Читать книгу Letters on the Cholera Morbus. - Fergusson William - Страница 2

In my last letter I adverted to the opinion forwarded to his Majesty's Council on the 9th of June last from the College of Physicians, in which the cholera, now so prevalent in many parts of Europe, was declared to be communicable from person to person. We saw that they admitted in that letter (see page 16 of the Parliamentary Papers on Cholera) the limited nature of the proofs upon which their opinion was formed; but I had not the reasons which I supposed I had for concluding, that because they used the words "ready to reconsider," in their communication of the 18th of same month to the Council, they intended to reconsider the whole question. Indeed this seems now obvious enough, as one of the Fellows of the College who signed the Report from that body on the 9th of June (Dr. Macmichael) has published a pamphlet in support of the opinion already given, in the shape of a letter addressed to the President of the College, whose views, Dr. Macmichael tells us, entirely coincide with his own; so that there is now too much reason to apprehend that in this quarter the door is closed. Contagionist as I am, in regard to those diseases where there is evidence of contagion, I find nothing in Dr. Macmichael's letter which can make an impression on those who are at all in the habit of investigating such subjects,2 and who, dismissing such inductions as those which he seems to consider legitimate, rely solely on facts rigorously examined. He must surely be aware that most of the points which he seems to think ought to have such influence in leading the public to believe in the contagion of cholera, might equally apply to the influenza which this year prevailed in Europe, and last year in China, &c.; or to the influenza of 1803, which traversed over continents and oceans, sometimes in the wind's eye, sometimes not, as frequently mentioned by the late Professor Gregory of Edinburgh. Who will now stand up and try to maintain that the disease in those epidemics was propagated from person to person? Could more have been made of so bad a cause as contagion in cholera, few perhaps could have succeeded better than Dr. Macmichael, and no discourtesy shall be offered him by me, though he does sometimes loose his temper, and say, among other things not over civil, nor quite comme il faut, from a Fellow of the College, that all who do not agree with him as to contagion "will fully abandon all the ordinary maxims of prudence, and remain obstinately blind to the dictates of common sense!" —fort, mais peu philosophique Monsieur le Docteur. The time has gone by when ingenious men of the profession, like Dr. Macmichael, might argue common sense out of us; it will not even serve any purpose now that other names are so studiously introduced as entirely coinciding with Dr. Macmichael; for, in these days of reform in every thing, opinions, will only be set down at their just value by those who pay attention to the subject.

Referring once more to the Report of the 9th of June, made by the College to the Council, and signed by the President as well as by Dr. Macmichael, the cholera was there pronounced to be a communicable disease, when they had, as they freely admit, "no other means of judging of the nature and symptoms of the cholera than those furnished by the documents submitted to them." The documents submitted were the following, as appears from the collection of papers published by order of Parliament: – Two reports made to our government by Dr. Walker, from Russia; a report from Petersburgh by Dr. Albers, a Prussian physician; and a report, with inclosures, regarding Russian quarantine regulations, from St. Petersburg, by Sir W. Creighton. Dr. Walker, who was sent from St. Petersburg to Moscow, by our ambassador at the former place; states, in his first report, dated in March, that the medical men seemed to differ on the subject of contagion, but adds, "I may so far state, that by far the greater number of medical men are disposed to think it not contagious." He says, that on his arrival at Moscow, the cholera was almost extinct there; that in twelve days he had been able to see only twenty-four cases, and that he had no means of forming an opinion of his own as to contagion. In a second report, dated in April from St. Petersburg, this gentleman repeats his former statement as to the majority of the Moscow medical men not believing the disease to be contagious (or, as the College prefer terming it, infectious), and gives the grounds on which their belief is formed, on which he makes some observations. He seems extremely fair, for while he states that, according to his information, a peculiar state of the atmosphere "was proved by almost every person in the city (Moscow), feeling, during the time, some inconvenience or other, which wanted only the exciting cause of catching cold, or of some irregularity in diet, to bring on cholera;" that "very few of those immediately about the patients were taken ill;" that he "did not learn that the contagionists in Moscow had any strong particular instances to prove the communication of the disease from one individual to another;" and that he had "heard of several instances brought forward in support of the opinion (contagion), but they are not fair ones: " he yet mentions where exceptions seem to have taken place as to hospital attendants not being attacked, but he has neglected to tell us (a very common omission in similar statements), whether or not the hospitals in which attendants were attacked were situated in or near places where the atmosphere seemed equally productive of the disease in those not employed in attending on sick. This clearly makes all the difference, for there is no earthly reason why people about the sick should not be attacked, if they breathe the same atmosphere which would seem to have so particular an effect in producing the disease in others; indeed there are good reasons why, during an epidemic, attendants should be attacked in greater proportion; for the constant fatigue, night-work, &c., must greatly predispose them to disease of any kind, while the great additional number always required on those occasions, precludes the supposition of the majority so employed being seasoned hospital attendants, having constitutions impenetrable to contagion. Those questions are now well understood as to yellow fever, about which so much misconception had once existed. The proofs by disinterested authors (by which I mean those unconnected with quarantine establishments, or who are not governed by the expediency of the case) in the West Indies, America, and other places, show this in a clear light; but the proofs which have for some time past appeared in various journals respecting the occurrences at Gibraltar, during the epidemic of 1828, are particularly illustrative. By the testimony of three or four writers, we find that within certain points, those in attendance on sick, in houses as well as hospitals, were attacked with the fever, in common with those who were not in attendance on sick; but that, where people remained at ever so short a distance beyond those points, during the epidemic influence, not a single instance occurred of their being attacked, though great numbers had been in the closest contact with the sick, and frequently too, it would appear, under circumstances when contagion, had it existed, was not impeded in its usual course by a very free atmosphere: —sick individuals, for instance, lying in a small house, hut, or tent, surrounded, during a longer or shorter space of time, by their relatives, &c. A full exposure of some very curious mis-statements on these points, made by our medical chief of the quarantine, will be found from the pen of the surgeon of the 23d regiment, in the Edinburgh Medical and Surgical Journal, No. 106.3 Those who are acquainted with the progress of cholera in India, must be aware how a difference in the height of places, or of a few hundred yards (indeed sometimes of a few yards) distance, has been observed to make all the difference between great suffering and complete immunity: – the printed and manuscript reports from India furnish a vast number of instances of this kind; and, incredible as it may appear, they furnish instances where, notwithstanding the freest intercourse, there has been an abrupt line of demarcation observed, beyond which the disease did not prevail. A most remarkable instance of this occurred in the King's 14th regiment, in 1819, during a cholera epidemic, when the light company of the regiment escaped almost untouched, owing to no other apparent cause than that they occupied the extremity of a range of barrack in which all the other companies were stationed! so that there would truly seem to be more things "on earth than are dreamt of in the philosophy" of contagionists. This seems so remarkable an event, that the circumstance should be more particularly stated: – "The disease commenced in the eastern wing of the barracks, and proceeded in a westerly direction, but suddenly stopped at the 9th company; the light infantry escaping with one or two slight cases only." – (Bengal Rep. 311.) It appears (loc. cit.) that 221 attacks took place in the other nine companies. We find (Bombay Rep. p. 11.) that, from a little difference in situation, two cavalry regiments in a camp were altogether exempt from the disease, while all the other regiments were attacked. Previous to closing these remarks, which seemed to me called for on Dr. Walker's second Report, it is fair to state, that in certain Russian towns which he names, he found that the medical men and others were convinced that the cholera was brought to them "somehow or other," an impression quite common in like cases, as we learn from Humboldt, and less to be wondered at in Russia than most places which could be mentioned. It will not be a misemployment of time to consider now the next document laid before the College, to enable them to form their opinion, – the Report of Dr. Albers, dated in March, and sent from St. Petersburg; – this gentleman, who was at the head of a commission sent by the Prussian government to Moscow, states, that at St. Petersburgh, where the disease did not then reign, the authorities and physicians were contagionists; but at Moscow, where it had committed such ravages, "almost all strenuously maintain that cholera is not contagious." The following extract seems to merit particular attention: —

"When the cholera first reached Moscow, all the physicians of this city were persuaded of its contagious nature, but the experience gained in the course of the epidemic, has produced an entirely opposite conviction. They found that it was impossible for any length of time completely to isolate such a city as Moscow, containing 300,000 inhabitants, and having a circumference of nearly seven miles (versts?), and perceived daily the frequent frustrations of the measures adopted. During the epidemic, it is certain that upwards of 40,000 inhabitants quitted Moscow, of whom a large number never performed quarantine; and notwithstanding this fact, no case is on record of the cholera having been transferred from Moscow to other places, and it is equally certain, that in no situation appointed for quarantine, any case of cholera has occurred. That the distemper is not contagious, has been yet more ascertained by the experience gathered in this city (Moscow). In many houses it happened, that one individual attacked by cholera was attended indiscriminately by all the relatives, and yet did the disease not spread to any of the inmates. It was finally found, that not only the nurses continued free of the distemper, but also that they promiscuously attended the sick chamber, and visited their friends, without in the least communicating the disease. There are even cases fully authenticated, that nurses, to quiet timid females labouring under cholera, have shared their beds during the nights, and that they, notwithstanding, have escaped uninjured in the same manner as physicians in hospitals have, without any bad consequences, made use of warm water used (a moment before) by cholera patients for bathing.

"These, and numerous other examples which, during the epidemic (we ought, perhaps, to call it endemic) became known to every inhabitant of Moscow, have confirmed the conviction of the non-infectious nature of the disease, a conviction in which their personal safety was so much concerned.

"It is also highly worthy of observation, that all those who stand up for contagion, have not witnessed the cholera, which is, therefore, especially objected to their opinion by their opponents." He closes by the observation, "The result of my own daily experience, therefore, perfectly agrees with the above-stated principle, namely, notwithstanding all my inquiries, I have met with no instance which could render it at all probable that the cholera is disseminated by inanimate objects." The words in italics are as in the Parliamentary papers on Cholera, pp. 8 and 9. Here is something to help to guide people in forming opinions, and to help governments on quarantine questions; but owing to a portion of the "perverseness" which Dr. Macmichael in anger talks about, Dr. Albers still speculates upon cholera being contagious, and the College, it would seem, take up his speculations and sink his very important facts. Sir William Creighton's Report gives what puports to be an extract from a memorial of his on cholera, given in to the St. Petersburg Medical Council, tending to establish the contagious character of the disease; and with this a report by the extraordinary committee appointed by the Emperor to inquire into the Moscow epidemic. The disease had not appeared at St. Petersburg when he drew up his Memorial, and it does not appear from any-thing which can be seen in the extracts he furnishes, that he had personal knowledge of any part of what he relates. He gives the reported progress of the disease on the Volga and the Don, but is extremely deficient exactly where one might have expected that, from the greater efficiency of police authorities, &c., his information on contagion would have been more precise, viz., the introduction of the disease into Moscow, which could not, it would seem have been by material objects, for, according to the Committee, composed "of the most eminent public officers," – "the opinion of those who do not admit the possibility of contagion by means of material objects, has for its support both the majority of voices, and the scrupulous observance of facts. The members of the Medical Council have been convinced by their own experience, as also by the reports of the physicians of the hospitals, that, after having been in frequent and even habitual communication with the sick, their own clothes have never communicated the disease to any one, even without employing means of purification. Convalescents have continued to wear clothes which they wore during the disease – even furs – without having them purified, and they have had no relapse. At the opening of bodies of persons who had died of cholera, to the minute inspection of which four or five hours a day for nearly a month were devoted, neither those who attended at their operations, nor any of the assisting physicians, nor any of the attendants, caught the infection, although, with the exception of the first day, scarcely any precautions were used. But what appears still more conclusive, a physician who had received several wounds in separating the flesh, continued his operations, having only touched the injured parts with caustic. A drunken invalid having also wounded himself, had an abscess, which doubtless showed the pernicious action of the dead flesh, but the cholera morbus did not attack him. In fine, foreign Savans, such as Moreau de Jonnés and Gravier, who have recognized, in various relations, the contagious nature of the cholera morbus, do not admit its propagation by means of goods and merchandise." (Parl. Papers on Chol. p. 13.) With the above documents the Council transmitted to the College a short description of the process of cleaning hemp in the Russian ports; and, lastly, the copy of a letter to the clerk of the Council from our ever-vigilant, though never-sufficiently-to-be-remunerated, head guardian of the quarantine department, who, taking the alarm, very properly recommends, as in duty bound, that a stir be forthwith made in all the pools, and creeks, and bays, &c., of the united kingdom, in order that all those notoriously "susceptible" old offenders, skins, hemp, flax, rags, &c., may be prevented from carrying into execution their felonious intention of covering the landing of a dire enemy. In truth, from the grave as well as from the sublime, there often seems to be "but a step;" and in reading over this gentleman's suggestions about susceptibles and non-susceptibles, one may fancy himself, instead of being in the land of thinking people, to be in the land of Egypt, where, as we are informed (Madden, 1825), the sage matrons discuss the point, whether a cat be not a better vehicle for contagion than a dog: – a horse may be trusted, they say, but as to an ass, he is the most incorrigible of contagion smugglers; – of fresh bread we never need be afraid, but the susceptibility of butcher's meat is quite an established thing: – or we might fancy ourselves transported to regions of romance, where it is matter of profound deliberation, whether an egg shall be broken at the large or the small end. Such things are too bad for the nineteenth century; and in England, too, with her enlightened parliament! But until these questions are better examined, our guardian must bestir himself about articles susceptible of cholera contagion, while he enjoys his good quarantine pay, his good half pay from another department as I believe, and withall, if we are not misinformed, a smart pension from the Gibraltar revenue, for what granted nobody can tell.

The documents above referred to, would appear then to be the whole on which the College admit that they formed their opinions, and people may now judge whether the verdict be according to the evidence, or whether it be not something in the lucus a non lucendo mode of drawing conclusions: – most persons will probably think that, on such evidence, there might at least have been a qualified opinion. It appears, however, that having come to a decision on the 9th of June, that the disease was communicable from person to person, they in three days after, approved of persons being sent to Russia to find out whether they had decided rightly or not. Are we now to expect that, should the occasion need, they will heroically make war against their own declared opinion? For my part I expect from them all that should be expected from men; and the liberal part of the world will not fail to see from this, that I do not despair of even Dr. Macmichael, being still open to conviction. Let it not be for a moment understood that, in any-thing which has been said, or which may remain to be said respecting this gentleman, or in any-thing which may be hereafter said respecting Dr. Bisset Hawkins's work, I mean to insinuate that contagion in cholera is not with them a matter of conscience; but I certainly do mean to say that their zeal has manifestly warped their judgment; and not only this, but that it has prevented them from laying statements before the public on the cholera questions with all the impartiality we might have expected from gentlemen of their character in the profession.

In Dr. Macmichael's pamphlet, consisting of thirty-two pages, and professing to be a consideration of the question, "Is cholera contagious?" we scarcely find the disease mentioned till we come to page 25; the pages up to this being occupied chiefly by a recapitulation of opinions formerly given "on the progress of opinion upon the subject of contagion;" – on the opinions of old writers as to the contagion of plague, small-pox, measles, &c.: – he would infer that whereas small-pox and certain other diseases have, by more accurate observations made in comparatively modern times, been taken from the place they once held, and ranged among diseases decidedly contagious, so ought cholera also to be now pronounced contagious! As an inducement to us to adopt this as good logic, he assures us that the list of diseases deemed contagious by wise men is on the increase – that non-contagionists are perverse people, blunderers, and so forth! As to his epithets, it shall only be said that among the disbelievers of contagion in cholera, and certain other diseases probably reputed contagious by Dr. Macmichael, are to be found hundreds possessing as much candour, as cultivated minds, and as much practical knowledge of their profession, as any contagionists, whether they be Fellows of a College or not; but as to the statement of Dr. Macmichael, is it true that we have been adding to the list of contagious diseases? Not within the last fifty years certainly. Even the influenza of 1803 was, if I mistake not greatly, termed, very generally, "infectious catarrh," but what professional man would term the influenza of 1831 so? Are there not yet remaining traces of the generally exploded doctrine of even contagion in ague, at one time attempted to be maintained? M. Adouard, of Paris, still indeed holds out. Do we not know that Portal, at one period of his life at least, would not, for fear of "infection," open the body of a person who had died of phthisis? Where is the medical man now to be found who would set up such a plea? or where, except in countries doomed to eternal barbarism, are patients labouring under consumption avoided now, as they were in several parts of the world at one time, just as if they laboured under plague, and all for the simpleton's reason that the disease often runs through families? What disinterested man will, on due examination of all that has been written on yellow fever, stand up now in support of its being a contagious disease, of which some thirty or forty years ago there was so general a belief? On croup, and a few more diseases, many still think it wise to doubt. Is dysentery, known to make such ravages sometimes, especially in armies, considered now, as at one time, to be contagious? If Dr. Macmichael's pamphlet was intended altogether for readers not of the profession, which seems very probable, his purposes will perhaps be answered, at least for a time, but I do not see how it can make an impression on medical men. Why not have been a little more candid when quoting Sydenham on small-pox, &c. and have quoted what that author says of the disease which he (Dr. M.) professes to write about, – the cholera? The public would have means of judging how far the disease which was prevalent in 1669, resembled the "cholera spasmodica," &c., of late years. Many insist upon an identity (Orton among others), and yet Sydenham saw no reason for suspecting a communicable property. It might have been more to the point had Dr. Macmichael, instead of quoting old authorities on small-pox, measles, &c. quoted some authorities to disprove that Orton and others are wrong when they state it as their belief that some of those old epidemics in Europe, about which so much obscurity hangs, were nothing more or less than the cholera spasmodica. Mead's short sketch of the "sweating sickness" does not seem very inapplicable: – "Excessive fainting and inquietude inward burnings, headach, sweating, vomiting, and diarrhœa."4 In the letter to the President of the College we see no small anxiety to prove that the malignant cholera is of modern origin also in India, for the proofs from Hindoo authorities, as given in the volume of Madras Reports, are slighted. These Reports, as well as those of the other presidencies, are exceedingly scarce, but whoever can obtain access to them will find in the translations at pp. 253 and 255 (not at page 3, as quoted by Dr. Macmichael), enough probably to satisfy him that cholera is the disease alluded to there. But I think that we have at page 31 of Dr. Macmichael's letter, no small proof of a peculiarity of opinion, when we find that he there states that the evidence in the Madras Reports of the existence of epidemics of malignant cholera in India, on several occasions previous to 1817, rests on imperfect records, and that the description of the disease is too vague to prove the identity with the modern spasmodic cholera; for in this opinion he seems, as far as I have been able to discover, to stand alone among writers on cholera; – indeed it seems established, on the fullest authority, that cholera, in the same form in which it has appeared epidemically of late years, has committed ravages in India on more than one occasion formerly: – this is fully admitted by Mr. Orton, an East India practitioner, who is one of the few contagionists.

For one piece of tact the author of the letter deserves great credit; for whereas his College collectively, when forming their opinion on the questions proposed to them by the Council, seemed to throw all India records overboard, – he, in his individual capacity, as author of the letter, sends after them all the Russian reports in support of contagion; for anxious as he is to prove his point, not a word do we get of the on dits so current in Russia about persons being attacked with the disease from smelling to hemp arrived from such or such a place; from having looked at a boatman who had been up the Volga or down the Volga, &c. &c.: all which statements, when duty inquired into, prove to be unsupported by any thing in the shape of respectable authority, and this is now, in all probability, pretty generally known to be the case, as Dr. Macmichael must be quite aware of.

To the medical gentlemen of India who have been concerned in the official reports, which do them, en masse, so much credit, Dr. Macmichael is little disposed to be complimentary; and, indeed, he seems to insinuate that those were rather stupid fellows who did not come to what he is pleased to consider "a just and right conclusion," as to contagion; he thinks, however, that he has got a few of "the most candid" to join in his belief. We shall see whether he had better reason to look towards the Ganges and Beema for a confirmation of his doctrines, than he had toward the Don or the Volga. How does the case stand with respect to one of the gentlemen whom he quotes, – Mr. Jukes, of the Bombay Establishment? This gentleman, like all who speak of cholera, mentions circumstances as to the progress of the disease which he cannot comprehend, and Dr. Macmichael shows us what those circumstances are; but Dr. Macmichael does not exhibit to us what does come perfectly within Mr. Jukes's comprehension, but which is not quite so suitable to the doctor's purpose. This omission I shall take the liberty to supply from an official letter from Mr. Jukes in the Bombay Reports: – "I have had no reason to think it has been contagious here, neither myself nor any of my assistants, who have been constantly amongst the sick, nor any of the hospital attendants, have had the disease. It has not gone through families when one has become affected. It is very unlike contagion too, in many particulars." &c. – (Bombay Reports, page 172.) – Ought we not to be a little surprised that so great an admirer of candour, as Dr. Macmichael seems to be, should, while so anxious to give every information to his readers, calculated to throw light upon the subject of cholera, omits the above important paragraph, which we find, by the way immediately precedes the one upon opinions and difficulties which he quotes from the same gentleman? But let us examine what the amount of force is, which can be obtained from that part of Mr. Jukes's paper, which it does please Dr. Macmichael to quote: – "If it be something general in the atmosphere, why has it not hitherto made its appearance in some two distinct parts of the province at the same time? Nothing of this kind has, I believe, been observed. It still seems creeping from village to village, rages for a few days, and then begins to decline." I find myself unable, at this moment, to ascertain the extent of Mr. Jukes's means of obtaining information as to what was passing in other parts of his province; but I think the following quotation, on which I am just now able to lay my hand, will not only satisfactorily meet what is here stated, but must, in the public opinion, be treasured, as it serves at once to displace most erroneous ideas long prevalent, and which, I believe, greatly influenced men's decisions as to contagion: – "It may, then, first be remarked, that the rise and progress of the disorder were attended by such circumstances as showed it to be entirely independent of contagion for its propagation. Thus we have seen that it arose at nearly one and the same time in many different places, and that in the same month, nay, in the same week, it was raging in the unconnected and far-distant districts of Behar and Dacca." (Bengal Reports, p. 125.) Again (p. 9), that in Bengal "it at once raged simultaneously in various and remote quarters, without displaying a predilection for any one tract or district more than for another; or any thing like regularity of succesion in the chain of its operations." In support of what is stated in these extracts, the fullest details are given as to dates and places; and at page 9 of those Reports, a curious fact is given, "That the large and populous city of Moorshedabad, from extent and local position apparently very favourably circumstanced for the attacks of the epidemic, should have escaped with comparatively little loss, whilst all around was so severely scourged." This seems to have been pretty similar to what is now taking place with respect to the city of Thorn, which remains free from cholera, though the communication is open with divers infected places in every direction. Should Thorn still be attacked by the disease (as it sooner or later will, in all human probability), the contagionists par métier will try to establish a case of hemp or hare-skin importation, I have no doubt. I wonder much that Dr. Macmichael or Dr. B. Hawkins, when favouring us with eastern quotations, did not give the public the opinion of Dr. Davy, who is so well known in Europe, and who saw the cholera in Ceylon; his conjecture (quite accessible, I believe, to every medical man in London) may perhaps be as valuable as that of any other person. The following is a copy of it: – "The cause of the disease is not any sensible change in the atmosphere; yet, considering the progress of the disease, its epidemic nature, the immense extent of country it has spread over, we can hardly refuse to acknowledge that its cause, though imperceptible, though yet unknown, does exist in the atmosphere. It may be extricated from the bowels of the earth, as miasmata were formerly supposed to be; it may be generated in the air, it may have the properties of radiant matter, and, like heat and light, it may be capable of passing through space unimpeded by currents; like electricity, it may be capable of moving from place to place in an imperceptible moment of time." Dr. Davy is an army physician, and the report of which this is an extract, may be seen at the Army Medical Office, a place which, of late years, has become a magazine of medical information of the most valuable kind in Europe. There is this difference between army and other information on cholera, that (whether in the King's or E. I. Company's service) the statements given by the medical gentlemen have their accuracy more or less guaranteed by a certain system of military control over the documents they draw up: thus, in the circumstance already noticed as having occurred in the 14th regiment, we have every reason to rely upon its accuracy, which we could not have in a similar statement among the population of any country; and we have, I think, no reason to believe that in pronouncing the cholera of Ceylon not contagious, Dr. Davy, as well as two other gentlemen of high character and experience (Drs. Farrel and Marshall), have not gone upon such data as may bear scrutiny.