above date (23d), was violently seized with Cholera, was sent to the military hospital in town, and died next day." — General Wilson's Letter, Papers, p. 56. Immediately after this the disease became general, but there is no attempt to shew that it spread from the flax-dealer ; so that, in this instance, the only evidence of contagion is, that the first case of the disease occurred in a man " who had reached the town " nearly three weeks before, and who had continued " until the day of his attack in perfect health ;" while the general prevalence of the disease immediately afterwards shews that it had a local, not a personal, origin. 118 CONTAGION. Drs Barry and Russell are avowed contagionists, and they appeal to their communication to the British government, as containing the evidence on which they have formed their opinion. I believe it is now generally admitted, even by contagionists, that the facts brought forward by these physicians are hardly sufficient to justify the conclusions at which they have arrived ; and most undoubtedly every second example in these papers is not only explainable on an opposite theory, but is actually the very fact which an anti-contagionist w T ould most readily select in support of his views. Thus, having disposed of the report from St Petersburgh, look at what they say of Cronstadt. Here the disease made its appearance at a place called the Merchant's Mole, the first case having occurred on board a boat which had just arrived from St Petersburgh. The boat was ordered off to the distance of three or four versts from the fortress, where the crew, and a barber who had bled the man first attacked, were placed in quarantine. The patient died within twenty hours ; " the other ten, six attendants at the hospital, the medical man in charge, and the barber, continued in close quarantine for five or six days, i. c. until the town was generally infected, yet not one of them was taken ill" — Papers, p. 50. The next case occurred in the centre of the town, more than a quarter of a mile from the mole-head, " not a trace of communication between him and the first case." This man also had arrived two days before from St Petersburgh, and the house in which he lay " was closed, put in quarantine, and continued strictly guarded for four days. The surviving inmates were nine in number, four of whom had assisted the dying man, not one of whom was attacked." — Papers, 119 CONTAGION. p. 51. In short, by a careful examination of what took place at Cronstadt, it will be found that here, as elsewhere, the disease commenced at a particular spot — that it was not carried thence to other points by the persons attacked and removed to a healthy quarter, but that, as usual, it gradually passed on, directed by its hidden source, until it had become general in the other parts of the fortress. The School of Cadets at Cronstadt is also referred to, as illustrative of the advantages of quarantine regulations. It may be thought that the advance of the disease, in the face of all quarantine regulations, is the best practical answer to any single instance of supposed benefit from this species of restraint. But it is unnecessary to meet this particular instance by a mere general remark. The statement of Drs Russell and Barry is, that " the gates of the establishment were shut on the 19th of June, and as strict a quarantine as possible maintained till the 6th of August, O. S. — No case amongst the pupils, who were from 9 to 20 years of age. The general health of this establishment was rather better than usual during the epidemic — Great praise is due to the officers of this establishment, and particularly to Dr Arden, for the very prudent sanitary and dietetic regulations recommended by him. — The discipline of this school was perfect. — Papers, p. 51. Now, had no case of the disease occurred within this establishment, it might have been a proof, if not of the preventive effects of quarantine, certainly of the benefit to be derived from dietetic and sanitary regulations. The truth, however, is, that cases of Cholera did occur here. " There were one or two cases among the servants, some of whom were unavoidably CONTAGION. 120 obliged to go out of bounds" But Drs Russell and Barry elsewhere inform us, that Cholera is not only communicable by contact with a sick person, but so subtile is the virus, and so diffusible, " that neither the near approach, nor the immediate contact, of an affected individual were indispensable to the infection of a healthy individual susceptible of the disease at the moment." So that even had com- munication been prevented between the sick servants and the pupils of the School of Cadets at Cronstadt, this highly diffusible contagion, on the principles of Drs Barry and Russell themselves, must have obtained a footing in the establishment, and necessarily must have been communicated to the pupils, unless it is meant to be said that not one of these young gentlemen was susceptible of the disease ; and if that be the fact, their immunity was not due to quarantine. With regard to the evidence afforded by the shipping in the roads at Cronstadt, it merely corroborates what had been again and again found to be the cas@ in India in similar circumstances, viz. that the crews of vessels do not suffer until they come within the tainted limits. Thus we are told that the frigates Anna and Olga arrived at Cronstadt from Dantzic about the end of June, and were ordered into ten days' quarantine, during which time they had no sick ; but that immediately on being admitted to Pratique, they had some cases of Cholera. — Papers, p. 53. Of the Venus frigate it is said, " This ship had been here twenty-three days before the epidemic. In consequence of her having sick, she had two short quarantines of five and three days, during which time the captain states that his ship was more healthy than when in free communication with the 121 CONTAGION. shore and other ships." — Ibidem, p. 53. And the last instance is still more striking. " The Phoenix brig, Captain Baron Soenenthac, had been stationed for two months midway between Cronstadt and Peterhoff, about six versts or four miles from either, to the SE. of the former, for the purpose of telegraphic communication with his Majesty. She continued in this situation till the 15th of July in perfect health, though she had sent her boat twice a-week of the fortress for provisions. On the 15th, she took up her\station one verst to the SW. of the town, and had two men attacked with Cholera on the 17th. Neither of these men had been on shore. Thesurgeon only had gone to Dr Lang's hospital on the 16th, for the purpose of observing the Cholera, which he had not seen before. The Doctor said to him, You had better not remain here long, else you may carry the disease to your ship, and I shall be responsible. Seven cases in all, and one death, — not a man of the seven had been out of the ship, and not one of those who had been on shore was attacked then or since." To what, I would ask, do Drs Russell and Barry ascribe the attack of the two men mentioned in the last instance, as having been attacked on the 17th July ? It is stated, that they were not on shore, while the only person who was on shore appears to have been the Doctor, who was not attacked. Is it meant, then, to be inferred, that the Doctor carried the contagion along with him onboard the vessel, and communicated it to those men, and if so, in what shape did he carry it ? In short, on the hypothesis of contagion, the attack on the crew of this vessel is wholly unaccountable ; while on the other hand, it appears to me equally clear, that the movement on .¦> 122 CONTAGION. the 15th of July, when the vessel left her former station, and took a position one verst to the southwest of the town, brought her within the limits of the disease, and fully explains the attack by which the vessel afterwards suffered. Before leaving the subject of contagion, it is proper to say something of the supposed mortality among medical men, and hospital attendants, who may be exposed to Cholera. It is said that medical men have suffered more than others of their rank, and certainly, a priori, we should expect this to be the fact, for whatever may be the remote cause of the disease, it is admitted on all hands, that mental anxiety and bodily fatigue are powerfully predisposing causes ; while at the same time both the medical men and the other attendants, as well as the hospital assistants, are much, if not constantly, exposed to the hidden cause of the disease, whether it be atmospherical or terrestrial. Instead, therefore, of looking upon the preponderance of deaths (if such be the fact) among medical men, as a proof of the contagious nature of the disease, it appears to me that the general immunity enjoyed by medical men affords very strong evidence the other way. lam persuaded, indeed, that the almost universal belief of Indian practitioners, that the disease is not contagious, rests in no inconsiderable degree on the conviction, that had the disease been communicable in this manner from . the sick to the healthy, no medical man who did his duty could by possibility have escaped. Looking to the Madras Presidency, the limited number of medical officers who have fallen victims to the disease is very remarkable #, and in Bengal the * During the years from 1818 to 1822 inclusive, the numerical 123 CONTAGION. result is even more surprising. In the latter Presidency during the first three years after the breaking out of the disease, only three medical, officers out of an establishment of 300 were attacked, of whom only one died •. Much of this immunity I think may be ascribed to the circumstance of Cholera patients being almost invariably brought into hospitals at some distance from their own habitations, and, as I conceive, beyond the immediate and limited local influence of the disease. I cannot help thinking, indeed, that this point has not been sufficiently attended to, or rather that it has been entirely lost sight of by the speculators on contagion. Were a medical man or a nurse called upon to attend a patient labouring under ague in the Fens of Lincolnshire or among the Pontine marches, if either the nurse or the physician were attacked, the attack would be at once ascribed to marsh miasm. But if a nurse or a doctor strength of the European troops in the Madras Presidency was kept up at 10,000 men. In the course of these five years 3664 cases of Cholera occurred in that force, of which 695 were fatal, that is at the rate per annum of 1 casualty from Cholera to every 72 men. During the same period, the Madras Medical Establishment was kept up at 200 commissioned officers, 33 of whom are knoAvn to have had attacks of Cholera, 13 of which were fatal, that is 1 in 77 per annum. See Madras Report. Under ordinary circumstances, the risk run by officers bears no proportion to the dangers arising from the habits of the European private soldiers in India, as predisposing causes to this disease. But medical officers, in addition to exposure to the remote cause, have the predisposing causes of fatigue and anxiety, and are moreover liable to be detached whenever the disease breaks out within reach of them. * " From a medical list, consisting of between 250 and 300 " individuals, most of whom saw the disease largely, only three " persons were attacked, and one death only occurred." — Bengal Report, p. 129. 124 CONTAGION. in attendance on a Cholera patient be attacked with the disease, no farther inquiry is made, nor does it ever occur to a contagionist to doubt that such an attack is proof positive of the existence of contagion. This appears to me to be not only illogical, but one of the strongest possible illustrations of the precipitate haste with which many of the writers on this subject have leapt to their conclusion *. In Russia, according to the communications of Drs Russell and Barry, the mortality among medical attendants appears to have been considerably greater. It is said that 15 hospital physicians out of 264 were attacked during the first eighteen days of the prevalence of the disease, and that six hospital attendants (invalids) out of 40 had been attacked in one hospital. * Nothing can prove the disadvantages under which home- bred authors on Indian Cholera labour more thoroughly than certain passages in the article in the Foreign Quarterly Review for October 1831 already alluded to. The writer of that article extracts the opinions of a few of the least experienced medical officers, as set forth in the Madras Report ; and even these ex- tracts prove nothing except that the attendants on the sick some- times suffer. This reviewer also affects to regard the Bengal report as the individual work of Mr Jameson, the Secretary to the Medical Board, although he ought to have known that that report was drawn up by Mr Jameson, from the communications and reports on Cholera made to him by the whole medical offi- cers of the Presidency who had seen the disease. And it is with all that information before him, that Mr Jameson, as the organ of the most distinguished Medical Board in India, reports that ' ' the whole body of the medical officers in Bengal who have had an opportunity of seeing and remarking on the disease, without a a dissenting voice, concur in declaring that it is not contagious ;" and in a foot-note, " to this unanimity of conviction, there was f* originally one exception, but from more extended experience,