ON MALIGNANT CHOLERA pTS ORIGIN, PATHOLOGY, TREATMENT, AND MODE OF PREVENTION, WITH THE OCCUPATIONS OF 5,568 MALES OVER 20 YEARS OF AGE jiXHAT DIED IN LONDON IN 1849, 1853, 1854, AND 1866 : WITH AN APPENDIX Cattle Plague as compared witlh Cholera and other human ; its history, pathology, treatment, and future preihtion. A Letter on Homoeopathy ; its false inferences and holloiu assumptions. With an Essay on the present state of the Medical and Veterinary Professions in this country. BY eJDWAEDS CRISP, M.D., M.R.0.5., L.A.O. late physician to the metropolitan dispensary; , voKMkbi/y one op the presidents op the gdy's hospital physical society; ywb-pkbsidbnt of the south london medical society, and onb of the committee 01? thb physiological society of london; a. , jbtxow of the patiiological, zoological, and agricultural societies op london ; cosrsBponding member op the medical society of nismes, and of the montreal, birmingham, and dumfries natural eistoby societies; p Editor of the London "Medical Examiner;" Author of "A Rejected Candidate at the "Royal . Qolleije of Physicians, and an Examination of the Examiners," 1849; Author of a Work on the 9truc(ure and Use of the Spleen, 185-1, with the weight of the Viscera and length of the BLfMnCίntary Canal in. more than 500 species of animals; Medallist at the Medical Society F qf London, 1843 ; Author of the Jacksonian Prize Essay on the Structure and Diseases "' of the Blood- Vessels, 18-15; the Jacksonian Prize Essay on Intestinal Obstructions, 1852; th. Astley Cooper Prize Essay (£300), on the Structure and Use of the Thyroid Gland, 1859; the Astley Cooper Prize Essay (£300) on the Struetwe and Use of the Pancreas, 1862; the I3ath and West of England Prize Essay on Parasitic Diseases in the Lungs of Lambs, 186-1, SfC Sfe.
. »V\ Surgeon General's Office vH ) I « ) i & . \ ; '(^ {section, .'. II n...X£P\3 |a
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ON MALIGNANT CHOLERA;
ITS ORIGIN, PATHOLOGY, TREATMENT, AND MODE OF PREVENTION,
WITH THE OCCUPATIONS OF 5,568 MALES OVER 20 YEAES OF AGE THAT DIED IN LONDON IN 1849, 1853, 1854, AND 1866 :
WITH AN APPENDIX
On Cattle Plague as compared with Cholera and other human maladies ; its history, pathology, treatment, and -future pre-
vention. A Letter on Homoeopathy ; its false inferences and hollow assumptions. With an Essay on the
present state of the Medical and Veterinary
Professions in this country. /'' C- t?J?
fimii
BY ',%. EDWARDS CRISP, M.D., M.R.C.S., hJH&T
\n-
LATE PHYSICIAN TO TEE METUOPOLITAN DISPENSARY; FORMERLY ONE OP THE PRESIDENTS OF THE GUY'S HOSPITAL PHYSICAL SOCIBTT; VICE-PRESIDENT OF THIS SOUTH LONDON MEDICAL SOCIKTY, AND ONB OF THE COMMITTEE OF TEE PHYSIOLOGICAL SOCIETY OF LONDON;
FELLOW OF THE PATHOLOGICAL, ZOOLOGICAL, AND AGRICULTURAL SOCIETIES OF LONDON;
CORRESPONDING MfMBER OF THE MEDICAL SOCIETY OF NISMES, AND OF THE MONTREAL, BIRMINGHAM, AND DUMFRIES NATURAL HISTORY SOCIETIES ;
Late Editor of the London "Medical Examiner;" Author of "A Rejected Candidate at the Royal College of Physicians, and an Examination of the Examiners," 1840; Author of a Work on the Structure and Use of the Spleen, 1854, with the weight of the Viscera and length of the Alimentary Canal in more than 500 species of animals; Medallist at the Medical Society of London, 1843 : Author of the Jacksonian Prize Essay on the Structure and Diseases '
of the Blood-Vessels, 1845 ; the Jacksonian Prize Essay on Intestinal Obstructions, 1882 ; the Astley Cooper Prize Essay (£300) on the Structure and Use of the Thyroid Gland, 1859; the Ast/'ey Cooper Prize Essay (£300) on the
Structure and Use of the Pancreas, 1862 ; the Bath and West of England Prize Essay on Parasitic Diseases in the Lungs of
Lambs, 1864, $c. $c.
" If an artery is bleeding, we endeavour to arrest the hemorrhage; and I think it is equally or more important to stop the flow of serum in the early stage of cholera," From the Author's Essay on Cholera, 1819.
LONDON: ROBERT HARDWICKE, 192, PICCADILLY.
1866.
COX AND WVMAN, PRINTERS,
GREAT QUEEN STREET, LINCOLN'S INN FIELDS,
LONDON, AY.C.
TABLE OF CONTENTS.
Preface Motives for publication Value of the statistics The danger of the so-called eliminative treatment Government Hospital for scientific inquiry Sanitary measures, importance of Officious meddling, danger of Reasons for introducing the Appendix on
Essay published in 1850 Discussions at London Medical Society Dirt and overcrowding will not alone produce Cholera Occupations 4,258 males, 20 years of age and over, that died of Cholera in London, 1849 Deductions Localities affected Contagious or non-contagious lature Famine Fever in Ireland Mortality among medical men compared with that in Jholera epidemics Edinburgh students Mental influence Pregnancy cases Treatment Government Hospital, importance of Cases Increase of heat after death Transfusion Calomel, ffect upon the biliary secretion Mysterious nature of the disease and its supposed causes. 1-13.
History and progress of Cholera epidemics of this country Symptoms Causes of eruption Temperature Pulse, respiration Symptoms in children Difference observed in the epidemics of 1866 London Hospital, remarkable cases at Gangrene Pregnancy Increased heat of body after death General features in 30 cases Time of diarrhoea in 68 cases Duration in 192 fatal cases The usual periods of death Rate of mortality in different countries Calcutta and the Steppes of Russia. 13-18.
t Causes Occupations Dr. Guy's statistics and proportions Mortality, 1853-54 Occupaon of males during the epidemics of 1849, 1853, 1854, & 1866 Deductions from these revailing errors Gentlemen, tailors, shoemakers, night-men, sewers-men, grave-diggers, ows, brewers' men, cyder drinkers, licensed victuallers, teetotallers Alcohol, use of. 18-23.
Causes Water Dr. Snow's views Broad-street pump Report Water-supply to those now affected with Cholera Sewers- men, remarkable exemption from Cholera Human excreta, what proof that they mixed with the water Water unusually free from impurities Microscopical examination of the water Experiments upon the lower animals Cholera evacuations Experiments upon the lower animals Conclusions Difference of diseases of man and of the lower animals. 23-26.
I Contagion and Infection Deductions from the occupations of medical men, ministers of ligion, nurses, and washerwomen Hospital inmates affected Number of cases in 313 tferent houses Husband and wife affected Directions of the Board of Health, 1831. 26-27.
Pathology Spasm of the pulmonary artery, no proof of its existence in this or in any other vessels Dr. Johnson's and Professor H. Bonnet's views Morbid appearances in Cholera Bile, urine, urea, and carbonic acid Quantity of bile daily secreted Dr. Johnson's cases examined Report of 12 autopsies recently witnessed at the London Hospital General remarks Blood, condition of Microscopical examinations Supposed erroneous views of Dr. Richardson respecting the coagulation of the blood The author's views respecting the cause of the blood's coagulation. 27-35.
Tbisatment Early diarrhoea, arrest of Comparative methods List of internal medicines, nd external applications used Importance of a government hospital The falsely called liminative treatment Danger of, in the early stages of the disease Dr. Johnson's cases Other trials Calomel treatment Cases treated by the author Objections answered Effect of nlomol in Cholera Sedative, not a purgative- -General testimony Prevention of Cholera jest medicines in the onset Disinfection of houses and infected localities Medicines Vater Cholera evacuations Disposal and disinfection of Exemption of the Chinese at the lauritius from Cholera Cholera Committee of the College of Physicians, advice objected to.
1 General conclusions as to the causes, pathology, and treatment of Cholera. 35-43. Comments on the Public Health Act, Aug., 186'G Paper by the Author, 1849, on the auger of our public conveyances as regards contagious and infectious diseases- Importance of overnment small-pox and fever hospitals. 43-4*5.
APPENDIX
k Preface Tho Author's early advice to the Government Statement of his suggestions and osed discoveries The study of disease hereafter will commence with the lowest forms of nization. 49-51.
Letter 1, Sept. 21, 1865. Line of investigation Offer to the Government The anomalous state of the Medical and Veterinary Professions in this country Author's Parliamentary Evidence on the Pharmacy Bill One large governmental experimental Hospital The prevention of all fairs and markets, and of the movements of all bovine animals by road and rail Establishment of dead meat, markets, and the slaughtering of foreign cattle at sea-ports. 53-56.
i Letter 2, Sept. 30, 1865. Plan of the proposed Hospital Nature of the experiments phylactics Quinine, arsenic, and various medicines Transfusion of blood Inoculation with virus of cow-pox matter Typhus, measles, and scarlatina from the human subject. 57-60.
Letter 3, Oct. 7, 1865. Insidious nature of the disease and the difficulty of early detectio Diseased meat eaten by the Author, and its harmless nature Experiments upon the lower animals Structure of ruminants The length of the alimentary canal of 40 different species of ruminants, as measured by the Author Capacity of the canal Quantity of dry 'oodon the fourth stomach in cattle plague Glands of the alimentary canal Comments. 61-65.
Letter 4, Oct. 31, 1865. Symptoms and pathology of Cattle Plague in oxen and sheep Conclusions Examination by the Author of 27 sheep affected with Cattle Plague (so called) State of the blood and its influence as affecting the morbid appearances Gravitation Disease in sheep less fatal from causes named Morbid specimens Wax casts, and descriptions Proceedings of the Pathological Society Temperature of the vagina Comments. 66-72.
(Letter 5, Nov. 11, 1865. Government trial of Homoeopathy and its injurious effects spreading the dis'-ase Power of nature, examples of Symptoms Morbid appearances of c four fevers of this country contrasted with those of Cattle Plague Non-typhoid nature of ittle Plague Errors of the Government advisers and injurious results Comments. 72-76.
I Letter 6, Nov. 18, 1865. Comments on the First Report of the Commissioners Faculty Medicine Concours, Author's advocacy of, 1831 Punch and Government appointments Rinderpest, a misnomer Piofessor Simonds and the " noble conduct of the Government" is report (1857) that the disease could never reach our shores Revel cargo First outbreak idence before the Commissioners Injustice of the Government Mr. Helps's private opinion d the patient working out of orders by local authorities The dissemination of the disease in nsequence of the tardy and useless measures of the Government Suggestions by the Author
Letter 7, Dec. 25, 1865. Doys and disinfectants Heat the best disinfectant Mode of using Solution for skins recommended by the Author Want of practical experiments by tho Government, as suggested in his first letter Animals should be killed and buried,not skinned Dissemination of the disease by dogs and by hunting All dogs in infected districts should bo tied up and hunting abolished Foxes Comments. 83-87.
i Letter 8, Jan. 4, 1866. The non-idontity of small-pox and Cattle Plague Dr. Murchin's views believed to be erroneous Evidence Eruption Symptoms and anatomical lesions accination Author's suggestions (Sept. 30th), if carried out, would have decided this matter. '-91.
Letter 9, Jan. 17, 1866. Kill and compensate The disease too far extended Cure one and endanger the lives of thousands Vaccination not a preventive Cattle Plague not smallpo Dr. Murchison's supposed errors Stop all movements of cattle, sheep, pigs, and dogs, and kill and compensate Benefit to the whole community Disease greatly extended by the « tempt to cure it Dutch cattle Professor Gamgce's views Objections to Mr. Bright's and r. Mill's false economy -Comments. 01-95.
V
recent experience Belgium, France, Aberdeenshire M. Bouley's opinion of our system of veterinary education Mr. Helps's evidence, 18(33 Cheshire, Fifeshire Starlings and pigeons convey the Plague, according to Prof. Simonds, but no proof that horses and hounds carry it.
Letterll, Feb. 9, 1866. Cattle Plague inSheep and other Animals. Sheep seen by the Autho inoculated from the ox Fire and local authorities General ignorance on the subject of Shee Plague Scotch experiments and shepherds of eminence Cattle Plague in zebu and muffto examined by the Author in two species of antelopes Zoological Gardens Animals affectec with Cattle Plague at the Jardin d" Acclimisation, Paris (43 different animals killed) Supposee mistake of M. Bouley respecting the Peccary outbreaks of Sheep Plague Farther examina tions by the Author Gulliver and the Lilliputians Concealment of Sheep Plague from th Weekly Returns accounts in some measure for the ignorance on the subject Government Bil Feb. 12, 1866 Mufflon, antelopes, zebu, elands, and other ruminants Sheep Plague, Hous of Commons, Feb. 21st, 1866. 99-104.
Letter 12, Sept. 1, 1866. The history, treatment and future prevention of Cattle-plague Old writers, 1745, 1769 Enactments- Present outbreak Tardy action of the Government Progress Number attacked Sheep and cattle Number of recoveries, why allowed ?? Mortality in different countries Returns no evidence of total loss Treatment Structure of ox and sheep Length of alimentary caDal of 40 different species of ruminant Answers from 74 veterinary surgeons and practical farmers Analysis Medicines Transfusion Prophylactic medicines Future method of prevention Meat supply General and County inspectors. 105-110.
ILktterl3, Sept. 10, 1866. Cholera compared with Cattle-plague and other human maladie Diseases of quadrupeds Author's examinations at the Zoological gardens Quadrumana 23 1 Penis bone anthropoid apes Wide line of demarcation as regards diseases, also genera ions in the circulatory and nervous systems Diseases recently imported Sheep-pox lizootic aptha and pleuro-pneumonia Diseases of horses Bovine animals Sheep and pigs tub diseases Parasites Fatal exanthematous disease in pigs Splenic apoplexy Glander Jholera in the lower animals Author's experiments Inoculating the lower animals witl olera blood Comparison between Cholera and Cattle- plague Causes Symptoms Morbic pearances Practical deductions. 111-118.
Letter 14. Homoeopathy, its false inferences and assumptions The worst species o quackery The Royal Society, selections at List of the aristocratic titles for the cure of Cattle plague by homoeopathy Cures of, Cbs. II. ~ Greatrix, Hohenloe, Southcote, Long Transla tion of Fabian's fable on gold The power of gold makes the British House of Commons, Mr Lowe's lambs -Psora or itch, origin of Bark, phosphorus, belladonna, arsenic, and tartarizec antimony do not produce the symptoms attributed to them by the globulists Evidence of this Modem homoeopathy The "Times " newspaper and Chiasmodiis, capacious swallow of both Cost to the country by the dissemination of the homoeopathic delusion, and of the spontaneou origin fallacy Arsenic supposed injurious effects on milk, meat, and tripe Homceopathi dogmas Result of the homoeopathic treatment of the Cattle plague Conclusions. 118-125.
Letter 15, Sept, 13, 18G6. On the state of the Medical and Veterinary Professions as affecting the diseases of man and brute Reasons for introducing the subject Brighter prospects for science Study of things, not words Foreign students System in France contrasted with that in this country Concours Money and interest the ruling powers The Veterinary College and Royal Agricultural Society Exclusion of veterinary examiners Deserved tribute of praise to members of the Veterinary Profession System in France, Belgium, Austria, and Prussia compared with our own Suggested improvements State of the Medical Profession Clubs', cliques, grades Price of parchment Author's speech on a One Faculty of Medicine, 1837 Sale of titles Quackery Medical council not elected by the Profession The only hope of change a different class of men in the House of Commons Carinichael and triennial prizes Author's plan of reform Importance of the subject Conclusion. 125-135.
PREFACE.
Im induced to reprint this essay on " Asiatic Cholera," read at Medical Society of London, October 28, 1849, and published in London Medical Examiner, and one Faculty Journal (which I 1 edited), for several reasons. Firstly, because I believe it contains istical information of much value that may be turned to useful >unt at the present time ; and because it was the first attempt le in this, or in any other country, to show the influence of occuon in the production of this fearful disease. The time allotted to reading of a paper at a Medical Society necessarily compelled me ondense the matter to a great extent, and I shall now endeavour, adding my subsequent information and experience, to make the ,y more practical and useful.
I Another motive which especially induces me to publish this treatise he endeavour to controvert what I believe to be a dangerous doctrine, ensively circulated at the present time by the public press, viz., the sailed eliminative or aperient treatment of Cholera. Dr. Gr. John, the recent promulgator of thi3 theory, says, in his " Notes on )lera," a book which has been extensively circulated and noticed by public press :: *" The main object of this publication is to sweep ty an erroneous theory with regard to the nature of Cholera, the ory in question being one which of necessity carries with it a misevous mode of practice, and an entirely wrong estimate of the influe of treatment in the disease."
Bt behoves one to speak with great diffidence respecting the nature treatment of a disease about which so little is known ; but I think
I Since this work appeared, Dr. Johnson has published a pamphlet upon the c subject, the greater part of which is composed of a laudatory review of his k in the Saturday Review, June 2, by Dr. Watson, the President of the iege of Physicians, "the most lucid account of the nature and treatment of ilera that Ims yet appeared," according to Dr. Johnson's opinion, as stated in Preface. The sanction of such a reputed authority as Dr. Watson's induces me nter more fully into this question than I otherwise should have done.
8
liall be able to show that the mischievous mode of practice applies i greater force to Dr. Johnson's treatment than to that which he so epingly condemns. If the suggestion I made in 1849 (p. 9), o the comparative treatment, had been adopted by the Government, might speak with more certainty and precision upon many points b are now involved in dobut and obscurity.
It is not pretended that castor-oil in the latter stage of Cholera, my medicine of a mild form, can do much good or harm ; but ;lieve that castor-oil or any aperient in the primary stage would n produce injurious results, and hence the importance of guarding public against the so-called eliminative or aperient treatment in early stages of the disease. The poison, I believe, may often ren inert in the system until some disturbing force, such as fear, bad , and water, or aperient medicine, acts as an exciting cause in singing the constituent parts of the blood.
There is one erroneous inference that might perhaps be drawn from the perusal of the re-published essay which I am anxious to prevent, viz., that I attach too little importance to sanitary measures. I believe now, as I did in 1849, that no amount of dirt, filth, or overcrowding will alone produce Cholera ; all these causes will predispose to the disease and increase the mortality, and therefore all sanitary regulations and house to house visitations, with a proper supply of medicine in all affected districts, should be strictly enforced ; but care must be taken not to increase the mischief, as in 1832, by over officious meddling ; by the removal of nuisances that may become more deadly the more they are disturbed. The time has passed for these disturbances, and better will it be to use disinfectants and shut out the deleterious gases than aggravate the evil by their greater dissemination.
I^o some, the addition to this essay of a treatise on Cattle Plague, n in the shape of an appendix, may appear out of place ; but aye fully explained my reasons for this unusual combination, I hope that a profitable comparison may be made between this aan scourge and the bovine pestilence. As I have said on a aer occasion, most of our discoveries in physiology have been ved from experiments on the lower animals ; and I see no reason r brute pathology may not be turned to equally good account in the sidation of human maladies.
i 2, Beaufort St., Chelsea, and 21, Parliament St.,
September, 1 860.
MALINGNAT CHOLERA
[Paper read at the Medical Society of London, October 28th, 1849, by the Author.*]
There is no disease about which so much paper and ink have been so uselessly and, I fear, injuriously consumed, as the Malignant o- Asiatic Cholera ; and although the present epidemic has afforded most medical practitioners in large towns abundant opportunities of invesr tigating the nature and origin of the malady, as well as its treatment, I doubt whether much progress has been made towards the elucidation of these important subjects. I am old enough to remember the first case of this mysterious scourge, which occurred in Sunderlund in 1831. I heard the various and contradictory opinions advanced at that time respecting the disease, and I was present at this society when Dr. Tytler for several evenings endeavoured to persuade the members that damaged rice was the fons et origo of the mischief. He denominated the disease Cholera Oryzea, and. most ingeniously traced the connection between the progress of the malady and the circulation of damaged rice ; several of the members were deluded by his arguments, and readily became converts to his views. Dr. Tytler, whose honesty of purpose I will not for a moment question, is now numbered with the dead ; many of his hearers have also slept their last sleep. Amongst those who took a prominent part in the discussion I may mention Dr. James Johnson, whose sensible and practical remarks upon the nature and treatment of this and other diseases many in common with myself have often listened to with great interest and instruction. I well remember, after numerous plans of treatment had been recommended, that Dr. Walshman (then an octogenarian), following the example of Sydenham, expressed his opinion that diluents, such as weak chicken broth given in large quantities, would be the best means of treating the disease. Young and inexperienced, and, like most juvenile practitioners, placing too much confidence in the power of medicine, I laughed at the old physician's remedy, and
* Reprinted from the London Medical Examiner and one Faculty Journal,
B
2
THEORIES.
Ised him with the cooks and nurses, whose office it is to prepare i-like slops. Profiting, however, by subsequent experience, and wing the thousand and one modes of treatment that have been pted and lauded by their respective promulgators, I am induced to , whether the chicken-broth system of Dr. Walshman would not many instances have been more efficacious than the host of mediis to which I have just alluded, and I am reluctantly compelled ,nswer this question in the affirmative. It is true that patients c recovered from' a state of collapse under almost every plan pted, but they have, I believe, often recovered in spite of the tor and his drugs.
Let it not be supposed from these remarks that I have any doubt about the efficacy of medical treatment in this disease ; I believe that there is scarcely a complaint to which the human body is subjected more amenable to treatment in the early stage, if the remedies are judiciously and opportunely applied. In almost every fatal case that has come under my notice, the preliminary diarrhoea or serous hemorrhage has continued for a longer or shorter period, and no attempt has been made to arrest it. The patient often appears to himself and friends in no peril ; in a short time, however, the cold hand of death is upon him, and the muddy current of the blood ceases to flow. Medical aid is generally in this condition unavailing, and a disease, which a few hours before was under the control of the physician, now defies his art. The above is not an overdrawn picture ; it was one of daily, nay, almost of hourly occurrence, and the fault rested more frequently with the patient than with his medical attendant.
Ifn the present communication my object is to direct the attention the members of the society to that which is practical, and I shall id, as much as the nature of the subject will admit of, all specula-3 considerations. I might occupy many pages in discussing the jstion as to whether the Malignant Cholera prevailed in this country ore 1831, and whether the disease was known in India before 1817. hall merely, however, express my opinion that the disease described Hippocrates, Celsus, Sauvages, Sydenham, and other writers, is ; the Malignant Cholera of the present time ; and when we examine i history of the black death, sweating sickness, and other epidemics the 14th, 15th, and J 6th. centuries, and observe their commencent and decline, the probability I think is greatly increased that olera is a new disease, and that, like the scourges of the middle 38, it will desolate the earth for a time, and then give place to some sh pestilence.
II shall not dwell long on the various opinions which have been vanced respecting the cause of the disease. I believe that it is still solved in as much obscurity as ever ; for whether we look to earth, y, air, or water, insurmountable difficulties offer themselves. All : at present know about the matter is, that this inscrutable agent s certain powerful assistants in its train ; such as a moist atmosphere
3
; animal and vegetable malaria ; depression and anxiety of mind ; certain articles of diet and drink, and probably some trades and occupations. But as a proof that these agents alone will not produce the disease, there are millions living in malarious districts where Cholera has not been seen ; thousands of the rural population are drinking water from ponds and wells near their cottages, which is swarming with animalculae, and contaminated with decayed vegetable matter ; numbers are in the midst of filth and wretchedness, and yet the pestilence comes not to their habitations. This scourge has decimated the inhabitants of one side of a river, whilst those on the opposite bank have remained unscathed. This hidden poison defies heat and cold, for its victims have been almost as numerous in the regions of Northern Europe as under the burning sun of India ; and what is especially remarkable in the present epidemic is the fact, that although man has been blighted, the lower order of animals has escaped the stroke, and the vegetable kingdom (especially the cereal species) has been more than usually productive.
IBut I must quit this part of my subject, and proceed to the chief ects of my paper, which I shall divide into three parts :l.: 1. The uence of occupation. 2. The contagious nature of the disease ; and The most approved mode of treatment. In investigating the first [ second questions, I shall take for my text the reports of the ristrar- General, which I have carefully analysed. And here I not forbear yielding a just tribute of praise to Mr. Farr, for the 3 bestowed in the compilation of these reports, which I think are tined at a future period to elucidate some of the difficult points nected with the etiology of disease.
I commence my analysis with the week ending June 30th, as the trades and occupations of those dying of Cholera are then more particularly given. Diarrhoea, too, had its victims ; but as these cases are not individually reported for the first seven weeks, I shall merely give the number of cases occurring during that time, viz. 872. It is necessary also to state, at the onset of the inquiry, that I consider that the greater number of deaths from Diarrhoea were produced by the choleraic poison, and that I believe serous purging is essentially one of the stages of Cholera.
During the 17 weeks through which I have carried my analysis, and ending October 20th, the deaths from both diseases amount to 16,172: Cholera, 13,410; Diarrhoea (so called), 2,762; making a weekly average of rather more than 951. Nearly three-fourths of (victims to Diarrhoea die under 15 years of age, viz. 1,927 ; Ist from the age of 15 to 60 only 365 have died ; of those 60 years and upwards, 470. Not so with Cholera ; in this disease the itest number of deaths, or considerably above the half, have irred from 15 to 60 years of age ; the numbers being under 3,640; from 15 to 60, 7,710; 60 years and upwards, 2,060. ) cases of Diarrhoea before alluded to, numbering 872, in which
b 2
4
OCCUPATIONS.
Bsex is not named, reduce the cases analysed to 15,302 ; of these L 4 were males, 8,088 females.
To ascertain the influence of occupation in the production of the disease, I have selected from these reports all the males 20 years of age and upwards, amounting to 4,258, and the following is the result of the investigation.* Accountants, clerks, and writers, 103 ; architects, builders, and surveyors, 13 ; actor, 1 ; agents, 10 ; artists, 6 ; bookbinders, printers, publishers, and compositors, 93 ; bakers, 49 ; butchers, 39 ; tripe-dressers, 2 ; bacon-drier, 1 ; pork-butcher, 1 ; poulterers, 5 ; pieman, 1 ; cat's-meat men, 2 ; horse-slaughterers, 2 ; drovers, 6 ; cattle-dealer, 1 ; skinners, fellmongers, and leatherdressers, 13 ; curriers and tanners, 26 ; bone-collector, 1 ; bricklayers, plasterers, and masons, 64 ; brickmakers, 8 ; beadles, 4 ; brewers, 6 ; brokers, 4 ; stock-brokers, 3 ; draymen, 2 ; basket-makers, 5 ; carpenters, cabinet-makers, coopers, millwrights, coach-makers, and all workers in wood, 338 (of these 119 are carpenters, 60 cabinet-makers, and 5 upholsterers) ; piano-forte makers, 6 ; coachmen, carmen, omnibus conductors and drivers, 111 ; grooms, 7 ; hostlers, 22 ; farriers, 11 ; horse-dealer, 1 ; horse-keepers, 6 ; livery-stable man, 1 ; coalheavers
I The subjoined account of the principal occupations in the metropolis recently lished (Feb. 4), by the intelligent writer in the Morning Chronicle, on Labour the Poor, will enable our readers to make their own deductions: -"Domestic r ants, 168,701; labourers, 50,279; boot and shoe makers, 28,574 ; tailors and ;ches makers, 23,517; clerks (commercial), 20,417; carpenters and joiners, $21 ; laundry-keepers, 16,220 ; porters, messengers, and errand boys, i 3,103 ; iters, plumbers, and glaziers, 11,517 ; bakers, 9,110 ; army, 8,043 ; cabinet:ers and upholsterers, 7,973 ; silk manufacturers, 7,151 ; schoolmasters, &c, J8; butchers, 6,450; bricklayers, 6,743; blacksmiths, 6,716; printers, 6,618; ksellers, &c, 5,499 ; coachmen, guards, &c, 5,428 ; weavers (all branches), 35." Prom the shoe makers 3,717 females must be deducted, and of the lestic servants, females will form a large proportion.
I may mention an interesting fact in ray own parish. In one of the Ragged Schools (the Juvenile Refuge, Old Pye Street, Westminster) there are about 110 children, boys and girls, whose needful certificate of admission is their utter destitution and unfitness to appear in other schools, many not indulging in the luxury of shoe or stocking. The children are engaged in various ways from nine in the morning until eight at night, and each child has a bath three times a week. 90 of them have two meals a day at the school ; for dinner, 1 pint of pea soup, meat soup, or cocoa alternately, and half a pound of bread, excepting Sunday, when those who remain are regaled on treacle instead of soup. Their supper always consists of 4 oz. of bread with water to drink. Of the 90 thus cared for, only one child has died of Cholera, and this was at the first appearance of the disease, when the premonitory Diarrhoea was neglected (five people died in the same house). Under the windows of this school there are three open privies, the stench from which is sometimes scarcely bearable. In the New Pye Street Ragged School, where there are 200 children, not one death has occurred. In Pear Street School there is about the same number, and only one girl died. In the New Tothill Street School, there has not been a single death among 63 children. So that in nearly 600 children living in a close and badly ventilated neighbourhood, miserably clothed and worse fed (they are only fed at the Juvenile Refuge) only 2 died of Cholera.
5
OCCUPATIONS.
and coal-whippers, 22 ; meters, dealers, and weighers, 8 ; cheesemongers, 1 4 ; chandlers, 6 ; corn-chandlers, 4 ; tallow-chandler, 1 ; cooks, pastry-cooks, and eating-house keepers, 13 ; chemists and druggists, 5 ; ministers of religion, 2 Episcopalians (one of them a lunatic), 1 doctor of divinity, 1 Wesleyan, 1 Unitarian, 1 dissenting ; costermongers, 10; green-grocers and fruiterers, 15; cow-keepers, 6 ; dairymen and milkmen, 9 ; dyers, 8 ; drapers and hosiers, 23 ; general dealers, 16 ; engineers, 40 ; furniture brokers and dealers, 3 ; furriers, 11 ; farmers, 6 ; millers, 2 ; maltster, 1 ; fishmongers, dealers in fish and fishermen, 22 ; gentlemen, 132 ; merchants, 21 ; retired ti'adesmen, 34 ; flusheraian of sewers, 1 ; sewers labourer, 1 ; ragsorter, 1 ; scavengers, 5 ; dustman, 1 (get. 81) ; chimney-sweeps, 7 ; sweeps, 4 ; well-sinker, 1 ; fireman, 1 ; french-polisher, 6 ; gas-men, 3; gas-stokers, 2; lamp-lighters, 6; link man, 1; gardeners, 52; grocers, 17 ; hatters, 26 ; hawkers, 32 ; inn-keepers, licensed victuallers, beer-shop keepers, and barmen, 40 ; potmen, 5 ; labourers, 689 ; lawyers, 1 4 ; (law clerks before stated, 1 4) ; master of workhouse, ]; medical men, 17; musicians, 12; oilmen, 6 ; officers, police 23, customs 12, relieving 1, sheriff's 1 ; pawnbrokers, 5 ; marine store keepers, 4 ; postmen, 6 ; painters, plumbers, and glaziers, 74 ; pensioners, 72 (old) ; porters, 111 ; servants, waiters, and messengers, 54 ; soap-makers, 2 ; sailors and men employed on the water, 307 ; soldiers, including the invalided, 46 ; salesmen, 8 ; schoolmasters and teachers, 6; shoemakers, 154; tailors, 78; travellers, commercial, 21 ; tobacconists, 8 ; weavers, 96 ; warehousemen, 9 ; watchmen, 5 ; undertakers, 5 ; vagrants, 2 ; workers in iron, 102 ; silver and gold, 25 ; brass and copper, 30 ; tin, 9 ; glass and earthenware, 24 ; colours, 4 ; leather (exclusive of shoemakers) 22 ; hair, 27 ; wool, 9 ; tow, 15 ; paper, 9 ; bone, 3 ; miscellaneous occupations, difficult to classify, 103 ; occupations not stated (the returns in the first papers being imperfectly given), 399. Amongst the last, convicts, prisoners, and paupers are included.
Before commenting on these reports, I must premise that there are certain facts which it is especially necessary to bear in mind. First. The localities : and the interesting diagram of the Registrar-General, showing the deaths in every 10,000 inhabitants in each district, is important. In the 36 districts, Hampstead is the minimum, 8, and Rotherhithe the maximum, 263. On the north side the river the deaths amount to 42 only in 10,000, while on the south side they number 1 24. It must also be recollected that under the head of labourers, and those whose occupations are not stated, some important omissions may have occurred, although it is scarcely probable that any medical practitioner would tieglect the mention of a nightman, grave-digger, or any other employment that might be supposed likely to induce the UIsCJXSG.
Inferences. First. As regards the influence of occupation.
There is no particular employment, exclusive of locality, that
6
INFERENCES.
I ears especially to predispose to, or excite the disease. These returns lose one extraordinary fact, viz., that those engaged in some of the it filthy and dirty occupations have been peculiarly exempt from : epidemic. Thus no nightmen, sextons, nor grave-diggers are >rted, and those employed about dead animal matter form but a ,11 proportion of the whole. There is only 1 flusherman of sewers, 1 sewers labourer ; the former was 66 years of age. One dustl aged 81. Only 2 male vagrants are reported, and 1 female d 80 ; but some may have died in the poor-houses whose occupations c not known. Is it probable that the use of sulphur by these people ias a prophylactic ? This notion is somewhat strengthened by fact that there are but 8 straw-bonnet makers reported, 1 male 7 females, and the male was a master furrier as well. Men )loyed about gas-works appear to have enjoyed a great immunity a the disease. Mr. Holl, the Registrar, says, Sept. 15th:
I It is perhaps singular that up to the 15th instant no death nor case of Cholera irred in the Imperial Gas- Works, Maiden Lane. I inquired of a gentleman nected "with the establishment, who told me he had not heard of any case at or the other establishments at Hackney and Shoreditch. Mr. Fogarty, the lical gentleman under whose care the workmen are, informed me that the i are the most healthy persons in the neighbourhood. However, two cases s occurred, but the first was not a strong man, and rather intemperate ; the ;r had been engaged but three days, and was a kind of superintendent. Is coal gas destructive of the poison in the atmosphere which induces Cholera ?"
Irhe small number of persons attacked who sell spirituous liquors ds to the inference that the moderate use of alcohol rather tends ward off the complaint. I have no means of knowing the number teetotallers, but I learn that two members of our own profession o died of Cholera were water-drinkers. The dealers in fruit only ount to 25, including 10 costermongers. The mortality has been atest amongst the labourers, especially on the south side of the er: many of these men were employed about the docks, and in r , damp situations. Sailors also from the same cause have suffered a great extent, and amongst the latter the number of master riners and mates is remarkable.
IPhese returns also entirely disprove the prevailing notion that olera is a disease confined chiefly to the poor. Gentlemen, master desmen, and people in good circumstances were very numerous, but y were generally advanced in age : thus of the 132 gentlemen who d, only 18 were under fifty years of age, and 10 of these 18 were ween forty and fifty.
I\.Vi interesting question presents itself respecting the immunity of se labouring under chronic complaints. These returns show that atics (although they enjoy a comparative freedom from many ;ases) are not exempt from Cholera. There is reason to believe, rever, that although the law laid down by Hunter (" that two jases cannot exist in the body at the same time ") is often erroneous,
7
MEDICAL PRACTITIONERS.
I, it is applicable to a certain extent to Cholera, and that those uring under chronic maladies are less frequently attacked. Pregt women appear to have no peculiar exemption. I have seen but instance during the parturient condition, but Dr. Lever has met i 13 deaths in his own practice, in the present epidemic, and the rds in the French journals for 1832 afford many examples.
I now come to the subject of contagion. This question, especially 3gards the welfare of the sick poor, is one of great importance, authorities of Guy's Hospital closed their doors against the ission of Cholera patients, on the ground, as I understand, that disease might spread to the students and patients in the hospital, mst be borne in mind that this hospital possesses enormous funds ; isands in its vicinity fell victims to the disease ; but I believe, if fear of infection had not prevailed, and if temporary Cholera Is had been erected, that there would have been a great saving of lan life.
|sut what proof do these returns afford of the contagious nature of malady ? First, of the members of our own profession, 2,567 of >m (according to an Analysis I have made of the London Medical ectory) are practising in London, 17 only have died of Cholera and rrhoea ; 10 resided on the south side of the river, and 7on the th ; but two of the latter Dr. Burton and Mr. Key were attached he Boro' Hospitals. The ages of these gentlemen were as follows : SO, 36, 39, 40, 40, 41, 42, 44, 45, 47, 47, 50, 53, 55, 57, 76 ; one death of a medical assistant, student, or pupil has been recorded ; lough hundreds of these, as well as of the senior members of the fession, have been in constant attendance upon the sick, harassed anxiety of mind and almost prostrated by bodily exertion. But trast these deaths with those that occurred in Ireland in 1847 n typhus fever (Parliamentary Evidence). Dr. Cusac says (2982),
¦We found that 179 Irish medical practitioners, exclusive of pupils and army cons, died in the year 1847, about 1 practitioner in every 15, and 64| per . of the whole died of fever."
ILen in Edinburgh I learnt that about 12 students annually died of 3r in that city. Again only 5 chemists and druggists have died, of these a wholesale druggist and another a lunatic. Not one ggist's assistant nor apprentice has fallen a victim to the disease, 28 lawyers, including 14 clerks, have sunk under it. Take next ministers of religion, who it is presumed have been in close contact h the sick : of these there are 2 Episcopalian ministers (one a atic), 1 Doctor of Divinity, 1 Wesleyan, 1 Dissenting, and 1 Unian. Only 5 undertakers are mentioned, and no sextons norgravegers; but I know of one of the latter who recovered from a severe ick. Amongst the 8,088 females there are 38 nurses (7 or Bof se employed at hospitals), 71 charwomen, and 52 laundresses. The rths of 1,125 widows are recorded, and I have reason to believe that
8
XllG IlVTSDiillCl ttll (A. W IIG lIJWO OltCll UCCII CUt Oil L)V tJIIS riILIIIOSS DCStIIOHCO, although I am unable from the returns to give the numbers.
It would, I think, be presumptuous for any one to state that Choler s not contagious under any circumstances ; but surely these return how that it is so, if at all, to a very small extent. It should be re collected that persons who are thought to have taken the disease from ;he infected, have been exposed to the same deleterious influence a those first attacked. I also believe that many of the supposed example of contagion, if thoroughly investigated, might be otherwise accountec 'or. Mental influence, as a predisposing or exciting cause, has probabl not been sufficiently estimated. The following example, which occurrec ;o me in 1832, is a good illustration. A healthy boy, Eet. 6, saw on of his companions fall into the Surrey Canal ; he ran home, hi )owels became relaxed, and he died two days afterwards of Asiati Cholera : he had not been near a Cholera patient, but he was livin nan infected district. A gentleman whom I saw died at Brixton )is wife was much depressed in mind and was frequently over th corpse ; she died of Cholera a few days after her husband ; but bot were living in an infected district, and the lady from night-watchin and great anxiety of mind would be peculiarly liable to the disease A servant, act. 45 (a very timid woman), who was attended b my friend Dr. Parry, of St. John's Wood, went to visit a relation in Carey Street, Southwark, where she slept on Monday night. Ther were eight persons dead in the street, and the woman believed tha ;here was a corpse in the house. On Wednesday night she had diarrhoea and died of Cholera on the following evening. No case of Choler lad occurred in the street where she lived (Abbey Place) previous t ler death, nor has the disease appeared since. Fear and exposure t the noxious atmosphere, in this, and many other instances, are, I think alone sufficient to account for the occurrence of the disease. W enow little at present respecting the period of incubation of the poi son. The time probably varies much in different cases. In thi nstance it appears to have been about forty-eight hours. When th )oison, or a sufficient amount of it, has been received into the system he removal into a pure atmosphere does not always prevent the attack STumerous examples of this kind might be adduced. A gentleman, riend of mine, who had had slight diarrhoea, and who had been muc n the infected districts, went into Essex (60 miles from London) on Friday night, the 81st of August, intending to shoot on the following lay ; he said that "he felt better after his arrival/ but he was seize* with violent cramps and vomiting during the night, and died the fo] owing afternoon. This is the only case of Asiatic Cholera ever seen n this neighbourhood.
And lastly, as regards the treatment of the disease. This question is, I fear, likely to remain long in as unsatisfactory and uncertain a state as at present, unless a different and more rigid method of investigation be adopted. If at such of our public hospitals whose
9
funds would have enabled them to have received Cholera patients, a different method had been pursued, we might by this time have arrived at more positive conclusions respecting the effects of medicines in this disease. The system I would suggest, if this frightful epidemic should again visit us, is the following :: Three large well- ventilated wards, con taining4o beds each, should be set apart exclusively for Cholera patients, and (according to the present state of our knowledge) three of the most approved modes of treatment should be fairly and extensively tried, in each, under the inspection of medical men appointed by Government. It may be said that the poor should not be subjected to this kind of experiment ; but do the rich fare better in this disease ? Is not the treatment experimental, and to a great extent empirical ? Heat, cold, brandy, ice, aperients and astringents, acids and alkalies, calomel and tartarized antimony, and nearly a thousand other methods, many of them apparently as opposite in their effects as fire and water, have been recommended by different practitioners.
But to return to treatment. It is but fair to state in the onset, that although I saw many cases of Cholera in 1832 and opened several bodies, I have during the present epidemic attended only 20 cases of Asiatic Cholera, and, with one exception, they were all seen with other practitioners ; of these 13 died and 7 recovered. It is difficult to draw a useful or practical inference from the treatment, as although Dr. Ayre's plan was adopted in the great majority, other methods had been pursued at the commencement of the attack. I will allude to two or three remarkable cases. First, Mr. C, in the Westminster Road, seen with Mr. O'Shea. This patient was well at one o'clock in the morning (he assured me that he had had no premonitory diarrhoea),* and he died at seven (6 hours). Mrs. H., also seen with. Mr. O'Shea, appeared after a few hours to be dying. I injected 60 oz. of saline fluid into one of the brachial veins ; the effect, as in many cases recorded in 1832, was most remarkable ; the skin became warm, the pulse perceptible, the voice louder and a profuse perspiration bedewed the body, but after a few hours she got into her former state. I again injected about 40 oz. of the same fluid, and she lived nearly 24 hours from the first transfusion. Dr. Ayre's plan of treatment in this case was strictly adhered to, and carried on after the transfusion ; indeed, my principal object was to prolong life by the operation, so that the calomel, if of any efficacy, might have a better chance. One bilious evacuation occurred before death. I was anxious in this case, and in some others, to have tried the transfusion of blood and water, but 1 could not procure the blood. Believing with most practitioners that the loss of the serum of the blood is generally the cause of death, lam afraid transfusion has been too hastily abandoned. I think that
* Since tins gentleman's death, Mr. O'Shea has ascertained that he had slight diarrhoea for two days before the attack. I mention this to show the difficulty we have often in obtaining accurate information from the patient.
C
10
CASES
in most cases life may be lengthened by it, and iri this way the action of medicines may be prolonged.
But the most extraordinary case amongst the above was that of a gentleman, set. 18, residing in Nelson Square, whom I saw with Mr. Menzies of Stamford Street. He had taken, on the 10th of September (without advice), some blue pill, rhubarb, and effervescing medicine, which relaxed the bowels for a short time ; he was tolerably well, however, until Monday evening, when at seven o'clock he vomited once, and purged very profusely. The fluid from the bowels was the clearest I have seen, with a little flocculent sediment. He had taken effervescing medicine, calomel, and opium every half-hour, until I saw him at halfpast four in the morning. He was then nearly pulseless ; hands cold, feet warm, eyes sunk, voice feeble, great restlessness, and cramps in the legs and hands ; tongue and breath warm. I ordered 2 grs. of calomel every 10 minutes ; about 24 grs. were taken, but he died at eight, three hours and a half after I first visited him. After taking a few doses of calomel the symptoms appeared to improve ; the voice became louder, and the hands and forehead warm. A short time before death he had a sudden evacuation from the bowels ; I observed that the skin instantly changed to a blue colour, and he rapidly sunk. Soon after his death, when Mr. Menzies and myself were standing by the bedside, the arms, which were quite straight, were gradually flexed, so that the hands were brought up to the clavicles ; at this time no sound was heard, nor motion felt over the heart. I had sent for my transfusion apparatus, and on its arrival I injected a small quantity of saline fluid, but it did not pass readily through the vein. It is remarkable that in this patient the heat increased before death, and the body remained warm for 24 hours after. There is some resemblance between this case and the one which lately occurred at Bristol, in w r hich the warmth of the body continued for several days. I met with another instance of this kind during the present epidemic. I saw one remarkable case of suppression of urine with Mr. Taylor, of Camberwell. A man, set. 45, who had been in a state of extreme collapse, and whose life was despaired of, took 20 grains of calomel every 20 minutes, for several doses ; the quantity was gradually decreased, but altogether 360 grains were taken. When I saw him he was sitting up on the bed, and there was no evidence of oppression of the brain, although no urine had been passed since the attack, then 8 days. Mr. Taylor introduced the catheter, and drew off about a pint of urine, which appeared to have been recently secreted ; it was light-coloured, clear, and slightly acid ; had not a urinous smell, and on boiling it, no albumen was perceptible. This patient died comatose 12 days from the commencement of the disease, probably from the presence of urea in the blood. For several days before his death the secretion of bile had returned.
Ei forming an estimate of the comparative value of the various es of treatment, I unhesitatingly give the preference to calomel aedicine often powerless, as all medicine must be in some cases of
the disease), but I believe of more efficacy than any other we are at present acquainted with. I have heard that a learned lecturer on Materia Medica (duly licensed by the authorities), when calomel formed the subject of the discourse, said to his pupils: "Gentlemen, we are told when we are at a loss at whist to know which card to play, let it be a trump ; so, in treating disease, if you are at a loss, give calomel." A late President of the College of Surgeons (Parliamentary Evidence) thought it was not necessary for a surgeon to know the composition of this medicine, so that he knew its effect. Strange doctrines these, but I fear too common amongst some of the members of our profession. But what is the effect of calomel on the liver ? Unless we have been greatly in the dark for more than two centuries, it promotes the secretion of bile, and the vast majority of Cholera patients, after this fluid enters the intestines, are in comparative safety. Hence the advocates for the calomel treatment have, at least, a motive for the administration of the medicine. Mr. Grainger, now a gentleman of high authority (if correctly reported in the Lancet January, 1849, p. 25), recently told the students of St. Thomas's Hospital, " That the secretion of the bile is not arrested in Cholera, but that it does not pass into the intestine." Now, as the gall-bladder is oftenonly two-thirds full, and the amount of bile daily secreted amounts probably to 12 or 16* ounces, it is difficult, according to Mr. Grainger's theory, to understand what becomes of the surplus. But is calomel to be given in all cases of Cholera ? In the bilious diarrhoea, the chalk mixture, opium, and catechu, as recommended by the Board of Health, are, I believe, the best medicines ; emetics may assist, and other modes of treatment may accomplish the same object : but stop the purging in all cases without delay ; keep the patient in a state of quietude, and continue the astringents for some time after the cessation of the diarrhoea.
|[n the serous diarrhoea, where there is an absence of bile in the estines, I would at once commence with a grain of calomel and eat it every half- hour. If the above mode of treatment had been re generally adopted, I believe that there would have been a great ing of human life. If an artery is bleeding, we endeavour to est the hemorrhage, and I think it is equally or more important stop the flow of serum in this disease, for it is the want of propori between the serous and red particles that is probably the ise of the stagnation that occurs. A larger quantity of pure od might be lost, and the discharge would be perhaps less injurious ! ere is one important fact to bear in mind in the treatment of this ease, and it is one that should lead us not to despair of any patient ; ? that in the worst cases there is no disorganization of structure, the extreme cases of collapse (I can only depend upon the stateats of others) I have not witnessed a single recovery ; but it is fair
* 24 or 30 oz. would probably have been more correct.
c 2
11
12
CALOMEL TREATMENT.
I state that in the ten cases of extreme collapse which I saw, Dr. re's plan of giving two grains of calomel (without any other iicine) every ten minutes had not been fully carried out. In five of se cases I have reason to believe that life was prolonged by calomel ; in five others it appeared to be of no efficacy whatr. In 1832 I treated nearly all my patients with emetics, calomel, I opium ; in some I combined sulphate of zinc injections per anum; a treatment which appeared to be tolerably successful in the first iemic would, probably, from the greater malignancy of the present,
I[ have omitted many important subjects connected with the origin I treatment of Cholera, but I have already occupied too large a re of the time usually allotted to discussion. I have not spoken the fungoid theory of Cholera, because I believe there are many ts which militate materially against this mode of origin, and that, 3 the rice theory of Dr. Tytler, it will soon give place to some new trine. I also anticipate that, when the matter is more fully estigated, these cells will be found (both in and out of the body) districts where Cholera has not yet appeared.
Kr. Ayre, of Hull, has furnished me with the following interesting ment, which he permits me to use :
" I am preparing my report, and shall have it out in a day or two, when I will send you a copy of it ; the results are somewhat striking. Our medical staff had of necessity a large proportion of the practice in the two parishes ; and yet, whilst we have had but 6 deaths in nearly 3,000 cases of diarrhoea, the rest of the practitioners attending in these parishes, and following another treatment, have had 146 deaths. And in the same way, whilst we have 360 deaths from Cholera, they have upwards of 900. There has been no report made of anything but the deaths, excepting by the medical staff, but they cannot have had, it is thought, one-half the paupers that we have had, if even one-quarter, and yet the deaths exceed ours nearly three-fourths."
tarn pleased to find that the guardians of Hull have presented Ayre with £100 for his exertions during the Cholera.
IMie above paper it must be borne in mind was read four months ;e, and although the numbers would be somewhat different if all returns were included, yet these would not affect materially the eral inferences. I am anxious not to be misunderstood upon one it, viz. the benefit likely to result from sanitary measures in all large cities and towns. But the ill effects arising from impure air, er, and diet are not confined to Cholera, and this disease I believe ever solely produced by these agents. For example, in the first week September the mortality in London was 3,183, and in the following ks 2,865, 1,981, 1,611, 1,290, 1,075, 1,028, 902, 837, c 5.93, I, 892, 931, 1,053, 1,002, 1,043, 1,053. So that from the 13th October to the 29th of December, the deaths for the twelve weeks c 2,348 below the average of the estimated mortality of the son. Now it will occur to every one that during this extraordinary
13
HISTORY AND SYMPTOMS.
Irease of mortality we had the same drains, cesspools, sewers, ti ditches, and burial-grounds, and in addition to the facts I have >re mentioned, viz. that persons engaged in some of the most filthy doyments have enjoyed a comparative exemption from the disease, aye known certain localities near the river where the stench from sewers has been almost insufferable and Cholera has not appeared ; the other hand, in places where this disease has been very fatal, perceptible change existed in the atmosphere. In the event of ther visitation of this fearful pestilence, I think great benefit might c from the burning of certain substances, such as sulphur, tar, n, nitre, &c. in the infected districts ; but I purpose on a future Lsion to enter more fully into this matter.
i?he above paper was published sixteen years since, and it will now my object to investigate the leading points connected with the ses, pathology, treatment, prevention, and cure of Cholera, and to uire what advances have been made in these important matters se I last wrote upon the subject.
HISTORY AND SYMPTOMS OF CHOLERA.
I need say little about the history of Cholera, as it has been fully alluded to by various authors ; some trace it back to 1769, and others to a later date; it was not, however, until 1817, that it especially attracted the notice of Europeans, when it occasioned great mortality in the delta- of the Ganges ; from this point it extended westward in various directions. After hovering about the western parts of Europe, it first appeared in Turkey, 1830. It reached Hamburg in the autumn of 183 J, and the first case in this country occurred at Sunderland, October 26, 1831, the disease having been brought from Hamburg in an infected vessel. In the outbreak of 1848-49, the first case in London occurred September, 1848, in a seaman who came from Hamburg, an infected city. In the autumn of 1853, the third invasion of Cholera occurred, but it was in 1854 that it became so fatal, commencing in London with one death in July, increasing weekly until in the week ending September 9, the deaths amounted to 2,050, after which the disease gradually declined.
As is well known, the present epidemic can be traced to the Mecca pilgrims, who died in vast numbers, and according to the Lancet (1832), where a history of the progress of the Cholera is given, more than 20,000 of the Mecca pilgrims died of Cholera before it reached this country. In nearly every instance it has travelled westward, and it is said that it always appears first at a seaport, and never attacks the crews of ships going from an uninfected country. The weekly
trns of the Registrar- General for London, beginning June 2nd, as follows: 2, 3, 3, 1, 6, 14, 32, 396, .904, 1,053, 781, 455.
rhe appearance of the disease at Liverpool, Southampton, Epping, other places, is too well known to need repetition here.
Symptoms. These may be comprised in a few words. In the great majority of cases more or less uneasiness of the bowels succeeded by diarrhoea often painless, and of a serous character ; this may continue for several days before the accession of grave symptoms ; at other times the invasion is very sudden and without warning, violent cramps of the muscles of the abdomen and of the extremities, vomiting and purging of ricewater-like fluid, thirst, feeble pulse, the voice often reduced to a whisper, clammy coldness of the skin, anxious countenance, cold tongue and breath, sunken eyes, blueness of the face and lips, blue finger-nails, shrivelled ends of the fingers, and a death-like change in a short time, that is produced by no other disease. Although, as I have said, preliminary diarrhoea is not in every case present in Cholera, in the vast majority of cases it goes on internally, so that the intestines contain a large amount of fluid before any evacuation takes place. In some instances a large amount of water in the shape of cold, clammy perspirations, is lost by the skin, the diarrhoea in such examples being generally lessened.
After the stage of collapse comes one of reaction and fever ; the tongue is furred ; delirium not unfrequently occurs, or a stupid listless condition supervenes, owing to the presence of urea, carbonic acid, and other deleterious matters in the system ; the pulse becomes full and frequent, the skin hot, and the patient often gets into a low typhoid state. Sometimes an eruption appears on the skin of a rosealous character, but this only occasionally. Of about 190 patients under the care of Dr. Clarke, seven only have been affected with this eruption. The symptoms vary much in different cases ; complications may occur, such as pneumonia, quick breathing from stagnation and clotting of blood in the right side of the heart, and in the pulmonary vessels. I scarcely need say, that the return of pulsation at the wrist, improvement in the voice, and the restoration of the biliary and urinary secretions, are some of the most favourable signs.
In children there is a remarkable difference in many of the ptoms ; the cramp in the extremities and abdomen are seldom vent, and the alteration of the features and the blueness of surface less marked. Of the numerous children admitted into the idon Hospital, under the care of Dr. Clarke, Mr. M'Carthy rms me that not one has had cramps of the extremities. I may ark that I have not seen in this epidemic the same marked ration of features and loss of voice that I witnessed in 1832 1849, although the disease has been equally or more fatal ; eruption I have mentioned I did not see in the previous iemics-
14
15
CASES PREGNANCY.
(he temperature, as is well known, is very variable in Cholera, careful observations have been taken at the London Hospital on ge scale. Mr. McCarthy tells me that the highest temperature hie met with was 105° Fahr., and the lowest 92.
K'he pulse varies much even in the same stage of the disease ; in c persons at the onset being apparently but little affected, whilst thers it is rapid, feeble, almost imperceptible, or absent.
The respiration varies from 18 to 60 in the minute, the rapid breathing taking place when the right cardiac cavities are loaded with blood, and when the nearly stagnant current is scarcely moved by the heart's feeble impulse.
I have recently several times seen a great many patients (more than 100), under the care of Dr. Andrew Clarke, at the London Hospital, who kindly permitted me, with the assistance of his clinical clerks, to make such observations as I desired. I do not allude to the treatment as at present ; but little practical good can be drawn from it. Dr. Clarke will probably give a summary hereafter. Mr. M'Carthy, a gentleman whose assiduity and great attention to the patients deserves all praise, has kindly furnished me with notes of the leading features of most of the cases. Among these patients, and others in the Hospital, aarte t many of great interest. I will allude only to a few of the symptoms in some of the patients, that cannot fail to interest the reader. Several have suffered from ulceration of the cornea, and one little girl, about two years of age, has lost the sight of both eyes from this cause. One patient that I saw had a semilunar patch of ecchymosis on the inner side of the pupil of each eye, and another had a round ecchymosed spot of the same form on the inner part of each eye. One man had gangrene of the nose and feet ; a boy suffered with dry gangrene of the right foot, with loss of pulsation of the femoral artery at the groin.
I Pregnancy, as I said in 1849 (p. 7\ appears to have no in:nce on the prevention of Cholera ; a great many pregnant nen have been admitted into the London Hospital during the sent epidemic ; of these, nearly all miscarried or aborted. One ient I saw who was at the ninth month of pregnancy, and she I not felt the child for more than a week. On the 15th of gust labour came on, and the woman was delivered of a dead Id ; on the 1 7th she was doing well ; the labour was not longed, and was comparatively painless ; I saw this woman on i 20th with Mr. M'Carthy, and she continued to improve. On i 20th of August, when the epidemic appeared to be on the line, a man was admitted in the blue stage of Cholera, whose -cuations were of a pinkish colour from the presence of bloodpuscles, and other similar cases have occurred.
I In my paper in 1849, I spoke of a case where the heat of the in increased before death, and continued for twenty-four hours er dissolution. A similar case has occurred at the London
16
duration; of diajrrhcea.
Kpital ; so great was the heat of the body twenty-four hours f death, in this instance, that Dr. Sutton ordered cold water to oured upon it before the autopsy was made.
I select from the notes kindly furnished by Mr. M'Carthy, some of the leading symptoms of 80 patients admitted in succession, who died of Cholera in the London Hospital, under the care of Dr. Andrew Clarke. 1. Blood from the bowels, extreme restlessness. 2. Delirium. 3. Never rallied. 4. Great desire for bottled ale, which was given. 5. Stupor, great intolerance of covering, convalescent, again comatose before death. 6. Coma, 12 hours. 7. Fearful cramps. 8. Died on admission. 9. Coma. 10. Dozed until death. 11. Ditto. 13. Cramps and lividity of surface. 14. Dull in intellect and slow in answering questions. 15. Convalescent, then sleepy stage, from which he could not be roused. 15. Never rallied. 16. Ditto. 17. Ditto. 19. Under treatment for diarrhoea a fortnight before, never rallied. 20. Never rallied. 21. Passed into the sleepy stage, hardly waking to take food. 22. Delirious before death. 23. Recovered from collapse, bloody motions, much dyspnoea. 24. Stupor, death in 24 hours. 25. Collapse, rejected the castor-oil. 26. Died in collapse. 27. Reaction set in on the third day, became sleepy and unconscious. 28. Never rallied. 29. Great pain in the abdomen, no reaction. 30. No reaction. Duration of the Preliminary Diarrhoea. This is an interesting question, although often a difficult one to solve. Patients when asked will say frequently that they have had no bowel-complaint, but when closely pressed they often remember that the bowels have been relaxed, and the diarrhoea often in the first stage of Cholera is so painless that it excites but little notice. Many of the undermentioned patients, too, were children, from whom it was difficult to obtain accurate information. It must also be borne in mind that a large amount of fluid may have accumulated in the intestinal tube before the first evacuation. From the same notes I extract the period of the occurrence of diarrhoea before admission into Hospital in 68 cases of Cholera.
I[ divide the cases into those where diarrhoea had existed for irs before admission, and into those where it had continued for ! day or more. I need scarcely say that perfect accuracy is not led at. Hours: 10, 6, 12, 6, 4, 6, 8, 2, 2, 6, 2, 4, 6, 8, 7, 2, 6, 6, 2, 12, 6, 6, 10, 6, 8, 7, 7, 7.
I Days: 4, 3, 3, 1, 3, 2, 2, 1, 1, 5, 7, 6, 2, 5, 6, 7, 2, 4, 1, 2, 3, 4, 4, 4, 4, I|, li, 2, 3, 4, 3, 11, 8, 10, 10, 1, 1, 3. In one tance it is said that no diarrhoea or vomiting occurred.
|[t should be remembered that in the eastern districts of London, ii which these patients came, many thousands of persons k opium and astringent medicines for the early diarrhoea, and c quickly cured by locking-up the poison (so called). In vvcastlc, during the epidemic of 1849, of 25,583 persons treated
by opium and astringents in trhe early stage of diarrhoea, only sixteen went into the second stage ; and innumerable instances of a like kind might be quoted.
Duration of Cholera. This is a difficult matter to determine, because the preliminary stage, that of internal serous hemorrhage, may have existed for some time before evacuations from the bowels take place, and patients are generally very loose and careless in their statements respecting the existence of diarrhoea. In the subjoined statements respecting the duration of Cholera, it must not be inferred that the time mentioned includes the whole period of the attack. In many instances it is recorded that neglected diarrhoea preceded the Cholera symptoms, and I believe that the choleraic diarrhoea is as much a stage of Cholera as that of collapse. I select from the daily returns for the present month, August 6th to August 25th, the duration of the disease, as stated by 192 medical practitioners, of adult males over twenty years of age. The period of death of women and children I find to be nearly the same. Hours : 5, 6, 6, 6, 7, 8, 8, 8, 9, 9, 9, 9, 9, 10, 10, 10, 10, 10, 10, 11, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 12, 13, 13, 14, 14,14, 14, 14, 14, 14, 14, 14, 14, 14, 14, 15, 15, 15, 15, 16, 16, 16, 16, 16, 16, 16, 17, 17, 17, 18, 18, 18, 18, 18, 18, 19, 20, 20, 20, 21, 23, 26, 28, 28, 28, 29, 29, 29, 29, 30, 30, 30, 34, 34, 36, 36, 36, 60, 64.
Days: 1, 1, 1, 1, 1, 1, 1, 1,1, 1, 1, 1, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2}2 } 2, jj, 2}2 } 2, 3, 3, 3, 3, 3, 3, 3, 3, 3, 3, o, 3, o, 3, 3, 3, 3, 3, 3, 3, 3, 3, 3, 4, 4, 4, 4, 4, 4, 4, 4, 4, 4, 4, 4, 5, 5, 5, 5, 5, 5, 6, 6, 6, 6, 6, 6, 6, 6, 6, 7, 7, 7, 7, 7, 7, 7, 8, 8, 8, 8, 8, 8, 9, 9, 9, 11, 11, 14, 14.
3
It will be seen that 12 hours is the most common time of death after collapse ; at this period there are 21 cases, and that during the stage of reactionary fever the third is the day when most deaths occur ; 23 of the 181 deaths having been registered on that day. A larger number of returns will be necessary to arrive at accurate conclusions upon this subject.
Mate of Mortality. This varies greatly in different localities, so much depending upon the period of the epidemic, on its malignity, the class of patients attacked, and the time of treatment. I have reason to believe that in private practice the mortality is much less than that at hospitals, a fact that is readily accounted for. Patients whose circumstances will admit of it are seen earlier, and are kept at rest, a matter of vast importance in the treatment of Cholera ; whereas among the poor the exertion required to get to an hospital has often, I believe, an injurious effect.
At the London Hospital up to the present time, according to the Secretary's report (Times, August 16), from July to August 16th, 431 patients have been admitted with Cholera, of whom 242 died and 108 recovered. Of 123 persons with choleraic diarrhoea, 84
r>
17
18
probably equal to that of any in London, and the ventilation of the wards, the nursing, and the various requisites for sick persons are superior to those at most similar establishments.
The rate of mortality in different countries has varied from £ to f of those attacked ; some writers believe that the mortality has decreased during the recent epidemics, but of this I think we have no positive proof ; indeed, the evidence is somewhat contradictory. According to a statement in the Lancet. August 18th, in Russia 7,191 persons had been attacked and 2,856 recovered. In the Gazette Med. de Paris, July 14, p. 464, Dr. Duilboulin stated that Cholera in Holland had been more fatal than in 1849. Of 1,851 persons attacked in Leyden, Lahaye, Rotterdam, and Utrecht, 1,131 died. Dr. Prosper de Pietra Santa, Epidemic Cholerique, 1865, Paris, believes that the cholera poison has been less virulent during each epidemic. Thus, in 1832 the deaths were lin 40 of the whole population of Paris ; in 1849, 1 in 51 ; in 1853-4, 1 in 112 ; and in 1865, lin 270. This author quotes a large number of authorities to show that the quarantine laws as regards Cholera are entirely useless. Dr. Parkes estimates the mortality in India at about 58 per Cent. ; in Aleppo more than one-tenth of the population were cut off.
In this country the ratio of deaths to recoveries is only obtainable hospitals, workhouses, and public institutions ; but as I have said are, great variations occur, according to the treatment, locality, and iod of the epidemic. The duration of Cholera too is equally ricious ; occasionally it remains only a few days in a place, in le localities for months and years. Dr. Macpherson ("Cholera; Home/ 1866) says " that it is never absent from Calcutta ;" in this pect bearing a great resemblance to the Cattle Plague in the ssian Steppes.
OCCUPATIONS.
I Occupations. Some time after my essay was read and printed, Guy, of King's College Hospital, published a paper, in which he } the occupations of 4, 51 2 males over 15 years of age that died of lera in 1848-49. If this paper be referred to, it will be seen that c is no material difference between his conclusions and my own. Guy begins at the age of 15, and I at the age of 20 ; assuming i, until this age, occupations are not settled. Dr. Guy, by means he census returns and by the London Directory, endeavoured to a rough estimate of the ratio the deaths bore to the living.
Thus gentlemen and men of independent means are put down at 1 in 200, the whole number of deaths being 135 ; whilst two fatal cases occurred in rag-sorters ; the assumption being that there were only 108 in London, whereas 700 to 1,000 would have been probably nearer the mark. It must be remembered, too, that most gentlemen and men of independent means get out of London during the prevalence of Cholera. Dr. Guy, if his statistics are examined, appears to have lost sight of the fact that the number of master tradesmen mentioned in the Directory is no indication of the number of men employed in the trade. Thus, the dustmen and scavengers are assumed to amount to 234, the ratio being lin 37 ; but the men employed in these trades would be at least five times the number here stated. As in my own table, the men employed in dirty occupations are but few, the tanners were all in a neighbourhood where the disease was specially virulent. But let me now analyze the Registrar- General's report for London, 1853-54, when 10,738 persons died from Cholera and Choleraic diarrhoea ; 5,093 males, and 5,645 females.
I select, as before, all males twenty years of age and upwards ; they amount to 970. Auctioneer, 1 ; assistants, 3 ;*artists, 4 ; agent, 1 ; bookbinders, 7 ; basket-makers, 3 ; butchers, 14 ; boot and shoe makers, 49; bargemen, 3; builders, 2; ballast-heavers, 2; bakers, 14 ; bricklayers, 9 ; block-makers, 2 ; blacksmiths, 6 ; boiler-makers, 4 j brush-makers, 2 ; boat-builder, 1 ; beggar, 1 ; bonnet-presser, 1 ; brick-makers, 4; beadle, 1; butler, 1 ; billiard-table maker, 1 ; bootclosers, 2 ; box-maker, 1 ; bed-hayer, 1 ; barmen, 2 ; candle-maker, 1 ; clerks, 23 ; cabmen, 7 ; carpenters, 26 ; coach-maker, 1 ; coalheavers, whippers, &c, 12 ; commercial travellers, 2 ; custom-house officers, 2 ; carmen, 10 ; coopers, 6 ; cabinet-makers, 4 ; carter, 1 ; cheesemongers, 2 ; coach-painter, 1 ; cowkeeper, 1 ; coal and tar manufacturer, 1 ; coal-dealers, 2 ; compositors, 2 ; corn-trusser, 1 ; chaff-cutters, 3 ; coachmen, 5 ; carver, 1 ; carriage-greaser, 1 ; cricketer, a professional, 1 ; crossing-sweeper, 1 ; chimney-sweeper, 1 ; cap-makers, 2 ; co3termonger, 1 ; cloth-worker, 1 ; chemists, 2 ; chaser, 1 ; coach- trimmers, 2 ; cloak-maker, 1 ; cider-merchant, 1 ; chair-maker, 1 ; cordwainers, 2 ; cellarman, 1 ; dust collectors, 4 ; dyers, 2 ; dog fancier, 1 ; drover, 1 ; dentists, 2 ; designer, 1 ; diesinker, 1; excavators, 2; engineers, 8; edge-tool forger, 1 ; eatinghouse keepers, 2 ; engine smith, 1 ; farmers, 2 ; farriers, 5 ; fishmonger, 1 ; firewood dealer, 1 ; feather-dresser, 1 ; firemen, 2 ; furniture dealer, 2 ; general dealers, 2 ; ginger-beer makers, 2 ; gunmaker, 1 ; gunner, 1 ; gun-case fitter, 1 ; gun-smiths, 7 ; gardeners, 10 ; grocers, 2 ; gentlemen, 30 ; gate-keeper, 1 ; greengrocers, 4 ; grooms, 5 ; glazier, 1 ; gas-fitter, I ; glove-maker, 1 ; gold-beater, 1 ; grave-digger, 1 ; hatters, 4 ; hawkers, 9 ; house agent, 1 ; hammerman, 1 ; hair-dressers, 5 ; house-painter, 1 ; hotel-keeper, 1 ; housekeeper, 1 ; horse-keeper, 1 ; husbandman, 1 ; instrument-maker, 1 ; ironmoulderers, 3 ; iron-planer, 1 ; jeweller, 1 ; labourers, 154 ; (dock)
i) 2
19
Ic*U\JUa cITDj J. T? y llLLlloL'l \lvllltlllLlisj O j ILtlLllCl" Ul L*.oL I t>, 1 L it 1 1 X1 dyer, 1 ; lithographic printer, 1 ; lead-pencil maker, 1 ; locksmith, 1 ; lithographer, 1 ; livery-stable keeper, 1 ; licentiate of Apothecaries' Company, 1 ; mendicant, 1 ; ministers, 2 ; maltster, 1 ; music engraver, 1 ; (males unknown, 15) ; milkman, ] ; miner, 1 ; millwright, 1 ; musicians, 6 ; mariners, seamen, &c, 60 ; messengers, 2 ; missionary, 1 ; mat-maker, 1 ; metal-planer, 1 ; oil-cloth painter, 1 ; ostlers, 2 ; oilman, 1 ; oil boiler, 1 ; porters, 37 ; polishers, 5 ; pensioners, 4 ; printers, 7 ; postmen, 4 ; packers, 3 ; pawnbroker, 1 ; prisoners, 9 ; paper-hangers, 2 ; plasterers, 5 ; pressman, 1 ; plumbers, 2 ; painters, 14 ; piano-forte makers, 3 ; percussion-cap maker, 1 ; paper-stainer, 1 ; plate powder manufacturer, 1 ; railway inspectors, 2 ; railway plate-layer, 1 ; silversmith, 1 ; sugar-bakers, 2 ; male servants, 8 ; sawyers, 4 ; ship-caulker, 1 ; shepherd, 1 ; silk-printer, 1 ; stokers, 8 ; stonemasons, 3 ; shawlsmaker, 1 ; stock-maker, 1 ; stay-makers, 2 ; salesmen, 5 ; seal engraver, 1 ; singers, 2 ; schoolmasters, 2 ; scripture-reader, 1 ; stationers, 3 ; surgeons, 2 ; soldiers, 5 ; shopmen, 2 ; scavenger, 1 ; sadler, 1 ; silk-winders, 2 ; shoebinders, 2 ; tailors, 61 ; tanners, 5 ; tin-plate workers, 6 ; toy-maker, 1 ; tallow-chandler, 1 ; tobacco-pipe maker, 1 ; toll collector, 1 ; theatrical dresser, 1 ; undertakers, 3 ; upholsterers, 2 ; umbrellamaker, 1 ; vagrant, 1 ; venetian-blind maker, 1 ; watermen, 3 ; watchmakers, 3 ; weavers, 6 ; wheelwrights, 2 ; whitesmiths, 4 ; woolsorter, 1 ; wool stapler, 1 ; wine merchants, 3 ; wood-cutters, 2 ; waiters, 3 ; waistcoat-makers, 4 ; warehousemen, 3 ; wire- worker, 1 ; whitening manufacturer, 1 ; wine cooper, 1.
|[n these 970 returns it will be seen that there are only two geons, one member of the Apothecaries' Company, and two nisters ; and among the occupations that might be supposed to prepose to Cholera are only one scavenger, one grave-digger, and four itmen. There are 30 gentlemen ; and tailors and shoemakers, as in i last return, form a large proportion, 61 of the former, and 49 of the 'er. The sedentary occupations of the members of these trades and ir remaining so long in the same atmosphere may account for the great rtality among them. It is worthy of note that there is one coal I tar manufacturer. Labourers, as in all the returns, form a large portion, as do sailors and mariners.
I Let us now take the printed returns for the Metropolis during the sent epidemic. These daily returns were commenced on the 6th August and extend to the 25th. Before this date the number of ;kly cases of Cholera, beginning June the 2nd, was 2, 2, 3, 1, 6, 14, 346, 904, 1,053 ending August 4, so that a large number of the ployments are not obtainable. The occupations of 340 males 20 rs of age and upwards are as follows : Auctioneer, 1 ; barman, 1 ; kbinder, 1 ; basket-maker, 1 ; butchers, 4 ; bootbinder, 1 ; bargea, 3 ; builders, 2 ; ballast-heavers, 4 ; bakers, 4 ; bricklayer, 1 ; sksmiths, 3 ; blockmaker, 1 ; candlemaker, 1 ; clerks, 6 ; cabmen,
20
DIRTY OCCUPATIONS, 1866.
21
2 ; carpenters, 12 ; chairmaker, 1 ; coachmaker, 1 ; coal-heavers, 3 ; commercial traveller, 1 ; custom officer, 1 ; carmen, 6 ; coopers, 5 ; cabinet-makers, 3 ; coal merchant, 1 ; carter, 1 ; carvers, 2 ; cowmen, 2 ; cheesemonger, 1 ; dyers, 4 ; dock constable, 1 ; earthenware dealer, 1 ; engineers, 2 ; farriers, 4 ; fishmonger, 1 ; fruit salesman, I ; foremen, 3 ; furniture dealer, 1 ; fur-puller, 1 ; general dealers, 4 ; gunsmiths, 2 ; glass-blower, 1 ; gardener, 1 ; grocers, 2 ; hatters, 3 ; hawkers, 4 ; house proprietor, 1 ; instrument maker, 1 ; iron-founder, 1 ; iron-moulder, 1 ; jeweller, ] ; labourers, 75 ; labourers (dock), 14 ; licensed victuallers, 3 ; letter-carrier, 1 ; looking-glass maker, 1 ; musicians, 2 ; mariners, sailors, &c, 20 ; messengers, 2 ; organ player, 1 ; porters, 15 ; polishers, 2 ; policemen, 4 ; pensioners, 3 ; printers, 4 ; packers, 2 ; pewterer, 1 ; pawnbroker, 1 ; potman, 1 ; pier-master, 1 ; poulterer, 1 ; railway inspectors, 2 ; rag-sorter, 1 ; tailors, 8 ; traveller, 1 ; travelling snowman, ] ; tobacco operative, 1 ; tinplate worker, ] ; tobacco-pipe makers, 2 ; umbrella-maker, 1 ; upholsterer, ] ; shoemakers, 1 3 ; saddler, 1 ; silk-weavers, 7 ; silversmiths, 2 ; sugar- bakers, 6; shipwrights, 5; stovemaker, 1; stereotyper, 1; servant, 1 ; sawyer, 1 ; silk-dyer, 1 ; stokers, 2 ; shopkeeper, 1 ; waterman, 1 ; watchmaker, 1 ; weavers, 5 ; wadding-maker, 1 ; warehouseman, 1 ; wheelwright, 1 ; watchman, 1 ; whitesmith, 1 .
lis I have said before, the occupations were first published on the of August, previous to which period more than 2,000 persons had lof Cholera in London. In comparing the occupations of persons lg during this present epidemic and those of 1849, 1853, 1854, it is ;ssary especially to take into account the rank and grade of the ibitants in the localities affected. Thus, in 1849 the returns ined 132 gentlemen ; in 1853, 1854, 30 gentlemen were registered ; among these 348 persons that died during the present month, not death among gentlemen (so-called) is recorded, the locality being ly sufficient to account for the circumstance. As I have said where, one medical man, Dr. Ansell, of Bow, died before the 6th August, and therefore his death is not recorded in these returns.
As regards the influence of dirty and filthy occupations, these returns, like those of 1849 and 1854, fully bear out the correctness of my first conclusion, so that the addition of the 1,310 occupations to the 4,258 already published, when class and locality are taken into account, makes but little difference in the inference. There is a prevailing error that only the ill-fed and destitute are generally affected with Cholera. During the present epidemic in the east of London, some of the most filthy and overcrowded neighbourhoods have been specially exempt from the visitation. Thus in Poplar, Bow, and Stepney, the mortality has been more than double that of Bethnal- Green. Those who have seen the great number of fine, strong, muscular men, women, and children in the deadhouse of the London Hospita.l must have come to the conclusion that it is not a question of strength, or power of constitution, but that Cholera poison is as
likely to kill the strong and the muscular man as it is the weak and enfeebled, although those living in a pure atmosphere are less likely to take the disease. To repeat my words used in 1849 (p. 2), this inscrutable agent has certain powerful assistants in its train, such as a moist atmosphere, animal and vegetable malaria, depression and anxiety of mind, certain articles of diet and drink, and probably some trades and professions. If the west end of London should again unhappily be visited by Cholera, let not the residents who are well fed and well cared for indulge in any such false security as the belief that Cholera is a disease chiefly confined to the poor. The upper and middle classes have many advantages over their poorer brethren, such as early treatment and nursing, a purer atmosphere ; but the history of Cholera in all countries shows that although the disease has been more fatal among the lower orders, those living in crowded localities and in a damp and vitiated atmosphere, yet it has numbered amongst its victims a great many of what are called the " better classes " of society. I mention this that all may be impressed with the importance of early treatment, and of the necessity of at once arresting the diarrhoea.
Before I conclude this chapter, let me allude to some prevailing errors that have been extensively circulated by the public press. It has been said that people employed about gas-works have been exempt from Cholera. It is probable that in the returns for 1849 and 1854 some of these are classed among labourers; but during the present epidemic I have met with two men in the London Hospital employed in gas works, and I have reason to know that many so employed have been affected. Another error is the belief that Jews are specially exempt from Cholera. During previous epidemics this may have been the case to a certain extent in this country, but I have seen a great many Jews in the London Hospital with Cholera during the present month ; and I believe in other countries they have not escaped the disease. The statement about the exemption of cider-drinkers has probably no better foundation. In my essay, 1849, I stated that of the 1 7 medical men who died in London, two were water-drinkers, and that the moderate use of alcohol probably tended to ward off the
Dr. Snow, in his excellent work on " Cholera," 1855, p. 122, quoting from Dr. Guy's table, says, " One master brewer died of cholera, being 1 in ] 60 of the trade ; but no brewer's man or brewer's servant is mentioned as having died of this malady ; Dr. Snow naturally attributing these exemptions to their abhorrence of water." He further states, p. 124, " that on looking over the returns he has met with two or three of these persons, and that there must be a few thousands of them in London."
In my first return there are 6 brewers, and 40 licensed victuallers, rshop-keepers, and barmen. In the returns for 1853 and 1854 re are 2 barmen and 8 licensed victuallers. In the imperfect rens for the present month there are % licensed victuallers ; so that
22
23
i.ii aiia -\q n +« -l |» m*oT^oT*i"i fin of sin ti f° (ifm kpt*^ I 'irn n. writer** drinker myself, and I am fully alive to the evils resulting from the immoderate use of alcohol poverty, crime, dirt, laziness, and bodily decay and suffering are its almost constant attendants ; but I am not sure that a moderate use of alcohol during a Cholera epidemic is not desirable, and probably good unadulterated malt beverage is the best.
CAUSES.
Water. One of the most frequent causes of Cholera is supposed to be water which contains the germs of the disease from excreta that have entered it by means of sewers, water-closets, and other methods. As is well known, the late Dr. Snow* was one of the first to promulgate his belief that the great majority of choleraic cases were occasioned in this manner, and the example so often quoted of the Broad Street pump was especially given in proof of the correctness of his theory. To quote from his own report on the Cholera outbreak in the parish of St. James's, Westminster, during the autumn of 1854, " The evacuations of Cholera patients found their way into this well. From the 19th of August, 1854, 616 persons died of Cholera in this district, but after the handle of the pump was removed, on the 9th of September, the mortality fell to one or two daily." Mr. Whitehead, in the same report (page 132), says, " Of the drinkers of the pump-water, the ratio of those attacked to those who escaped is at least 80 to 57, whilst the corresponding ratio of non-drinkers of that water was but 20 to 279." Mr. Yorke (page 170) also adduces evidence of a like nature. Dr. Snow and others have produced other facts to show that the water has generally much to do in the production of the disease ; and the result of the present epidemic in the east end of the metropolis appears to confirm the correctness of Dr. Snow's opinion, for at the present time (August 24th), of those who have died of Cholera in the east of London, nearly all have drunk the water of the river Lea. According to the Registrar-General's report, the six districts supplied from the Old Ford reservoir of the East London Water Company have suffered from the ravages of Cholera to a remarkable extent. Thus, the mortality in Bethnal Green has been 30 per 1,000 ; Mile End, 50 ; St. George's-in-the-East, 60 ; Whitechapel, 70 ; Poplar and Bow, 70 ; and Stepney, 80 per 1,000 ; whilst the other metropolitan districts have suffered comparatively but little from the epidemic. It must be observed that the rate of mortality does not correspond with the poverty of the inhabitants. During the
* " Mode of Communication of Cholera," 1855.
Bemic of 1848-9, the greatest sufferers were those who drank the mes water, then in a very impure state.
But in these instances, and in others that have been adduced, what proof is there that human excreta have entered the water ? In the case of the Broad Street pump, and in the remarkable instance that recently occurred at Epping it is more than probable that such a contamination occurred, and so with the Thames and other rivers polluted by sewage. There are some facts, however, that appear to militate against this theory, especially the remarkable exemption that I was the first to notice in 1849, of sewers-men and nightmen from Cholera. It may be said that these men are not water-drinkers, but their habits are not very cleanly, and they are constantly exposed to the influence of sewage. Again, if the water produces the deleterious effect attributed to it, how does it happen that Cholera subsides often very suddenly, although it is impossible to suppose that any material change can quickly take place as regards its purification ? And it is a curious fact, as shown in the report of the Medical Officers of Health, and in Dr. Letheby's report, that London water has been unusually free from impurities. It may be said, however, that the germs of Cholera poison from human excreta may multiply rapidly, and that it is impossible to detect them by any means that we are acquainted with. There is another fact that I think is beyond dispute, viz., admitting that the water drunk is the most frequent cause of Cholera, a vast number of cases cannot originate in this manner. The important matter to determine hereafter will be whether certain impurities exist in the water, irrespective of choleraic contamination, that may act as exciting or predisposing causes ?
I have carefully examined several specimens of water microscopically before mixture with Cholera evacuations, and some time after this adulteration. Let me briefly allude to some of them. To 2 oz. of water, taken from a water-butt, I added on August 20th twenty drops of recent Cholera evacuation. On the 15th of August I carefully examined this fluid under various powers from 60 to 1,000, and the only remarkable change was the enormous quantity of one species of infusoria {paramwcium), and also of active monads. There were present also fungous threads and some of the supposed Cholera cells, or bodies very like them, as figured by Drs. Brittain and Swayne, in the London Journal of 1849. In the Cholera water where the fishes had been confined, I did not find one infusorial animal. I mention this to show that fresh-water fishes are great scavengers and purifiers of water, although I believe that all the infusoria in the world would not alone produce Cholera. I gave some of the fluid first named to a rabbit, a white mouse, and a pigeon, without producing any apparent effect upon any of them.
Effect of Cholera Evacuations upon the Lower Animals. In the Medical Times and Gazette, 1854, vol. i. p. 182, it is stated that a dispenser at the Newcastle Infirmary drank, by mistake, some riceler
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25
EXPERIMENTS BY THE AUTHOR.
evacuation without any injurious effects. I am not aware that well-conducted experiments have heen made upon the lower mals, for the purpose of showing the effect of this assumed Cholera son. I have performed the following experiments not without ;ure and due consideration, for I hold that no experiment should made upon any animal without it can be clearly shown that it is sly to be of service to suffering humanity.
The question as to the influence of human excreta in the production of Cholera is one of great importance, and it is on this account that I have instituted the inquiry. The experiments were made in a detached building, under lock and key, and I took care to bury all the excreta of the animals employed.
liug. 18, 1866. A drachm of the rice-water fluid from the bowels . Cholera patient taken the day before, was put into a glass globe conling two quarts of water, in which was a small carp and two gudgeons. sse fishes were watched for some time, and no perceptible effect i produced upon them. The next morning the gudgeons had diseared in a mysterious manner, but the carp was lively and appatly healthy ; it remained for three days, apparently unaffected.
t'.ug. 22. Two small carp were placed in a glass jar containing tart of water ; to this a fluid drachm of rice-water from the bowels added, the fluid having been taken five days before and kept in a pered bottle. It was in a state of ferment ; the fish were kept for days in this fluid ; and, like the last named, were, a3 far as I d judge, uninjured.
Aug. 20. A healthy frog was treated in the same manner as the above. After remaining two days, it was apparently unaffected, and was set at liberty. A second, with the above discharge in a state of ferment, afforded the same result.
1^ healthy pigeon was fed upon peas. These had been immersed the same fluid, after having been kept for five days in a stoppered tie. The bird, after five days, was to all appearances well, although Iso drank water mixed with the Cholera discharges.
Slug. 19. A hedgehog was fed on meat and egg, containing the ; day a drachm of the same fluid, and the next day the same ntity was taken. After four days the animal was liberated from box, no perceptible effect having been produced.
BA.ug. 19. A kitten three-fourths grown was treated in the same nner and with a similar result.
A rabbit about one-third grown had Cholera evacuations that had been kept from five to eight dfcys mixed with its oats and cabbage : after three days it was liberated without apparent injury.
As I shall endeavour to show in the Appendix, the diseases of man and those of the lower animals differ so materially that I scarcely expected that these evacuations would produce an injurious effect upon the animals taking them. The animals were all kept so that the evacuations could be carefully examined. No important good
E
Cholera, the experiments, would have given great support to the water theory. I may add that I have had an opportunity of watching most of the animals up to the present time, and that they appear to be perfectly healthy. Other modes of experiment, such as injections into the veins, have occurred to me ; hut I am glad to escape on this occasion with an easy conscience, and I gladly abandon them, believing that no positive good would result.
CONTAGION.
I Contagion and Infection. Although as I have said in my first Br (p. 7) that Cholera is contagious only to a certain extent and , very limited degree when compared with small-pox, scarlatina, other zymotic diseases ; yet there can be no doubt that a vast iber of cases can be traced to infection, and in a great many in- Lees where it appears in a fresh locality some clue is afforded as to mode of ingress ; thus, it is tolerably certain that the late outiks in Dublin and Belfast may be traced to the importations from erpool, and so with the remarkable case at Epping, and a great ly others that could be enumerated.
In commenting upon the influence of trades and occupations (in 1849, p. 5), I have fully shown that persons especially exposed to the influence of the poison, such as medical men, students, clergymen, and nurses, have not been more affected than others who have been away from Cholera patients. In 1849 only 17 medical men died in London of Cholera, and not one medical student, whilst 28 lawyers and law-clerks, 14 of each, fell victims to the disease.
|[n 1853-1854, as will be seen by the statistics, only two medical ,ctitioners died of Cholera in London, whilst during the present demic I only know of one medical man in England, Dr. Ansell Bow, who has died from this cause.
I During the recent outbreak of Cholera at Amiens two physicians re died and several inmates of the hospital, but those acquainted h this town, which possesses all the requisites for the propagation I spread of Cholera, will not be surprised at this. During the sent outbreak, of 70 nurses at the London Hospital, who have ended upon 559 patients with Cholera and choleraic diarrhoea, four re been attacked, three of them slept out of the hospital, and one ? a regular nurse. It must be borne in mind that this hospital, as 3 the case at Amiens, is in an infected district. In the medical
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and surgical wards not a single patient, I believe, has been affected with the disease ; but at Vienna, Amiens, and other places, many inmates of hospitals where Cholera patients have been introduced have
Irhere is one circumstance that demands especial attention, viz., the ?ility of women who wash the clothes of the infected to take the ;ase. Many examples of this kind are on record ; but then it must emembered that these persons are mostly in infected localities. Asling that the disease is conveyed in this manner, does the poison er the body by the skin or by the lungs, and what influence has increase of temperature in favouring its ingress? From the abers of persons employed about dead bodies and their singular mption from the disease, I am induced to believe that warm water f have favoured the introduction of the poison in the cases first
In the Report of the Cholera Committee of St. James, Westminster, 5, page 19, from which I have before quoted, occurs the following : f the 825 houses in this area, fatal attacks of residents occurred 13 ; there were 159 houses having single deaths ; 85 with 2 deaths ; with 3 ; 15 with 4 ; 12 with 5 ; 3 with 6 ; 4 with 8 ; and 1 with There were no less than 21 instances of husband and wife dying bin a few days of each other," a circumstance I have alluded to in first essay ; grief, I believe, acting as a depressing cause.
I'o show that something has been done towards the elucidation of question of contagion I extract the following recommendations of Board -of Health, with Sir H. Halford, the President of the ege of Physicians, at its head, October 20th, 1831 : " Rags, ?rs, and cordage should be burnt, and the victims burried in deed ground." " All articles of food shall be placed in front of house, and taken in when the person carrying them shall have cd." " Convalescents should be kept under observation for twenty i." "It may be necessary to draw troops and police around the jted place."
Before I finish this chapter I refer the reader to page 7, to the unt of the mortality among medical practitioners during the ne fever in Ireland by way of contrast.
PATHOLOGY.
I 'ore I speak of the pathology of Cholera, let me briefly allude to hysiological question of great importance upon which the theory )r. Johnson mainly hinges, viz. spasm of the minute pulmonary ries. Dr Johnson says, " I suppose that no physiologist of
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as spasm of the muscles." (P. 50.)
Dr. Johnson will not, perhaps, class me with the physiologists of the present day ; but I have devoted a good deal of attention to this study for the last fourteen years, and I hope that my labours are not altogether fruitless. I first deny that spasm can take place in any but a muscular structure, and I moreover assert that there is no proof that spasm ever takes place in an artery or in an extreme
I have long been looking for the proof, and shall be pleased if Dr. Johnson or any physiologist will furnish me with it. In 1848 Dr. Hughes Bennet was a candidate for a university chair in Edinburgh. He told the learned Town Councillors in his trial dissertation by a kind of Scotch concours, which very properly elected him, that the doctrine taught by Cullen in that university of spasm of the extreme vessels was proved to be perfectly true. In the next room to the lecture-room were a large number of microscopes, some of them showing the circulation of the blood, and I asked Dr. Bennet to give us proof of the correctness of his assertion. Dr. Bennet and others assume that the application of stimulants and other agents to a vessel, and the consequent stoppage of the blood, is a proof of its muscularity ; but I believe the effect is simply mechanical. If spasm of the extreme vessels were possible, I fear that we should be often subject to greater evils than those even occasioned by the Cholera. It is a mere assumption unsupported by proof. But, assuming that Dr. Johnson's theory of spasm of the minute arteries is correct, what a labyrinth of difficulties we get into if we take the doctor's views of the question. If these pulmonary arteries possessed muscular fibres, and they were in a state of spasm, what so likely as opium to relieve them ? And could the advocates of the opium treatment, if they are converts to Dr t Johnson's spasmodic theory, have a better proof of its correctness ? But, unfortunately for them, Dr. Johnson ignores both opium and the warm bath. This question in relation to spasm of the minute arteries does not refer to Cholera alone, but it is one of very wide application, and therefore I have made it prominent.
|[n Cholera there is no special disorganization of structure in the t and second stages, except the loss of a large amount of the thelial lining of the intestines and other parts, as evidenced by microscopical examination of the alvine evacuations, and by the >earances after death. The hyperemia that is seen in some organs, >ears to me to be due rather to the loss of the via a tergo, the ing powers of the heart, and to the thickened state of the blood, c central organ is unable to propel the thickened blood through the tern ; hence the loaded condition of the right cardiac cavities, and comparatively anaemic state in many instances of the pulmonary ans. In the third or reactionary stage, congestion of the lungs, neys, and other organs, may be met with, that are not present in
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I stage of collapse. The small size of the spleen and its firm ;ure in most cases, forms a remarkable contrast to its appearance ever and in other diseases of a low type. There is one important umstance in the pathology of Cholera that demands, I think, c consideration than it has met with from pathologists and siologists. The suppression of the urinary secretion and the irious influence of urea, have been fully alluded to by some lologists, but the effect upon the system of the bile secretion has been, I think, properly appreciated. The gall-bladder is, in the it majority of cases, distended with thick bile ; the liver is ewhat congested, and bile may be squeezed out of the cut -tubes ; but, judging from the contents of the intestines, but c bile passes into the alimentary canal ; indeed, one of the most )urable signs in Cholera is the presence of bile in the evacuations, lat becomes of this secretion ? I have already alluded to this in former paper, the liver, the great depuratory, blood-forming (as )elieve), and heat-giving organ, ceases to secrete, its normal ,ntity of bile being from 20 to 24 oz. daily. I quote from my ay " On the Morbid Conditions of the Bile and Gall-Bladder, " idoti Medical Examiner, p. 227, vol. ii.
I have ascertained by measurement that the gall-bladder of an It holds from ten to twelve fluid drachms of bile, and that of a d fourteen months old two drachms. It is difficult to ascertain exact quantity of the fluid secreted daily by an animal in a lthy state. In cases of fistulous openings, where the bile has been y collected, it may be said that the liver is in an unnatural condition, that its secretion may be more abundant. Taking the size of i organ into account, as well as the experiments that have been le by various physiologists, it is probable, I think, that the amount of the secretion has not been much overrated. L'Heretier mentions a case of biliary fistula, in which about 16 oz. of bile escaped in twenty-four hours, and probably all the secretion did not pass through the fistulous opening. Haller estimated the quantity at 24 oz. in the twenty-four hours in man ; Burdach from 17 to 24 oz. ; Liebig 24 oz. In the horse the quantity daily secreted is supposed to amount to 36 lb. ; in the ox 37^ lb. ; and in the dog to 36 oz.
If the greater part of this fluid in a normal state is burnt in the circulation and affords fuel for the respiratory apparatus, the loss of temperature and the sudden sinking can readily be accounted for, without having recourse to the speculative theory of spasm in the extreme vessels. I believe, moreover, as I have often publicly stated, that the liver has more to do with blood-formation than any other organ, and that the assertion made by Professor Bennet, of Edinburgh, that the spleen and other ductless glands secrete the blood, and that of Kolliker and others, that the corpuscles are destroyed in the spleen, are equally erroneous. But to return to morbid influences. Unfortunately many of nature's secrets are at present hidden from us,
till vi. vllvOv vviilivvlvlA » A vLX vU\s L/Cv v 11 UX vq ₯ \J L V/ilvlvl (A) (U C vSUCviUII Jf U\5C Lf and obscure ; but although we may not be able properly to interpret the phenomena, the suppression of the biliary and urinary secretions and the disintegration of the blood, are alone sufficient to account for the fatal results.
The feeble heart, the pulseless wrist, often for many hours before death, and the loss of the suction power of the auricle, are, I think, amply sufficient to account for the condition of the heart and lungs, without having recourse to such speculative theories as spasm of the minute pulmonary arteries. But what do Dr. Johnson's own cases prove? In his work on Epidemic Cholera and Diarrhoea, 1854-55, cases of Cholera and diarrhoea treated at King's College Hospital are recorded, and as far as the pathology is concerned, it does not, I think, tend to support his conclusions. Fourteen of the fifty-four cases were fatal, but examinations were not permitted in all. Let us see the condition of the heart and lungs in the inspections that were made. The numbers indicate the cases, which can readily be referred to. " Case 9. Heart contained a small quantity of blood ; lungs pale and sanguineous. Case 10. Intestines pink ; other viscera healthy. Case 11. Lungs pale and exsanguineous ; heart healthy. Case 23. Viscera of chest healthy ; lungs not so anaemic as usual. Case 35. Lungs much congested ; reactionary stage. Case 37. Fatty heart ; lungs healthy. Case 45. Coma during reaction ; heart healthy ; lungs congested at the back and base."
I^hat the lungs are specifically lighter in the vast majority of ilera cases Dr. Parkes and many others have long since determined, I believe that the anaemic condition arises from the causes I have merated, and not from spasm of the arteries. Assuming that the >page of the blood depends upon spasm of the pulmonary arteries, Johnson is wrong in supposing that the spasm is relaxed during ;tion, for in a great many cases this anaemic condition of the 3rior parts of the lungs is found in the reactionary stage. If Dr. kes' cases are carefully examined, I believe it will be found that ¦f give no support to this doctrine of spasm of the pulmonary
As I have said before, I made several autopsies in ] 832 of persons dying of Cholera. Through the kindness of Dr. Andrew Clarke and Drs. Hughlings Jackson and Sutton, I have been present at the undermentioned inspections at the London Hospital, with a view especially to test the correctness of Dr. Johnson's statement respecting the condition of the lungs and heart in reference to the assumed existence of spasm in the minute pulmonary arteries during life. The notes are taken from my own observations.
Aug. 7. Case No. 1. Girl, act. 5 years ; collapse. Examined by Dr. H. Jackson. Brain normal ; no serum in the ventricles ; lungs, upper part anaemic, but not destitute of blood, and on exposure to the air when a section was made, the surface became red. The lower and
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PATHOLOGY-CASES.
I ending parts congested with fluid blood ; heart in situ ; the right icular appendix distended. On cutting into the auricle and tricle, a large quantity of thickish black blood was seen, some of it i-coagulated ; a less quantity was present in the left cavities ; in se it amounted to about one ounce. The liver slightly congested ; -bladder full of thick dark bile ; the kidneys normal in structure ; cortical part pale, the medullary portions red and congested ; the sen firm and healthy, but very small. The stomach contained a te pultaceous matter ; in the duodenum, and in other parts of the c, a thick white creamy greenish fluid was present.
Ixamined, with Dr. H. Jackson and Dr. Sutton, the bodies of two !, one about sixteen years of age, the other fourteen, who died of lera in the stage of collapse. One boy came from Guernsey, and lk the same water on board the ship that the other sailors drank, declared that he had not tasted any other water.
Case 2. Aug. 7. A strong muscular boy. I need not recapitulate all the morbid appearances, as they much resembled those above described, except that in this case the right cavity of the heart was more distended with dark fluid, semi-coagulated blood, with a soft fibrinous clot adhering loosely to the parietes. The left ventricle contained about three ounces of semi-fluid blood. In this case the pericardium at the base of the heart was studded with minute ecchymoses and extravasations, not unlike those seen in cattle plague under the endocardium in the left ventricle. The stomach of this boy was lined with a greyish- white pultaceous matter, that somewhat resembled calomel, and as calomel had been given in rather large doses it was at first inferred that the medicine had remained unabsorbed on the mucous membrane. On careful examination, however, the matter appeared to be composed chiefly of curdled milk, but no chemical* examination was made. The liver, kidneys, and spleen were in the same condition as last described. In this boy the mesenteric glands were more than double their natural size, and the intestinal solitary glands were also large. Peyer's patches were more vascular than usual. The large intestines likewise contained the same pultaceous fluid, and small yellow excrementitious masses were present in some parts. Peyer's patches presented no abnormal appearance, nor did the solitary glands. Externally some parts of the small intestines were of a pinkish hue, the lower and depending parts being more congested. The urinary bladder contained about an ounce of urine.
I3ase 3. The morbid appearances in this boy were much the same in the first case, but in some parts of the small intestine there c ecchymoses and red patches, producing a mottled appearance. 3 aorta contained an unusual quantity of semi-fluid blood ; the nary bladder empty ; gall-bladder full of thick bile.
* In a somewhat similar instance Mr. Dove told me that the deposit was chemically examined, and no calomel found.
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cases it was less so. I carefully examined the blood, intestinal con-
E'he blood-corpuscles were lax, yielding, not assuming the same ided form as in healthy blood, but when dried on glass, the appear) was more natural. The intestinal discharges all contained a c amount of epithelial cells, and the villi were generally denuded.
IjASE 4. August 13. A girl about 20 years of age died in the ly part of the reactionary stage ; the left side of the heart contained ut 3^ oz of dark fluid blood, the right side about 5 oz., the spleen mal. The stomach contained a dark grumous fluid, the lining mbrane ecchymosed in several parts with round small spots of ravasated blood ; a few of these were seen in the intestines. The 1-bladder full, the urinary bladder empty, and coated with thick , The brain congested externally, but the interior free from blood ; serum in the ventricles.
IDase 5. Boy, act. 6, died in the early stage of collapse. The , ventricle of the heart contained 1^ oz. of blood, the right six chms ; a portion of the right lung soft, and, from recent inflamtion, left congested. The bronchial tubes lined with purulent tter. The stomach ecchymosed in several parts, and the lower t of the oesophagus stained and spotted from extravasation of od. Small patches of ecchymosis were also seen in the intestines.
Ease 6. A girl, set. 4, died in the early stage of reaction. The s anaemic. The quantity of dark fluid blood in the sides of the t about equal. The right lung weighed 2 oz., the left 2^ oz. vessels of the brain congested externally. The cerebral substance aal. No fluid in the ventricles.
Ease 7. Child, set. 2. The morbid appearances differed but little l those last named, and the brain was much in the same condition.
IJase 8. August 15. Autopsies performed by Dr. Sutton. A mg powerful woman, about 30 years of age, died in the reactionary ye, five days after the commencement of the attack. The lungs eh congested ; both sides of the heart contained fluid black blood about equal quantities, with a small fibrinous clot in each of the ities. The whole tract of the alimentary canal was singularly free n congestions or ecchymoses ; the external part of a pinkish hue. c lining membrane covered with the white pappy matter before cribed. The cortical part of the kidney pale ;. the medullary por-3S of a dark-red colour. Urinary bladder empty.
Case 9. A girl, 6 years of age, died in a state of collapse. The lungs rather anaemic anteriorly, congested posteriorly ; weight 9 oz. The heart contained less blood than usual. The intestinal canal of this girl, like that described in the preceding patient, was to the naked eye apparently free from any trace of disease. Peyer's glands and the solitary glands were quite normal, and the intestinal mucous membrane of a pale whitish colour.
En all the above autopsies the viscera were weighed, and in those noticed nothing remarkable was observed.
I3ase 10. August 20. A man, 45 years of age, died in the reonary stage. The lungs much congested ; left 18^ oz., right i oz. The right side of the heart contained about 4 oz. of blood ; left 2£ oz. The intestinal tube contained a greenish-yellow ;ter, the colour apparently produced by bile ; the mucous surface he naked eye healthy. The gall-bladder distended with about 5. of bile. Spleen small. Cortical portion of the kidney pale ; mamillary part red and congested. The renal bodies and the roid gland normal, as was the pancreas.
IjASE 11. A woman, get. 40, died in the reactionary stage, after eral days. The anterior part of the lungs anaemic, posterior parts gested ; weight of right lung 16 oz., of the left 11^ oz. ; a long, se, fibrinous clot extending into the pulmonary artery. A large mtity of dark-colcured blood on the right side of the heart, less in left cavities. Other organs as described in the last-named autopsy.
IJase 12. A woman, aged about 30. Both lungs much congested, c heart contained black fluid blood on both sides, but no clots fibrinous deposits. The gall-bladder much distended, and some iow faecal matter in the large intestines, of an offensive smell. The cous surface, as in the preceding cases, healthy to the naked eye. thing worthy of note about the remaining organs, except an ovarian lour, about the size of a cocoa-nut.
I could add largely to these autopsies, but the above twelve examinations will suffice, I think, to give the general characters of the morbid appearances in cholera ; viz., congestion of the right side of the heart, a smaller amount of blood in the pulmonary structure, and the consequent diminution of weight of the lungs ; a somewhat congested liver and full gall-bladder. The cortical part of the kidneys pale, the medullary portions red and congested, with a small quantity ; a viscid urinary secretion in the pelves. The renal bodies normal, as are the pancreas and spleen, the last-named organ firm and diminished in weight. The intestines often externally present a pinkish appearance, in other cases they are partially congested. The mucous membrane of the stomach, and the lower part of the oesophagus, often ecchymosed and stained ; the gastric membrane not unfrequently covered with a white viscid pap-like matter, as is the lining membrane of the intestines. The intestinal tube often contains a large quantity of the peculiar rice-water secretion ; the mucous membrane being in many instances unusually pale and white. The urinary bladder is contracted and empty ; the vessels of the dura mater somewhat congested ; the substance of the brain normal, and the ventricles free from fluid. Other lesions may be present, depending upon the stage of the disease, such as emphysema, extreme congestion of the lungs, inflammation of these organs, extravasations of blood into the alimentary canal, great congestion of the brain, enlargement of the
P
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BLOOD- CORPUSCLES.
Ktid and other salivary glands, stains and ecchymoses of the periium at the base of the heart.
B^he great loss of epithelial scales on nearly all the thoracic and ominal mucous surfaces, is another point of particular interest.
Eudging from my own observations, persons labouring under chronic adies are less liable to cholera ; but a more extensive examination ecessary to determine this.
The state of the blood demands especial notice.
I The Blood. There is one expression in the first published essay it requires explanation ; the blood is described as tarry and treacly, t this was intended to refer more to the appearance than to the ual consistence of the sanguineous fluid ; the blood is generally ck, black, fluid, and some portions of it semi-coagulated. It has ;n chemically examined by O'Shaughnessy, Parkes, 'Schmidt, Bec¦el, Garrod, and others. Dr. Garrod {London Journal of Medicine, i 9, p. 436) says "that cholera blood can readily be distinguished in any other blood." Taking Beckerel's standard for healthy blood, ,le 1,062, female 1,060, Dr. Garrod found the specific gravity of )lera blood in males 1,076 1,081 , in females 1,068 1,074 1,076 ; s blood globules increased from 140 to 166 171 in 1,000 parts, c density of the serum was greatly augmented ; the fibrine changed quality, so that it could scarcely be collected ; the urea was in ;ess, especially during the reactionary stage. In one case the urn of the blood taken during life yielded I*l4 parts of urea in )00. It can scarcely be wondered at that with such a condition of >od as this, combined with the other causes I have named, the ht side of the heart should be generally loaded, and the capillary isels of the lungs nearly free from blood.
In eight specimens of blood that I have preserved and kept in stoppered bottles, there is no separation of the serum, the blood remaining of uniform consistence ; of a deep claret-colour when shaken upon the glass. There is one peculiarity in cholera blood that I believe has not been before noticed. In all the recent specimens of blood that I have examined under the microscope, I have found the corpuscles, when in motion, more yielding and changeable in form than in blood taken from patients labouring under other diseases ; and when at rest, before the corpuscle is dry, there is generally a central depression, although, after a short time, when the blood is dried on the glass, this is less apparent. Does this laxity of the corpuscle (as I believe) arise from the partial escape of its serous contents, and if so, will this account for some of the morbid appearances in Cholera ? This is a matter that requires further investigation ; but from the examination of the blood of man, and of a very large number of the lower animals, suffering from various diseases, I am enabled to speak with some degree of confidence upon this matter ; and here let me very briefly allude to an interesting question respecting the cause of the coagulation of the blood, and of its tendency to stagnate in
the vessels of the living body. I was a candidate for the Astley Cooper " Prize Essay on the Cause of the Coagulation of the Blood," obtained by my friend Dr. Richardson, in 1856. My essay was a, very imperfect one, for I devoted too much time to the investigation of the size and formation of the blood-corpuscle of the lower animals, including the thickness of the parietes of the heart and large arteries, to allow of the prosecution of experiments that I intended to have made. During my microscopical examinations, I came to the conclusion, from repeated observation, that the escape of the fluid in the corpuscle by exosmosis played an important, part in the coagulation of the blood ; a conclusion, as far as I know, not before made. That the chief cause of the coagulation of the blood was the loss, or partial loss, of its vital or electric influence, and that the corpuscles became aggregated in consequence of the loss of their fluid contents. I believe I was the first, in my " Prize Essay on the Structure and Use of the Thyroid Gland/ to protest against the correctness of Dr. Richardson's conclusion that the loss of ammonia is the cause of the blood's coagulation, believing that no such cause could exist within the vessels, and believing, also, that the blood begins to die as soon as it leaves the body, and that the escape of ammonia is a necessary consequence of such death. The papers of Mr. Lister, Mr. Gamgee, and others who have attempted to refute Dr. Richardson's conclusions, were published after my Essay was sent to Guy's Hospital. I hope to make this matter plainer on a future occasion, and to show that the state of the blood in Cholera has a material bearing upon this question.
TREATMENT.
When investigating such a mysterious and fatal malady as Cholera, it behoves one to speak with great modesty and diffidence, and to confess that we are now, as in 1832, utterly and entirely ignorant both of the cause and nature of this disease. We know that a subtle poison, which probably first exercises deleterious influence upon the nerves, pervades the system, and it may be is now in the blood of more than half the inhabitants of London. We know also that any depressing cause, such as fear, great bodily labour, vitiated air and water, improper diet, may so derange the atomic constituents of the vital fluid that a great proportion of the serous particles filter away, leaving the red corpuscles in excess, and thus the poison to a great extent destroys the heart's power, the blood remaining in many of the vessels still and stagnant ; and hence, as I fully explained in 1849, the necessity of arresting the serous discharge at the onset, and maintaining the integrity of the blood. It is in the early stage that the benefit of medicine is positive and unmistakable, and probably in this stage in the great majority of cases there is no disease so amenable to treatment.
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It is true in some instances, especially in hot climates, the patient is struck down without vomiting or purging ; but these are exceptions to the general rule, and I have never seen a fatal case in this country where these symptoms have been absent ; and it must be borne in mind that in many fatal cases the intestines are filled with a large amount of the serous portion of the blood. Dr. Macpherson, who has seen a large number of Cholera cases in India, in his recent work on " Cholera at Home " says, " I have never seen a- case in which there has not been vomiting and purging." Dr. Hardie, Surgeon 73rd Regiment {British Medical Journal, August 25th, page 209), who has seen the disease in India as well as in two epidemics in the Mauritius, says he has never met with a case of the so-called dry Cholera ; and I believe that this statement will be confirmed by the majority of medical practitioners who have fully investigated the cases of malignant Cholera that have come under their notice. In all diseases we find occasionally strange deviations from the general type, and so in Cholera examples may occur of what is called dry Cholera (Cholera sicca), but these are rare and unfrequent.
Comparative Methods of Treatment. As I have before said, much will depend upon the period of the epidemic, the locality, and probably on the mode of treatment, although in all localities this is varied enough, and we have had vaunted remedies of all kinds, and many that appeared to be successful when first tried, but have afterwards lost their reputed efficacy. Dr. Bushman, in his work' on " Cholera and its Cure," 1850, gives the preference to the saline treatment, and of 446 cases, he says " only eight were fatal " under Dr. Stevens' plan (page 164), and yet so little confidence is placed in this treatment that it has scarcely been resorted to during the present epidemic. Under the calomel treatment and under various other methods of cure, or of reputed cure, I could quote examples of success equally startling. It is evident, that if the hospital establishment which I advocated in 1849 (page 9), had been formed by the Government in 1854, or during the present outbreak, and three of the most approved modes of treatment had been carefully and accurately tested, we should not be in our present state of doubt and uncertainty. As I said in 1849 no objection could fairly be made on the ground that the poor should not be the subjects of experiment, for at the present time, if we look to the Hospital Reports, all treatment is to a great extent experimental.
Irrespective of family ties, what medicil man would object, if he Cholera, to enter such an hospital ? Instead of the niggardly sum £500, employed by Mr. Simon (as reported in the medical journals), amount required for the building of one iron-clad ship for the truction of life would scarcely have been sufficient for the establishlt of temporary experimental hospitals, and for the prosecution of ntific investigation of a comprehensive kind.
The treatment of Cholera may conveniently be divided into the
ctuu. liiiLi lull, iuc luruicr iiicm ... . «"*' «t*iiii uai , water with or without spirits of turpentine, ice to the spine, chloroform, counter irritants and rubefacients of various kinds, such as mustard, turpentine, ammonia, horseradish, galvanism, dry cupping, and exhaustion of the air from the surface of some parts of the body. Among the internal remedies are catechu, aromatic confection, diacetate of lead, kino, dilute sulphuric acid, ipecacuanha, common salt, saline salts, as sesquicarbonate of soda, chloride of soda, chlorate of potash, castor oil, calomel, bichloride of mercury, the mineral and the vegetable acids, preparations of arsenic, iron, copper, and zinc, sulphite of lime, bisulphuret of carbon, nitrous oxide, chloroform, chlorodyne, camphor, ether, oxide of silver, strychnine, quinine, chlorate of gold, bismuth, starch, various emetics, ammonia, tobacco, carbolic acid, permanganate of potash, elaterium, yeast, cannabine, tartarized antimony, oxygen gas, aloes, alum, sugar, charcoal, turpentine, Epsom salts, sulphur, rhubarb, asafoetida, black pepper, colchicum, Indian hemp, terchloride of carbon, salacine, creasote, Cayenne pepper, prussic acid, phosphorus.
In addition to these, various astringents and other medicines have been thrown up the rectum, blood and' saline substances have been injected into the veins, solutions of morphia, quinine, and other Impounds have been by the hypodermic method passed under the n, and the rectum has been plugged to prevent the escape" of serous id.
Itt must not be supposed that I have enumerated half the medics and modes of treatment that have been tried in Cholera. I ak of those only I happen to remember, and I trust that I shall be riven by any of my readers who may suppose that I have omitted asures that they may think of greater importance than any I have imerated.
Ilperient or Eliminative Treatment. I have already endeavoured how that the theory upon which this treatment is based is unstable visionary, for there is no proof whatever that spasms of the small ries of the lungs take place in this or in any other disease, nor here any proof that vomiting or purging are efforts of nature to rid of the poison from the system. It would be as rational, I ik, to infer that the sweating stage of ague is an effort of nature id the system of the malarious poison, and that it would, therefore, mproper to stop it by means of quinine.
I jet me give the following examples, which have been witnessed by usands of practitioners. Two persons have choleraic diarrhoea ; the takes the necessary precautions and the diarrhoea is at once sped, and although the poison remains in his system, he is ;ored to health in two or three days ; the other, as in the case menled at page 8, neglects the early treatment-, goes on with his al occupation, losing a large amount of serous fluid by the bowels,
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liiting is soon present, the stage of collapse sets in, and all medical in too many instances is unavailing. This is not an overdrawn ;nre, but one of daily occurrence. It is not pretended that all is of Cholera are so amenable to treatment in the first stage ; ortunately too many patients have succumbed when early assiste has been had recourse to, and no means have been neglected, as as our present knowledge extends, to arrest the progress of the ady. It cannot be too often impressed upon the public that a rrhoea that in ordinary times may be salutary, during the prevalence Cholera, if neglected, leads to a fatal termination.
But let us come to a practical question, and ask what evidence we have as to the efficacy of the castor-oil or eliminative treatment, so called, in Cholera ? Let us pause for a moment, and ask whether this treatment is really eliminative ? I think most of my readers will infer with me that the term eliminative is a misnomer. If we wished to adopt an eliminative mode of treatment, Elaterium, Epsom salts, Glauber's salts, or some saline aperient that would increase the serous discharge from the bowels, would surely be more appropriate, and more in accordance with common sense. There are few persons who have not experienced the action of castor oil ; and there are few, I believe, in the profession who will come to the conclusion that the poison of Cholera can be eliminated by castor oil, which removes only the contents of the alimentary tube. But again let us ask, what evidence have we of benefit that has accrued from this treatment ? In Dr. Johnson's 54 cases of Cholera and diarrhoea treated at the King's College Hospital in 1854, only 14 deaths occurred ; but many of these were examples of the first stage of Cholera, choleraic diarrhoea, and therefore more amenable to medicine. I could find examples where the success has been apparently much greater under various modes of treatment. But what evidence have we of the efficacy of this mode of treating the disease during the present epidemic ? According to the reports of the Lancet and Medical Times, Aug. 11, Drs. Frazer and Davis, of the London Hospital, have tried it and abandoned it. Dr. Barlow, Physician to Guy's Hospital, in his excellent and practical articles on Cholera in the Medical Times and Gazette (Aug., 1866), neither favours Dr. Johnson's practice nor his pathology ; nor do the vast majority of the members of the profession. I could quote numerous examples where the treatment has entirely failed ; indeed, where all the patients who took the oil died ; but this, it is fair to observe, will^apply to any mode of procedure in the treatment of Cholera.
As I said in my preface, castor oil can do but little good or harm in the latter stages of the disease, and it may be more successful than many other medicines whose virtues have been equally lauded ; but people are told, through the public press, to take castor oil in repeated doses in the early stage of Cholera, to eliminate the poison, instead of having recourse to astringents and opium a doctrine, I believe, alike dangerous in practice md false in theory
38
39
question as to the best treatment to be adopted ; and I now, as in 1849, give the preference to calomel. It may naturally be said, " But why administer calomel, and condemn the use of castor oil ? they are both aperients." But all who have had sufficient experience of the use of these medicines know that their action is very different ; the one, calomel, often acting as a sedative by arresting the vomiting and assisting the passage of the bile into the intestines, whilst the other is too often an irritant as well as an aperient. Calomel, according to my experience, tends to diminish the gastric and alvine serous discharges, and does not act as an eliminative in the sense used by Dr. Johnson. Another great advantage in the calomel treatment is that the medicine is readily administered by placing it upon the tongue, whereas the castor oil is generally disagreeable to the patient ; and many, to my knowledge, have positively refused to take it. But lat is the calomel treatment ? By this I mean the simple administion of a grain of calomel, with the same quantity of sugar, every een minutes for a few hours ; after which the dose can be linished ; or two grains of calomel every half-hour, without opium stimulants of any kind. I have stated (p. 9) that in 1849 I ited twenty cases of Cholera ; and that, with one exception, they re all seen with other practitioners. Of these only seven recovered, i several were nearly moribund, and in the great majority the omel treatment was not fairly carried out ; stimulants, opiates, ines, and other medicines having been given before it was comnced. I have but little faith in this treatment unless it be early >pted. Let me give an example or two of its efficacy (or supposed cacy) when given at the onset of the attack of serous purging.
In 1848-49 I attended three members of our profession for Cholera, IVIr. Smales, then living at Walworth, the late Mr. Jos. Beane, of ikham, and my brother, Mr. F. Crisp, of Walworth. All had tnps, cold skin, and serous vomiting and purging. I need only >rd the particulars of one case. Mr. Smales, after neglected rrhoea for two or three days, was seized with serous vomiting and ging early in the morning when in bed (the most common period of tck). He had partial loss of voice, severe cramps of the legs and omen ; the skin and tongue were cold, the eyes sunken, and the ntenance much altered. I gave him a grain of calomel and a grain of sugar on his tongue every fifteen minutes, with a little ice and soda-water occasionally. After a few hours the vomiting, or, rather, the gulping up of fluid from the stomach, diminished ; the diarrhoea became less frequent ; the countenance and the pulse improved. The next day a bilious motion was passed, the secretion of urine returned, and the patient gradually recovered after taking about forty grains of calomel. The other cases were rather less severe, but the result of treatment was the same. I believe, in these examples, as in many others that might be adduced, it was the early administration
I the calomel, without injurious complications, that favoured recovery, rould never administer astringents after the appearance of serous niting and purging, not because I believe that the vomiting and rging are the means of eliminating the poison, but because the omel appears to me by its action on the mucous lining of the mach and intestines to arrest the discharge of serous fluid, and to p those actions that are called eliminative. To use a homely rase, an astringent that may act as a plug in the bilious stage of ,rrhcea has but little influence in checking the discharge at a later iod, when the intestinal villi are rapidly losing their epithelial ering. The reader must not suppose that I put much faith in calomel, or any other medicine, in the latter stages of Cholera ; but in the early ge, although admitting its failure in a great many instances, I ye more confidence in this medicine than in any other, not judging ne from my own experience, but from the testimony of the great ik of those who have written upon the treatment of Cholera.
I Two very contradictory objections have been urged against the use calomel ; the one is that it is not absorbed, the other that it fduces salivation. Who would not be glad to escape with a sore uth from an attack of Cholera? I may remark that calomel jcted the gums only in one of the cases above mentioned. The tement so often made that the calomel remains on the coats of the mach, and does not enter the system, I believe, is generally founded ; in two cases I have alluded to, what appeared to be omel, proved on examination to be other matter. In the last ge of collapse, with a loaded and oppressed heart and a highly soned blood, neither calomel nor any other medicine can be of much vice ; the time for calomel is at the onset of the serous purging and niting.
I Best Means of Prevention. I believe that no person in a Cholera trict, whatever his occupation or station in life, is free from the bility to an attack of this disease. The statistics I have given indantly show this. The best plan for all who can afford it is to ye the infected district and seek, a pure atmosphere. For those o are compelled to remain, from conscientious or other motives, I ieve the best precautions that can be taken are to keep to the t and drink that they are accustomed to ; to avoid excesses of kinds ; and especially to stop diarrhoea at the onset, by opium 1 astringent medicines ; to avoid so-called specifics ; and to send once for their medical attendants, who are best acquainted with peculiarities of constitution that may exist, and who can vary the itment according to circumstances. For those who cannot at once cure medical advice, I recommend the following mixture, a fourth t to be taken every two or three hours, until the diarrhoea is eyed. One dose will generally suffice until medical aid is
40
U Tinct: Opii, si.
Tinct: Catechu, 3ii. , Spts: Aramon: Aromat: s'. Vini: Ipecac: 5i-
Aquae Cinnamomi, Jvi. ft. Mistura.
Other means, such as three grains of diacetate of lead, with a quarter of a grain of opium, repeated every two or three hours, if necessary, may accomplish the same end. But above all things, as I said in 1849, stop the diarrhoea at once. Attention to drains, to water-closets, and to good ventilation in all parts of the house is highly necessary. The use of disinfectants, such as carbolic acid, permanganate of potash, chloride of lime, vinegar, burnt tar, and sulphur, may also be had recourse to.
During a cholera epidemic, as I said in 1849, I believe the making of large fires in infected districts, and the burning of tar, rosin, nitre, charcoal, and sulphur would have a good effect ; and in all private houses I think it is a good plan two or three times daily to burn brown paper, with a small quantity of tar and sulphur. These measures may not altogether prevent attacks of cholera, but I believe that they would diminish their number. Boiling the water that is drank is a matter of special importance ; and in addition to this, filtration through animal charcoal may be resorted to.
Hereafter it is to be hoped that the water of London, and that of all our large towns, will be obtained from a greater distance than at present. The Thames, although comparatively pure, contains abominations of all kinds ; and so with the greater number of rivers supplying large cities.
The necessity of disinfecting and of properly disposing of all cholera evacuations is most important, and it is better, where it can be done, to have a hole dug in a suitable locality, and cover them with a ler of earth. Sulphate of iron should also be mixed with them. I ?d scarcely say that cleanliness on the part of all nurses should be ictly enforced, and all bedding, clothes, and linen should be destroyed carefully disinfected.
Dr. Jules Worms, in an able pamphlet on " The Diffusion of Cholera," Paris, 1865 (p. 43), says, " Cholera patients were admitted at the Military Hospital of Gros Caillou, during six weeks. All the lections were received into closed vessels, and mixed with sulphate iron, and all the linen plunged into a solution of chloride of lime, ice this, not a single case has appeared among the wards occupied by the other patients, although they are only 30 metres from the special service wards, and no medical officer has been attacked."
In closing this chapter on the prevention of Cholera, I cannot help alluding to a remarkable circumstance mentioned by Dr. Hardie, whose paper I have before referred to. During the outbreak of Cholera at the Mauritius, June, 1854, 1,800 Chinamen were in the midst of the disease, and of these only two died. Did the use of opium and
a
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42
ROYAL COLLEGE OF PHYSICIANS.
1 occasion this immunity? I think it more than probable that is the correct explanation.
I Before I conclude this chapter on treatment I cannot help comnting upon the widely-circulated directions given by the Cholera mmittee of the Royal College of Physicians, at the solicitation of i Privy Council, to captains of ships, and to the public generally, the treatment of Cholera. Of all things commend me to a conve of doctors ! The greater the number, I believe, the greater the lger to the patient. All have their pet crotchets, and the result is it instead of plain common-sense directions, the whims and caprices all must be consulted, and too often a namby-pamby, half-and-half itment is adopted. The President's and Dr. Johnson's (soled) eliminative medicine must have its due influence, so castor-oil y be given at the onset, if " bad or obviously indigestible food has sn taken, or if the discharges are unnaturally offensive." Fancy the tain of a ship attending to offensive discharges or obviously indiitible food. Better invoke the aid of Neptune.
I jet me give, at the risk of again being charged with presumption in ering from such learned authorities, the treatment I have recently pted in my own case when suffering from diarrhoea. On the 7th August I saw a large number of Cholera cases at the London spital, through the kindness of Dr. Andrew Clarke. I also spent ie time in the dead-house, as well as in the examination of the )d and excreta under the microscope ; added to this, my diet at per was not of the most orthodox kind. In the night I was icked with diarrhoea, and in a short time I took catechu, chalk, rain and a half of opium, with some ipecacuanha, and I was well a, few hours. Ido not assert that I had Cholera, but I think no son can be long in Cholera wards and over dead bodies without >ibing some of the poison. Let no one with diarrhoea in Cholera es trust to five-drop doses of laudanum, or to ten grains of aromatic rder of chalk and opium.
En too many cases patients, when seen at the earliest stage, will die er every mode of treatment, but I believe the best plan is to stop purging at the onset with a sensible dose of opium, combined with c astringent.
GENERAL CONCLUSIONS.
Conclusions. 1. That cholera is a disease occasioned by a specific poison that affects first the nervous centres, paralyzes the heart and the most important organs of secretion, the liver and the kidneys ; disorganizes the intestinal secretory apparatus, disintegrates the blood, thereby allowing a large portion of its serous constituents to escape from the system.
and the consequent sinking in Cholera, depends upon spasm of the pulmonary arteries, is not founded upon correct physiological inference nor upon pathological proof.
11. That the belief that the vomiting and purging are efforts of ure to get rid of the morbific matter from the system has little 10 real foundation, and that the general adoption of the so-called linative or aperient treatment in the early stage of Cholera is likely cad to injurious results.
4. That, judging from the occupations of 5,566 males dying in London in 1849, 1853, 1854, and 1866 over 20 years of age (some of them engaged in the most dirty and filthy employments), occupation alone exercises but little influence in the production of the
5. That there is every reason to believe that under certain circumstances Cholera is a communicable disease, but to a much less extent than small-pox, scarlatina, and other zymotic affections.
13. That bad water, improper food, a vitiated atmosphere, want cleanliness, intemperate habits, fear, the incautious use of aperient iicines, and other depressing agents, all act as predisposing and iting causes of the disease.
17.I 7 . That the general belief that Cholera is a disease confined especir to the poor and destitute is entirely disproved by the statistics t I have adduced.
11. That the great majority of Cholera cases, when seen at the onset he first stage of choleraic diarrhoea, are for the most part readily ler the control of opium, combined with astringent medicines.
I). That, judging from our present knowledge, the calomel treatat when commenced early in the second stage of Cholera and perly carried out offers the best chance of cure, but that, like every er medicine, in many cases it appears to have no salutary effect.
10. That, as shown by my experiments, Cholera evacuations proe no injurious effect upon fishes, reptiles, birds, and quadrupeds ; that, from the evidence I have adduced, the lower animals and the abers of the vegetable kingdom during Cholera epidemics in this ltry have been as healthy as usual.
COMMENTS ON THE PUBLIC HEALTH ACT.
Public Health Act. It will not be out of place at the present time to say a few words on the Public Health Act, August, 1866, especially as regards the conveyance in public vehicles of persons labouring under infectious diseases. 1 was the first in the London Medical Examiner, January, 1851, to bring this matter before the medical
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44
Ifession. No other medical journal had treated upon the subject. *py the article to show that after fifteen years my suggestion has n but very imperfectly carried out.
ON THE PUBLIC CONVEYANCES OF LONDON.*
More than twenty years ago, we were in the habit of riding frequently in the Paris omnibus, a nice, roomy, well-ventilated vehicle, with plenty of room for knees and elbows, where a duchess might sit at her ease, and the asthmatic patient breathe with the same freedom as in his own chamber. The conductors well dressed and civil ; the coachman going a steady pace, but though rather tortoiselike, he reached his destination without loitering on the road; he gave his passengers time to get fairly seated before he started, and did not endanger their lives and limbs by jolting them off the steps at their departure. Drunken people, bundles of linen, sheep's heads, baskets of fish, and other offensive articles, were not permitted to annoy the eyes and noses of the travellers, and dirty straw did not encircle their feet. Moreover, for threepence a person could be put down in any quarter of Paris. The above description will apply to the present mode of travelling in Paris, as well as to that of 1829. At the latter period there was not an omnibus in London. But why are our vehicles so badly regulated ? Simply because government takes no concern about the matter, so long as it gets the duly; like the sale of quack medicines, the money is the object; the public welfare is a secondary consideration. But what has this question to do with a Medical Journal, it will be asked ? We have introduced the subject, because we believe it is one that materially concerns the public health. It is nothing to us if people wish to be squeezed and wedged together like the oxen at Smithfield ; this and other matters we could name, do not come within our province, but if we can show that many persons lose their lives, by the bad arrangement of our public conveyances in London, our time will not have been unprofitably occupied. We need not inform medical readers that a certain number of people require a given quantity of pure air, for proper respiration, and that, according to the present size and ventilation of the London omnibus, they cannot obtain this. That if a person predisposed to illness breathe such an atmosphere as he is frequently subjected to in one of these carriages, he must soon be on a sick bed. That an individual, during the prevalence of Cholera, or any other epidemic, when the tendency to disease, and the preservative powers of nature, are nicely balanced, need only get into an omnibus to turn the scale. If rheumatism should be his bane, he may obtain draughts without a doctor's prescription ; or he may inhale the vapours from bundles of dirty linen, reeking from the bed of contagion.
I jet us now turn to another evil respecting the public health, that has been irely overlooked. At the commencement of the present year, we attended a y beautiful woman, who fell a victim to that former scourge of the human 3, small-pox. A few days before the eruption appeared, she was on board a imboat at Southampton. The man who gave the cheques, had his skin ered with small-pox pustules. This lady believed she had taken the disease, )re it appeared, and thought that it would prove fatal. But who can get into ired vehicle of any kind in London, and feel sure that the lining is not saturated h. the miasms of small-pox, scarlatina, or typhus ?
IVe see no chance of redress for these evils, until we have a Board of Health )erly constituted, and a government that thinks more of the public good, than of He pensions. There is no reason why the conveyances of London should not .s comfortable and as salubrious as those of Paris. We would have vehicles arious districts for the express purpose of carrying those affected with conous diseases ; and we would inflict a severe penalty upon those who, by injing this law, endangered the health of the community.
* from the London Medical Examiner, 1851, vol. i.. p. 243.
Let me now ask how this Act will remove the clanger of which I complained in 1851. I copy clauses 24, 25, 38 :
14. It shall be lawful at all times for the nuisance authority to provide and utain a carriage or carriages, suitable for the conveyance of persons suffering er any contagious or infectious disease, and to pay the expense of conveying person therein to an hospital or place for the reception of the sick, or to his i home.
Ik If any person suffering from any dangerous or infectious disorder shall r any public conveyance without previously notifying to the owner or driver sof that he is so suffering, he shall on conviction thereof before any justice be c to a penalty not exceeding five pounds, and shall also be ordered by such cc to pay to such owner and driver all the losses and expenses they may r in carrying into effect the provisions of this Act, and no owner or driver of public conveyance shall be required to convey any person so suffering until shall have been first paid a sum sufficient to cover all such losses and nses.
18. Any person suffering from any dangerous infectious disorder, who ully exposes himself without proper precaution against spreading the same irder in any street, public place, or public conveyance, and any person in charge me so suffering, who so exposes the sufferer, and any owner or driver of a lie conveyance who does not immediately provide for the disinfection of his veyance after it has with the knowledge of such owner or driver conveyed such sufferer, and any person who without previous disinfection gives, lends, 3, transmits, or exposes any bedding, clothing, rags, or other things which c been exposed to infection from such disorders, shall, on conviction of such ace before any justice, be liable to a penalty not exceeding five pounds, proid that no proceedings under this section shall be taken against persons transting with proper precautions any such bedding, clothing, rags, or other things the purpose of having the same disinfected.
I^s I interpret the Act, nuisance authorities may provide these icles ; but it is not compulsory, as it ought to be, for every Metrotan vestry, or two or three vestries, to have such a vehicle in liness, for which those using it should pay ; and clauses 24 and 25 so easily evaded that it will be almost impossible for a magistrate :onvict under them, and the same remark will apply to clause 08.
lirrangements can easily be made with cabmen ; and all who carry ctious bundles of linen in omnibuses will continue to do so with unity. It is a difficult matter for the law to reach.
IPhe only remedy, I believe, will be to have proper vehicles for the pose, thoroughly disinfected, so that people may have no excuse evading the Act ; and railway authorities should be compelled to c a carriage to be used only by those who are affected with tagious diseases. Adults and children recovering from small, scarlatina, and measles, are constantly removed in first-class iages, leaving the fomites on the cloth for the benefit of the t occupant. There is less danger in second or third-class carriages. : a matter of greater importance is the establishment by the rernment of two Metropolitan Hospitals on a large scale, the one small-pox and the other for fever, so that poor people arc not jeeted to the formalities, delays, and expenses that they are put
45
GOVERNMENT HOSPITALS.
lit present. This is a national question, and it is not one that ild be left to private charity. Small-pox has been fearfully prent of late, and I need not say that the delay and difficulty often irienced in getting patients to the small-pox hospital is often the ns of spreading the disease. When shall we have anything national in this country ? The very ducks before the Queen's palace in k James's Park belong to a private company, although they are conred to be Royal ducks by the public. What slow steps will be le in advance during the next sixteen years ?
¦he Act contains some good clauses ; but I fear, as regards the enlents I have named, that they will be nearly inoperative.
ADDENDUM.
Since these pages were in print I learn that a full account of the Cholera cases at the London Hospital will appear in the forthcoming Hospital Reports. lam ture, from the great assiduity and zeal of all engaged in this inquiry, tl at this report will well repay perusal. In my letter on "Cattle Plague as Compared with Cholera and other Human Maladies," I sha.l have occasion again to speak of this pestilence.
APPENDIX.
I the origin, cause, pathology, treatment, and best mode of prevention of Cattle Plague A comparison between Cattle Plague, Cholera, and other human maladies A Letter on the treatment of the diseases of man and brute by Homoeopathy, with an expose of the false inferences and hollow assumptions of this pretended science, and on the present state of the Veterinary and Medical professions.
PREFACE
The first eleven letters were sent to the Lords of the Privy Council, and I publish them verbatim,* because I am anxious that they should form a record of the outbreak of Rinderpest in this country, and of the tardy and inefficient steps taken by those in authority to stamp out the pestilence at an early period. The letters were sent in manuscript to the Lords of the Privy Council, and then forwarded to the Mark Lane Express, where they were published, my object being to circulate my opinions amongst the agricultural community. In addition to this I had slips struck off, and these were forwarded to the London daily press, and to many of the Provincial newspapers. I now purpose, in addition to other matter, to add my comments to each letter, as the communications were for the most part hastily written By this means I hope to make the essay more valuable than it would have been, had it appeared at an earlier period.
It was my intention to have published a larger treatise, with numercoloured drawings that I have made, many of which were exhibited he Pathological Society of London ; but the advent of Cholera, a belief that a comparison of the two diseases may be profitably ituted, have induced me to alter nay plau, and to publish without her delay.
Xl man who " sounds his own trumpet," does not generally gain good opinion of his readers, but at the risk of being charged with umption I state some of the results of my investigations.
1. I was the first to show, by experiments made upon myself and
* Some few additions were occasionally made to the manuscript letters to the
ii
>
Cattle Plague in its first stage was not injurious to man when used for food. (Letter 2, September 30th.)
2. That the poison of Cattle Plague, when introduced into the human system by means of inoculation, occasioned no injurious effects, with the exception of papular eruptions on the skin, and that the reported deaths from supposed Cattle Plague inoculation arose from splenic apoplexy. (Letter 2, September 30th.)
11. That the disease was a malignant spotted fever (febris maligna tata), and had little or no resemblance to typhus or typhoid fever nan, and that the ulceration of the stomach and intestines, spoken by the Government advisers and others, but rarely existed. (Let-2, October 31st.)
I That the disease not only affected sheep and goats, as shown in fourth letter (p. 66), but that I knew of six different species iiminants that had died of it.
5. That an hospital should be formed by the Government in a suitable locality, with a staff of competent officers. (Letter 1, September 21st, 1865.)
I). That experiments should be made by the Government on a large le, irrespective of cost, at the suggested hospital ; and the prophytic powers of small-pock matter, and that of scarlet fever, measles, hus, and typhoid fever virus by inoculation, should be tested, as 1 as the virtues of various medicines as prophylactics or otherwise, jtter 2, September 30th.)
7. That all fairs and markets should be suspended, the movements of sheep and cattle by rail or road should be stopped, that dead meat markets should be established, and that all foreign animals should be killed at the ports of landing, that all dogs should be shut or tied up, and all hunting prevented. (Letter 1, September 21st.)
EThat an animal may be affected with this plague in an incit form so that no inspector can detect its presence, and that in manner the plague has been disseminated in all directions to a *ul extent. (Letter 3, October 7th.)
K. That the Cattle Plague has been extended by means of hounds hunting. (Letters 7 and 10, December 20th.)
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l\j. i nut tne tneory fis to the identity 01 small-pox and vyiittlc Plague is not founded on correct evidence. (Letter 8, January 4th.)
It will naturally be asked by some of my readers whether, if I had obtained a government appointment, my strictures upon the proceedings of the Privy Council would have been equally severe. My answer is that the views I have enunciated respecting the state of our medical and scientific institutions have been long publicly expressed, and I think this a good opportunity of repeating them. Redtapeism would probably have had some soporific influence upon myself, as it appears to have had on all who have been encircled by it.
All new matter is in a larger print. The chapters relating to treatment, future prevention, and the comparison between Cattle Plague, Cholera, and the diseases of man and the lower animals, have not been before published, nor has the letter on the homoeopathic treatment of Cattle Plague and other diseases, nor that on the state of the medical profession. I have pursued this investigation, as I have all my inquiries respecting the diseases of the lower animals and of plants, under the belief that I shall be able to throw much light hereafter on human pathology and treatment. The only proper method of studying the structure of organized beings is to begin with the lowest forms and work upwards to man : so I believe in the disorders and derangements of these structures, Nature's secrets are best revealed in the lowest grades of organization ; and I predict that hereafte the period it is impossible to calculate all students will study morbid derangement, as they now do, or should do, anatomy and physiology, by adopting the ascending scale. If my life be spared a short time, I hope to be the pioneer of this new method of investigating
51
APPENDIX.
I LETTER I. ON THE STOPPAGE OF THE MOVEMENTS OF
LETTER I
CATTLE, AND ON THE ESTABLISHMENT OF DEADMEAT MARKETS.
TO THE RIGHT HON. THE LORDS OF THE PRIVY COUNCIL.
My Lords, When the Cattle Plague first made its appeai'ance in this country, I placed before the Clerk in Waiting various documents, to show that I had for many years been investigating the diseases of the lower animals and of plants, for the purpose of throwing light upon human pathology and treatment, believing that in the study of disease the same system should be pursued as in the study of organized beings viz., the ascent from the lowest to the highest, a mode of investigation which, I believe, is exclusively my own. Among the publications forwarded were my prize essay *on " Lamb Disease " (awarded by Lord Portman) ; my essay on the " Causes of Death of the Animals dying at the Regent's Park Gardens, from 1851 to 1862;" my essay on 11 Splenic Apoplexy in the Ox, Sheep, and Horse " (a disease that kills sooner than the Cattle Plague), and a numerous list of my papers and morbid specimens of diseases of the lower animals, exhibited at the Pathological Society of London. I have, moreover, made the largest collection of the diseases of the lower animals yet formed (many of them in wax). I offered my services to the Government, to investigate the cattle murrain in this or in any other country ; and I presume to think, my Lords, that, if my offer had been accepted, I could ere this
have placed before the Government and the people such a history of the origin, cause, extension, mode of prevention, &c, of this disease as would have been of service to the country and to the cause of science. In answer to my letter to Sir G. Grey, I am informed by Mr. Waddington "that the appointment of inspectors is made by the Privy Council." Believing that my long and unrequited labours in the cause of science entitle me to a better and more useful post than that of a
I* None of these are sold for my own benefit, or I should not have noticed them.
Pur Lordships, from time to time, certain facts connected with se that will, I hope, throw some light upon the subject. The 3 one of national importance ; and I can, therefore, well afford any charge of presumption and vanity that may be brought le.
I-iet me first place before your Lordships the line of investigation t I have chalked out in studying this disease ; and then, without owing the programme, I will in this and other papers touch upon a ¦ points that I consider of immediate and pressing importance.
B. A brief history of epidemic and endemic diseases in man, in the er animals, and in the vegetable kingdom.
I}. The history of the Cattle Plague in this and in other countries ; variation and abatement, according to season, locality, and the pretionary measures adopted.
tThe origin and cause of the disease in this country, the localities hich it has appeared in the United Kingdom, with statistics of age sex, the number of animals affected, and the amount of mortality.
X, The symptoms, duration of the disease, and its morbid appearis, especially in relation to the microscopical and chemical condition he blood.
B. Is the milk or flesh of animals affected with this disease injurious luman beings when taken as food 1
I. What resemblance does the disease bear, in the symptoms and bid appearances, to the typhus or typhoid fever in the human ject?
7. Is the disease now prevailing the rinderpest of Prussia 1
8. On the parasitic origin of the disease.
I. The normal visceral anatomy of the ox, sheep, and other ruminants, l a view to ascertain the peculiarities in the structure of the bovine ily that especially render them liable to be affected by this mystes poison.
80. The most practical and efficacious means of prevention, especially egards the prophylactic treatment by the internal administration of licine and the distribution of gases through the atmosphere.
Kl. An estimate of the success attending the various modes of treatt, with suggestions as to the best methods to be pursued.
K2. The best and most practical modes of disinfection, and an investion as to the efficacy of chloride of lime, and other agents as disin-
K3. On the importation of foreign cattle as a means of engendering disease, with practical suggestions for the better regulation of this ort in future ; and on the necessity of restrictions in the conveys of cattle by rail.
14. A general summary of the above, with practical conclusions for guidance of the Government, of agriculturists, cow-keepers, and k-dealers.
El said before, my Lords, it is not my intention to trouble you the series of investigations enumerated above, but rather to place 3 you, from time to time, such selections from my labours in this
54
difficulty presents itself at the onset in the proper investigation of this disease, in consequence of there being no scientific central authority in this country, to which the Government can refer in a calamity like the present ; and the same remark will apply to the medical profession. We have in the one profession * twenty licensing bodies, all requiring different curricula and different examinations ; and in the other a college granting a degree, but one which is not compulsory ; so that nine-tenths of the veterinary practitioners of this country have had no proper education or examination ! Again : let us look to agriculture, where, instead of an agricultural university and museum (the establishment of which I have long publicly advocated), where a good education might be obtained, degrees granted, and professors paid by the State, some of whom might be consulted in such an emergency as the present, we have another club (of which I am a member) in the shape of the Royal Agricultural Society, who eke out education by driblets at their model establishment at Girencester. My Lords, all is clubism in this country, and there is nothing national or universal about any one of our scientific institutions. But let me suppose, my Lords, for the sake of exemplification, that when this " Cattle Plague " first made its appearance, we had had in this country a representative Faculty of Medicine in England, Ireland, and Scotland ; a veterinary college in each of the three kingdoms, the examination at which all who (as in France) act as veterinarians would be compelled to pass ; and an agricultural university, in which the study of the lower animals would form an important item in the curriculum ; and that selected from these faculties or colleges a commission had been formed to investigate this disease, and to report upon it ; is it likely, my Lords, that many important matters would be in the same state of doubt and uncertainty as at present 1 Let me explain. In the lengthy document by Dr. Thudicum (approved of by the Privy Council), constant reference is made to the use of chloride of lime " A healthy animal is to be washed with chloride of lime, with tepid water ; then fodder, both dry and green, is to be given ; then sop and pure cold water ; and next, the animal is to be rubbed dry with wisps of straw and hay." My Lords, there is no proof whatever that chloride of lime will prevent the noxious effects of this poison when received by the lungs, its ordinary and perhaps sole mode of access ; but assuming that the poison may be introduced by the skin, I can conceive no method so likely as this washing, wetting, and rubbing to effect the introduction of the poison ; and as to " pure water," everybody connected with cattle knows that these animals give the preference to, and do better upon, the water of ponds and ditches, which is so impure that it would be considered unfit for human beings. The occurrence of this disease is not a question of health. A diseased animal would probably be more likely to escape the malady which the strongest and healthiest readily succumb to. As I shall have occasion to allude to this curious document hereafter, I will
* See my evidence before the Parliamentary Committee ou the Phurmacy Bill, Blue Book, 1852, pp. 156165.
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I the present confine myself to the chloride of lime question viz , a this substance the disinfecting influence imputed to it ? How are to determine this 1 My Lords, if the imaginary commission I have ken of had been formed, a large sanitarium or hospital would have n established in an open space near London, where experiments ;ht have been made to determine this and fifty other matters that now in doubt and uncertainty. Experiments to be useful must be formed on a large scale ; few and isolated experiments only lead to c inferences. To such an establishment formed by the Government, jased animals, in closed vehicles constructed for the purpose, might c been taken ; cows and oxen of little value might have been surnded with chloride of lime, and introduced among the diseased mals ; others that had had their systems saturated with sulphur, tar, , and many other substances, might have been similarly tested ; and Jical and other modes of treatment might have been tried ; and in i way, as I believe, a vast number of important facts would have n elicited. On the score of cruelty, some would object to these teriments ; but they (the experiments) would be " cruel kind," as Irish say, as the sacrifice of the lives of a few cattle might be the ms of saving a large number, and the extension of the malady by ti a method as I advocate would not, I believe, be likely to occur.
fefore concluding this my first letter, let me, my Lords, urge upon the necessity of at once placing restrictions upon the conveyance of ig cattle by railroads ; it is by this means that the disease has been tly disseminated and conveyed, to almost every part of England ; I think that the transport of all living cows, bulls, oxen, and calves ild be at once prevented, and all large gatherings of cattle at fairs agricultural shows prohibited.
|>cad-meat markets should be established in various parts of London, in all our large cities and towns ; and the flesh only of oxen, cows, calves should be admitted, when properly dressed, and inspected by petent persons. lam aware that such a prohibition would excite a ,t deal of opposition and discontent in certain quarters ; but the sssity of taking stringent and active measures for preventing the ad of this disease is so urgent that all should be willing to make ifices for the general good. All foreign cattle (like our home-bred ts), for the present, should be slaughtered out of London, and the i sent to the dead-meat mai'ket, after proper inspection ; and so at >ur seaports where foreign oxen are landed.
I have the honour to be, my Lord,
Yours respectfully,
Edwards Crisp, M.D.
42, Beaufoit Street, Chelsea, Sept. 21, 1865.
Remarks. Circumstances occurred that obliged me to deviate somewhat from the plan of investigation I had chalked out. The state of our medical and scientific institutions in connection with the progress of Cattle Plague I shall speak of hereafter.
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57
LETTER lI EXPERIMENTAL GOVERNMENT HOSPITAL.
LETTER II
TO THE RIGHT HON. THE LORDS OF THE PRIVY COUNCIL.
My Lords, I learn from the Clerk in Waiting, Mr. Helps, that my letter published in the Mark Lane Express, September 25, was placed in the hands of Professor Simonds ; but, my Lords, as I have informed Mr. Helps, these letters are intended for your Lordships' perusal, and not for that of Professor Simonds, for whom I scarcely need say I entertain no unfriendly feeling, and you will pardon me, I hope, for repeating what I stated in my first letter, where I offered to investigate this disease.
I trust that the special researches respecting the diseases of the lower lals, which have so long occupied my time and attention, will be a cient excuse for the present application, and that it will not be mid that I am desirous of infringing upon the province of the veterinary ossion.
lefore entering upon the question of prophylactic treatment, and of best means of testing this treatment, let me observe that, as far as researches have gone, I do not find the same resemblance, either in symptoms or morbid appearances, to the so-called typhus and typhoid rs, that many have insisted upon ; but this is a question that I shall 3 to bring more fully before your notice hereafter.
Let us now, my Lords, consider the important and vital question of prophylactic, or preventive treatment ; for, by this method chiefly, combined with the precautionary measures recommended in my <3rsb letter, I believe, we are likely to stay the progress of the pestilence ; and I may here remark, that although I am an advocate for a large experimental hospital in the first instance, in the neighbourhood of London, I see many objections to the establishment of numerous sanitaria in cities and towns ; for I believe, if such hospitals were numerous, the plague would be greatly extended, and from the inadequacy of the funds at the disposal of private persons no experiments could be performed of a sufficient magnitude to lead to satisfactory results. The failure of the City Sanitarium, partly patronized by your Lordships, and the return of the money to the subscribers, are surely sufficient to show that such undertakings are not likely to succeed in the hands of private individuals. The .£1,500 subscribed would scarcely be sufficient to supply the closed vehicles that would be required for the conveyance of the diseased animals. My Lords, to carry out this scheme effectually £100,000 at least would be inquired ; a very small sum when the magnitude of the evil is considered and when the probable good that might accrue from the undertaking is contemplated. There is one objection that may be brought against the establishment of this experimental hospital, viz., " that it may become, by the accumulation of a large number of diseased animals, a focus of contagion ;" but I believe if proper precautions were taken no such evil would result, but on the contrary, diseased and dead animals that are
I
58
PLAN OF THE HOSPITAL.
now driven about the streets*, and their bodies exposed in open carts, would here be leas likely, by their greater seclusion and the proper disposal of their bodies after death, to be the means of disseminating the disease. It must not be supposed that I advocate the attempt to treat the generality of animals affected with this disease ; I believe, according to the present state of our knowledge, as suggested by the advisers of the Government, the best plan is to kill a diseased animal at once, and by this means endeavour to prevent the extension of the plague. But where is this killing and slaying to end 1 Are we to rest satisfied with our present knowledge, or rather ignorance, of the nature of the disease and its treatment 1 A remedy has been found for small-pox ; and Asiatic cholera (a disease now in our midst) is, in its first stage, I believe, more amenable to treatment than many others. Why may not a remedy be found for the " Cattle Plague " "] Why should we sit with our hands folded, and say, " The disease is incurable ; doctors know nothing about it, and the animal must die." Let certain modes of treatment, my Lords, be fairly tested before we arrive at so unsatisfactory and so un philosophical a conclusion ; and let us not suppose, because the disease has hitherto baffled our efforts, that a remedy may not yet be found. Have we tried the right method of searching out Nature's secrets and of unveiling one of her hidden mysteries? Have we endeavoured to trace the incipient and early effects of this subtle poison 1
t*et me now, my Lords, briefly sketch an outline of the mode of inigation I recommend to the Government : many modifications and rovements may be made by others.
I\. space of five acres on Wandsworth-common, or in any suitable ility near London, should be covered with temporary wooden builds, for the reception of 300 or 400 cattle, especial care being taken t the floors where the cattle are placed are of brick or asphalte, and t suitable means be taken to ensure good drainage that large pits be ; for the reception of dead animals, and a good supply of fuel, quickc, and of various substances for the fumigation of the atmosphere, be vided.
I Attached to this hospital should be a commission composed of a good ilytical chemist, a good pathological microscopist, four or six veteriy practitioners, and two medical men, who would at once make a ies of experiments and investigations respecting the progress of the rbid changes in this disease, as shown by chemical analyses of the ious organs and their secretions by the changes of structure as iudied by the microscope, and especially by the investigation of the effect certain medical treatment, external and internal, upon diseased and m healthy animals, with the view to test the efficacy of supposed phylactic or preventive measures. The introduction of two members ;ne medical profession to this commission would scarcely be objected I think, by the veterinarians; as, without any disparagement to the ;er, it is well known that members of the former profession have been re minute in their investigations of disease than the practitioners of veterinary art.
If such a commission were formed, the members would need no guide
TRIAL OF VARIOUS MEDICINE, ETC.
59
to direct them as to the line of experiment to be pursued ; but no harm will result from my giving a short outline of my own plan.
First, as to the efficacy of chloride of lime. In addition to the test suggested in my last letter, six healthy oxen might be inoculated with ten parts of the secretion from the mouth of a diseased animal, mixed with one or more parts of chloride of lime. Many experiments of various kinds might be made with other disinfectants, or supposed disinfectants, to test their efficacy. It is worthy of remark that in the directions put forth by the Royal Agricultural Society of England, chloride of lime is not mentioned.
Eealthy animals, that had been for some time under the influence of me, iron, sulphur, tar, salt, vegetable and mineral acids, mercury, antiy, arsenic, hellebore, and other agents, might be introduced among the diseased cattle, and in this way the virtue of certain substances now of doubtful repute be thoroughly tested, and the important question answered, as to whether by any mode of treatment we can so alter the blood of an animal as to render it unsusceptible to the effects of this poison 1 The efficacy of quinine as a prophylactic might be especially tested by giving animals from 40 to 60 grains twice daily for a fortnight, and then introducing them among diseased cattle. It is not pretended that such an expensive medicine could be generally employed ; but, my Lords, we have a great number of animals in this country, worth hundreds and thousands of pounds, animals upon which the continuance of the present superiority of English stock depends, and in the treatment of these no expense should be spared. The question is not only one that concerns the food and health of the people, but it is one that especially affects us as breeders of cattle ; for if measures of a more stringent and active character are not taken by the Government, many of our most valuable stock will be lost. Although, as I have said before, Ido not see so great an analogy between this disease and typhus or typhoid fever as is generally supposed, yet I should in the present state of our knowledge place more confidence in the administration of quinine as a prophylactic than in any other medicine, and I would advise all stock-keepers who have very valuable animals to put them at once under this treatment. We have abundant evidence of the efficacy of quinine in preventing fever in the malarious and poisonous districts of Africa and other countries. A gentleman, who in one of the Nile expeditions was the only one to escape fever, told me " that he attributed his exemption to the circumstance of his having taken five grains of quinine twice daily for several months."
I jet me, in conclusion, my Lords, mention a few medicines, the efficacy which may be fairly tested at this experimental hospital, in the itment of diseased animals. First, let twenty diseased animals be left rely to nature ; let the same number be treated with stimulants, and twenty be subjected to the saline treatment without alcohol ; the c or a greater number might be treated with turpentine, nitrate of er, decoction of oak-bark, the vegetable or mineral acids, alum, nuth, sulphur, sulphate of copper and opium, sulphate of zinc, acetate cad, sulphate of iron, pepper, catechu, and many other medicines, ie or in combination.
Again, the effect of the injection of certain substances into the veins,
in the treatment of valuable animals.
|?o many the purport of my letter is already sufficiently Quixotic ; there is one matter that 1 cannot refrain from mentioning, viz., the ct of inoculation (under guarded circumstances) of the virus of r -pock, typhus, measles, and scarlatina from the human subject, as phylactics or as remedial measures. It is surely worthy of trial. c of the direct scourges of humanity has been kept in abeyance by introduction of vaccine matter from the cow into the human body.
Irhese, my Lords, and many other matters crowd upon the mind in estigafcing this all-important and vital question. We are now in the rth month of the disease. The members of Lord Stanley's model liament are taking their ease, and are not to be disturbed ; a Royal nmission, composed of men learned in comparative anatomy and in te pathology, is "looming in the distance;" and when thousands re of cattle, and perhaps of sheep, have fallen victims to the disease shall have their report.
Xi my next letter, my Lords, I will touch upon the peculiarities of structure of the ox, sheep, and other ruminants in relation to this ise.
I have the honour to be, my Lords,
Yours respectfully,
Edwards Crisp, M.D.
42, Beaufort Street, Chelsea, Sept. 30