What is its nature?

CHOLERA MORBUS.

In what manner ought it to be treated? And is it likely to visit the British Islands? BY DAVID UWINS, M.D.

My reader must not imagine that I am about to frighten him out of his senses with medical polemics, and technical jargon, when I advert to three or four errors which have always (as it appears to me, for I would not be dogmatical) clung with more or less tenacity to, and thereby occasioned more or less of confusion in, the doctrines and principles of the healing art.

In the first place, the excitant of a disease, or one of its prominent characters, has by a curious sort of metonymical nomenclature been considered and described as the disease itself; or what is more to the purpose of our present argument, the error as to its consequences being in some measure similar, varied degrees of morbid action have been received, as differences absolutely in kind.

Secondly, the ideas of contagion and infection have been strangely confounded, even by men, who, for the most part, are precise in their language, and particular in their designation, of other things.

It has, thirdly, been taken for granted, and acted upon as a practical truth, that an infectious disease cannot be a contagious one, nor a contagious an infectious one.

Lastly, the management of a malady has been considered a mere abstract affair, whereas, in point of fact, it is one of the most circumstantial and relative of all things. The physician, in his endeavours to combat morbid action, has been supposed to be engaged with a substantial entity-and you hear talk of remedies for this, and cures for that distemper, as if, like the chemist, a medical practitioner had only to learn the opposites of the several derangements to which we are obnoxious to apply that to the particular case and thus to obtain the tertium quid of health.

I will give one or two instances of these several errors, and endeavour to make the argument apply to the resolution of the important queries placed at the head of the present article.

We will suppose a certain condition of atmospheric temperaturean undefinable and hitherto inscrutable state of circumambient aira too fearless exposure to sudden alternations of heat and cold-a dejected or apprehensive turn of mind-an indulgence in unwholesome fruits-to operate separately, or, to a greater or less extent, conjunctively, upon the frame, and the consequence shall be some kind or other of nervous, and stomach, and biliary derangement. Upon an individual of one constitution and under particular circumstances (and I have seen this happen in our own country) the rush of disordered action shall be such as to occasion a general cramp or spasm upon almost every part of the body (the biliary ducts included) and the patient shall be hurled to the ground a lifeless corpse before medical aid can be procured. Surely the malady would in this case possess every title to the appellation of spasmodic Cholera-and yet it shall have been induced by the very same means which in other individuals of the family or the district shall merely occasion an acrimony in the quality, and superabundance in the quantity, of bile, a mere diarrhoea, or, at the most, what is named a bilious Cholera, being the result. To imagine then that spasmodic Cholera, bilious

Cholera, and windy Cholera (the divisions of systematic writers), are so many abstract essences, necessarily acknowledging each its specific excitant, is to imagine erroneously

Again, let a certain virus or poison, however generated, so be made to impinge upon the body as to bring about those particular effects to which the term fever has been very improperly applied.* If the attack is made in the autumnal season, or upon what is called a bilious constitution, the consequence will be "a bilious fever;" if its influence be directed to the poor and ill-fed and filthy inhabitants of a miserable alley in a miserable part of the metropolis, the distemper will prove a "typhus fever;" if we could suppose an individual labouring under this form of disease to be immediately, or with much more than rail-way rapidity conveyed to the shores of the Levant, and to communicate with another-the second with a third, and so on in rapid succession, under external and internal circumstances calculated to foster it, plague in all its enormous malignity shall rear its head and carry dismay and destruction among the community. Let the conveyance of the typhoid sufferer be supposed in another direction; let him be transported to the swampy shores and burning suns of a West India island-here his own malady will assume more of the bilious character, and if the cause and causes effecting this change in the kind of malady act with sufficient intensity, he shall become the subject of yellow fever himself, and be the medium of communicating the yellow fever to others. Who, I have elsewhere asked, has ever heard of the yellow fever becoming general in Britain? and why, with all its acknowledged powers of communication, does it not become so? Because it is an infectious as well as contagious distemper-in other words, it is dependent upon time, place, and circumstance, as well as upon a virus or poison. But I am told that Cholera has travelled from the East to the North, and that the virulent plague of the Levant has in past times been an English distemper. It is true that Cholera has so travelled, and that plague has in past times become general in this country; but among what people and under what circumstances has Cholera thus been transported from place to place? and under what circumstances has the real plague ever been an English malady? The first has taken its route with migratory tribes and caravan travellers, among whom, from the very nature and mode of their existence, that kind of association is established which is the most calculated to preserve the seeds and foster the germination of a contagious poison. It has been conveyed to and communicated amongst districts where, as in the instance of the Cossacs, the subjects of its operation are in their habits and customs but one remove from thorough barbarism; and it has visited provinces which are torn and rent by the horrors of present or anticipated war, and where famine, and fear, and carnage, and their consequences, have rendered the people vulnerable to almost any species of malady, especially such as act particularly and prominently upon the nervous and biliary functions.

Fever is a word taken from a prominent symptom-viz. the increased heat-but this increase of heat is by no means proportioned always to the intensity of other marks, and there is, therefore, an impropriety in making it the essence of any malady. But I must not allow myself to go further into these objections, as my present design is of a popular nature.

I have just admitted that plague has heretofore visited Britain, in its true, and proper, and virulent form, instead of being the more mild or more malignant typhus of present times. But I hope and trust, nay, I am fully assured, that this will never again be the case. Upon what is my hope and expectation founded? not upon quarantine enactments, which I fear are as useless as they are expensive and vexatious;* but upon the feeling that the polity of this comparatively happy country has, in conjunction with the active good sense of its inhabitants, brought the land and the particulars of its climate into such a condition as to prevent the generation of malaria, thus to prevent plague from becoming an infection, and to dilute it into a mere contagion. Blasts from noxious winds, and blights from baneful states of the atmosphere, still occasionally visit us; but the industry of our peasantry, under the direction of our men of science, has in a great measure rent asunder the formerly joint influence of soil and atmosphere; and our citizens have effected the same disunion of animal and putrid effluvia from aërial conditions of a noxious kind. I have heard it suggested that atmospheric infection is produced by myriads of insects, or their larvæ―a suggestion which may be considered as authorised by the appearances that vegetation assumes after what is named a blight has for a short time been hovering over the land. Others ascribe the malaria, which converts a contagious into an infectious distemper, to intestine commotions of the earth engendering chemical compounds, which mixing to a certain extent with the air, impart to it its deleterious qualities. No theory, however, has hitherto proved satisfactory which aims at the explication of atmospheric poison; but certain it is that man possesses considerable power, by the management of the soil, of mitigating its malign influence; and to the exercise of this power is, I repeat, our comparative immunity from pestilential influence in a great measure to be ascribed. Assuming Cholera, about which there is at present so much, and in my mind such needless apprehension, to be a contagious disorder, (and its contagious quality seems established by the best authority,) I say, assuming that it is communicable from one individual to another by immediate contact, you assume what is rather favourable to the supposition, that we shall always be preserved from any very formidable measure of its influence; because we can dilute the poison into comparative nonentity by our habits and by our polity; and we may meet its visits, not under the paralyzing depression of alarm, but with a manly determination to do all that man has a right and a power to effect, in the way of opposing what was in former times, and still is in some countries considered as an immediate visitation from Heaven of a punitory nature, and, therefore, that resistance to it is impious, and opposition unavailing.

The Cholera in question seems to have been originally of sponta

* If articles of merchandize could cause plague in the way that quarantine institutions suppose, we should often and often have been visited by the distemper, in spite of all the precautions of the most rigorous police. It is well known that officers at the several stations smile at what they are obliged officially to perform, in the same spirit that some of the more liberal priests of an austere and ceremonious religion, after going through the duties their functions impose on them, thank God that "the farce is over." If "Reform" be required in any thing, it is required in the laws enacted for the prevention of plague. At the same time I should be far from countenancing the lawless proposals of your thorough anti-contagionists.

neous or atmospheric origin, to have been communicated to and conveyed through parts and provinces as a mere contagion; this contagion, however, being nursed and fostered into a species of artificial infection, and thus, from being in the first instance an infection, it became a contagion; this contagion itself being again converted into some sort of infectious character by the habitudes and circumstances of the parts and persons affected.

Now, were the malady more properly and strictly infectious-that is, were it like the influenza, ab origine ad finem, both infectious and contagious-we should have more reason to fear its descent upon our shores. Even then, as in the instance of influenza, much might be done in the way of mitigation by separating the sick from each other; and thus preventing artificial from mixing itself with natural or aërial poison; but, in the present case, I conceive that every thing may be done by a care commensurate to its demands, and I should say, that were a whole ship's crew to be landed to-morrow on our coast, it would only be for medical men to treat the disease properly, and to insure a separation of the sick from each other, as well as from the inhabitants of the village or town into which the ship had unburdened its cargo, for the inhabitants of a neighbouring village to remain as secure in their dwellings as if the much-dreaded plague were three thousand, instead of only three miles from them.

They have only, I say, "to treat the disease properly;" and here we have to advert again to the last species of error which has been said to mix itself up with vulgar speculations on the subject of medicinal agency. "What is the cure for Cholera?" do we hear in every company reiterated. I would reply, it is that which the immediate circumstances and complications, local and constitutional, of the case demand. Medical men, I repeat, when they encounter disease, do not encounter an abstract essence. Disorder has occasionally "a local habitation," but it can never, properly and strictly, have "a name." The same course shall be followed in different individuals with vastly different effects; and opium and ammonia, and calomel and blood-letting, and sudorifics, shall be all proper-nay, imperiously called for in this instance--they shall some be demanded, and some contra-indicated, in that instance the malady still retaining from its excitant an appellation implying identity.

I alluded to cases, in the beginning of this essay, where frightful spasms had seized their victims, and crushed the vital principle by an eager grasp before medicinal aid could be procured. I recollect one particular instance, where a fine young woman, in the full vigour and flower of life, was thus cut off from among the living, and who, most probably, might have had her life preserved to this day had a qualified person been at hand to pour down opium and ammonia in sufficient quantities, to drown, as it were, the cruel spasms. I have been called to other cases, where the timely administration of opium in due quantities has appeared to effect the purpose of immediate preservation, while the radical, or eventual indication, so to speak, has been for an opposite system of treatment; but it is obvious that in all severe cases of disordered visitation the main object of the medical practitioner ought to be to think of his patient circumstantially, and not of the malady abstractedly, and to prevent the extinction of the living principle by measures apportioned to the magnitude of the occasion.

And with what conscious satisfaction may not medical men appeal to the astonishing success attendant upon the treatment of Cholera, even in its direst degrees and forms, when called upon tauntingly by sceptics to show the ground of their pretensions to restoring power!

On this head, we may extract the following statement from Dr. Mason Good, who, in alluding to the Cholera of 1817, remarks, “Of the dreadful spread and havoc of this cruel Asiatic scourge we may form some idea, from the report to the Medical Board at Bombay by George Ogilvy, Esq. Secretary. The population in this district alone is calculated at from 200,000 to 220,000; the total number of ascertained cases amounted to 15,945, giving a proportion of seven and a half per cent. Of these cases, 1294 sick had been without receiving medical aid; and there is reason to believe that of these, every individual perished! Mr. Ogilvy, indeed, expressly asserts it was not ascertained that any case had recovered in which medicine had not been administered; while it is gratifying to learn, on the other hand, that among those who had received the advantages of the judicious and active plan concurrently pursued, the proportion of deaths was reduced to 6.6 per cent. an alarming mortality still, but a marvellous improvement upon the natural course of the disease. In other parts of India, indeed, the deaths under the same plan of treatment seem to have been still fewer; for Dr. Burrell, surgeon to the 65th regiment at Seroor, out of sixty cases, makes a return of only four deaths; and Mr. Craw, on the same station, asserts that, on an early application for relief, the disease, in his opinion, is not fatal in more than one in a hundred cases.' Than this statement nothing can be more satisfactory-nothing more demonstrative in favour of medicinal interference." "Let Nature alone to work its own cures" is the cant of many; but who, after perusing the above narrative, can fail to be convinced that this notion of leaving things to Nature is utterly and often fatally erroneous?

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If in the few foregoing intimations I have made myself understood by the reader, he will infer that I have very little apprehension of Cholera ever being an epidemic in Britain. It is possible that the bilious affections which are common with us at the autumnal season, may this year assume a little more than their wonted malignity; but we have only to be dietetically careful and medicinally watchful, and I believe that much may be done in counteracting even such tendency. At the same time, I am far from joining the fierce and fearless anti-contagionist, who laughs at all preventive measures, and who derides Government enactments by comparing them with commands to build up high walls in order to keep in larks. The term contagion, these gentlemen contend, ought to be restricted to such maladies as measles, scarlatina, and small-pox; for it is these and these only which are capable of being conveyed by a specific poison from district to district, and from clime to clime. Dr. M'Lean, indeed, was so thoroughly imbued with this sentiment, that he entered, without the smallest scruple or care, into the Lazarettoes of the Levant, in which hundreds were labouring under plague. He became himself the subject of plague, and was cured of his distemper, but not of his conceit : for he afterwards returned to this country, and wrote an interesting July.-VOL. XXXII. NO. CXXVII.

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