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"RMCS: Snow on Smith's paper regarding the essential seat of cholera"

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(28 February 1855)

Royal Medical [and] Chirurgical Society

"On the primary or essential seat of cholera; with an appendix on the relation of temperature and cholera"

by Edward Smith, M.D.

The aim of the author, in this communication, was to establish the doctrine that the essential seat of cholera was the organic or sympathetic system of nerves. A very elaborate argument was based on the following grounds: As neither the symptoms nor the post-mortem evidences indicate the presence of any diseased organic action proceeding within any separate tissue or any organ, and as the whole system is affected at about the same period, there must have been some general cause acting anterior to any local manifestations. Therefore it must be either the blood or the nervous system; and of these two, the former is excluded on the ground that in health it is more under the control of the nervous system than the previous system is under its influence; and in disease, that there is no proof whatever of the existence of any poisonous body in any of the ingesta, or in the blood, or any other part of the internal system. It is not the cerebral system, for that remains intact, except that it is lessened in activity; nor the cerebro-spinal system, for in many and perhaps the typica1 cases, that is not manifestly involved, and in all cases there is a period of the disease prior to its manifestation; nor in the reflex system or function; nor in the respiratory system or function; and, consequently, that it must be, so far as our present knowledge guides us, in the vital organic nervous system. And, lastly, the leading symptoms of the disease may be explained by this key, and by no other at present known: such as the early, continued, and extreme prostration, the lessened respiration, cardiac action, secretion, absorption, production of animal heat; also the pallor, listlessness, and general inactivity of mind, absence of pain, [etc.] [etc.] The author's inferences, with regard to treatment, were as follows: That it is unphilosophical in cholera to attempt to arrest the flux,-to supply fluid to the circulating system by injection,-to excite the power of endosmose, as by mercury,-or to overcome the spasm by large doses of opium; since all these aim at the removal of results, or secondary conditions, and not the essential, anterior and superior acting condition. To do all these things may be proper, but not in themselves, only in the expectation that the remedies used for that purpose will have a yet anterior effect, that of removing the conditions which preceded them. Our aim mast be to produce not a local, but a general effect, as there is no evidence of a cholera poison, its neutralization or elimination should not be attempted. He (Dr. Smith) thought it probable, that on the theory of this communication, pure stimulants would be found the most appropriate remedies. By pure stimulants he meant, not those which were followed by secondary effects-such as spirituous stimulants, and opium-but such as capsicum, ginger, turpentine, the moxa and the actual cautery.

The paper was accompanied by an Appendix, with some Diagrams, exhibiting the relation of the epidemic cholera of 1849 and 1854, with the general mortality, and with the various questions in respect of temperature.

Dr. Snow said he considered nothing was more satisfactorily proved respecting cholera than that it was communicated from person to person. But the communication of a disease required a morbid material passing from one individual to another. A malady could not be propagated by any immaterial influence. Dr. Smith was, however, possibly one of those who disbelieved the communicability of cholera, and therefore he would state some other objections there were to Dr. Smith's views. There was no reason to believe that the organic system of nerves was directly necessary to nutrition or secretion, since these functions, and also a process of aëration, took place in plants, without the aid of nerves. The organic system of nerves appeared to preside over the vermicular contractions, which were necessary to the motion of the blood and other fluids, and therefore the influence of these nerves was indirectly necessary to secretion and nutrition. He agreed with Dr. Smith that the blood was not poisoned in the first instance in cases of cholera, but it did not follow on that account that a cholera poison did not exist. Itch and intestinal worms were propagated without poisoning of the blood, and this might be the case in other diseases. Those diseases, such as the irruptive fevers, which were caused by a blood poison, commenced with headache, rigors, and other general symptoms; whilst cholera, on the other hand, always began with an effusion into the alimentary canal. The altered physical condition of the blood, occasioned by this effusion, was the cause of all the general symptoms. The thickened blood could pass only with great difficulty through the capillaries of the various organs, and hence the secretion of the kidneys, liver, [etc.], was arrested; whilst, owing to the obstruction of the pulmonary circulation, from the same physical cause, the blood could not be properly aërated, and this was the cause of the blueness and coldness of the patient. The fact of all the general symptoms of cholera being removed, for a short time, by injecting the veins with a few pints of warm water, containing a little carbonate of soda and common salt, proved that these symptoms did not depend either on poisoning of`the blood, or any influence acting on the organic system of nerves. He (Dr. Snow) concluded that a disease which commenced with an affection of the alimentary canal, and was communicated from person to person, must be propagated [262/263] by the morbid matter being swallowed, by its increasing and multiplying in the stomach and bowels, and then passing off in the ejections and dejections. The circumstances attending the progress of cholera illustrated this mode of its propagation. It commonly spread directly from person to person in the crowded habitations of the poor, who lived, slept, cooked, and ate in a single room. The evacuations in this disease were devoid of colour, and were often passed involuntarily and with great force; hence it could not fail to happen that the hands of the persons waiting on the sick would become soiled, and amongst people who did. not very often wash their hands, the cholera evacuations must contaminate the food of those waiting on the patient, and, indeed, of the other inmates. On the contrary cholera, was rarely found to spread amongst people in comfortable circumstances, having distinct apartments for cooking, eating, and sleeping. The cholera has been particularly severe in the mining districts of this country in every epidemic. Now, the pitmen always took food with them into the mines, and ate it with unwashed hands, and without knife and fork; there were no privies in the coal-pits, which were themselves, in fact, like huge, dark privies, so dirty were they; hence, when cholera was present, the workmen could hardly fail to take small quantities of the evacuations with their food. An important manner in which that disease was propagated was through the drinking water. He had been able to prove this very clearly, as he considered, last autumn. The greater part of Lambeth and Southwark, and the whole of Newington, were supplied by two water companies, whose pipes were intimately mixed, each company supplying all classes of the community. One of those companies, about two years ago, began to supply water from Thames Ditton, quite free from the sewage of London, whilst the other company continued to supply it from the Thames a little above Vauxhall-bridge. Having been favoured by the Registrar-General with the addresses of persons who died of cholera throughout these districts, he (Dr. Snow) went to the respective houses, and he found that, in the first four weeks of the late epidemic, the mortality was fourteen times as great in the houses supplied by the last named water as in those supplied by the purer water from Thames Ditton. As the epidemic advanced, the disproportion became not quite so great, owing to the mixing of the people, but it remained very striking-about seven to one.

Dr. Webster remarked that when cholera prevailed in London the temperature was high; and, in the attacks of 1849 and 1854, the atmospheric phenomena presented the same characters. At the Auxerre Asylum, when cholera prevailed in 1849, out of 100 lunatics confined in the new, well-aired, and salubrious wards, only 2 died; whereas, amongst 130 inmates of the old, confined, and badly-ventilated apartments, 19 persons died. During 1854, although cholera proved most severe in the neighbouring city of Auxerre, it did little harm in the asylum, as only three deaths occurred, and all the lunatics occupied the new and admirably constructed apartments. At Paris, the fatality of cholera last year was three times more fatal, according to population, than in London; the ratio, in the former capital, being 1 death in 84 inhabitants; whilst, in the English metropolis, it only reached 1 death in every 234 inhabitants. At Messina, in Sicily, the cholera proved more fatal, during last summer, than in any other locality throughout Europe. Nearly half the entire population fled from this city through fear; and out of the 40,000 who remained, there was 1 death in every 4 residents, the disease being most fatal on the 28th and 29th of August, when from 1300 to 1400 died in each of these days. The weather was then very warm, serene, and dry–just as in London at the same period; a heavy shower of rain having occurred early in September, the discase very rapidly declined, as he observed during 1832 in St. Giles's, where cholera was then very prevalent. An Italian physician, having informed the government of Messina that cholera had occurred, he was told to say nothing about it; but having spoken to others, he was put into prison for his pains, and so punished!

Dr. O'Connor said, that it must now be admitted by all who had opportunities of observing cholera to any extent, that its immediate cause was an impression. produced by some, as yet unknown, agency on the organic system of nerves; whilst, with the author of the paper entertaining that opinion, he did not pretend to any new doctrine; for nearly twenty-five years ago, Dr. Griffin, of Limerick. propounded a similar theory, and more recently Dr. Bell, of Manchester, who resided many years in Persia, in a series of Lectures on Cholera, published in the Provincial Medical and Surgical Journal about ten years back, advanced and fully developed the same views. Dr. Bell does not look on cholera as a disease sui generis, but as one of a malarious type and origin, and in that opinion he (Dr. O'Connor) was inclined to concur. It has been stated by the author, that the evacuations are innocuous, and that they do not propagate cholera. Mr. McCoy, formerly one of the medical officers of the Grange Gorman Cholera Hospital, Dublin, in a very elaborate report in one of the early volumes of the Dublin Journal, states that he frequently tasted the evacuations of cholera patients. Dr. O'Connor stated the particulars of a case of cholera that he attended during the last epidemic with Dr. Cumming, and which he was enabled to trace to malarious origin. His observations of the various cholera epidemics since 1832, led him to the opinion that turpentine, the internal use of which, in puerperal fever and low forms of typhus, was first brought under the notice of the profession by the late Dr. Breman, was a most valuable remedy. Its use should be preceded by a stimulating emetic-as mustard. He was in the habit of using it internally and externally; his usual dose was a drachm, in the form of emulsion, every one, two, or three hours, as circumstances required.

Dr. Copland remarked that the views advanced by the author of the paper respecting the ganglionic system of nerves were not new, but had been brought forward by himself (Dr. Copland) in the Foreign Quarterly Review for 1830, and subsequently in his "Dictionary." The treatment was the same as he had recommended. Several cases which had come under his observation in 1854 had been successfully treated by camphor, cayenne, and creasote. In other cases he had ordered with benefit ten or fifteen minims of spirits of turpentine every fifteen minutes, or less frequently if necessary.

Dr. Edward Smith, in reply, did not think that it had been clearly proved that temperature had much influence in the spread of cholera.

"Royal Medical [and] Chirurgical Society." Lancet 1 (1855): 262-63.

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