HINT S RELATING TO THE CHOLERA IN LONDON: ADDRESSED TO THE PUBLIC IN GENERAL, BUT ESPECIALLY TO THOSE WHO POSSESS INFLUENCE IN THEIR AND A LETTER TO A MEMBER OF THE BOARD OF HEALTH. BY THOMAS HODGKIN, M.D. Ei' Xiv Savixrov yi tpuyoiftiv . — HOM. Iliad. " Neque enhn hac nos patria lege genuit aut educavit ut nulla quasi alitnenta expectaret a nobis, ac tantummodo nostris ipsa commodis serviens tutum perfugium otio nostro suppeditaret." — Cic. de Republ. LONDON: HIGHLEY, FLEET STREET: J. & A. ARCH, CORNHILL: HARVEY & DARTON, GRACE CHURCH STREET. 1832. It. Watts, Printer, Crown Court, Temple Bar. HINTS, &C. &.C. So many of my Professional Brethren have offered their various opinions, on the numerous points connected with the disease which at the present moment is the subject of intense and general interest, that I have more than once shrunk from the idea of bringing myself forward in connexion with it, lest my motives for doing so should be mistaken. When, however, I observe that some Medical Men of the highest reputation are denying its existence ; and others, equally distinguished, are magnifying its importance ; and that the public, bewildered by our differences, are naturally inclined to censure the Members of the Medical Profession ; I cannot be easy to refrain from making a few remarks, founded upon careful inquiry, and some personal observation. 1. Does the Cholera exist in London ? The concurrent testimony of many experienced and competent judges — to which I may add the evidence of my own senses — affords to my mind the most irrefragable proof, that, to a certain limited extent, there does indubitably exist a very fatal disease, accompanied with striking and uncommon symptoms ; which, without taking upon myself to assert them to be absolutely novel, must at least be regarded as of very rare occurrence. 2. Is this the disease which, under various names, has spread itself, according to the evidence of a cloud of witnesses, in a fatal but somewhat irregular track, across the Continent of Europe, towards the Eastern shores of our Island? This is a question to which we are not left to reply by the single test of our ability to compare the described symptoms, with those which now present themselves to our immediate observation. We have likewise the united testimony of those who have witnessed the disease, both in the place of its commencement and in our own vicinity, and that of others who have studied it in several of the intermediate situations which it has visited ; and all agree, notwithstanding some slight discrepances, reasonably to be expected from variety of climate and differences of habit, in regarding the disease as identical. 3. What is the degree of suffering, which careful inquiry, rather than the impulse of panic, leads us reasonably to regard as the probable result of the visitation ? Though this is a question to which no positive answer can be 4 given, yet we may, without presumption, believe that the amount of suffering will in some degree be influenced by the mode in which we prepare ourselves to meet the evil ; and we may consequently trust, that, without a combination of causes beyond human controul, our lot will not be proportionably more severe than that of countries and cities that have suffered before our own. Now it would appear, that although, in those situations in which the disease has been marked by peculiar severity, an appalling mortality has occurred on particular days, the total mortality of the district, even within a period not exceeding a few weeks, has rarely greatly exceeded the average, and in some instances has even fallen below it. 4. The next question, which naturally presents itself, is, What produces the disease ? Here we are met by a difficulty, which is confessedly one of the greatest with which Medical Science has, in the present day, to contend. The non-medical part of the community should be made aware of this; otherwise they will be led to very erroneous conclusions, not less prejudicial to the public interest, than injurious to the reputation of the Medical Profession. When the public find a large and respectable body of Medical Men maintaining the idea that the disease is altogether the result 'of an imported poison; and an equally numerous and equally respectable portion of the Profession as warmly supporting the opinion that it is the product of a prevailing influence, to which a combination of local causes with a peculiarity of season has given birth ; they should recollect that similar diversities of opinion are to be met with in the annals of other sciences as well as that of Medicine. Thus we have the Newtonian and Hygenian hypotheses concerning Light — the advocates of a positive and negative, and of a vitreous and resinous, Electricity — Volcanists and Neptunists in Geology — and in Chemistry, the now settled question, whether Chlorine be a simple or a compound body. The public must be sensible, that, notwithstanding these and similar differences of opinion among Chemists and Natural Philosophers, many of the abettors of both sides of these questions have been ably and practically acquainted with their respective subjects. Ought they not, then, to make a similar concession in favour of Medical Men, when they find them at issue respecting the obscure origin of a new disease ? The point which essentially interests the public, is, to know whether the practice inculcated is borne out by facts, whatever be the explanation which may be attempted to be given of them. Dismissing, then, as a subject of controversy, the question of the contagious or non-contagious nature of the disease, we may now proceed to the last and most important question :—: — 5. What can be done to check and mitigate the malady ? If the Cholera had not already reached our shores, it would be of prime importance to consider how it could be best prevented from doing so : — from this very difficult inquiry we are unhappily freed, 5 by the presence of the disease. The first point which claims our attention, is, to find out and obviate the circumstances under which the production and propagation of the evil are encouraged. It is notorious, that not only in our own metropolis, but in the majority of the places which have hitherto been visited by Cholera, it has first and most fearfully assailed the districts inhabited by the poor. The contagionists may say, that in those situations the inhabitants are predisposed, and therefore more ready, to be influenced by infection ; and the non-contagionists will say, that in those situations there exists a combination of circumstances, which only await the occurrence of an epidemic influence to create the disease. I think it must obviously appear, that, to whichever side we incline, our main — nay, I might say, our only resource — is to be found in altering the condition of these districts ; since it would be equally difficult for the non-contagionists to remove the epidemic influence, and for the contagionists to eradicate, by any measures of seclusion, all the latent germs of infection. I have seen several of the cases which have occurred, and examined the situations and circumstances under which they broke out ; and could not but be struck with the accumulated filth, evidently of long standing, which is still allowed to remain in them. In several instances, the individuals who were affected were not only in a state of general distress from poverty, but had been more particularly exposed for a length of time to the inclemencies of the weather, in a very ill-prepared state as respects both clothing and food, having either been beggars, or venders of the lowest class exposing various articles in the streets, or hawkers, or persons in search of work. In a few instances, abject want was not present ; but, in some of these, either error in diet, or disturbance of the digestive organs, appeared to concur with the situation of the patient's residence to favour the production of the malady. In some instances, a careful investigation appeared to trace the steps by which a communication might have taken place ; in others, all attempts to do so were fruitless ; whilst nothing could be discovered to shew that communication had not taken place. It has been to me matter of painful surprise and regret, that, whilst all classes are morbidly alive to this awful visitation, the possible effects of which may justly excite our apprehension — whilst much real inconvenience, loss, and distress, have been occasioned by what I might almost call the panic that has been excited — little or nothing has been done to correct the evils so obviously existing in those situations in which the disease has already shewn itself, or in which there is every reason to fear it may shortly make its appearance. Not only humanity towards our poor neighbours, but our own interest, ought to lead, us to correct these evils, as the most important means for our self-preservation. The cases which have already occurred have, it is true, been visited by hundreds who have been anxious to make themselves early acquainted with the disease, without there being any reason for stating that this extensive communication has propagated it amongst those classes of society 6 which are blessed with the necessaries and comforts of life. Yet we must not rely upon this exemption, if there should happen to be an accumulation of cases in the miserable districts of which I have been speaking. The great danger of such accumulation, whether in crowded dirty districts, or in wards specially devoted to the reception of the sick, is fully admitted, even by those who, under other circumstances, are disposed to doubt the propagation of the disease by contagion. Such a fatal accumulation is however seriously to be apprehended, if the state of these situations is neglected, whilst their wretched inhabitants are suffering from those privations, as to food, clothing, and fuel, which want of employment must occasion, and which the best-directed efforts of charity can only temporarily and imperfectly remedy. It is alike the duty and the interest of those who live in parts of the town which are still healthy, and of those who reside in the quarters occupied by the disease, to be unremitting in their co-operating efforts to remove the evils, of which there is so much reason to apprehend the effects. We, who happily escape to-day, must not satisfy ourselves with the idea that we are owing no debt to our nearest connexions and to our country at large, so long as our own streets, and our own dwellings, are exempt. It is not enough to prepare receptacles for the sick, against a time when they may be required by our fellowparishioners, and provide the apparatus of local Boards of Health, whose zealous exertions will, ere long, be too late. Before the disease becomes general — before the cause, however produced, becomes intense — before misery has multiplied predisposition, it behoves one and all of us to meet the evil, and, if possible, to avert, or limit, or mitigate, or shorten it. I wish that I could find words to carry to the minds of those whose influence might avail, the full persuasion which I feel, of the immense importance of promptly removing those conditions, under which, and perhaps under which alone, the disease which threatens us is certainly in some sort contagious. Before the various branches of Commerce and Manufacture are more seriously and generally injured — before failures and bankruptcies abound, and the givers of relief are reduced in number and resources, and the claimants multiplied — before individual cases demand our attention, and divert it from general measures — let us bestir ourselves with energy ; and act as if we thought nothing effected, whilst any thing remains undone. I know, from indisputable sources of information, that a want of work amongst the poor has for a long time been progressively increasing, until it has arrived at a lamentable extent. In many families, weeks have passed and nothing has been earned, but by a few days of ill-paid labour, performed by the oppressed females. It is self-evident, that the want of the means of subsistence is not the only or the chief evil, great as it is, which must flow from this long-continued absence of employment amongst our labouring poor, when we consider the good habits and principles which they lose, and the bad ones which they acquire. At all events, they must be maintained ; but let us not maintain them in 7 idleness — let us make them the engines of their own deliverance and of our protection — let us set them so effectually to work, at cleansing the interior as well as the exterior of their abodes, that, whilst we put our hands in our pockets to save them from present starvation and sickness, we may have the satisfaction of knowing that, at a time when cleanliness is of peculiar importance to the public health, our once filthy and repulsive and pestilential districts are making some sensible approaches to the admirable condition of the Dutch Towns ; — an advantage which, were it the only consideration, would well repay a considerable outlay ; and which, if it shortened and mitigated the visitation of disease, would be economy as well as charity, and would in no small degree serve our Civic — I might say, our National weal. Repeated and general recommendations have been made in favour of cleanliness : some notice has, in most places, been taken of them ; and the public seems satisfied on this point : but, after careful inquiry and inspection, I am disposed to say it has been very imperfectly and inadequately attended to, especially in those situations in which it is of the most vital importance. I will not use so harsh an expression, as to ascribe this fatal omission to criminal negligence : I am only desirous of calling efficient attention to pernicious defects, which are not the less fatal, because those who allow them to exist may completely exculpate themselves from the omission. I have already extended this communication to a far greater length than I designed : I shall therefore not enter into the details of plans by which the measures that I have recommended may be carried into effect. There are some other points, on which I must touch, before I conclude. In many of the superior parts of the town, conspicuous, and I may say liberal, attention has already been paid to the promotion of cleanliness ; nevertheless, the well-intended measures which have been adopted, require, in some instances, considerable amendment. In illustration of this remark, I may point out the misapplication of the very important and abundant supply of water, which has been so laudably afforded. I have regretted to see it wasted in torrents, from the fire-plugs to the kennels ; while the purity with which it flowed, shewed the little part which it performed in removing the impurities against which it was ostensibly directed. Almost the only beneficial influence of the flow of water is directed to the large under-ground drains ; which perhaps require the least attention of this kind, since they almost exclusively receive the whole amount of rain which falls over the city, and, after all, from their size, can be very little affected by any temporary artificial supply of water. The water afforded ought to be so generally and. extensively applied, as effectually to cleanse the streets ; instead of which, it merely produces partial injury to the pavement. I lay the more stress on this, because the quantity of rain which has lately fallen has not been sufficient to effect the general washing of the streets ; and experience has shewn that, in sickly times, disease is promoted by the rains which follow a comparatively dry period. The care which lam anxious to obtain would tend 8 to obviate this. It is quite as important that the supply of water should be devoted to the cleansing of small streets and courts, with their drains and sewers : and special attention should be paid to house-drains, which not only receive the largest quantity of absolute filth with the smallest proportion of fluid to carry it off, but are necessarily so situated, as to apply their noxious effluvia permanently and closely to the persons of the inhabitants. It has been often pointed out, that food and clothing are as essential as cleanliness, in counteracting the extension of the epidemic. Although productive employment is unquestionably the best, because it is the most legitimate and effectual means of providing these necessaries, yet it is quite obvious, that, as this cannot be commanded, there are very many cases which can only be relieved by charitable distributions. The truth of this is so generally felt, that considerable sums have been cheerfully contributed for this purpose. It is however almost as difficult as it is important, that the application of these sums should be properly made. Circumstances, which I shall not detail, have given me abundant opportunity of becoming personally acquainted with the difficulties and abuses which so often attend and mar these acts of charity. It continually happens, that while, from honest shame and unwillingness to obtrude, the most necessitous, and at the same time the most deserving, are concealed from attention, and fail to obtain the means of assistance, the sturdy and practised beggars — by which I do not merely mean those who appear in the streets — lost to shame, and indifferent to the appearance of external comfort, which it is their interest not to maintain, acquire a tact in their mode of application, which procures them a continued and dispro portionate supply, from those charitable sources which they divert from their legitimate objects. To obviate this evil, the respectable inhabitants, both Ladies and Oentlemen, in some large parishes, have nobly set a praiseworthy example, by applying themselves to the arduous task of personal inspection. It is too much to expect, because it is nearly impossible, that this should be performed either so generally, or so regularly and permanently, as to accomplish, by itself, the end in view. These labours are indeed invaluable ; and those who are engaged in them will, I hope, be encouraged to persevere : but their time is too valuable and too essential, either in their own business or in their families, to admit of its being given up, to the extent which would be absolutely necessary, were they the only inspectors. This difficulty would be obviated, and more extensive and more efficient relief would be afforded, by employing some suitable and trust-worthy individuals who stand in need of occupation, not only in making a general and careful inquiry, but in following up the urgent cases, when discovered. Such persons not only have the advantage of more completely supplying relief where it is needed : they are also much more likely to detect and avoid imposition, that hateful bane of almost all charitable operations on a large scale. Actual experiment has satisfied me that this plan is easy and efficient. I know an individual who has for weeks past employed 9 a proxy of the description here pointed out, in a district of peculiar difficulty, with the most gratifying result, both as to the investigation and the relief of cases of distress. The measures to which I have solicited attention, in the foregoing remarks, are the most powerful which can be had recourse to, for the purpose of limiting and mitigating, not only the disease which is so generally dreaded, but other prevailing affections which attend it, and which concur in marking the peculiar epidemic character of the present period. They are opposed by the theories of no party ; and therefore claim the co-operation of all, however conflicting the doctrines which they profess. As to the public measures adopted, with respect to those actually affected with the disease, I am aware that my own deliberately confirmed opinion is opposed to that of many Medical and other authorities ; but I feel that I should be participating in the sacrifice both of the patients and their attendants, were I to refrain from strongly protesting against the plan of collecting Cholera patients into wards solely devoted to that disease. I appeal for confirmation to the experience afforded by every epidemic which has admitted of observation being made on this point ; — but I appeal, in an especial manner, to the Cholera Hospitals both of Asia and the Continent of Europe. Let us not, then, remove the sick, unless the houses be peculiarly wretched, or situated in quarters marked by the severity of the disease, and by the neglect of those evils to which I have adverted in the early part of this address. But, above all, when removal is expedient, do not congregate the patients as you would justly fear to do in the case of other diseases of known or suspected communicability. With the experience of other countries before us, let us not fall into this fatal error, or in any degree imitate those measures which have been the scourge and misery of cities which they were fruitlessly designed to protect. I deeply lament my inability to give adequate weight to the remonstrances which I have offered. With all the earnestness of sincerity on a subject of momentous and vital importance, I entreat those who have the power to act, not hastily to reject these considerations. I have been anxious that the Board of Health, the source whence sanatory recommendations ought officially to flow, should take up these subjects more actively than they have done : but I conclude that their attention has been too much distracted by the multiplicity of the communications which they receive, to notice a Letter which I addressed to one of their number. I give the Board full credit for the purity of their intentions ; and admire the zeal and devotion with which some of those who compose it, undertook the investigation of the disease whilst it was yet a stranger to our land : yet I cannot forbear offering a remark, rather by way of stimulus than censure. I confess lam perfectly at a loss to know in what their present labours consist, beyond the mere publication of the interesting, but not very useful, Report of the daily progress of the Cases ; and upon which Report there is necessarily, but little reliance to be placed. In the very district of 10 the metropolis in which the disease has existed the longest time and with the greatest severity, I have sought in vain for the fruit of their operations. Whilst the disease was yet at distance, there was a useful and obvious duty for the Board to perform ; but I suspect that the home-operations of a novel authority of this kind are uncongenial to the character of our countrymen, and that the Board proceeds with prudent reserve in refraining from over-acting its part. Yet I should have conceived, that its central position, and its abundant sources of information, would have given it peculiar advantages for pointing out and promoting various ameliorations, and bringing the rich and healthy districts into co-operation with the poor, distressed, and sickly, for the purpose of carrying them into execution. Before I conclude, I cannot refrain from recording my testimony to the zeal and benevolence with which the Members of the Medical Profession, residing in the vicinity of affected districts, have cheerfully and assiduously devoted their valuable time, both night and day, to the care of the sick ; not merely refuting the infamous calumnies heaped upon the Profession, but richly earning the double reward of public gratitude and internal satisfaction.* Since the preceding pages were hastily prepared for the press, Dr. Hancock's short but interesting Pamphlet has come into my hands. It is replete with useful matter, relating to the presence and propagation of epidemic diseases ; and is highly important, with reference tothe present period. I would also direct special attention to the valuable Letter of Dr. J. Johnson, which appeared in the Times of the 2d instant. To conclude, — although I have pressed various recommendations with a confidence founded on the conviction of their salutary tendency, I do not forget, that " if the Lord keep not the city, the watchman waketh but in vain/ Yet surely our humble but consoling reliance on His protection, may be strengthened by our endeavours faithfully to discharge our various duties to those around us, and by our diligent performance of whatever the faculties with which we are blessed point out to us as expedient. THOMAS HODGKIN, M.D. New Broad Street, 7. 3. 1832. * In some instances, these philanthropic exertions have not been confined to unremitted attention and medical assistance of every kind, but the necessaries and comforts which were required to render them availing have been supplied by the Medical Men, from their own resources. Although we ought scarcely to be surprised that the uncivilized slaves of Russia for a time suspected that the nume- rous and sudden instances of mortality which alarmed them were the effect of poison, it is matter of utter astonishment that such an idea should be entertained in this country and in this metropolis. It indicates a degree of ignorance and imbecility in the class in which it is received, no less appalling as respects their moral and intellectual condition, than the dreaded evils of the Cholera are with reference to their physical : it offers up, in favour of general education, a forcible appeal to the adherents of every party, addressing itself with equal cogency to those who are filled with dismay, as to those who rejoice in the contemplation of the present momentous juncture of our national affairs. 11 Since the first few hundred copies of the preceding Hints were printed off, I have been informed., by a communication from the Central Board of Health, that in two of their Circulars they had already proposed several regulations very closely resembling- some of the measures I have recommended in my Hints. Had I been aware of this circumstance, I should have been glad to avail myself of such a sanction and corroboration of my views ; or, I might rather have suppressed my remarks, as uncalled for. I hope, however, that what I have said will not be altogether useless ; since much still remains to be done; and many, like myself, may not have been aware of the existence of the Circulars in question. With this explanation, I trust that the feelings of no Member of the Board will be hurt by any expression of mine ; and that they will not be offended at a private individual's endeavouring to urge the employment of measures which continue to be greatly needed. A similar explanation seems called for, in giving publicity to the following Letter, which is alluded to in the same paragraph. It was written before the Board existed as it is now constituted ; and it appears to have been mislaid, in the possession of the Member to whom it was addressed. It has been intimated to me, that whilst many of the points which I have recommended will meet with general assent, little can be expected to be done, from difficulty in the execution, more especially in making a commencement. I think this difficulty is somewhat magnified. It is only necessary for an active individual or two to select a district for operation ; and having quietly taken a general view of it, to apply for information to such persons in that district, or connected with it, as will be most likely to give a correct account of the condition and character of the poor in it. By seeking such information from each separately, before the object is made known to those who will be likely to require assistance, not only much imposition may be prevented, but many really distressed would be discovered, who would otherwise be inevitably passed over. The Heads and Collectors of Benefit Societies, the Medical Men who attend in the district, the bakers and grocers and other venders of articles in constant consumption, and the Masters and Mistresses of Charity and other schools for poor children, are the most suitable persons to apply to : and when the object is explained to them, they will generally be found very willing to furnish their lists. These will mutually confirm or check each other, and be found of great assistance to the person appointed to distribute relief. When the time of the visitor is not so closely occupied, as to allow no interval for the inquiry, it will be very desirable to obtain information of the same description from the Parish Officers charged with the relief of the poor, and from 12 the distributors of any funds already in application for the relief of the district. I am aware, that to make all these inquiries would require greater strength of hands than can, in many situations, be brought into the service ; yet, wherever the plan can be adopted, I am persuaded that it would not only tend to secure the funds from misapplication through imposition, but would in the end be a saving of labour, by leading to a co-operation which would obviate the necessity for many visitors being occupied on the same ground. The inquiries which I first pointed out, may be easily made ; and ought not, in any situation, to be omitted as a preliminary step. As voluntary labourers cannot often be found possessed of sufficient leisure and zeal to act as visitors in a district with the necessary regularity and attention to detail, it will generally be found that a double benefit will arise from engaging the services of some trustworthy individual who may be in want of employment. The visitor should commence his operations by going round to those poor whose names are in his list, before he commences distribution ; and, without raising expectations with regard to the relief to be afforded, make his observations, and concisely note the result in the book containing his list of cases. He will then be able suitably to adapt his distribution to his means ; and at his future visits, which should be regularly performed at fixed intervals, he will only have to note the bread, soup, potato, coal, or clothing tickets which he may have given, with any fresh fact of importance which may come to his knowledge. The tickets so distributed are to be returned as vouchers by the shopkeepers agreed with for the supply of the articles. It will, in general, be far better for the articles to be distributed at extremely low prices, rather than be actually given away. The relief so afforded may not only be rendered more extensive and of longer continuance, but it will also tend to ensure the proper application of the smallest sums which the poor may be able to raise. Whilst engaged in this distribution, a visitor will not only have frequent and good opportunities of giving suitable hints, as to cleanliness, and various points of domestic management too often neglected by the poor through carelessness rather than necessity, but with a very trifling sum he may promote the white-washing of the apartments by providing the materials and-the loan of brushes &c. He will likewise find out particular cases, in which the able, but unemployed, may have work given them, in rendering occasional assistance to the infirm and helpless. I have next to observe, with respect to the cleansing of the streets, which is so lamentably neglected in most of the districts inhabited by the poor, that there are, to each district, authorised scavengers, to whom application may be made by any individuals who happen to be struck with instances of neglect ; and if the hint be neglected, an information should be lodged against the delinquent, who would then either be compelled to perform his duty, or receive assistance to do so, if it could be proved that his salary 13 was decidedly insufficient for the object. It can scarcely escape the attention of many, that the scavengers' men are very inadequate to their task, both as respects their number and individual strength. The Institution for the Relief of the Houseless Poor have the means of finding out many able-bodied men, who might be advantageously employed in this and many other services conducive to the public health and convenience. I have said nothing respecting the means of raising the necessary funds. The liberality of the public has never been backward in shewing itself for the relief of the distressed, on occasions less pressing, and much less personally interesting to them, than the present. We need not, therefore, fear that the means will be withheld, when their well-directed and economical distribution can be insured. I do not therefore anticipate that the individuals, whom I have supposed to apply themselves to the operations of the kind which I have pointed out, will have much difficulty in raising a few pounds amongst their acquaintance and neighbours. They ought moreover to be cautious not to let the limits of their district be disproportioned to their means. I would also recommend, that they should make application to the managers of the different public Collections which are raised for the Relief of the Poor : and the managers, on their part, can hardly do better than encourage such offers of co-operation from respectable quarters, seeing that, whilst, in their means of publicity and regular organization, they have many facilities for gaining subscriptions, they are, from their large scale, unavoidably exposed to great imposition in the application. The following Extract from a Visitor's Book is given as a Specimen of a mode of registering the Cases ; which will be found very convenient, not only on the present occasion, but at other times, when a general distribution of relief is called for. The letters B, C, and P, stand for Bread, Coals, and Potatoes. When Visited. 1831. 12.23 1832. 1 . 6 11 28 2. 2 . 10 21 3 . 3 12 19 31 GENERAL } DESCRIPTION 5 Relief. C& B C & B C B P C B P C B P, extra B CBP C B P, extra B CBP, extra P CBP, extra P CBP, extra P C B P, extra B N° of Case, Jeremiah Driscale, Labourer, 2, Ireland Court, Red- Lion Street. REMARKS. Six Children, and an aged Grandmother ; wretched in the extreme. Man ill, and long out of work; very, very destitute; but grateful for the relief afforded. Grandmother died about the 12th ult., apparently of old age and exhaustion. The Wife died, 6 . 4 . 32, supposed of Cholera. 14 A period like the present, marked by the prevalence of a fatal and very extensive epidemic, whilst it must necessarily excite feelings of serious anxiety in the minds of the public as well as of the Medical Profession, is, to the latter, one of extreme interest. It affords an opportunity of making important inquiries and pursuing interesting investigations respecting some of the most obscure questions connected with the science of Medicine. From the time that the Cholera first made its appearance in the Northern parts of England, I have been strongly impressed with the importance of the Medical Men of this kingdom combining for the purpose of carefully observing and minutely and accurately recording facts of every description directly or indirectly bearing upon it. I know that the Press is already teeming with Publications, in almost every form, on this very engrossing subject. It is foreign to my purpose to discuss the merits of any of these, the value and utility of many of which I am fully prepared to admit ; yet I may observe, that whilst we are still in possession of far too few well-authenticated and fully-detailed facts to warrant our coming to any conclusion, there is much too general a disposition to become the advocates of one or other of the parties, which have been prematurely formed with reference to this subject. Observations are consequently brought forward to support the opinion which happened to be the favourite in the mind of the individual : and though nothing be said but what may be perfectly true, there is, in some instances, a deficiency in the evidence on those points which might bear in favour of a different view of the case. The object which I am anxious to bring about, is, a general co-operation, for the purpose of observing and recording, rather as philosophers than advocates, whatever may tend to make us better acquainted, not only with the present epidemic in particular, but with the laws which appear to regulate wide-spreading epidemics in general. Many of the epidemics, which, at different periods, have visited mankind, have had their historians, whose works have immortalized their authors, and enriched our medical literature. Thus, Thucydides has given us the history of the plague in Athens ; Dr. Caius has been the historian of the Sudor Anglicus ; Diemerbroek described a plague as it prevailed in Holland ; and Rhoederer and Wagler have preserved the account of a remarkable epidemic which occurred in the North of Germany. Our own great Sydenham, with a care which has been too little imitated, has noticed and recorded the striking characters which marked the peculiarities of several epidemic periods ; and Noah Webster, though not a member of our profession, has, with extraordinary perseverance, collected the details of every pestilential period known to have existed from the earliest times. If we neglect to observe and record the facts connected with the present epidemic, we shall not only ourselves hereafter have cause to regret the omission, but it will be a tarnish upon our character, in the eyes of posterity, that we did not take advantage of our opportunities, at a period unprecedented for the abundant 15 opportunities of communication — for the extent to which Science has been pushed — and for its diffusion through almost every class of society. The points of inquiry connected with this subject are so various, and the objects so scattered, that nothing less than extensive co-operation can perform the task. It appears to me, that, for practical purposes, the inquiry may be divided into three parts : the First, comprising whatever relates to the production of the disease, whether existing in the individual attacked, or in the circumstances in which he is placed: the Second, that which relates to the disease itself; such as, its mode of attack, the functions which it deranges, the state of the secretions, when they are not wholly suppressed and can be properly examined. The Third will relate to the post-mortem appearances. Amongst the objects comprised under these different heads, for which co-operation is essential, I would lay particular stress on the topography of the disease. Whilst the circumstances are fresh in the memory, it would be very desirable minutely to map out the districts in which the Cholera may exist, or have existed ; and also those in which derangement of health may have prevailed, bearing some relation to the more fearful epidemic, although far from meriting the same appellation. By a careful collection of all the phaenomena connected with Natural History, including Meteorology, we may hope to become better acquainted with the circumstances which, to say the least, have tended to promote a peculiarity of disease at the present period; and, by similar pains in discovering the condition, habits, and casualties connected with those who have been attacked, we may hope to make a salutary distinction between those circumstances which promote exemption from the disease, and those which favour predisposition to its attacks — a knowledge which can scarcely fail to be of useful application, should we be again threatened by a like awful visitation. 16 A LETTER to a Member of the Board of Health, on the first appearance of the Cholera at Sunder land. 7. ll mO . 1831. Respected Friend, j) R * * * * * I have no doubt but that the Board of Health finds that it has an arduous duty to perform ; and lam fully sensible that it must be, as thou sayest, one of very great difficulty — of difficulty, not only inherent in the nature of the duty, but in the various and conflicting wishes and expectations of the public. I have no doubt but that it is assailed by numerous suggestions and other communications; and I feel a delicacy in trespassing on its time and attention by any addition of my own : yet, as one who has long taken a lively interest in the means of promoting the public health, and who has endeavoured carefully and impartially to weigh the measures which have been directed against the Cholera in particular, I trust I shall be excused for soliciting its attention. Under the influence of impending danger, there is often a wonderful propensity to court the dreaded evil. I devoutly hope that we, as a nation, may labour under no such influence, with respect to the Cholera. I cannot say that I am either a Contagionist or a Non-contagionist; and I shall not attempt to disturb the knotty question which has so long divided the Medical Profession. Whilst, on the one hand, very many circumstances, which are related respecting the extension of the malady from place to place, render it impossible, in the present state of our knowledge, to reject the conclusion promulgated in one of your Reports — that the disease in question is, some way or other, conveyed by Man himself; on the other hand, very many individuals, both Professional and Non-Professional, who have had the fullest opportunities of becoming practically acquainted with the Cholera, with the utmost assurance stand forth as Non-contagionists. They state unnumbered instances of persons exposed in every possible way to the influence of the sick, with perfect impunity. They advance various instances of the complaint having a local origin, quite independent of contagion. These facts, like those of the Contagionists, require further examination. Yet it seems impossible, but that, after the utmost sifting, and the most scrupulous rejection of every doubtful statement, there will rest sufficient evidence to shew that the cause of the disease, whether contagious or not, is not so potent, but that a large proportion of persons may be exposed to it with impunity.- This important fact should be generally impressed on the minds of the public : — First, in order that the sick may not suffer, either from want of attention, resulting from fear on the part of those about them ; or from the confinement and accumulation, to which, 17 with the view of securing others, they may be fatally subjected : — « (this point is so important, that I shall return to it.) Secondly, because it leads to the search after the causes by which this exemption is conferred, that we may promote it to the utmost. Could we bring these causes, in their greatest strength, into general operation, the power of contagion would be a vanishing quantity. On the other hand* if we reduce or destroy the protecting influence, it will be impossible to check the fecundity of the weakest germs of the disease. For my own part, I see little difficulty in admitting the apparently conflicting evidence adduced by both parties. It is not surprising, that the Contagionists 3 party should be the strongest, amongst those who view the malady from a distance, and consider the general features of its progress ; since it is their assemblage which forms the most convincing evidence on this side. Individual and isolated facts may be very much explained away. To those who are personally engaged with the disease, and have obtained an intimate, but partial and local, knowledge of it, the grand outlines of its operations are not necessarily visible ; and they are too much biassed by their Own escape, or by that of multitudes who surround them, We all know that the most indisputably communicable diseases, such as Small-pox and Scarlet Fever, require the concurrence of other causes besides the contagious principle, to become generally prevalent, or particularly severe and fatal: and, as this concurrence does not happen in all places simultaneously, epidemics have been almost invariably progressive. The fact appears certain ; but as to the cause, what have we but conjecture ? But for this circumstance, Cholera might long since have prevailed here ; for numerous individuals, coming from infected foreign parts, are constantly going about, who have either recently had the disease themselves, or have been closely connected with those who have had it. I must therefore be excused, if I cannot admit it as proved, that our past exemption is the effect of our Quarantine Regulations. Though the strict visitation of arriving vessels is highly important, and ought by all means to be observed with rigid exactness, yet it is manifestly no certain protection. The utility of the Quarantine which follows is still more doubtful. Independently of the inevitable violation of the laws which will take place — for we must not calculate on more exactly maintaining them than our neighbours on the Continent, who are both under more despotic controul and have fewer temptations to intercourse — there must be innumerable opportunities for the communication of the infection, even from the examined and detained vessels. This necessarily proceeds from our having no test of the presence of the infection, either in persons or goods. The cause of the evil, whatever be its nature, is undoubtedly present in some instances, without the presence of any one actually labouring under the disease. In this state, which is notoriously short and transient, the patients neither go about like a rabid animal to affect others, nor can they be at work with goods like individuals affected with Scabies. Yet the disease, when once n 18 introduced, spreads rapidly : which seems to prove, that whatever influence belongs to persons or goods, must be present with the former, either before or after their actually labouring under the severe symptoms of the disease ; and must attach itself to the latter, even without their coming in contact with the sick. Of the permanency of this influence we know nothing ; and it must therefore be impossible to pronounce on the purity of either persons or things. The important advantages of the strict visitation of vessels coming to our ports, is, the greater regard to cleanliness which it will enforce, and the immediate attention which it will secure to the sick who may happen to be on board. The effects of a subsequent Quarantine, in case of discovered or suspected disease, must, I conceive, be rather injurious than otherwise. Inactivity and confinement on board a stationary vessel are not unlikely to give rise to disease ; and thereby inflict cruelty on the crew, and impregnate the goods with infection. If it were ascertained that the vessel had disease on board, it would, I conceive, be imperiously necessary to remove the men ; and speedily, but carefully, to unload the vessel, and ventilate the goods. Delay would increase the danger ; and, in sickly periods, those on land, if to leeward of the vessel, would not be safe. If the Cholera were actually here — which there seems great reason to fear is the case — it would be next to impossible to secure an effectual barrier to internal communication ; and the attempt to do so would, in all probability, be productive of fatal consequences. In a Letter from Hamburgh, it is stated, that " all Germany has, for some months past, presented one great chaos of Quarantine Regulations ; which do not appear, in any one instance, to have arrested the progress of infection for a single day ; though, by depriving many thousands of the usual means of subsistence, ihe calamitous effects of the visitation have been materially increased." The inefficacy of the restrictive measures may be somewhat exaggerated ; but I can readily believe the effects attributed to them. We have already seen, in this country, the effects of two days' panic, and the temporary delay of coal ships from one of our coal ports. The price of coals was considerably increased : it is said that the advance went as high as 10*. per chaldron. It is easy to conceive the effect which the continued operation of a cause like this would produce. Dearness and scarcity of fuel during the winter would directly increase the miseries of the poor. When we consider how intimately coal is connected with our manufactures and commerce, it is obvious that an interruption in the supply would greatly injure both : the rich and the poor would suffer from this, but especially the latter. Other articles, besides coal, are liable to be similarly affected in various places ; and the enforcement of restrictions on intercourse, and the shutting up of inhabitants to their respective quarters, would necessarily occasion such an obstacle to almost every species of production, that distress would be general and inevitable. For a while, the immmediate wants of the poor would 19 be supplied by the liberality of the rich. This, however, could only be a partial and imperfect remedy, even though carried by some to the extent of inconvenient sacrifice. The serious check to business of every kind would bring 1 some concerns to bankruptcy, and cause others to make great losses and sacrifices. The Revenue would fall off ; the Funds, and every other species of property, would sink. Every one would, to a greater or less extent, be suffering. With the minds of many of the working class, already in a state of great excitement on various subjects^ it is impossible not to have serious apprehensions for the consequence of such general distress. Nor ought it to be forgotten, that the Foreign Disease, at which the public is so much alarmed, is not the only fatal malady which is to be dreaded. General distress amongst the poor, especially in winter, will inevitably cause a great prevalence of sickness. Already there is evidence of a more than usual tendency to the production of fever of a fatal character ; and I have the most authentic information, that some of the deaths which have occurred in the North, and excited so much alarm here, were of that description. No one can be more fully persuaded than myself of the great anxiety which the Board of Health feel properly to discharge the duty which has been imposed upon them, rather than sought by them ; yet I greatly fear that some of the steps to which their Official Papers at least indirectly lead, and which some Local Boards are, I know, disposed to take, will tend to produce a more serious and general evil than that which they are designed to avert : and we shall have cause to think, with David of old, that it is better to be in the hands of the Almighty, than of Man. As yet, I have stated but a part of my apprehensions : I fear that some of the plans which are proposed, may have the effect of aggravating or extending the disease, against which they are directed. The accumulation of the sick in Hospitals and Wards specially devoted to their reception, (to the tendency of which I have already alluded,) appears to me to be of this description. In admitting the contagious nature of the Cholera, we must, even a priori, attribute to it the character of contagious diseases in general ; and believe that accumulation adds to the danger of the disease in the patients themselves, and incalculably to that of their attendants. In the Hospital with which I am myself connected, this fact has been so fully proved, with respect to common continued fever, that the utmost care has long been systematically taken to prevent many patients affected with it from being placed together ; and with the most satisfactory impunity, they are dispersed through the different wards. The Fever Hospitals, strictly so called, have proved the influence of the opposite plan ; although it must be confessed, that the great care that is taken in some of them does much to lessen the danger. Erysipelas, of which the contagious nature has been as much disputed as that of Cholera, is another affection in which I have seen sufficient proof of the mischief of accumulation. 20 Hospital-gangrene, Yellow-fever, &c. might also be mentioned. The history of Cholera sufficiently shews that this disease forms no exception to the principle. The Physicians of India, who generally dispute its contagious nature, have nevertheless given proof of this fact, and they inform us of the dangerous consequence to the attendants ; whilst, in various places, the mortality in Hospitals, compared to that of private cases, attests the mischief to the sick. If the effects, which I have supposed restrictive measures to produce, more especially on the condition of the poor, are not unfounded — and that they are not so, appears to be demonstrabl — the protective principle which many individuals possess must be greatly impaired, and the extension of the disease necessarily promoted. When I reflect on all these points, and address myself to those, who, in their benevolent desire to secure the health of the community, seek to do so by restrictive measures, I cannot refrain from adopting the words of Anchises :—: — " Neu patrise validas in viscera vertite vires." At the same time, I am very far from thinking that the Institution of a Board of Health is useless or undesirable. Furnished as it is with every advantage which the assistance of the Government can afford, it may render essential service to the country, by collecting all the fruits of the experience of our neighbours ; and by diffusing the knowledge which it has acquired, through the. medium of its Official Publications, it may put the Medical Men of this country in possession of the best means of treating the untried enemy with which they may have to contend. I believe that precautionary measures might be taken, with incalculable and certain benefit ; and I think that the Board of Health, more than any other set of men, has the power of causing those measures to be brought into effectual operation. Although I think that there is reason to object to some of the measures which the Board appears disposed to inculcate, yet no one can approve more highly than myself of the recommendations which it has given, with respect to general cleanliness and the promotion of the comforts of the poor : but whilst those recommendations are placed in the rear of its Bulletin*, I fear that the mass of the public will neglect them, to run after nostrums, and provide themselves with powerful and injurious stimulants, to be needlessly employed as supposed preventions, or, as we would rather hope, to be kept by them as uncalled-for means of cure. Whilst I have apprehended that some of the measures, proposed with the best intentions by. the Board of Health, may have the damping and discouraging effect of the sound of a retreat upon an army in the presence of the enemy, I feel a firm conviction that the * This was the case with the earlier Official Papers of the Boar 4. 21 Board might produce the precisely opposite effect, and give that salutary excitement which is known to exist when a decisive engagement is in contemplation — an excitement which, whilst it is one of the elements of victory, has been repeatedly known to counteract the influence of disease. Could I gain the hearing of the Board, I would endeavour to urge it to make a collection of all such instructions as might be communicated to the public, with the reasonable hope of their tendency being to promote that state which seems to afford protection against the cause of the disease, be it what it may. I would endeavour to induce it to take advantage of all those existing channels which promise ready access to, and effectual influence upon, the working classes. For this purpose, I would recommend an immediate and direct communication with all Benefit Societies. To my own personal knowledge, they are keenly, but very properly, alive to whatever tends to deteriorate their common funds ; and nothing has so strong a tendency to produce this effect as the sickness or death of their members. They must therefore see, in the approach of Cholera, a fearful enemy, which it is their deepest interest to oppose. Moreover, their feelings would be gratified by the attention ; and they would be stimulated to carry into effect those measures which the members individually reject with disdain, when urged upon them by Parochial authority, or Local Boards of Health, composed of the higher classes of society. The very interest which this general call to exertion would excite, would itself be a means of pro tection. If, by such measures, cleanliness, and temperance, and frugality could be promoted — and Cholera, after all, pass by and leave this hitherto highly-favoured Island either wholly untouched, or with light measure corrected — instead of the evils which I have been apprehending, an important advantage would be unwittingly gained, like that which the sons of the husbandman are fabled to have derived from the assiduous turning up of their patrimonial estate in search of promised treasure. It is stated, that the fear of the Cholera produced a most salutary effect in Moscow, by the influence which it exerted in promoting temperance among the inhabitants. The Board of Health, by the statements which it has already published, has, I hope, begun to induce a similar effect here : and when I reflect on what Temperance Societies have done in America and in Scotland, I confess, that, though I once thought them highly chimerical, I cannot help now regarding them as an engine of tried power, and one which it would, at the present moment, be an important advantage for the Board of Health to bring more extensively to bear on the spirit-consuming portion of the community. I have already stated my doubts as to the expediency of establishing temporary Hospitals for the reception of Cholera patients. I may add, that the evidence of past experience has shewn that the poor are often unwilling to avail themselves in due time of such asylums. 22 I would suggest that the Board might recommend the quiet augmentation of all the Medical force at present existing for the relief of the sick poor. Thus, Dispensaries might, for a time, double or treble the number of their Medical Officers, and thereby be able to give more frequent and prompt attention to those applications which the poor are ever ready to make. Other Institutions, which relieve Out-patients, might adopt a similar plan ; and in extensive and populous parishes, a temporary increase of the number of the appointed Medical attendants might quietly afford all the aid which the sick could require. The Boards might, with advantage, procure the suppression of Fairs, and other occasions which have the effect of needlessly bringing multitudes together for idle and useless, if not for dissolute and corrupting, purposes : they might see that all regulations for the suppression of mendicity and vagrancy are completely but humanely carried into effect. If disease is conveyed from place to place, (and Cholera is by no means the only disease which may be so conveyed,) it is certain that none are so likely to convey it as vagrants, and miserable and distressed beggars, who are obliged to seek their temporary shelter in the meanest and filthiest, and. consequently in the most sickly, parts of the places which they visit : for, by wandering through the streets, and not unfrequently collecting around them numbers of the class peculiarly susceptible, they take the most effectual means of becoming general contaminators, not less of the body than they too often are of the mind ; and, from being exposed to cold and wet, to want and intemperance, and in short to every hurtful vicissitude, they are perhaps the most likely persons with whom disease of an infectious character may originate. Again, the Boards might stimulate the Governors of Public Institutions, and the Committees of existing Charities, to the discharge of their respective duties ; and possibly bring about their acting with a certain degree of concert — the defect of which not only limits the good which might be effected, but opens a wide door to abuse and imposture, which not unfrequently intercept the relief designed for the unobtrusive and really deserving. There is, perhaps, no way in which these Boards could afford a more essential service, than by procuring the judicious employment of the means devoted to the relief of the poor. I am well aware that this is a most difficult subject, on which much has been said, and much more might be said : but I shall endeavour to be as short as possible. No one, I trust, will attribute to me the least approach to want of feeling, when I assume that the legitimate objects of Charity are those, who, whilst, from infancy, or old age, or other infirmities, they are incapable of effectually helping themselves, are exposed to the sufferings of poverty and want. Instances may occur, from accidental and fortuitous circumstances, in which the able, the vigorous, and the healthy, may very properly be the objects of temporary assistance ; but it is scarcely less deplorable for the country at large, than for the sufferers themselves, when a number of such 23 individuals are, for any length of time, unemployed. The workin 1 classes are obviously a most important part of the wealth of a nation. Every day that a workman passes unemployed, must be a loss to the community, proportioned to the value of an equal portion of his time devoted to labour. When thousands of workmen are out of employ for several weeks together, the total loss to the country would be very considerable, even were no expense incurred in maintaining them during the interval. But the sums so expended are necessarily, but irrecoverably, lost to the national stock, having left behind them nothing to represent their value. I readily admit, that we cannot contemplate the employment of these sums, without feeling a pleasure derived from the knowledge that, whilst they afforded relief and comfort to the distressed, they evinced the noble, and generous, and benevolent feelings of the more fortunate members of society. But greater benefits would be enjoyed by the former, and equal philanthropy and more operative patriotism would be displayed by the latter, if the capital devoted to this branch of Charity were so laid out, as, by giving employment to those capable of labour, it might, in part at least, remain under a new form, and in combination with so much value as may have been rescued from the lost time of the operatives. Why should not Charity, as well as Avarice and Ambition, turn over her capital, instead of being limited in her exertions, and restricted to unproductive consumption ? That this course is so seldom pursued, argues its difficulty, not its impracticability. I can scarcely conceive a more legitimate and praiseworthy object for the ingenuity of the lovers of their country, than the contrivance of suitable plans for the profitable employment of operatives when thrown out of their ordinary work. When the Gentlemen of Paris, from the most studied and intricate fashion in the dressing of their hair, suddenly passed to the simplest crop, and deprived the hair-dressers of their means of subsistence, De Prony acted the part of a true philanthropist, when he conceived the idea of giving them occupation in the construction of extensive Tables of Logarithms. Whilst want of occupation must lead to poverty and distress, and promote depression of mind and the prevalence of disease, active employment has the opposite tendency. It was therefore counsel worthy of the Oracle, when the Romans, visited with pestilence, were ordered to draw off the waters of the Lake of Nemi.* * The construction of Rail-roads, on well-chosen lines, would seem to be a very desirable occupation for the unemployed strength of our Labourers. They would not only tend to maintain those Iron Works which form so es- sential an element in our national prosperity ; but these important facili- ties for communication might be formed with far greater economy at the present time, than by waiting until the increased demand of more pro- sperous times shall have raised the price both of labour and materials, -bfsj The Foot-ways in the neighbourhood of London might well engage the genius 24 It is high time that I should conclude these suggestions ; and, requesting that the deep interest which I feel in the subject may be admitted as an excuse for their length, subscribe myself, Thy Respectful Friend, T. H genius of a second M'Adam — if not with equal pecuniary advantage to himself, yet with very great comfort to the public. These footways almost universally present a most disagreeable undulating surface, thickly strewed with loose and sharp stones ; and drive many of the foot-passengers to seek the more even horse-road, to the imminent danger of their own lives, as well as to the peril and annoyance of those who may happen to be riding or driving. Great praise is due to G of Randwick, for the pains which he has taken to give productive occupation to the unemployed Labourers in the neighbourhood of Stroud : and it is devoutly to be wished that liis truly patriotic and Christian example may find many successful imitators. [See a very brief statement of these operations, published by Harvey and Darton.]