REPORTS ON EPIDEMIC CHOLERA. ° WHEN the College of Physicians appointed
a Committee to issue a circular of questions on the cause, treatment, and prevention of cholera, and the profession had responded to the invitation, Doc- tors Baly and Gull were deputed to investigate the returns, deduce the conclusions to be drawn from them, and present the whole in a succinct shape. In fulfilling their duty, those physicians had recourse to official documents, and to the more authoritative indi- vidual publications' as well as to the returns made to the College. The results are contained in the volume before us ; and the gene- ral conclusions of the reporters are illustrated and supported by a digested selection of statistics and particular facts submitted to them. Each physician has taken a subject : Dr. Baly reports on the cause and prevention of cholera ; Dr. Gull on its morbid anatomy, pathology, and treatment. A council of war, it is said, always counsels a retreat. Official or deputed responsibility seems generally to lessen the freedom. and decision of most men. Perhaps originality of view depends upon actual observation, and a man who is set down to arrange and decide upon the observations of others is not in the best posi- tion to strike out new theories or indulge independent thoughts. Caution is the motto, running into over-caution. Except in some propositions of strained or questionable character, the influence, power, and delegated skill of the College of Physicians, has arrived at no more satisfactory opinion upon cholera than that
"All that we know is, nothing can be known."
In investigating the cause of cholera, Dr. Baly begins by stating six theories that have been promulgated as causes of the pesti- lence, Of these, two or at most three only, seem broadly discrimi- nated; the others being combinations or variations which might be further multiplied. 1. A morbific condition of the atmo- sphere, requiring more or less of predisposition in the patient to be affected by it. 2. A morbid matter not produced in the air, but in the body of the sick, and affecting others by transmission— that is, contact or contagion, in some shape. 3. A. morbifie mat-
• Reports on Epidemic Cholera. Drawn up at the desire of the Cholera Com- mittee of the Royal College of Physicians. By William Rely, M.D., and William
W. Gull, M.D., Members of the Committee. Published by Churchill. ter produced in the air, but reproduced by the sick and contagious. Of these, it appears to US that the first is the most reason- able; the power of the disease being assumed to depend on the virulenee of the poison and the state of the patient, or on both combined; while circumstances of weather, situation, and social or hygienic conditions, may check or aggravate the intensity, of the dis- ease, as indeed they may in all the theories, or in any theory. Some weight is to be attached to Dr. Baly's argument, that the limited direction of cholera in a country, or even throughout the world, and its varying range in particular places, seem opposed to a gene- ral skyey influence. But though the theories of man and the laws of nature are stated by philosophers in a manner pure and simple, things rarely exist in nature perfectly unmixed; modifying, per- haps counteracting causes, being always at work. Neither is the theory stated in the rigid way assumed by Dr. Baly's logic. A certain degree only of intensity is assumed for the poison, what- ever it may be; considerable power of resistance is conceded to the constitution, and modifying or even nullifying force to surround- ing circumstances. Were it not so, few could escape death or at least attack ; which is indeed sometimes the case in Tropical fevers. At the same time, we know so little of causes, that the indefinite ideas conveyed by "atmospheric influence," "constitutional pre- disposition," and "qualifying circumstances," may be the reason why this hypothesis seems reasonable.
The theory evidently entertained by Dr. Baly, and really advo- cated by him, is this : a morbific matter, not a gas, in—not of—the atmosphere, capable of being conveyed through it for com- paratively short distances, though its more usual and probable mode of transmission between distant places is by intercourse. This opinion is not advanced broadly, nor is the advocacy very ob- vious; for the whole report is drawn up on a system of cautious balancing, which overlays the work in a literary sense, as well as by frequent repetitions. This defect is difficult to avoid ; for it might appear unseemly to have an authorized delegate too plainly advancing a decided opinion in a case where proof is difficult. The strong bias of the writer's mind, however, appears to have given an appearance of fallacy to his report. He seems to ascribe greater weight to facts or arguments that favour his own opinion than really belongs to them; while he brings forward reasons against the other theories, which are all far less conclusive than he deems them, and in fact sometimes obviously contain an answer to his arguments. One strong point of Dr. Baly is the view in favour of the transmission of cholera by means of intercourse. The manner in which it accompanies troops—travels along the usual lines of communication, neglecting situations out of those lines, apparently not less favourable for its development—makes its way even against the monsoon—its outbreak both in this country and in America immediately after the arrival of ships from countries where cholera was rife and with choleraic patients on board—are very well ar- gued, and all point to something like communication, if not what is strictly called contagion. The general influence of atmospheric temperature (for there were exceptions) is equally well established. Heat and damp are favourable to the development of cholera, which is checked by cold dry weather ; in other words, we are less ob- noxious to the disease, or it has less power in winter and in early spring than as the year advances. The Doctor is equally conclusive as to the power of unfavourable hygienic circumstances.
"The persistence of the epidemic for a certain time, even in localities of small extent, and its very partial distribution in a country, a town, and even parts of towns, are two facts which at once suggest the inference that the cause of the disease is a material substance, and that it is only partially dis- tributed. This inference is confirmed by the characters above referred to, as those presented by the epidemic in its progress over a country, and by the fact that, within a limited area, many spots have remained free from it, which exactly resembled the localities attacked in respect of the supposed localizing conditions. It is certain, however, that cholera is so far connected with the conditions of low site and defective sanitary provisions, that it is never very rife except where they are present in a marked degree. Now, all these conditions alike tend to produce a damp and impure state of the sir in the places where they exist; while the variations of the intensity of the epidemic, attending variations of season and temperature, and the slighter effects of other known meteorological changes, are most easily explicable by referring them to the increase or decrease of moisture and impuri- ties in the air, which necessarily result from a rise or fall of tempera- ture, and from a stagnant or rapidly-moving atmosphere respectively. The natural inference is, therefore, that the matter which is the cause of cholera, increases and finds the conditions for its action under the influence of foul or damp air with the aid of some degree of warmth ; and this being premised, other facts become intelligible,—namely, the persistence of the disease in the winter, for the most part in the interior of large establishments, where there is warmth, together with that impurity of air produced by the accumulation of many human beings within a limited space; the preference manifested by the disease throughout an epidemic for low and densely-populated districts, especially the tracts of countries about the mouths of rivers, and for crowded towns and dirty and ill-ventilated parts of towns, or single dwellings of the same character even in elevated situations; and likewise its appearing at the commencement of an epidemic, as a general rule, first in places of the character described, since in those places the impure and damp air would be found earliest and in greatest abundance."
There is nothing very new in the section on the prevention of cholera, unless it be the greater stringency of the recommendations. Dr. Baly, indeed, gives up quarantine, on account of trade, though that would seem the most effectual means ; but advises a more rigid hygienic police, as it were, and severer regulations in public institutions, together with the establishment of hospitals and houses of refuge where needful.
The report of Dr. Gull on the treatment of cholera is less ela- borate in composition and argument. It is rather a digest of the facts, accompanied by opinions that have attended particular modes of treatment, than a report of the nature of a regular treatise. The results of particular medicines or modes of practice as deduced front the returns are exhibited, followed by illustrative quotations from the different practitioners. It is much more satisfactory in a literary and logical than in a practical sense; seeing that patients who get nothing but cold water do pretty nearly as well as those for whom the whole pharmacopeem is laid under contribution; while those who are favoured by the most active resources of art die in greater numbers than those who are let alone. The follow. ing remarks, though not free from the taint of indecision or cautious balancing, perhaps inseparable from works of delegated responsibility, are well to bear in mind, on the principle of looking the enemy in the face.
"The amount of success obtained by early treatment is not yet deter- mined : there is a general opinion that it was very great ; but this must be received with some limitation, as the facts upon which it is founded are not unequivocal. By far the larger number of cases of diarrhcea would pro- bably never have passed beyond this stage if no medicines had been admmis- tared ; and, on the contrary, in many instances the symptoms were unin- fluenced by any treatment, and fatal collapse came on in spite of every effort to prevent it. "Epidemics cease at last, as fire does, from the want of combustible materials ; and on this point we may quote from the communication made to the College by Dr. Burrows- " 'According to my experience,' he says, the facility with which the serious diarrhcea may be checked depends mainly upon the period of the epidemic when the treatment is adopted. Those remedies which are power- less in the height of the epidemic, in any locality, will prove efficacious to- wards its decline. Thus, cases of serious diarrhcea, with symptoms of ex- haustion short of collapse, appeared, in spite of unremitting attention, to be quite uncontrollable in the month of July ; whilst cases of equal urgency at the time of admission, in the month of 'September, were controlled with a facility which often quite astonished me when I reflected upon my want of success at an earlier period of the epidemic.' " On comparing the curve indicating the decline of the epidemic in the whole country in the autumn of 1849, with that for London in particular at the same time, (see the Maps in the Registrar-General's Report,) there is the closest coincidence between them : from which we may conclude that the causes in operation were the same in both ; and hence we cannot attribute the diminution of the mortality in the latter, in any great degree, to the interference of preventive treatment."
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