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"Medical Society of London (MSL): Snow disagrees with Mr. Headland's notion that cholera is a blood disease, spread atmospherically, etc. "
(14 October 1854)The minutes of the October 14 meeting, the first of the 1854-55 session for the society, appeared in Lancet 2 (21 October 1854): 339-41.
PDF courtesy of Elsevier, via the Health Sciences Center Library, Emory University.
Megan Anderson and Cori Heacock made the following transcription.
Mr. Headland, President.
Saturday, October 14th, 1854.
The first meeting of the Society for the session was held on Saturday last. The room was crowded. On taking the chair, the President alluded to the alterations which had been made, and eulogised the committee on the pains and labours they had taken to improve the premises, and add to the comfort of the fellows. The room had been lowered considerably, and a complete system of ventilation, on Dr. Chowne's plan, carried out.
A paper was read by the President, entitled
He commenced by stating that it had at first been his intention to write a paper upon "certain Forms of Hypochondriasis," but the subsequent occurrence of the terrible epidemic of cholera had diverted his thoughts from that channel, and suggested the propriety of offering to the fellows, at the commencement of the session, some few remarks upon a subject which must for some time past have more or less occupied every mind. And he did this, not so much as wishing to lay stress upon any opinions which he might himself entertain, but rather with the hope of eliciting some of the opinions and experience of others upon so important a subject. The facts to be dealt with, so far as the history and prominent characters of this disorder are concerned, were succinctly enumerated. Its first appearance in India about half a century ago; its terrible destructiveness, and the consternation produced throughout the East by its uncontrollable outbreaks--matters which were at length summed up in the Government Reports upon Cholera; the appearance of the disease at Sunderland in November, 1831, and its rapid spread through England in the year 1832; the second epidemic in 1849, and the third in 1854, in all of which medical men had been taken at a disadvantage, because unresolved and at variance as to the real nature of the malady, and the proper mode, if any were feasible, of meeting so destructive a disease. The probable causes of this indecision were next inquired into. Is not much of it to be attributed to the unfortunate name which has been selected for it,--a name which does not remind us of its essential characters, and which had been previously used to denote another disease long known in England, and chiefly characterized by aggravated vomiting and purging? Though these symptoms also strongly attract our notice in Asiatic cholera, they are not perhaps so worthy of remark as the very peculiar signs of the cholera-collapse, the coldness and blueness of the skin, the pulselessness, and arrest of the secretions of the liver and kidneys. One very prominent and yet very natural result of the attention which has been paid to the evacuations, as if they alone were the cause of death, is, that of the immense number of remedies proposed and actually used in Asiatic cholera, including a large proportion of the available materia medica, the great majority have been aimed chiefly at the arrest or control of the vomiting and purging. It has apparently been supposed also, that cases of ordinary diarrhœa, if neglected, would be apt to degenerate into real cholera. Here the President expressed a decided opinion that such a consequence was comparatively a rare result; in fact, that diarrhœa could no more produce cholera than any other agent which lowered the system, and so far rendered it more liable to the inroads of an epidemic poison. Diarrhœa would be just as likely to terminate in scarlet fever or small-pox, if the poisons of those disorders were abroad. No hope could be [339/340] entertained of discovering, by chemistry or otherwise, the exact nature of the influence which produces cholera, any more than that which operates in any of the other terrible disorders which afflict mankind. But though we must despair of detecting its essence, an idea as to the working of this poison might perhaps be ventured. In its epidemic nature and in the general character of its symptoms, cholera is evidently a blood disease. A serious impression of some sort is made upon this fluid. The suddenness of the attack, its frequent rapidity of progress, and the speedy development in many cases of fatal symptoms, seem all to point to the more vital part of the blood as being impressed in the first instance--i.e., the blood corpuscles, and not the liquor sanguinis. And there are some other indications of this which would seem to come nearer to the nature of proofs. It has been just observed that the coldness and blueness of the state of collapse are amongst the most characteristic of the symptoms of cholera. The process is impaired by which the animal heat is maintained. This function is generally admitted amongst physiologists to reside in the blood corpuscles. The collapse symptoms may occur before the blood has been thickened by the copious discharge from the bowels. It has been even observed by Heller, a German microscopist, that the red corpuscles at this period appear "hacked and mutilated," as if physically injured. The lacteal and lymphatic glands, organs engaged mainly in the manufacture of the corpuscles of the blood, are found, after death from cholera, to be softened and disorganized. Add to which that Virchow and others have discovered in the right side of the heart large whitish coagula entangling multitudes of white corpuscles, from which it would seem as if these had been somehow prevented from undergoing their normal development into the red cells. The blood-corpuscles being thus injured or arrested in their development, not only are the functions which are essential to life fundamentally and fatally disturbed, but the plasma apparently becomes itself affected in the second place. Now the corpuscles, being solid, cannot be ejected from the system, but the plasma is capable of excretion. Next, then, it is passed out by the mucous membrane of the bowels, as if it were a foreign material, constituting the characteristic colourless or "rice-water" discharges, which contain serum and salts, with mucous and fibrinous coagula. This theory is offered as apparently explaining the phenomena of this disease, which no other notion appears to do satisfactorily. The idea of a morbid poison to be eliminated seems hardly sufficient--the discharges, in their non-feculent character, being so much unlike those of any instance of diarrhœa observed in other diseases. The fact, that the ingeniously devised injections of saline fluids into the veins in the latter stage of cholera have never succeeded in reviving the patient for more than a brief period, seems to indicate that the thickening of the blood is not to be considered as the sole cause of death, which is probably rather to be attributed to the extensive devitalization of that fluid. The fatality of an attack of cholera no doubt depends less upon the means which are adopted in the treatment, none of which have been found to control it effectually, than upon the previous condition of the patient himself, rendering him more or less obnoxious to the full effect of the poison. Some have their blood in that peculiar condition which is most likely to be influenced by this. Those who are most impressible are attacked the first, and die the fastest. Afterwards those sicken who are liable in the next degree, none of whom recover. Again, towards the end, those who are least liable, who will escape most easily of all. The epidemic, having then few or none left whose systems it can invade, takes its departure for a season, only to return again when the way is once more prepared for it. By this means we can explain what is always observed, but is at first sight difficult to understand: the terrible mortality of the first outbreak; and the lessening severity of the disease, as though it had become amenable to remedies, remarked at the close. It has been stated on good authority that the absolute rate of mortality is not increased by the epidemic of cholera; but that on taking the average of five years, two before and two after the outbreak of this disease, the real number of deaths is about the same as usual; from which it would seem as though those who are stricken with cholera would, at no long distance of time, have perished of other blood diseases had the opportunity been left to them. This notion of blood liability seems far preferable to the idea of its being a contagious disease. Were the latter the case, it would seem strange that the disease should not spread more regularly, and remain longer at a place, instead of departing so suddenly as it does. (Several facts were here adduced as bearing decidedly against the doctrine of contagion.) The occurrence of the disorder in each case is probably to be accounted for by two distinct things--an epidemic influence, and a pre-existing wrong in the blood of the person attacked. An atmospheric change co-operates with a systemic wrong; we need not define either, but we must admit their agency. Neither of these causes will suffice by itself. Thus a bar of soft iron will not attract a bar of steel; but if we pass a galvanic wire round the former, converting it into a temporary magnet, it will acquire a power which it had not before. The iron and the electricity together will co-operate in effecting what either alone would be powerless to do. We may learn from this conclusion that the cause of the disease is in great part a pre-existing wrong, as well as from the fatal nature of the malady when it has once fully developed itself,--how important it is to take preventive measures in anticipation of the outbreak. These measures should no doubt mainly consist in all those means which may ameliorate the condition of the poor, or which may serve to counteract those noxious and baneful influences which render the lower and more densely-populated quarters of our large towns the very hot-beds of all epidemic diseases. For this disorder is not one which is equally distributed to all classes. It is shown by the returns of the cholera deaths in 1849, that by far the largest proportion of deaths occurred amongst the labouring classes, and more of the tradesmen died than of the gentry. We may, then, well display our zeal, and evince our real interest in the removal of those depressing causes which tend so fatally to shorten their lives and to thin their numbers. In remarking, in conclusion, upon the prolific subject of treatment, the President insisted strongly upon the erroneous character of the notion, so commonly entertained, of the connexion between cholera and ordinary diarrhœa. As an illustration of the strongly-marked nature of the symptoms of the former disease, he narrated the history of the first case which happened to him in the present epidemic, the character of which was such as to defy all treatment. He concluded by expressing a hope that we might, by judicious sanitary measures, be enabled to render the re-occurrence of this terrible malady more unlikely than it seems at present to be.
Dr. Crisp, although agreeing with the author of the paper on some points, differed from him in the main question, concerning the disintegration and destruction of the blood-corpuscles. He moreover thought, that the statistics adduced respecting the influence of rank and occupation did not warrant the inference drawn from them; for when the relative numbers were considered, it would be found that the proportion of cases amongst the mechanics was not greater than amongst the gentry and tradesmen. The assumption, too, that the human constitution was degenerating was disproved by the fact, that the general longevity was never so great as at the present time. Mr. Headland supposed that the white corpuscles of the blood were converted into the red, and that the blood-corpuscles were formed in the lymphatic glands. Dr. Crisp believed that at present no sufficient proof could be given of this. A few weeks since he had injected some saline fluid into the veins of a patient suffering from cholera in its worst form. He examined the blood which flowed from the vein under the microscope, before it was dry, and with the exception of a greater number of red corpuscles, and their more intimate aggregation on some parts of the glass, no important difference was perceptible between this and the blood of a healthy man. Some of the dried corpuscles were now visible, and probably would be so a hundred years hence. In the examination of the blood of a great number of the lower animals he had found, in many instances, more examples of disintegration than in cholera-blood. As regarded the preliminary diarrhœa, he (Dr. Crisp) thought that it would be as rational to say, "that scarlatina simplex was not scarlatina," as to assume that this diarrhœa was not "choleraic;" probably half the members present had had cholera in a modified form, as shown by cramps, aching of the legs, and by diarrhœa of a peculiar kind. One fact he thought was indisputable--viz., that thousands of cases of cholera had been cured in the early stage, and what, he would ask, became of the poison, or supposed poison? Chalk, opium, astringents, and calomel, had no specific power over it; but, yet, if you lock it up in the system, the patient is generally cured. He (Dr. Crisp) thought that in the later stages of the disease we had made no progress in the treatment, nor had our knowledge advanced respecting the cause of cholera.
Dr. Winn remarked, that in India the disease usually travelled in straight lines, frequently affecting only one locality, and passing in some instances through the centre of an army.
A member considered that there must be a predisposition in an affected person to contract cholera, combined with a specific condition of the atmosphere. The disease occasionally affected one side of the street, or one block of houses, but usually chose [340/341] the most crowded, and the worst ventilated and lighted neighbourhoods, and persons dissipated in habit. He eulogised the employment of the nitrate of silver in this complaint, which not only acted as an astringent on the mucous membrane of the bowels, but had a beneficial influence on the nervous system.
Mr. Hunt regarded diarrhœa and cholera as essentially different, and remarked that cholera might be wholly without premonitory symptoms. Sixty such cases had come under his notice.
Dr. Risdon Bennett would not enter into the theory which had been advanced by the author of the paper, which was not new, and did not appear to be supported by facts: these appeared indeed to be against the assumption of any disintegration of the blood in cholera. If it were a poison, in his opinion it operated as a shock upon the nervous system, the influence being exerted on the great sympathetic, the solar plexus chiefly being affected. Two or three facts which had come under his notice during the present epidemic, seemed to show that the disease did not depend on the presence of a poison in the blood, which was attempted to be, or was, carried off by purgation. In St. Thomas's Hospital two patients, one affected with typhoid fever, the other with acute rheumatism, were seized with cholera, from the collapse of which they recovered, and after the reaction consequent upon it, went through their original diseases just as if no cholera had intervened. He thought these cases, with others of a similar kind which he had seen, were opposed to the opinion, that cholera was a blood disease, the poison of which was carried off by purgation; if it were so, the poison of the fever and the rheumatism would also have been eliminated in the same manner.
Mr. Dendy believed that the blood was much altered in cases of cholera, as he had found, after bleeding cholera patients in 1832, as ordered by the then Board of Health, great difficulty in washing away fluid from his hand. Diarrhœa might, or might not exist as a premonitory symptom. By reducing the system, it might be a predisposing cause of cholera, such a cause, as also an exciting one, being necessary in all cases. With respect to treatment, castor oil only reduced the patient lower. The treatment should be directed to the arrest of the flux, the binding up of the exhalants, and the stimulation of the absorbents. He reprobated the system of medical practitioners communicating their opinions to the political journals, the medical periodicals being their legitimate means of communication with the profession.
Dr. Snow considered that the cholera poison acted upon the alimentary canal, and not on the blood or nervous system. In every case which he had seen, the evacuations had been sufficient to account for the collapse, without reference to any other cause. There was no poison in the blood in a case of cholera; in the consecutive fever, as it was called, the blood became poisoned from urea getting into the circulation in consequence of the kidneys not acting, but not from any poison having been present from the beginning. There was nothing in the atmosphere to account for the spread of cholera, which he believed was spread from person to person; and that in all cases it could be traced in this manner. If atmospheric, why did it attack one or two persons only in a locality, and these having direct communication with each other? Such cases he had seen at Sydenham, where there had been only two instances of the disease. The first case in the outbreak of 1849 had occurred to a sailor in Bermondsey; the second affected person was the successor to the sailor in the room in which he died. He thought he had collected evidence enough to show that in all cases cholera was propagated by swallowing some portion of the evacuations of an affected person. These, as was well known, flowed into the bed, etc., and persons attending on the sick might easily take the poison unawares. With respect to the class of persons affected by the disease, he believed that the very poor and vagabonds suffered less, in proportion, than decent, respectable persons. He regarded the cholera and diarrhœa, as lately prevalent, to be the same disease in different degrees of intensity. We observed the same difference in scarlatina and other diseases.
Dr. Richardson remarked that, as death in cases of cholera resulted from the loss of fluid from the system, and as it had been found that injections into the veins did no permanent good, he suggested that the peritonæum should be injected with water. He had found, from numerous experiments on animals, that such a proceeding, if care were taken, was not fatal, and he believed it might act beneficially in cholera. He inquired if members had observed cholera to be connected with hysterical symptoms, several such cases having come under his own observation.
Mr. Jabez Hogg had made some observations on the state of the atmosphere during the prevalence of cholera, and had found it to abound in small animalculæ--the vibriones--the powers of life in which were so great, it was almost impossible to kill them. If the air examined had been collected over sewers, the animals were found to be larger and more tenacious of life.
On the motion of Dr. Lankester, seconded by Mr. C. Clark, the debate was adjourned.
