ON THE UNITY OF THE ZYMOTIC OR EPIDEMIC POISON; AND THE NATURE AND TREATMENT OF CHOLERA: HENRY GREENWOOD, M.D., M.R.C.P. Lond. MAY, 18 66. Greenwich : PEINTED BT B. 0. BERBYMAN, ' BATH ' HOUSE, - BLACKHEATH ROAD. ON THE UNITY OF THE ZYMOTIC OR EPIDEMIC POISON. The unity of the efficient cause of epidemics has not, I believe, been acknowledged by any medical authority. Various theories have indeed been proposed to account for the origin of epidemics, but the question of an individual agency has never been so determined as to meet with general acceptance. I will adduce such evidence as I consider relevant to the subject, and really applicable to its determination, and after a review of that evidence consider whether it will sustain any positive conclusion. The late Dr. Hancock, of Liverpool, at the conclusion of an article on epidemics, contained in the Cyclopaedia of Practical Medicine, of the date 1833, says, " In conclusion, the separate points of evidence, added together and weighed impartially, constitute a theory or system of connected observations and dependent results, tending remarkably to establish the opinion with as much certainty as the case will admit, that the whole apparatus of an epidemic pestilence from beginning to end, is the production of the country where it rages." 4 (The report on cholera, published under the thority of the General Board of Health, of the te 1852, says, " There is now no reason to doubt at the disease is induced in man by a certain specific itter, a variety of which was produced in India in certain unfavourable circumstances ; that this matter has the property of propagating and multiplying itself, in air, or water, or food, and of destroying man by producing in successive attacks, the phenomena which constitute Asiatic cholera." To this matter, this something, the report assigns the name of cholerine, leaving it for future investigation to discover what that something may be. 1 Again, in the "Laws of Cholera," published in 1854, the statement, " It has been already observed that the datic cholera originated in the low, marshy, jungly tract of country which forms the delta of the Ganges, from which and similar sources, it has certainly been Inewed and propagated during its progress into and rough this country. In the history of its progress, nstant notice is being given of its development in low Ld marshy places, and along the course of rivers, but Lly np to a certain level, and also by the sea-side, in places where deltas are formed, and into which masses of impurity are being constantly carried down. The relation between the level and the strength of 5 ! cholera has been most carefully tested in the case London, and the result has been the discovery of mathematical correspondence of the two elements ler consideration. The districts of London have in classed according to their elevation above the el of the Thames. They are divided into those elevation of which is not on an average above 20 t ; and at this level the deaths from cholera were 102 in every 10,000 persons. In the 2nd group at from 20 to 40 feet elevation, the deaths in the same number were reduced to 65. In the 3rd group, from 40 to 60 feet high, the numbers sunk to 34 in 10,000. In the sth group, with an elevation of from 80 to 100 feet, the deaths were but 22 in 10,000. In a district 100 feet high the mortality was 17, whilst at Hampstead, about 350 feet above the level of the Thames, the deaths were only 8, one of which resulted from infection brought from Wands worth." Mr. Grainger, in a letter received from him in December, 1853, says, " There is no doubt of there being a deep covert connexion between the main epidemics, and malaria is doubtless a potential agent in the whole class. One of the best illustrations that I know of the distinct operation of marsh water in k using different forms of epidemic disease, is stated ' Dr. Boddin, a French physician and writer. I 6 in my official report on the cholera of 1849 to the General Board of Health :— ln July, 1834, 800 soldiers, all in good health, embarked on the same day ? three transports at Bona, and arrived together at arseilles ; they were exposed to the same atmospheric influences, and were with one essential difference, supplied with the same food and subjected to the same discipline. On board one of the vessels were 120 soldiers, of these 13 died on the passage from a destructive fever, and 98 more were taken to the Military Hospital of the Lazarette at Marseilles, presenting all the pathological characters proper to marshy localities ; so that by the side of a simple intermittent, was seen a pernicious fever, here having a type recalling the yellow fever of the Antilles, and there that of the cholera of the Ganges with its most terrible traits. On an enquiry being instituted it was ascertained that, on board the affected ship, the water supply for the soldiers, owing to the haste of embarcation, had been taken from a marshy place near Bona, while the crew, not one of whom was attacked, were provided with wholesome water. It farther appeared that the 9 soldiers who escaped, had purchased water of the crew, and, consequently, had not 7 Eor of the other two transports, who were supplied b. pure water, suffered." Dr. Barlow who, from his local position and extensive practice, has had as large an opportunity of observing 1 the phenomena of epidemic disease as most men, in a letter received from him of the date Jan. 16th, 1854, says, "In the main I agree with your views, and my tendency, or I should rather say the tendency of all facts with which I am acquainted, is certainly towards a unity of poisons, modified by local and individual peculiarities, rather than to the attempts lately made to diversify morbid poisons without number." There are two other incidents of some importance ;o this enquiry. Whilst the cholera raged in the ocalities on the banks of the Thames, in 1849, every ;her form of disease of the zymotic character, both ommon and contagious, prevailed also, and it was jserved that sometimes two, three, or even four of us class of complaints, occurred at the same time, in the same house, and in the same family. The other incident must have come within the experience of most medical men, namely, the not unfrequent occurrence of individual cases of contagious disease, where no trace or evidence of contagion 8 can be discovered. This occurs equally in populous neighbourhoods and in more open situations, and is often a great perplexity to the medical attendant, who can neither satisfy himself nor those who are immediately interested. I have now concluded the evidence, and will at once, by a brief analysis, indicate the points which it tends to establish. Dr. Hancock, who appears to have carefully studied the subject, emphatically declares the local origin of all epidemics. JThe General Board of Health, in its report on olera, states its conviction that the disease was luced in man by a certain specific matter produced in India. In the "Laws of Cholera," the same authority states the nature of the locality as low, marshy, and jungly, and declares that from such and similar sources it has been renewed and propagated in its progress through this and other countries. That it has been developed in low and marshy places, and along the course of rivers up to a certain elevation, and by the sea-side when favoured by the presence of masses of impurities. In support of these views it refers to the effect of elevation in modifying the action of the cholera poison, as care- 9 Silly tested in London, where it was found that at an evation not exceeding 20 feet from the level of the Thames, the deaths from cholera were 102 in every 10,000 persons, whilst at an elevation between 80 and 100 feet the deaths declined to 22 in 10,000. tThis observation indicates the source of the cholera ison and suggests malaria as its nature. Mr. Grainger, whose observation on the subject must have been very extensive, states his conviction of the close connection between the main epidemics* and that malaria is a potential agent in the entire class. In the incident he relates from the French writer, is presented, on unimpeachable evidence, the fact that water, impregnated with marsh miasm, is capable of producing three distinct forms of epidemic disease, namely, a simple intermittent ; a pestilential fever resembling the yellow fever of the West Indies ; and Asiatic cholera in its most deadly form. Dr. Barlow considers that the tendency of all the facts on the subject, with which he is acquainted, is towards a unity and not a diversity of morbid poison. The presence of various other forms of zymotic origin, during the prevalence of cholera, naturally offers two solutions :—: — Ist. — That various kinds of poison are all acting B 10 independently, and producing their several effects, or 2nd. — That some potential agent, having the same relation to the others, which the master-key of a house has to that of each apartment, produces the entire result. JThe former of these solutions would be unreasonle and highly unphilosophical, the latter simple and fficient, and the agent at hand and in full operation. I The other incident suggests the action of a poison dependent of and superior to contagion, and points the presence of malaria on the spot as the true lution. I The conclusions then which I consider to be legitiitely established by the premises are :—: — E-That there is one essential zymotic or epidemic capable of originating every form of epidemic 2nd — That malaria is that poison. ON THE NATURE AND TREATMENT OF CHOLERA. In the "Laws of Cholera," it is stated :— "At the first appearance of the epidemic in 1832, and for many subsequent years, it was a subject completely shrouded in mystery : its nature was not understood, its movements were a riddle, and its proper treatment, even amongst the most scientific and experienced, was unknown." This statement is literally true, and the explanation is to be found in the fact that the attention of Medical men was diverted from a calm consideration of the phenomena of the disease to a wild search for an immediate remedy. 1A review of the symptoms ought soon to have coniced any dispassionate inquirer that no remedy was applicable to the condition of collapse — that is to say, that no medicine administered to a person in that state was capable of removing it. But the inquiry which would have led to this unsatisfactory result was also capable of affording important suggestions, and on them might have been founded a rational mode of treating cholera in the collapsed state. 12 (I will just give tlie symptoms of cholera in the llapsed state, as described by Mr. Moss, of Windsor, in words of terrible precision," to be found in a ipular and highly valuable article on cholera, conined in the " British Almanack " of 1849 :—: — " It is characterised by vertigo, great prostration of strength, severe cramps in the legs or abdominal muscles, with loud and violent vomiting of large quantities of a thin gruel-like fluid, devoid of smell at the same time forcible and most profuse ejections rom the bowels of a precisely similar fluid, in such stonishing quantities as to show that all the watery >ortions of the blood are being drained off ; the bodj >ecomes colder than an ordinary corpse, and often as mlseless ; and the countenance far more cadaverous nd ghastly than that of death under any other form f disease. The eyes are deeply sunk in their ockets, which are perfectly hollow from the abstrac ion of their natural fluids; the voice is a tremulous roak, or sunk to a deep sepulchral whisper; the >reath strikes your cheek like the air from an ice louse ; and the tongue feels like the touch of a frog Different parts of the body assume a leaden hue owing to the thick and stagnant blood of the cutaneous vessels shining through the attenuated skin which is as cold and clammy as in the approach o 13 death from low fever. When a vein is opened in the I the blood will rarely flow, and, on being squeezed has the appearance and consistence of treacle ; :o this that the thirst is insatiable and restlessextreme, and you will have a faithful portrait of ease which none can fail to recognise or mistake for any other." A sense of heat and intolerance of heavy clothing must not be omitted. Such are the phenomena which characterise the state of collapse, and a moderate consideration of them will very distinctly point out the cause of that state, and, at the same time, the hopelessness of finding a remedy. The facts prove satisfactorily that the state of collapse is occasioned by the blood being so drained of its fluid portion as to be greatly diminished in quantity, and at the same time rendered incapable of free circulation by the thickened state to which it is reduced by that drain ; so that there is not only an effect equivalent to that produced by large sanguineous depletion, but also another, arising from the difficulty of circulation in consequence of the inspissated condition of the blood remaining. The state of a person in the collapsed stage of cholera is analogous to one who has lost a very large quantity of blood, with the additional evil that the 14 sufficient fluidity. So that whilst in the case of sanguineous depletion reaction may be safely restored as quick as possible by means of stimulants, in the condition of collapse it cannot be so without considerable danger, until sufficient time has been allowed for the absorption of fluid into the system to fit the blood for circulation. Ec state in some degree resembles that of the bitten limb, for though the causes differ the is nearly the same. The condition in both cases is one of low vitality with suspended circulation, occasioned in one by the application of cold, in the other by the thickened state of the blood, and in both cases reaction may be encouraged by suitable means, but cannot safely be forced. Experience tends to confirm these views. The necessity of restoring the fluidity of the blood was recognised in 1849, and various means were adopted to effect this first condition of reaction. Transfusion was employed, and various forms of fluid were injected into the veins, but although early reaction was thus obtained, the cases ended fatally. On the other hand, it now and then happened that a person in an extreme state of collapse, who had been left to die quietly, after every means to induce reaction 15 i p y re iv , n eventually recovered, thus proving that the natural powers are capable of producing reaction, even under the most hopeless circumstances, and suggesting that the state of collapse, however dangerous in itself, is yet favourable to absorption, and therefore to eventual restoration of the circulation. Having endeavoured to establish some principles of treatment, I will now attempt their application. The necessity of restoring to a certain degree the fluidity of the blood before a beneficial reaction can be established, as suggested by the cause of collapse, would lead us to encourage absorption by every means in our power. There are indications, moreover, in the state of collapse to assist us in applying the most appropriate means. The excessive thirst, for which cold fluid, and especially cold water, is earnestly coveted, suggests a free supply of fluid, and as cold water is most agreeable to the sufferer, so it will also be found a very important agent in relieving the existing condition. Another indication is afforded by the great heat complained of, even during the coldest state of collapse, accompanied by intolerance of heavy clothing. This seems to indicate that fresh air and light covering are very likely to assist the absorption of fluid, and concur with the cold water in bringing about the 16 gradual change required in the condition of the blood. The general treatment that I would recommend in cases of cholera in the collapsed state consists in preserving the patient carefully in a recumbent position, allowing no exertion that can be avoided, and providing for the removal of all discharges without disturbance ; in admitting the air freely, covering the bed lightly, and satisfying the thirst by giving cold water in small quantities at a time, frequently repeated ; in avoiding all stimulants, whether external or internal, heat and friction especially included, and applying tbhs wrung out of cold water to the parts affected cramps instead of rubbing them. Kit will be found that whilst by these means a great al of annoyance is saved to the patient, and a great deal of trouble to the attendants, the probability of a favourable reaction is considerably increased. The only medicine I would recommend is a grain of calomel every hour until reaction' is established. When reaction does take place and the patient rallies, the case must be treated as one of low fever, stimulants, however, being avoided until the period of dangerous congestion is passed, nourishment being supplied in the meantime principally by the use of 17 animal bi'oths in small quantities, at intervals of from two to three hours. Besides the complete state of collapse of which I have been speaking-, there occurred frequently in the attacks of 1882, 1833, and 1848, 1849, a state of incomplete collapse of a much less dangerous nature. It was characterised by great prostration and some of the symptoms of complete collapse, but the circulation was never suspended, though very depressed. This state was readily amenable to treatment, and after the early part of the attack in 1848, 1849, I saw no patient sink under it. The general treatment was as before directed ; the Medical modified to suit the less dangerous condition of the sufferer. Thus the grain of calomel was administered only every four hours, followed by a tablespoonfql of simple saline mixture until a proper reaction was established. It is necessary to distinguish these two states, or rather degrees, of collapse, as by confounding them a much larger number of recoveries from cholera in the collapsed state appear to have occurred than really took place, and the varying degrees of success recorded by Medical men can be reconciled only in this way. It is a melancholy fact, but in accordance with o 18 Jeral experience, that of any given number of pers in the state of complete collapse a large proportion will die in that state, and of those who rally a considerable portion will sink during the period of reaction. Thus, according to my own experience, of twelve persons in that condition six will die, and of the six who rally two will sink during the period of reaction, leaving only four, or one-third, who eventually recover. It may be inferred, from what I have said on the treatment of collapse, that I do not consider that state as cholera at all, but a sequel, and a very fatal one, of this disease. Real cholera consists of that stage of painless diarrhoea which precedes the symptoms of collapse, and to suppose that no cholera exists until those symptoms occur would be a very dangerous error, likely to lead to a disregard of the only period when medical treatment is available. tarn of opinion that no disease is more manageable t cholera, and quite agree with the Editor of The Times in believing that more cures are effected in it than in any other form of complaint. I believe then that the cholera poison acts on the organic system of nerves, more especially those of the alimentary canal, 19 Jit produces great congestion of the mucous mcmi, from which the body endeavours to relieve by excessive purging. It is this stage of the laint which, as I have said before, constitutes cholera, and it is only when this has been negi, or unsuccessfully treated, and the blood so ed of its serum as to be no longer fit for circulathat the symptoms of collapse occur The treatment is neither difficult nor complicated. To relieve the congestion, which forms the basis of the complaint, a grain of calomel and \ of a grain of Em the form of pill, given immediately and 3d at bed time, is generally sufficient, and a »oonful of the following mixture, every four as generally controls the diarrhoea effectually : — Aromatic Confection, one dram ; Compound Tincture of Lavender, three drams ; Tincture of Opium, thirty drops ; Chloric JEther, twenty drops ; Water, five ounces ; Mix. Rest in the recumbent posture should be enjoined, and abstinence from solid animal food during the continuance of the diarrhoea. Beef tea in moderate quantities at intervals, and bread and butter, afford quite sufficient nourishment. The diarrhoea preceding the stage of collapse is so painless, and so little 20 accompanied witb any feeling of illness, that it is almost impossible, especially amongst the workingclass, to persuade those affected, that they are ill at all, or induce them to take any precaution whatever. Such was the state of feeling in the epidemic of 1849, and such I have no doubt would be the case should we unfortunately be visited by the disease during the ensuing autumn. Nothing wi}l meet this indifference but a regular house to house visitation amongst the working population, which may by timely help, prevent an unnecessary amount of mortality. I There is a matter connected with the subject of olera which has not, I think, obtained that attention >m Medical men which it really deserves. II allude to the great mortality which occurs longst infant children from diarrhoea, during the summer and autumn months. To give some idea of the extent of this mortality, I may just state, that in the single week which ended July 12th, 1865, the returns of deaths from diarrhoea were 280, of which number 257 occurred among infants under two years of age. I This appears to me a remarkable result, and cant, I think, be satisfactorily accounted for on the 21 ground of the delicate organization of those who suffer. The question, therefore, suggests itself whether any other morbid agency, by producing predisposition, renders this class of sufferers more especially obnoxious to the epidemic influence which then prevails. I believe that such is the case, and that in the dietetic treatment of young children will be found a very important assisting agency. The great bulk of the victims belong to the working and lower classes, and consist of infanta, as before mentioned, under two years of age. Now, a large proportion of such children must necessarily be at the breast, and we may suppose not very likely to be seriously influenced by external morbid agents. But from a pretty large experience of the habits of those classes, I know, that a woman nursing an infant, considers that no amount of stimulating drink, whether in the form of porter or spirits, is too much under the circumstances. The consequence is, that the milk acquires a very exciting character, the frail functions of the infant frame are constantly carried on at a high pressure, and yield readily to any additional strain thrown on them by external causes. But this is not all. Most of the infants whilst at the breast are fed by hand also, and the substantial nature and large quantity of the food given, renders it quite impossible that it can be digested by so delicate an organ as the infant stomach. Those that are weaned are subject to the same management, and thus at the susceptible and critical period of dentition, readily become the victims of external morbid agencies.