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minions, the north of Germany, and in be drawn, it will be manifest tnat fluctuaEngland, is too familiarly known to ren- tion or total scepticism must have been der it needful that we should present its its result. As this evidence consists of details to the reader. The space traversed, facts already before the public, we shall, as yet, by this extraordinary epidemic, for the sake of brevity, rather refer to than may be conceived from the following sim- detail them, classing them, as nearly as ple calculation. The Philippine islands their nature admits, according to the very form (so far as is known) the eastern, and precise rules laid down by doctor Alison Mauritius the southern, boundary of the for discriminating the operation of contadisease. The former lie in east longitude gion.-1. Strong evidence of a disease 125°, and the latter is in south latitude being contagious is furnished by its ap20°. Archangel is the most northern, and pearance in communities previously the vicinity of Edinburgh the most west- healthy, shortly after the arrival of perern, point to which it has extended. The sons from infected districts, who are themformer is in north latitude 64°, the latter selves suffering under the disease, or who in west longitude 3°. Hence it is mani- sicken of it soon after their arrival. A fest that the disease has passed over 128° striking example of this sort is related, in of longitude, and 84° of latitude. The the Madras Report, of the appearance of questions naturally occur, What agent the disease at Jaulnah, after the arrival of first generated the disease? and, What has a detachment there from Nagpore, then subsequently diffused it over so large a infected, and its subsequent diffusion portion of the globe? The first question from the former place to the towns of must be answered by a simple statement Malligaum and Hydrabad, and various of the facts, that it originated in the district villages. Other cases, though few so mentioned, after an unusual disturbance striking as this, might be selected from of the seasons with respect to alterna- the Indian records; but we prefer refertions of heat and moisture; that it made ring to examples which occurred in the its appearance at the commencement of a Russian epidemic. In the fortress of rainy season, so excessive that the Gan- Razüpna, in that of Iletsk, and, towards getic Delta was converted into a sheet of the close of the epidemic, at Caramalawater; and that the very first point in Gubeerra, all in the government of Orenwhich it was observed was the district of burg, the invasion of the epidemic coinNuddea, noted for the endemic prevalence cided, in point of time, with the arrival in of cholera, where the whole year had them and sickening of persons coming been rainy, and during every week of from infected places. It should be reApril and May (it began to manifest itself marked, however, that in these cases in the latter month) there had been a suc- communication was not always traced cession of thunder-storms. From this dis- between the individuals subsequently and trict it appeared to diffuse itself over the those first attacked; and in the case rest of Hindoostan, its progress throughout at Razüpna, it is distinctly mentioned, the country being accompanied, as Mr. that of the individuals who visited the Orton informs us, by circumstances some- man first seized on his arrival from Orenwhat similar to those which attended its burg, then infected, not one took the disorigin. The second part of the question order.* Into the opposite scale, that of cannot be dismissed so lightly. As is the non-contagionists, may be thrown well known, the doubt and difficulty re- facts which tend to prove that it has origigarding the subject exist chiefly with re- nated in districts previously healthy,. spect to the share which contagion has without any ascertained communication had in its diffusion; and this question we with infected persons, and that, on the shall endeavor to discuss as succinctly, other hand, the most ample intercourse and certainly as dispassionately and fairly, has existed on various occasions between as possible. That our opinion, in the healthy and infected communities, withcourse of the investigation, has fluctuated, out the former having participated in the we feel it no discredit to avow. This disease. Its introduction into the city of fluctuation was either prior to the appear- Orenburg, in 1829, was not only not traced, ance of the disease in this country, or to to communication from an infected dis-our having it a sufficient length of time trict, but a conjecture that it might have under observation to enable us to at- been introduced either by the caravan, tain a settled conclusion; and when we show the conflicting nature of the evidence, from which, under the circumstances mentioned, a conclusion was to
* On the Asiatic Cholera as it appeared in Russia in the Years 1829 and 1830, by doctor J. R. Lichtenstadt (translated in the Edinburgh Med ical and Surgical Journal, No. cviii).
which arrives from Central Asia at mid-
furnished by the staff-physician, doctor Schimanski, with regard to the extension of the disease at Iletsk. He says he was able to trace the progress of the disease in the first eight cases, thus:-The husband of the woman (a soldier's wife) from Orenburg, was taken ill three days after her; and about the same time, also, two girls, who lived in the immediate neighborhood of the soldier, and who visited. him soon after his arrival from Orenburg; the aunt of these girls, who nursed him, was next attacked; and from her it passed to her own two sons. 3. There is no circumstance connected with the disease, on which the information received from different quarters is more contradictory, than the comparative liability to it of attendants on the sick and other members of the community. From India the 'testimony on this head is so conflicting that no conclusion can possibly be drawn from it: a state of complete scepticism is that in which it leaves the mind of an honest inquirer after truth. That from Russia is not of a much more decisive character: such as it is, we shall present it to the reader. During two months, observes professor Lichtenstadt, while the disease prevailed at Orenburg, and 299 patients were admitted with cholera into the military hospital, the personal attendants on the sick remained entirely exempt from the disease. They consisted of one hospital assistant, six pupils, as many Baschkir lads, and fourteen hospital servants, in all twenty-seven; and their duties were to perform blood-lettings, apply leeches, poultices and frictions, and administer baths, and the like, so that they were compelled to be constantly breathing the exhalations from the bodies and clothes of the sick, as well as to touch and handle them. The washerwomen of the hospital likewise escaped-a class of individuals, who, it is well known, are extremely apt to suffer from contagious diseases. On the other hand, doctors Russell and Barry inform us "that the number of medical men and hospital attendants attacked with cholera during the pres ent epidemic, in proportion to the whole employed, and to the other classes of society, has been, beyond all comparison, greater here (St. Petersburg) than in India, under similar circumstances: twentyfive medical men have been already seized, and nine have died out of 264. Four others have died at Cronstadt, ou of a very small number residing in that Edinburgh Medical and Surgical Journal No. cviii. p. 130.
Taken from Mr. Spence's Manuscript, since published in the Medical Gazette.
fortress at the time the disease broke out there. Six attendants have been taken ill at a small temporary hospital behind the Aboucoff." With regard to this last circumstance, it is not stated, as in another report by the same gentlemen (not published), bearing date 4-16 July, that "in the great Aboucoff hospital, where there were no cholera patients, but to which a temporary cholera hospital was attached behind the building, ten persons, residing within the area of the establishment, had been severely attacked up to the 12th instant (N. S.), with cholera." This leaves a very different impression; and, not being aware of what is meant by "the area of the establishment," we cannot form an opinion how it may or may not bear towards the side of contagion. In the last mentioned report, those gentlemen also state, that in the military general hospital, in which four hundred cholera patients had been admitted from distant quarters, up to the morning of the 13th, "one attendant had been attacked." But one attendant where so many cases had been treated! These specimens, taken from an immense mass of foreign evidence, will suffice to show its conflicting nature on points essential to the decision of a much litigated and very important question. There are certain branches of the subject, such as the immunity apparently afforded by seclusion, which we have designedly omitted; partly because they were unavoidably exposed to sources of fallacy, and the testimony regarding them was of the same conflicting nature as the specimens which we have already presented to the reader; and partly that we might preserve space for an examination of the question, how far the general progress of the disease favors the opinion that human intercourse has been the instrument of its diffusion; and for the narration of certain facts illustrative of the general question which have fallen under our observation. The progress of the disease on the great scale having been tolerably regular, both geographically and chronologically-that is, its having passed from country to country, without leaving interjacent countries untouched, and those infected having been so in some proportion, in point of time, to their distance from its original source has been appealed to by two parties, as evidence of the accuracy of their opinions; the one seeing in it a proof of a continuous stream of epidemic influence, flowing from the point where the disease originated; the other, a transport of the malady by human inter
course from the same source. To the opinion of a flow of epidemic influence, have been objected, and apparently with justice, the slowness of the progress of the disease; that it has extended its territory in spite of the opposition of continued and violent monsoons; and that, notwithstanding a degree of general regularity of progress, there have been anomalies observed in its course (such as its having left districts untouched, whilst all around them were suffering), utterly irreconcilable with the opinion advanced. On the other hand, circumstances have been observed, which render it almost equally questionable whether contagion has been the sole instrument of its diffusion. It has been asserted, by the advocates of the exclusive operation of this principle, that the disease has always been found to move in the line of human intercourse; and it must be acknowledged that, whilst so migratory an animal as man inhabits the earth, it cannot well do otherwise; but if it is meant to be asserted that its diffusion has been in proportion to the intercourse between infected and healthy districts, the assertion is by no means supported by facts. Its appearance at Madras, for instance, whither, according to this doctrine, it ought to have been conveyed almost three months earlier by trading vessels from the infected districts, was simultaneous, as Mr. Bell informs us, with its origin in parallel latitudes in the interior. It did not reach Ceylon, to which, on the contagious principle, it ought to have been conveyed at a much earlier period, by shipping from infected points of the coast, until it had previously gained the nearest point to it on the continent, about Adam's Bridge, and had been long prevailing on both coasts of the peninsula.* Unfrequented villages have been observed to suffer the invasion of the disease as early as the marts of intercourse and commerce: thus, from a statement of Mr. Orton, it seems to have reached some villages on the north bank of the Cavery,-detached from any frequented road, and considerably to the eastward of Trichinopoly, quite as soon as this large and frequented town, whither it appeared to have been imported by a company of sepoys. Its movement along navigable rivers has been dwelt upon as evidence that human intercourse has been the means of its diffusion; and it is an argument of some force in showing that such intercourse may have oc* Orton on Cholera, 2d ed., p. 332 + Ibid., p. 331.
casionally been instrumental in effecting it; but when we are informed by Mr. Orton, that the disease manifested this predilection for the course of rivers in the peninsula of Hindoostan, "where navigation is scarcely carried on, even to the most trifling extent, on any river, and scarcely an instance can be mentioned of a great road running on the bank of a river, for they almost all cross them," we must acknowledge that more weight has been attached to the argument than it is calculated to bear. The disease, in its general course, has manifested a preference for one line of movement, and has rejected another, though there has been no striking difference in the amount of human intercourse between the two directions, to explain the preference and rejection. Its progress in a north-western direction, across the European continent, has been briefly described, and is fully known to the reader. For three years, it prevailed in the Ottoman territories bordering on the Levant, and, it would appear, without any deficiency in the productive (or at least destructive) force of those germs of which we have recently heard so much; for in November, 1822, it numbered 4000 victims in eighteen days, in Aleppo; yet it has not penetrated into Turkey in Europe, and other extensive realms on the shores of the Mediterranean. Assuredly this could not arise from want of means of transport; and few will be disposed to ascribe it to the perfection of the quarantine department of the Sublime Porte. Since its appearance in this country, a similar predilection has been displayed; for we find it at this instant a hundred and forty miles to the north-west of Sunderland, whilst six miles south is the extreme distance to which it has reached in that direction; and from the point which it attained, Seaham harbor, after attacking eight persons and destroying three, it has since vanished. A circumstance which may be urged against the exclusive operation of contagion (and it is against attributing too much to one principle alone that we are arguing), is the unusual prevalence of disease, bearing a considerable relation to epidemic choleric fever, which generally occurs prior to the appearance of this in any given locality. The facts which might be mustered in proof of the antecedence of such disease, are far too numerous and consistent to be accidental. Ordinary cholera, sporadic cases not distinguishable from the epidemic, excepting by the isolated manner in which they oc
cur; epidemic diarrhoea; gastric and intestinal fever, have been observed in so many situations, and by so many individuals, from 1817 to the present instant, to have been the precursors of the disease, that there cannot be a reasonable doubt of the accuracy of the observation. During the last year, the prevalence of these affections, in various parts of this country, has been matter of familiar remark among medical men, and many of them have very properly taken care to record their observations.* In this neighborhood, what Mr. Orton felicitously terms the skirts of the approaching shower, were manifest long before the epidemic made its formal inroad. Ordinary cholera was most unusually prevalent; whilst cases of disease, certainly not distinguishable by symptoms from the epidemic, occurred on the 5th, 8th, 14th and 27th of August; and cholera continued to be very prevalent and severe throughout September. The cases which occurred in August were not matters of secrecy, but were the subject of conversation among the medical men of the place; and the writer frequently made the remark, that we were partakers of an inferior degree of the epidemic influence which existed on the continent. But certainly at the time he did not (nor does he yet) ascribe them to imported contagion; nor did he then conceive that we had, properly speaking, the epidemic among us. Whatever view others may now feel disposed to take of these cases, it would be difficult for them to suppose that the case we have mentioned, as having occurred in the interior in the beginning of July, was attributable to foreign importation. Under either view, as it appears, whether we conceive that a current of contagion flows towards a district, or suppose the disease to be engendered there by indigenous causes (not customary ones certainly, any more than those which existed in the Delta of the Ganges, in 1817), and then to be invested with some contagious property, which observation of the disease will induce most candid persons to admit it possesses, it requires the operation of two principles to explain all the facts of the case; for even on the first supposition, we are compelled to imagine this double operation to be in progress,a current of contagion to be flowing from one point, and a nidus for its reception to be preparing in another. We have been
* See doctor Burne's 'Dispensary Reports, in the Medical Gazette for July 2, and July 16.
led to the conclusion that the disease possesses a contagious property from having observed that a considerable proportion of attacks have taken place in individuals shortly after communication with the sick, or exposure to emanations from the dead bodies, and, in part, from a few examples having occurred of the disease appearing in parts of the town or neighborhood where it did not previously exist, on the sickening there of persons who had communicated with the infected districts; but, at the same time, we beg to remark that there are circumstances which tend to show that this property is abstractly feeble in degree, and to render it more than questionable whether it can be the sole agent in diffusing the disease. This opinion is founded on the singular anomalies observed in the course of the disease, and which still mark its progress, and on the following considerations:-1. Members of that class of society which has manifested the strongest predisposition to the disease, have been very long exposed to the emanations from the sick, under circumstances the most favorable to the propagation of the disease, without being infected. 2. No death, and scarcely an attack of serious indisposition, has occurred among the medical men, though they have spent hours in the patients' chambers, assisting in frictions and other offices usually performed by nurses, and, from the fatigue they were undergoing, might be supposed to be peculiarly obnoxious to contagion. 3. Medical practitioners have not, in any ascertained case, conveyed the infection in their clothes to patients whom they were attending for other diseases, or to their families. Certain of them have mingled unreservedly with their own families, after long attendance on cholera patients, without any indisposition, however slight, occurring in consequence. It is proper, however, to remark, that two cases have occurred, one of them a fatal one, which might be attributed to the intercourse of medical men with their families. 4. When the disease has appeared in a private family, in a situation in life above the laboring class, it has been confined, so far as the writer's knowledge extends, and he is of opinion that he is acquainted with the circumstances of all the cases of the kind which have occurred, to the individual first attacked, and has not, in any instance, spread to the other members of the family; nor have, in these instances, nurses, or other casual attendants on the sick, suffered, though belonging to a class more
obnoxious to the disease. 5. The agricultural villages in the immediate neighborhood of Sunderland, which had, throughout the whole progress of the epidemic, the most unreserved intercourse with us, remained and still remain exempt from the disease. The populous village of Deptford, situated near the river, at the distance of half a mile from Ayre's Quay, where the disease was very prevalent and fatal, and having the most constant communication with it, partakes of this exemption.* The town of South Shields, containing nearly 14,000 inhabitants, and distant from Sunderland but seven miles, remained exempt from the disease (with the exception of two cases, stated to be very slight, and not traceable to any communication with this place), during the whole of its epidemic prevalence here, though calculations have shown that eleven hundred persons pass weekly between the two places. Explanations have been offered of this exemption; but they appear inadequate, if we suppose this disease transmissible to every locality by human intercourse, since typhus, scarlatina, and other infectious diseases, frequently prevail there to a great extent. Even to the present moment (Feb. 2, 1832), though its intercourse with Newcastle and other infected places has been incessant, but seven cases have occurred, and, as our intelligent correspondent there remarks, "We have not as yet got the disease as an epidemic, the cases have been so few and far between." 6. Though the disease has appeared, in certain cases, to be transferred to previously uninfected districts, by spreading from persons who had sickened there after arriving from places where the disease prevailed, yet facts have occurred which tend to show that the sickening of such persons and the diffusion of the disease have, at least in some instances, been mere coincidences. A woman of the name of Liddle, who lived in Sunder land, sickened at the town of Houghton le-Spring, six miles from this place, and died on the 5th of December. The next case occurred on the 8th of the same month, in the person of a female named Cockburn, who lived at a considerable distance from the house where Liddle died, and in a different street, and had had no communication with her, direct or indirect; the family of the house in which the death occurred, and the per
village, inhabited by the class most susceptible of *There were two slight cases in this crowded the disease; but it did not spread from them to the rest of the population.