Government Regulations FOR THE PREVENTION OF CHOLERA. (From the Gazette of October G, 1848. EDINBURGH: . ANDREW MURRAY, PRINTER, HANOVER STREET. 1848. " A short statement should be drawn up, published, and left at every house, calculated to allay unnecessary fears, shortly stating a few of the known particulars regarding cholera — its non-infectious nature, the non-necessity for removal of the sick from their homes, the aggravating causes of the disease, and the measures to be adopted for its prevention and cure." — Dr Stark's Letter in " Scotsman" of 7th October. GOVERNMENT REGULATIONS. General Board of Health, Gwydir House, October 5, 1848. The General Board of Health having considered the official accounts which have been received of the course of Asiatic cholera, since the presentation of the reports of the Metropolitan Sanitary Commissioners, and having consulted medical practitioners of eminence and of special knowledge of the subject, and having compared the tenor of those recent accounts, with the observations made respecting the former mode of the propagation of Asiatic cholera in Europe, have now to represent,— That the experience obtained of this disease, during its former invasions of this country, in the years 1831 and 1832, and the still larger experience acquired during its recent progress through Persia, Egypt, Syria, Russia, Poland, and Prussia, appears to afford ground for the correction of some views formerly entertained concerning it, which have an important bearing on the measures, both of prevention and alleviation, that are expedient to be adopted. The extent, uniform tenor, and undoubted authority of the evidence obtained from observers of all classes, in different countries and climates, and amidst all varieties of the physical, political, and social conditions of the people, appear to discredit the once prevalent opinion that cholera is, in itself, contagious ; an opinion which, if fallacious, must be mischievous, since it diverts attention from the true source of danger, and the real means of protection, and fixes it on those which are imaginary ; creates panic ; leads to the neglect and abandonment of the sick ; occasions great expense for what is worse than useless ; and withdraws 4 attention from that brief but important interval between the commencement and the development of the disease, during which remedial measures are most effective in its cure. Although it is so far true, that certain conditions may favour its spread from person to person, as "when great numbers of the sick are crowded together in close unventilated apartments, yet this is not to be considered as affecting the general principle of its non-contagious nature ; nor are such conditions likely to occur in this country ; moreover, the preventive measures founded on the theory of contagion, namely, internal quarantine regulations, sanitary cordons, and the isolation of the sick, on which formerly the strongest reliance was placed, have been recently abandoned in all countries where cholera has appeared, from the general experience of their inefficacy. The evidence also proves, that cholera almost always affords, by premonitory symptoms, warning of its approach, in time for the employment of means capable of arresting its progress. If, indeed, in certain situations, as where there is an unusual concentration of the poison, or in certain individuals, who are peculiarly predisposed to the disease, the attack may sometimes appear to be instantaneous, still the general conclusions that cholera is not in itself contagious, and that it commonly gives distinct warning of its approach, are two great facts, well calculated to divest this disease of its chief terrors, and to show the paramount importance of the means of prevention, so much more certain than those of cure. The proved identity of the causes which promote the origin and spread of epidemic diseases in general, with those that favour the introduction and spread of Asiatic cholera, appear to indicate the true measures of precaution and prevention against a pestilence, which, after an absence of sixteen years, and at a season when other formidable epidemic diseases are unusually prevalent and deadly, menaces a third visitation ; and the General Board of Health would appeal to all classes for their cordial cooperation in carrying into effect the measures which careful consideration has led them to recommend, in the full conviction that the powers given by the Legislature for 5 this purpose, though they may not be fully adequate, and though the time to use them may be short, cannot fail, with such co-operation, to be attended with highly beneficial results. With a view of carrying into operation all available means of precaution against the impending danger, the General Board of Health recommends that the guardians of the poor in England and Wales, and the parochial boards for the management of the poor in Scotland, and their officers, should hold themselves in readiness to execute such directions as the General Board of Health may see fit to issue from time to time, under the provision of the Act of the 11th and 12th Vie, c. 123, entitled " An Act to renew and amend an Act of the 10th year of her present Majesty, and for the speedy removal of certain nuisances, and the prevention of contagious and epidemic diseases." The guardians of the poor and the parochial boards will probably be required, either by themselves individually, or by persons employed or to be specially appointed by them for the purpose, to make examinations from house to house of their several districts, and report to their boards upon the state of each locality as far as regards the prevalent sickness, and the removable causes upon which it may appear to depend. These visitations from house to house will be especially required in the dangerous districts ; and it is to be kept in view, that every district or place is dangerous in which typhus and other epidemic diseases have regularly occurred. The boards of guardians and parochial boards will have to put in force, whenever it may appear to be required, those provisions of the Act that relate to nuisances. Great benefit having been derived from the cleansings that were resorted to on the former visitation of cholera, and experience having shown that preventive measures against cholera are also preventive against typhus and other epidemic and endemic diseases, the board of guardians should carry into immediate effect all practical measures of external and internal cleansing of dwellings in the ill-conditioned districts. The chief predisposing causes of every epidemic, and especially of cholera, are damp moisture, filth, animal and 6 vegetable matters in a state of decomposition, and in general whatever produces atmospheric impurity ; all of which have the effect of lowering the health and vigour of the system, and increasing the susceptibility to disease, particularly among the young, the aged, and the feeble. The attacks of cholera are uniformly found to be most frequent and virulent in low lying districts, on the banks of rivers, in the neighbourhood of sewer mouths, and wherever there are large collections of refuse, particularly amidst human dwellings. In a recent proclamation, issued for the protection of the population of the Russian empire, the important influence of these and similar causes has been recognised, and the practical recommendations founded thereon are to keep the person and the dwellingplace clean, to allow of no sinks close to the house, to adrait of no poultry or animals within the house, to keep every apartment as airy as possible by ventilation, and to prevent crowding wherever there are sick." Householders of all classes should be warned, that their first means of safety lies in the removal of .dung heaps and solid and liquid filth of every description from beneath or about their houses and premises. Though persons long familiarised to the presence of such refuse may not perceive its offensiveness, nor believe in its noxious properties, yet all who desire to secure themselves from danger should labour for the entire removal of filth and the thorough cleansing of their premises ; which also the law will require of each person for the protection of his neighbours, as well as for his own safety. Next to the perfect cleansing of the premises, dryness ought to be carefully promoted, which will of course require the keeping up of sufficient fires, particularly in the damp and unhealthy districts, where this means should be resorted to for the sake of ventilation as well as of warmth and dryness. From information recently obtained from Russia, it appears that, in some barracks and other places in which large numbers of people are congregated, where these conditions have been attended to in a manner that may be equally practised in private houses, there has been a comparative immunity from the prevailing epidemic, exactly as in this country, where in public institutions, though as 7 yet by no means perfect in the means of ventilation, there has been an almost entire exemption from epidemics which have ravaged private houses in the very same districts. But while a certain amount of cleansing can be effected by every householder, each in his own premises, the means of thoroughly purifying the densely populated districts are beyond the power of private individuals. Accordingly, by the recent Act 11th and 12th Victoria, c. 123, sec. 1, in case of inability, insufficiency, or neglect, the law has charged the cleansing operations upon certain public bodies, namely, " the town-councils, or any trustees or commissioners for the drainage, paving, lighting, or cleansing, or managing or directing the police, or any other body of a like nature, or any commissioners of sewers, or guardians of the poor." By this Act it is provided, that upon notice in writing, signed by two or more inhabitant householders, that any dwelling-house or building is in a filthy and unwholesome condition, or that there are upon such premises any foul and offensive cesspool, drain, gutter, or ditch, or any accumulations of filth, or that swine are so kept as to be a nuisance or injurious to health, the authorities shall examine, or cause the premises to be examined ; and if, upon examination, or upon a medical certificate of two legally qualified practitioners, it appears tnat the nuisance exists the public authorities shall make complaint before two justices, who are required to make order for the removal of such -nuisance. The amended provisions contained in this Act should be early considered, promulgated, and enforced, especially those for the proper cleansing of open and foul ditches, near habitations, by the labourers under the direction of surveyors or trustees of highways. The union medical officers, whose duties take them to the relief of the destitute sick, are necessarily familiar with the places in which disease is most prevalent and fatal, and these are invariably found to be the dirtiest localities, where, consequently, the cleansing operations are most required ; and the Nuisances Removal Act imposes upon the guardians the duty of directing and enforcing the proper performance of these operations. In several districts the police, in going their usual rounds, 8 have been employed with great advantage in reporting daily as to the houses, courts, alleys, passages, and streets "within their district, most in need of cleansing; as to the carelessness or neglect of the scavengers in the performance of their duties, and as to the existence of nuisances of various kinds. The boards of guardians, or special committee formed out of their body, are therefore recommended to associate themselves with special committees of town councils, who, by their watch committees, have the control of the police, and to engage for these purposes the valuable services of the force. Highly important services have been rendered by the parochial clergy and other ministers of religion, in association with lay committees, for the purpose of maintaining a system of house to house visitation in the more depressed districts ; and, wherever it is practicable, the boards of guardians are recommended to associate with a special committee of their own number (who for the time maybe exempted from ordinary duties), the clergy of the respective parishes and the ministers of other religious denominations, and to call upon the medical and other union officers to give their aid to this committee. It is conceived that such parochial special committee would, among other useful purposes, be peculiarly serviceable in communicating information to the poorer classes as to the particular means of prevention within their reach, and as to the urgent necessity, at this season, of personal and household cleanliness, of ventilation, and of a careful and temperate mode of living. By the Contagious Diseases Prevention Act, the General Board of Health is required to frame rules and regulations to assist and direct the guardians of the poor and other local authorities, in the performance of the special duties imposed upon them, whenever the country is visited or threatened by any formidable epidemic or contagious disease ; and accordingly, the Board has lost no time in putting itself in communication with the Poor-Law Commissioners, with the view of taking all practical precautions against the scourge which is so steadily approaching our shores ; and the Board is now engaged in preparing regulations for the more public and general measures of precaution and alleviation, which will be issued and put 9 in execution in the several districts, as soon as their particular condition shall have been ascertained. In the meantime, if, notwithstanding every precautionary measure which can be taken, this disease should unhappily break out in any district, then it will be essential to the safety of the inhabitants that they should be fully impressed with the importance of paying instant attention to the premonitory symptom that announces the commencement of the attack. This premonitory symptom is looseness of the bowels, which there is reason to regard as universally preceding the setting in of the more dangerous stage of the disease. Sometimes, indeed, under the circumstances already described, namely, where the poison exists in unusual intensity, or the constitutional predisposition is unusually great, the first stage may appear to be suppressed, as occasionally happens in violent attacks of other diseases, but in cholera this event is so rare, as to be practically of no account ; and in all conntries and under all varieties of conditions in which this disease has been epidemic, the experience as to this point uniformly agrees with what is observed at the present moment at Hamburgh. " In most cases," writes the British Consul respecting the epidemic which has just broken out in that city, "the disease has first manifested itself in a slight relaxation of the bowels, which, if promptly attended to, the patient generally recovers ; but if the symptoms are neglected, spasmodic attacks ensue, and death follows mostly in from four to six hours." This looseness of the bowels may be accompanied with some degree of pain, which, however, is generally slight ; but in many cases pain is wholly absent ; and for some hours and even days, this bowel complaint may be so slight as to appear trifling ; so that, without a previous knowledge of the importance of the warning, it might easily escape notice altogether. It must be repeated, however, that whenever Asiatic cholera is epidemic, the slightest degree of looseness of the bowels ought to be regarded and treated as the commencement of the disease, which at this stage is capable of being arrested by simple means, but if neglected only for a few hours, may suddenly assume a fatal form. 10 It will be indispensable, therefore, on the first outbreak of cholera, that the local authorities should immediately make arrangements for daily house to house inspections of the poorer localities, in their respective districts, this being the only practical means by which, in the most dangerous situations, and among the most susceptible subjects, the existence of the premonitory symptom can be ascertained in time to administer the proper remedies, so as to arrest the progress of the disorder. Heads of families, masters of schools and work-houses, proprietors of large establishments and works, such as factories, mines, warehouses, wharfs, and docks, should either be their own inspectors, or employ some trustworthy agent to examine daily every person in their employment, and to give at once the proper remedy, if the premonitory symptom should be present. Every member of the visiting committee should be provided with proper remedies, prepared in appropriate doses for administration on the spot, in every instance in which the premonitory symptom is found to exist ; and should report every person so treated as requiring the instant attention of the medical officer. Dispensaries for bowel complaints should be established at convenient stations, at which the neighbouring inhabitants may apply for the proper remedies and advice the moment they are attacked by the premonitory symptom. Experience having shown that the establishment of cholera hospitals was not successful, the best provision practicable must be made for affording assistance to the individuals who may need it at their own houses ; and one of the best modes of effecting this object will probably be the selection of proper persons who may be instructed as nurses, in the special services required on this occasion, and paid for devoting their whole time to attendance on the sick at their own habitations, under the direction of the medical officers. It will also be necessary to engage a sufficient number of medical officers, at suitable remuneration, some to devote their whole time, by day and night, to the service of the dispensaries, and others to attend the sick at their own dwellings. As, however, cases may occur of extreme destitution in 11 neighbourhoods and houses wholly unfit for the curative treatment of the sick, provision should be made for the reception of such cases, either in the common hospitals, in the union-houses, or in separate apartments specially prepared for the purpose, and properly warmed and ventilated. Medical authorities are agreed that the remedies proper for the premonitory symptom are the same as those found efficacious in common diarrhoea ; that the most simple remedies will suffice, if given on the first manifestation of this symptom ; and that the following, which are within the reach and management of every one, may be regarded as among the most useful, namely, twenty grains of opiate confection,* mixed with two table spoonsful of peppermint water, or with a little weak brandy and water, and repeated every three or four hours, or oftener, if the attack is severe, until the looseness of the bowels is stopped ; or an ounce of the compound chalk mixture, with ten or fifteen grains of the aromatic confection,! and from five to ten drops of laudanum, repeated in the same manner. Prom half a drachm to a drachm of tincture of catechu may be added to this last, if the attack is severe. Half these quantities should be given to young persons under fifteen, and still smaller doses to infants. It is recommended to repeat these remedies night and morning, for some days after the looseness of the bowels has been stopped. But in all cases it is desirable, whenever practicable, that even in this earliest stage of the disorder recourse should be had to medical advice on the spot. Next in importance to the immediate employment of such remedies is attention to proper diet and clothing. Whenever Asiatic cholera is epidemic there is invariably found among great numbers of the inhabitants an extraordinary tendency to irritation of the bowels ; and this fact suggests that every article of food which is known to favour a relaxed state of the bowels should as far as possible, be avoided — such as every variety of green vegetables, whether cooked or not, as cabbage, cucumber, and [* Scottish Formulae — Electuary of Opium, 20 grs.] [f Scottish Formula? — Aromatic Powder, 10 or 15 grs.] 12 salad. It will be important also to abstain from fruit oi all kinds, though ripe and even cooked, and whether dried or preserved. The most wholesome articles of vegetable diet are, well baked, but not new bread, rice, oatmeal, and good potatoes. Pickles should be avoided. Articles of food and drink which, in ordinary seasons, are generally wholesome, and agree well with the individual constitution, may, under this unusual condition, prove highly dangerous. The diet should be solid rather than fluid ; and those who have the means of choosing, should live principally on animal food, as affording the most concentrated and invigorating diet ; avoiding salted and smoked meats, pork, salted and shell fish, cider, perry, ginger beer, lemonade, acid liquors of all descriptions, and ardent spirits. Great moderation both in food and drink is absolutely essential to safety during the whole duration of the epidemic period. One smgle act of indiscretion has, in many instances, been followed by a speedy and fatal attack. The intervals between the meals should not be long ; cholera being uniformly found to jirevail with extraordinary intensity among the classes that observe the protracted fasts common in eastern and some European countries. The practical importance of these cautions might be illustrated by striking examples. Dr Adair Crawford states, that in Russia the most intense of all the attacks were those that followed a hearty meal, taken immediately after a protracted fast. In our own country, during its former visitation, the most frequent and deadly attacks were observed to be those that took place in the middle of the night, a few hours after a heavy supper. The three fatal cases that have just occurred to sailors who had been at Hamburgh, and who were brought sick to Hull, turned out on inquiry to have followed very shortly after the men had eaten a large quantity of plums, and had drunk freely of sour beer : and the two still more recent fatal cases on board the ship Volant, of Sunderland, both occurred in drunkards, who persisted in the practice of intoxication, notwithstanding the earnest warnings that were given them against the dangers of intemperance. On account of the intimate connection between the external skin and the internal lining membrane of the 13 bowels, warm clothing is of great importance. The wearing of flannel next the skin is therefore advisable, llecent experience on the Continent seems to show that it was useful to wear in the day time a flannel bandage round the body, and this may become necessary in our own country during the damp and cold weather of the approaching season. Particular attention should be paid to keeping the feet warm and dry ; changing the clothes immediately after exposure to wet, and maintaining the sitting and bed rooms well aired, dry, and warm. It may be necessary to add a caution against the use of cold purgative medicines, such as salts, particularly Glauber salts, Epsom salts, and Seidlitz powders, which taken in any quantity, in such a season, are dangerous. Drastic purgatives of all kinds should be avoided, such as senna, colocynth, and aloes, except under special medical direction. If, notwithstanding these precautionary measures, a person is seized suddenly With cold, giddiness, nausea, vomiting, and cramps, under circumstances in which instant medical assistance cannot be procured, the concurrent testimony of the most experienced medical authority shows that the proper course is to get as soon as possible into a warm bed ; to apply warmth by means of heated flannel, or bottles filled with hot water, or bags of heated camomile flowers, sand, bran, or salt, to the feet and along the spine; to have the extremities diligently rubbed; to apply a large poultice of mustard and vinegar over the region of the stomach, keeping it on fifteen or twenty minutes ; and to take every half hour a tea spoonful of sal volatile in a little hot water, or a dessert spoonful of brandy in a little hot water, or a wine glass of hot wine whey, made by pouring a wine glass of sherry into a tumbler of hot milk — in a word, to do everything practicable to procure a warm, general perspiration until the arrival of the medical attendant, whose immediate care, under such circumstances, is indispensable. It has not been deemed necessary or proper to give instructions for the treatment of the advanced stage, from the confident expectation that the proposed arrangements will supply medical attendance to all cases that may reach 14 that condition, by which means the specific symptoms of each individual case will receive their appropriate treatment. Though the season of danger may demand some extraordinary exertion and sacrifice on the part of all classes, yet this period will probably not be protracted, since on the former visitation of cholera, it seldom remained in any place which it attacked longer than a few months, and rarely more than a few weeks ; while it may be reasonably expected that the improvements effected with a view to check its progress will be equally efficacious in shortening its durations ; and that these improvements will not be temporary, like the occasion that called for them, but will be attended with lasting benefit. In conclusion, the General Board of Health would again urge the consideration, that whatever is preventive of cholera is equally preventive of typhus and of every other epidemic and constantly recurring disease ; and would earnestly call the attention of all classes to the striking and consoling fact that, formidable as this malady is in its intense form and developed stage, there is no disease against which it is in our power to take such effectual precaution, both as collective communities and private individuals, by vigilant attention to it in its first or premonitory stage, and by the removal of those agencies which are known to promote the spread of all epidemic diseases. Though, therefore, the issues of events are not in our hands, there is ground for hope, and even confidence, in the sustained and resolute employment of the means of protection which experience and science have now placed within our reach. By order of the General Board of Health, Henry Austin, Sec.