A LETTER TO THE PRESIDENTS OF THE WESTMINSTER MEDICAL SOCIETY, ON Cholera. BY JOHN WEBSTER, M.D. PHYSICIAN TO ST. GEORGE'S AND ST. JAMES'S DISPENSARY. LONDON: Printed by A. U. Thiselton, 37, Goodge Street, Fitzroy Square. 1832. ADVERTISEMENT. The substance of the following pages was embodied in a speech delivered at the Westminster Medical Society, on Saturday Evening, the 25th of February last. Subsequent consideration, as well as an anxiety to prevent any misconception regarding the opinions then promulgated, has induced the author to print them in the present form ; embracing, at the same time, some minor points, which the hurry and excitement of the moment, prevented from being entered upon in the manner they deserved. 56, Grosvenor Street, Ist March, 1832. LETTER TO THE PRESIDENTS OF THE WESTMINSTER MEDICAL SOCIETY. In the controversy now agitating the medical profession, and to the satisfactory settlement of which, the public mind is directed with the most intense anxiety, too much importance, in my humble estimation, has been all along attached to the point, whether or not, the disease now prevalent in the Metropolis, and in the north of England, be really identical with that seen in Poland, in Russia, and so well known to the inhabitants of India. Because, even if this question was settled, beyond the shadow of a doubt, it would prove but little ; and certainly, could not give any important information, either to satisfy the public, or to instruct the practitioner. To my mind, the question which ought to be discussed, as the one most essential at the present period, and because on its decision must principally hinge the measures of government, and the opinions as well as practice of medical men, undoubtedly is; not whether the disease prevailing in Southwark be the same, as that common in India, under the name of Cholera ; but whether this epidemic be really a new disease, and if not, it must be an aggravated and more fatal type of that Cholera Morbus so admirably described by Sydenham, by Morton, Heberden and other authors ; with which complaint, most practitioners in this country are familiar, although generally only observed in a milder, or less rapid form. Now I would respectfully ask, who are the judges most competent to decide this important question ? not surely those who have passed their whole professional life in India, in the navy, or in the army; but with all due respect for gentlemen, who have served their country, with credit to themselves, and advantage to the state, I should assuredly think, medical men who have been long conversant 4 with the diseases of the poor of this country, with their habits of life, their constitutions, and the various epidemics to which they are liable ; these are best qualified to make so important an inquiry. In fact, practitioners, Avho have gained their experience in the diseases of the lower ranks, by visiting the cellars and the garrets of the metropolis, and by long attendance as officers of its numerous and extensive hospitals. I do therefore hope, in future, when severe cases of Cholera occur, said to be spasmodic or Asiatic ; that the practice, which has of late, been too frequent and exclusive, of sending as judges, only one class of medical men, will not be continued ; but, instead of referring on nearly all occasions to those who have observed Cholera in other countries, practitioners of the description I have mentioned, the most experienced physicians and surgeons of London, will at the same time be consulted ; as thus in addition to the valuable information procured from those now employed, the opinion of others may also be obtained; and so prove the disease now epidemic, to be really a new complaint, a nova pestia, as it has been called of so virulent and contagious a character, that even the strictest quarantine could not prevent from spreading ; if the contrary, we must then enquire is the disease not a severe and most fatal form of Fever ; or only that Cholera which has been already often witnessed in the empire : which, if we may invert a common saying, is an old enemy returned with a new, and perhaps, a blue, face. In making these remarks, I beg to repeat, that it is far from my wish to throw any imputation upon the official men of the country, or to reflect in the slightest degree, upon individuals placed in responsible, and by no means enviable situations; the former have a most difficult duty to perform, and the latter cannot but be cautious in their proceedings ; whilst I know, that all are anxious to do what has proved to be advantageous. Still as a member of the medical profession of London, although of little influence, I trust I shall be justified in offering these observations, by advocating the cause of science, and my professional brethren. Instead, therefore, of hearing as we now do, on all occasions, that the case has been seen by gentlemen who have had experience of the complaint in 5 other countries; let medical authorities such as I have before mentioned, be likewise consulted, and examine whether the disease be really unknown in England. Suppose an individual has got his leg fractured, or labours under a violent attack of inflammation of the lungs ; it advances the knowledge of the physician or surgeon but little, and cannot contribute to the cure of the disease, neither can it allay the anxiety of the patient, nor the fears of his friends, to be told, that the affection of his lungs, or the broken limb, have identically the same symptoms as the cases seen in India, or in Russia. The point of most utility to learn is, whether the inflammation be of a new character or not ; as on this, in a great measure, must depend the opinion to be given, and the treatment to be pursued. It would be presumption in me to allude to the opportunities I may have possessed of seeing disease ; but after carefully comparing the history and symptoms of those which I have visited or were described by others ; there appears to my mind, no convincing argument, that the complaint now prevailing is altogether an unknown one in this country ; and in this opinion, some of those practitioners most conversant with the epidemics of London coincide. The disease, from all yet known of it, would appear to be either a most aggravated form of pestilent or typhus fever, in which the cold stage is so overpowering, as even to kill the individual at the very first attack ; or it may be called the English Cholera, whose cold stage is much more sudden and fatal, than is in most years, or in modern times, observed. The question has been repeatedly asked, and apparently, with some degree of triumph, of those maintaining the doctrine, that the disease now prevalent, is only an aggravated, and more fatal form of the complaint well known under the name of the English Cholera: if in any other epidemic, with which medical men are familiar in this country, it ever happens that a patient will in some years fall a sacrifice, at the first onset of the disease, whilst in other seasons, the type of the same complaint assumes a more mild form, and seldom or ever proves fatal? In answer to this question, usually considered, by the bye, as a leading onej and upon which much of the argument is thought to 6 hinge; it can be replied, although ague is very seldom fatal at its commencement in this country, being more frequent in hot climates, instances do occasionally happen, where the cold stage is so overwhelming, that the patient even dies in the very first attack. Of this, examples are mentioned in the older authors, and a friend of mine, knew two patients, while practising in Lincolnshire, who died in the first, or cold stage of an ague, one of these, indeed, in his own presence. But surely, no one would contend, because these individuals expired on the first attack, that the disease was therefore a new species of Ague. And if this occurs in intermittent fever, the same variety may also happen in the Cholera of this country ; as it will not be denied, that epidemics of essentially the same character, may be occasionally accompanied in different years, even in the same country, by a variety in its form, and symptoms. The same modification of symptoms is often likewise remarked in other epidemics, such as in the typhus fevers of Great Britain ; one year it is mild, and easily treated ; in another, it is most rapid in its course, very fatal in the result, and attended with unusual symptoms, as by petechial spots, hsemorrhagies, or the like ; but still it is typhus. And if we compare the accurate description of fever given by Sydenham, with those which have recently, or previously occurred, there will be observed a variety in the type, although the disease be considered by nosologists, as belonging to the same class. Similar reasoning equally applies to Cholera ; one year, or for a series, it is mild ; at another period, it is frequent and most fatal, depending like other epidemics, upon causes sometimes, it must be acknowledged, difficult to explain. Much has been said on the subject of blueness of the skin, as constituting a pathognomic, and perhaps one of the most characteristic symptoms of the disease. Too great importance has all along been attached to the presence of this formidable feature ; the very mention of which has caused the greatest dismay. If however it be taken as a proof of similarity to the disease of India, great misapprehension on that head seems to exist ; and in confirmation of this opinion, I would refer with confidence, to the excellent paper on Cholera, published by Mr. Mouat, in 7 the fourth volume of the Transactions of the Medical Society of Calcutta. In this treatise, although the author minutely details the particulars occurring in 132 cases of Spasmodic Cholera, not in natives, it should be observed, but in the soldiers of an European corps, viz. His Majesty's 14th Regiment of foot : yet in all these patients, not during the epidemic is stated to have shewn this much talked of blueness ; it therefore cannot be considered as constituting a constant symptom in Asia. But besides this, as great a variety is also observed in some of the premonitory symptoms, and in the subsequent fever. Thus in India, diarrhoea is said seldom to precede the Cholera ; in this country, it generally appears some days before. In India again, they have seldom any fever, on the contrary, in this country, most commonly, a severe secondary fever follows before convalesence. Shewing, as in the symptom of blueness, that a marked difference may occur in diseases of the two countries ; whilst it demonstrates the small reliance we ought to place on conclusions, drawn from proofs like these, of its invariable identity. In conversation, I have always admitted that the Cholera of the East and of this country, is, nosologically considered, the same disease. As much so as the ague of Lincolnshire, of the Pontine Marshes, and of the banks of the Nile^ is essentially a similar complaint ; varied, undoubtedly, by peculiarity of climate, by local circumstances, and the constitutions and habits of the people affected. Still none can deny but it is the same kind of intermittent fever. To suppose, however, that the Cholera of India will be transplanted to this country unchanged in every feature, appears to me doubtful ; with our present knowledge, and before such can be fully admitted, more facts and proofs must yet be produced in support of the doctrine. As well, as once observed a physician, might we expect pine apples to grow in this country more plentifully than cabbages. During the valuable remarks made by a member at the meeting of the 25th ultimo, an admirable table was laid before the Westminster Society, shewing a striking identity in the symptoms attending the cases, and occurring at Limehouse early in February last, reported to be genuine Spasmodic Cholera, with those which were observed in patients affected in August 183 L Nothing 8 could be more convincing, than these facts to shew, the disease now in the* Borough is not new. And apparently the same conclusion is amply borne out, by the symptoms observed in the frequently mentioned cases of the soldier Webb, and of the taylor taken to St. James's Infirmary, in the month of November. How the advocates for a new and recently imported disease, can get over the marked similarity of the symptoms observed in these individuals, it is difficult to understand. By some physicians, it has been attempted to argue, that neither identity of symptoms during life, nor post mortem examinations, prove any thing conclusively j but that there is acting a something which cannot well be described, sufficient however to explain the whole difficulty. With such reasoning, it is impossible to grapple ; and those who employ this mode of explanation can only be left to the quiet cogitation of their own favorite hypothesis, as with their opponents, it would be hopeless to expect any approximation. On the subject of contagion, it is not now necessary to dilate at any length, seeing, that many points in dispute have been surrendered by the contagionists ; and at present we hear no more of internal quarantine, nor of the strict rules at one time laid down, for those in attendance upon the sick ; besides nothing is now said of the portentuous words, once recommended to be placed over the doors of houses, where Cholera patients might be contained ; these views are wholly abandoned. Still, however, many talented members of the profession, besides others, consider, that the Cholera is only communicated from individual to individual, and therefore seclusion of the sick, and the continuance of quarantine are still absolutely required ; nay, should be strictly enforced ; because without such regulations, the complaint must inevitably spread and devastate the country. In the course of the enquiries, I have thought it necessary to make, for the purpose of gaming information on this, as on other points ; I have not, in any case, it must candidly be confessed, yet been able to find sufficient or irrefragable proofs of the contagious nature of the disease, in the sense this expression is usually understood ; and in such an opinion, I am confirmed by all the facts stated in the conversations held with the practitioners in the Borough, 9 who have attended the cases reported in that district ; and to whom my best thanks are due, for their civility as also readiness to shew cases, or to give information. There seems to be little discrepancy on this question, in those who have had personal experience on the subject. And in confirmation of this, the publicly expressed sentiments of gentlemen who have discussed the subject of contagion, at the London Medical Society might be cited; for few decided opponents of the non-contagious character of the disease, offered any strong 1 contradiction. And even in the Westminster Society, where formerly, members seemed a good deal divided, many have seen reason to re-consider their opinion. And some who were contagionists, are now zealous anti-contagionists— proving, as has been advanced, in the countries where the Cholera is common, that many who have not seen the complaint, in its severe form, are advocates for contagion; but when they have had actual experience, arid have personally examined into the nature of the disease, they then gave up the doctrine. Whilst I cannot concur in the theory of contagion, as fully accounting for the propagation of the disease, although it is the most easy way to solve all difficulties ; it may naturally be asked, how the spreading of Cholera is otherwise explained ? It can be so, easily ; and to my mind, the explanation is satisfactory ; whilst by many the conclusions are readily granted, or considered sufficient. The epidemic appears to originate in a peculiar state of atmosphere, joined to local miasmata, and other causes ; which tend so to vitiate the air of a particular district or habitation, that individuals in such deteriorated places, and constantly breathing this tainted atmosphere, have their blood thereby less highly oxyginated, than is consistent with perfect health. The tone of their system, at the same time becomes lowered, and the digestive functions get so irritable or deranged, that any slight external cause, which would have produced no effect, under other circumstances, now prove influential, in producing the disease. Of these, being ill fed or worse clad, intemperance, exposure to cold, to wet, and the like injurious agents, are the most active. And if to such be added, diseased, broken down, and aged constitutions j no wonder, it will be B 10 allowed, if in the sequel, the stomach and bowels are disordered, particularly from the extreme irritability of these organs, considered to exist in persons placed under the above circumstances. Thus developing the Cholera, or a pestilential fever, according to more recent nomenclature. In illustration of the decided influence particular states of atmosphere and local situation have in the production of disease, reference might be made to what takes place in ague countries. There physicians do not explain the occurrence of intermittent fever, by referring it to contagion, but to local and other causes. So well marked, indeed, are these circumstances, that in Rome, for instance, during the unhealthy season, an individual will have Ague from only living on one side of a street ; whilst, if he but remove to the house a few paces opposite, he may escape ; and similar facts are known to all who have inhabited countries where this disease prevails. Take also the case of a number of human beings incarcerated in a loathsome and confined dungeon ; as in the black hole of Calcutta ; but here, and in such a place, no one will therefore conclude, that the cause of death, in those who fell victims, proceeded from contagion. That alterations have lately taken place, in the constitution of the atmosphere, joined to some other general causes, whereby the character of disease has been materially influenced, is the subject of daily remark, by medical men. And this is shewn, as well, by the diminution of the inflammatory complaints, usually observed in the cold season, as likewise, by the nature and the treatment required, for those which have actually prevailed. Most diseases, indeed, have lately assumed a decided character of debility ; and have at the same time, shewn a great want of tone in the nervous and vascular systems; so as to require the administration erf tonics and stimulants, even at their commencement. Whereas, in ordinary years, diseases in this country, are, for the most part, those shewing excitement, at least, in the beginning ; and it is only afterwards, that debility supervenes. It is, however, remarkable, and is observed by many practitioners, that several diseases of the chest, which from the symptoms would indicate the necessity of blood-letting, and the like 11 remedies, now require the use of bark and ether. And this I have myself met with, not in individuals of the lower ranks, but in those of a superior condition. The fact is instructive, and shews that some great influence is in operation, to lower the tone of the animal system. This peculiarity, scientific men have endeavoured to account for, by ascribing it to changes in the atmosphere, to electricity, to emanations from the earth, to the frequent south-east winds, to volcanic eruptions, and similar phenomena. Before leaving this subject, I might dilate upon the injurious consequences, which the fear of contagion produces on the public mind, but as these are too well known, and of too serious a character, it is not necessary to enter upon the subject. I cannot, however, avoid relating an amusing instance of the absurd length, to which a dread of catching the disease, sometimes leads an individual. At the Dispensary, a man was brought in from the street, labouring under a fit of apoplexy ; after being bled, and otherwise treated, he had soon so far recovered, that a hackney coach was sent for, to carry the patient to his home. When the vehicle came up to the door, the driver, having some suspicion of the nature of his future fare, insisted upon first seeing the person he was to carry ; on being pointed out, lying on a sofa, pale and almost speechless, with scarcely power to move a limb, the coachman instantly declared, " the patient had the Cholera Morbus, and to take such a passenger was more than his coach, and his horses were worth." This accordingly made alientreaties unavailing. Quarantine is so essentially based upon the doctrine of contagion, that the settlement of this question, must materially influence the adoption of any sanatory measures, for the prevention of Cholera. The origin of quarantine, has always thrown great doubts, over its utility ; and from being adopted by Popes, and despotic governments, to disperse refractory councils, or to repress the rising spirit of a nation, has only confirmed suspicion. But when liberal governments actuated by very different feelings are induced, also to impose restrictions, the question then assumes a different ground, and requires examination. In the views, I would take of quarantine, it appears to be placed on a wrong principle. The object being to prevent 12 the spreading of a disease, I should consider, the restrictions ought to be, not, how to keep individuals from coming out, but to prevent them going into infected places ; as they thus expose themselves to the same influential causes, with others of the diseased district. The removal of the inhabitants to a healthier, would be more beneficial. To refer again to the black hole at Calcutta, we find, that the surrounding cordon, or quarantine, there caused the death of almost every victim confined ; who would have suffered no injury, had they been only allowed, to leave that horrid dungeon. Had a cordon of troops been placed round Sunderland, as was once gravely recommended, the consequences of such a measure, besides its almost impracticability, can scarcely be imagined. And the experience of those governments, where the strictest quarantine has been tried, only shews its inutility. Indeed, the disease was aggravated by its adoption, and when the restrictions were removed, the Cholera soon afterwards became materially lessened. Experience is therefore against quarantine, and accordingly, Government have abolished all intervention, with internal trade and commerce. In delivering the sentiments now expressed, it is by no means intended, to paralyze the laudable exertions, so meritoriously made by the charitable and humane, in the upper and middle classes, in order to alleviate the miseries and wants of the poor. Far be it ever from my intention, even in the slightest manner, to obstruct, or neutralize such praiseworthy exertions. For conduct so beneficial as this, not only proves to the lower ranks, that their more rich and elevated neighbours, attend to their distresses and situation, and are most anxious to release them. But such proceedings have also a most material influence, in preventing the spreading of this, or of other epidemics, to which the poor are liable. If, therefore, what is now said, could by possibility, have the slightest influence, in checking the exertions of benevolent individuals, of boards of health, or of vestries, not a word would be advanced on this topic of contagion. But as such an effect, cannot result from the present observations, no fear is therefore felt, this will be the consequence. If, however, on the other hand, any thing now stated shall, in the slightest 13 degree, serve to allay the existing alarm ; or if what has been said by others of similar sentiments, shall impart confidence into the relations and attendants of the sick, by convincing them, that there is really no danger, whilst they aid the sick in every possible way ; nay farther, if the dread and dismay this pestilence has produced, is shewn to be unfounded, or much overrated; then the exertions of those who have attempted to stem the torrent, will be amply rewarded with approbation. During the discussions on Cholera, a great deal has been said of the danger, and devastating influence of the pestilence, which has overrun other countries ; whilst the imaginations of a few have painted the effects of the disease, in so strong a light, as to make them think, the metropolis would be depopulated, should it actually arrive. It has even been acknowledged, that the very thoughts, have caused sleepless nights and anxious days, believing nothing could be more certainly dangerous, than attendance upon those, suffering under the excruciating agonies of the disease. Now, Iby no means wish to make light of, or to disparage the feelings of those who entertain such opinions ; because, although mistaken, they derive their sentiments from a source, shewing their minds are alive, to the sufferings of their fellow creatures. Nevertheless, as one who thinks differently, and feels anxious, if possible, to allay the fears of the timid, but not to make others foolhardy, or thoughtless ; I would beg in proof, that there is yet little cause of alarm, to refer to the weekly bills of morr tality, thereby shewing, that notwithstanding this scourge is amongst us, the number of deaths is actually much less than usual. Thus, by the bills of mortality, for the week ending the 14th February, when the Cholera was not in London, the number of burials in the metropolis amounted to 479. In the following one, that ending the 21st, when, it will be remembered, the whole population had been alarmed by the portentous announcement, that the eastern pestilence was actually arrive^, the total burials, including the reported cases of Cholera are only 385. Thus proving, there had been a diminution in the number of deaths, to the amount of one-fifth, or 94; and demonstrating;, beyond the shadow of refutation, that hitherto, instead of London being depopulated by the Cholera, the 14 fact is really the reverse. Again, in the populous parishes of St. Giles and St. Mary-le-bone, the same satisfactory conclusions are obtained. In the latter, the number of burials in all its extensive districts, from the Ist of January 1831 to the 22d of February in the same year, being 436, whilst, from the Ist of January to the 22d of February of 1832, the burials were diminished to 383; making therefore 53 deaths less, than during the same period of 1831. Farther, in the Infirmary of that parish, there is at the present moment, fewer patients by almost one-fourth, than in the month of February, of last year. Such consolatory facts may not, perhaps, continue to be obtained, from future returns ; nevertheless, it is a matter of great gratification to find, that hitherto, the fears of the public hare been mistaken. And it will be pleasing to every one, although contrary to the theory of some, if we always have similar satisfactory statements, of the health of the metropolis." After occupying so much time, in the examination of the causes which tend to produce this disease, it will not be also expected, to enlarge upon the means of prevention. Indeed, to do so at any length, would be exceeding the original intention I was actuated by, in making the present observations. A few words, however, on this important topic, will not be altogether misplaced. Carefully to avoid being influenced, by all those predisposing causes already mentioned, would undoubtedly be one of the first steps taken, to prevent the supervention of Cholera. And although contagion is not admitted, as the cause producing this disease, no prudent person would unnecessarily place himself under the action of the same atmospheric, or local causes, giving it to another ; any more, than a traveller would sleep in the middle of the Pontine Marsh, instead of the high ground near Albano. To avoiding of all local and atmospheric influences, must be added, unlimited reliance on the goodness, and bounty of Providence ; along with equanimity of mind, and moral courage. Because, whatever depresses the spirits, or destroys confidence, must infallibly tend to render the body more susceptible, of those external causes, which induce the disease. Besides these precautions, ventilation, cleanliness, and warm clothing must not be neglected. Whilst good nourishing food is administered^ at the 15 same time, every thing of a sour, indigestible character, should be sedulously avoided. Nevertheless, however care- Fully these general directions are followed, if excesses, either in eating, or in drinking, are committed, equally bad consequences must follow. And I would add, for the benefit of non-medical readers, wherever there is the slightest indication of debility, or indisposition, appropriate remedies ought to be prescribed. But the habitual, or injudicious use of drugs, should never be permitted. The description of symptoms, the history, and the progress of this formidable malady, as likewise the consideration of any 'medical treatment, which ought to be pursued, are quite beyond the limits, or design of the present letter ; especially, since the examination of these various questions, are of too great importance, to be discussed in a cursory manner. I have therefore thought, it would be better to leave all these topics untouched, than to do so, either partially, or inconsiderately. In taking leave of the subject, a caution of importance maybe mentioned, namely; that active or powerful remedies, should be administered with the greatest circumspection, and if possible, with medical authority. As otherwise, much injury may be the consequence, and even serious results sometimes supervene. On a disease like the present, surrounded by so many difficulties, where yet farther information, than is already possessed, must be acquired, to clear up the points in dispute, and which has at the same time puzzled the members of the medical profession, in almost every country ; it would be presumptuous in me, to consider the opinions now entertained are so well founded, that they could not be shaken. Such an assumption, is foreign to my sentiments. It is only because I feel anxious to understand, all the phenomena, so well marked in this complaint, that I have thrown together these observations. Since, in questions of importance, the collision of opinions generally elicits truth, and in the counsel of many, we get wisdom. Should subsequent knowledge, however, lead me to believe, the opinions now expressed, are subverted by facts, which cannot be withstood, or explained in any other manner ; then, it will be no disparagement, for an individual, in a question relating to medicine, a science of experience and observation, to reconsider, or remodel a conclusion- But 16 until conviction arrives, every one, whilst zealously supporting his own theories, ought assuredly to respect, and examine into those, from whom he may differ. With these sentiments in view, the preceding pages have been penned, and I trust, my motives will neither be misrepresented, nor mistaken. Lastly, I would again direct attention to one of the principal points adverted to in the early part of this letter, namely; that the question requiring decision, from being one of paramount importance, is, not whether the disease, now prevailing in England, be identical with that of India, or the north of Europe ; but whether it be really a new complaint, and never hitherto known in England, Or to repeat the question, Avhether it is only an aggravated, more rapid, and fatal form of pestilent typhus fever; if denied to be the Cholera so well known to English practitioners. This important topic, upon which I have dilated, at considerable length, can only be satisfactorily settled, by being referred, speaking as it were legally, to a jury of medical men, composed of the oldest, and most experienced members of the profession. This, 1 would beg leave to suggest, ought not longer to be delayed, for until something similar, or a more efficacious plan be instituted, and unless means be taken, to clear up the doubts, enveloping some other much disputed points ; the public will neither have confidence, in the opinions of r^edical men, nor will they be convinced, by wh*t s'iiall be promulgated from authority. Ncr la iflikely that the medical profession themselves will rest satisfied, that every measure has been adopted, in order to explain the difficulties, with which these controverted questions are now embarrassed; thereby throwing distrust on the well intended, although perhaps joined, with some mistaken, measures of Government. I have the honour to remain, Gentlemen, Your very faithful Servant, JOHN WEBSTER.