Kitabı oku: «Letters on the Cholera Morbus.», sayfa 4

LETTER IV

It need scarcely be said how much it behooves all medical men to keep in view the subject of the wide-spreading cholera, and not to suffer themselves to be led from an attentive consideration of all that appertains to it, by the great political questions which at present convulse the whole kingdom.

I totally disagree with Dr. Macmichael, as I believe most people will, that the notion of contagion in many diseases is "far from being natural and obvious to the mind;" for, since the time that contagious properties have been generally allowed to belong to certain diseases, there has been a strong disposition to consider this as the most natural and obvious mode of explaining the spreading of other diseases. A person sees evidence of the transmission, mediate as well as immediate, of small-pox, from one person to another; and, in other diseases, the origin of which may be involved in obscurity, he is greatly prone to assign a similar cause which may seem to reconcile things so satisfactorily to his mind. Indeed there seems, in many parts of the world, a degree of popularity as to quarantine regulations, which is well understood and turned to proper account by the initiated in the mysteries of that department: – for what more common than the expression – "we cannot be too careful in our attempts to keep out such or such a disease?" For my part, I admit that I can more easily comprehend the propagation of certain epidemics by contagion, than I can by any other means, when unaccompanied by sensible atmospheric changes; and if I reject contagion in cholera, it is because whatever we have in the shape of fair evidence, is quite conclusive as to the non-existence of any such principle. Indeed abundance of evidence now lies before the public, from various sources, in proof of the saying of Fontenelle being fully applicable to the question of cholera – "When a thing is accounted for in two ways, the truth is usually on the side most opposed to appearances." How well mistaken opinions as to contagion in cholera are illustrated in a pamphlet which has just appeared from Dr. Zoubkoff of Moscow! This gentleman, it appears, has been a firm believer in contagion, until the experience afforded him during the prevalence of the disease in that city proved the contrary. He tells us (p. 10), that in the hospital (Yakimanka) he saw "to his great astonishment, that all the attendants, all the soldiers, handled the sick, supported their heads while they vomited, placed them in the bath, and buried the dead; always without precaution, and always without being attacked by cholera." He saw that even the breath of cholera patients was inhaled by others with impunity; he saw, that throughout the district of which he had charge, the disease did not spread through the crowded buildings, or in families where some had been attacked, and that exposure to exciting causes determined the attack in many instances. He saw all this, gives the public the benefit of the copious notes which he made of details as to persons, places, &c., and now ridicules the idea of contagion in cholera. Grant to the advocates of contagion in cholera but all the data they require, and they will afterwards prove every disease which can be mentioned to be contagious. Hundreds of people, we will say, for instance, come daily from a sickly district to a healthy one, and yet no disease for some time appears; but at last an "inexplicable condition of the air," and "not appreciable by any of our senses" (admitted by Dr. Macmichael and others as liable to occur, but only in aid of contagion), take place; cases begin to appear about a particular day, and nothing is now more easy than to make out details of arrivals, there being a wide field for selection; and even how individuals had spoken to persons subsequently attacked – had stopped at their doors – had passed their houses, &c.⁸ Causation is at once connected with antecedence, at least for a time, by the people at large, who see their government putting on cordons and quarantines, and the most vague public rumour becomes an assumed fact. We even find, as may be seen in the quotation given from Dr. Walker's report, that contagionists are driven to the "somehow or other" mode of the introduction of cholera by individuals; so that it may be deplored, with respect to this disease, in the words of Bacon, that "men of learning are too frequently led, from ignorance or credulity, to avail themselves of mere rumours or whispers of experience as confirmation, and sometimes as the very ground-work, of their philosophy, ascribing to them the same authority as if they rested upon legitimate testimony. Like to a government which should regulate its measures, not by official information of its accredited ambassadors, but by the gossipings of newsmongers in the streets. Such, in truth, is the manner in which the interests of philosophy, as far as experience is concerned, have hitherto been administered. Nothing is to be found which has been duly investigated, – nothing which has been verified by a careful examination of proof."

In their efforts to make out their case, there would seem to be no end to the contradictions and inconsistencies into which the advocates of contagion in cholera are led. At one moment we are required to believe that the disease may be transmitted through the medium of an unpurified letter, over seas and continents, to individuals residing in countries widely differing in climate, while, in the next, we are told – regarding the numberless instances of persons of all habits who remain unattacked though in close contact with the diseased – that the constitution of the atmosphere necessary for the germination of the contagion is not present; and this, although we see the disease attacking all indiscriminately, those who are not near the sick as well as those who are at a very short distance, as on the opposite side of a ravine, of a rivulet, of a barrack, or even of a road. They assume that wherever the disease appears, three causes must be in operation – contagion – peculiar states of atmosphere (heat now clearly proved not essential, as at one time believed) – and susceptibility in the habit of the individual. However unphilosophical it is held to be to multiply causes, the advocates of contagion are not likely to reduce the number, as this would at once cramp them in their pleadings before a court where sophistry is not always quickly detected. Those who see irresistible motives for dismissing all idea of contagion, look, on the contrary, for the production of cholera, to sources, admitted from remote times to have a powerful influence on our systems, though invisible – though not to be detected by the ingenuity of man, and though proved to exist only by their effects.

Many who do not believe that cholera can be propagated by contagion under ordinary circumstances, have still a strong impression that by crowding patients together, as in hospitals or in a ship, the disease may acquire contagious properties. Now we find that when the experimentum crucis of extensive experience is contrasted with the feasibility of this, cholera, like ague, has not been rendered one bit more contagious by crowding patients together than it has been shown to be under other circumstances. We do not require to be told that placing many persons together in ill-ventilated places, whether they labour under ague, or catarrh, or rheumatism, or cholera, as well as where no disease at all exists among them, as in the Calcutta black-hole affair, and other instances, which might be quoted, fever, of a malignant form, is likely to be the consequence, but assuredly not ague, or catarrh, or rheumatism, or cholera. On this point we are furnished with details by Dr. Zoubkoff, of Moscow, in addition to the many previously on record. It may be here mentioned that, on a point which I have already referred to, this gentleman says (p. 43), "I shall merely observe that at Moscow, where the police are remarked for their activity, they cannot yet ascertain who was the first individual attacked with cholera. It was believed at one time that the disease first showed itself on the 17th of September; afterwards the 15th was fixed upon, and at last persons went so far back as August and July." As this gentleman had been a contagionist, occupied a very responsible situation during the Moscow epidemic, and quotes time and place in support of his assertions, I consider his memoir more worthy of translation than fifty of your Keraudrens.

Respecting those mysterious visitations which from time to time afflict mankind, it may be stated that we have a remarkable instance in the "dandy" or "dangy" disease of the West India Islands, which, of late years, has attracted the notice of the profession as being quite a new malady, though nobody, as far as I am aware of, has ever stated it to have been an imported one. We find also that within the last three years a disease, quite novel in its characters, has been very prevalent in the neighbourhood of Paris. It has proved fatal in many instances, and the physicians, unable to assign it a place under the head of previously-described disease, have been obliged to invent the term "Acrodynia" for it. I am not aware that even M. Pariset, the medical chief of quarantine in France, ever supposed this disease to have been imported, and to this hour the cause of its appearance remains in as much obscurity among the Savans of Paris, as that of the epidemic cholera.

Considering all the evidence on the subject of cholera in India, in Russia, Prussia, and Austria, one cannot help feeling greatly astonished on perceiving that Dr. Macmichael (p. 31 of his pamphlet) insinuates that the spreading of the disease in Europe has been owing to the views of the subject taken by the medical men of India.

In turning now more particularly to the work, or rather compilation, of Dr. Bisset Hawkins, let us see whether we cannot discover among what he terms "marks of haste" in getting it up for "the curiosity of the public" (curiosity, Dr. Hawkins!), some omissions of a very important nature on the subject of a disease respecting which, we presume, he wished to enlighten the public. And first, glancing back to cholera in the Mauritius, Dr. Hawkins might, had he not been so pressed for time, have referred to the appearance of cholera in 1829, at Grandport in that island; when, as duly and officially ascertained, it could not be a question of importation by any ship whatever. The facility with which he supplies us with "facts," – the false facts reprobated by Bacon, and said by Cullen to produce more mischief in our profession than false theories – is quite surprising; he tells us, point blank (p. 31), speaking of India, that "when cholera is once established in a marching regiment, it continues its course in spite of change of position, food, or other circumstances!" Never did a medical man make an assertion more unpardonable, especially if he applies the term marching regiment as it is usually applied. Dr. Hawkins leads us to suppose that he has examined the India reports on cholera. What then are we to think when we find in that for Bengal the following most interesting and conclusive statements ever placed on record? Respecting the Grand Army under the Marquis of Hastings, consisting of 11,500 fighting men, and encamped in November 1817 on the banks of the Sinde, the official report states that the disease "as it were in an instant gained fresh vigour, and at once burst forth with irresistible violence in every direction. Unsubjected to the laws of contact, and proximity of situation, which had been observed to mark and retard the course of other pestilences, it surpassed the plague in the width of its range, and outstripped the most fatal diseases hitherto known, in the destructive rapidity of its progress. Previously to the 14th it had overspread every part of the camp, sparing neither sex nor age, in the undistinguishing virulence of its attacks." – "From the 14th to the 20th or 22d, the mortality had become so general as to depress the stoutest spirits. The sick were already so numerous, and still pouring in so quickly from every quarter, that the medical men, although night and day at their posts, were no longer able to administer to their necessities. The whole camp then put on the appearance of a hospital. The noise and bustle almost inseparable from the intercourse of large bodies of people had nearly subsided. Nothing was to be seen but individuals anxiously hurrying from one division of a camp to another, to inquire after the fate of their dead or dying companions, and melancholy groups of natives bearing the biers of their departed relatives to the river. At length even this consolation was denied to them, for the mortality latterly became so great that there was neither time nor hands to carry off the bodies, which were then thrown into the neighbouring ravines, or hastily committed to the earth on the spots on which they had expired." Let us now inquire how this appalling mortality was arrested; – the report goes on to inform us: – "It was clear that such a frightful state of things could not last long, and that unless some immediate check were given to the disorder, it must soon depopulate the camp. It was therefore wisely determined by the Commander-in-chief to move in search of a healthier soil and of purer air," which they found when they "crossed the clear stream of the Bitwah, and upon its high and dry banks at Erich soon got rid of the pestilence, and met with returning health." Now just fancy epidemic cholera a disease transmissible by "susceptible articles," and what an inexhaustible stock must this large army, with its thousands of followers, have long carried about with them; but, instead of this, they were soon in a condition to take the field. Against the above historical fact men of ingenuity may advance what they please. There is no doubt that, in the above instance, severe cases of cholera occurred during the move, the poison taken into the system on the inauspicious spot, not having produced its effects at once; it is needless to point out what occurs in this respect in remittent and intermittent fevers. The India reports furnish further evidence of mere removal producing health, where cholera had previously existed. Mr. Bell, a gentleman who had served in India, and who has lately written upon the disease,⁹ informs us (p. 84), that "removing a camp a few miles, has frequently put an entire and immediate stop to the occurrence of new cases; and when the disease prevailed destructively in a village, the natives often got rid of it by deserting their houses for a time, though in doing so they necessarily exposed themselves to many discomforts, which, cæteris paribus, we should be inclined to consider exciting causes of an infectious or contagious epidemic." We even find that troops have, as it may be said, out-marched the disease, or rather the cause of the disease; that is, moved with rapidity over an extensive surface where the atmosphere was impure, and thereby escaped – on the principle that travellers are in the habit of passing as quickly as they can across the pontine marshes. Mr. Bell says, "In July, 1819, I marched from Madras in medical charge of a large party of young officers who had just arrived in India, and who were on their way to join regiments in the interior of the country. There was also a detachment of Sepoys, and the usual number of attendants and camp-followers of such a party in India. The cholera prevailed at Madras when we left it. Until the 5th day's march (fifty miles from Madras) no cases of the disease occurred. On that day several of the party were attacked on the line of march; and, during the next three stages, we continued to have additional cases. Cholera prevailed in the countries through which we were passing. In consultation with the commanding officer of the detachment, it was determined that we should leave the disease behind us; and as we were informed that the country beyond the Ghauts was free from it, we marched, without a halt, until we reached the high table land of Mysore. The consequence was, that we left the disease at Vellore eighty-seven miles from Madras, and we had none of it until we had marched seventy miles further (seven stages), when we again found it at one of our appointed places of encampment; but our camp was, in consequence, pushed on a few miles, and only one case, a fatal one, occurred in the detachment; the man was attacked on the line of march. We again left the disease, and were free from it during the next 115 miles of travelling; we then had it during three stages, and found many villages deserted. We once more left it, and reached our journey's end, 260 miles further, without again meeting it. Thus, in a journey of 560 miles, this detachment was exposed to, and left the disease behind it, four different times; and on none of those occasions did a single case occur beyond the tainted spots." What a lesson for Dr. Hawkins! But for whom could Dr. Hawkins have written his curious book? Hear Mr. Bell in respect to the common error of the disease following high roads and navigable rivers only: – "I have known the disease to prevail for several weeks at a village in the Southern Mahratta country, within a few miles of the principal station of the district, and then leave that division of the country entirely; or, perhaps, cases would occur at some distant point. In travelling on circuit with the Judge of that district, I have found the disease prevailing destructively in a small and secluded village, while no cases were reported from any other part of the district." What is further stated by Mr. Bell will tend to explain why so much delusion has existed with regard to the progress of the disease being remarkably in the direction of lines of commerce, or great intercourse: – "When travelling on circuit, I have found the disease prevailing in a district before any report had been made of the fact, notwithstanding the most positive orders on the subject; and I am persuaded, that were any of the instances adduced in support of the statement under consideration strictly inquired into, it would be found that the usual apathy of the natives of India had prevented their noticing the existence of the disease until the fact was brought prominently forward by the presence of Europeans. It should also be brought to mind, that cholera asphyxia is not a new disease to these natives, but seems to be, in many places, almost endemical, whilst it is well known that strangers, in such circumstances, become more obnoxious to the disease than the inhabitants of the country. Moreover, travellers have superadded to the remote cause of the disease, fatigue and road discomforts, which are not trifling in a country where there are neither inns nor carriages." (p. 89.) Cholera only attacks a certain proportion of a population, and is it wonderful that we should hear more of epidemic on high roads, where the population is greatest? High roads too are often along the course of rivers; and is there not some reason for believing, that there is often along the course of rivers, whether navigable or not, certain conditions of the atmosphere unfavourable to health? When Dr. Hawkins stated, as we find at p. 131 he has done, that where the inhabitants of certain hilly ranges in India escaped the disease, "these have been said to have interdicted all intercourse with the people below," he should have quoted some respectable authority, for otherwise, should we unhappily be visited by this disease, the people of our plains may one day wage an unjust war against the sturdy Highlanders or Welsh mountaineers.¹⁰ Little do the discussers of politics dream of the high interest of this part of the cholera question, and little can they conceive the unnecessary afflictions which the doctrine of the contagionists are calculated to bring on the nation. Let no part of the public suppose for a moment that this is a question concerning medical men more than it does them; all are very deeply concerned, the heads of families more especially so.

We see that the identity of the European and Indian epidemic cholera is admitted on all sides; we have abundant proof that whatever can be said as to the progress of the disease, its anomalies, &c., in the former country, have been also noted respecting it in the latter; and Dr. Hawkins, when he put forth his book, had most assuredly abundant materials upon which to form a rational opinion. It is by no small effort, therefore, that I can prevent all the respect due to him from evaporating, when he declares, at page 165, that "the disease in India was probably communicable from person to person, and that in Europe it has undeniably proved so." But Dr. Hawkins is a Fellow of the College of Physicians, and we must not press this point further than to wish others to recollect that he has told us that he drew up his book in haste; and, moreover, that he wished to gratify the curiosity of the public. The Riga story about the hemp and the fifteen labourers I shall leave in good hands, the British Consul's at that city, who was required to draw up, for his government, a statement of the progress, &c. of the cholera there, of which the following is an extract: —

"The fact of non-contagion seems determined, as far as a question can be so, which must rest solely upon negative evidence. The strongest possible proof is, the circumstance, that not one of the persons employed in removing the dead bodies (which is done without any precaution) has been taken ill. The statement of fifteen labourers being attacked, while opening a pack of hemp, is a notorious falsehood. Some physicians incline to the opinion, that the disease may sometimes be caught by infection, where the habit of body of the individual is predisposed to receive it; the majority of the faculty, however, maintain a contrary doctrine, and the result of the hospital practice is in their favour. There are 78 persons employed in the principal hospital here; of these only two have been attacked, one of whom was an 'Inspecteur de Salle,' and not in immediate attendance upon the sick. I am assured that the other hospitals offer the same results, but as I cannot obtain equally authentic information respecting them, I confine myself to this statement, on which you may rely. On the other hand, in private families, several instances have occurred where the illness of one individual has been followed by that of others: but, generally, only where the first case has proved fatal, and the survivors have given way to grief and alarm. Mercenary attendants have seldom been attacked, and, as mental agitation is proved to be one of the principal agents in propagating or generating the disease, these isolated cases are attributed to that cause rather than infection.

"It is impossible to trace the origin of the disease to the barks; indeed it had not manifested itself at the place whence they come till after it had broken out here. The nearest point infected was Schowlen (at a distance of 200 wersts), and it appeared simultaneously in three different places at Riga, without touching the interjacent country. The first cases were two stone-masons, working in the Petersburg suburbs, a person in the citadel, and a lady resident in the town. None of these persons had had the slightest communication with the crews of barks, or other strangers, and the quarter inhabited by people of that description was later attacked, though it has ultimately suffered most.

"None of the medical men entertain the slightest doubt of the action of atmospheric influence – so many undeniable instances of the spontaneous generation of the disease having occurred. Half the town has been visited by diarrhœa, and the slightest deviation from the regimen now prescribed (consisting principally in abstinence from acids, fruit, beer, &c.) invariably produces an attack of that nature, and, generally, cholera: fright, and intoxication, produce the same effect.

"Numerous instances could be produced of persons in perfect health, some of whom had not left their rooms since the breaking out of the disease, having been attacked by cholera, almost instantaneously after having imprudently indulged in sour milk, cucumbers, &c. It is a curious circumstance, bearing on this question, that several individuals coming from Riga have died at Wenden, and other parts of Livonia, without a single inhabitant catching the disease; on the other hand, it spreads in Courland, and on the Prussian frontier, notwithstanding every effort to check its progress. The intemperance of the Russians during the holidays has swelled the number of fresh cases, the progressive diminution of which had previously led us to look forward to a speedy termination of the calamity." This is a pretty fair specimen of the undeniable manner in which cholera is proved to be contagious in Europe, and we shall, for the present, leave Dr. Hawkins in possession of the full enjoyment of such proofs.

Some attempt was made at Sunderland, to establish that, in the case which I mentioned in my last as having proved fatal there, the disease had been imported from foreign parts, but due inquiry having been made by the collector of the customs, this proved to be unfounded; the man's name was Robert Henry, a pilot: – he died on the 14th of August.¹¹

Abroad we find that, unhappily, the cholera has made its appearance at Hamburgh; official information to this effect arrived from our Consul at that place, on Tuesday the 11th inst. (October). The absurdity of cordons and quarantines is becoming daily more evident. By accounts from Vienna, dated the 26th September, the Imperial Aulic Council had directed certain lines of cordon to be broken up, seeing, as is stated, that they were inefficacious; and by accounts of the same date, the Emperor had promised his people not to establish cordons between certain states.

We find at the close of a pamphlet on cholera, lately published by Mr. Searle, a gentleman who served in India, and who was in Warsaw during the greater part of the epidemic which prevailed there this year, the following statement: – "I have only to add, that after all I have heard, either in India or in Poland, after all I have read, seen, or thought upon the subject, I arrive at this conclusion, that the disease is not contagious."

In confirmation of the opinion of Mr. Searle, we have now the evidence of the medical commission sent by the French government to Poland. Dr. Londe, President of that commission, arrived in Paris some days ago. He announced to the minister in whose department the quarantine lies, as well as to M. Hèly D'Oissel, President of the Superior Council of Health, that it was proved in Poland, entirely to his satisfaction, as well as to the satisfaction of his five colleagues, that the cholera is not a contagious disease.

The Minister of War also sent four medical men to Warsaw. Three of them have already declared against contagion; so it may be presumed that the day is not far distant when those true plagues of society, cordons and quarantines against cholera, shall be abolished. Hear the opinion of a medical Journalist in France, – after describing, a few days ago, the quarantine and cordon regulations in force in that country: – "But what effect is to be produced by these extraordinary measures, this immense display of means, and all these obstructions to the intercourse of communities, against a disease not contagious; a disease propagating itself epidemically; and which nothing has hitherto been able to arrest? To increase its ravages a hundred-fold, – to ruin the country, and to make the people revolt against measures which draw down on them misery and death at the same time." What honest man would not now wish that in this country the cholera question were placed in Chancery; where, I have no doubt, it would be quickly disposed of. I shall merely add, that the ten medical men sent from France to Poland, for the purpose of studying the nature of cholera, have all remained unattacked by the disease.

October 15, 1831.