Week3_Cholera

Week3_Cholera - Lancet 28 January T ’ OF...

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Unformatted text preview: Lancet 28 January T ’ OF LONDON—HARVEIAN SOCIETY. MEDICAL SOCIE 1854, i, 109 109 3lst Sample. Purchased—of R. Farmer, 40, Mount-street, Lambeth. Adulterated.—Contains POPPY-CAPSULE, a little WHEAT- rLot’n, and extraneous woonr-rnann 100 parts consist of—‘llol-stzu'e, 11"5; resin and fat, lG'l; sugar, colouring matter,and organic acids, '26 ‘6; ALKALOIDS, 10'2; gum and salts, 9'1 ; insoluble matter, 26'5. 32nd Sample. Purchased—of J. H. Bannister, 4‘26, Oxford-street. Enormoitsly mlultemtetl.—Contains a very considerable amount of POPPY-CAPSULE, and an immense quantity of VVHEAT-FLOUR. 100 parts consist of—M’oisture, 6‘0; resin and fat, 10'9; sugar, colouring matter, and organic acids, 42 'l; ALKALOED'S, 6'1; gum and salts, 6'3; insoluble matter, 28‘3. (To be continued.) mural genetics. MEDICAL SOCIETY OF LONDON. SATURDAY, Jan. '21, 1854. — Mn. Enwn: (juror, V.P., in the Chair. APPLICATIOH 0F COLLODION IN ENTROPIUM. DR. “’15): referred to a plan of treating entropium with col- lodion, which he had suggested and carried into effect some time since. It consisted in passing a camel’s hair brush, which had been dipped in collodion, rapidly over the fibres of the orbicularis palpebrum muscle, a second line being drawn ex- ternally to this if necessary. If the collodion were coloured with cochineal it was scarcely noticeable. It was only a tem- porary cure, and the process might require to be repeated every other day. He had seen the plan succeed in many cases. It acted by con-ugating the skin, upon which it did not produce such a strain as did the application of plaister. Mr. CANTO)‘ had seen it applied in some cases with tempo- rary benefit. Upon what did the entropium depend in the cases in which Dr. Winn used the collodion? Dr. WIN): regretted that he could not give information upon this point. Dr. SNOW read a paper, entitled— TEE PRINCll’LE 0N \VHICH THE TREATMEV'T OF CHOLERA SHOULD BE BASED. He said that the absence of settled opinions respecting the na- ture of cholera. was the cause of the various and contrary plans on which it was treated. In the greater number of epidemic or self-propagating diseases the morbid poison entered the blood in some way, and after multiplying itself during a period of so-called incubation, it affected the whole system, the illness commencing by fever and other general symptoms. Cholera, on the other hand, commenced with an effusion of fluid into the alimentary canal, without any previous illness whatever, and the subsequent symptoms were the result of the change in the blood occasioned by this effusion of its watery part. The analyses of the blood of cholera patients, performed by Dr. O’Shaughnessy, Dr. Garrod, and others, proved that its thick and tarry condition was caused by the loss of a great part of its water, tovether With a portion of its saline constituents. The physical state of the blood prevented it from passing through the capillaries of the lungs, except in very small quan- tity, and these occasioned the symptoms of asphyxia; whilst the arteries throughout the body, being almost deprived of blood from the same cause, produced the coldness and other symptoms of collapse. These circumstances indicated that the immediate action of the cholera poison was confined to the alimentary canal, and this View was confirmed by the circum- stance that all the general symptoms could be removed for a time by the injection of a weak saline solution into the veins, which merely replaced the portion of the blood which had been lost, and could not remove the effects of a poison circulating in that fluid. The preliminar ' diarrhoea with which the greater number of cholera cases commenced could generally be cured by the ordinary remedies for diarrhoea, which could not have any efi‘ect on a poison circulating in the blood. The evidence respecting the mode of communication of cholera that he had brought before the Society on a previous occasion tended also to show that the materies morbi entered the alimentary canal by bemg accidentally swallowed, and there propagated itself, and was discharged in the evacuations. The following were the principles of treatment which the above view of the patho~ logy of cholera suggested :— lst. Medicines should be chosen which have the effect of de- stroying low forms of organized beings, and of preventing fer- mentation, putrefaction, and other kinds of molecular change in organic matter. Prepared animal charcoal, sulphur, and creasote were amongst the agents which deserve a more ex- tended trial 2nd. The remedies should be administered with a view to their action in the stomach and bowels, and not to their being absorbed. 3rd. They should be given in such quantities and in such a. form as to ensure, as much as possible, their application to the whole surface of the alimentary tube. 4th. These medicines should be continued till there was no danger of a return of the purging. 5th. It was useless and injurious to attempt to bring the pa- tient out of the state of collapse by stimulants and the appli- cation of heat, and they should give watery drinks, and be content to wait till they were absorbed, unless in desperate cases, in which it might be desirable to inject into the blood vessels :1 weak saline solution, resembling the portion of the blood which had been lost. The discussion which ensued, like all the discussions which have taken place on cholera at the medical societies, termi- nated without any fresh light being thrown upon the nature or treatment of that formidable disease. Indeed, if a layman had been present at the meeting, he might have witnessed a re- markable illustration of the manner in which “ doctors differ," and surely his faith in physio would have been scarcely in- creased in strength. Every speaker seemed to have an opinion of his own on the subject of the nature and cause of the dis- ease: one regarded it as a blood disease; one as a specific dis- ease, like the exanthemata ; another that it depended on atmo‘ spheric causes, (to. The treatment was no less contradictory. The drinking of water ml libitum, the employment of sulphur, of calomel and opium, of sulphuric and tannic acids, of nitrate of silver, of large quantities of whey, of saline injections, of creosote, of charcoal and lime water, had each its advocates. One or two facts of importance came out in the discussion. One gentleman, in cases of choleraic diarrhrra occurring in the out atients of one of the hospitals, had found the treatment by c ' uted sulphuric acid of no avail until he ordered the pa- tients to take everything cold. Another gentleman, in the epidemic of 1849, had treated upwards of 500 cases of choleraic diarrhoea with liquor potassa, and in every case with success. Another practitioner had found, in a vast number of cases, that the diarrhoea. was arrested by the sulphuric acid for a time, but returnedinmany instances again and again; when mercury was employed this did not take place. In Canada, it was stated that most of the crew of an emigrant ship being seized with cholera, all recovered by drinking copiously of cold water; and in the same cornitry a quack had effected a great number of cures by giving lime-water and charcoal. Another speaker had found nitrate of silver one of the most effectual remedies. Dr. SNOW said, in reply, that his theory respecting the mode of communication of cholera was not merely a water theory, as he considered water only one of the vehicles which conveyed the poison; still this accormted very well for some of the iso- lated cases, as well as the groups of cases, such as that at Albion-terrace. The cholera poison having the property of propagating its kind, must be organized to some extent, and. consist of particles that cannot be infinitely divided; now, if a few of these particles gained admission to the main pipe of any of the water companies, one person might draw a prize and others not. It had been remarked, that the water remains always the same, but this was not the case; for, until the cholera was introduced from Hamburgh or some other place, there could be no cholera evacuations in the water. The sup- posed presence of the cholera poison in the atmosphere would not account for isolated cases. It was necessary to assume that the persons who were taken with the disease had a. predisposi- tion of which there was no evidence. The predisposition was only a metaphysical abstraction assumed to account for the facts. HARVEIAN SOCIETY. THURSDAY, JAN. 19, 1854.—Mn. COULSON, President in the Chair. As this was the first meeting of the Society since the election of the new office-bearers, there was a goodly assemblage of members to inaugurate the new President. LONDON Hohifi‘fitnndxdhg gfiRéERY.—MEDICAL SOCIETIES. n , but redness Of a fugitive nature still pre- by Velpeau, Houston, and others. dgifi'erent 455.. . _. the'leg is subsidi cents itself about arts of the posterior surface of the thigh, bein of a. duller an less bright character than that ob- served at rst. The countenance of the patient is indicative 6f prostration, pale and exsanguine; the skin of the leg and foot is desquamating. Ordered ammonia and decoction of bark, three times a day, and a more liberal diet. 5th. —Desquamation of the skin over the knee is now going on. The foot and leg are greatly reduced in size, and the redness has almost disappeared. 9th. —The patient complains of a severe pain in the stomach, which came on first during the preceding night. Poultices ordered to be applied for its relief. . 13th. —-There is no complaint of any kind to-day. He is sitting up, and says he is feeling quite well. The leg and foot have returned to their natural condition, presenting a remark- able contrast to the tumefied, diseased state they were in at the time the patient was admitted. Discharged cured. modal Sadistic. MEDICAL SOCIETY OF LONDON. SATURDAY, APRIL 14TH, 1855. DR. SNOW, Psasmmr. . Dr. Tnumcm read a paper on m INFLEXIONS AND INFRACTIONS OF THE UNIMPREGNATED UTERL'S. The author proposed to enter into the consideration of the pathology and symptoms of these disorders, as he had con- ceived an idea of them from facts, observed either by trust- worthy writers or himself, leaving the discussion of the treat- ment to a number of cases of which he intended to ofier the history on another occasion. After some remarks in vindica- tion of the terms adopted, the Writer entered into the con- sideration of the nature of inflexions and infractions, which mainly depended on the art of the womb where, and on the direction in which, it too ‘ place. These disorders were next considered with regard to their degree or mode of origin. Observations of Congenital Antero- and Retro-fraction, by Madame Boivin, M. Du ES, and Dr. Rigby, were quoted. The author then showed that the principal diseases predispos- in to acquired inflexions and infractions were atrophy and refantion of the mass of the uterine tissue. The latter was often the consequence of intense puerperal processes; the writer had observed it predisposed to by an abnormally at- tached lacenta, or by that disease of the womb or placenta of which the attachment of the latter was a result. A third class of predisposing diseases efl‘ect inflexions, by relatively diminishing the size of one half of the uterus—viz, healing abscesses, tumours, and predominant development of the upper and front part of the co us uteri, at the beginning of puberty. Secondary inflexion an infraction have their proximate or remote causes external to the substance of the uterus, such as perimetritis and peritonitis exudations, and their. difi'erent transformations and effects, as abnormal adhesions. writer mentioned a case which came under his observation, where the ileum was found adhering to the back of the corpus uteri. The practical importance of the time of mi 'n was then pointed out. Of the symptoms, those of arreste or retarded circulation of blood through the uterus were considered more fully. It was shown from the anatomical researches of Theile, Briquet, and others, that in these disorders the return of the blood from the uterus was treny checked—first, by the im- md place in the uterus; secondly, by compression in the ligaments of the veins leaving the uterus; and by pres- sure upon the left iliac vein, produced by accumulations in the ending colon. The inflammatory symptoms were then alluded to, as well as those of hypemsthesia of the uterine nerves, uterine colic. A case was mentioned which had been under the care of the writer, in which the uterine colic made legular returns every seven or eight days after each menstrual period. The disturbances of defecation, such as constipation sud pressure, were considered critically, and several facts were advanced showing that the constipation attending retroversion and flexion is not the‘simple consequence of mechanical pres- sure of the uterus against the rectum, but caused by the con- (auction, through nervous influences of the sphincter recti supe- rior, the existence and physiology of which had been elucidated 456 An anatomical obseq-mfu made by the author, was quoted in support of that opinion The yrn toms in the urinary organs were shown to hem], cipally ependent on the mode and degree of inflexions‘m‘ infractions. But though the severity of these Symptom m, rally stand in a direct proportion to the degree of these ations, yet exceptions take place, of which the author quoted several examples from within his own experience. Of anomafifl in the function of the urinary bladder, the most frequem *, stran ry, less so retention of urine. The anomalies in the functions of the kidneys were illustrated by cases; in on d these, the long, lasting strangury had caused hypertrophvg the kidneys by transferred stimulus. The symptoms in ah”, more remote systems were then shortly enumerated. In a, case the author observed a peculiar degeneration of the hem, fibre, along with leutrasmia, in a woman, who, for thima years, had suffered from ante-flexion. The paper was in” trated by diagrams, showing the normal shape of the mm and its cavity, and the changes which both undergo in t}, different degrees of inflexions and infractions. A discussion ensued in which several fellows took part. SATURDAY, Arm 2lsr. PROPAGATION or CHOLERA. The Pnnsmsx'r said that some excavations had been made within the last few days, by order of the authorities of 91. J ame’s parish, which shed additional light on the outbreak d cholera which occurred last autumn in the neighbourhood (l Broad-street, Golden-square. A child died at 40, Broad-stun on the 2nd of September, a few days after an attack of cholera or choleraic diarrhoea. This child had been ill three or four (hp before the great outbreak of cholera in the neighbourhood, and the Rev. John Whitehead, at whose suggestion the drains lllll been opened, ascertained that the faces of this child was emptied into the privy of this house, which was situated int): front area, and only three feet from the pump-well in it: street. The privy was situated over a cesspool, the side: d which were decayed, the bricks being loose and allowing ll: contents to percolate freely into the ground around the We! The drain which passed the well, in its course from the at I pool to the street sewer, was also in a leaky condition. ltn . evident that the contents of the cesspool percolated into it! I well, the osser particles being separated as the liquid pend through 1'. e ground. He (Dr. Snow) traced the outbreak d ‘ cholera to the water of the pump well last autumn, by ill effects of drinking the water, and these additional discoveries made the case complete, and brou ht it under the same (rule as the outbreak in Albion-terrace, fi’andsworth-road, and cilia in Horseleydown and elsewhere. which he had related on form occasions, where the contamination Of the water was physically proved, and where a sin 1e case or two of cholera preceded ti great outbreak. The ev. Mr. Whitehead had lately baa making very careful and laborious inquiries respecting the! of the water of the above pump, amongst the ersons who had and those who had not, the cholera, in road-street, l1 autumn, and he found that nearly all the persons who lmd ‘5 malady, during the first few days of the outbreak. drank of th water, and that very few who drank of the water during“! days escaped. These enquiries entirely confirmed those Willa be (Dr. Snow) had made last autumn. Dr. Room mentioned an instance in which it would that typhus fever had been propagated and kept up In I W at Hastings, from the escape of the contents of the water-‘9“ into those of the water-cistern. It was known that dym was propagated in hospitals from patients using the We“ or necessary seat. , D1}. SNOW remarked that Sir John Pringle had 1118135“: the act of d sentery bein re a ted by patients 118M same water-Zloset, and DELPBliddga had traced the 8PM ‘ cholera in the same way. Dr. WILLSEIRE remarked that bad drains was doubt” one of the predisposing causes of disease, but could not gm a specific complaint, such as typhus or cholera. Dr. Runny read a paper on THE ANCIENT AND MODERN DOCTRINES OF CANCER The author, after a few introductory remarks, (ll-few” tion to the opinions regarding cancer expressed by Hippo?“ Celsus, Galen, Paulus of Egina, and other ancxent phll‘" It was evident that the ancients included tumours 0f ‘1“: kinds under the name of cancer. And this W33 “0‘ '0 wondered at, as they were destitute of the me}!!! Of {M an accurate diagnosis—except by somewhat Violent W ’634 THE PUBLIC HEALTH AND'NUISANCES REMOVAL BILL: DR. SNOW’S EVIDENCE. 2 THE LANCET. LONDON: SATURDAY, JUNE 23, 1855. IT is the misfortune of Medicine, :in its conflict with the pre- judices of society, that it is continually exposedto discomfiture, ‘through the perverse, crotchetty, or treasonable behaviour of certain of its own disciples. This is never more true than 'when it is striving, in the purest and most disinterested spirit, to promote the welfare of society. A kind of an- tagonism is aroused and kept alive in the public mind, which is not less prejudicial to the public than unjust to Medi- cine. The free progress of science is always sure to advance the interests of humanity. Society but wounds itself when it seeks to discredit the teachings of Science, by setting against the comprehensive and we'll-weighed decisions of her true repre- sentatives, the crude opinions and hobbyistic dogmas‘ofuuen - whose perceptions are dimmed by the gloom of the den inwhich :they think and move. 'In the case of Bummu the civilized world has recently been scandalized by the spectacle of the law and the adminis- 'tration rejecting, with studiedindifiierence, the direct evidence and the deliberate judgment of men whose names stand fore- .most in the rank of scientific and practical psychologists. And in this course the law and the administration fancy they‘were supported and justified, because they were able to procure the strictly individual opinions of two physicians. We have another example in the conduct of the Committee . on the Public Health and Nuisances Removal Bills, now before Parliament. It is known that these Bills have encountered .a “formidable opposition from a host 'of “ vested interests” in the production of pestilent vapours, miasms, and loathsome abominations of every kind. 'These unsavoury persons, trembling for the conservation of their right to fatten upon the injury of their neighbours, came in a crowd, reeking with putrid grease, redolent of stinking bones, fresh from seething heaps of stercoraceous deposits, to lay their “case” before the Committee. They were eloquent upon the health-bestowing properties wafted in the air that had been enriched in its playful transit over depOts of rotten bones, stinking fat, steaming dungheaps, and other accumulations of animal :matter, decomposing into wealth, suchas the imagination ‘- shrinks from picturing, and 'which language cannot de- scribe. The Committee had before it a soap-boiler, worthy of the fame conferred upon the enthusiastic tallow-chandler of SAMUEL J OENSON: this tallow-chandler had the misfortune to grow rich; the insane ambition of retiring seized him; he sold his business, and bid adieu to happiness, until he had negotiated with his successor, at the cost of two hundred-a year, for the privilege of assisting on melting-days! Mr. ARCHIBALD Klwmm (Why should his namenot live?) is asoap- boiler. He denies that soap~boiling produces disagreeable 'ufiuvia; he “rather‘ likes it himself;” nay, more, "‘he means to say, that people generally enjoy it”—ladies especially. And as .to its being prejudicial to health, he only knows, that whilst 'he and his children lived upon the premises, they revelled in exubeth health, and have fallen ofi‘ since they left. The fact is, it is all a matter of as‘sociation or of fashion. 'The odour of putrefying fat is not only salubrious, but agreeable, if you can only make up your mind to discard vulgar prejudices. " Rufillus pestillos olet,-Gorgouim hircum." Some ladies live in an atmosphere of Eau de Cologne m. annn’s vinegar; others—Mr. Km'mu’s fair fiiendkdote upon the delicious fragrance of the copper “when the so”. boiling is going on with intensity.” But Mr. KINTREA and his colleagues do not rely upon these acts alone. 'They have “ scientific” evidence ! They bring before the Committee a doctor and a barrister. They have formed an Association. They have a Secretary, 2 bone-merchant, who has read the‘writings of Dr. Snow. ’Now, the theory of Dr. SNOW tallies wonderfully with the views of the “Ofi‘enaive Trades’ ” Association—we beg pardon .if that is not the right appellation—and so the Secretary puts himself in communica. tion with Dr. SNOW. And they could not possibly get a witness more to their purpose. Dr. SNOW tells the Committee that the efliuvia from bone-boiling are not in anywayprejudicial to the health of the inhabitants of the district; that “ ordinary “decomposing animal matter will :not produce disease in the “human subject.” He is asked by Mr. ADDERLEY, “Have “you never known the blood poisoned by inhaling putrid “matter ?—-No; but by dissection-wounds the blood maybe “poisoned. “ Never by inhaling putrid matter ?—No; gases produced-by ' “ decomposition, when very concentrated, will produce sudden “ death; but when the person is not killed, if he recovers, he “ has no fever or illness.” Dr. SNOW next admits that gases from the decay of animal matter may produce vomiting, but says this would not be in- jurious unless frequently repeated. Is this evidence scientific? Is it consistent with itself? Is it in accordance with the experience of men who have studied the question without being blinded by theories? Let it first be observed that Dr. Snow admits that thegases from decomposing animal matter maykill outright—a pretty convincing proof of their potency. He also admits that in Mesa concentrated form they may cause vomiting. And here he stops, msuringns, that if they don’t 'kill us, or cause repeated vomit- ing, they do us no harm. Now, as a mere matter of reasoninggwe think the conclusion inevitable, that agents capable, when in a certain degree of concentration, of killing or causing vomiting, win, in a lesser degreeof concentration, also act on the animal economy; albeit, in a. less sudden and perceptible manner. It will be very diflicult to persuade us that the long-continued action of ,gases known to have such lethal powers, if concen- trated, is not injurious to health when in a state of dilution. We shall not easily be reconciled, on' the assurance of Dr. SNOW, to endure a leakage in our house-drains. We have a strong conviction, that as soon as our noses give us intimation of a communication between those conduits of decomposing animal and vegetable matter and our dwellings, it is time to call in bricklayer and plumber. We decline to wait until re- peated vomiting, or a sudden death amongst our children, satisfy us that the gases evolved are in a. highly concentrated state. Our professional avocations have, indeed, frequently given “5 the opportunity of tracing failing strength, flabby muscles, pallid cheeks, lassitude of body, and torpidity of mind to this cause. We have felt it our duty to urge removal from the houses so afi'ected, when the drains could not be repaired efiec- tually, and we have commonly been gratified by observing I rdstoration to bodily and mental vigour. And we presume that there is hardly a practitioner of experience and avenge l THE NAVAL MEDICAL REFORM ASSOCIATION. 635 Powers of observation who does not daily observe the same wing. \Vhy is it, then, that Dr. SNOW is so singular in his . opinion? Has he any facts to show in proof? No! but he has a theory, to the efi'ect that animal matters are only injurious when swallowed! The lungs are proof against animal poisons; but the alimentary canal afl'ordsa ready inlet. Dr. Snow is satisfied that every case of cholera for instance, depends upon a previous case of cholera, and is caused by swallowing the excrementitious matter voided by cholera patients. Very good! But if we admit this, how does it follow that the gases from decomposing animal matter are innocuous? We cannot tell. But Dr. Sxow claims to have discovered that the law of propagation of cholera is the dflnking of sewage-water. His theory, of course, displaces all other theories. Other theories attribute great eficacy in the spread of cholera to bad drain- :ge and atmospheric impurities. Therg‘ore, says Dr.’ SNOW, gases from animal and vegetable decomposition are innocuous ! If this logic does not satisfy reason, it satisfies a theory; and we all know that theory is often more despotic than reason. The fact is, that the well whence Dr. SNOW draws all sanitary truth is the main sewer. His spews, or den, is a drain. In riding his hobby very hard, he has fallen down through a gully-hole and has never since been able to get out again. “ Facilis descensus Averni: Sed revocare gradual; supensque evaderrsd auras-r Hoe opus, his labor est-J} And to Dr. SNOW“ animpossible one: so there we leave him. In that dismal Acherontic stream is contained the one and. _only true cholera-germ, and if yontake care not to swallowthat 5you are safe from harm. Smell it you may, breathe it fear- lessly, but don’t eat it. Now we do not think it necusary to prove, by adducing ' evidence in opposition. to Dr. SNOW, that decomposing animal and vegetable matters are injurious to health. They ought not lobe sufi'ered to be stored ininhabited localities. We are not. acquainted with afsingle medical practitioner of established reputation who wouldnot consider that the removal of deposits of decomposing animal. and vegetable matters was an essential condition for the improvement of the health of towns. We have adverted to the evidence of Dr. SNOW, for the purpose of repu- diating it as the expression of the teaching of medical science. We have made it the subject of stricture for the same reason that we have lately animadverted upon the pseudo-medical evidence of Drs. MAYO and Smxn—that is, to prevent true science from being misrepresented and ridiculed, and to pro- tect the community from injury. The Committee seems to have contented itself with listening to the statements and objections of those who are interested in opposing the Bills. Those ' objections it was of course bound to hear. If it did not call for any scientific evidencein reply, we hope it' was because the statements of the dirt-and~efluvium-interest containedtheir own refutation. The onlythoroughly scientific witness examined was Dr. Russ, and his evidence bore upon-a totally distinct ques~ tion. He did not deal with the causu- of mortality, but with the rates of mortality in! difi'erent districts. The facts he adduced went to prove that there is a natural mortality which does not exceed 17 in- 1000; that. whensoever that rate is ex~ ceeded there are noxious and generally removable causes in operation, and therefore that any- excess of deaths above this proportion ought to be the signal forrapplyiug the resources of- !cience to the improvement of the health of the district. In the original Public Health Bill it was proposed that a mortality of 23 in -1000 should warrant the extension of the Act to any. locality. After-hearing the objeetionoi the great Bone and Stench interest, and the evidence of- 'Dr. FARR, which proves to demoutration that anything over ~17 in 1000 is unnatural, the Committee has amended the Bill. by raising the rate which. shall bring the Board of Health into action to 27 in 1000! ' Verin the Committee has small faith, or little courage. We shall review this branch of the subject next week. WI .arge ion treat- ..n important .umue pressure till nation of the sac and . to allow time for the de- ..,o the bore of the artery, since ..s in the treatment by ligature, in ,., but remains in all its force, as soon as withdrawn. .5 narrated a case of a young woman, from diffe- . of the surface of whose body he had, in about six is, removed a hundred needles—a great many from the .ammae. She had previously had a eat many extracted at the Bath Hospital. None had ever 11 found in the mu- cous passages. She gave no account whatever of how the needles had entered her body. EPIDEMIOLOGICAL SOCIETY. MONDAY, JUNE 4TH, 1855. DR. BABINGTON, PRESIDENT. DR. SNOW read a paper ON THE COMMUNICATION OF CHOLERA THROUGH THE MEDIUM 0!? WATER. The author said that he had on a former occasion explained the circumstances connected with the athology of cholera, and with its history as an epidemic, which ed him to the conclusion Tue LASCETJ the disease is to agated by the morbid poison which pro- it being accineEtally swallowed; and that the morbid mater increases in the interior of the alimentary canal by}, process of reproduction, and passes off, to cause the disease in other persons who may take it into the stomach. He (Dr. Sncw) had endeavoured to show that there were ample oppor- tunties for the evacuations of cholera patients to be swallowed in the crowded habitations of the poor, where a number of (2‘ one lived, cooked, ate, and slept in the same apartment, iii-113111: dcjcctions, which often flowed into the bed, were almost devoid of colour and odour, and could not fail to sorl the hands of those about the sick erson. It was amonost the poor and uncleanly that the choliara frequently spreatf from person to person, whilst this rarely happened in the better class of houses, where the rooms for eating and sleeping were distinct, and where the hand-basin and towel were in constant use. The great prevalence of cholera. in the mining districts of this country, during each epidemic, was owmg, in the author’s opinion, to the constant ractice of the workmen of taking food into the pits, which t ey ate with unwashed hands, and without knife and fork, whilst the pits were like huge, dark )rivics, so dirty were they. He.ha in his former paper re- atcd a number of instances, which occurred in the epidemics of 18:12, 1848, and 1849, to show that the evacuations of cholera. patients would reproduce the disease, after being mixed with the drinking water of the community, by getting into pump wclls, either through accidental opening, or )y permeating the ground, and also by passing down the sewers into the rivers from which the water supply of many towns was obtained. In this way, the malady often became more extensively diffused than it otherwise would be, and reached classes of the com- munity which it would not reach by its more ordinary mode of Ho (Dr. Snow) had become acquainted with many striking instances, also, in the epidemics of 1853 and 1854, of the communication of cholera through the medium of propagation. water, but would confine his remarks, on the present occasion, chiefly to a single example on a large scale, which took place in the south district of London, the chief art of the Lambeth Company, and the Southwark and Van all Company; and throughout the greater part of the area which these companies supplied, their pipes were intimately mixed, a few houses being supplied here and there by one company, and a few by another, and very often a single house had a supply difi‘erent from that on either side. There was no difference in the class of persons supplied by the two water companies; each company supplied both rich and poor alike. In 1849, the water sup lied by the two companies was almost equally impure, that o the liainbeth Company _being obtained from the Thames, near Hungcrford Suspensronbridge, and that of the Southwark and Vauxhall Company being obtained, as at present, from Battersca-fields; and the cholera was almost equally severe in the. districts supplied exclusively by one company; and in those in which the supply was mixed. In 1854, how- ever, an important change was made in the water supplied by the Lambeth Company, who ceased to obtain the water in the middle of London, and removed their works to Thames Ditton, some distance beyond the influence of the tide, and quite out of reach of the sewage of London. When the cholera returned in the latter part of 1853, it was observed by Dr. Farr that it was less fatal in the districts partly sup lied by the Lambeth Company than in those entirely supplie by the Southwark and Vauxhall Company. On the recurrence of cholera in 1854 the same circumstance was observable, and be (Dr. Snow) resolved to call at the houses in which deaths from cholera took place in the districts where the supply of the two water companies was intermingled in the way mentioned above, in order to ascertain whether the diminished mortality was really due to the improved quality of the water. Being kindly fumished with the addresses at the General Register (H'ncu, he made a personal inquiry respecting every death which took place in the first seven weeks of the epidemic, in all the sub-districts in which the supply of the two companies is mixed. 'l‘lie_dcaths were 652 in number. Of these he ascer- tained that in 525 instances the water supply of the house in which the attack took place was that of the Southwark and \ auxhull Company; in 94 instances it was that of the Lam both Company; and in the remaining 33 instances it was from pump-wells and other miscellaneous sources. As the Lambeth Com {any supply considerably more than half the houses in the sub- istricts in which the water supply is mixed, it was evi- dent thatlthe people having the new supply of water from Thames Ditton enjoyed a very great immunity from cholera as compared With those receiving the water from Battersea-fields. In order to get an exact result, by comparing the number of deaths amongst the customers of each water company, with EPIDEMIOLOGICAL SOCIETY. [J {in 7, 1855. the entire number of houses supplied by each company, as indi- cated in their returns to Parliament, he (Dr. Snow) had ob- tained the assistance of a medical man, and had extended his inquiries to all the districts and sub-districts to which the supply of either company extended. In stating the result, he should divide the time of the inquiry into two periods. In the first four weeks of the epidemic there were 334 deaths in the districts to which the supply of the two companies extended. In 286 cases the supply of water was that of the Southwark and Vauxhall Company; in only 14 cases it was that of the Lambeth Company; and in the remaining instances it was from other sources. When the number of houses supplied by each . company respectively was taken into account, it was found that the cholera was fourteen times as fatal at this period in the houses supplied by the former company as in those supplied by the latter. In the next three weeks of the epidemic, as the number of cases greatly increased, the mortality was eight times as great in the houses supplied by the one company as in those supplied by the other. During the remaining ten weeks of the e idemic the Registrar‘General caused an inquiry to be made, t tough the district re ' trars, of the water supply of the houses in which fatal attac of cholera took lace in the south districts of London, and the result was, t at at this period the cholera was five times as fatal in the houses having the impure water of the Southwark and Vauxhall Company as in those having the improved water of the Lambeth Com any. The cholera increased during the progress of the epi emic amongst the customers of the latter company as it increased amongst the opulation of London at large; but they enjoyed throughout t e epidemic an immunity from cholera greater than that of the avera e of the metropolis, or even the average of the districts situated on the north of the Thames. The following, amongst other reasons, proved that the water conveyed the specific cause of cholera, and did not act as a mere redisposing cause:-— 1. any persons had been fatally attacked with cholera within forty-eight hours after arrivin from healthy parts of the country, and drinking water whie had received the eva- cuations of cholera patients. 2. Great numbers of persons drank very impure water from limp-wells and neglected cisterns throughout the epidemic, ut did not sufi‘er so long as the water was not liable to be contaminated with What came from cholera patients. 3. When a pump~well, or 'other limited supply of water, became accidentally contaminated with the evacuations of a cholera patient, as in Wandsworth-road, Horsleydown, Broad- street, Golden-square, and other places, a great number of persons using the water were attacked altogether, showing that the water contained the real determining cause of the malady. It was an error to suppose that cholera was always, or even generally, associated with impurity of the air; the compm~ tively genteel and airy districts of Clapham and Kennington, which were chiefly supplied with water by the Southwark and Vauxhall Company, sufl‘ered very much more in the late epi.- demic than the districts of Lambeth by the river side crowded with poor people, and sprinkled over with offensive factories, but receiving chiefly the new and improved sup 1y of water from the Lambeth Company; and, a ain, the su -district of Saflron-hfll, on the north side of the es, through which the open Fleet ditch flows and streams along, had a greater exemption from cholera than any sub-district of London, ex- cept the neighbouring one of St. George the Martyr, Holborn. Mr. J. G. FRENCH said, that althou h he knew that there would be just such an outbreak of ciolera in some part of London as that which occurred in his district, (after what had happened in the latter part of the previous antumn,) because that uniformly forms a. part of the history of cholera, he was wholly ignorant of the cause which would produce it. This had been entirely ex lained by the labours of Dr. Snow and of the Rev. Mr. Whitehead, a curate of the district. This latter gentleman conceived that he possessed a. sufiicient know- ledge of the facts to enable him to disprove that hypothesis which regarded the pum in Broad-street, Golden-square, as the cause of the evil; an he proceeded to make the most cares ful inquiry into the subject with the expectation rather of excluding this, as the cause of the outbreak, than of establish- ing its truth. _This, however, was the result of his inquiries, which was conducted with the greatest care and labour, cen- fined however wholly to one street—viz, Broad-street. It may be briefly stated (continued Mr. French) that those per sons only were attacked who drank of this water, and but few of those who really drank of it escaped the disease. Dr. ROGERS said he could not allow the evening’s discussion to terminate without stating that he was not convinced of the 11 l THE Lsncn'n] REVIEWS AND N soundness of Dr. Snow’s theory of the propagation of cholera. He (Dr. Rogers) could not too highly eulogize the perseverance, zeal, and indefatigable industry which characterized Dr. Snow’s labours to elucidate and work out his views, because in so doing, even if he did not really prove the soundness of his theory, he brought to light many violations of the laws of hygiene, and remedial and salutary measures would, he hoped, he the result. A case of one of his (Dr. Rogers’) patients having been referred to as supporting Dr. Snow’s views of the propagation of cholera, by the drinking of water into which cholera evacuations had gained admission, he would beg the Society to suspend their Judgment until the whole of the facts were brought before them. He did not believe it was a. case of cholera, and unless they accepted the theory enunciated by Dr. Greenhow, that during the prevalence of cholera, all cases of even simple diarrhcea must be regarded as choleraic, or incipient cholera, he did not believe that it would be found to prove all that was now ima- gined were direct and conclusive consequences from the case cited. The whole of the facts connected with the terrible out- break of cholera in the neighbourhood of Broad-street requires to be known before we can arrive at any really satisfactory evi- dence as to the cause of it. -e uterus, and to a .struction in the latter, .ltonitis. The patient was .4 had never suffered from a par- ..sturbance until about three days prior Ag only complained of pain in the hypogastric months before her decease she had been confined -arge, healthy child. mess zmh italics of finds. 07; the M ode of Communication of Cholera. By J OHN Snow, M.D., Member of the Royal College of Physicians, Fellow of the Royal Medical and Chirurgical Society, and Vice- President of the Medical Society of London. Second Edi- tion. London: Churchill. pp. 162. Report on the Cholera. Outbreak in. the Parish of St. James, Westminster, during the Autumn of 1854. Presented to the Vestry by the Cholera Inquiry Committee Jul , 1855. London: Churchill. pp. 175. ’ y THE publication of these books must exert considerable in fluence on sanitary reform, and in fact prove the position, hitherto scarcely demonstrated, that zymotic diseases are, to a certain extent, removable by sanitary measures. We deem the subject so important, that we are desirous of putting the facts contained in these volumes clearly before the reader, re- commending, however, the study of the works themselves to his consideration, as showing the steps by which such important conclusions are arrived at. Dr. Snow commences his treatise by showing that cholera is .a communicable disease. This doctrine, advocated by the first Board of Health, was totally ignored by the second, until such decisive instances fell under its notice as induced a modified expression of that opinion. It may now be regarded as a settled 524 {OTICES OF BOOKS. [DI-:crsmsn 1, 1555. m point that cholera can be communicated from one personto another. Our author then argues that the disease commences with the affection of the alimentary canal, and not, as some have sup. posed, by the introduction of a poison into the blood; for these reasons—via, that the disease is not ushered in by fever or other general constitutional disturbance, and that all the syrup. : toms are referable to the discharges from the bowels, and pro. ceeds:— 1 “ If any further proof were wanting than those above stated, that all the symptoms attending cholera, except those con- , nected with the alimentary canal, depend simply on the phy. ; sical alteration of the blood, and not on any cholera poison V circulating in the system, it would only be necessary to allude ; to the effects of a weak saline solution injected into the veinsin ’ the state of collapse. The shrunken skin becomes filled out, and loses its coldness and lividity ; the countenance assumes a 3 natural aspect; the patient is able to sit up, and fora time § feels well. If the symptoms were caused by a poison circula- i ting in the blood, and depressing the action of the heart, it is i impossible that they'should thus be suspended byan injection i of “111’? water, holding a httle carbonate of soda in solution." I —p. . ‘ From this view of the matter, Dr. Snow deems it easyto infer how the disease is communicated. To this reasoning it I may be answered that the fact that some blood-poisons give rise to constitutional disturbance, &c., only proves them to be the poison of other diseases, and not of cholera; but it does not I prove that poison existing in the blood cannot produce such symptoms as those of cholera. Thus digitalis and elaterium, administered in a certain way, are quite capable of producing very analogous symptoms to those of cholera, without fever or other constitutional disturbance, and yet these poisons are fully admitted to pass into the blood. Nor can we perceive any reason why the heart, because incapable of circulating choleraic blood, should be also incapable of circulating another fluid, or even choleraic blood, when it is considerably diluted with some more innocent or at least different material. We talk familiarly of the stomach refusing food; if our knowledge of pathology were greater, we should perhaps, in the same tone, speak of the heart refusing to circulate certain blood, and of the pulmonary artery refusing to receive blood under some morbid conditions. This is at least the only way in which that state of the pulmonary organs can be expressed, sometimes observed in severe cholera, and also in cases of poisoning with known substances, where no blood whatever is contained in the lungs, which are collapsed, as in the state of the still-born foetus, leaving the cavity of the chest nearly empty. Let not, however, the fact that aqueous injections may be freely circulated by the heart, while undiluted choleraic blood remains nearly stagnant, be regarded as any argument of their eficacyas a remedy. Experience by no means warrants this conclusion. It may be regarded as parallel with the fact, that although the stomach may be temporarily in a condition wholly incapable of digestion, and therefore incapable of con- tributing to the process of sanguification, yet it may still be capable of transmitting poison into the blood; for nobody doubts the fact, that although a man, under certain circum- stances, may be incapable of being nourished, yet still he may be poisoned. We see no reason whatever to doubt that cholera is properly classed with zymotic diseases; that the fanmful analogy of fermentation applies to this as much as to other” and. that the rapidity of its progress is a mere point of (1158!- ence, instead of resemblance. The objections we have taken to our author’s theory, however, in no way disturb his inferencf: respecting the mode of propagation. We know that theelulfl- nated matter of small-pox is capable of propagating the discs"; we might expect, therefore, that that of cholera would be dowed with a similar property. Without, therefore, 30mg further into an analysis of Dr. Snow’s theory of the nsturg 0f the disease, we propose to confine our attention to that Pm“ which is the object of the work—viz., the mode of its 00mm“ nication. Tun Lucas] REVIEWS AND NOTICES OF BOOKS. [DECEMBER 1, 1855. f—————_—“——%——-—— f—‘———'——_—“—‘-—“‘_—_‘——“— At page 16, et seq., the author shows, with much ingenuity, how variously the want of strict attention to cleanliness amongst the crowded poor may be the means of bringing the poison into direct contact with the mucous membrane of the afimntary canal, and at page 22 says— “If the cholera had no other means of communication than those which we have been considering, it would be constrained to confine itself chiefly to the crowded dwellings of the poor, and would be continually liable to die out accidentally in a place, for want of opportunity to reach fresh victims; but there is often a way open for it to extend more widely, and to reach the well-to-do classes of the community; I allude to the mixture of the cholera. evacuations with the water used for drinking and culinary purposes, either by permeating the ground, and getting into wells, or by running along channels and sewers into the rivers from which entire towns are some- times supplied with water. ” It is impossible to over-estimate the importance of the doc- trine contained in this passage, and we may well look with anxiety to perceive if this suggestion is supported by the care- ful observation of facts. It is difficult, indeed, to understand on this hypothesis, not the suddenness of an outbreak, but the rapid culmination and speedy decline of the disease which constantly form part of the history of the disease; but this may be owing to the imperfect investigations hitherto made; and we may gain a. step in this direction by the study of the meful, laborious, and elaborate report constituting the second article of this notice. This work consists of separate reports from Dr. Snow, the Rev. Mr. “Whitehead, curate of the infected district, and Mr. York, the surveyor to the Paving Board; and the whole is assessed by Mr. Marshall It appears that Dr. Snow, from a prefious investigation at Horsleydown and at Albion-terrace, Wandsworth-road, became convinced that water was the medium of infection; and find- ing that certain streets in South Lomheth were served by two different water companies, obtaining their supply from sepa- rate sources, Dr. Snow here pursued his inquiries, and. found his conjectures to be correct—via, that the customers who derived their supply from the more impure source—i. e., im- pure from fcecal contamination—had sustained more less by cholera than the other. Thus “ there were 334 deaths from the 8th of July to the 5th of August in the districts to which the water supply of the South- wark and Vauxhall and the Lambeth Companies extend. Of these it was ascertained that, in 286 cases, the house where the fatal attack of cholera took place was supplied with water by the Southwark and Vauxhall Company; and in only 14 cases was the house supplied with the Lambeth Company’s water.” ~page7 . With this knowledge Dr. Snow, soon after the outbreak, conferred with the St. J ames’s Local Board of Health, and sug- gested that the handle of the pump in Broad-street should be removed. This was done at once as a. precaution, although but little faith was placed in the eficacy of the measure; for, at the time the representation was made the epidemic appeared b have culminated, and was rapidly declining. Now the Rev. Mr. Whitehead had worked very hard in another direction. He had noted the facts relating to the Pfstilence, as they fell under his observation, with the greatest Vigilance ; he had charted out a map of the outbreak, which must ensure the discovery of some local cause, if suflicient lifbour were only bestowed on its detection: yet so little disposed was he at that time to attribute it to the influ- 8use of the Broad-street water, that, on the publication of Df- Snow’s views, Mr. Whitehead wrote to him, admitting their plausibility, but advancing objections. With the object 0‘ truth only in view, and to take an ingenious investigator ofl‘ ffalse scent, Mr. Whitehead undertook a searching inquiry “no one street only, selecting Broad-street as that which was the most severely visited. It may be remarked, to show that that it occupied many hours a day for a period of three months, before it was completed; by which time Mr. Whitehead found that, so far from being in a position to convince Dr. Snow that the pump-water in Broad—street had nothing to do with spread-» ing the pestilence, he was himself convinced that but for this source of water supply, the deaths from cholera, instead of' amounting to 7 00, would not have reached 50. The evidence is so elaborate that we must refer the reader to the work itself for the details. Mr. York’s report establishes the fact of a direct communicate tion between the Broad~street well and a. cesspool, which must have received the dejections of a patient who died on the 2nd of September, after a diarrhoea. commencing on the 25th of August—i. e. , the fourth day before the great outbreak. Mr. J. Marshall sums up the collected evidence with praise- worthy impartiality and great ability :— “ Anxious to give due weight to every fact and consideration that have offered themselves in this inquiry, the Committee is unanimously of opinion that the strikin disproportionate mor- tality in the ‘ cholera area,’ as compare with the immediately surrounding districts, which constitutes the sudden, severe, and concentrated outbreak, beginning on August 31st, and lasting for the few early days of September, was in some measure attributable to the use of the impure water of the well in Broad-street.”——p. 83. Various hypotheses are stated of the modus operandi of the water, but “ the Committee refrains, however, from expressing an opinion in favour of any hypothesis of its mode of action.” The Committee recommends that all the superficial wells should he stopped; that stand-pipes from the mains of water supply should be erected, instead of the pumps; and that cisterns should be abolished, and the method of constant supply adopted. The Report is a most important document, and. should be carefully studied by those who are interested in the question. 0n the Theory and Practice of ilIirvafery. By FLEETWOOD CHURCHILL, M.D., he. 8:0. Third Edition, corrected and enlarged. London: Renshaw. 1855. DR. FLEE'rwoon CHURCHILL’S manual has long been a. favourite with students. Clear and concise in style, methodical in arrangement, and sound in matter, it eminently deserves the position it has attained. There are some books on Mid-v wifery that are more bulky, and in every way more preten- tious; but it is our deliberate opinion, founded upon much experience of the comparative practical utility of the various- elementary works upon the subject, that there is no book in the English language equal to Dr. Churchill’s as a guide to the junior practitioner. It possesses this rare merit: it brings together into a compact form the important opinions of the leading obstetric authorities, and weighs their relative value impartially, and yet with decision; it leaves the mind of the reader imbued with a full knowledge upon the leading obstetric questions, and possessed with a clear impression of what he ought to do in difficult conjunctures. This is a third edition. It is not necessary to pursue a de» tailed analytical criticism. But it is superfluous to say that so able and conscientious an author as Dr. Churchill has neglected little that diligent inquiry into the writings of others and his own experience could suggest to add to the value and increase the reputation of his earlier editions. THE MEDICAL STAFF Corps—This body will consist,. when complete, of nine com anies, each of which is calculated for attendance in an hospit for 500 patients. In each com- pany there are a. steward and four assistant-stewards, who rank respectively as sergeant-major and sergeants; a. ward- master, and eight assistants, who rank, the former as colour- sergeant and the latter as corporals. Then there are issuers, washermen, and assistant cooks, barbers, and orderlies, who rank as privates; and a cook who takes rank as sergeant. The pay is very good. About 100 young men have joined the. fill“ inquiry was neither hastily nor superficially conducted, Medical Stall Corps during the month. 525 ...
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Week3_Cholera - Lancet 28 January T ’ OF...

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