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diff --git a/old/67041-0.txt b/old/67041-0.txt deleted file mode 100644 index 9c4742f..0000000 --- a/old/67041-0.txt +++ /dev/null @@ -1,1199 +0,0 @@ -The Project Gutenberg eBook, Treatment of the Cholera in the Royal -Hospital, Haslar, by John Wilson - - -This eBook is for the use of anyone anywhere in the United States and most -other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms of -the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you'll have -to check the laws of the country where you are located before using this ebook. - - - - -Title: Treatment of the Cholera in the Royal Hospital, Haslar - during the months of July and August, 1849 - - -Author: John Wilson - - - -Release Date: December 29, 2021 [eBook #67041] - -Language: English - -Character set encoding: UTF-8 - - -***START OF THE PROJECT GUTENBERG EBOOK TREATMENT OF THE CHOLERA IN THE -ROYAL HOSPITAL, HASLAR*** - - -Transcribed from the 1849 Simpkin, Marshall, and Co. edition by David -Price. Many thanks to the British Library for making their copy -available. - - - - - - TREATMENT - OF - CHOLERA - IN - The Royal Hospital, Haslar, - DURING THE MONTHS OF JULY AND AUGUST, 1849, - WITH - REMARKS ON THE NAME AND ORIGIN - OF THE DISEASE. - - - * * * * * - - BY - - JOHN WILSON, M.D., F.R.S., - - INSPECTOR OF NAVAL HOSPITALS AND FLEETS. - - * * * * * - - SIMPKIN, MARSHALL, AND CO., LONDON; - LEGG, GOSPORT. - - 1849. - - * * * * * - - - - -TREATMENT OF CHOLERA. - - -ON admission the patient was immediately placed in a hot bath, from 104° -to 112° of Fahrenheit, in relation to the reduction of circulatory power, -and of superficial heat; diligent friction of the abdomen and -extremities, according to the place and violence of the spasms, being at -the same time practiced. The measure seldom failed, except in cases of -extreme collapse, to excite some warmth, abate cramps, and lessen -suffering, at least, for a time. - -While in the bath, or as soon as carried from it, a drachm of tincture of -opium, in aromatic water, was administered. If, as almost invariably -happened, the draught was instantly rejected, the proper practice of the -hospital was forthwith commenced and steadily pursued. It consisted of -the following means:— - -Two grains of calomel, in bolus, every hour, or every half hour. - -Half a drachm of oil of turpentine, in two ounces of mucilage, repeated -every hour, or every second hour; most frequently the last. In one -instance it was given every half hour. - -An enema, consisting of two ounces of oil of turpentine, two drachms of -tincture of opium, three ounces of mucilage, and three ounces of camphor -mixture, repeated according to circumstances. - -Friction applied to cramped parts assiduously, and as forcibly as could -be borne, with turpentine and olive oil. - -Such, in brief, was the treatment adopted and relied on, though various -auxiliaries were, from time to time, and in different cases, employed. - -Occasionally, but chiefly when the patient represented the vomited fluid -as being sour, a solution of carbonate of soda in water was substituted -for plain water, as a portion of drink. Sinapisms were sometimes -applied; aromatics were now and then, though seldom, prescribed; and in -two cases, where with moderately firm pulse, spasms were universal and -excessively severe, blood was taken from the arm. Pans with hot water -were often applied to various parts of the body, but could seldom be long -borne, or kept in place, from spasms or other causes of restlessness in -the patient. - -One remarkable and gratifying effect of the turpentine draughts consisted -in what may be called their acceptability to the stomach. While aromatic -and cordial mixtures were instantly rejected, they were generally -retained for considerable periods. The turpentine injection had similar -effects on the intestines, allaying irritation and checking discharges. -With few exceptions they arrested the flux for a time, in most instances -for a considerable time. So powerful, in fact, was their restraining -power, that they did not require to be often repeated. Their controlling -influence was unquestionably great. - -Many years ago, while serving in the West Indies, and often looking -anxiously but in vain, for the constitutional effects of mercury in the -precipitous fever of that region, the writer was led to inquire whether -some accessory agent might not be found to accelerate and determine the -action of the mineral; and turpentine, from its penetrating properties, -rapidly entering the circulation, exciting the capillaries, and -stimulating the kidnies, presented itself as probably possessing the -desired qualities. It was tried, and did not altogether disappoint -expectation. It was thought afterwards that it did not only precipitate -mercurial action, but increased its remedial power. A paper on the -subject was printed in the “London Medical and Physical Journal,” -especially in reference to the treatment of neuralgic affections, in -1830. - -Calomel in some shape, in various quantities, after various intervals, -alone or combined, has long been the most popular remedy for cholera; -and, from the concurrent testimony of many witnesses, it has properly -gained its reputation. The practitioner has not always, perhaps, -considered very carefully the grounds on which he prescribed, nor the -channel through which he expected its remedial agency, being satisfied -with the result. It is certain, however, that the result from it—as from -other things—has been too often the reverse of satisfactory. It is -equally certain, that if an auxiliary accelerating agent is a desideratum -in the precipitous fevers of the West Indies, it is much more so in -dealing with the yet more precipitous disease under consideration. -Looking at the matter in this light; believing that calomel, as it is -commonly administered, in the worst and most suddenly fatal cases of -cholera, seldom passes beyond the stomach; and being satisfied that to -act as a remedy it must enter the circulation, and reach secreting -extremities, the method of treatment specified above was adopted. - -The results on the whole were satisfactory. Though not such as were -desired or even hoped for, they at least exhibited a full average amount -of success, inspired confidence, and tended to support the belief, that -the practice was founded on right principles. - -Of 37 cases admitted 12 terminated in death, the remainder in complete -recovery. {9} - -All the cases in the above number were considered to belong strictly to -the epidemic cholera of the season, characterized chiefly by depression -of vital power, suppression of biliary and urinary secretion, and great -tendency to death. Pains were taken to exclude from it allied -affections, especially bilious, or as it is sometimes called, English -cholera, of which there were many, and some grave cases. Want of care in -this respect renders useless comparisons of the respective value of -different modes of treatment; and it is suspected that it is more to such -carelessness, to use no strange word, than to superior skill in the -practitioner, that the high proportion of cures claimed in some instances -should be ascribed. This is said without meaning to insinuate that one -method of management is not better than another, or wishing to damp the -inquiry in which so many men are now anxiously engaged, as to how more -may be done than has yet been effected for choleral patients. In -attempting to balance the respective merits of different lines of -practice, it is also necessary, in order to render the comparison fair or -instructive, to know whether as a whole, the cases treated by each were -equally severe. - -Of the 12 fatal cases which occurred here, eight of the subjects were in -a state of complete collapse—cold livid and pulseless—on admission; in -another collapse was nearly complete, and death speedily followed in all, -without the slightest sign of re-action. In one of the remaining three -cases, there were slight and transient periods of re-action, alternations -of promise and discouragement for fifty hours, when fatal sinking came -on. In the other two, the first danger was past, but severe re-actionary -fever followed. In one there was restoration of the biliary secretion; -in the other, during the last eighteen hours the subject had the complete -appearance of a patient in West Indian fever, discharging largely from -the stomach, and more sparingly from the bowels, a fluid exactly -resembling _black vomit_. - -In the cases, which terminated in recovery, the impression was severe, -though not equally so; and in each the symptoms, as already stated, were -considered clearly characteristic of the prevailing epidemic. In some of -them no hope was entertained for a time; especially in two cases, where -there was in excess, lividity of surface, cold sweats, corrugated skin, -bent fingers and toes, and failure of pulse. - -In considering the probability of recovery from cholera, there is reason -to think that the manner of attack should be taken into account, jointly -with the severity of subsequent symptoms. From what was observed here, -it appeared that when there had been precedent diarrhœa, or when there -had been—though sudden—a gradual progress to the collapsed state, there -was a much better chance for the patient than when the disease, in -overwhelming force, fell upon him at once. When, soon after eating a -hearty meal, in perfect health, the subject is obliged to be relieved -from duty in the ranks, or on deck, becoming in an instant faint and -giddy, with a rush of fluid from the stomach and bowels, shrinking of -features, fluttering pulse, coldness of surface tongue and breath—struck -down, as it were, by electricity—to which soon followed the up-turned -ecchymosed eye and whispering voice—when the disease thus sets in, it is -doubtful whether art has any power to arrest, or materially modify its -fatal career. Such, at least, is the impression from what was observed -here; and such, without questioning what has been alleged to have been -done by others, or disparaging the means they employed, it is apprehended -will be the conclusion of most observers elsewhere. - -The practice pursued in Haslar Hospital is submitted to the profession, -not because it had any very eminent success, nor on account of its -including new remedies, but because the proportion of recoveries was at -least fully as large as that which has followed other modes of treatment; -because there was some novelty in the combination of the means employed; -and because it is thought that any contribution to the therapeutics of -cholera will be acceptable. - -Among the diseases allied to cholera which have been treated in Hospital -during the last two months, should, it is believed, be included grave -cases of fever, with striking predominance of gastric symptoms, and -excessive discharges from the alimentary mucous surface, as well as the -following:— - -Forty-three cases of febrile diarrhœa, with rice water digestions, and -strong choleral tendency. - -Ten cases of colic, with spasms of extremities. - -Twenty cases of bilious cholera, making a total, exclusive of fever, of -73 cases of allied affections, all of which have ended in cure, or are -making favorable progress. Some consideration of these cases, and of the -various appellations applied to cholera, have led to the following -remarks on - - - - -THE NAME OF THE DISEASE. - - -Although the term cholera, when applied to the disease under notice, is -derivatively erroneous, it has been so long adopted, and universally -employed, that it would be vain, perhaps useless, to attempt to alter it; -but the adjective appellatives coupled with it are so numerous and -inappropriate, so confusing, and so likely to lead to unjust conclusions, -that it is desirable to substitute for them a single significant epithet. - -Asiatic cholera is the most common designation, and appears to be the -most incorrect, inasmuch as it assumes that the disease is an import from -Asia, while there is strong reason to conclude that it has no more claim -to be called Asiatic than American. There is reason to conclude that the -cholera now widely diffused over the United Kingdom, is not an imported -product of any foreign country, near or remote, but is as much the -product of the places and the circumstances of the subjects where it -exists, as is ague, or bronchocele. - -Spasm is not peculiar nor essential to it; for severe spasms often -accompany bilious cholera; and in the worst forms of this disease cramps -are not violent nor continued. Spasmodic cholera, consequently, is not a -proper designation. - -The terms “malignant,” “pestilential,” &c., which have been joined with -it, convey no idea but that of destructive force, and are destitute of -discriminative meaning. - -With a view to getting rid of these, and such erroneous or unmeaning -terms, it is proposed to couple with the substantive _cholera_ the -adjective _abiliosa_, the prefixed privative being intended to denote the -suppression of the biliary secretion, so constant and important an -element in the diseased actions constituting cholera. It is true that -other secretions essential to health, as that of urine, are suspended, or -materially lessened; but the total want of bile in the fluid discharged -from the stomach and bowels, is one of the most striking and unequivocal -characteristics of the disease; and the term suggested would serve to -separate it from the form of cholera in which the biliary secretion is -excessively augmented, and with which it is perhaps sometimes confounded. -It would, at any rate, have the merit of giving one distinctive idea, and -leading to no false conclusion. There would then be two intelligible -names for the two forms of the disease, namely, _cholera abiliosa_ and -_cholera biliosa_. - - - - -CAUSE OF THE DISEASE. - - -It is not intended in this place to discuss at length the question of the -contagious power, or personal communicability of cholera, but in support -of the opinion given above, that it is a domestic, not a foreign malady, -with which we have to deal, a few incontrovertible facts will be cited. - -The disease broke out at the same time in Gosport, and in Portsea -Portsmouth and Southsea, situated on opposite sides of the harbour, and -affected numbers in different parts of those towns at once. - -At the same time—almost to an hour in some of the places—it appeared in -Southampton, Salisbury, Bristol, and Plymouth. Such simultaneous -eruptions of disease, in different distant places, appear incompatible -with the hypothesis of contagion—irreconcileable with the belief that it -arises from, and is communicated by one body to another, either directly -or indirectly, either by recent emanations from a diseased body acting -speedily on proximate healthy bodies, or by the same emanations, in a -concrete form—called formites—acting on distant healthy bodies, after -uncertain lapses of time. - -In the Minden, hospital ship at Hong Kong, in 1843, when periodic fever -and flux were prevalent and highly fatal, a man, convalescing from an -attack of the latter, was suddenly seized with unquestionable symptoms of -cholera, which ran its destructive course in a few hours. The case is -noticed in the “Medical Notes on China,” as curious from its isolation; -and a conjecture was hazarded at the time as to some affinity between its -cause and that of fever and fluxes, then rife at that place. No other -case of cholera appeared before or after it, though the subject was -affected and died in the midst of a mass of men, accumulated between the -decks of a ship. - -A similar case occurred in the Rattlesnake, while employed in the West -Indies, in 1826, with this difference, that it happened in a healthy ship -to a healthy man. With incessant rice water vomiting and purging, rapid -failure of circulatory power, lividity of surface, cold sweats, cold -breath and tongue, the subject sunk in eighteen hours. No other case -occurred in the ship, nor was another heard of on the station. - -Whatever difficulty there may be in accounting for the occurrence of -those cases of cholera, it can scarcely be imagined that they arose from -human contagion. It is certain that the disease was not propagated by -them. - -In the year 1832, the north of Ayrshire generally suffered severely from -cholera, while the south part of the county entirely escaped. The -disease was excessively fatal in the county town—Ayr—situate about a mile -north of the river Doon. It approached close to the north bank of the -stream, but did not cross it. From that river to the river Stinchar, a -distance of about 30 miles south, no case but one was known to exist; and -that one occurred in a letter carrier who had been in Ayr, when, or -immediately before he was attacked. He returned to his residence in -Girvan, where he soon died with unequivocal symptoms of the disease which -was raging in the town from which he came, but had not till then appeared -in the town to which he returned. Yet with him the disease not only -began, but terminated in Girvan—a poor place, in which the inhabitants -are not remarkable for cleanly or orderly habits. Here then was a -district extending 30 miles in one direction, by about 20 in the other, -bounded on the north by the river Doon, on the west by the sea, on the -south by the river Stinchar, and on the east by a chain of hills, where -there was but one case of cholera, and that one carried into it, from a -deeply affected place 20 miles distant. {17} - -How was its immunity to be accounted for, if the disease which was -destroying so many in Ayr was endowed with a contagious property? The -intercourse was uninterrupted, and the district in question populous, -containing many villages and considerable towns, including Girvan, with a -population of about 5,000, mostly hand-loom weavers, a great majority of -whom lived in crowded, ill-ventilated, ill-kept rooms. Cholera was -carried there: the place and persons seemed especially fitted to foster -and extend a contagious disease; yet the disease made no way there. - -These instances, and hundreds of similar import which might be cited, -seem to show that cholera is not primarily and necessarily a -self-propagating disease. The question, as to whether, when, and how it -has contagious power grafted on it, is one of more difficult solution, in -which it is not meant now to enter; but reference may be made briefly to -some circumstances which have been alleged in proof of the contagious -property of cholera—of power possessed by it, either originally belonging -to, or engendered by it. - -In the autumn of 1833, Beith, a considerable town in the north of -Ayrshire, was suddenly affected by cholera, which, in a few days extended -to many persons, and in a few weeks cut off a large proportion of its -inhabitants. About the time that the disease broke out, a poor family -had arrived from Glasgow, where cholera still lingered, where it had -existed more than twelve months, and where during the previous year it -had been prevalent and destructive. The poor family that went thence to -Beith were not affected by cholera, nor was it shown that they had been -in communication with choleral patients in Glasgow. All that was proved -against them was the fact that they had lived in that city, and yet on -them was charged the introduction of cholera into Beith, and indirectly -the mortality which followed. - -It is worthy of remark, in illustration, with many such cases, of the -mysterious movements of the cause of cholera, that Beith in the preceding -year had wholly escaped its power, while adjacent towns and villages with -which it had constant intercourse were suffering severely from it. That -Beith should evade the contagious power of cholera in 1832, when the -disease was rife in its near neighbourhood, and fall under it in 1833, -when there is no evidence of its being nearer than Glasgow in mitigated -force and occurring rarely, is, to say the least, difficult to -understand. - -In the spring of this year a custom house officer who had been on board a -foreign vessel in the Thames, in which were cases of cholera, was soon -after attacked by the disease, and died at Gravesend. A little later, a -nurse who had attended a choleral patient in the Dreadnought Hospital -ship was attacked by the disease and died. {19} - -These two cases have been considered by some as all but decisive of the -question; they have been looked on as furnishing cumulative proof of the -self-propagating power of cholera. But to satisfy others, especially -those gifted with only a moderate share of credulity, it would be -necessary to show that there was not at the time an endemic cause of -cholera on the banks of the Thames, which, though then but sparingly -developed, was capable of exciting the disease in persons strongly -disposed to it, by previous disease, destitution, or other debilitating -agents. It would be necessary to show that one of the laws of other -febrile endemics, such as yellow fever, does not influence this, namely -that when the _essential_ cause is in much force it attacks persons, -though with a certain relation to individual susceptibility, with various -degrees, up to the least conceivable degree of it; while reversely, when -the cause is little diffused or concentrated, only those who are -especially disposed to it—only those who have excessive susceptibility, -natural or acquired—constitutional disposition, or disposition from -circumstances of life—suffer from it. It can scarcely be denied, that on -such difference mainly, if not entirely depends the difference in the -prevalence of many febrile endemics; in one instance causing many, in -another few attacks; now leading to a sweeping epidemic, and then giving -rise to a few cases, or to one case. It would, in short, be necessary to -show that while we are trying to trace the disease from one person to -another, its cause is not springing from under our feet, and mingling -with the air we breathe; which in the cases in question would not be an -easy task, seeing that the disease had much endemic extension both before -and after their occurrence, and that for years sporadic cases have been -reported in the same or neighbouring localities. Nor will the doubts -left in the minds of some enquirers, after full consideration of those -cases, and allowing them all the weight they deserve, be lessened by -reflecting on those which happened in the Minden and Rattlesnake -respectively. - -But the case of the nurse in the “Dreadnought,” suggests questions -respecting the fate of nurses attending choleral patients in other -places. If it be true, as it is believed to be, that they are affected -by cholera in a degree scarcely, if at all, exceeding that of persons in -the same social condition otherwise employed, the fact would appear to -furnish a strong general argument against the contagious nature of the -disease. How does it happen that persons living in the same room with, -and constantly handling and helping patients in all stages of the -disease, so constantly escape its power, if it be not only readily -communicable by the person to healthy persons, who are in juxtaposition -with its subjects for a short time, but capable of being propagated by -their clothes, in distant places, after undefined periods? - -Five fresh nurses were brought into Haslar Hospital to attend the -choleral patients. They passed at least half their time, night and day, -in the ward, and slept there in their turn. They were much employed in -rubbing the patients, and consequently leaning over them, administering -injections, removing ejections, &c., in short performing all the duties -of their place, which were at once trying, laborious, and likely to -excite apprehension,—yet none of them was affected. - -These, and such facts, of which a multitude might be accumulated, may be -objected to, on the ground that they afford negative evidence only, and -that one positive proof of contagion would outweigh them all. Be it so. -But where is the positive proof to be obtained, and by what -distinguishing mark is it to be recognised? Suppose one of the five new -nurses brought into Haslar to attend on the subjects of cholera had been -attacked by the disease, during, or soon after that service, must it be -admitted that the disease was communicated by the patient to his nurse? -It is submitted that it should not. Before such admission can be held -necessary, it must be shown that the disease which attacked the nurse was -not derived from places outside the Hospital, which he was allowed to -visit, or from the cause diffused in the air of the neighbourhood, in -less or greater concentration, and manifesting its powers relatively to -the degree of concentration, and the force of pre-disposing co-operating -agents. - -It would be unsafe to assert that cholera can never, under any -circumstances become contagious; but if the conditions which lead to its -acquiring that property, the crisis by which it is effected, and the -period of its accomplishment cannot be ascertained, the policy of -searching for it may be questioned. Truth is desirable on its own -account certainly, but the truth or falsehood of a position is relatively -important according to its bearing on the business of life; and if the -position that cholera may become contagious could be demonstrated, to -what practical purpose could it be turned? It does not appear how it -could be used to stay the progress or mitigate the power of the disease. -It would not likely be proposed as a reason for separating the sick from -the healthy, or enforcing quarantine regulations of any kind. He must be -a very ardent believer in the self-propagating power of cholera who would -urge authority to shut up, and surround with guards, houses standing in -many different parts of Gosport, Portsea, Portsmouth, and Southsea, and -half the towns and villages of England. There is little danger of such -measures being adopted now, although they were seriously put forth by the -General Board of Health, under sanction of an order in Council, in -October, 1831; but, if they were put in force, it would not be rash to -assert that they would aggravate the evil immensely. They would turn -fear into terror, and interfere with, or prevent the ordinary offices of -humanity; thus, at the same time, supplying one of the most powerful -predisposing causes of the disease, and fearfully augmenting the misery -and danger of the affected. In such a state of things it would be -impossible to persuade persons of character, like those who, without -hesitation, undertook the duty of nursing the choleral patients in -Haslar, to enter on similar service for eighteen-pence a day; nay, it -might be impossible to persuade men to enter on such a forlorn hope by -any consideration. - -Although the pro-contagionist might not be moved by facts and inferences -like these, he would perhaps be disposed to ask the man propounding them, -some such question as the following.—As you do not admit that contagion -is the cause of cholera, what in your opinion is the cause? In return it -would not be impertinent to say to the querist, what is the cause of -ague? Something emanating from the surface of the earth, on the spot, or -not far from the place where its subjects are resident?—something so -subtle as to be imperceptible by the senses, and hitherto beyond the -scrutiny of chemists and meteorologists. He would, it is presumed, -answer in some such terms, or if he attempted any much more precise and -instructive, he would proceed without the warrant of fact and experience. -Such at least would be the general reply of the profession, and a more -complete and unconditional confession of ignorance of every thing -respecting the essence of a most powerful and wide spread cause of -disease cannot be made. Though we know a good deal of the places most -prolific in its production, as well as of the agents which co-operatively -increase its force, we know it solely by its effects. - -In very similar, if not precisely the same terms, it seems to the writer, -should the question, what is the cause of cholera, be answered. Little, -if anything more can be affirmed respecting its origin, but almost every -thing authentic in its history, progress, and phenomena, testify to its -having a local source, and generally very limited scope of operation. -Thus it appears simultaneously in different, distant places, leaving -intermediate places untouched. It attacks in one town a particular -district, street, or portion of street, beyond which it does not travel. -In another town it shows itself among distant portions of the -inhabitants, leaving long spaces unscathed. Again, while one town -suffers severely from it, another in the neighbourhood has not a single -case then, or thereafter; or the town which escapes this season, falls -fatally under its sway the next, when all the rest of the country is -clear. These and such circumstances as these, point as clearly as it is -possible to point at the endemic source of cholera, although the -_essential_ cause of the disease cannot be ascertained. - -But although we cannot in cholera, more than in periodic fever, ascertain -the _essential_ cause, there is no difficulty in showing the accidental -auxiliary agents, which both in disposing to, and co-operating with it, -give it much of its prevalence, and most of its fatal power. They -consist in whatever deranges healthy action, and impairs constitutional -vigour—such as unwholesome insufficient or irregular supplies of -food—over labour—crowded and defective ventilation—dissolute habits, -including vicious indulgences in intoxicating drink, and want of personal -and domestic cleanliness—apprehension, anxiety, and inordinate emotions -of the mind; and defective drainage, including sewerage, with resulting -accumulation of organic matters. For the last, at least, the State and -the authorities acting under it ought to be held responsible. - -Whether the last named agent—defective drainage and its -consequences—constitutes any thing positive to the _essential_ cause of -the disease, or is necessarily connected with it, or whether it only -co-operates with those specified before it, in lowering the standard of -health, by the production in excess of hydrogen and other gases, -injurious to life, and thereby predisposes the body, through augmented -susceptibility, for the action of the _essential_ cause cannot be -determined. It is pretty certain, however, that neither it in any -quantity, nor any amount of the other agents classed with it, as -disposing and co-operating powers, in the production and extension of -cholera, can of themselves create it. If they could, not only part of -Ireland, but of places nearer home, must have been decimated, some of -them depopulated. - -Whether excess or deficiency in the electric element, or disturbance in -its ordinary relations, in the place where cholera appears, acts any part -in the production of the disease, is not known. It seems probable that -there is something abnormal in its distribution and movements; but that -is all that can ever be reasonably conjectured, at least for the present, -respecting it. - -Whether there is any affinity between the _essential_ cause of cholera -and periodic fever, and, if any, of what kind, are questions that -naturally suggest themselves in investigating the etiology of the former. -That the question, as far as it relates to a certain affinity in the two -cases, should be answered affirmatively, the following considerations -seem to shew. - -Swampy undrained soils, the banks of rivers, the margins of harbours, and -other low lying localities, with places where organic remains are -artificially accumulated, or allowed to accumulate, prove the most -prolific positions in the production of cholera, as well as of periodic -fever. - -Both before the outbreak of cholera, and on its subsidence, fever of -type, more or less distinctly marked, with predominance of gastric -symptoms, are more frequent than usual. - -Some remarks, as already stated, were made on this subject in the -“Medical Notes on China;” it may be added that many circumstances might -be cited, tending to show that there is a close connection, not only -between the causes of cholera and periodic fever, but also between it and -endemic fever generally. - -All this is very vague and unsatisfactory, but with such generalities, -negatives and probabilities, it is feared we must for the present at -least, be as content as we can, unless we are disposed to leap to -conclusions, without finding the steps of evidence by which alone they -can be safely reached; or are willing to subscribe the creed, that -cholera, however first produced, is reproduced only through the -instrumentality of the human body—that, by whatever acts, combination of -acts, or of accidents it began, it is continued solely by contagion. - -The essential cause of cholera—the _causa sine qua non est_—as well as of -other things in nature with what are more familiar, is, and perhaps ever -will be, beyond the reach of human penetration; and were its nature and -properties ascertained, such knowledge might contribute little or nothing -to our means of resisting its effects. But while this ignorance exists, -and candour requires its confession, there is none respecting the -associated concurrent agents, through whose influence it acquires -extended prevalence and augmented fatal force. They have been already -alluded to, and are so palpable as to be beyond question; and as they are -on the surface, and susceptible of abatement or removal, it becomes us to -deal with them promptly, vigorously, and perseveringly. - -They divide themselves into two classes, the first of which concern -private citizens, both as individuals, and as forming families; the -second are subjects for legislative enactments, and consequent executive -interference, constructive and restrictive. - -Respecting the first, it may appear superfluous to reiterate what has -been so often repeated, and universally admitted, namely the paramount -importance of sobriety, cleanliness, and industry, in conjunction with -sufficiency of nutritious food; nor to aver that if the former were more -sedulously practised, there would be much less ground for complaint of -the last than unhappily there is. It would be out of place to enlarge on -such a subject here, but it may be allowable in passing to observe, that -it behoves the more intelligent and wealthy members of the community, lay -as well as clerical, to unite and help the more ignorant and needy in the -great—vast as to results—reform, which it contemplates and embraces. A -good deal has been attempted, and something has been done, but much is -wanting. The work is great, requires many labourers, and gives scope for -the combined exertions of enlightened philanthropists of all kinds. Yet -we may say of it, without profanation or levity, and in the literal -meaning of the words—truly the harvest is great but the labourers are -few. - -The second class of reformatory measures required for the object in view -must devolve on the legislature, and on authorities constituted by it, as -all experience shows they cannot be entrusted to the voluntary efforts of -individuals, or to those of municipal, or other local self-acting bodies. -The enlarged and disinterested consideration of men having authority, -independent of the conflicting interests, and removed from the prejudiced -opinions, affecting particular places, who look to the welfare of the -whole, must do the work, if it be ever done effectually. Enlightened and -benevolent men in parliament and out of it have not been scared from the -undertaking by the obstacles real and fictitious in the way. Let them -however, especially those in parliament persevere, leading others to join -them as they assuredly will, disregarding the selfish and ignorant -objections raised against their truly patriotic efforts, and they cannot -fail of their reward. - -The measures especially required comprise the form and situation of -houses, width of streets, complete underground drainage, and the instant -removal or destruction of refuse organic substances from and on the -surface, by strict enactments, rigidly enforced. This like the former, -is a hacknied theme, but it not the less important on that account, and -its interest can never be exhausted till the objects which it embraces -are accomplished. - -If it were objected that such interference by the state in the ordinary -affairs of life would trench injuriously on the liberty of the subject, -it should be answered that the functions of government are not merely -repressive of public outrage, and punitive of offences against the -person, that improvements of the people’s condition at large ought to be -its great aim, and that it can no more be justified in permitting the -lieges, by omission of what is right or commission of what is wrong, to -poison themselves on a great scale, than it would be in looking -complacently on at the suicide of individuals. - -It is true that the measures in question cannot be completed without much -labour, and opposition, extending over uncertain periods of time, but -they must ultimately become part of the hygienic economy of the land, if -we would avoid the imputation of being criminally accessory to the death -of thousands, and do our duty honestly to our neighbours. Unlike the -other, which as they must be effected by individuals and families will -depend on improvements in the intellectual and moral condition of the -persons themselves, these can be achieved authoratively by the -Magistrates. Both classes of reformatory measures are required to show -what may yet be done for the welfare of the people, and how incalculably -the people can contribute to it themselves, especially in respect of -health; but while only one of them is at the command of power, that one -should no longer be neglected. Had all been done which might have been -done in this way, it may be asserted fearlessly that cholera would not -have exerted the fatal power which it did in 1832, and which it is -exerting in 1849; and that other epidemics which have prevailed in the -period would have had fewer victims. - -Unsatisfactory and reproachful however as the sanitary condition of the -country is, when it appears how much it might be improved by the moral, -social and physical reforms alluded to above, it is excellent when -compared with what it was at former periods of our history. On looking -back to the terrible epidemics, which in the thirteenth, fourteenth, -fifteenth, sixteenth, and even so late as the seventeenth century, under -the names of pestilence, black death, sweating sickness, and plague -ravaged this, and other portions of Europe, we find such was the -destructive power of disease then, that the most sickly seasons recorded -for nearly two-hundred years have been, in comparison with them, seasons -of health and enjoyment. The questions which suggest themselves as to -the cause of difference will be variously answered. Amid the obscurity -which involves the subject, one thing however is evident, and seems to -offer a sufficient explanation of the difference, namely, the miserable -condition of the people in those remote periods relatively to the -present, the results of ignorance, apathy, licence and -oppression—periodical recurrence of famine—wretched habitations, -wretchedly kept—and the total want of sewerage, with accumulations of -filthy decomposing substances, producing corruption in every corner and -at every turning, sufficient to poison every living thing in their -neighbourhood. - -Since those disastrous times much, especially of late, has been done to -preserve the health of the people, but much remains to be done, and, -looking at the spirit in which the subject is taken up, and the arguments -furnished from without to illustrate and enforce it, especially the -urgent ones supplied by the daily lists of death from cholera, much more -it is hoped, will be done speedily. If the legislature executive, and -people at large would co-operate heartily and systematically, each doing -their proper part to further the work—if stagnant fluids on and near the -surface, and poisonous exhalations from decomposing vegetable and animal -matter were prevented—if the dwelling places of the poor were -sufficiently large, properly ventilated and cleansed, while the -inhabitants conducted themselves industriously and morally, the effect, -though it might not realize expectation, would unquestionably be great. -The sanitary state of the people might then as far surpass that of the -present time, as it does that of the fourteenth and fifteenth centuries: -and this age in respect of health, would occupy a middle station between -the dark ages which are past, and the practically enlightened age which -is to come, and ought to come speedily. The _essential_ cause of -cholera, and of other febrile endemics might be brought into existence, -but without indulging in idle visions, it may be predicted that they -would be comparatively harmless, in as much as they would be deprived of -the concurrent, fostering agencies, from which they derive their -prevalence, and chief instruments of destruction. And not only would -cholera and other endemic diseases, whether prevailing epedemically, or -occurring rarely, be checked and mitigated, but other forms of disease -would be lessened, while constitutional health would be invigorated. -Such great ends are surely worthy of great means zealously employed. - - - - -POSTSCRIPT. - - - 14_th_ _September_, 1849. - -IN addition to the 12 fatal cases of cholera recorded in the text, one -occurred late on the 3lst of August. The subject was received at 6 P.M. -of that day, in a state of complete collapse, and died six hours after -admission. - -During the currency of the month there have been admitted 12 cases of -cholera, two of which, being in a state of profound collapse, terminated -speedily in death; 5 cases of bilious cholera which are doing well; 10 -cases of febrile diarrhœa which are doing well; and one case of colic -with spasms of the extremities. - -The number of cases of cholera, and of allied affections, excluding -fevers, and adopting the nomenclature proposed above, between the 4th -July and this date, are as under. - - CHOLERA ABILIOSA. - Cases. Cured Dead. Remain, covalescent or improving. - 49 26 15 8 - CHOLERA BILIOSA. - 25 19 0 6 - FEBRILE DIARRHŒA. - 53 44 0 9 - CONVULSIVE COLIC. - 11 10 0 1 - -Further experience has confirmed the opinion that the means specified at -the commencement of this paper constitute fit and remedial treatment in -the formidable division of cholera to which they especially refer; and -established the conviction that when the impression is not overpoweringly -severe at the onset, and when sinking has not made great progress, a -large proportion of patients will pass safely through the disease, under -their use, if perseveringly and unswervingly employed. Latterly the -opiate draught administered on admission has been omitted, the treatment -consisting almost exclusively of calomel, turpentine draughts, and -turpentine enemata, with friction when required. A rubefacient, -consisting of strong mercurial, and cantharides ointment, each one ounce, -with half-an-ounce of oil of turpentine, well mixed, has been used with -effect. The calomel, and turpentine draughts have generally been given -every half hour, at first, in violent cases, and less frequently as the -symptoms subsided, being suspended when tendency to collapse was -overcome, or when bilious vomiting set in. - -The practice in bilious cholera, febrile diarrhœa, and convulsive cholic, -was simple, and similar in all, consisting of a bolus containing three -grains of calomel, and one of crude opium, repeated every second, third, -or fourth hour, according to the force of symptoms. Cathartics were -often required in the colicy affections, as was occasionally abstraction -of blood by venesection, or leeches. The remedies were extremely -uniform, and have been uniformly successful. - -It may be observed in conclusion that, up to this date, none of the -nurses, medical attendants, or other persons associated with the sick of -cholera have been affected by the disease, although one or more of the -medical officers of the Establishment have been almost constantly in the -ward, and one or other of the juniors has slept in an apartment close to -it; and further that no case of cholera has arisen within the walls of -the Hospital, while it has been frequently brought in, and had continual -existence within them, upwards of ten weeks, amid a population of -patients, servants, including the women who washed the foul linen, and -officers with their families, of nearly 600 souls. - - * * * * * - - * * * * * - - LEGG, PRINTER, GOSPORT. - - - - -FOOTNOTES. - - -{9} See postscript. - -{17} An anonymous writer in the _Times_ of the 11th August, states that -Birmingham had like immunity in 1832, and up to that date of the present -year. - -{19} Paper by Dr. Mc William in the Medical Gazette of 15th June of this -year. - - - - -***END OF THE PROJECT GUTENBERG EBOOK TREATMENT OF THE CHOLERA IN THE -ROYAL HOSPITAL, HASLAR*** - - -******* This file should be named 67041-0.txt or 67041-0.zip ******* - - -This and all associated files of various formats will be found in: -http://www.gutenberg.org/dirs/6/7/0/4/67041 - - -Updated editions will replace the previous one--the old editions will -be renamed. - -Creating the works from print editions not protected by U.S. copyright -law means that no one owns a United States copyright in these works, -so the Foundation (and you!) can copy and distribute it in the United -States without permission and without paying copyright -royalties. 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