1823.

Dr Robson on
Epidemic Cholera. 507

II.

" "
History of Epidemic Cholera, as it appeared on hoard His
Majesty s Ship Malabar, its passage from
on Bombay to the
Equator, in the month of April 1819. By W. lloBsoN, M.D.
late rhysician to the forces.

"?quibus concurrentibus, non mi rum est, si subito quis morltur: Neque tamcn
ulli morbo minori momcnto succurritur."?Crfsus, Lib. 4.11.

'T'he spasmodic or epidemic cholera has of late years excited

considerable interest, on account of its destructive pro-
gress through the whole of the peninsula of India, the islands
of Ceylon and Mauritius, and- several other islands in the In-
dian Ocean. The opinions of medical practitioners have been
much divided about the origin of this disease, as well as the
practice. The pathology of it also appears to be very little un-
derstood. The exciting cause of the disease has, by some, been
supposed to be bad rice; by others, it has been ascribed to
contagion; and, by the greater number, I believe it has been
considered to be epidemic, without any attempt to account for
Jts origin.
The opinion that it was occasioned by the use of bad rice, or
any other provision in a state unfit for consumption, appears to
have been sufficiently refuted by the history of the progress of
the disease. That it was contagious, has also probably been
sufficiently refuted by many facts and observations. There ap-
pears little doubt of its epidemic nature, and that its progress
Was made in the same manner as that of the catarrh, or any o-
tner disease epidemic, and probably not contagious. Without
Pretending or attempting to throw any light on this obscure
subject, I propose, in this paper, to give a short account of the
disease as it appeared among the crew of his Majesty's ship
Malabar, 011 the passage from the coast of Malabar to the
equator.
I he crew of the Malabar,
consisting of upwards of two hun-
dred seamen and marines, had served
nearly three years 011 the
Indian station in the Orlando frigate. During that period,
they had at intervals suffered severely from fever and dysentery,
particularly while lying in a hulk in the harbour of Trincomali,
*n the summer of 1818, at the time when the frigate was under-
going a repair.
In the Orlando sailed for
succeeding January, the Bombay,
508 Dr Robson on
Epidemic Cholera. Oct.

where the crew were employed in rigging and fitting for sea the
Malabar man of war, then newly launched, and loading her
with the timber already prepared for constructing another ship
of equal rate, on her arrival in England.
During that period the crew had been unusually healthy.
They had worked hard, but their comforts were much attended
to in other respects; and they had
regular sleep by night in
their births, which they had for some weeks occupied in the
Malabar.
On the morning of the 5th of April the ship left the harbour
of Bombay, and proceeded to sea on the voyage to England.
On the morning of the 6th, I was informed by the surgeon, a
very active and intelligent medical officer, that he had been
called, soon after midnight, to a seaman, who had been brought
into the sick-bay, labouring under most violent symptoms, which
appeared to be those described as belonging to the spasmodic
cholera. The complaint had proved fatal in a few hours, not-
withstanding the application of the most powerful antispasmo-
dic remedies.
In the course of the next night two rtiore cases were brought
into the sick-bay, affected in a similar manner, and both termi-
nated fatally in a few hours. One of the patients was a marine,
who was attacked, when on duty as a sentry on deck, outside
the door of a cabin on the poop. They had both been severe-
ly purged before any complaint was made. They were treated
with tincture of opium and rether, in large doses, arrack, bran-
dy, stimulating frictions, and warm fomentations, without any
relief. In one of the cases, venesection was employed without
apparent benefit. On the morning of the 7th, several very se-
vere cases presented; one of which was the captain's steward*

a black man, a native of the West Indies. I was requested by

the surgeon to see him and the others, and to consult with hun
on the treatment. The steward had laboured under diarrhoea
for several days previously to leaving Bombay, but made no
complaint till 10 o'clock on the morning of the 7th. As, in ad-
dition to the other symptoms, he complained of some degree of
of
pain oil pressure of the abdomen, he was bled to the extent
g xvi., when syncope had nearly supervened; and the warm

bath was also used, without any permanent relief, as he sank

very rapidly, and died about six o'clock p. m.
The symptoms, generally, were great' thirst, constant retch-
ing, and vomiting of a whitish coloured mucous substance,
sometimes frothy, and of a watery appearance, and frequent
with
discharges of a similar matter from the rectum, attended col-
violent tormina and tenesmus. The features were much
1823. Dr Robson on
Epidemic Qholerd. 509

lapsed; the eyes dull and glossy as the disease advanced ; the
pulse very quick and feeble; the toes and fingers much shrivel-
led, cold, and apparently bloodless; much oppression at the
precordium, with dyspnoea; violent spasms in the muscles of the
abdomen, thighs and extremities, particularly in the arms, and
probably also in the diaphragm. The skin was generally cold,
and partially covered with clammy sweat. The pulse frequent-
ly could not be felt for some time before the fatal termination ;
but the violent distress, retching and cramps generally conti-
nued to the last, though the functions of the sensorium were
unimpaired.
As every medicine hitherto given had been rejected from the
stomach, enemata, with tincture of opium, in considerable quan-
tity, were administered, but without benefit. The warm bath,
in several cases, gave only temporary relief. As venesection,
in the two cases in which it was performed, appeared rather to
have had a pernicious than a beneficial effect, and as even ca-
lomel, in doses of gr. v. and x. with tinct. op. 3 ss. & 5 i. had
always been vomited, or at least produced no favourable effect,
and every case had hitherto terminated fatally, it was thought
advisable to try the combination of calomel with opium in the
form of pill. The success of this practice was very soon re-
markably evident. The combination was given every two
hours in the quantity of extr. op. gr. i. with hydrar. submur.
i. In very violent cases, where the disease had been of longer
continuance, and the patient was brought in almost in articulo
mortis, the medicine was given in double that dose.. The first
good effect of the pills being retained in the stomach was to
allay the retching, vomiting, and tormina, gradually followed
by an abatement of the severe cramps, a return of the pulse at
the wrist, and a copious warm perspiration. In the course of a
few hours, there were generally several copious bilious evacua-
tions from the rectum ; the pulse became more full and slow ;
and, in consequence of the circulation being generally equal-
ized, warmth was restored to the extremities, and the shrivelled
and exsanguine appearance of the toes and fingers before men-
tioned gradually disappeared. It.was seldom found necessary
repeat the medicine above three or four times; and, in ge-
to

neral, the convalescence was regular, though slow, in conse-

quence of the very strict attention to regimen and the state of
the intestinal canal, which was necessary, and, in many of the.
Worst cases, the very severe ptyalism which followed the exhi-
bition of the larger doses of the submuriate of mercury. I am
m
possession of very short notes on the subject; yet I am con-
fident that not above two or three cases terminated fatally after
 510 Dr Robson on
Epidemic Cholera, Oct.

the treatment above described was

adopted; one of which re-

lapsed, and the others were brought into the sick-bay at the
last extremity. The greatest attention was paid by the cap-
tain and the other officers; and strict orders were given to
men from
prevent the sleeping on deck during the night-
watches, and for the petty officers to watch and report the first
appearances of indisposition; but, nevertheless, so characteris-
tic is the thoughtlessness of sailors, that they, in many instances,
allowed themselves to be affected with tormina and diarrhoea,
which were generally the first symptoms for several hours be-
fore any complaints were made.
I find it set down in my notes, that in all eighty-nine cases
were treated, of which fourteen terminated fatally,?a much
smaller mortality than is recorded in any of the reports which
I have seen from the different places where the disease prevail-
ed, with the exception of the reports of Mr Corbyn and Dr
Burrel, in the 64-th Number of the Edinburgh Journal, pub-
lished 1st July 1820. The former, it appears, treated 108
cases out of 110 successfully, with large doses of calomel and

laudanum, and peppermint in water. Such treatment would

have failed altogether in the disease as it appeared on board
the Malabar, as liquids of every description were immediately
rejected by the stomach. The practice of Dr Burrel, it appears
from the Report, was to bleed in every instance, and then to
administer calomel and laudanum in large doses. This practice
was
equally successful, as he lost only two patients out of 88 so
treated. With respect to venesection, I am convinced, that it
would have failed in every instance on board the Malabar; so
that although the patients, in both cases, were Europeans, the
constitutional circumstances, and probably also the symptoms,
must have considerably varied. The disease certainly appear-
ed to be rather of a spasmodic than an inflammatory dharacter;
and if there be any truth in the aphorism of Bobrhaave, (I be-
lieve), " Debilitas gignit spasmum," surely the most powerful
cordial and antispasmodic medicines were in the first instance
indicated, instead of evacuants, unless venesection be consider-
ed to act as an antispasmodic.
There were only two officers, out of more than twenty, at-
tacked with the disease,?one a midshipman, the other a master's
mate, who was much addicted to drinking. They both reco-
vered, after a severe struggle in the case of the latter, and a
long continued ptyalism. One woman passenger, out of four,
was attacked; but none of the children, of whom there were
four or five on board. The woman also recovered, after a se-
 ^
1823. Dr Robson on Epidemic Cholera. 511

vere and long continued illness, with only a slight affection of

the salivary glands.
There were only two bodies inspected after death, at the
commencement of the epidemic; and, in these, only the viscera
of the thorax and abdomen, where were generally observed ap-
pearances of vascular congestion.
In a tropical climate, on board ship, in a crowded sick-bay,
where there were incessant calls, day and night, to administer
to the most alarming symptoms of disease?where, in the ap-

propriate words of the Roman poet, "

horce
Momento aut cita mors venit, aut victoria lata "?
leisure and opportunity were equally wanting to investigate the
morbid appearances so important and interesting in similar
cases, under other circumstances.
The epidemic continued to rage from the 5th to the 24th of
April, on which day the last case appeared. The ship was then
near the equator, which was passed on the 30th of the month,
after the usual delay from calms and irregular breezes. The
thermometer had ranged from 85? to 88? since our departure
from Bombay; and, upon the whole, the weather had been
fine, with the exception of some squalls, attended with thunder
and rain, which were encountered, as is common, off the coast
of Ceylon.
The epidemic had prevailed at Bombay in the preceding au-
tumn, but had disappeared for some months previously to the
departure of the Malabar from that presidency. It was, how-
ever, raging among the native inhabitants at Cochin, on the
Malabar coast, in the month of March, as I was informed by
the Company's surgeon at that station, in my passage from
Ceylon to Bombay, in his Majesty's ship Mindcn. We left the
last named vessel in the harbour of Bombay, with the crew in
good health; nor did the cholera appear at Trincomali, the
station for men of war in the island of Ceylon, until several
months afterwards. As the disease made its first appearance
oil the
very night when the ship left the harbour, it can scarce-
ly be ascribed to any change in the habits or discipline of the
seamen and marines acting as a predisposing or exciting cause.
There was an abundant supply of fresh provisions and water,
both of which were added to at Cochin on the 10th of the
month ; and great attention was directed to the health and com-
fort of the crew.
When we left Bombay, the monsoon was blowing strongly
from the south west.
Oi the remote and
proximate causes of the disease, I do not
512 Dr Robson on
Epidemic Cholera. Oct.

profess to know any thing. The ratio symptomatum appears to

be almost equalfy obscure; and therefore the practice ultimate-
ly adopted, though in a great degree successful, was almost
purely empirical. I had found from experience, that small
doses of calomel and opium were often very useful in restrain-
ing vomiting, and removing the irritability of the stomach,
which takes place in the advanced stage of remittent fever; and
as these medicines, given
separately, had produced no apparent
effect, it was consequently suggested to try them in combina-
tion.
Calomel in very large doses has been supposed to act as a
sedative, though that operation may certainly be doubted. In
this instance, may it not be supposed to have acted beneficially,
by exciting into action the whole of the chylopoietic and assist-
ant chylopoietic viscera, particularly the hepatic system, and in
this manner equalizing the circulation, and carrying off, what-
ever
might be its nature, the deleterious agent acting so power-
fully in the depression of the circulating and nervous systems ?
In this operation, the action of the calomel might be much as-
sisted by having its absorption promoted by the stimulating
power.of the opium, while the irritability of the stomach was
allayed by its anodyne influence. In whatever manner these
medicines act separately, the " tertium quid " resulting from
their combination exerted a powerful, and, perhaps it may be
said, specific effect. The well-known operation of this combi-
nation as a sudorific might also have a powerful beneficial effect.
I do not know that ptyalism was necessary to the resolution
of the disease; and I am exceedingly unwilling to come to that
conclusion, from having too often had occasion to observe the
destructive consequences of the mercurial practice, so strongly
inculcated by some modern practitioners in the treatment of in-
termittent and remittent fevers.
Although salivation, to a certain extent, took place in all the
cases which recovered, it
appears probable that the disease, if
taken in.every instance at its commencement, might have been
successfully combated with a smaller proportion of the submu-
riate of mercury, in combination with the same quantities of
opium, with less consequent suffering to the patient, as well as
economy of his constitutional
"
powers;?but "no season then
for counsel or delay: the practice once found to succeed, was
had recourse to in every instance?" ea visa salus morientibus
una."
"
The term " epidemic cholera has been objected to, in con-
sequence of the progress of the disease in opposition to the
monsoon in some instances, as well as perhaps to some of the
other usual laws of the progress of epidemics.
1823. Dr Robson on Epidemic Cholera. 513

<c
Theepithet spasmodic" has also, I believe, been consider-
ed improper, on what grounds I do not know, unless that it
may be thought to be a pleonasm, in consequence of cholera
having been placed by Cullen among the order " Spasmi."
The definition of cholera by that illustrious nosologist, certain-
ly does not apply to this disease, as there is neither vomiting
nor
passing of bile by the rectum. In the seventh edition of
"
his Synopsis, he mentions " Cholera Indica, sp. 7, but does
not define that disease. This epidemic resembled, in many of
the symptoms, that which has been called t(
Mort de chien," as
described by Mr Curtis and Dr Johnson to have occurred for-
merly in the ships of war on the Indian station, and to have
been perhaps occasionally endemic, or
produced by exposure to
vicissitudes of temperature in the harbour of Trincomali; but
the practice so strongly recommended by the last named writer,
would probably have proved destructive in the treatment of the
epidemic as it
appeared on board the Malabar.