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 f 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 depart ment 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, 1831. 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 VOL. XIII. 36 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 Sunderland, sickened at the town of Houghtonle-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 *There were two slight cases in this crowded village, inhabited by the class most susceptible of the disease; but it did not spread from them to the rest of the population. having commenced on the following successive dates-the 11th, 12th, 13th, 16th, 17th and 20th of December. The case which occurred on the 20th was that of an infant, aged thirteen months, taken from the breast of the fifth patient in the order of succession. Many other examples of transmission through families have occurred, but few so striking as this. We are disposed to attribute to contagion its full share in the production of such cases, aided by the circumstances of nightwatching, neglect of order and cleanli sons who surrounded Liddle in her illness, escaping all infection. In many other instances in which the disease has appeared in a mining district or village (and it has spread extensively in such situations), the first cases could not be traced to communication with infected places. In certain cases, however, and we shall mention that of Hetton,-the perseas first seized had been in communication with infected districts. 7. On the first appearance of the epidemic in certain places, several have been simultaneously attacked; at Earsden colliery, for example, thirty-ness, &c., which are accompaniments of two. On its first breaking out here, it manifested itself in three distinct points, between which no communication could be discovered; and the attacks in two of these points were simultaneous. It could not be traced from any source of infection to the individuals first attacked. In many instances, likewise, instead of residents in the same house being successively attacked, its invasion of several has been simultaneous. 8. There were feelings experienced by various persons, either otherwise in perfect health, or laboring under complaints distinct from the epidemic during its prevalence here, such as spasms, thrilling sensations of the extremities, and various affections of the nervous system, which appeared to betoken the influence of some cause more generally diffused than contagion; since many persons thus affected had not been exposed to any source of infection. The writer was at first disposed to attribute these occurrences to the influence of imagination; but they occurred in too many instances, and in persons too little sensitive and imaginative, to allow him to adhere to this explanation. After assigning these reasons for questioning the exclusive operation of contagion, we think it right to remark that epidemic choleric fever has committed fearful ravages in some families, especially in those of which the circumstances were calculated at once to give intensity to the causes of the disease, and to render the individuals composing them more obnoxious to the action of such causes. Of one family, seven were attacked with the disease, of whom five perished. The case of the first individual of the series constituted one of the sporadic cases; and it is incredible that the next in succession should have received infection from him, four months having elapsed between the dates of the respective attacks; but it is probable that contagion was transmitted from the second and subsequent cases, the diseases sickness in the dwellings of the poor; but we must remark that cases have fallen under our observation, and come to our knowledge, which show a proneness to the disease in certain families, independent of reception from a contagious source. The following is an example of this kind: A respectable female, living in the village of Jesmond Vale, where the disease did not exist, and who had had no intercourse with the sick, received a letter, announcing that a sister, whom she had not visited during her illness, and who resided at Hartley, a distance of nine miles, had died of the complaint. She sickened in an hour from the receipt of the intelligence, and died in thirteen hours from the commencement of the attack.* The following propositions appear to be reasonable corollaries from the facts presented by this extensive and intricate subject. 1. Epidemic cholera originated in a certain district under peculiar atmospheric circumstances; but, these circumstances having previously occurred in the same district without the production of a disease identically the same, we must regard its terrestrial or atmospheric cause unascertained. 2. On many subsequent occasions, there have been marks of its commencement and gradual rise in other districts, which show that, in their soil or atmosphere, there has been a tendency to the production of the disease from causes equally unascertained as those which first originated it, and, in such districts, it has ultimately displayed itself. 3. It has thus appeared to arise in various districts, not by any means always continuous with those previously contaminated, but often situated in some general direction with regard to them, declining in one district as it arises in another, and thus appearing to move in a succession of local epidemic visitations. 4. Within the district which it occupies, it possesses a contagious property, or, in * Related to the writer by Mr. Greenhow surgeon, of Newcastle, who attended the case, ! other words, those individuals who have intercourse with the sick, especially in a locally impure atmosphere, are attacked in a greater proportion than other members of the community; and it is probable that this same contagious property may be the means of diffusing it through a district disposed to the production of the disease, earlier than it might have risen spontaneously there, or of exciting it in a district in which, notwithstanding a degree of predisposition, epidemic choleric fever might not have arisen spontaneously; but facts which we have mentioned tend to render it questionable whether it can be thus transferred to districts unpredisposed to receive or engender it. 5. Within the district where it prevails, ordinary endemial causes mingle their agency with that of the general cause of the disease, and the malady is found to vary in prevalence and intensity in different portions of the same district: thus the disorder is found to assail more individuals, and to be more destructive in parts which are dirty, and in those placed low or near the banks of a river, than in portions of the district differently situated. The effect of these endemial influences is illustrated by the progress of the disease in the town of Sunderland, and by the ravages it has committed in the village of Newburn. The latter place is built along the margin of the river Tyne, and between it and the river there intervenes only a bank, formed of a mixture of mud and sand, partially covered at high water, whilst a shallow stream of water flows through the village. Here, although the disease has not yet ceased, 320 persons have been attacked, and 55 have perished, out of a population of 550. 6. The character of the disease varies considerably in the different districts which it invades. Thus we had occasion to observe that, in a mining population dispersed over an extensive tract of country (the township of Hetton), the disease was attended with less collapse than in the lanes and alleys of a populous commercial town, and the mortality was consequently much less; for we cannot too strongly repeat what we have already remarked, that the collapse is the measure of the danger. These observations are made with no view of depreciating the medical practice adopted in that district, which was extremely skilful and prompt, and even with due allowance for the difference of the character of the disease, very successful. It should be remarked,moreover, that extremely collapsed were intermingled with the milder cases, but in proportions the very reverse of those we had observed elsewhere. In certain districts in Northumberland, we have reason to know the disease resembled, in its general character, that which prevailed at Hetton; but, among some other mining communities, the extremely collapsed has been the common form of the disease. We have remarked, too, that, whilst in some situations the cases have, almost without exception, commenced with diarrhoea, in others the proportion of instances in which this has constituted the initiatory symptom, has been smaller. This difference in the form of cholera in different local epidemic visitations, the cases occurring in any given district possessing a general correspondence in character, and being distinguished from those which occurred elsewhere, was observed in India by Mr. Scot; and it appears to us that this circumstance, coupled with the transmutation of the disease more and more into a febrile form, as it has approached more northern climes, displays a deviation from that sameness of character observed in diseases engendered exclusively by human contagion. It will hardly be expected that we should leave entirely untouched the question, whether the disease originated spontaneously in Sunderland, or was introduced from abroad; but the extent to which we have already pursued this intricate portion of our subject, forbids our discussing it at any considerable length. Those who reason from the postulate that the disease is diffused only by human contagion, will of course decide for importation; but others will very reasonably expect that, before this be admitted, it should be proved by the same positive evidence that would be required to substantiate any other fact of importance. Any thing approaching to this, or even any considerable probability of such an occurrence, we have been unable to discover; and we cannot but agree with doctor Ogden, that, whatever were the facilities for the importation of cholera here, they were much greater in other places; and that if it has been imported, so far from following the great routes of human intercourse, it has chosen one of the least frequented paths.* The predisposing causes of the disease, and the means to be adopted for preventing its diffusion, have been published to the world in such multitudinous documents, that we consider it unnecessary to occupy our * See Medical Gazette for January 21, 1832. |
