Part 115

To cauterize a diphtheritic membrane or infiltration I consider wrong, unless I shall be able to do so thoroughly and to limit the action of the caustic to the diseased surface. Therefore potassa or chromic acid cannot be utilized, because of the impossibility of limiting their effect. Nitrate of silver and mineral acids can be restricted in their effects, but these are not sufficiently thorough, particularly as but few patients will consent to have the remedy applied properly. When I do cauterize, I prefer a mixture of equal parts of carbolic acid and glycerine or the undiluted acid. The membrane crumbles and falls off in pieces. Force must never be used. Where it would be required in the case of obstinate children mild washes must be employed instead of the caustic. Besides, the internal medication detailed above meets every indication. When there is a slight swelling of the lymphatic glands, cold water or ice applications are usually all that is needed. The latter should be made according to general indications. The glandular and peri-glandular swellings are less the result of an actual filling up with foreign matter than of secondary irritation. Ice has a happy effect in such cases, both on internal administration, in the form of frequent small quantities of ice-water, ice-pills, ice cream, and iced medicaments, and also externally by ice-cold cloths or india-rubber bags filled with ice.

In general, the treatment of the swelled glands must be both based on its causes and adapted to the present condition. The adenitis and peri-adenitis is of secondary nature, the irritation being in the mouth, pharynx, and nares. In these localities is where the main treatment is required. The sooner the primary affection is removed or relieved or rendered innocuous, the better it is for the secondary complaint. Frequent doses of chlorate of potassium or sodium, or biborate of sodium in mild doses frequently repeated, according to the principles laid down in another part of this article, mouth-washes, gargles, nasal injections with water, salt water, or solutions of disinfecting substances, are not only {710} indicated, but highly successful. When the case is recent, cold applications are required, but no washes. When it is of older date, stimulant embrocations are in order. Iodine ointments are absorbed but slowly; mercurial plasters do good in some cases; iodide of potassium dissolved in glycerine (1:3-4), frequently applied, iodine in oleic acid (1:8-12), iodoform in collodion or flexible collodion (1:12-15) applied twice daily, the latter frequently with very good result, are beneficial. Copious suppuration is very rare. Cases in which a free incision meets with an abscess ready to heal are very uncommon. But numerous small abscesses with gangrenous walls and pus mixed with a sero-sanguinolent or sero-purulent liquid, are more frequently found. In such cases a probe introduced into the lancet wound enters easily into the broken-down tissue in every direction, to a distance even of three to six centimetres, (several inches), according to the size of the tumefaction. I have seen fatal hemorrhages from such gangrenous destructions; therefore the treatment must be both timely and energetic. The incision must not be delayed too long. When the skin assumes a purplish hue or is simply discolored, it is time to incise and to apply concentrated or nearly concentrated carbolic acid to the interior, unless the neighborhood of very important blood-vessels or nerves yields a contraindication to concentrated applications. In that case a milder preparation is advisable, but the application should be repeated often, until the suppuration becomes more normal. Then mild disinfectant injections into what has now become a cavity will be found satisfactory, particularly when meanwhile the general condition of the patient has been improved.

Treatment of Nasal Diphtheria.--Especially during the prevalence of an epidemic of diphtheria must we be careful not to allow a nasal catarrh to have its own way; we must likewise guard against considering the thin and flocculent discharge in infected cases as a mucous secretion. Whatever be the origin of nasal diphtheria, whether primary or the result of a similar affection in the throat, local treatment should at once be instituted, and if this be done the great majority of cases will terminate favorably. The danger in this form of disease consists in an excessive absorption of putrid substances and in the breathing of contaminated air. The interior of the nasal cavities must be thoroughly cleaned and disinfected. If this be commenced early, the original seat of the affection may be reached, and the disinfectant process will, as a rule, have good results. It is not necessary to select very energetic disinfectants; a solution of twelve to twenty-five centigrammes (two to four grains) of carbolic acid in thirty grammes (an ounce) of water is at once mild and effective, and hardly gives rise to more discomfort than lukewarm water. Nasal injections must be made very frequently, until each time the stream of fluid has a free exit through the other nostril or through the mouth. They must be made at least every hour, and even oftener if necessary; at the same time it is advisable to be careful that the fluid does not enter the Eustachian tube. This can be prevented, to a certain extent, by compelling the patient to keep the mouth open during the procedure. I have seldom seen evil or even disagreeable results from the administration of nasal injections in diphtheria. It is likely that the mucous membrane of the pharynx is swollen as far as the openings of the Eustachian tubes to such a degree as to render the entrance of fluids into the latter improbable. {711} The hardness of hearing, which is of so frequent occurrence in the course of a severe catarrh or of a diphtheritic attack, seems to indicate that the mucous membrane of that part is in a state of swelling. An ordinary syringe will suffice. However, when administered by parents or nurses the blunt nozzle of an ear syringe is preferable. Occasionally here, as in local applications to the mouth and pharynx, the atomizer may be used to advantage, but the tube must be properly introduced into the nostrils. There are cases of nasal diphtheria, however, which are far more troublesome to manage than the foregoing would seem to indicate. I have seen cases in which the nasal cavities, from the anterior to the posterior nares, were filled and completely occluded by a dense, solid membranous mass. I was then compelled to bore a passage with a silver probe, to gradually introduce a larger-sized one, and then to apply the pure carbolic acid, in order to remove the densest and thickest masses, and finally was able to make injections; even in such cases I have had the gratification of being able to give a favorable prognosis. The dangerous secondary swelling of the glands will often subside after a steady employment of disinfectant injections for from twelve to twenty-four hours. It will be found that children frequently do not object to this method of treatment; I have even met with some who, after convincing themselves of the relief afforded thereby, asked for an injection. When we are about to bring each injection to a close it is well to press together the nasal cavities for an instant with the fingers. By this procedure the fluid is forced backward to the pharynx, and is swallowed or ejected through the mouth, and thus washes the pharynx and mouth at the same time. Frequently, however, this latter object is obtained with every injection; for, the palate being swelled, oedematous, and paretic, the fluid is not prevented from reaching the pharynx, even in the average case. In regard to the choice of a disinfecting agent, I have but a few words to say. I believe that no one of them has important qualifications above the others. I avoid those which stain or which produce firm coagula. For the latter reason I do not use the subsulphate and perchloride of iron; for the former, the permanganate of potassium. I employ, as a rule, carbolic acid in solution, of the strength above mentioned. Where there is but a slightly fetid odor I have frequently employed lime-water or water with glycerine, or a solution (1:100, 1:50) of chloride of sodium, or of bicarbonate of soda or of borax, or a saturated solution of boric acid. Disinfecting agents and antiseptics, whether carbolic acid, salicylic acid, or iron, are of no service when administered internally only, unless the seat and cause of the septic infection be attended to previously. Under the local employment of antiseptics, as described, or by simply washing out with water or salt water, most cases recover; without them, death will result. Of late, in many cases, the local applications, injections, etc. of the corrosive chloride of mercury in water (1:5000-10,000) has proved very effective. It has this advantage over carbolic acid, that the swallowing of the former is not so dangerous. This much, after all, my experience has assured me of, that there is a certain number of cases which terminate fatally; but it is likewise true that the mortality need not be excessively great. I cannot grant that it is hard to carry out the exact and apparently barbarous treatment necessary for a favorable result, for it is certainly more barbarous to sacrifice than to save life.

{712} It is a positive fact that when children suffering from nasal diphtheria, with its peculiarly septic character, are permitted to sleep much--and they are apt to be drowsy under the influence of the poison--they will certainly die. To allow them to sleep is to allow them to die.

The first symptom of improvement is often a rapid diminution of the glandular swelling wherever it exists. It is not present in all cases, but chiefly in those in which a bloody serum was discharged in an early period of the disease. In these the blood-vessels appear to be very vulnerable, superficial, and apt to absorb; these are also the most dangerous cases, and require the greatest attention and care, and also prompt disinfection.

Treatment of Laryngeal Diphtheria.--The severest form of diphtheria is that located in the larynx, constituting membranous croup. Its general treatment, whether the disease has originated primarily in the larynx or trachea or has been communicated from the pharynx, does not differ from that laid down for diphtheria in general. Naturally the larynx calls for special treatment on account of the symptoms of suffocation which result from its stenosis. The main indication of removing viscid mucus or partly-detached membranes is best met by the administration of an emetic. Such is their only indication in my experience. The selection of the emetic, when indicated, is of great importance. Antimonials ought to be avoided because of their depressing and purgative effect. Ipecacuanha is but rarely effective. The sulphates of zinc and copper, and particularly the latter, deserve preference. Turpeth mineral acts promptly and satisfactorily. When no emesis can be obtained the prognosis is decidedly bad. Recourse must then be had to tracheotomy, the good results of which are however only too often delusive and transient.

When, after the operation, there is scarcely any relief, and particularly when the case takes a very rapid course, it is probably one of ascending croup which commenced in the trachea. Mechanical relief by pushing down a hen's feather or a bundle of them, and turning it about and twisting, must be tried. It is a much better instrument than pincers of all sorts and shapes. But what relief will be accomplished is but of very short duration. When fever sets in within a few hours it means very much more frequently pneumonia than diphtheritic fever. It is apt to be soon complicated by that disproportion between pulse and respiration so characteristic of inflammatory diseases. Then quinia in larger doses, 0.25 or 0.5 (grs. iv-viij) every two, four, eight hours, at the same time doses of sodium salicylate 0.25-0.40 (grs. iv-vj) every hour or two hours until the temperature goes down, and small doses of digitalis where the heart requires it, must be given at once. Procrastination is dangerous; the patients want careful watching; many of them die within two days after the operation.

Diphtheritic conjunctivitis requires great attention and permits of no loss of time. Cold applications to the affected eye must be made constantly. Pieces of linen or lint kept on ice (better than in ice-water) of little more than the size of the eye, must be changed every minute or two day and night. The danger to the cornea is so imminent that constant watchfulness is required. Boric acid in concentrated solution should be dropped into the eye once every hour. Care must be taken that the well eye shall not get infected; for that purpose it is best to cover it {713} with lint and collodion, or with lint or cotton held in place by adhesive plaster.

Cutaneous diphtheria requires the destruction of the membrane or of the infected surface by carbolic acid, either concentrated or somewhat diluted with glycerine, or the application of the actual cautery. After that the use of ice or iced cloths, or diluted carbolic acid, is indicated. As soon as the surface is no longer diphtheritic the local and general treatment is to be continued on general principles.

Diphtheritic paralysis is invariably complicated by anæmia and debility, and the diet and medical treatment must be regulated accordingly. However, neither overfeeding nor a sameness of diet are to be permitted, for not rarely the muscular coat of the stomach suffers with the rest of the muscular tissue, and the secretion of gastric juice is very deficient in anæmic individuals. While, therefore, iron is indicated, we must not neglect to pay particular attention to nutrition and digestion, and to aid the latter with pepsin and moderate amounts of muriatic acid, well diluted. Quinia in small doses and stimulants are appropriate whenever there is no contraindication to their employment. The treatment of the paralysis itself will naturally depend on the diagnosis of the condition present in each individual case, which we have seen to differ considerably. This alone can explain why various modes of treatment, the electric current among others, after being recommended by some authors, are branded by others. Where we have to deal with those rare changes in the brain and spinal cord, the utmost care is necessary in order not to make the condition still worse; and in such cases there would be a contraindication to the use of the faradic current, though this would not hold true with regard to the use of the galvanic current in short sittings. Besides, central paralyses are by no means so frequent as peripheral ones. In most cases there is not the slightest elevation of temperature during the course of the paralytic phenomena. I lay great stress upon this point, for I am aware that many cases of central congestion and even of inflammation exhibit but very insignificant elevations of temperature. But, as the diagnosis will depend on a positive knowledge of whether there have been changes of temperature, I rely on the rectal temperature only, for many a myelitis runs its course with no greater elevation above the normal than one-half or one degree. In all cases in which the temperature is normal or subnormal, I do not hesitate for a moment to employ the faradic or the galvanic current. In addition to the internal administration of iron I advise by all means the employment of strychnia. When there is no necessity for haste, we may give moderate doses, gradually increasing them, and using iron in combination. When there is danger in delay, recourse ought to be had to subcutaneous injections of the sulphate of strychnia, once or twice daily. They are mainly indicated in paralysis of the muscles of deglutition and of respiration. Of course, where the former are affected it is necessary to nourish the patient artificially, partly perhaps by nutrient enemata, but principally by means of the stomach-tube. In using the latter it is unnecessary to introduce it into the stomach, as it only requires to be passed a few inches below the affected parts, when the oesophagus will usually be found able to undertake the further disposal of the food. In these cases strychnia should be injected subcutaneously in the neck, {714} once or twice daily. In a similar manner it should be injected in the region of the chest, diaphragm, or neck in paralysis of the respiratory muscles or of the glottis. In paralysis of the muscles of accommodation (in which Scheby-Buch claims to have seen the process cut short by the use of the Calabar bean, considered as inert by Hassner) they may be given in the forehead or temples.

Frictions dry and alcoholic, hot bathing, friction with hot water, kneading of the affected parts, will be found beneficial and pleasant.

{715}

CHOLERA.

BY ALFRED STILLÉ, M.D., LL.D.

DEFINITION.--Cholera is an epidemic disease, characterized by the transudation of serum into the stomach and bowels, and usually by the profuse discharge by vomiting and purging of a liquid resembling rice-water, followed by a tendency to collapse. It is endemic in India, but has been conveyed thence to almost every part of the world.

SYNONYMS.--Cholera algida, C. asiatica, C. asphyxia, C. maligna, C. spasmodica. In English it is generally spoken of as Asiatic cholera.

HISTORY.--It is sometimes stated that Hippocrates, Galen, Celsus, and the Greek, Roman, and Arabian medical writers generally record "the fact of the presence of cholera in the various countries in which they lived" (Macnamara). Nothing could be more contrary to the truth. All of these writers describe "cholera morbus" in nearly identical terms; they all include bilious discharges among its symptoms, and no one of them speaks of it as a mortal or even as an epidemic disease. (Compare, especially, Celsus, Aretæus, Cælius Aurelianus, and Paulus Ægineta.) Their description of sporadic cholera morbus is very precise. For example, Cælius Aurelianus says: "Cholericam passionem aiunt aliqui nominatam a fluore fellis, per os et ventrem effecto."

Asiatic epidemic cholera is a very different disease. It seems to have been known in India from a very remote period, but no detailed account of it was published until the beginning of the sixteenth century. During that century many successive descriptions of the disease exhibited its extreme violence and mortality. It is believed to have occurred repeatedly, if not annually, in the same localities down to the present time. The invasion of India by the Portuguese, and afterward by the English, contributed to spread the disease throughout the Peninsula, partly by military occupation and partly through commercial channels, by which it was also carried to the islands in the Indian Ocean. It prevailed in Batavia in 1629. Between 1768 and 1790 numerous epidemics of cholera occurred. About the former date no less than 60,000 persons are said to have perished near Pondicherry, and in 1783 it is reckoned that 20,000 victims to the disease fell in a single week during the religious gathering at the sacred city of Hurdwâr, where, as will be seen hereafter, it became in later years more fatal still. The English armies extended their conquests in Hindostan, and established commerce between that country and Western Asia and Europe, and by the year 1817 opened new channels of {716} communication in every direction, both within and beyond the Peninsula. Along them the disease was carried; it invaded Ceylon and the Burmese empire, and extended to Batavia, Java, and China on the east, and advanced westward to Persia in 1821. In that year also it was carried from Arabia into Africa, and at various later periods penetrated more and more deeply into the Dark Continent, always following the track of pilgrims returning from Mecca, the routes of armies engaged in war, or those of trading caravans.

In these cases, as in others elsewhere, the spontaneous origin of the disease has been assumed by certain writers, but at every stage of its progress careful investigation led uniformly to the conclusion that it was propagated directly or indirectly from pre-existent cases of cholera. From Persia it moved northward as far as the shores of the Caspian Sea, and westward to the Levant in 1823, and there for a time its ravages were stayed. Meanwhile, it prevailed at various places throughout Hindostan, and, assuming a greater degree of violence in 1826, it advanced steadily in a north-western direction across Afghanistan and Persia in the following year. In 1829 it reached Orenburg, to the north of the Caspian Sea, and was speedily conveyed into the interior of the Russian empire, where it raged with great violence in 1830. In 1831 it prevailed at Mecca among the pilgrims, who had brought it from India, and so virulently that one-half of them are computed to have perished. Hence it speedily passed with returning pilgrims to Alexandria and Constantinople, and was carried to St. Petersburg, to Sweden, to Hamburg, and other places in Northern continental Europe. From Hamburg and other seaports it was conveyed to commercial towns on the eastern coast of England, whence it extended to Edinburgh in the north and London in the south.

In 1832 cholera prevailed in France, and within the year caused 120,000 deaths, 7000 of which occurred in Paris in the space of eighteen days. In the spring and summer of that year it was reproduced in England, and extended to Ireland. From Liverpool, Cork, Limerick, and Dublin five vessels filled with emigrants sailed for Quebec, Canada, and they, together, lost 179 passengers by cholera during the voyage.

The immediate results of this importation and first appearance of cholera on the American continent are described by Dr. Peters as follows: "All these ships and their passengers were quarantined at Grosse Isle, a few miles below Quebec. On June 7th the St. Lawrence steamer Voyageur conveyed a load of these emigrants and their baggage, some to Quebec, but the majority to Montreal on the 10th. The first cases of cholera occurred in emigrant boarding-houses in Quebec on the 8th, and the same pest-steamboat, the Voyageur, landed persons dead and dying of cholera at Montreal, a distance of two hundred miles, in less than thirty hours. Over this long distance, thickly inhabited on both shores of the St. Lawrence, cholera made a single leap, without infecting a single village or a single house between the two cities, with the following exceptions. A man picked up a mattress thrown from the Voyageur, and he and his wife died of cholera; another man, fishing on the St. Lawrence, was requested to bury a dead man from the Voyageur, and he and his wife and nephew died. The captain of a passing boat requested an Indian to bury a man from on board; this man and five other Indians were attacked {717} and died. The town of Three Rivers, halfway between Quebec and Montreal, forbade steamers to land, and escaped for a long time. From Montreal the great influx of emigrants were forwarded away, by the Emigrant Society, as fast as they arrived, and by them the pestilence was sown at each stopping-place. Kingston, Toronto, and Niagara soon became affected. In the end, over 4000 persons died of cholera in Montreal, and more than an equal number in Quebec. The epidemic reached Detroit in the same way, ... and continued west along the Great Lakes, until in September it reached our military posts on the Upper Mississippi.... Fort Dearborn, near Chicago, was temporarily reoccupied in 1832, and it was here that epidemic cholera displayed its most fatal effects among our troops. Out of 1000 men, over 200 cases were admitted into hospitals in the course of seven or eight days.... When these troops again marched for the Mississippi, they appeared in perfect health, yet the cholera broke out again on the way, and when the command reached the Mississippi it had been as fatal as it had been at Fort Dearborn."

Meanwhile, an emigrant ship with cholera on board reached New York, whence the disease spread up the Hudson River, and was also carried southwardly to Philadelphia and the West. The mortality in New York City from this epidemic is stated at 3500. In 1833 the disease broke out in the cities of Havana and Matanzas in Cuba, and is said to have destroyed one-tenth of the entire population. Hence it was carried to Mexican and American towns on the Gulf of Mexico, and up the Mississippi and Ohio as far as the western border of Pennsylvania. In the following year it was again introduced at the port of Quebec by a vessel filled with emigrants, of whom many had died during the passage. It prevailed in Canada and the State of New York and spread over the whole country in 1835 and 1836. In the former of these two years it was confined to several Southern cities, whither it was brought, as on a former occasion, directly from Cuba. It then gradually subsided, and at last disappeared for the space of nearly ten years.

But in 1845 it was known to be advancing on its former path, which it steadily pursued, and entered England in October, 1848, at Sunderland, the very town at which it first appeared in 1831. "During the second epidemic in Europe, in 1848, two vessels sailed from Havre, where cholera prevailed--one, the New York, for New York, and the other, the Swanton, for New Orleans. Both contained large numbers of German emigrants. On one vessel the cholera appeared when it was sixteen days out, with fourteen deaths; on the other, in twenty-six days, with thirteen deaths. The New York arrived at Staten Island Dec. 2, 1848, and a severe epidemic broke out, but was confined to the quarantine grounds. The Swanton arrived at New Orleans Dec. 11th; no quarantine was instituted, and in two days its sick were taken into the Charity Hospital. This was the beginning of a severe epidemic, which increased in power all winter, till, in June, 1849, 2500 died of it in New Orleans. December 20, 1848, it reached Memphis by steamboat from New Orleans, and for twenty-five days was confined to the landing-place of the former city, whence it afterward spread. In the spring it was carried to St. Louis and Cincinnati and the whole Mississippi Valley. In October it reached Sacramento, Cal., by means of overland emigrants, and, almost at the same time, San Francisco, by the U.S. steamer Northerner from {718} Panama. The Chinese of California suffered most severely" (Peters). In April, 1849, cholera reappeared in the public stores at the quarantine station, Staten Island, N.Y., and in the city of New York, where it was fatal to 5000 persons.

A pause now took place in the ravages of the disease which lasted until 1853. In that year it destroyed no less than 11,000 persons in the Persian city of Teheran. At Messina its victims numbered 12,000, in France 114,000, and in England about 16,000. In 1854 it was introduced by emigrant ships into New York, causing a mortality of 2000 persons, and was carried to Philadelphia, where its victims numbered 500. It extended to many towns in New England and westward along the great channels of emigration. In Montreal the deaths were 1300, and in the then small town of Detroit, 1000.

After an interval of quiescence longer than any previous one the cholera again broke out among the pilgrims to Mecca in December, 1864. It appeared in Alexandria during May, 1865, and thence was carried to many parts of Europe, and from them to North America and the West Indies. This period of exemption included that of the Civil War in the United States, when, if ever, the local causes which have been erroneously assigned to the disease existed in all their forms and in the most intense degree. It was only when its specific germs were once more imported that cholera began to prevail again. Official records show that in 1866 it was introduced from Europe into Halifax, N.S., the city of New York, and the military posts of New York harbor. Thence it was carried in troop-ships to various Southern ports, from which its progress could be traced to Texas and other Gulf States, and to the towns on the Mississippi and Missouri Rivers. From New York, also, the disease travelled westward to Cincinnati and the U.S. barracks at Newport, on the opposite side of the Ohio River, whence it advanced in a south-westerly direction to meet the trail that, coming from the South, followed the great rivers of the Mississippi Valley. During the summer of 1867 cholera again prevailed, although less fatally, at most of the points, especially of the Mississippi Valley, which had been invaded the previous year, and some cases occurred at the military posts around New York in recruits who had shortly before arrived from places in the West where cholera prevailed. Thus did the disease complete the circuit of the United States.

Meanwhile, cholera prevailed to a greater or less extent in the east of Europe between 1865 and 1874. After the latter date it seems to have been confined to Syria, Arabia, and the African shore of the Mediterranean. In 1877-78 it existed to a limited extent among the pilgrims at Mecca, and since then it has not been known in Europe. The latest appearance of cholera in the United States was in 1873, when it occurred at three points far distant from one another. It was introduced in the effects of immigrants. The vessels that brought them were in a perfect sanitary condition. The passengers themselves were healthy, and remained so after landing and until they reached the distant points of Carthage, Ohio, Crow River, Minn., and Yankton, Dak., where their goods were unpacked. At each place, "within twenty-four hours after the poison particles were liberated, the first cases of the disease appeared, and the unfortunates were almost literally swept from the face of the earth" (E. McClellan).

{719} In 1881 cholera was brought from Hindostan to Arabia by pilgrims on their way to Mecca, where it soon afterward broke out and caused the death of about 8000 persons. In the following year several vessels from Bombay evaded the quarantine and reached Djeddah, the port of Mecca, and the pilgrims on reaching the latter city disseminated the disease. The unusually small number of persons who were there at the time, and their prompt dispersion before the danger, limited the mortality, and gradually cases of cholera ceased to appear. In 1882, the English at that time carrying on war in Egypt, very rigid sanitary precautions against the importation of cholera were enacted and successfully enforced, but in the following year, the same urgent necessity no longer commanding, they were considerably relaxed. At the end of June, 1883, the cholera made its appearance at Damietta (at one of the mouths of the Nile), and soon afterward at Rosetta, Port Said, and Mansourah. During July it spread to various places in direct communication with those named. At Cairo it was peculiarly fatal, and on July 20th it was reported to have caused 600 deaths. For several days the daily mortality varied between 500 and 600. The disease prevailed somewhat in Alexandria during the height of the epidemic, and near the end of October it was fatal to numerous European residents of that city, and some deaths occurred in the British army of occupation. In all Egypt, during the week ending Aug. 13th, the total mortality is said to have been 5000, but in the following week it fell to 2000. It is estimated that the epidemic destroyed at least 20,000 lives. The germ of this epidemic has not been accurately determined. Some regard it as a survival of the cholera of the previous year--a supposition which is at least plausible and sufficient; but certain "sanitarians" have attributed the outbreak to the ordinary causes of disease intensified by the civil war which had recently devastated Egypt. It is sufficient here to say that while such causes have in all ages generated typhus and typhoid fevers and dysentery, they never produced cholera. Some, more unwise than judicious, declared that the Egyptian disease of 1883 was not cholera. It is alleged, on the one hand, that several East Indian merchants from Bombay arrived at Damietta on June 18th, or three days before the disease was recognized in that city. It is also said that a stoker from on board an English steamer from Bombay introduced the cholera into Damietta. But the judgment of Surgeon-General Murray carries with it greater weight. He is of the opinion that the Egyptian epidemic of 1883 was simply a revival of the Arabian epidemic of 1882. He shows that cholera existed in several villages on the Damietta branch of the Nile in the latter part of May and during June, and that it broke out in the capital itself, during a fair which had lasted for eight days, on the 22d of June, and was spread by the people on their return from Damietta to their villages. This, adds Mr. Murray, "is a literal transcript of the accounts of many of the severe epidemics that have raged over India." It also appears from M. Proust's narrative that the Ottoman government had already, as early as April, notified the government of Egypt that certain Indo-Javanese pilgrims were on their way to Mecca, and that ought not to be allowed to land without quarantine. The French delegate to the sanitary council also begged that those of the pilgrims who reached Suez without previous quarantine should be isolated and kept under {720} surveillance for three days. But owing to the opposition of the English delegates these measures were not duly enforced, the council did not meet again, and no protective system was adopted.

ETIOLOGY.--The essential cause of cholera is unknown, unless the investigations of Koch, described below, may have revealed it. Its secondary causes, or the conditions of its dissemination, are better understood. Some general propositions concerning them will here be laid down, and illustrated so far as the argument requires and the available space will allow.