Part 118

In 1884, Dr. Koch, during his investigations of cholera in India, found bacilli in the bowel which he believed to be peculiar to the disease, and which presented the following characters: they were not straight, like other bacilli, but curved or comma-shaped; they proliferated rapidly and displayed very active movements. Bodies of persons who died of various other diseases did not present them, although abounding in different bacteria. The bacilli were not found, or only exceptionally, in the stomach, but abundantly in the intestine, and most so in the diarrhoeal discharges that occurred at the height of the disease. As soon as the stools began to be fecal the specific bacilli disappeared from them. After death at the height of the disease they were most abundant in the intestinal contents, and especially in the lower part of the small intestine. When death took place at a later period none of them might be detected in the liquids in the bowel, but they would still be present, in considerable numbers, in the tubular glands. They were not found at all in cases fatal from some sequela of the disease.

Other abdominal lesions in cholera possess a very subordinate importance. The isolated and the agminated glands are both prominent, chiefly because they are swollen by the liquid imbibed from the bowel. A whitish substance which they sometimes contain may perhaps be the albumen or fat which they have taken from the intestinal liquid. A very similar condition of the mesenteric glands is probably due to a like cause. The liver is pale and flaccid when death takes place in collapse, and it is also described as presenting a "dirty grayish-red, homogeneous appearance, and indistinctness of the lobular structure, as if some glutinous matter had been poured throughout the tissues of the organ" {746} (Sutton). This appearance would seem to be due to the total suspension of the blood-supply through the portal vein.

At all stages of the disease the gall-bladder is usually found full of bile, which is apt to be dark during the collapse and more watery after reaction has commenced.

The spleen is small, pale, and, as a rule, firm, but occasionally it is soft.

The kidneys present no marked changes when death has taken place early in the attack, or at most only exhibit a lighter color than usual of the cortical substance and a darker one of the pyramids. They show that the arteries are comparatively empty and that the veins are congested. Similarly contrasted appearances are met after death from obstructive disease of the heart and other causes that produce obstruction of the venæ cavæ. In the tubules, later on, fatty degeneration of the epithelium has been observed, and some cylindrical casts. These alterations, especially of the tubules, are most marked when death occurs in the stage of reaction, and are then apt to be accompanied by more or less hemorrhagic transudation. The urinary bladder is always contracted after death in collapse; after febrile reaction its mucous membrane may be more or less coated with false membrane.

The brain and the spinal marrow offer nothing peculiar; their venous systems are everywhere more or less engorged, and sometimes effused blood has been found in the spinal canal.

In the state of the respiratory organs the most important facts are that in algid cholera the lungs are always more or less collapsed, "shrunk and small, and lying back in the chest, toward the spine," and that, so far from being congested, they are (with the exception of a small portion of their posterior part rendered dense by hypostasis) singularly bloodless, dry, and tough. As might be inferred from these conditions, they are also lighter in weight than natural. To Dr. Parkes belongs the credit of having first described this very important fact in the morbid anatomy of cholera, as follows: "In fourteen cases the lungs were completely collapsed, appearing in some cases like the lungs of a foetus. In three cases they were considerably, in eight slightly, collapsed, and in the remaining fourteen cases the collapse was in some altogether, and in some partially, prevented by old adhesions." So Dr. Sutton found that the average weight of the two lungs during collapse was about twenty ounces, and after reaction--that is, after the passage of the blood into the pulmonary artery had become completely re-established--about forty-five ounces. In the latter condition also the lungs presented the usual signs of congestion of those organs, being dark-red throughout or in portions only. Sometimes also they contained masses or nodules of apparent hepatization, and of these some may have undergone partial softening.

In absolute conformity with the condition of the lungs that has been described is that of the heart. If the lungs are bloodless, it follows necessarily that the left side of the heart must be empty, and almost as necessarily that the right side of the heart must be distended with blood. All careful investigators of the subject agree that such is the condition of the heart when death takes place in cholera during the stage of {747} asphyxia. All report that the pulmonary artery is either empty or that it contains a small quantity of dark and usually of thick blood; that the right side of the heart and the coronary veins are distended with blood of the same description, while numerous ecchymoses exist along the course of the coronary veins; that the venæ cavæ are filled with half-coagulated blood of a tarry aspect; and that even the femoral and splenic veins contain similar blood. On the other hand, the left ventricle of the heart is usually contracted, and contains a very little semi-fluid blood, with perhaps a small and pale clot. This engorged condition of the right cavities and emptiness of the left cavities of the heart diminish very slowly during the passage from collapse to reaction, during which time the pulmonary blood-vessels are being gradually replenished. Besides the thick and tarry aspect of the blood above described, it has been observed that when the blood is withdrawn by means of a pipette, its globules rapidly subside and are surmounted by a transparent serum, and that such blood may remain for a long time uncoagulated. The red corpuscles are said to be pale and viscous, but not adhesive, and the white corpuscles abnormally numerous and easily crushed. In the free intervals are observed "very pale little objects, slightly elongated and constricted in their middle," which multiplied in blood kept for one or two days at a temperature of 38° C. (100.4° F.). If death does not take place until reaction is far advanced or has merged into a febrile condition, the left ventricle is usually found not contracted, and it contains a quantity of blood. The term "usually" is employed to show that even to this rule there are some exceptions, and that, as in all other diseases, the issue does not depend absolutely and exclusively upon a definite degree of any anatomical lesion, but upon the aggregate condition of all the functions upon which life depends. The pericardium, like the pleura and the peritoneum, may be covered with a saponaceous film which is albuminous.

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In looking now over the field that has been traversed in the foregoing pages, and searching for some link that will unite in a consistent whole the causes, symptoms, and lesions of cholera, it is evident that only one factor can possibly be so described. That factor is the gastro-intestinal flux. This it is that produces the vomiting and the purging; that prostrates the patient and wastes away in a few hours the fullest and the firmest form; that chills the limbs and afterward the trunk; that thickens the blood so that the capillary vessels can no longer convey it, and that spreads a cyanotic shadow over the whole surface of the body; that cuts off the supply of blood from the lungs and heart; that paralyzes the nervous system, ganglionic as well as cerebro-spinal; that obstructs the kidneys and arrests their secretion; and that, acting through the several links of this pathological chain, becomes the cause of death. But the question still recurs, What is the cause of the gastro-intestinal flux? To this also, in the light of observation, it is possible to give only one answer. It is a specific poison which originates in Hindostan, and, being taken into the stomach and bowels, not only produces in the individual the symptoms and lesions of cholera, but is capable of multiplying itself and rendering infectious the discharges from the stomach and bowels of the subjects of the disease, so that it may be transmitted from {748} one person to another round the whole circumference of the globe. Regarding the form and nature of that poison little or nothing is definitely established, beyond what has already been stated as the result of Koch's observations. As far as they go, they harmonize with a long-prevalent opinion that the cholera poison consists of certain microscopic germs, which, on being received into the bowels, propagate their kind and destroy the epithelium. It is believed by some that these bodies are products of the rice-plant on the banks of the Ganges, and that, having once originated the disease, the germs contained in the discharges become mixed with water or are borne upon the wind, and enter the system of new victims, who, in their turn, disseminate the plague. This theory will be further considered below.

Another view, that of B. W. Richardson, is that, "as pus undergoes changes which convert it into a septic poison, so the excreted matter from the alimentary canal is equally capable, under peculiar conditions of oxidation, of producing an alkaloidal organic poison, which, soluble in water, but admitting of deposit on desiccation," becomes the agent for disseminating the disease. In these theories a false datum and a hypothesis are offered us in place of the fact which we seek. The cryptogamous nature of the essential cause of the disease has no positive proof, but only the probability of coincidence in its favor. There is no proof, because one after another organic form has been alleged to be the essential generator of the disease, and each has been proved to be either not peculiar to cholera or has been shown to be present in other diseases than cholera.

At the present time (1884) it is the fashion to trace every disease to specific bacteria or analogous organisms. But it may be that the occurrence of cholera only furnishes the occasion for the development of these organisms, just as a certain temperature, hygrometric condition, and deficient light and air will cause mould to form on bread and other organic substances. The judgment pronounced by Dr. Beale in this question as long ago as 1866 appears now, as it did then, to approach the truth upon this point: "There is no good reason for supposing that the bacteria in such numbers in the alimentary canal in cholera have anything to do with this disease or with the falling off of epithelium from the intestinal and other mucous membranes. Bacteria are developed in organic matter which is not traversed and protected by the normal fluids of the body, and they invade the cells and textures in cholera after those cells and textures have undergone serious prior changes, just as they would invade textures removed from the body altogether. Nor would it be in accordance with known facts to infer that cholera was due to the invasion of some peculiar form or species of bacterium."

We repeat, then, that while nothing can be simpler than the mechanism of cholera viewed as a gastro-intestinal hyperidrosis, nothing is more mysterious than the mechanism of the primary cause which gives rise to it. That its real nature has been correctly described is rendered all the more probable by the fact, presently to be insisted upon, that sporadic cholera morbus, which is always the consequence of a direct irritation of the gastro-intestinal mucous membrane, is often with difficulty distinguishable from Asiatic cholera, which, indeed, differs from the former {749} disease chiefly by the intensity of its cause as measured by the gravity of its symptoms and by the nature of the special agent that produces it.

The above views regarding the essential cause of cholera were substantially indited before the Egyptian epidemic of 1883, but they are in accord with the more definite conclusions arrived at by the German and French commissions on the subject. Before their reports appeared, however, a communication was made by Dr. Kartulis of the Greek hospital in Alexandria, setting forth that the drinking-water and the stools and blood of the cholera patients contained, the first a mass of micro-organisms, and the others bacteria and micrococci, which, however, presented no distinctive characters. The German report was prepared by Dr. Koch, the French by Dr. Strauss. The former, alluding to the enormous quantity of micro-organisms found in the contents of the bowels and in the stools, did not perceive any connection between them and the phenomena of the disease. On the other hand, he did assign this relation to a species of bacterium found in the walls of the intestine, and which he compared to the bacilli of glanders. They were lodged in great quantities within the intestinal glands and behind their epithelium, as well as upon the surface of the villi and within them, and sometimes even in the muscular coat. They were most numerous at the lower end of the small intestine. Dr. Koch concluded that although these bacilli, beyond doubt, are in some manner associated with the development of cholera, they are by no means shown to be its cause, and may indeed be themselves the product of the morbid conditions belonging to cholera. All his attempts at that time to develop cholera in animals by inoculating them with the organisms gave only negative results. The conclusions of Dr. Strauss were in entire conformity with those of Dr. Koch, but involved an additional and very important statement--viz. that the shorter and the more violent were the fatal attacks of cholera the fewer were the bacteria found in the intestine. It is evident that this fact is the very opposite of what should have been found had bacteria been essential in the causation of cholera. The more recent investigations conducted in Calcutta by Dr. Koch, which have already been cited, led him, however, to attribute to bacilli of a specific form the absolute origination of the disease. He poses the question in the following manner: Either these "comma bacilli" are a product of the cholera process, or "the disease only arises when these specific organisms have found their way into the bowel." The former alternative he rejects, because, in his judgment, it assumes that the bodies in question must be pre-existent in every person who becomes affected with the disease--a hypothesis which he rejects, because they have never been found except in cholera. He therefore concludes that they are the cause of cholera. He points out that their first appearance coincides with the commencement of the disease, that they increase with it, and that they disappear with its decline. The statement of Strauss quoted above does not, however, appear to harmonize with this conclusion, since the bacteria are said by him to have been fewest in the more violent and fatal attacks of the disease. Another of Dr. Koch's remarks is also open to criticism. After showing how rapidly the cholera bacteria multiply when kept moist, he states that they die after drying more quickly than almost any other form of bacteria. "As {750} a rule, even after three hours' drying every vestige of life has disappeared." It is evident that this statement is not in harmony with the numerous facts, several of which have been cited, that cholera fomites have preserved their infectious qualities after several weeks. Dr. Koch endeavored to produce in animals, artificially, with these bacteria, a disease analogous to cholera, but without success; and he adds, "If any species of animal whatever could take the cholera, it would surely have been observed in Bengal, but all inquiries directed to this point met with a negative result." Dr. Vincent Edwards, who, however, is of opinion that the cholera poison is "not an organism, but of the nature of a chemical compound of comparatively unstable nature," reports that he produced fatal cholera in pigs by giving them the dejections of cholera patients. But the Times and Gazette inclines to question that the pigs employed in Dr. Edwards' experiments were affected with true cholera.

DIAGNOSIS.--The most characteristic symptoms of Asiatic cholera have repeatedly been mentioned in the foregoing pages. They are rice-water evacuations by vomiting and purging, rapid emaciation of the whole body, a cadaverous hollowness of the cheeks and eyes, a livid color of the face, hands, and feet, a feeble, thready, and at last absent pulse, an icy coldness of the extremities, face, and even the breath, a loss of the elasticity of the skin, a thin and feeble voice, and intense thirst. But every one of these symptoms may occur in cholera morbus produced by a direct irritation of the stomach and bowels. It is rather their nature, we repeat, than their phenomena that distinguishes these two affections from each other. In attempting to separate Asiatic cholera from other forms of cholera we must endeavor to dismiss from the mind the erroneous notion that the term cholera denotes a definite disease identical in its cause, phenomena, and results. It is no more a disease than dropsy or fever is a disease. It is a complex group of symptoms which have in common the fact that they proceed directly from gastro-intestinal irritation, whose degree of severity--i.e. the presence or absence of certain grave symptoms--and, above all, its issue, depend chiefly upon the nature and intensity of the cause of the attack, and also, necessarily, upon the degree of resistance opposed to it by the subjects of the disease. Nothing has led to more error in regard to epidemic cholera than the ignorance of this pathological fact by some and the disregard of it by others.

In the first portion of this article it was shown that the Greek, Roman, and Arabian conceptions of cholera morbus included a discharge of bile, the very symptom for the absence of which Asiatic cholera is notorious; and also that the classical cholera, or cholera morbus, ended in recovery even more frequently than Asiatic cholera terminates in death. But local epidemics of cholera morbus sometimes take place which are of a severe and even of a grave type, and which also appear to originate in some peculiar atmospheric influence, for they prevail to a limited extent and in connection with vicissitudes of weather. Still more circumscribed epidemics have been traced to unwholesome food and drink, and innumerable instances of individual attacks have been caused by irritants that are ranked as poisons and others which are reckoned as food or medicines. Now, under these various circumstances, which have in common gastro-intestinal irritation, there may be produced, if the irritation is excessive, {751} a series of symptoms closely resembling, if not identical with, those of Asiatic cholera.

In illustration may be cited the comparatively familiar description of Sydenham. These are his words: "There is vomiting to a great degree, and there are also foul, difficult, and straining motions from the bowels. There is intense pain in the belly, there is wind, and there are distension, heartburn, and thirst. The pulse is quick and frequent, at times small and unequal. The feeling of sickness is most distressing, and is accompanied with heat and disquiet. The perspiration sometimes amounts to absolute sweating. The legs and arms are cramped and the extremities cold. To these symptoms, and to others of a like stamp, we may add faintness." ... "As the summer came to a close the cholera morbus raged epidemically, and, being promoted by the unusual heat of the weather, it brought with it worse symptoms, in the way of cramps and spasms, than I had ever seen. Not only, as is generally the case, was the abdomen afflicted with horrible cramps, but the arms and legs, indeed the muscles in general, were afflicted also." ... At the risk of repetition an additional passage may be quoted from Sydenham's later definition of cholera morbus: "This is limited to the month of August or the first week or two of September. Violent vomiting, accompanied by the dejection of depraved humors, difficulty on passing them, vehement pain, inflation and distension of the bowels, heartburn, thirst, quick, frequent, small, and unequal pulse, heat and anxiety, nausea, sweat, cramps of the legs and arms, faintings, and coldness of the extremities, constitute the true cholera--and it kills within twenty-four hours."

In spite of the general likeness between this description and the symptoms of Asiatic cholera, there are differences of considerable importance which have been italicized in the quotations. These differences are such as may be attributed to the action of a harsh irritant in the case of cholera morbus, while in the epidemic (Asiatic) disease the distinctive phenomena are the result of a sudden and profuse intestinal flux. Macpherson, who had a long and extensive experience of epidemic cholera in India, after contrasting in detail its phenomena with those of cholera nostras, sums up the discussion in these words: "Cholera indica is essentially a very fatal disease, while cholera nostras is usually a mild affection and is seldom fatal, although it was called atrocissimus et peracutus, and has undoubtedly killed in from eight to twenty-four hours." In regard to the individual symptoms this very competent reporter does not recognize a single one as being absolutely peculiar to either disease. Even the ancients, already referred to, after describing bilious evacuations as being characteristic of cholera nostras, add that sometimes also they are whitish; and modern writers, both before and since the advent of Asiatic cholera in Europe, have made a similar observation. Thus, Quinquaud, in his description of cholera nostras, of which a slight epidemic occurred in 1869 at the Hospital St. Antoine in Paris, says: "The principal symptoms were vomiting and purging, sometimes of a bilious and sometimes of a rice-water liquid; a shrivelled and cyanotic skin, the latter appearance being sometimes strongly marked; anxiety, coldness, cramps, altered voice, and suppression of urine." In 1875 thirty-three cases of this {752} disease occurred at Valenciennes, near Paris, and its symptoms were thus summarized by Manouvriez: "Repeated vomiting, first of food, and then of a dark-green liquid; diarrhoea, which was at first fecal and then bilious, but afterward serous and like rice-water; painful tension of the epigastrium and tenderness of this part; headache, cramps in the legs, suppression of urine; pallor, coldness, and dryness of the skin, especially of the limbs; pinched features, a blue circle around the eyes, a small and scarcely perceptible pulse, and a faltering and whispering voice." Yet of the thirty-three cases only two were fatal--the one a child of four years and the other an infant of as many months. The substantial identity of nature of these two local epidemics, and the almost equally close relation of their symptoms to those of epidemic cholera, must be quite apparent.

Yet the contrasts are neither slight nor unimportant; and the most striking and significant is the trifling mortality of the European as compared with the Asiatic disease, notwithstanding the grave symptoms present in the former. It may be regarded as certain, we think, that the reason of this difference of danger lies in a corresponding difference in the nature of the causes of the two forms of disease. The rapid recovery from cholera morbus produced by changes of weather, acid fruits, and indigestion renders it certain that no material lesion of the gastro-intestinal mucous membrane has been produced; while, on the other hand, inspection after death from epidemic cholera or by corrosive poisoning renders it equally certain that the damage to that membrane is substantial and widespread, as well as often irreparable, and that, therefore, "the powers of life that resist death" must be engaged in a very unequal and often fruitless struggle. The cramps in cholera nostras are, as a rule, less severe than in epidemic cholera, while the colicky, and in general the abdominal, pains are greater in the former than in the latter disease. The reason of this difference appears to be that muscular spasm is the natural result of depletion, whether sanguine or serous, while colic is an effect of irritation of the surface of the mucous coat of the bowel, and not of its destruction, such as occurs in epidemic cholera.

It is true only in a limited degree, and indeed only upon a superficial survey of the symptoms, that the effects of irritant poisoning are like those produced by Asiatic cholera. The analogy between the two was pointed out, among others, by Sedgwick in 1867. The resemblance appeared so striking to the vulgar eye that in Paris, and perhaps elsewhere, a popular tumult followed the first violent outbreak of epidemic cholera, and it was charged that the wells had been poisoned. The cases that most resemble cholera are the following: "Acute poisoning by corrosive sublimate, by arsenic, and by mineral acids, especially nitric acid; the effects which follow the eating or drinking of poisonous animal matters, such as tainted or simply unwholesome meat or fish, and milk which has undergone some injurious but yet unknown change, decomposing vegetables and some of the poisonous fungi, and the excessive action of certain drugs, for the most part belonging to the class of drastic purgatives," as elaterium and croton oil. The effects produced by these agents constitute a cholera morbus, and therefore resemble cholera, and have been occasionally, and almost unavoidably, mistaken for it. It {753} is remarkable that suppression of urine may occur among them, as well as vomiting, purging, and collapse. As Griesinger and others have pointed out, the order in which the symptoms occur is a valuable, and generally an available, ground of diagnosis. In cholera, diarrhoea always occurs before vomiting, while in the various irritant poisonings mentioned vomiting precedes diarrhoea. In irritant poisoning also there is generally severe abdominal pain--not so much colicky and paroxysmal as constant and burning; the stools are not so copious as in cholera, and they do not possess the rice-water aspect, but are rather dark, bloody, and fetid, and are voided with tenesmus or with heat in the anus; and even when the urine is suppressed it is less persistently and completely so than in cholera, and attempts to void it are attended with vesical tenesmus and strangury. In a doubtful case it is important to ascertain whether a metallic or other unpleasant taste is perceived in the mouth, whether this cavity or the throat bears marks of corrosion, whether any unusual article of food has been used, etc. Moreover, it is of extreme importance to learn whether Asiatic cholera prevails, not merely in the immediate neighborhood, but at any place from which diseased persons or infected goods may have arrived. The instances should not be forgotten in which cholera-infected clothing from Europe has developed the disease in the valley of the Mississippi. Nor should those still more numerous cases be overlooked in which travellers affected with choleraic diarrhoea have disseminated the disease at great distances from their starting-point, although unconscious of the nature of their own ailment, whose seed they were sowing along their route.

PROGNOSIS.--Like the diseases called septic, of which the eruptive fevers may be taken as examples, and also like the effects of irritant poisons, the gravity of cholera must mainly depend upon the amount and the activity of the specific poison that is received into the system. It is most probable that the cholera poison is organic, and that it has a limited power of reproduction and term of existence, a period also of intense activity and a period of exhaustion; in a word, that either by progressive dilution as an inorganic substance or by organic senescence it finally ceases to exist. By no other theory is it possible to explain the numerous degrees of severity which cholera exhibits, from a mild indisposition to a malignant and rapidly fatal disease. On the one hand, the patients, if they may so be called, are hardly prevented from attending to their customary occupations. They may even be able to travel and carry the disease to distant places, and so appear to justify the erroneous and irrational doctrine of the atmospheric or spontaneous origin of cholera. On the other hand, the entire apparent duration of an attack may not exceed two or three hours, during which all the distinctive symptoms of the disease may be crowded together in the most appalling forms. Such grave cases are always most numerous at the commencement of an epidemic. These statements are true not only in regard to individual cases in the greater number of epidemics, but they represent the distinctive character of particular epidemics, some of which are as remarkable for their benignity as others are for their extreme malignity. For such contrasts no plausible reason can be suggested, unless it be a difference either in the essential virulence of the morbid poison or in the dose of it imbibed. That they are due to the activity rather than to the quantity of the poison seems to {754} be proved by the progressive weakening in the gravity of the cases; for if the quantity of the poison remained the same some malignant cases might be expected to occur even during the decline of an epidemic.

These considerations help to explain the extreme diversities of mortality in different epidemics. The extremes may be stated at 10 and 90 per cent., and they would perhaps be still wider apart if all the mild cases, which are never reported--many of which, indeed, do not even fall under medical observation--were included in the reckoning. The general or average mortality of cholera is about 50 per cent. According to Allbu, the epidemics in Berlin from 1831 to 1873 gave a total of 28,753 cases and 18,916 deaths; that is, a mortality of 65.8 per cent. (Eichhorst). It should be noted that, as in other epidemic diseases, there is no uniform proportion between the extent and the mortality of cholera epidemics. Some of very limited extent have been proportionally the most destructive. It should also be remembered that the disease is far more fatal in infancy and old age than at any other period of life, and for a similar reason it is very dangerous to all who are weakened by any cause, such as an inherited morbid diathesis, a chronic debilitating disease, etc. There seems to be a doubt whether its male or female victims are the more numerous. In this connection it may be suggested that while males are more likely to contract the disease by drinking contaminated water, etc., more women are exposed to its contagion by their intimate relations with the sick, by their handling and washing infected fomites, by carrying away the cholera discharges, etc.

Undoubtedly, the class of society to which cholera patients belong is not without influence on its prognosis. Not only is the total mortality greater among the laboring classes, but the individual belonging to those classes has a less chance of recovery, because he is not apt to resort to treatment on the appearance of the premonitory signs of the disease, and because the treatment he receives is less intelligently and sedulously pursued by his physicians and friends.

In regard to the particular symptoms which are favorable or unfavorable, nothing need be added to what has already been stated in detail, unless it be that during the height of the attack the danger is to be measured by the degree of prostration and of the stasis of the blood, and, during reaction, by the grade of the typhoid state. Gradual reaction, as denoted by the state of the skin and the pulse and a more natural aspect of the stools, is generally indicative of improvement.

Finally, a word of caution may be given to those who are apt to attribute all the favorable changes in the conditions of an epidemic to the sanitary or medicinal measures they have instituted. Cholera epidemics are remarkable for the comparatively short period of their duration, which may be stated at less than a month in the same place. Doubtless, judicious sanitation and timely treatment save a great many lives, but the qualifying fact, already insisted upon, must not be overlooked, that the mortality occasioned by the disease in a given place is greatest during the first period of its prevalence, and that thenceforth it gradually declines. Yet it is of essential significance that the disease rarely attacks a large number of persons simultaneously; the epidemic proper is usually preceded by a few scattering cases which are apt to become foci of ignition that presently unite to form a widespread conflagration. The recognition {755} of these cases, their isolation, and the proper treatment of the localities where they occurred have frequently stamped out what might have been the commencement of a deadly epidemic.

PREVENTION.--The history of cholera demonstrates conclusively that since the disease, outside of India, never arises spontaneously, it must be more or less preventible, partly by excluding its seeds and partly by rendering the soil in which they are planted more or less unfit for their development; in other words, by quarantines and sanitary cordons and by various measures of local sanitation.

In regard to the former there would be comparatively little difference of opinion, at least theoretically, if both measures were alike efficacious. But there would seem to have prevailed a tendency in official quarters to undervalue the efficiency of both. Those who made and administered the sanitary laws relating to cholera seem to have forgotten the emphatic question, "What will not a man give for his life?" or at least to have considered that whatever value some men may set upon their own lives, the lives of other men become of no account when balanced against the needs, or even the conveniences, of commerce. The ethics which justified the introduction of opium into China by the English and the American gift of alcohol to the Indian to gratify a lust for lucre or for land is only paralleled by those contained in the official protests against cholera quarantines. At the International Medical Congress held in 1873 at Constantinople, it was almost unanimously resolved that "the practice of (land) quarantine as now carried out ought not to be maintained, because, on the one hand, it does not constitute a real protection, and, on the other hand, it is directly opposed to the interests of commerce and industry." A leading critic, in commenting upon this, remarks that if a quarantine were possible it would give no real security, because it would be evaded, just as customs laws are evaded by smuggling. A logical deduction from this curious argument would be that customs laws should be abrogated. In 1880 was published the report of the German Imperial Commission on the cholera epidemic of 1873 in Germany, edited by Hirsch, from which we learn that "all the German medical experts agree in condemning the employment of quarantine, for, while largely detrimental to the interests, welfare, convenience, and happiness of a community, it is quite inert and inefficient as a safeguard against the further diffusion of cholera." Whether this opinion refers only to land quarantine or not is left in doubt, but the spirit of subordinating the lives of the people to the commercial interests of a country is just the same as, and is not less worthy of condemnation than, the spirit which has more than once blinded customs officials to the disease on board of vessels from which it has afterward issued to destroy thousands of lives.

It seems to be overlooked that in national as well as in personal affairs "honesty is the best policy," and that if, instead of concealment or false statements regarding the sanitary state of ships, their passengers, and cargoes, and equally false assertions respecting the contagiousness of cholera, and a contemptuous neglect of well-tried preventive measures,--if, instead of this delusive and disastrous policy, all nations had honestly carried out the rules prescribed by experience for the exclusion of the disease, and for its management after it had passed the frontiers of a country, {756} there can be little doubt that its ravages would ere this have been confined to the region in which it originated. As we have seen, there is urged against the enforcement of a rigid quarantine by land or sea the singular argument that it has not always excluded the disease. A more logical inference would seem to be that since it succeeded, not completely, but yet partially, its inefficiency should be charged to its imperfect execution; or, even granting that the absolute exclusion of cholera is impracticable in every instance, including cases of choleraic diarrhoea, contaminated clothing and merchandise, does it therefore follow that the transit of men and things should be unimpeded? As well might it be maintained that because one or more houses cannot escape destruction by fire, therefore no effort should be made to save the remainder of a threatened city; as well might it be argued that because some men must be killed in battle, no precautions should therefore be used to preserve the rest of the army; as well abstain from all local sanitation intended to mitigate the ravages of the disease, because, do what we may, some victims it will surely have. This is taking counsel from despair; is a stupid fatalism which one might imagine to have been imported with the disease from the East; or it may be a sign of the unconscious blindness of Mammon-worshippers, who, neither fearing God nor regarding man, have as little pity for the victims of cholera, permitted, if not invited, by them to scourge the nations, as devout Christians once felt for the negroes who were bought or kidnapped in Africa to toil and die under the lash of the slave-driver.