COLUMBIA LIBRARIES OFFSITE 
 
 HEALTH SCIENCES STANDARD 
 
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 RC1 26 .St6 Cholera, its protean 
 
 RECAP 
 
 By Dr. G. Archie 
 
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 COLUMBIA UNIVERSITY 
 EDWARD G. JANEWAY 
 
 MEMORIAL LIBRARY 
 

A TONIC. 
 
 HORSFORD'S ACID PHOSPHATE 
 
 Prepared under the direction of Prof. E. N. Horsford. 
 
 A most excellent and agreeable tonic and appetizer. It 
 nourishes and invigorates the tired brain and body, imparts 
 renewed energy and vitality, and enlivens the functions. 
 Dr. Ephraim Bateman, Cedarville, N. J., says: 
 
 " I have used it for several years, not only in my practice^ 
 but in my own individual case, and consider it under all cir- 
 cumstances one of the best nerve tonics that we possess. For 
 mental exhaustion or overwork it gives renewed strength and 
 vigor to the entire system." 
 
 Descriptive pamphlet free. 
 
 RUMPORD CHEMICAL WORKS, 
 
 PROVIDENCE, R. U 
 
 Beware of Substitutes and Imitations. 
 
 CAUTION:— Be sure the, word " MIorsford's " is printed on the lut^el. 
 All others are spurious. Never sold in bulk. 
 
CHOLERA, 
 
 ITS PROTEAN ASPECTS AND ITS 
 MANAGEMENT. 
 
 DR.. G. ARCHIE STOCKWELL, F.Z.S. 
 
 (^Member New Sydenham Society, Londoji.) 
 
 In Two Volumes — VOL. I. 
 
 ^^ Respice, aspice, prospice.' 
 
 1893. 
 GEORGE S. DAVIS, 
 
 DKTROIT, MrCH. 
 
Copyrighted by 
 
 GEORGE S. DA^^S. 
 
 1893. 
 
DEDICATION. 
 
 To Or, Cyrus M. Stockwell, of Port Huron, Michigan — the 
 kindest and best of fathers; the most thorough, exemplary, and 
 painstaking of tutors ; the companion of youth and manhood ; 
 who early inculcated the necessity of close habits of observa- 
 tion and ratiocination, including self-segregation in all matters 
 scientific — this volume is dedicated in deepest sympathy and 
 
 love by 
 
 THE AUTHOR- 
 
 December 1st, 1892 
 
PREFACE. 
 
 When this volume was undertaken, on the spur of the 
 moment and at the solicitation of the publisher, it was not 
 expected to be more than an exponent of personal views; but 
 in seeking collateral evidence, I was agreeably surprised to 
 find myself by no means singular in an estimate of cholera — 
 that many had recognized in greater or less degree the role 
 played by the nervous system, and even admitted the possi- 
 bility of profound toxicity of the cerebro-spinal centres. 
 Hence was necessitated a work more extended in scope, and 
 more generally particularized in outline. 
 
 Again, I am pleased with the opportunity of contribut- 
 ing my mite toward undoing the evil wrought by the greatest 
 medical heresy of any age — a heresy that seeks to elevate to 
 the acme of pathological knowledge, a vain, visionary, 
 theatrical egoist, devoid of even the shadow of medical 
 training. The exponents of bacillar pathology depend solely 
 upon hypothetical assumptions, ignoring all forms of evi- 
 dence not adduced by themselves. With them the microscope 
 is no longer an accessory to skilled observation, but may 
 supersede the latter altogether. With profound contempt 
 for biologico-zoological laws and their applications, factitious 
 maladies, artificially produced, are made to replace real 
 maladies. Their pathology is merely an experimental ex- 
 perience admitting of neither negations or offsets; their ther- 
 apeutics, a form of still hunt with untried weapons, in an un- 
 known jungle, after a hypothetical prey. Indeed, it is a sad 
 travesty upon medical science when authors and would-be 
 teachers wantonly assert Rabies, Cholera, Yellow-fever, 
 Dengue, Tetanus, Endo-carditis, Pneumonia, etc., are '' dis- 
 
eases zvhose microhic origin is positively known'" when two of 
 these are supported only by manifest fraud, in two more the 
 evidence has never been adduced in any form, and in the 
 other three it is of the most flimsy, superficial character. — 
 The list might be considerably increased as regards the lat- 
 ter. The tendency is to sacrifice truth to temporary self- 
 aggrandizement; to assert individual preferences as estab- 
 lished facts, regardless of results, forgetting Science is a 
 stern mistress who permits neither preferences or personal- 
 ities, and refuses to acknowledge evidence that is not freed 
 from the errors of coincidence and ably supported by neg- 
 atives; 
 
 In conclusion, I will here make special acknowledgment 
 of indebtedness to Doctor Alexander Harkin of Belfast, Ire- 
 land, for copies of his researches into the aetiology, pathology 
 and treatment of cholera, which lead anything hitherto pub- 
 lished upon this subject; his views are so in accord with my 
 own, that frequently the former have by preference been 
 adopted in toto, consequently the chief merit of this work 
 will remain with him — not me. 
 
 I have also availed myself freely of the labors of Felix 
 von Niemeyer. Thomas Hawkes Tanner, and Hermann 
 Lebert, whose cholera essays are models of diction and pro- 
 found epitomes of information concisely expressed; also of 
 the researches of Surgeon-Majors T. R. Lewis, D. D. Cun- 
 ningham, J. M. Cunningham, E. A. Parkes, and J, C. Hall; 
 Sir Wm. Aitken, Sir Thos. Watson, Geo, Johnson, M. J. von 
 Pettenkofer, G. V. Black, A. M. Brown, Geo. Crookshanks, 
 Rudolf von Jaksch, James Gagney, et al. 
 
 I will likewise acknowledge special courtesies at the 
 hands of Dr. Thos. C. Minor, of Cincinnati, and the Sec- 
 retary of the Tennessee State Board of Health, whereby was 
 obtained a large portion of the material embodied in the 
 Appendices. 
 
VII 
 
 Thus the volume makes little pretense to originality 
 further than as a condensed rescript from others, supple- 
 mented by personal views as evolved by practical observa- 
 tion and experience. 
 
 Geo. Archie Stockwell. 
 
 650 Congress Street E., 
 Detroit, Mich. 
 
CHAPTER I. 
 
 HISTORY. 
 
 In the ranks of the medical profession, no less 
 than in lay circles, the subject of Cholera* is one of 
 supreme and absorbing interest, especially now that, 
 in epidemic form, it is knocking vigorously at our 
 very gates, so to speak, and sedulously endeavoring 
 to force an entrance. 
 
 For a number of years Americans have solaced 
 themselves with the idea that modern science had 
 effectually barricaded cholera from Europe, and con- 
 sequently from the Western Hemisphere, except in the 
 sporadic form that is always more or less prevalent in 
 Mediterranean ports, and occasionally asserts itself 
 in the United States as a concomitant of the heated 
 term. But, while the general progress of sanitation 
 in the civilized world has been considerable, and such 
 as in great measure to remove the faulty conditions 
 under which the disease flourishes, scientists are 
 rudely awakened by the fact the danger line has by 
 no means been eradicated, that the barriers of pro- 
 tection have been silently and unexpectedly forced, 
 and that if immunity of the American continent is to 
 be secured it is only at the price of " eternal vigi- 
 lance " coupled with more perfect knowledge. 
 
 *From ;^^oAaS, "the bowels," and peoo, "to flow" — not, 
 as has been imagined, from X<^^V< "bile," and psoa. — S. 
 
 I KKK 
 
When are recalled the fearful and weird tales of 
 various visitations, and the universal panic that in each 
 instance has resulted, it is little wonder the public 
 await breathlessly each successive cholera bulletin, 
 fearing the dread malady has broken bounds and, con- 
 sequently, may at any moment manifest itself in the 
 very midst of the most remote community. 
 
 Evidently the disease has prevailed for untold 
 centuries in portions of the Orient, and manifested 
 itself as both an endemic and epidemic in the Indian 
 Peninsulas, where — until quite recently at least — it 
 has ever been regarded as a filth disease. It is only 
 within the last three-fourths of a century, however, 
 that it has manifested any predilection for Europeans, 
 prior to this period being universally regarded as a 
 plague peculiar exclusively to dirty, badly-housed, ill- 
 fed "heathen." In Siam and Burma cholera is always 
 present; in Hindustan it is wont to ravage certain dis- 
 tricts with great regularity, being in the main an ac- 
 cessory to religious pilgrimages, shrine-worship, etc., 
 especially when any considerable number of natives 
 are assembled together. It remains a regular visitant 
 at the annual festivals held at the great Conjeveram 
 Pagoda, forty-five miles from Madras, whence the lat- 
 ter city is regularly infected, and at the great gather- 
 ings of Allahabad. It was a constant attendant upon 
 " The Jagannath," as held at Puri, a town of 35,000 
 inhabitants, that was generally healthy in June and 
 July, but invariably developed cholera the succeeding 
 
— 3 — 
 month with the influx of some 150,000 pilgrims, who 
 filled the lodging-houses almost to the point of suffoca- 
 tion, and crowded even the streets and fields, literally 
 covering both with their urine and excrement the 
 decaying odors of which terribly impregnated the at- 
 mosphere for miles about; here the disease claimed 
 its victims, not by scores but by hundreds, yet speed- 
 ily ceased its ravages on the dispersion of the multi- 
 tude and subsequent thorough amalgamation of their 
 filth with the soil. 
 
 It was only in the early part of the present cent- 
 ury that the malady first appeared in Jessur, in 
 Bengal (sixty-seven miles north-east of Calcutta), as 
 an epidemic, infectious, pestilential disorder, and over- 
 stepping its natural boundaries began a deadly march 
 northward and westward that did not cease for seven- 
 teen years, and is supposed to have claimed nearly 
 600,000 victims. Sir Archibald Allison thus tells the 
 tale :* 
 
 "After the signature of the treaty of alliance 
 with Scindia, November 5th, 181 7, the cholera, then 
 for the first time known in British history, broke out 
 with the utmost violence in Lord Hastings' army, and 
 from the very outset committed the most dreadful 
 ravages. The year had been one of great scarcity; 
 the food crops were of inferior quality; the situation 
 of the British cantonment low and unhealthy. Every- 
 
 *" History of Europe," vol. vi. Edinburgh, 1865. 
 
— 4 — 
 
 thing was thus prepared for the ravages of the epi- 
 demic, which soon set in with terrible severity. For 
 ten days the camp was nothing but a hospital; in 
 one week 764 soldiers and 8,000 camp-followers 
 perished. At length the troops were removed to 
 higher and more airy cantonments, and upon this the 
 malady ceased — a memorable fact for the instruction 
 of future times. As was afterwards experienced, the 
 ravages of the pestilence were greatest among the 
 lower classes of the people. Only 148 Europeans 
 perished in November, but about 10,000 natives fell 
 victims to the malady during the same period. When 
 it spread to Calcutta it destroyed 200 a day for a long 
 time, chiefly amongst the worst-fed and most destitute 
 people." 
 
 So far as can be gathered, the epidemic that now 
 threatens this country, and is already afflicting por- 
 tions of Western Europe, in March or April of the 
 present year appeared in the northern portion of 
 hither India, near the head waters of the Ganges. It 
 first manifested itself in a region a hundred miles or 
 so from Mirut, and two hundred and fifty north from 
 Lucknow, among the pilgrims at the great Hurdwar 
 Fair. Thence it moved northward by Lahore into 
 Kashmir, reaching Peshawar, showing itself violently 
 at Srinagar and in the Punjab in May, a month later 
 ravaging Askabad after traversing the whole breadth 
 of Afghanistan. Here, having reached the Trans- 
 Caspian railway, it moved more rapidly, securing two 
 
points of distribution — one at Baku via the Trans- 
 Caucasian railway, whence it reached Tiflis, Persia, on 
 June 26th; the other at Astrakhan, at the mouth of the 
 Volga, where it broke out June 30th, and was carried 
 by steamboat traffic up that river as far as Tzaritzyn, 
 . Saratov, Samara, Kazan, into the Province of Kos- 
 troma, even spreading to Perm and Nijni-Novgorod, 
 and to Ekaterinburg in the Oural. Moskva (Moscow) 
 became infected August 5th, St. Petersburg twelve 
 days later, when the German ports quickly caught the 
 -epidemic, which probably entered both by crossing 
 the Prussian frontier (rail route) and by sea (via the 
 Baltic).* 
 
 Since its inception in the Northwest Province of 
 India, not only has it traveled the course just indi- 
 cated, but it likewise covered or overflowed many 
 thousand square miles of territory, disseminating itself 
 in very much the same way as did the terrible epidemic 
 of sixty years agone; and all the epidemics that have 
 afflicted Europe, both before and since, appear to 
 have closely adhered to the same line of progression, 
 showing that epidemic history tends to repeat itself. f 
 
 This is a matter worthy of more than passing at- 
 
 * It is to be remarked also, that Hamburg has ever 
 appeared a dangerous point of distribution for Western 
 Europe. — .S. 
 
 f It is notable, both the present epidemic and that of 
 1867, began at the Hurdwar Fair, which is said to attract as 
 high as three millions of pilgrims each season. — S. 
 
— 6 — 
 
 tention, since the present plague, unless abruptly- 
 stayed in its course, may possibly (though it is not 
 probable) in its ravages duplicate those of 1829-34. 
 It may be added, moreover, that the malady follows 
 precisely the same laws in Europe and America as in 
 the Orient; that it adheres closely to trade routes, 
 and advances from the various points where the seed 
 is sown (for reasons hereinafter explained) with inter- 
 vening intervals of uncertain duration, in proportion 
 to the facilities of communication; that it is in no 
 inconsiderable degree dependent upon, and influenced 
 by, seasonal and atmospheric conditions, dying out 
 when these latter are modified or removed. Further, 
 since it is only too plainly apparent that land quaran- 
 tines and sanitary cordons, which European nations 
 are ever ready to enforce against their neighbors, 
 have not been successful in keeping out the epidemic, 
 the utterance of Prof. S. L. Pisani, who is one of the 
 most practical as well as sanguine sanitarians, pos- 
 sesses double weight: "Experience has taught that it 
 is not in our power to prevent the importation of the 
 germs of cholera, and that on good sanitation we 
 should exclusively rely; let the soil be sterilized; let 
 the seed fall on barren rock, and it will not germinate 
 whether the season be favorable or not." 
 
 According to Dr. Wm. Farr,f and also Dr. J. C. 
 Morton, cholera has probably always existed in spor- 
 
 •j- " Report on the Mortality of Cholera in 1848-49." Lon- 
 don, 1852. 
 
adic form in England and Europe, and this fact only 
 serves to add fuel to the flame of an epidemic. They 
 cite several " plagues" as presenting choleraic charac- 
 teristics, among others that so carefully described by 
 Sydenham in the seventeenth century, but which, 
 however, appears to have more nearly approached a 
 dysenteric flux. * 
 
 *See Appendix A. 
 
CHAPTER 11. 
 
 EPIDEMIOLOGY. 
 
 The medical world is to-day as ignorant of the 
 primary derivation of cholera as ever, though numer- 
 ous and varied hypotheses are not wanting. It is 
 possible, perhaps even probable, that in its natural 
 home, in the great river deltas of lower Bengal and 
 of Siam and Burma, where it is endemic, it results 
 from miasm; but whether or not this miasm is devel- 
 oped on diseased rice, as has been suggested, it must 
 be admitted the disease, in its more malignant form 
 at least, was originally exotic to Europe and America, 
 and even now depends for its vigor, more or less, 
 upon the constitutional dyscrasige of individuals, and 
 for its persistence upon certain telluric, meteoro- 
 logic, atmospheric, and concomitant unsanitary con- 
 ditions. 
 
 It is especially noticeable, all others things being 
 equal, that epidemic cholera flourishes best — that is, 
 attacks more people, is more fatal, and more rapidly 
 extends itself geographically — under two special con- 
 ditions: 
 
 First. — During a high temperature of air and 
 earth : 
 
 Second. — At periods when the variations of 
 ground water and temperature are capricious, abrupt, 
 without warning. 
 
— 9 — 
 
 Thus, in October, and early November perhaps, 
 in the northern temperate zone, when the majority of 
 people are day by day vacillating between light cloth- 
 ing and heavy wraps — when colds, influenza, and 
 malaria, are especially rampant, and other diseases 
 prevalent that are the outcome of carelessness, de- 
 ficient body-temperature, or overheating, — the ravages 
 of cholera are apt to be greater than in December, 
 when heavy clothing and heated houses are the rule. 
 So too, the epidemic is more active in July and 
 August, when the days are insufferably hot and the 
 nights cool with heavy dews, than in either September 
 or June. Again, the history of the disease in Asia, 
 Europe, and America, evidences that in high and dry 
 situations, in cold climates, wherever there is a mod- 
 erately uniform or gradually progressing or regressing 
 temperature during the twenty-four hours, its spread 
 in the main is limited and slow; while in low-lying 
 moist places, especially in hot climates that present 
 extremes of humidity between meridian and the suc- 
 ceeding sunrise, its ravages are apt to be most severe 
 and oftentimes quite uncontrollable. In both farther 
 and hither India, it has been observed the pestilence 
 suddenly springs into activity with the arrival of the 
 southeast monsoon which, charged with humidity 
 from the Pacific Ocean, frequently causes a fall in 
 temperature of as much as fifteen to thirty degrees 
 within almost as many minutes. 
 
 Further evidence of the part played by telluric. 
 
meteorologic — and likewise astronomic — conditions, is 
 had in the fact that when cholera is endemic to vol- 
 canic regions, it becomes more active and virulent in 
 those seasons when there is an accession of volcanic 
 action, or when such is pending; the disease was ex- 
 ceedingly active and pernicious throughout the Indian 
 Archipelago and the Malay Peninsula after the Sum- 
 bwa eruption, and all enteric maladies of choleraic 
 nature were then greatly increased and obtained new 
 impetus. In Middle and Eastern Europe, when the 
 epidemic of 1830-34 was at its height, it was ob- 
 served, birds, quadrupeds, fish, and even insects, suf- 
 fered, both prior and during the epidemic, from un- 
 known maladies that caused their death in great 
 numbers; the same was true in India; also of the 
 United States, in varying degree according to topo- 
 graphical features and surroundings. Dr. O. D. 
 Norton, of Cincinnati, recalls that in that city, in 
 1849, when cholera was especially virulent, birds died 
 in their nests, and even the house flies and musqui- 
 toes were exterminated. The same phenomena have 
 accrued to certain portions of Europe the present 
 year. Again, each successive cholera epidemic that 
 swept the civilized world, has been preceeded or 
 accompanied by profound disturbances within the 
 solar system, this year it being the occultation of 
 Mars; also by evidences of famine: Finally, the 
 great epidemics of influenza of this century, though 
 their appearance may be coincidences merely, are 
 
— II — 
 
 certainly suggestive in that in each instance, viz., in 
 1805-34; 1847-49; 1851-53; 1864-65; 1890-91, they 
 preceded an epidemic of cholera. Sir Thomas Wat- 
 son especially notes this fact; and John McLean for 
 twenty-five years a Hudson Bay factor, observed the 
 same in the peninsula of Labrador, where the natives 
 (Nascopies and Innuits) were first decimated by influ- 
 enza, then ravaged with an epidemic of choleraic char- 
 acter; further, it is somewhat striking that both mala- 
 dies, to use the words of Watson, " issuing from their 
 cradle in the East, traversed the northern countries of 
 Europe till, arriving at its western boundary, they 
 divided into great two branches; the one proceeding 
 onward across the Atlantic, the other turning in a retro- 
 grade direction toward the south and east." Between 
 the two epidemics moreover, there is marked similitude 
 or analogy, the main differences being that, whereas 
 one spared but very few and was seldom fatal, the 
 other smote yery few, but with so deadly a stroke that 
 the death rate was exceptionally high. Both are in a 
 sense general epidemics, affecting the whole system 
 but especially manifest in the nervous portion; in both 
 the most prominent symptoms are referable, in the 
 majority of cases, to the mucous membranes— to 
 those of the air passages in influenza, to those of the 
 alimentary canal in cholera. 
 
 Surgeon-Majors T. R. Lewis and D. D. Cunning- 
 ham, who investigated cholera in India for eleven 
 years consecutively (1869 to 1880) under orders from 
 
Her Majesty's Secretaries of State for War and India, 
 remark,* that in manifesting a marked partiality for a 
 soil of the character of the Brahmaputric and Gangetic 
 alluvium, " cholera is by no means singular, for it is a 
 well established fact that malarious fevers and kindred 
 disorders flourish with most vigor about the deltas of 
 large rivers all over the world," . . . but they 
 would not, however, " be understood to imply that the 
 causes productive of malarial fevers and cholera are 
 identical, or that the localities providing the condi- 
 tions necessary for the development of the one must 
 necessarily provide those for the other also." 
 
 Speaking of the Andamans, where this malady 
 has never flourished and malaria is always rampant, 
 Dr. Lewis says: " Notwithstanding the Islands are 
 within three days of India, and twenty-four to thirty- 
 six hours of Burma, and that during the last twenty 
 years steamers have constantly passed between the 
 two countries and the Settlement, ... it is only 
 on rare occasions that cases of cholera have been reg- 
 istered as occurring." 
 
 Of these rare cases Dr. Rean, principal medical 
 officer of the Settlement, says " the patients were 
 generally admitted from some feverish locality, or had 
 been employed on works of an unhealthy character." 
 
 The importance of well authenticated cases of 
 this nature can scarcely be overrated in connection 
 
 *"Physiological and Pathological Researches." London, 
 
— 13 — 
 with the aetiology of cholera; they strongly evidence 
 the correctness of the views promulgated by both Chas. 
 Macnamara* and Max von Pettenkofer,f and assimi- 
 late, so to speak, the two. Questions of possible in- 
 fection or of water-contamination by specific imported 
 material, can hardly be seriously entertained here. 
 With the restrictions surrounding this isolated con- 
 vict settlement there can be no casual importation 
 of cases, as the recent history of every person is ac- 
 curately known. Similar seizures, moreover, occur 
 habitually in every city of India, as well as every 
 summer and autumn in all the large cities of Europe, 
 and also in America, but excite no special comment 
 unless an epidemic supervenes, or is already rampant, 
 when these otherwise ignored cases are seized upon, 
 collated, and described as foci of the pestilence. It 
 is not the custom then to regard such cases as due to 
 a localized generation of the disease, and the fact the 
 comma bacillus may be detected is held conclusive 
 evidence, ignoring the well established fact that this 
 microbe is by no means pathognomonic, but present 
 even in conditions of health. | 
 
 * " A Treatise on Asiatic Cholera," London. 1870. 
 
 f " Die Verbreitungsart der Cholera in Indien, nebst 
 Atlas." Braunschwig, 1871. 
 
 X At the moment of this writing it is announced cholera 
 has found foot-hold in the city of New York, the evidence 
 resting solely upon the presence of the comma bacillus. That 
 this is, presumptively, an error is shown by the press reports, 
 
— 14 — 
 
 That in the present stage of knowledge it is im- 
 possible to explain all the phenomena of cholera 
 distribution by telluric or meteorologic conditions, 
 may be allowed, yet neither can such influences be 
 denied. It must be remembered the same difficulties 
 obtain in regard to malaria and kindred diseases, and 
 that one has as substantial claim to this theory of 
 diffusion as the other. And that cholera in its setio- 
 logical relations does present marked parallelism to 
 other diseases that are dependent chiefly upon topo- 
 graphical surroundings for propagation, is proved by 
 the fact even malaria sometimes breaks loose from 
 its endemic haunts and shows itself in places where 
 it before was totally unknown. Thus, says M. von 
 Hertz* it " sweeps over considerable regions of 
 country as an epidemic, and over vast sections of the 
 globe as a pandemic. ... It does not seem probable 
 that currents of air are capable of carrying the poison 
 generated to a distance of any considerable number 
 of miles; I believe rather it is in a majority of cases 
 generated upon the spot. It is a still more difficult 
 matter to account for those isolated areas of malarial 
 
 that declare two patients were ill with the malady eight 
 days. In exotic cholera, fatality supervenes, or convalescence 
 begins, usually, ere the fifth day succeeding seizure has 
 opened. Presumably the cases were all indigenous in 
 character. — S. 
 
 * " Cyclopoedia of Practical Medicine;" von Ziemssen. 
 New York. 1874. 
 
— 15 — 
 poison that are often confined to single streets, to one 
 side of a street, or even single houses."* 
 
 It is a matter of common experience that removal 
 from a locality m which cholera exists is a remedy 
 against the spread of the disease, and the East Indian 
 Government has for many years acted on this knowl- 
 edge, with regard to its troops and convicts, with 
 gratifying success. It is equally a matter of experi- 
 ence the disease is most virulent in those years when, 
 owing to telluric and meteorologic conditions, the food 
 crops are more or less a failure and famine threatens; 
 and that, while it manifests itself with unusual severity 
 
 *That the parallel between malaria and cholera is much 
 more close than generally imagined is, however, evidenced 
 in that both depend for their phenomena (as is shown of chol- 
 era in Chap. IV, p. 56, and Chap. VIII, pp. 105, no) upon 
 disturbances of the vaso-motor system. 
 
 The contracted vessels of the skin and the rigors asso- 
 ciated with the cold stage in malaria, are evidences of hyper- 
 trophy and hyperesthesia of vaso-motor nerves; while 
 increased temperature, flushed surface, full pulse, and the 
 dilated blood vessels accompanying pyrexia, exhibit tissue 
 paralysis, both nervous and muscular. The splenic and 
 hepatic engorgements, and the diarrhoeas and dysenteries 
 that are so frequent sequels of malarial poisoning, are 
 derived from dilated and paralyzed arteries, and conse- 
 quently excessive flow of blood to undilated, enfeebled tissue. 
 In cholera, too, we have paralyzed blood vessels; but there 
 is also another dangerous factor, in a measure specific and 
 dependent upon the former, in that the blood itself is con- 
 stantly and rapidly being deprived of its serum. — S. 
 
— i6 — 
 
 in certain localities, in others closely contiguous its 
 ravages are comparatively mild or wholly absent. — 
 How often has it been observed in the case of an 
 outbreak that shifting a ship a few hundred yards 
 from its anchorage, or crossing to the other side of a 
 river, has sufficed to end an epidemic ! 
 
 An instance in fact may be cited in the visitation 
 of America in 1853-54, when Sarnia, Ontario, and St. 
 Clair, Michigan, suffered severely, while Port Huron, 
 just across the river from the former and twelve miles 
 above the latter, had but three cases, and these, there 
 is every reason to believe, obtained the infection in 
 Canada. 
 
 At this period neither of these towns was 
 provided with sewers or any form of drain- 
 age other than afforded by natural topography, 
 and the fermenting and decaying " sawdust pave- 
 ments" of the streets of Port Huron, it might be 
 supposed, would naturally tend to foster the epidemic. 
 But the real reason for the immunity was, doubtless, 
 the dwellings for the most part were confined to a 
 sandy or loamy porous soil overlying a substratum of 
 blue clay, the latter with a dip of from twenty to 
 thirty feet to the mile, sloping toward the St. Clair 
 River. Sarnia and St. Clair both rest on an out- 
 cropping of clay that was baked and seamed by the 
 hot sun of a summer supervening upon a wet spring. 
 
 Again, on November 9th, 181 7, cholera attacked 
 the camp of the East India Company troops stationed 
 
— ir- 
 on the borders of Scindia; this cantonment was on 
 the n'g/ithank of the Sindh or Betwa river; but the 
 ravages were stayed as by magic when the forces 
 were moved over to the /e/t bank, a distance of not 
 more than three-eighths of a mile. 
 
 It is also interesting, in this connection, to know 
 that in India, in 1819, the citadel of Jaragurth, situated 
 in a slight depression 1,000 feet above the level of the 
 plain, lost many of its inhabitants, while a city»near 
 the foot of the mountain, with good natural drainage, 
 entirely escaped attack ! 
 
 Another peculiarity more or less positive in its 
 evidence is, that while certain districts are exempt 
 during any one epidemic, or any series of epidemics, 
 the same may on a subsequent occasion be attacked, 
 though there is" always a decided predilection for 
 some localities at all times. It is not uncommon to 
 find the epidemic passing over large tracts of coun- 
 try, with»the wind perhaps in its very teeth, and it 
 seldom spreads itself on any systematic or geographi- 
 cal plan, since it may appear simultaneously in regions 
 a thousand miles apart. 
 
 Indeed, nothing can be more capricious than the 
 variation in the intensity of the malady in different 
 places and at different times, or at different times in 
 the same places. An imported case may end in a 
 local attack confined to a single room or single house; 
 even a simultaneous importation of a number of cases 
 at different points may exhaust itself in a number of 
 
local (circumscribed) epidemics; while at other times 
 a single case suffices simply to produce a general epi- 
 demic or even a raging pestilence. The history of 
 different epidemics in large cities shows the greatest 
 variety of effect, according as the cholera poison 
 found the conditions for development more or less 
 suitable. 
 
 And when the disease is fairly established as an 
 epidemic, its spread in a severely infected place is by 
 no means general, or in anyway uniform. A row of 
 houses, a series of streets or blocks, or perhaps a ward 
 or other section, becomes an epidemic centre. Then, 
 again, there are individual room (or several room), 
 epidemics, sometimes with a certain preference for 
 damp cellar lodgings; or individual groups of houses 
 are attacked in one street; often only one side of a 
 thoroughfare is ravaged, or out of a series of blocks 
 perhaps only one complete square and one or two 
 streets will be visited, while all about in the vicinity 
 there will only be, here and there an isolated case, or 
 none at all. Here is illustrated the combined effect 
 of importation and of local fixation of cholera germs 
 in the ground or drinking water, in the moisture of 
 the walls, in the damp, heavy, musty air of unventi- 
 lated rooms, and in the emanations of sewers; while 
 the dissemination is effected by adhesion of the germs 
 to the washing, bedding, vessels, etc. 
 
 What the primary factor may be, then, is un- 
 known, but the fact remains that the production and 
 
— 19 — 
 
 course of the malady are so greatly under the control 
 of sanitation that neglect of measures essential to the 
 latter, on the part of individuals, and municipal, 
 county, and state authorities, as well as the general 
 government, is little (if any), less than criminal. 
 
 Even without knowledge of essential cause, we are 
 perfectly familiar with results and . effects, and these 
 afford the text upon which to work. We do know, 
 aside from telluric or meteorologic conditions,* that 
 
 *The arguments for and against the contagious nature 
 of cholera are many and varied, and some of the positive are 
 the result of misunderstanding and misapprehension. Thus 
 certain German writers are frequently quoted as contagion- 
 ists, when, in fact, more careful perusal of their writings 
 show they are only infectionists; this error arises from the 
 fact there is but one term {Ansteckung) in the German lang- 
 uage to express both conditions. 
 
 Surgeon-Lieut. Colonel J. M. Cunningham, Health 
 Commissioner of India, who for years has studied cholera 
 where it is endemic, emphiatically declares it is not con- 
 tagious. Dr. Edward Goodeve,who likewise has had ex- 
 tended experience in various portions of the Orient, insists 
 the malady "does not spread from the sick to the well by 
 any rapidly acting emantion. Surgeon-General Chas. Hunter, 
 in his report upon the epidemic in Egypt in 1884, is equally 
 assured of its non-contagious nature. Many others have 
 noted that patients ill with the disease may be attended, 
 washed, lifted, etc., with very little risk, and that the dis- 
 charges from stomach and bowels are the chief, if not the 
 only, sources of danger. Hermann Lebert pointedly remarks 
 (Ziemssen's " Cyclopoedia, of the Practice of Medicine," vol. i): 
 
the disease, though not in strict sense contagious, dur- 
 ing epidemic times is, in considerable degree, at least, 
 infectious, the poison apparently being constant in the 
 dejections of cholera patients; that this poison may 
 be disseminated at points remote from the ravages of 
 the malady by being carried thither in the intestines 
 of individuals, who perhaps present no evidences of 
 cholera other than a slight intestinal flux, hence have 
 no idea they are victims, or being made involuntary 
 means of communication; a transient traveler may 
 thus, through a single privy or water-closet, infect a 
 whole community. 
 
 Niemeyer tells us that in 1848 a detatchment 
 
 "Cholera can be spread only by contagion, that is by 
 germs which are carried from a diseased to a healthy per- 
 son; but these germs infect only comparatively rarely by 
 intercourse or contact with cholera patients, since they pos- 
 sess relatively but little vitality in the air of the sick-room, 
 and are present mostly in inconsiderable quantity. On the 
 other hand, a certain number of the germs and a given 
 vitality are necessary for the propagation of the disease, and 
 these conditions are better met in fluids than in the air; 
 hence contagion is more frequent when the germs are com- 
 municated through a fluid than when transmitted through 
 the air." 
 
 Thus it seems, while Lebert apparently pronounces for 
 contagion, he really means what in English would be infec- 
 tion. Felix von Niemeyer (" Text Book of Practical Medi- 
 cine," vol. ii.) expresses himself in like manner, and subse- 
 quently adds he is a non-contagionist, later explaining his 
 position, making him in fact Siuinfectionist. — S. 
 
of recruits from Stettin, where cholera was raging, 
 came to Magdeburg, two of whom on the night of 
 their arrival fell ill of the malady, and were immedi- 
 ately sent to the military hospital without coming in 
 contact with the inhabitants. Nevertheless, a few 
 days later cholera asserted itself first, in the house 
 where they had sojourned a few brief hours, and later 
 along the street on which the dwelling was situated — 
 all from the use of a privy by one of the unfor- 
 tunates. Again he remarks:* "A small epidemic 
 in Greifswald gave me excellent opportunity for 
 observing the spread of cholera, and in almost 
 every case I could find that the patients had used the 
 privy of affected houses, or that they had used a privy 
 in common with persons from these houses who had 
 diarrhoea." 
 
 F. D. Alexandre tells of a soldier attacked with 
 diarrhoea, who arrived at the village of Haime, from 
 Paris where cholera was raging, April 4th, 1849, and re- 
 mained three days at his father's house, when he went 
 to hospital — there was no supposition of cholera in 
 his case, so light was the attack: In the course of 
 ten days seven persons in the household contracted 
 the malady, four of whom died. Fred'k Wm. Goer- 
 ing corroborates with an account of a vagabond, suf- 
 fering in like manner, who was committed to the 
 workhouse at Dieburg, with the result the epidemic 
 
 *" Text-Book of Practical Medicine," vol. ii. New 
 York, 1884. 
 
swept through that institution, but nowhere else man- 
 ifested itself in the town, save in a single instance; 
 the exception was the woman who acted as laundress 
 to the prison. 
 
 Also, Prof, von Pettenkofer relates the case of a 
 man committed to the prison of Ebrach, from Munich, 
 during the existence of cholera at the Bavarian capi- 
 tal, and who suffered from intestinal flux. His diar- 
 rhoea persisted, though its nature was not recognized, 
 and he was sent to prison hospital. Immediately the 
 epidemic developed within the institution, the first 
 victim being a female prisoner who had washed the 
 clothing soiled with the diarrhoeal discharges of the 
 Munich convict. 
 
 Of the pernicious effects of general or common 
 latrines may he cited the fact that, during epidemics 
 in America, the soldiers of the U. S. Army and of the 
 Marine Corps suffered more severely than any other 
 relative number of people; the closets or privies in 
 connection with barracks, are usually in a foul state, 
 and in most instances are merely open trenches with 
 but a rude shelter to protect from the weather. 
 
 Since it has been shown that the malady is only 
 transferred to healthy persons — persons possessing no 
 special or abnormal receptivity — through the dejec- 
 tions of those afflicted with the disease, the previously 
 enigmatical and apparently contradictory observations 
 concerning the spread of an epidemic are satisfactorily 
 explained. Further, that it spreads more rapidly than 
 
formerly is accounted for by the fact the facilities for 
 travel and communication are greatly increased; and 
 it is little wonder the generally traveled routes ex- 
 hibit the greatest ravages, or that extension is against 
 wind, or by long leaps with occasional retrocessions, 
 while places intervening escape — traveling cholera- 
 victims infect only those places where they leave their 
 dejections. Again, if the cholera germs were contained 
 only in the dejections of those who suffer from the 
 severest form of the disease, as they cannot travel, 
 long springs of cholera epidemics could only occur 
 through spontaneous generation, or when persons 
 infected with the poison traveled during the period 
 of incubation, and the disease in them did not assert 
 itself en route. But besides such, numerous examples 
 prove that persons suffering from simple choleraic 
 diarrhoea (as in the Magdeburg cases cited by Nie- 
 meyer) and who at no time are very ill, carry with 
 them the fatal germs, and by infecting a single water- 
 closet or out-house may start an epidemic de novo, 
 as it were. 
 
 Lebert believes even a healthy person may carry 
 the germ from locality to locality, and yet suffer no 
 inconvenience— ?>., he may escape the malady alto- 
 gether. He calls attention to the fact one seizure also 
 renders individuals in some degree personally immune, 
 though their aptitude for carrying the infection is in 
 no way lost providing they have been exposed to its 
 influence. While he declares his doubt whether 
 
— 24 — 
 
 the cause is an organic poison or living organism, 
 he is inclined to accept the mycetic theory which, as 
 he remarks, " explains without strained effort why it 
 is that fluids, and especially stagnant fluids, contain- 
 ing more or less organic nutritious matter, are chief 
 vehicles of the cholera germs, as they are of all proto- 
 mycetic forms. It is on this account that the water 
 of the soil, the drinking water, and every fluid, play 
 so highly important a role in the diffusion of the dis- 
 ease; and yet neither the ground water or the drink- 
 ing water theories can ever prevail in sole soverignty 
 as causes of the disease, since such are not necessary 
 for the development of the germs, but only become 
 so when they can furnish these germs with proper 
 nutritious matter, when other favorable conditions of 
 growth are presented, and when more especially the 
 way of communication with the human organism is 
 open. The germs of cholera may be spread without 
 ground or drinking water just as easily as with them, 
 through the air, by becoming attached to solid bodies, 
 etc. . . . True, cholera finds in drinking water 
 also a very frequent and most potent medium of dis- 
 semination, as it may be impregnated with the poison 
 (from water of the soil by filtration from privies and 
 sewers) which may then flourish in further develop- 
 ment; still drinking water alone cannot be considered 
 as the exclusive or necessary means of dissemination. 
 Over- flowing or badly cemented drainage or sewer 
 pipes, for instance, conveying infectious matter, may 
 
— 25 — 
 carry their foul contents directly into the ground 
 walls of cellars, and dwellings, and swiftly develop 
 destruction among the inhabitants." 
 
 It is probable, however, the dejections do not 
 when first expelled contain the cholera germs in 
 the stage of development necessary to infection, but 
 that they become strictly aggressive only after hav- 
 ing undergone fermentation, which result is furthered 
 by admixture with decomposing animal substances — 
 and this is why the midden privy is always a greater 
 source of danger than the modern closet. This 
 theory is supported by numerous facts. 
 
 Dr. O. D. Norton, a veteran practitioner of Cin- 
 cinnati, who had extended experience with chol- 
 era in the epidemic of 1849, remarks, regarding ex- 
 periments with /Vr^-^ alvine excretions of "rice-water" 
 character, that he and a confrere fed such by buckets- 
 full to numerous chickens and pigs, but induced in 
 them no evidences of the disease; on the contrary, 
 these creatures seemed to "grow fatter " thereon.* 
 
 The observations of C. von. Thiersch show that 
 while recent dejections are not dangerous to animals, 
 feeding the same with old excreta of the same sort 
 invariably induces the malady, f 
 
 Further, experience shows that physicians passing 
 
 * Cincinnati Lancet-Clinic, vol. xxiv; Sept. 24th, 1892. 
 
 f'Meine Cholera-Infectionsversuche vom Jahre, 1854, 
 und die des Herrn Dr. B. J. Stokvis vom Jahre, 1866." 
 Munich, 1867. 
 
— 26 — 
 
 from bedside to bedside are comparatively immune. — 
 Niemeyer says his experience in cholera epidemics, 
 wherein he wrapped patients in blankets and often 
 held them in his arms for some time, made him a 
 "decided anti-contagionist;" that those who wash the 
 body and bed linen after they have lain some time, 
 are more apt to be infected than those who directly 
 care for the patient, even to removing the dejecta. 
 
 Again, Lebert says: " I have noticed in all epi- 
 demics, and have seen it mentioned in the writings of 
 many authors, that practicing physicians, even hospital 
 physicians, are seldom attacked with cholera." 
 
 In Cairo, Egypt, in 1831, of one hundred servants 
 employed as rubbers or masseurs of cholera patients, 
 not one was ever attacked; of eighty rubbers at the 
 hospital at Mansurah, and sixty at Damietta, all 
 escaped save one. None of the physicians or nurses 
 of the cholera service at Constantinople in 1855-56, 
 and Oran in r86i, ever suffered from any form of 
 the disease. 
 
 Washerwomen, whenever they wash linen soiled 
 with cholera dejections, without any precautions, are at- 
 tacked in all places in no small numbers.* In Branson, 
 
 *The frequency with which washerwomen fall ill with 
 the disease from contact with infected linen has often been 
 mentioned, but there are also examples where cholera has 
 been spread by rags and other objects. The same is true in 
 still higher degree of unclean bedding. C. von Zehnder 
 ascribes the origin of two cholera centres in the Ziirich epi- 
 
— 27 — 
 
 in the Canton of Valais (Switzerland), in 1867, one of 
 the Sisters of Charity nursed, with the greatest self- 
 sacrifice, all the cholera patients in very filthy 
 chambers, and yet remained healthy, but at the close of 
 the epidemic " her sympathy prompted her to assist in 
 washing up the soiled linen, when she was attacked 
 with the disease and died. It was from a washer- 
 woman, who died after washing the clothes of a 
 cholera fugitive, that the epidemic developed later in 
 Zurich, 1867." (Lebert.) 
 
 Very numerous facts might be cited to demon- 
 strate that cholera may be communicated, and carried 
 from place to place, by clothing or other material 
 soiled by cholera dejections; the observations of 
 Etienne Moulin, Gaston Pellissier, Jas. Simpson, 
 Jules Bucquoy, J. M. and D. D. Cunningham, Max von 
 Pettenkofer, Antoine Fauvel, Augusto Guastella, and 
 others, are most definite. Guastella remarksrf "■ There 
 were persons living in places sheltered from the epi- 
 demic who, after washing linen soiled with the dejec- 
 tions of cholera, carried the disease afar." Fauvel 
 adds other f actsj showing that camping places where an 
 
 demic of 1867 to an accumulation of bedding, mattresses, 
 pillows, etc., that had been used on the beds of cholera 
 patients, and afterwards piled up, before being carried off 
 for disinfection, in the neighborhood of the houses affected. 
 — S. 
 
 •f" D' igiene e medicina navale ad uso della marina 
 merchantile." Trieste, 1861. 
 
 I" Le Cholera; etiologie et prophylaxie." Paris, 1868. 
 
— 28 — 
 
 epidemic has occurred, hospital wards, sick chambers, 
 ships and cars carrying cholera patients, etc., may 
 preserve for some time, under certain circumstances, 
 the power of transmitting the disease; nevertheless, 
 such examples are comparatively rare. To transmit 
 cholera by clothing, he considers, demands certain 
 conditions, viz.: "To transport it a short distance 
 requires certain contact with objects in connection 
 with the patients, especially those soiled by vomit and 
 rectal discharges; to transport long distances, the ob- 
 jects previously exposed to contact must be confined 
 to close quarters where the fresh air is not renewed, 
 and where sunlight does not enter. There are few 
 examples of objects freely ventilated carrying the 
 disease for any long time, or long distance, while 
 there are many cases to prove that the transmission 
 may easily occur where soiled effects have been 
 closely packed for several months." 
 
 As to the influence of dead bodies in disseminat- 
 ing infection directly — i. <?., by handling, — Lebert 
 expresses himself as doubting it very much. "We 
 occupied ourselves almost daily in Paris, in 1849 — 
 my friends and myself — with investigations into the 
 pathological anatomy of cholera. In Zurich, in 1855, 
 I made all the post mortem examinations, with my 
 assistant. Dr. Wegelin, and neither of us, and no one 
 of our dead-room attendants, were attacked with the 
 disease. I consider it, therefore, merely an accident 
 when a body-carrier falls sick. I believe, indeed, 
 
— 29 — 
 
 -that animal putrefaction rather diminishes the capacity 
 for infection, and that the bacteria of decomposition 
 destroy the germs ot cholera." 
 
 Hugo Wilhelm von Ziemssen* lays especial stress 
 upon the fact " it is more dangerous for the persons 
 in a house if the evacuations are emptied into a privy 
 filled with excrement, into a cess-pool, or thrown on 
 a dunghill, as in such places the germs seem to find 
 circumstances most favorable to their development 
 and increase." 
 
 A. von Hirschf insists marshy and malarial re- 
 gions are especially favorable to the dissemination of 
 cholera, in that they furnish nourishment for the 
 germs, favoring their multiplication; also because 
 the soil in such localities is eminently fitted to trans- 
 mit, by soaking and slow filtering, cess-pool fluids and 
 sewage waste, carrying into cellars and basements; 
 that thus the privy of a neighbor may be more dan- 
 gerous than one's own, especially if in close prox- 
 imity to the residence of the latter. 
 
 From observations made during the last three 
 epidemics in France, Dr. Hippolyte Mireur concludes 
 cholera is not transmitted directly from the ill to the 
 well by contact or through the respiratory passages; 
 that the products emanating from cholera patients — 
 
 * " Die Choleraepidemie, vom Jahre 1867." Greifswald, 
 1870. 
 
 f " RUckblickauf die neuereCholeralitteratur." Schmidt's 
 JahrbUcher. Bd. Ixxxviii. 
 
— 3° — 
 the dejections and vomited matters — alone contain 
 the germs, which are not immediately transmitted by 
 themselves, but when placed under favoring condi- 
 tions give rise to an infectious principle; that cloth- 
 ing and merchandise, — such as skins, hides, rags, etc. 
 — much more than individuals, are the agents for the 
 transportation of this principle. * 
 
 If then there is any justice in the belief of 
 Lebert, Hirsch, et al., that the cholera germ lies 
 within a spore,f it is more than probable the ripening 
 of such in the faeces after evacuation is the real 
 source of infection; or that the product of the ripened 
 spore, on being returned to an economy, further de- 
 velops producing perhaps certain alkaloids that, in 
 turn, taken up by the absorbents, induce violent toxic 
 symptoms — symptoms that, made manifest through 
 the nervous system, constitute the phenomena of the 
 disease. Dr. Thos. King Chambers remarks:J " There 
 is every reason to believe the chief exciting cause of 
 the disease is a poison generated by decomposing 
 
 *" Etude historique et pratique sur la prophylaxie et le 
 traitement du cholera," etc. Paris, 1884. 
 
 fThe question of a spore is an interesting one from a 
 certain standpoint since the majority of observers of and 
 believers in, deny such to the comma bacillus; yet Huppe,, of 
 Prague, declares this germ does possess "a fructification 
 propensity by virtue of an arthrosporulation," which he 
 personally observed. — S. 
 
 I " The Renewal of Life; Lectures Chiefly Clinical." 
 London, 1864. 
 
— 31 — 
 organic matter and received into the body from with- 
 out. To judge by its effects, it seems widely diffused 
 through the air, especially in the neighborhood of its 
 origin— in the air of privies, cess-pools, sewers, putrid 
 marshes, and crowded human habitations. One is 
 perhaps tempted to ask how it is, if the poison is 
 spread so broadcast, that everybody does not get poi- 
 soned; but it must be remembered two things are 
 necessary to poisoning, viz.: Not only a poison, but 
 a person in condition to be poisoned; and in point 
 of fact the latter is the more important element in the 
 transaction." 
 
 Thus the weight of evidence goes to show chol- 
 era epidemics, for existence and dissemination, demand 
 three prime factors, viz.: 
 
 First. Conditions of soil, atmosphere, etc. (gen- 
 eral surroundings), favorable to the nourishment of 
 the germ or germs, which would otherwise speedily 
 lose the power of infecting: 
 
 Second. Conditions in each human subject, indi- 
 vidually, favoring receptivity : 
 
 Third. Direct infection /^r.y<?.- 
 
 And regarding the last, it is believed the princi- 
 pal, if not the only way of insuring infection, is 
 through the medium of the intestinal canal and its 
 absorbents: 
 
 That the germs are ordinarily carried but a short 
 distance through or by the air: 
 
 That the great danger lies with the alvine evacu- 
 
— 2,2 — 
 
 tions and vomited matters, but only after fermenta- 
 tion has been set up therein: 
 
 That contamination of the water supply and of 
 food, by cholera discharges, is ever a grave factor: 
 
 And, finally, that linen, cotton, or woollen fab- 
 rics, soiled by cholera discharges, if excluded from 
 air and sunlight, serve to keep alive the germs of the 
 
 disease for an indefinite period. The history of the 
 
 barque Swanton, on which cholera did not appear 
 until she had been at sea for twenty-seven days, 
 when clothing was unpacked by the passengers, alsO' 
 of the ship JVew York, on which the disease did not 
 manifest itself until she was sixteen days out from 
 her port of departure, and then under the same cir- 
 cumstances as on board the Swanton, both evidence 
 the truth of this statement. 
 
CHAPTER III. 
 
 TRANSMISSION DANGERS. 
 
 It is to Prof, von Pettenkofer we are indebted for 
 the discovery that porosity of the soil, by enabling the 
 contents of privies and cess- pools containing the chol- 
 era germs to freely permeate and soak the ground for 
 some distance around, and poison wells and sewers, 
 favors the rapid extension of the disease, while the 
 opposite quality to some extent inhibits dissemination; 
 and the same author was the first to demonstrate that 
 the " manifest fitness of any locality for the disease 
 depends on excrement, containing the germs, perme- 
 ating the soil and exposed to circumstances favorable 
 to decomposition." 
 
 Next to soaking of the soil is the danger from gut- 
 ters and drains, which may carry the infection from 
 house to house; and it is well known that a soil-pipe, 
 or untrapped rain-gutter, has carried the disease into 
 an uninfected dwelling through a window of the latter 
 being contiguous to, and at higher elevation than, the 
 upper end of the latter. 
 
 There can be no doubt foul drinking water plays 
 no inconsiderable role in dissemination. Mr. J. Snow* 
 established the connection of the fearful local epi- 
 
 *" Cholera and the Water Supply in the South Districts 
 of London in 1854." London, 1856. 
 
— 34 — 
 
 demic in Broad street, St. James' Parish, London, in 
 1854 with an infected well; its ravages ceased when 
 this supply of water was shut off from the public. J. 
 Simon* declares in the portion of London supplied 
 with river water drawn from the stream after it had 
 received the contents of a large number of sewers, so 
 that it had forty-six grains of solid constituents to the 
 gallon, the number who succumbed to the malady was 
 thirteen out of every thousand, while in other situa- 
 tions, under precisely parallel circumstances and sur- 
 roundings, save the water supply contained but thirteen 
 grains of solids to the gallon, the death rate was only 
 3.7 per 1,000. Edward Frankland,f speaking of the 
 same city and relation of water supply to cholera, 
 says: 
 
 " On the i8th of August, 1866, a family removed 
 from London to Margate; on the 26th there was a 
 storm with heavy fall of rain, and the water had an 
 unusual odor and taste. On the 27th four persons 
 were attacked with cholera, and on the following day 
 still more, the most of whom died. The water in the 
 well at the end of the garden furnished, in 100,000 
 parts, 93.4 of solid matters, of which 7.36 parts were 
 of organic or volatile nature. The cess-pool adjoin- 
 ing the garden had clearly poured its contents into 
 
 *" Report on the Two Last Cholera Epidemics as Af- 
 fected by the Consumption of Impure Water." London, 1856. 
 
 f " The Water Supply of London and the Cholera." 
 Quarterly Journal of Science, 1867. 
 
— 35 — 
 the well after the overflow caused by the rain, and 
 this had caused the fatal contamination, for an anal- 
 ysis made Sept. i8th showed 82.75 solids (in 100,000), 
 of which but 1.13 parts were of organic or volatile 
 nature. Is was proven that all who were attacked 
 had drank from the well. A similar occurrence was 
 established by Dr. Lancaster, of Epping Forest." 
 
 The same author declares the inhabitants of 
 London who used Thames water from Kew, above 
 the city, showed a mortality from cholera of but 8 in 
 10,000; those who used the water from Hammer- 
 smith, 17 in 10,000; from Battersea to Waterloo 
 Bridge — that is water contaminated by the sewage of 
 the city — 163 in 10,000. In 1854 only the half of a 
 district was supplied from Teddington Loch, and the 
 mortality therein was 87 in 10,000, but in 1866, all the 
 water in the Loch having been drawn off, the mor- 
 tality was less than one-tenth of that in 1854. Again, 
 in 1866 the cholera was very severe in the East End, 
 which was supplied by the East London Water Com- 
 pany, from Oldford, the reservoir, on the river Lee, 
 being little better than an open excrement and sewer 
 receptacle, even filtration being neglected. The re- 
 sult was the mortality in this portion of the city 
 was from 63 to 112 per 10,000, while the balance of 
 the London, with a pure water supply, exhibited a 
 death rate of only 2 to 12 per 10,000. 
 
 Manchester suffered terribly from cholera in 1832 
 and 1849, when the water supply was very impure, 
 
- 36 - 
 
 but in 1854 and 1866, the water being derived from 
 the interior of Derbyshire through an aqueduct, there 
 were very few cases, and these only of a sporadic 
 character. 
 
 Dr. W. Schiefferdecker, too, mentions a fact 
 worthy of note concerning the six great cholera epi- 
 demics that ravaged Kpnigsberg, Prussia, from 1831 
 to 1866, in which more than 2500 people succumbed 
 out of nearly six thousand attacked.* The inhabi- 
 tants of those portions of the city supplied with drink- 
 ing water from the river Pregel, and from wells, were 
 those that suffered most, while those supplied by a 
 system of water-works from the so-called " upper 
 tank," in which the water was exceedingly pure, suf- 
 fered much less severely; the Pregel and wells were 
 fed with ground water and sewage. 
 
 Dr. J. Gratzer also describes an instance occur- 
 ring in Breslau during the epidemic of 1867,! in which 
 the walls of a badly constructed privy attached to a 
 newly built and well arranged house rendered the 
 water in an adjacent well impure; besides, the privy 
 vault was not regularly emptied, and its contents 
 overflowed into an unwalled excavation in the neigh- 
 borhood of a large accumulation of ground-water. 
 The consequence of this contamination, which affected 
 the drinking water was, that in the beginning of the 
 
 "*Die Choleraepidemie vom Jahre 1871 in Konigsberg."^ 
 Konigsberg 1873. 
 
 f " Die Breslauer Cholera-Epidemic." Breslau 1873. 
 
— 37 — 
 epidemic no less than twelve of the inhabitants of the 
 house were attacked, eleven of whom died; also other 
 persons in the vicinity, who obtained water from the 
 same well, were seized. In this instance, it was 
 proved the cholera poison first entered the privy, 
 thence passed into the ground water, then into the 
 drinking water, and so on into the digestive organs of 
 the unfortunates. 
 
 Again, when cholera is once introduced it some- 
 times happens only those are attacked who are in the 
 house where the first infection is received, or who 
 visit the same closet; and in some instances the 
 malady has been restricted solely to house epidemics 
 — further illustration of the care that should be 
 exercised in the way of sanitation. 
 
 Niemeyer believes the poison is rarely taken into 
 the system in the drinking water, but in the main enters 
 the economy during the act of respiration and, lodg- 
 ing in nose, mouth, or throat, is swallowed with the 
 saliva. " Using infected privies is so dangerous, be- 
 cause they are the favorite lurking-places of cholera 
 germs, and the gases arising always contain dust-like 
 particles." The poison passes from the closet to the 
 dwelling, and A. Biermer insists the latter are " more 
 liable than individuals to infect." 
 
 So far I have said nothing, relatively, regarding 
 the claims of two schools the members of one of 
 which, like sheep, blindly follow their bell-wether over 
 any obstruction regardless of cause or reason. First 
 
- 38 - 
 
 of these stand the followers of Louis Pasteur — a 
 visionary whose utterances have never been worthy 
 of dependence, who is utterly devoid of physio- 
 logical or other medical knowledge, and who, more- 
 over, is not even a reputable chemist — the bacil- 
 lary pathologists. Second, those walking in the foot- 
 steps of Francesco Selmi and Armand Gautier, the 
 latter of whom stands first in the discovery and 
 investigation of vital alkaloids, and has had courage 
 to approach some problems of physiology and pa- 
 thology most abstruse and complex in nature, open- 
 ing up a wide territory that has hitherto escaped 
 investigation. It might be added there is a third 
 coterie, who, between the "devil and the deep sea," 
 have appeared anxious to reconcile the foregoing, and 
 by blending the two evolve a new pathology, Eman- 
 uel Klein, perhaps, being the most able representa- 
 tive of the class. 
 
 Practical medicine has suffered much from the 
 invasion of new theories as well as experimental 
 methods; traditional pathology has given way to 
 the experimental, and spontaneous maladies to those 
 forms that may be artificially provoked in inferior 
 creatures. Further, the upholders of bacteriological 
 pathology have followed too closely in the steps of 
 their masters, in that they sedulously ignore all nega- 
 tive evidence while magnifying the positive. For in- 
 stance, the monumental report on cholera just issued 
 from the Government press at Washington, was com- 
 
— 39 — 
 piled by an ardent bacteriologist, who, while gather- 
 ing everything favorable to his view, carefully ex- 
 cluded all evidence calculated to invalidate; he quotes 
 the early reports of Surgeon-Major D. D. Cunning- 
 ham, which are indefinite, and sedulously ignores 
 the later investigations of the same author as well 
 as those of Surgeon-General Wm. R. Cornish, Sur- 
 geon-Major Timothy R. Lewis, Professor Ray Link- 
 ster. Sir Wm. Aitken, Doctor A. N. Brown, et al. 
 — an act which renders the "sin of omission "even 
 greater than that of commission. Etiology, theoreti- 
 cally, has been very much simplified by the discovery 
 of microbes, but certainly scientific medicine has 
 very little profited thereby, since attention has been 
 diverted from clinical observation and research. The 
 fallacious charms of the germ theory have caused med- 
 ical men to forget their mission, have prevented the 
 relief of the ill, and produced misconceptions of dis- 
 ease. Dr. B. W. Richardson * only recently protested 
 against the idea it was necessary "to subject a patient 
 to a kind of modified snake-bite in order to settle a 
 question of diagnosis," and adds: "Twenty years 
 ago the profession was steering well and steadily 
 towards great principles on the preventive, as well 
 as curative side of medicine; then crept in the wild 
 enthusiasm of bacteriological research — research 
 good enough in its way as a piece of natural history, 
 
 *The Asclepiad, 1891. 
 
— 40 — 
 
 and as disclosing some curious tribal phenomena 
 developed under morbid states of the organic struct- 
 ures and the blood, but a positive insanity when ac- 
 cepted as the one absorbing pursuit, restoring hu- 
 moral pathology, ignoring nerve function, leading 
 to Babel with its utter confusion of tongues, and sep- 
 arating for a time the modern art of cure from the 
 accumulated treasures of knowledge, wisdom, and 
 light of over two thousand years." 
 
 It may here be remarked, likewise, that the 
 majority of maladies to which popular pathology 
 ascribes bacterial origin, are very severe in character, 
 and most generally fatal. Therefore, in cases where 
 dissolution is rapidly impending, it. is not without the 
 bounds of probability or possibility — indeed has been 
 triumphantly demonstrated in many instances, — that 
 partial death may affect the fluids and tissues to 
 greater or less extent preceding the general death of 
 the organism; that is to say the sum of the deaths of 
 the constituent elements. Again, in certain cases, 
 changes usually observed post-mortem may and do 
 take place in the fluids and tissues, or a portion 
 thereof, ante-mortem — sloughing, gangrene, phthisis, 
 malignant diseases, etc., are evidences of this. Conse- 
 quently, bacteria, which under natural surroundings 
 and habits of life are ever the products of decomposi- 
 tion, may be found in the tissues, blood, and other 
 fluids during life, and be the results merely of the 
 advanced decree of the diseased condition — not the 
 
— 41 — 
 cause of its development. And to force inductions as 
 the result of artificial cultivation of microbes, and the 
 artificial diseases induced thereby, instead of through 
 natural development of the same and the pathological 
 factors under which such development occurs, is not 
 alone contrary to all scientific precedent, but must 
 always remain a source of error. Just as tame fruits 
 differ from the wild, and domestic creatures from 
 those that are ferx natura, so must bacilli differ 
 according to their mode of cultivation and develop- 
 ment, and in their results; a parallel under such cir- 
 cumstances cannot but be fallacious, as every zoolo- 
 gist or botanist well understands, and a more thorough 
 knowledge of these branches of science, on the part 
 of the medical profession, would lead to fewer errors 
 in pathological investigation. 
 
 Again, Dr. Burdon-Sanderson's investigations* 
 prove the development of infective inflammatory 
 products as the result, purely, of chemical irritants, 
 while Lewis and Cunningham alike observed bacteria 
 in the blood of creatures dying from such experi- 
 ments. These important facts have a most pertinent 
 bearing on the aetiology of cholera, as will be observed 
 in a subsequent chapter. 
 
 In the report of the Ger7nan Cholera Commis- 
 sion dated Calcutta, February 2d, 1884, Koch an- 
 nounced the comma bacillus as the specific cause of 
 
 *The Lancet (London), voL i, 1873. 
 
— 42 — 
 
 cholera; and since his claimed discovery was based on 
 microscopic slides from four specimens of cholera in 
 natives, said slides being furnished by Surgeon-Major 
 T. R. Lewis, the latter, in conjunction with Surgeon- 
 Major D. D. Cunningham, deemed the matter worthy 
 of further investigation. In their report it is re- 
 marked:* 
 
 "So far, therefore, the selection of the comma- 
 shaped bacillus as the materies morbi of cholera ap- 
 pears to be entirely arbitrary. Dr. Koch and his 
 colleagues have adduced no evidence to show that 
 it is more pernicious than any other microbe; in- 
 deed, as a matter of fact, the sole argument of any 
 weight which has been brought forward ... is 
 the circumstance it is more or less prevalent in every 
 case of the disease, and that the German Cholera Com- 
 mission had not succeeded in finding it in any other." 
 
 With regard to the suggestion that the cholera pro- 
 cess may in some way favor the growth of these 
 bacilli, and that they are not necessarily a cause of 
 the disease, Dr. Koch, in the report from Calcutta, 
 declares such a view is " untenable," inasmuch as it 
 would have to be assumed "that the alimentary canal 
 of a person stricken with cholera must have already 
 contained these bacteria; and, seeing that they have 
 been invariably found in the comparatively large 
 number of cases of the disease in Egypt and India, it 
 
 *" Physiological and Pathological Researches." Lon- 
 don, 1888. 
 
— 43 — 
 would be necessary to assume further, that every 
 individual must harbor them in his system. This, 
 however, cannot be the case, because, as already 
 stated, the comma-like bacilli are never found except 
 in cases of cholera." 
 
 To this Drs. Lewis and D. D. Cunningham reply,* 
 if Koch and his colleagues had submitted the secretions 
 of the mouth and fauces — the very commencement of 
 the alimentary canal — to careful microscopic examina- 
 tion of the same kind as that to which they have 
 submitted the alvine discharges, " we feel persuaded 
 that such a sentence would not have been written, 
 seeing that comma-shaped bacilli, identical in size, 
 in form, and in reaction to anilin dyes, with those 
 found in cholera dejecta, are ordinarily present in the 
 mouth of perfectly healthy persons." 
 
 Koch subsequently admits he had examined the 
 mouth of healthy persons but found no comma bacilli; 
 on another occasion, as claimed by C. S. Dalleyf 
 (though I can nowhere find such utterance in Koch's 
 own publications), he declared his familiarity with the 
 comma bacillus of the mouth, and that it differs from 
 his cholera bacillus in "being longer, more slender, 
 and not so blunt at the ends," etc.; but T. R. Lewis, 
 Douglas Cunningham, Ray Linkster, Arthur E. Brown, 
 and Sir Wm. Aitken subsequently proved the identity 
 
 * Ibid. 
 
 f "Technology of Bacteriological Investigation." Bos- 
 ton, 1885. 
 
— 44 — 
 
 of the organisms by accurate tests and measurements 
 applied respectively to colonies taken: 
 
 (a) From the mouth of healthy human beings 
 ranging from four to fifty years of age: 
 
 (d) From the alvine discharges of cholera-affected 
 persons: 
 
 (c) From the intestines of persons who had died 
 of cholera: 
 
 (d) From cultivations of all three in agar-agar 
 jelly, in weakly alkaline peptone gelatin, etc., and: 
 
 ((f) By the reaction of all to staining fluids — 
 fuchsin, gentian violet, methylen blue, etc. 
 
 Further, during a subsequent and independent 
 investigation, D. D. Cunningham found ten different 
 kinds of comma bacilli in the dejections of sixteen 
 consecutive cholera patients, that of Koch "being 
 very far from the most numerous of the lot." Lewis, 
 too, found the Koch bacillus most abundantly in the 
 drinking waters of India in the season when the 
 people using such waters were absolutely free from 
 cholera. And M. Neller* observed the bacillus of 
 the present cholera epidemic in Europe to differ 
 markedly from that claimed by Koch to have been 
 discovered in India, in that it is thicker, shorter, and 
 larger than the latter, causes turbidity of bouillon, 
 and in peptonized gelatin grows more rapidly; it was 
 found in twenty-nine cases of cholera, also in the 
 
 *Le Progres Medicale. 1892. 
 
— 45 — 
 sputum of a case of broncho-pneumonia; and in thirty 
 additional cases of cholera, no comma bacillus whatever 
 could be found. 
 
 The result of these investigations conclusively 
 prove the so-called cholera-bacillus to be only an 
 "old friend under a new name" — an everyday spiril- 
 lum. 
 
 Again, the investigations of Pettenkofer,* Bier- 
 mer, and others, are founded on clinical data too 
 
 * Prof, von Pettenkofer who, together with Robert Koch, 
 has been actively engaged in studying and observing cholera 
 in the present Hamburg epidemic, declares that the latter's 
 theory of the origin of the malady " has not stood the test of 
 experience." It has not been proved that the pestilence was 
 brought to the city in the way indicated by Koch, or that the 
 comma bacillus is the cause of the epidemic. Commenting 
 editorially upon this. The Lancet (London) remarks: " One 
 of the difficulties attending the acceptation of the cholera 
 bacillus theory of the causation of cholera is, to account for 
 the occurrence of isolated and sporadic cases of that disease, 
 which in the aggregate amount to a large number — in India, 
 for example. One man is attacked and dies of cholera in 
 the barrack room occupied by a number of others, the air, 
 food, water supply and all other conditions being the same 
 for all alike. There is perhaps no other case of cholera in 
 the station at the time, nor is there any history of any hav- 
 ing occurred before; and this is not at all an uncommon but 
 a frequent occurrence in India at certain seasons, and out- 
 side and beyond the so-called endemic area. The relation 
 of these cases to larger outbreaks and epidemics has not 
 hitherto been exactly defined, for when the epidemic occurs 
 later on, it does not at, all follow that it should be at the 
 
— 46 - 
 
 absolute for disapproval, while Koch declares:! "In 
 these experiments, as to the influence of development- 
 inhibiting materials, the surprising fact was estab- 
 lished that comma bacilli extraordinarily easily die 
 when they are dried;'" and again — " For the spread of 
 the infective material the main condition is, that the 
 dejections should remain in a moist state, for as soon 
 as they dry up they lose their activity y\ And labora- 
 tory experiments and experiences have demonstrated 
 these bacilli are among the most sensitive and non- 
 resistant of organisms of their class, since a tempera- 
 ture of either 15° or 50° C. (59° or 122° Farh.) is sure 
 death thereto within a z'^rjv^/'zV/ period of time; more- 
 over their resistance to chemical agents is almost nil, 
 especially in relation to acids, hence their destruction 
 would be assured in the stomach by means of the 
 gastric Juice if the latter is of normal reaction; only 
 in an alkaline or neutral medium is it possible to 
 secure development. Koch tacitly admits this, and 
 Klein and Herman Bigg, and the whole host of fol- 
 lowers are compelled to corroborate. Further, the 
 
 same place or time or soon after the occurrence to which we 
 are referred; and parallel with this inquiry, how did the 
 River Seine become infested with the comma bacillus, and 
 how was the cause of the disease introduced into Hamburg, 
 or, to take the latest example, into the well at Portel, the 
 fishing village near Boulogne?" — S. 
 
 f Report of July, 1884 — " Cholera in Europe and India," 
 by E. O. Shakespeare, Washington, 1892. 
 
 X Italics mine. — S. 
 
— 47 — 
 fact may be recalled that while cold in the main seems 
 to inhibit certain epidemics of cholera — as those of 
 1849 and 1866 in certain other instances it appeared 
 to have no effect; in 1830 and 1831, in the height 
 of a severe Russian winter, its ravages were of a 
 most virulent nature, in Moscow with a temperature 
 of minus 4° Farh., and even in Orenburg with a 
 temperature of minus 22° Farh. 
 
 If, then, the comma bacillus is the cause, infec- 
 tion'should be much more active at the bedside than 
 in the closet — among physicians and nurses than 
 laundresses, scavengers, and those who handle and 
 cleanse the dried and soiled bed-clothing and body- 
 linen, — whereas the precise contrary has been re- 
 peatedly proven by the best of all tests, practical ex- 
 perience. (Thiersch, Niemeyer, Tanner, Flint, Wat- 
 son, Lebert, et al.) Again, it is a well known fact 
 cholera dejections may be boiled to the utter de- 
 struction of the last bacillus, yet be not deprived of 
 their virulence; (Virchow, Aitken, Lewis.) 
 
 Arnaldo Cantani and Klebs repeatedly obtained 
 cholera poisoning from sterilized cholera fluids, and 
 Lewis and D. D. Cunningham as far back as 1874 
 made a like observation. Finally, Jno. Simon, A. 
 Delpech, Wm. Sedgwick, Dutrieux Bey, Alex. Har- 
 kin, J. M. Cunningham, Lionel Beal, Thos. J. Mays, 
 B. W. Richardson, John Chaine, Mariano Semmola — 
 the latter recognized as one of the most profound 
 pathologists of our century — and others, attach no 
 
- 48 - 
 
 importance to microbes, which they believe at most to 
 be only modified anatomical elements, and sequels 
 of the pathology instead of a cause thereof; that 
 they are accidental accompaniments of disease, of 
 which nothing can be predicated of the action of any 
 particular form; they are scavengers only. 
 
 Thus is confirmed the trite utterance of Trichum, 
 d propos of Koch's bacillus, when he adjured his 
 listeners not to believe the purported discovery settled 
 the question of cholera any more than knowledge of 
 the tubercular bacillus would eradicate pulmonary 
 phthisis. Semmola adds:* " This doctrine at best is. 
 based only on a hypothetical basis;" and, '* I cannot 
 comprehend how true clinicians can accept as of 
 practical value results that are established solely in 
 the laboratory." 
 
 Again, the Koch theory of infection embodies the 
 belief that when a patient fails to succumb under an 
 attack of cholera, it is owing to his organism having 
 not only withstood the onslaught of the bacilli or the 
 virulence of their morbific products, but that the 
 invading hordes must have perished within the body. 
 But that these hordes are a sequel rather than a cause, 
 has just been shown by Dr. Cornet, of Berlin and 
 Reichenhall, who discovered that persons apparently 
 convalescent from the malady may carry about with 
 them in their intestines, active living Koch bacilli. f 
 
 * Berliner Klinische Wochenschrift. 1891. 
 
 f " The case in which this important discovery was 
 
— 49 — 
 
 Regarding the teachings of the Gautier school, it 
 may be said they have Httle in common with pan- 
 germic and bacterial theorizings, but rest upon data 
 positive, precise, easy of verification; and if the in- 
 dications submitted meet with the attention they seem 
 to deserve, a sweeping reformation will result. 
 
 Both Gautier and M. Peter, following the lead of the 
 great Selmi, believe there are elements resident with- 
 in the economy that may induce certain specific dis- 
 eases; that these elements remain inoffensive whilst 
 elimination and oxydation of detritus is normally 
 operative, but give rise to disease if from some cause 
 or other this eUmination and oxydation are interfered 
 with whereby the detritus accumulates and exerts a 
 toxic influence upon the nerve centres; in fact, that 
 not only after death, but even during life, the animal 
 organism— in accordance with physiological and 
 chemical processes readily determined — has the power 
 of elaborating a numerous class of alkaloids essen- 
 
 noticed was that of a man whose mother, wife, and son died 
 of cholera. He himself had a slight attack, and was put 
 under the care of Dr. Carl Lauenstein, of the Seemann Hos- 
 pital. He was nine days in the hospital, . . . recovered 
 perfectly, and was on full diet. Last Friday he was up and 
 anxious to go home, but was induced to stay. On Saturday 
 he was still better, and no motion at all, and it was with 
 difficulty he was induced to remain. On Sunday Dr. Cornet 
 discovered that in the stools passed there were large quan- 
 tities of comma bacilli." — British Medical Journal, Oct. 8th, 
 1892. 
 
_ 50 — 
 
 tially toxic in properties, those evolved from dead 
 tissue being termed pfomaines, those from living tissue 
 leucomaines.^ But this is not all. Gautier has also 
 ascertained that in the living animal economy there 
 are elaborated azotized uncrystallizable salts, sub- 
 stances the precise character of which is still undeter- 
 mined, and which are the extractive matters (tox- 
 albumins ?) ; and while the ptomaines and leuco- 
 maines are both highly poisonous, the extractives are 
 far more toxic than either ! This discovery of 
 ptomaines, leucomaines, etc., though perhaps of com- 
 paratively little value from a therapeutic standpoint, 
 is nevertheless of the greatest importance to path- 
 ology. 
 
 The importance of such authoritative teachings 
 has not escaped the germ theorists, who are forced to 
 admit the symptoms that supervene upon a cholera 
 attack obviously indicate a form of poison. Even 
 Koch, along with others, has been compelled to hesi- 
 
 * Ptomaine, from UrcSi-ia a "carcase" or dead body, 
 and ivo, " material — or in from Latin, inus "belonging to." 
 Leucomaine from AEvxoo/xa^ anything whitened as albumen 
 or white of egg. 
 
 This nomenclature is far from satisfactory. The selec- 
 tion of the term ptomaine, indicative merely of the'conditions 
 under which animal alkaloids were first discovered, as a root 
 whence to derive a name for these bodies, is ,"too restrictive, 
 since it is only appropriate for alkaloids of post-mortem 
 origin. A title is still needed for alkaloids formed by mor- 
 bid processes during life — the ptomaines of disease. — S, 
 
— 51 — 
 tate, and to inquire if some ptomaine is not a specific 
 cause, even while claiming a microbic origin for the 
 disease; and Klein strongly supports this view. Dr. 
 A. M. Brown,* who is vouched for by Gautier as an 
 English exponent of his ideas, remarks: 
 
 "Cholera, . . . monopolizing as it does so 
 much scientific interest, supplies the finest field for 
 airing the respective claims of the two pathological 
 theories, . . . the one bacillar, organic, and 
 strictly biological; the other toxic, inorganic, and 
 strictly bio-chemical. The first, so high in favor, and 
 with the entire field to itself, has failed egregiously in 
 its assumed solution. The various expeditions under- 
 taken — Indian, African, and European — in bacterio- 
 bacillar interests, have proved as practically hopeless 
 and unprofitable as the discovery of a north-east pas- 
 sage to Cathay. By such missions Koch has only 
 added to his hypothetical perplexities, while Klein 
 and Bouchard, with modified appreciation, preserve 
 their germ proclivities, and hope by vested but truly 
 humoralistic concessions to solve the cholera problem." 
 
 Koch thought he had found the pathogermic 
 entity, but, confronted and constrained by cold facts, 
 has later felt himself obliged to modify his positive 
 utterances, and consequently now admits the comma 
 bacillus does not directly engender cholera, and that it 
 
 * " Animal Alkaloids — The Ptomaines and Leuco- 
 maines." London, ifcSq. 
 
— 52 — 
 can only do so indirectly by the intervention of a 
 ptomaine which he supposes it secretes. Thus he 
 seeks to ally himself with the third class, who en- 
 deavor to reconcile theory with fact by preaching the 
 " Good Lord, good Devil " doctrine ! And this must 
 imply two suppositions — first, a specific bacillus which 
 Koch has not discovered; second, the secretion of a 
 ptomaine by that bacillus which the Berlin savant and 
 his following are equally as far from discovering. — 
 Says Sir Wm. Aitken,* d propos of the foregoing: 
 
 " A. G. Pouchet obtained an oily base belonging to 
 the pyridin series from cholera stools, and Brieger got 
 from pure cultivations of the comma bacillus in beef 
 broth, in addition to the common ptomaine of putre- 
 faction, two poisons which he regarded as specific 
 products of this bacillus." But none of the poisons 
 which have been thus isolated produce exactly the 
 symptoms of cholera: In Cantani's experiments, 
 tremor, prostration, spasms, and repeated vomiting 
 were observed; Klebs noticed muscular contractions 
 and alterations of the kidney; the poison obtained by 
 Pouchet irritated the stomach and slowed the heart; 
 one of L. Brieger's produced muscular tremor and 
 cramps, while the other induced lethargy and feeble- 
 ness of circulation with occasional bloody diarrhoea. 
 These facts, remarks Aitken, evidence " the symptoms 
 of cholera are not caused by a poison formed by the 
 
 *" Animal Alkaloids." London, iS 
 
— 53 — 
 action of the comma bacillus, and it is evident that 
 much more extended investigation is required before 
 the pathology of the disease is accurately understood." 
 C. H. Fagge* suggests that in all such investigations 
 one must bear in mind the possibility of the poison 
 being formed, not in the intestines merely, but in the 
 blood, nerves, and general tissues. 
 
 —Thus Koch assumes, Gautier demonstrates, and 
 Klein and Chas. Bouchardf vacillaite while sedulously 
 essaying to promote fusion. 
 
 * " Principles and Practice of Medicine." London. 
 
 f Since the above was written, attention has been called 
 to an editorial in the Boston Medical and Surgical Journal 
 for July 28th, 1892, from the pen of my friend Dr. E. P. Hurd, 
 of Newburyport, Mass., as follows: 
 
 " The toxic theory of Bouchard, as set forth in his book 
 'On the Auto-Intoxications,' fairly well explains the symp- 
 tomatology of cholera. He demonstrated, as early as 1884, 
 by experiments made with toxic substances found in the 
 stools and urine of cholera patients, that the pathogeny of 
 cholera may be referred to multiple intoxications. 
 
 " Professor Bouchard has some doubts as to the fact of 
 the comma bacillus being the pathogenic agent of cholera. 
 'The only serious argument,' he says, 'in favor of Koch s 
 claim, is the presence in the intestines of cholera patients of 
 special micro-organisms, which are not supposed to be found 
 in the intestines of healthy persons or of persons affected with 
 other diseases. These micro-organisms exist often in con- 
 siderable abundance, from the very first, and often to the 
 exclusion of every other microbe in the digestive tube. 
 Apart from this empirical ascertainment, which warrants 
 only a presumption, all the other arguments which have 
 been alleged are illusory.' 
 
 "The toxic alkaloids which Bouchard has extracted 
 from the intestines and urine of cholera patients, greatly ex- 
 
— 54 — 
 
 ceed those ordinarily contained in fsecal matters. One of 
 these, which forms acicular crystals, seems to have a special 
 virulence, and to be identical with the 'cholera poison' 
 which Koch and Brieger have isolated from the intestinal 
 contents of cholera patients, and which they believe to be 
 generated by the comma bacillus. There is, however, no 
 agreement as to what really are the soluble toxic substances 
 secreted by the microbe of cholera. Bouchard affirms that 
 the real virus is eliminated in the urine in appreciable quan- 
 tities. In injecting into the veins of animals cholera urine, 
 he has caused pronounced cyanosis, collapse, albuminuria, 
 anuria, cramps, and pale, yellowish or bloody diarrhoeic 
 evacuations, like those which characterize true cholera. In 
 injecting the alcoholic extract of the urine of cholera patients,, 
 he has determined somnolence, albuminuria, diarrhoea, and 
 death in two days. 
 
 " 'There is,' says Bouchard, 'in cholera-urine a poison 
 which I call the true cholera poison. I cannot chemically 
 define it; I only know by its physiological properties. I 
 know not if it is fabricated by the sick organism or by 
 microbes.' 
 
 " Bouchard's view then is, that besides the primary 
 infection there exists in the pathogeny of cholera a second- 
 ary intoxication, consequent on the infection. He thinks 
 that the symptoms considered as characteristic of cholera 
 are the result of this intoxication. To this we may attribute 
 the cyanosis, the chilliness, the respiratory troubles, the hic- 
 cough, the special diarrhoea, the intestinal desquamation, 
 the cramps, the de-hydration of the blood and tissues, the 
 albuminuria, the anuria. But very soon ' there supervenes 
 a new source of systemic intoxication superadded to the 
 first, and this clinically expresses itself by intellectual torpor 
 — by somnolence, apathy, and coma. The respiratory 
 rhythm changes, sometimes rising, sometimes falling; it is 
 the rhythm of uraemia. The pupils are contracted, and be- 
 come punctiform.' 
 
 " This is evidently a different symptom-aggregate from 
 that of the initial period, and is due to another kind of 
 poisoning; in other words, we have the clinical tableau of 
 uraemia from excess of disassimilation and blocking of the 
 kidneys. 
 
 " ' In short, cholera furnishes us an example of a double 
 auto-intoxication; one by an abnormal product, — this the 
 
— 55 — 
 
 choleriac intoxication properly so called; the other by nor- 
 mal products, — constituting a variety of uraemic poisoning.' " 
 
 From the foregoing it would seem Bouchard is gradu- 
 ally " undergoing a change of heart." — S. 
 
CHAPTER IV. 
 
 PATHOLOGICAL DISCUSSION. 
 
 Setting theories aside, I may now deal with real 
 facts. With all the wrangling of pan-germists, bio- 
 chemical physiologists, and fusionists, one thing is 
 most evident, viz. : The neurotic character of 
 cholera ! 
 
 As far back as the time of Wm. CuUen, who was 
 upheld by Sir Thomas Watson, the disease found place 
 in nosological nomenclature under the ^'- order Neu- 
 roses, class Spasms." Jules Marey always considered 
 the nervous system as primarily affected by cholera 
 poison, and as determining the principal phenomena 
 of the attack, even the gastro-iritestinal symptoms. 
 The poison, he declares, first excites the sympathetic 
 system, whence ensues the contraction of the muscles 
 under the dependence of that system. The spasm 
 of the arteries of the greater and lesser circulation, 
 as well as of the bronchial radicles, explains the 
 phenomena of the cold period. In the period of 
 reaction, the arterioles and capillaries relax, aad there 
 is stasis of the circulation and excessive watery exu- 
 dation. And everything manifestly points to pro- 
 found toxication of nerve centres inducing changes 
 that are chiefly revealed through the great sympa- 
 thetic, particularly in its abdominal and thoracic area. 
 
— 57 — 
 Sir Henry MacCormac* and Chas. Lever,f both of 
 whom had extended experience in Ireland in the 
 epidemic of 1834, alike regarded the malady as pro- 
 voked by a lesion of the sympathetic — a view sup- 
 ported by Wm. Sedgwick, Jas. Johnson, Claude 
 Bernard, D'Arsonval, the elder Chermak, Fillipo 
 Picani, D. Cannataci, Foster, Guerin, and Alex. Harkin. 
 But it is evident we must look even further. Mani- 
 festly the gastric and enteric pathology is not primary, 
 but secondary, since in " dry cholera " (cholera sicca; 
 cholera asphyxia; cholera siderans) death supervenes 
 ere there is any evidence of intestinal or stomachal 
 disorder or distress, and through failure of the res- 
 piratory and cardiac centres. Indeed, the latter fac- 
 tors are so prominent in every attack that Drs. 
 E. A. Parkes, Jonathan Hutchinson, Geo. Johnson, 
 J. Snow, W. Grissinger, and Surgeon-Major J. C. 
 Hall, were inclined to believe the real morbid factor 
 exists in the blood whereby is induced spasm of 
 arterioles inhibiting pulmonary circulation and pre- 
 venting oxydation, laying especial stress on the fact 
 that there is likewise evidence of spasmodic contrac- 
 tion of the circular organic muscular fibres of the 
 bronchi. Says Dr. Parkes: J " That there is some 
 
 *"Observations on Spasmodic Cholera; Its Origin, 
 Nature and Treatment," etc. London, 1834, 
 
 f'Cholera in the Southland West of Ireland." Dublin, 
 1834. 
 
 X " Researches into the Pathology and Treatment of 
 Asiatic or Algid Cholera." London, 1847. 
 
- 58 - 
 
 impediment or arrest of the circulation in the capil- 
 lary system generally, and in the pulmonary capilla- 
 ries in particular, appears almost certain; and it is 
 by no means improbable, from the whole bearing of 
 the facts, that this is due to chemical change in the 
 fibrin and in the mode of its combination consequent 
 on the direct action of the active cause." 
 
 Evidently the latter "builded better than he 
 knew," and had a partial insight into the truth, as is 
 seen in the terminal portion of the above sentence. 
 
 Dr. George Johnson, as cited by Thos. Hawkes 
 Tanner, remarks: "During the state of collapse the 
 passage of the blood through the lungs from the right 
 to the left side of the heart is in greater or less degree 
 impeded."* But he differs from Dr. Parkes as to the 
 cause of this impeded circulation, his hypothesis being 
 that the poisoned blood causes contraction of the mus- 
 cular walls (instead of spasm) of the minute pulmonary 
 arteries, the effect of which is necessarily to diminish 
 or arrest the flow of blood through the pulmonary- 
 capillaries. Alburtus Eulenberg, Chas. Francois, J.. 
 M. French, and others, attribute cholera-algidity to 
 cardiac adynamia provoked by nervous irritation pro- 
 ceeding from the intestine, a theory that derives sup- 
 port from the experiments of Tarchonoff and Franck 
 who showed that irritation of the digestive tube and 
 
 *" Notes on Cholera, its Nature and Treatment," 1866 
 " The Practice of Medicine." London, 1874. 
 
— 59 — 
 
 mesenteric nerves may determine more or less pro- 
 longed arrest of the heart. 
 
 Though these views in a measure clash, they may 
 all be considered as containing great germs of fact, 
 being based upon observation in different individuals 
 under variable conditions; moreover they are, in a 
 measure, reconcilable when later pathological knowl- 
 edge is brought to bear thereupon, and due consider- 
 ation is given to the influence of the nervous system. 
 
 Though the theory of primary intestinal lesion has 
 many advocates, who lay especial stress on two mani- 
 fest symptoms, viz., dehydration of blood and tissues, 
 and blood poisoning — that under the influence of the 
 profuse watery discharges, provoked by such intes- 
 tinal lesion, the blood and tissues became unfit for 
 nutrition and functional work, — it must be remembered 
 that in many cases no changes whatever are to 
 be observed after death, either in the stomach, 
 intestines, or elsewhere, save perhaps congestion of 
 the pulmonary and cutaneous systems; but the left 
 heart (as shown by Simon and others) is generally 
 empty, while the right is distended and filled with 
 blood. Sicluna and J. M. Bruce,* performing autop- 
 sies on the victims of the epidemic that ravaged Malta 
 in 1887, always observed the cavities of the left 
 heart empty and of the right filled with blood! 
 
 *" Treatment of Cholera." Dublin Jour. Med. Science. 
 March, 1890. 
 
— 6o — 
 
 George Budd* reports concentric hypertrophy in cases 
 of sudden death from cholera: and Jas. Jacksonf 
 especially noticed that at post-mortems of victims 
 the hearts usually exhibited hypertrophy of the left 
 ventricle. 
 
 Again, the elder Flint| lays stress upon the fact 
 "epidemic cholera has no constant, appreciable, 
 anatomical characters — none which appear to be com- 
 mensurate with the gravity of the malady; the 
 morbid appearances after death do not afford an 
 adequate explanation of the symptomatic phenomena, 
 nor do they elucidate the pathology of the disease." 
 
 Tanner declares§ " post-mortem examinations 
 have thrown little light . . ." ; that " we naturally 
 look first to the gastro-intestinal mucous membrane, 
 but beyond distension of the follicles with serum, an 
 oedematous condition of the mucous lining, patches 
 of venous congestion, and here and there rupture of 
 the vessels producing ecchymoses, we find nothing. 
 The blood is altered more or less, is usually of tarry 
 appearance and consistence, the proportion of water 
 being much diminished, the fibrin being either re- 
 duced in quantity or affected in character, and the 
 corpuscles increased, while the serum is rich in albu- 
 men, contains a slight excess of urea, and its salts. 
 
 * Medical Chronicle, vol. xxi. 
 
 f " Report on Cholera in France." London, 1872. 
 X "Practice of Medicine." Philadelphia, 1873. 
 §" The Practice of Medicine." London, 1874. 
 
— 6i — 
 
 collectively, perhaps, diminished . . . the heart 
 is often flaccid, its right side dilated, the left side 
 contracted." 
 
 Niemeyer, barring those cases where death oc- 
 cured during the stage of reaction, emphasizes the 
 fact* "the characteristic changes consist chiefly in 
 extensive catarrh of the intestines accompanied by 
 detachment of the epithelium and copious transuda- 
 tion, and in decided thickening of the blood and ex- 
 cessive venous hypersemia of the kidney " (the latter 
 mentioned also by Tanner as an occasional but by no 
 means constant feature). 
 
 Lebert remarks:f "The anatomical leisons of 
 cholera are of peculiar character, but clearly more the 
 consequences than the cause of the disease, hence pos- 
 sess no pathognomonic character whatever." And 
 again: "The anatomical changes, the hypersemia of 
 the mucous membrane, the distension of the mesen- 
 teric veins with thick blood, the ecchymoses and 
 hsemorrhagic suffusions of the mucous membrane, the 
 swelling and great softening of the lymphatic appa- 
 ratus of the small intestines, are, I am convinced, not 
 the cause of 'rice-water' stools." 
 
 Rudolf von Jaksch, Jas. Cagney, Hoppe-Seyler, 
 C. Schmid, C. Zehnder, Jas. Sterling, T. R. Lewis, F. 
 
 *Text Book of Practical Medicine," vol. ii. New York, 
 1882. 
 
 f " Ziemssen's Cyclopoedia of the Practice of Medicine," 
 vol. i. New York, 1874. 
 
— 62 — 
 
 Delafield, et al., corroborate these authors, admit- 
 ting an inadequate pathology as evinced by the dis- 
 ease in any stage; and when is further recalled the 
 fact there is no malady in the whole nosology that is 
 more efficiently assisted in gaining a foothold in the 
 economy, or the fatal tendency of which is more 
 vigorously promoted and hastened by mental causes, 
 we have most convincing evidence the ultimate source 
 or cause of cholera lies deeper than in the organs that 
 permit of general review and inspection. 
 
 Chas. Bouchard insists " from the study of the 
 various attempts of pathologists to explain the symp- 
 tomatology of cholera, it results that we must admit 
 multiple causes. If the most powerful come under 
 the head of intoxications, we must still make due 
 account of the dehydration of the blood and tissues, 
 and of the reflexes which take their start in the 
 digestive tube and affect the vaso-motors. In favor of 
 this latter influence, may we not refer to the algidity 
 and collapses which sometimes follow the gastric 
 crises of tabes, and which bear so striking a resem- 
 bance to cholera ?" 
 
CHAPTER V. 
 
 CHOLERA CHARACTERISTICS. 
 
 The characteristics of cholera, those most man- 
 ifest in its so-called epidemic or malignant form, and 
 upon which differential diagnosis chiefly rests, are: 
 
 First Stage. — A feeling of stupidity, general 
 weakness, chilliness — more rarely a regular chill, — 
 followed by uncontrollable watery diarrhoea devoid of 
 color or nearly so, lacking also in odor. The first 
 dejections are apt to be dark and pappy, but once 
 the contents proper of the intestines are cleared out, 
 they become of whey-like character, sometimes of 
 pale reddish hue owing to admixture with blood, with 
 not the slightest traces of bile pigment, and on stand- 
 ing usually deposit a fine granular, whitish-gray sub- 
 stance which contains triple phosphates, bacteria, fine 
 shreds of algae and blood-corpuscles, sometimes also 
 phosphate and crystalloid salts of lime; this fluid is alka- 
 line, being disproportionately rich in sodium chloride, 
 and may contain some albumen, though not in great 
 quantity. The mvestigations of Surgeon-Major Lewis 
 evidence the flakes and corpuscles of " rice-water " 
 stools do not consist of epithelium, nor of its debris^ 
 but that their formation " appears to depend upon the 
 effusion of blood plasma;" that "the bodies found by 
 Surgeon E. A. Parkes, moreover, correspond very 
 closely in their microscopic and chemical characters, 
 as well as in manifestations of vitality, to the corpus- 
 
- 64 - 
 
 cles which are known to form in such fluid and are 
 generally to greater or less degree associated with 
 blood-cells, even when the presence of such is not 
 suspected, especially when the disease tends toward 
 fatal termination, when the latter have been frequent- 
 ly seen to replace the former altogether."* This 
 diarrhoea, which varies in frequency in different epi- 
 demics, may be regarded as the warning of an attack; 
 and where it is absent, patients before the outbreak 
 usually feel depressed, tired, and uncomfortable. These 
 first manifestations, which are however some times to- 
 tally absent, may be regarded as stadium prodromorum. 
 The duration of prodromic diarrhoea in cases of 
 absolute cholera, as ascertained by Lebert, does not 
 as a rule exceed three days, "but may continue five 
 or even eight days." He gives a table of thirty-five 
 cases,, closely observed during the Zurich epidemic of 
 1855, which is here reproduced: 
 
 DURATION OF PRODROMIC 
 
 DIARRHCEA. DIED. RECOVERED. TOTAL. 
 
 One day 178 
 
 One to two days 369 
 
 Three days 4 5 9 
 
 Five days i i 2 
 
 Six days 112 
 
 Eight days i 3 4 
 
 Three weeks i . . i 
 
 12 23 35 
 
 * " Pathological and Pathological Researches." London ^ 
 18&8. 
 
- 65 - 
 
 Second Stage. — This stage, with which cholera 
 not infrequently precipitately commences, constitutes 
 the attack proper, and has been defined as algid or 
 asphyctic — terms not altogether pertinent. There is 
 a feeling of stupidity, general weakness, chilliness — 
 occasionally a marked rigor, — followed by increased 
 intestinal flux, the passages being expelled with great 
 and sudden force, without warning; there appears to 
 be complete loss of power over the sphincters. In 
 addition to the " rice-water " evacuations, there is 
 usually vomiting — which in many cases is a prom- 
 inent and persistent symptom, — the expelled matters, 
 like those from the intestine, being devoid of color 
 and odor; this emesis may appear as a much more ter- 
 rible symptom than the diarrhoea. A notable fact is, 
 absence of pain, whereby the sufferer is enabled to 
 endure the attack with comparative indifference up to 
 the actual occurrence of cramps. 
 
 The cramps — in the lower extremities and abdo- 
 men, perhaps across loins, rendering the muscles as 
 "hard as wood " or " drawing into knots," as it were, 
 the frequency of which varies indifferent epidemics, 
 — constitute one of the most remarkable symptoms of 
 the malady. Lebert usually observed in the second 
 half of the attack proper, rarely earlier, and that they 
 always assumed a tonic character in adults, while 
 in children the tetanic form commonly obtained; oc- 
 casionally, though rarely, the muscles of the face are 
 involved. Each attack lasts but a few minutes, but 
 
— 66 — 
 
 the frequent recurrence and excruciating character 
 mark as the most distressing manifestation of the dis- 
 ease. Sometimes cramps persist to the very end in 
 rapidly fatal cases, but usually they cease with the 
 progress of the asphyxia, and in more protracted, 
 cases, in the cold period just preceding reaction. In 
 a few instances both cramps and vomiting are ob- 
 served together at the very outset of the malady, in 
 conjunction with dizziness, headache, very great dis- 
 quiet and anxiety — though, as a matter of fact, most 
 patients exhibit a certain indifference. At the height 
 of a very intense epidemic are sometimes seen pa- 
 tients who rapidly collapse with symptoms of great 
 distress, becoming cold, cyanotic, dying after one, two 
 three, five, six or more hours; but in such there is 
 usually an abundance of colorless transudation into 
 the intestine. 
 
 In the most intense or malignant development of 
 the malady, persons may die pulseless, cold, cya- 
 nosed, etc., with no evidences of vomiting or diar- 
 rhoea, and with positively no characteristic changes to 
 be found in the intestines or elsewhere, and no tan- 
 gible cause for fatality; but these cases are so rare 
 of late years that a large number of medical men are 
 inclined to deny the existence of " dry cholera," which 
 was generally considered as proved in the earlier epi- 
 demics. 
 
 Thirst is invariably a most assertive symptom, 
 and usually very urgent, though its degree is apt 
 
- 67 - 
 
 to be in inverse proportion to the severity of the 
 seizure; patients clutch at the attendants' hands as 
 the glass or cup is held to them, in terror lest it 
 should be taken away too soon.* 
 
 The circulation is greatly diminished, the pulse 
 frequent and proportionately weakened, ranging from 
 t2o to 140 per minute, though under some circum- 
 stances it becomes more and more feeble without 
 acceleration, and in more pronounced or asphyctic 
 conditions may fall below normal. When the state of 
 collapse is fully developed the pulse is extinct at the 
 wrist; next the pulsation in the carotids disappears; 
 finally there is feebleness or absence of the apex beat 
 of the heart, and of all cardiac sounds, evidencing 
 greatly diminished power of the central organ of cir- 
 culation. There is also general venous stasis giving 
 rise to remarkable lividity or blueness at the roots of 
 
 *Says a correspondent of the British Medical Journal, a 
 volunteer nurse of the Eppindorf hospital, writing from 
 Hamburg recently: 
 
 " There are two pretty yellow-haired sisters who lie in a 
 cot, with whom the characteristic ravenous thirst is the most 
 pronounced symptom. They have no vomiting and but little 
 diarrhoea. They sleep about twenty-three hours out of the 
 twenty-four, and in their lethargy thirst seems to be the 
 only consciousness. One lies grasping a cup with both her 
 small hands, and if an attempt be made to take it from her, 
 she automatically and drowsily opens her mouth for a 
 draught, not knowing when the milk is given her, but 
 swallowing mechanically." 
 
— 68 — 
 
 the nails, in the lips, face, and on the surface of the 
 body generally; icy coldness of the skin everywhere — 
 of the nose, tongue, and even the breath; frequently 
 noises in the ears or head, dizziness, dimness of vision, 
 deafness. The skin becomes shrivelled, and if picked 
 up in a fold remains puckered for a time, retracting 
 but slowly. Finally the entire surface of the body is 
 bedewed with death-like dampness. 
 
 The number of respirations is usually increased, 
 often to twenty-four, thirty, or even forty per minute, 
 at the same time short, confined, and imperfect, fre- 
 quently of sighing or irregular rhythm; the expired 
 atmosphere, when collapse is complete, besides being 
 of low temperature, contains more oxygen and less 
 carbonic acid than in health, evidencing notable de- 
 ficiency in the changes incident to the function. 
 There is also marked alteration of the voice (vox 
 cholericd), which becomes whispering and unnatural 
 owing to diminished volume of respiratory gases; 
 oppression and pain at the praecordia are manifest, 
 often of such excruciating nature as not to be ac- 
 counted for solely by the dyspnoea present. — In many 
 instances this dyspnoea is more particularly marked 
 during the period of violent discharges from stomach 
 and intestines and at the beginning of the absolute 
 algid stage, only to disappear again with the conclu- 
 sion of this period; pressure over the stomach usually 
 aggravates. Cough is scarcely ever observed; and 
 stertor is but exceptionally noticed and only in fatal 
 
- 69 - 
 
 cases. In many instances complete aphonia super- 
 venes, the motion of the lips being seen during efforts 
 at articulation alone; and though this condition may 
 at times yield for a brief moment, it is usually only 
 when the intensity of the spasmodic muscular con- 
 tractions causes the patient to cry out. 
 
 Nothing is more constant in this stage than the 
 participation of the kidneys, and the manifold effects 
 resulting therefrom. Albuminuria may sometimes 
 supervene, the cloudiness varying from light opales- 
 cence to abundant deposit on ebullition, followed by 
 partial or complete suppression of the renal secretion. 
 Usually the microscope reveals a large number of 
 wavy casts, most manifest when the urine has not 
 been clouded by heating; also uric acid salts, as well 
 as some blood corpuscles; and test with muriatic acid 
 is apt to exhibit a large amount of indigo pigment 
 (indican) which is certainly suggestive of profound 
 disturbance of nerve centres, and also of the close re- 
 lationship of the disease to malarial disorders. Lebert 
 shows, in his report on the Zurich epidemic of 1855, 
 that discoloration and commencing fatty degenera- 
 tion may be recognized in the cortical substance of 
 the kidneys of individuals who have died early in the 
 asphyctic stage, and that this degenerative parenchy- 
 matous nephritis, which is more distinctly anatomical 
 the longer it lasts, is not sufficient to explain the 
 anuria that supervenes; further, it must be noted that 
 the nephritis of cholera depends for its origin upon 
 
— 70 — 
 
 disturbance in the nerve-centres, since it never by any 
 accident becomes chronic, but disappears with the final 
 vestiges of the disease. Lebert adds: " In all the four 
 years after the epidemic in Zurich, I never was called 
 upon to treat one of my patients for chronic nephritis, 
 and among a great number of nephritic patients in 
 Basel, I never found one in whom the nephritis could 
 in any way be referred to a past attack of cholera." 
 
 It should be remarked that all the foregoing 
 symptoms are apt to follow each other much more 
 rapidly in children, especially under three years of 
 age, than in adults, and death usually terminates with 
 convulsions; all, however, may exhibit different com- 
 binations . in different degrees of intensity, and so 
 establish from the start the distinction between 
 lighter and graver forms as well as between the nu- 
 merous transitional grades. As a rule patients really 
 suffer but a very few hours, and then, as already 
 noted, only in consequence of cramps, since the 
 intestinal and stomachal discharges are painless, be- 
 tween which profound rest occurs that closely bor- 
 ders on apathy. The expression of the face, in the 
 beginning may manifest exhaustion and discomfort, 
 but such is speedily followed by apparent indiffer- 
 ence; later the sunken eyes, which are peculiar to 
 grave cases, become remarkably dull and dry, and 
 are only imperfectly covered by the lids. 
 
 The diarrhoeal discharges may vary from three 
 to twenty, but seldom exceed ten or twelve, each 
 
— 71 — 
 amounting to perhaps four or six ounces, so that on 
 the average the material transuded from the intes- 
 tines does not exceed three or five pints; the quantity 
 lost by emesis is perhaps much less; further, in either 
 case the amount of fluid lost is not more copious in 
 fatal seizures than in those which recover. The ease 
 with which the contents of the stomach are expelled 
 is most remarkable, since the act partakes of the 
 character of simple regurgitation, occurring in series 
 of efforts, repeated three, four, eight, ten, or more 
 times. The whole period of all discharges varies be- 
 tween eight and twenty-four hours; they then become 
 m-ore and more infrequent, finally wholly cease for 
 several hours, perhaps for a day or two, only to 
 return, perhaps, at irregular periods; vomiting is 
 especially apt to return after the ingestion of fluids. 
 The absence of bile pigment in the stools seldom 
 lasts more than twenty-four hours, when the period of 
 reaction (third stage) sets in and they become yellow- 
 ish-green; but before they wholly return to normal, 
 there is an irregular exhibition of faecal material 
 varying between moderate diarrhoea and constipation, 
 unless dysentery complicates. 
 
 There is entire absence of fever or febrile con- 
 dition. The temperature is depressed, the thermom- 
 eter falling to 93° and to 90° Farh.— rarely below 
 the latter figure, though it has been known to reach 
 . 75° Farh., — notwithstanding which the sufferer com- 
 plains of oppression and prefers to lie uncovered; 
 
— 72 — 
 
 generally during both collapse and reaction, the tem- 
 perature in vagina or rectum (or both) is three or 
 four degrees higher than in the axilla, which in turn 
 is at least one or two degrees lower than in the 
 mouth. 
 
 Malignant (asphyctic) cholera, runs a very acute 
 course, and patients may die at any time in from two 
 to twelve, eighteen, or twenty hours; death, however, is 
 comparatively rare in the first twelve hours, occuring 
 usually in the succeeding ten or sixteen, and when oc- 
 curring on the second day is usually in consequence of 
 imperfect reaction. The algid stage rarely lasts longer 
 than two days, and the evacuations often cease some 
 time before dissolution, though this is very far from be- 
 ing a favorable sign, since it is due, not to cessation of 
 transudation, but to complete paralysis of intestinal 
 muscles; per contra, patients in whom the evacuations 
 continue for a long time, recover more frequently than 
 those in whom the)'^ cease suddenly; consequently the 
 occurrence of intestinal paralysis must be regarded as 
 a most unfavorable manifestation, while, on the other 
 hand, persistence of evacuations evidences such par- 
 alysis has not supervened, hence justifies more favor- 
 able prognosis. 
 
 Niemeyer early advanced the opinion that temper- 
 ature diminishes only at the periphery of the body re- 
 maining elevated within, an assumption now generally 
 accepted by the medical world. Through numerous 
 careful observations of the temperature of cholera pa:- 
 
— 73 — 
 tients in the algid stage, Jiiterborgk arrived at the 
 following conclusions: 
 
 " The head, extremities, etc., are colder than in 
 almost any other disease: 
 
 "The temperature of the cavities of the body, such 
 as the vagina and rectum, is the highest (that can be 
 measured) in the body, and should always be taken 
 for measurements: 
 
 " Whether the case be favorable or fatal, the tem- 
 perature within the body is usually increased, rarely 
 normal, and more rarely diminished, although no 
 cause for this has ever been found in the pathological 
 symptoms during life or on autopsy — [Another evi- 
 dence of the neurotic character of the disease. — S.]: 
 
 " The temperature of the whole body usually rises 
 with the approach of death; but there are cases where 
 this rise takes place without one being able to find 
 any reason for this deviation:" 
 
 Again: ''The commencement of reaction is not 
 accompanied by any elevation of temperature, but the 
 interior of the body usually cools off, while the outer 
 parts warm up: 
 
 " In cases of protracted reaction, the temperature 
 of the whole body generally sinks below the normal: 
 
 " The inflammatory sequelae usually, if not always, 
 excite decided elevation of temperature: 
 
 " During perfect convalescence, an abnormal 
 elevation of temperature is often seen without any 
 pathological cause therefor being discoverable." 
 
— 74 — 
 An abnormal and notable condition of the nervous 
 system, is manifest from the fact that, while the intel- 
 lect remains clear to the last*— and though the sufferer 
 is sometimes quite hopeful, — there is in general an 
 apathetic condition frequently amounting to com- 
 plete callousness; there are no apprehensions, and 
 little care as to what the ultimate result may be, 
 though perhaps prior to the seizure there may have 
 been intense dread of the disease. — The terrible 
 clearness of mind and recognition of the end which 
 is said to have characterized the earlier epidemics, 
 has not been witnessed during the present rav- 
 ages of the disease in Europe. In some cases 
 there is great restlessness and tossing — unconscious 
 movements to-and-fro, — though often the sufferer is 
 quiet, and appears to experience no inconvenience save 
 when disturbed by the evacuations, vomitings, or 
 cramps. Delirium is generally absent, but occurs 
 
 *" It is remarkable, notwithstanding the great debility 
 which makes every motion difficult, and the profound pros- 
 tration that is expressed in every feature," says Lebert, 
 " that the patients not infrequently possess entire conscious- 
 ness. This, to me, was one of the most disagreeable im- 
 pressions of the Paris epidemic — to hear sufferers in whom 
 the pulse was no longer perceptible, in whom the face was 
 cyanosed and cold, still speaking with the most perfect 
 possession of all the faculties of the mind." According to 
 Reinhardt and Leubuscher, some insane patients entirely 
 recover sanity for the time being, though the sanity vanishes- 
 with convalescence; others remain insane to the end. — S. 
 
— 75 — 
 more frequently among alcoholics, and later in the 
 typhoid state (third stage) during which it alternates 
 with sopor; in cases of pronounced ursemia, it is some- 
 times attended with convulsions. Strange to say, 
 muscular strength, real or apparent, appears to persist 
 in most extraordinary degree to the very last, and pa- 
 tients if not prevented will frequently get up and walk 
 about a few moments before dissolution. Again, **walk- 
 ing cholera" is by no means uncommon, the sufferers 
 keeping their feet until fairly in the throes of death, and 
 in such cases locomotion appears to hasten fatality. 
 
 Death is usually peaceful, by asthenia and, as 
 already noted, may take place at any time from two 
 to twenty-four hours after the attack — it is a gradual 
 "going out," the " rattling of the throat " which per- 
 tains to most diseases, being conspicuous only by its 
 absence; or if surviving beyond twenty-four hours, 
 there is usually manifest evidence of amendment. 
 Commonly patients become lethargic, the lethargy cul- 
 minating in sleep; sleep in turn is merged into coma, 
 and coma into dissolution. As in many other severe 
 diseases, there is usually observed an elevation of 
 temperature as the fatal end approaches, while the 
 exhalation of carbonic acid gas is very much dimin- 
 ished; the temperature continues to rise, in many 
 instances even after death, as Davey observed as long 
 ago as 1839 — an observation that has since been con- 
 firmed in a series of other satisfactory tests. The 
 bodies cool off very slowly. 
 
- 76 - 
 
 Regarding the mortality of cholera, it may be 
 remarked no one has ever been able to complete sta- 
 tistics of the graver cases, because the lighter ones 
 for the most part escape accurate observation, while 
 as to the more serious the mortality varies (according 
 to the most conscientious statements), between two- 
 fifths and three-fifths (the average may be put at 
 one-half), though in some local epidemics under 
 unfavorable circumstances, especially in asylums for 
 the aged and for incurables, it reaches as high as 
 two-thirds, or even three-fourths. Nearly one-third 
 of the deaths occur within twenty-four hours, and 
 about one-half of all the deaths occur in the first 
 two days. In the neighborhood of one-sixth die on 
 the third day in consequence of imperfect reaction, 
 and about one-third during protracted convalescence 
 and in the typhoid state — after from four to twelve 
 days. In favorable cases of confirmed cholera, and 
 in half of all cases that recover, convalesence occurs 
 in three or four days; in the other half which re- 
 cover, it occurs irregularly up to the second half of| 
 the first week. From the beginning of convalescence 
 to perfect recovery, a period of from three to eight 
 days usually intervenes, varying according to the 
 character of the attack, and the characteristics of the 
 individual patient and his surroundings. 
 
CHAPTER VI. 
 
 REACTION AND CONVALESCENCE. 
 
 Third Stage. — Although in the preceding stage 
 all symptoms may reach such intensity that a large 
 number of those seized cannot survive, yet in other 
 numbers a third or so-called "stage of reaction" 
 supervenes, which exhibits most remarkable tendency 
 to restoration of physiological function, though cer- 
 tainly not always with equal results; it is possible 
 (though rarely witnessed), for recovery to be most 
 rapid. 
 
 The first improvement is manifested by some 
 repression of the discharges; even though emesis and 
 diarrhoea are still persistent, the quantity is dimin- 
 ished and the whey-like character lost; in some in- 
 stances, thus early, repression may be complete, even 
 to a degree constituting absolute constipation. An- 
 other evidence of improvement is when the stomach 
 fails to reject the fluids ingested, whereby assurance is 
 had that the function of absorption is no longer 
 in abeyance, and restoration of the fluids of the 
 circulation, lost by transudation, possible. The 
 capillary circulation is first renewed. Next that con- 
 trolled by the carotids. Then the radial pulse (which 
 before could not be felt or was scarcely perceptible) 
 quickly regains its strength, and in a few hours is 
 often stronger and fuller than in the normal condi- 
 
— 78 - 
 
 tion; usually, also it is rapid, though seldom increased 
 above ninety or one hundred, perhaps with distinct dic- 
 rotic beat. The double heart tones also soon become 
 normal and regular, the blowing sound synchronus 
 with the diastole, disappearing. Should venesection 
 now be attempted, the blood will be found to flow 
 almost as freely as in health, though of course, the 
 proportion of serum is greatly diminished. As soon, 
 too, as circulation is restored, the cyanosis disappears, 
 though many patients preserve for some time a 
 marble or cadaverous appearance. Heat gradually 
 diffuses hself into the peripheric parts of the body, in 
 fact often transcends a normal medium temperature; 
 and possibly profuse perspiration may be induced, 
 either of spontaneous character, or as the result of 
 hot drinks; when temperature exceeds the normal, 
 and the cheeks become suffused with dark red, the 
 eyes also injected, lachrymose, and painful, and gen- 
 eral evidences of fluxionary cerebral and other 
 organic hyperaemia, a clinical picture is presented 
 that oftentimes is most difficult to interpret; it 
 sometimes disappears spontaneously, and again is 
 evidence of imperfect reaction and threatening se- 
 quelae. Such congestions are more frequent, violent, 
 and dangerous in children; indeed, the stage of re- 
 action is, in the main, more intense in the little folk, 
 though of shorter duration, and demands watchful 
 care. Even most adults complain of a feeling of cold 
 and heaviness in and about the head, more manifest 
 
— 79 — 
 about the occiput or sinciput; roaring of the ears or 
 tintinabulations are common; and notwithstanding a 
 certain tendency to somnolence, those persons most 
 enfeebled are usually sleepless. 
 
 Cramps cease, as a rule, with the beginning of 
 reaction; but the urine remains scanty, or altogether 
 suppressed, for twenty-four or more hours, and 
 always exhibits traces of albumen as soon as passed, 
 which traces persist for from two to seven days.* Res- 
 piration is normal; dyspnoea absent or nearly so, having 
 been markedly lessened toward the conclusion of the 
 second stage. When the convalesence is rapid, the 
 tongue clears off, the bad taste is lost, appetite re- 
 turns, sometimes to a degree that causes error in diet 
 and consequent relapse. The discharges from the 
 intestines may persist, but soon assume a more 
 
 *In observations at Zurich, Lebert found the first urine 
 after total suppression, was not passed until forty-eight 
 hours after the beginning of the disease. As a rule it was 
 regarded the secretion would be restored in the course of the 
 third or in the beginning of the fourth day. "The first urine 
 passed was, usually, small in quantity, in two cases bloody, 
 and once attended with violent pains about the kidneys. 
 Several hours, from eight to twelve, usually elapsed between 
 this first and the second discharge. Specific gravity varied 
 between 1.007 and i.oio. At first there was considerable 
 brown coloring matter present, and on boiling with nitric 
 acid it aften showed a light bluish tint (indigo coloring mat- 
 ter). Only once was the first urine somewhat cloudy, with- 
 out albumen; in all other cases albumen was present, and 
 
— 8o — 
 
 natural color and solid consistence; the casts and 
 albumen disappear, and progress toward health is 
 rapid, so that the latter, barring accidents and slight 
 after-pains, may be regarded as established in from 
 ten to fourteen days subsequent to the primary 
 seizure. Says Lebert, " If nearly half the patients 
 die in the algid stage, in more than half of the rest, 
 the stage of reaction goes on to favorable termina- 
 tion." In women, metrorrhagias, during or in the 
 intervals of menstruation, are not infrequent during 
 reaction and convalescence. 
 
 At all periods of life, especially in advanced age, 
 reaction may be imperfect, may even be followed by 
 a relapse to the second stage; yet many cases recover 
 in spite of numerous vicissitudes and fluctuations: Or 
 the diarrhoea and vomiting may recur from time to 
 time with critical symptoms; or a dysentery may alter- 
 
 remained for three or four days and sometimes longer; the 
 quantity of albumen varied, and when it disappeared the 
 quantity of urine became much more copious." 
 
 According to investigations of Lehmann and Volk, 
 confirmed by Prof Buhl, of Munich, the first urine voided is 
 only quantitatively small and albuminous, but contains 
 traces of sugar, a little sodium chloride, and relatively very 
 little urea; but in the two succeeding days the quantity of 
 urine, as well as its relative proportions of urea and salt, 
 greatly increases, even far exceeds the normal, and then, 
 after some variation, again returns to the natural condition, 
 when the albumen, casts, and abnormal pigment disappear, 
 and the specific gravity becomes normal. — S. 
 
nate with obstinate constipation, the former green or 
 greenish yellow and gelatinous; the tongue does not 
 clear up; anorexia, bad taste in mouth, and thirst, 
 continue to torture; the little nourishment taken is 
 either speedily rejected or induces profound distress. 
 
 Catarrhal inflammation of the genito-urinary 
 tract is especially apt to delay convalescence, and 
 often in conjunction with, or succeeded by, a diphthe- 
 ritic condition of the prima vioe induced by irritation 
 of the denuded intestines or their contents. Most 
 patients who fall into this state die of exhaustion. 
 
 Pneumonia, or so-called typhoid pneumonia, is 
 especially apt to supervene; and Niemeyer remarks 
 that "in old, decrepit persons, if physical examina- 
 tion be neglected, the outward resemblance and the 
 subjective symptoms often cause pneumonia to be 
 diagnosed as catarrhal fever, nervous influenza, 
 typhus, etc." According to his experience, acute 
 croupous nephritis, with the retention of urine it causes 
 by plugging of the uriniferous tubules, is a common 
 sequel of cholera asphyxia, but by no means the con- 
 stant cause of cholera typhoid, as has often been 
 asserted. 
 
 " If the secretion of urine remains suppressed 
 after the disappearance of the symptoms of collapse, 
 or if the scanty urine contains quantities of albumen 
 and fibrinous casts for days; if vomiting recommences 
 and the patients complain of severe headache and 
 become comatose, or have epileptiform convulsions; 
 
 6 KKK 
 
— 82 — 
 
 it is safe to make a diagnosis of acute croupous 
 nephritis with so-called ursemic intoxication; in such 
 cases the skin has occasionally been found encrusted 
 with crystallized urea." (Niemeyer.) 
 
 If the first or second day after the cessation of 
 the asphyctic symptoms the patients do not pass a 
 normal or at least large amount of urine, or the 
 albumen, at first very constant, does not disappear 
 after a few days, they are apt to fall into a state of 
 exceeding apathy and stupor, or muttering delirium, 
 when the tongue becomes dry and crusted, the pulse 
 frequent and often double, the temperature elevated, 
 and they slip down toward the foot of the bed; indeed 
 the condition so exactly resembles severe enteric fever 
 as to fully warrant the title of cholera typhoid. Be- 
 sides, there is usually a foetid diarrhoea in which are 
 discovered shreds of epithelium; and while the pa- 
 tients can scarcely be aroused from the comatose 
 state, they twitch the face, or recover consciousness 
 and complain of pain, if strong pressure is made upon 
 the abdomen.* 
 
 If there is catarrhal or diphtheritic inflammation 
 of the intestine, or of the genito-urinary tract, a pneu- 
 monia, a pleurisy, or other of the inflammatory sequelae 
 of cholera, the appearance of the patient does not 
 materially differ from the above description. The 
 
 * So called cholera typhoid is one of the most common 
 forms of protracted convalescence, and considered by Fre- 
 richs as a uraemic condition purely. — S. 
 
- 83 - 
 
 typhoid peculiarities prevail in completeness, while the 
 symptoms of the origmal or local disease become sub- 
 jective, falling into the background or disappearing en- 
 tirely. Finally, in many cases, neither during life nor 
 on autopsy, is it possible to discover any local lesions 
 to which can consistently be referred the exhausting 
 fever, of which so many die after the cholera proper 
 has run its course — further evidence of nerve-toxaemia. 
 
 Particular importance has been attached by some 
 to the fact that during the so-called cholera typhoid 
 a maculated, papular, erythematous exanthema has 
 been observed, that may appear of decided urticarial 
 character, or show a roseola-like appearance; it differs 
 from the eruption of typhus in that it begins at the 
 toes and spreads up to the trunk, where it is most man- 
 ifest, becoming very imperfect on the face and head; 
 the spots and papules may also run together and form 
 a diffuse redness in different places — very much as is 
 seen in certain forms of malaria. This eruption 
 seldom manifests itself before the end of the first, and 
 often not until during the second week, and notably 
 most of the patients thus affected recover; it is not, 
 however, so constant a symptom of cholera typhoid as 
 to be pathognomonic, and is more apt to occur, per- 
 haps, where sinapisms have been repeatedly or con- 
 tinuously applied to the extremities during the algid 
 stage, or massage has been energetically used. 
 
 Sleeplessness, a condition of suUenness, etc., some- 
 times supervenes during apparent convalescence, when 
 
— 84 - 
 
 the patients may either fall back into the condition of 
 asphyxia, or continue to improve; but the latter is 
 usually at the expense of numerous suppurations^ 
 manifested as a crop of boils, perhaps as abscesses of 
 the parotid or of the larynx, or by general pyaemia. 
 
 It is needless to remark that this third stage is 
 one of danger accordingly as it manifests in greater 
 or less degree the pneumonic or typhic condition, 
 though in any event it is apt to induce general im- 
 pairment of the system that persists for a long 
 period. 
 
 Of the anatomical changes that take place during 
 or supervene upon a cholera attack, it is impossible to 
 speak in complete detail. However, the great with- 
 drawal of serum from the blood enables the bodies of 
 those deceased to resist decomposition to a remark- 
 able degree, hence the changes usually encountered 
 post-mortem are lacking. It has before been re- 
 marked that the corpses are greatly shrunken, of 
 dusky or livid color; that rigor mortis is rapidly de- 
 veloped and persists for an unusual length of time; 
 and that very remarkable and violent contractions of 
 the muscles are by no means uncommon, so much sa 
 as to give rise to weird tales of unfortunates buried 
 alive, etc.* 
 
 Bodies of those who succumb six, twelve or 
 eighteen hours after the attack, exhibit the same 
 
 *See pages 112, 113. 
 
- 85 - 
 
 cyanotic appearance, and collapse of features, as in 
 the last hours of life. 
 
 The circulatory organs and the blood exhibit the 
 following conditions: When death is early, absence of 
 the pericardial fluid is noted, or it is scant and sticky; 
 later it is normal or slightly increased. The portion of 
 the pericardium, which lies open and is attached to 
 the outer side of the heart, i.e., the visceral layer, is 
 almost constantly the seat of ecchymoses, most nu- 
 merous towards the base and posteriorly; it is rare to 
 find on the parietal layer. Much more blood appears 
 in the right heart than in the left — indeed the left 
 heart is almost always empty, — which is apt to be of 
 a pappy appearance, or exhibit soft coagulable and 
 fibrinous clots, the latter gelatinous, or firm and color- 
 less, either of which conditions may be present in the 
 typhoid stage. 
 
 Lebert remarks he once found a fine fibrinous 
 clot separated in the form of a membrane spread over 
 the whole inner surface of the right ventricle; and 
 that the perfectly soft dissolving clots which are often 
 seen, correspond to no particular stage or condition. 
 He also made a chemical examination of the blood of 
 a patient dying in the typhoid stage, that revealed no 
 increase either of urea or carbonate of ammonia as a 
 constant condition, yet adds he would not "like to 
 draw conclusions from these individual examinations." 
 Virchow admirably described the increase in the 
 number of the white corpuscles in the heart clots. 
 
— 86 — 
 
 As to the respiratory organs, they are seldom 
 affected in their principal portions, though occasion- 
 ally secondary diphtheritic and pseudo-membranous 
 processes are encountered. The mucous membranes 
 of trachea and bronchi are very much engorged with 
 blood in cases of early death, and when there is mod- 
 erate hyperteraia often covered with mucus in which 
 are discovered more or less leucocytes; in exceptional 
 cases the glands of the trachea are considerably swol- 
 len. Ecchymoses are not uncommon, but appear 
 more frequently on the surface of the lungs, which 
 latter are deeply engorged with blood, especially in 
 their inferior and posterior portions, and often oede- 
 matous. Purulent mucus in the smallest bronchi, and 
 the anatomical lesions of broncho-pneumonia and of 
 typhoid-pneumonia, are conditions sometimes seen in 
 cases of death— after three, five, or eight days; and 
 pleuritis with sero-purulent effusion also belongs to 
 these rarer complications; haemorrhagic pulmonary 
 infarctions are not infrequent. 
 
 The isolated oesophageal glands are often exces- 
 sively swollen, the tube itself being cyanotic in the 
 algid stage and ecchymosed at a later period. In his 
 Zurich autopsies, Lebert often " found the epithelium 
 detached, and once the lower part of the oesophagus 
 covered with fibrinous diphtheritic membranes." 
 The stomach is distended and filled with colorless 
 fluid in cases of early fatality, but later is empty and 
 collapsed; when death occurs after the third or fourth 
 
- 87 - 
 day it is apt to be filled with yellowish-green, sticky, 
 gelatinous or mucous fluid; and the mucous mem- 
 brane, at first hypersemic, shows later numerous 
 ecchymoses, and occasionally spots of bloody infil- 
 tration; when death occurs late, it is covered with 
 abundant, tough, thick mucus, and perhaps spots of 
 softening that probably are, in part at least, the effects 
 of commencing decomposition. 
 
 The most marked changes, however, are found in 
 the small intestine. Where the malady runs a rapidly 
 fatal course, the intestinal peritoneum is dry, of a 
 rosy color, or covered with a light layer of sticky 
 fluid. In more prolonged cases the lesser bowel con- 
 tains a greenish pultaceous mas^ while the colon 
 coecum, etc., may harbor half-soHd faeces; in the early 
 periods the contents are of "rice-water" character. 
 
 During the attack proper, and immediately fol- 
 lowing, the glands of the small intestine are chiefly 
 affected: Brunner's first, a condition that is constant; 
 then the isolated and agminated glands, the former 
 standing out in relief, their size varying from that 
 of a millet seed to a pea; Peyer's patches are gran- 
 ulated on the surface; swelling and engorgement 
 most pronounced toward the ileo-ccecal valve. Aside 
 from the hypersemia and ecchymoses, the prominent 
 glands give the surface a pale, milky, or yellowish 
 appearance, and if the follicles are pierced they ex- 
 ude a whitish-gray fluid with fine granules and cell- 
 nuclei, without leucocytes; the surface is smooth, for 
 
the most part deprived of epithelium and viUi, and 
 the engorged glands admit of perfect artificial in- 
 jection. 
 
 These typical changes are generally found in the 
 first forty-eight hours; Lebert often observed the 
 engorgement began to diminish at the end of from 
 thirty-six to forty hours, though in some cases the 
 glands continued infiltrated for four or five days, par- 
 ticularly if this condition persisted in the tissues im- 
 mediately adjacent; as a rule, however, infiltration 
 rapidly diminishes at the end of the second or in the 
 course of the third day, when the glands present a 
 flattened and somewhat wrinkled appearance, later 
 becoming almost granular; they are still prominent, 
 however, though shrunken in circumference, and of 
 yellowish-gray (later almost slaty) color; occasionally 
 a blackish-gray, brown, or brownish-red pigment is 
 noticed, especially if ecchymoses have previously 
 existed. In the second week, with rare exceptions, 
 all infiltration and congestion disappears, though the 
 glands may still continue thickened and abnormally 
 colored. In the first period Peyer's patches are often 
 found converted into a net-work, the follicles fissured 
 as if ruptured; and as this condition is present in 
 bodies twelve to eighteen hours after death, the sup- 
 position it is a post-mortem phenomenon is manifestly 
 incorrect. In cases of early death, in some epidemics, 
 the patches are ulcerated as in typhoid fever; the 
 glands of the large intestine, also are found swollen, 
 
prominent, and they likewise collapse at a later period, 
 showing the same retrograde changes as those of the 
 small intestine. 
 
 The mucous membrane between glands may share 
 in the infiltration, and in the first stage is very deeply 
 congested (almost cyanosed), generally ecchymosed 
 or with extensive extravasations, so that great patches 
 of mucosa are deeply ensanguined, a condition more 
 frequently observed in the colon than in the small 
 intestine; at an early stage also it quite often is 
 softened, swollen, even oedematous, a condition that 
 later is confined chiefly to spots; extensive softening 
 of either the small or large intestine, however, is rare. 
 The same changes in color, as noticed in the retro- 
 grade metamorphoses of the glands, occur throughout 
 the mucous membrane, though less pronounced.* 
 
 The anatomical characters of secondary colitis 
 of a diphtheritic or dysenteric nature, are seen com- 
 paratively often in some epidemics, in others are 
 almost entirely absent. The mesenteric glands are 
 quite often moderately swollen, but usually with- 
 out much infiltration. f 
 
 " The spleen is in general small, rather wrinkled 
 and shrunken, of good consistence, and moderately 
 
 *Lebert faithfully pictures all these details in his "Atlas 
 of Pathological Anatomy." — S. 
 
 fFor the succeeding anatomical descriptions I must 
 acknowledge my indebtedness to Herman Lebert's mono- 
 graph on the Zurich epidemics. — S. 
 
— 90 — 
 
 supplied with blood, though sometimes seen enlarged 
 in consequence of apopletic effusion; in cases where 
 cholera complicates typhoid fever, it is usually en- 
 larged. 
 
 " The liver, in speedily fatal cases is often hyper- 
 Eemic, and shows also numerous sub-peritoneal ecchy- 
 moses; at a later period is pale, marble-yellow or red, 
 with isolated islands of fatty degeneration; the gall- 
 bladder distended, in the first period with dark-brown 
 bile, later of a bright-green color, semi-fluid, resem- 
 bling mucus. Catarrh of the biliary passages, even 
 of purulent nature, occasionally develops as a second- 
 ary affection. During the attack the bile is retained, 
 but later, when again discharged, during a protracted 
 convalescence or in the typhoid state, it seems to be 
 abnormally constituted — a fact which makes chemical 
 examinations at this period much to be desired. 
 
 "The bladder usually shows nothing abnormal; 
 if death occurs in the first two days, it is contracted 
 and empty. Still I have found in it, in exceptional 
 cases, an ounce or more of cloudy albuminous urine, 
 even after the disease has lasted from thirty-six to 
 forty hours. Usually a little urine is found in the 
 bladder in case of death on the third day, though 
 often it may be empty even when death occurs on the 
 fourth or fifth day. The mucous membrane of this 
 viscus, in the beginning takes part also in the general 
 cyanosis, but it is comparatively little marked and 
 of little consequence. 
 
— 91 — 
 
 " The kidneys may early take part in the disease 
 processes, and even when death occurs in from sixteen 
 to twenty-four hours, there is always observed an 
 increase in the volume, and at the same time they are 
 generally filled in both the cortical and medullary 
 substances with blood in the form of stripes and 
 punctated injections, and on the surface in star-shaped 
 and marbled spots, with numerous and thick anasto- 
 moses; the superficial inter-canalicular vessels and 
 capillaries of the Malpighian glomeruli also share in 
 this congested condition, and ecchymoses are likewise 
 not infrequent. Even in cases of death in the second 
 half of the first day, the cortical substance of the 
 kidneys is often found in an unmistakable condition 
 of commencing decoloration, extending even from 
 the surface deep down into the pyramids; also the 
 capsules are frequently abnormally adherent. The 
 microscope reveals at this early stage a remarkable 
 epithelial proliferation in the urinary canaliculi, with 
 cloudy swelling of the cell, the contents of which 
 (consisting of numerous albuminoid granules) may be 
 dissolved by acetic acid. Now and then may be dis- 
 covered, as early as at the end of the first day, distinct 
 transparent cylinders in the interior of the urinary 
 canals. The kidneys, therefore, are decidedly affected 
 on the very first day of a pronounced attack of 
 cholera. 
 
 " In the course of the second day I have noticed 
 either the same commencing decoloration, or more 
 
— 92 — 
 
 marked changes. The hyperaemia is now either con- 
 fined to spots, or general with simultaneous decol- 
 oration of the canals and cortex; casts are present 
 in great quantity — pressure empties from the papillae 
 a cloudy albuminous urine containing them, and not 
 infrequently crystals of uric acid. The mucous mem- 
 brane of the calyces and pelves is usually hyperse- 
 mic, with injection of the fine vessels, and the micro- 
 scope reveals progressive degeneration of the cells. 
 In the course of the third day the decoloration is 
 so far increased as to involve the whole cortex, and 
 granulations are present; the blood seems to be^ 
 very unequally distributed; the surface, uneven, 
 rough, and closely adherent to the capsule. The cells 
 continue to be detached, the development of casts 
 proceeds, the fatty elements increase and now 
 show themselves as granules and oil drops in con- 
 stantly increasing quantity in the epithelium and out- 
 side of it, in the interior of the canaliculi, and in the 
 casts. 
 
 " These alterations increase in the typhoid stage 
 as well as during imperfect convalescence. The kid- 
 neys, according to many accurate measurements, are 
 from one-sixth to one-third larger than normal, the 
 granulations more abundant, and the decoloration 
 advanced to the pyramids and even between them. 
 The substance of the kidneys is now softer, more 
 easily torn, and infiltrated with a dirty yellow, fatty, 
 and albuminous fluid. The mucous membrane often 
 
— 93 — 
 seems thickened. In cases where death occurs 
 late, all the signs of resolution are present; in favor- 
 able cases, all these seemingly grave lesions quickly 
 disappear, and the kidneys regained their normal 
 condition. Strange to say, chronic nephritis caused 
 by or incidental to cholera, is rare " (Lebert). 
 
 The chemical examinations of the various organs 
 undertaken by Staedeler, in Zurich, in 1855, yielded 
 no special results. Leucin was found in the liver, 
 and small quantities of uric acid in different organs. 
 In the spleen, leucin was once detected; in other cases 
 inosite, uric acid, and much pigment. The kidneys 
 contained comparatively a great amount urea, some 
 leucin, bile-pigment, and uric acid, but no inosite. 
 
 Glancing now at the whole duration of cholera: 
 For the period of incubation may be allowed from five 
 to seven days, often much less, sometimes longer. 
 Where orodromata exist, their average duration is 
 from one to three days. Next comes the stage of 
 attack, which is the second, or (when prodromata 
 are lacking) at times the first stage; this may prove 
 fatal, in from six to eight hours, or even less, but 
 varies in fairly severe cases from twelve to twenty- 
 four hours. 
 
 With the end of the attack proper (the second 
 stage) comes the period of reaction, usually at the 
 end of from eighteen to twenty-four hours, and now 
 the patient either dies from cyanotic asphyxia, or the 
 reaction is perfectly established and the real cholera 
 
— 94 — 
 is happily and definitely over. The stage of reaction 
 may pass into speedy convalescence, which may ter- 
 minate in the second half of the first week; or the 
 convalescence is protracted, either without further 
 critical symptoms or with transition into the typhoid 
 stage. The typhic stage, in turn, may lead to fatal 
 or fortunate termination in the last days of the first, 
 or in the first days of the second week of the whole 
 duration of the disease. It is a rare exception for 
 patients to die of cholera after ten or twelve days, or 
 to be affected with long-continued, bad sequelae, 
 though a weak invalid condition may persist for a 
 long time as the result of defective nerve action. 
 
 Finally, it must be remarked that it is impossible, 
 no matter what the scope of the work, to describe all 
 the sequelae and complications of cholera; where the 
 circulation is so profoundly disturbed, and the nerve 
 toxaemia so virulent, the most multiform local con- 
 gestions and inflammations are possible. 
 
CHAPTER VII. 
 
 CHOLERA DIARRHOEA AND CHOLERINE. 
 
 The mildest form of cholera is that simulating a 
 simple diarrhoea, in which the evacuations follow each 
 other more or less closely, are very copious and 
 watery, but not altogether devoid of consistence and 
 color, and retain in some degree the characteristic 
 faecal odor; they perhaps are not accompanied by 
 colicky pains or tenesmus, and cause no constitutional 
 or other disturbance except a moderate degree of de- 
 pression and relaxation. Such frequently do not ap- 
 appear in official lists, but, as Niemeyer pertinently ob- 
 serves, "though not considered by the police as chol- 
 era, they should be so recognized by science. This is 
 shown: 
 
 (i) "By the larger number of cases of diarrhoea 
 occurring during cholera times, although almost all 
 sensible people carefully avoid errors of diet, catch- 
 ing cold, and other sources of injury: 
 
 (2) " The great obstinacy of these cases: 
 
 (3) " The well known transportation of the dis- 
 ease by persons suffering therefrom: 
 
 (4) " Especially by the numerous transformations 
 of simple cholera diarrhoea into the most severe form of 
 the malady. — Many patients, especially of the poorer 
 classes, worried by a diarrhoea which will not give way 
 to domestic remedies, go to the doctor for a prescrip- 
 
_ 96 - 
 
 tion at noon, and in the evening lie cold, pulseless, and 
 cyanotic, almost in a hopeless state. ... I deem 
 it much more important to determine the frequent 
 occurrence of gradual transformation from simple 
 cholera diarrhoea to so-called cholerine, and to malig- 
 nant cholera, and to prove the identity of these three 
 forms, than to seek for pathognomonic signs of epi- 
 demic cholera."* 
 
 Cholera diarrhoea and cholerine, which constitute 
 the milder forms of the disease, during the preva- 
 lence of epidemics also present varied phases, and 
 more than all varied characteristics in different epi- 
 demics. Lebert, Zehnder, Karl Liebermeister, and 
 others, have noted how greatly personal predisposi- 
 tion favors or inhibits, as the case may be, extension 
 or repression; that an imported case in any one 
 locality may be confined to a single individual, to a 
 single house, even to single room in a dwelling, while 
 at other times one case may be the focus of a raging 
 pestilence. Thus the history of different epidemics,, 
 particularly in large cities, shows the greatest variety 
 
 *"Text Book of Practical Medicine," Vol. ii. New 
 York, 1884. 
 
 * How probable it is that a swiftly fatal attack is de- 
 veloped from profound toxicity of the central nervous system 
 through the medium of the absorbents, especially those of 
 the portal area, by an excess of the cholera poison, is shown 
 by phenomena developed in acute arsenical poisoning, which 
 has several times been mistaken for true cholera (see p. 107)., 
 — S. 
 
— 97 — 
 
 of effect, accordingly as the cholera poison finds con- 
 ditions for development more or less suitable. Again, 
 it has been observed, as a rule, that prodromic diar- 
 rhoeas are more frequent and more widely diffused in 
 malignant and extensive epidemics than in those of 
 less extent. Yet Lebert declares,f in the great epi- 
 demic in Paris of 1849, which is computed to have 
 claimed something like ten thousand victims, premon- 
 otory intestinal flux was wholly absent in from five to 
 ten per cent, of the pronounced cases; in Zurich it 
 was absent in ;^^.^ per cent, of pronounced cases; and 
 that absence or presence of prodromic diarrhoea had 
 no apparent influence in determining the ultimate re- 
 sult of the attack, as the recoveries and deaths were 
 about equally proportioned in regard to this symptom. 
 Also, he adds, " I found that the prodromic diarrhoea 
 was absent in seven-eights of the cases of true choler- 
 ine (with colored stools). In Paris as well as in Zurich 
 and Breslau, in 1866 and 1867, I saw a number of 
 cases of diarrhoea which were due to the influence of 
 cholera, recover without treatment and without sub- 
 sequent cholera. On the other hand, in July and the 
 beginning of August, 1866, I witnessed such obstin- 
 ate and violent cases of cholera diarrhoea in the 
 Breslau garrison of cuirassiers, where I had charge of 
 a large ward of wounded patients, that it required the 
 utmost effort to prevent on outbreak of cholera." 
 
 fZiemssen's " Cyclopoedia of Practical Medicine." New 
 York, 1874. 
 
There is no marked distinction between common 
 intestinal catarrh and cholera diarrhoea, yet the latter 
 presents certain definite peculiarities which are en- 
 titled to consideration in seeking a definite diagnosis. 
 
 Cholera diarrhoea is usually sudden and unex- 
 pected: As already remarked, is apt to be excited, or 
 receive its ultimate development, through "taking 
 cold" or errors of diet; and to intemperance in the habit- 
 ual use of alcoholic beverages more than any other 
 single cause may the proclivit)'- to this form of flux 
 be ascribed. 
 
 Loss of appetite, thirst, indigestion, are either 
 present or absent in only slight degree; patients gen- 
 erally, however, complain of an excessive feeling of 
 lassitude — are extraordinarily weak, feeble and uncom- 
 fortable, — and not unfrequently exhibit despondency, 
 out of all proportion to the frequency or quantity of 
 the flux. 
 
 There is nothing specially peculiar about the 
 stools other than they are simply fluid, as in any 
 diarrhoea; often there are but two or three dis- 
 charges during the twenty-four hours, more rarely 
 from six to eight, and are more apt to supervene 
 during the night, and to be accompanied by distressing 
 rumblings and gurglings. 
 
 In some cases the diarrhoea persists only a few 
 hours or days; in others, one or two weeks, with con- 
 siderable intermissions, during which the individual 
 feels perfectly well. Sometimes it regularly intermits or 
 
— 99 — 
 
 remits during the whole course of the epidemic in that 
 particular locality, and ceases only as the latter dis- 
 appears. Even in the milder cases of cholera diar- 
 rhoea may be sometimes observed individual evidences 
 of cholera proper, such as suppression of urine, light 
 cramps in calves, colorless and odorless "rice-water" 
 stools, that are merely of temporary duration, and are 
 more generally characteristic of cholerine. Neither 
 is it a rare occurrence for a cholera diarrhoea, which 
 remains in other respects without danger, to suddenly 
 increase in virulence, with violent, quickly repeated 
 stools, as in true cholera, and yet cease quickly and 
 be followed by prompt recovery. 
 
 Cholerine, as the term indicates, is a lesser 
 cholera; in other words, it is a condensed picture of 
 the mildest form of the more grave attack, and may, 
 indeed often does, present some of the serious symp- 
 toms peculiar to the latter. It is usually ushered in 
 by such prodromal symptoms as malaise, headache, 
 diminution of appetite, muscular or general physical 
 weakness, of at least twelve and often twenty-four 
 hours' duration; there is also general restlessness, in- 
 somnia — or at least the hours of sleep are productive 
 of discomfort rather than rest; and the attack culmin- 
 ates in the middle of the night or early morning by 
 sudden awakening due to demand for stool. Now 
 is observed a copious yellowish-brown, almost 
 watery discharge, with characteristic diarrhoeic odor, 
 but succeeded by a second still more fluid, and others 
 
again at brief intervals to the number of three, six,. 
 eight, twelve or more, until — when they become very 
 numerous — there is gradually less and less evidence 
 of odor, color, or form, and they assume a decided 
 " rice-water " character. 
 
 With the first evidence of diarrhoea, nausea is 
 apt to supervene which, after repeated stools, is merged 
 into emesis, the ejected matter being first of a yellow- 
 ish green hue with intensely sour bitter taste, very 
 fluid in character, finally, perhaps, colorless, whey- 
 like, showing a deposit very like grains of bruised 
 rice; after a few times, the quantity is lessened,, 
 the act itself becoms more infrequent, and finally it 
 ceases altogether after a few hours; this vomiting is not 
 at all painful, retching being a comparatively rare 
 concomitant, but the fluid pours forth in a manner 
 resembling an easy act of regurgitation, though its 
 profuse quantity is very suggestive of its choleraic 
 nature. The sufferer in the meantime becomes very 
 much reduced; but with the cessation of vomiting 
 and diarrhoea, either recovers very rapidly, or tem- 
 porary typhoid symptoms manifest themselves. While 
 complete convalescence may be established in a few 
 days, it is often a matter of two or three weeks. In 
 the favorable cases of cholerine, convalesence occurs 
 in two, three or four days. 
 
 Sometimes the inclination to diarrhoea lingers for 
 some days after the convalescing stage has set in, 
 with all the concomitants of anorexia, borborygmus. 
 
occasionally twinges of colic, etc.; not infrequently 
 also there is continued nausea, especially after the 
 ingestion of food; and a distressing tendency toward 
 cramping of muscles of legs (calves) is more or less 
 apparent according to the severity of the attack. 
 Lebert remarks he has also seen moderate cooling of 
 extremities; that he personally experienced almost 
 complete aphonia for twenty-four hours after a seiz- 
 ure, and di'd not fully recover his voice until "at the 
 end of several days; " also noticed considerable re- 
 duction in the quantity of urea, as well as the tem- 
 porary occurrence of albumen and casts in very dark 
 scanty urine. It is perhaps needless to say that 
 gastric catarrh not infrequently interferes with con- 
 valescence; that errors in diet may lead to fatal re- 
 lapse; and that the temporary typhoid state, when it 
 supervenes, is manifested by such symptoms as head- 
 ache, vertigo, roaring in ears, cloudiness of vision, 
 great debility, sopor, etc. 
 
 It is also of interest to remember that where 
 this "little cholera" is seen in houses and families, 
 frequently in the course of a few days a malignant 
 asphyctic cholera will develop, and that it therefore 
 may lead to genuine and fatal cholera when the in- 
 dividual (or individuals) is sufficiently receptive toward 
 the poison; that cholerine may itself prove fatal in 
 weak and aged patients; and when cholera prevails in 
 a large city with great severity, the number of per- 
 sons attacked with real cholera is always relatively 
 
smaller than those attacked with cholera diarrhoea 
 and cholerine. Moreover, cholera diarrhoea and 
 cholerine occur much more frequently in places 
 some distance from the centres of the disease, while 
 true cholera prevails at these centres. In all these 
 cases it is probably the diminished capacity of the 
 surroundings for infection accounts for the relatively 
 greater dissemination of the lighter forms of the dis- 
 ease; but, as just remarked, these lighter forms by 
 rapid multiplication, or increased virulence of the poi- 
 son of the disease, under favorable conditions of the 
 organism, may lead to dangerous attacks of cholera. 
 
 In enumerating these phases of the epidemic 
 more specifically, it must be understood that' in 
 differentiating the three forms there is no reces- 
 sion from the position I shall, in a later chapter, 
 endeavor to establish that all are de facto cholera. 
 And, further, it may be added, it is a matter of 
 great personal doubt whether any cholera is derived 
 from a special germ or poison, other than that 
 resultant upon any common decomposition; or possi- 
 bly that the Asiatic form is due to the common poison 
 supplemented by an imported one, that after all is 
 but the same intensified in its original habitat and by 
 transmission; or, again, that all cholera is due to a 
 poison of common decomposition that was foreign 
 originally, but since importation has become in a 
 sense acclimated. There are few medical men who 
 have not seen cholera nostras — or as it is termed in 
 
— I03 — 
 
 this country, sporadic ciiolera, or cholera morbus — 
 with positive " rice-water " discharges, colorless and 
 odorless, outside of the period of any epidemic; I 
 have repeatedly encountered such in my own experi- 
 ence, and in the service of others; and Lebert, J. M. 
 and D. D. Cunningham, Bouchard, Leiter, Zehnder, 
 Fayrer, Niemeyer, Trousseau, Semmola, Tanner, 
 Sir Wm. Aitken, and a list who are fairly " Legion,"* 
 corroborate, and have also expressed the opinion 
 cholera infantum is only cholera sporadica, modified 
 by age. — A propos of this it may be mentioned that 
 Chas. Talamonf has recently adduced considerable 
 evidence tending to demonstrate the unity of these 
 maladies : 
 
 He points out that ravages of cholera diarrhoea, of 
 epidemic nature, occur from time to time without any 
 evidence of a foreign or imported factor, in localities 
 in which true cholera has, sometime or another, mani- 
 fested itself; and likewise reference is made to a recent 
 epidemic, the exact prototype of another occurring in 
 1866, in the neighborhood of Paris, clinically diag- 
 nosed as cholera nostras, but which on investigation 
 in no way differed pathologically from the so-called 
 Asiatic malady. The cholera bacillus was demon- 
 strated in the dejections also. 
 
 *See "Nature and Treatment of Sporadic Cholera" 
 by Alex. Harkin. W. Renshaw, London, 1885. — S. 
 \ La Medicine Moderne, 1892. 
 
CHAPTER VIII. 
 
 SPECIFIC PATHOLOGY. 
 
 I have been thus particular in enumerating the 
 general outlines and peculiarities of this disease, 
 which presumably are familiar— or, at least, they 
 should be, — to every medical man, in order to more 
 forcibly call attention to their physiologico-therapeu- 
 tical relations. It has already been remarked, the 
 neurotic character of the disease is most apparent, 
 and that there is no relation between the quantity of 
 fluid lost by the bowel and stomach and the malig- 
 nancy of the onslaught. 
 
 The simple diarrhoea which ushers in an attack, 
 or that may constitute almost the only manifestation 
 of the malady, is especially remarked upon by all 
 observers for its stubborn character; it yields to none of 
 the customary remedies, and is influenced scarcely at 
 all by opiates or astringents. This presupposes a 
 lesion deeper than, and behind, the visceral and tho- 
 racic organs that, apparently, are most involved, and 
 one has no option but to refer the same to the central 
 nervous system. 
 
 In 1870 M. F. Moreau, and also S. G. Vasquez, 
 demonstrated by a series of observations, — corrobo- 
 rating those of Edward Pfliiger and Otto Nasse, 
 and since repeated by many others, — the influence 
 of the sympathetic nerves upon the intestinal canal, 
 
— I05 — 
 which influence is most pertinent as evidencing the 
 source and character of the watery diarrhoea in 
 cholera, and likewise its sudden occurrence without 
 any form of premonition or warning. 
 
 Both found when these nerves were divided, the 
 portion of the intestines segregated by the operation 
 rapidly filled with clear alkaline fluid, colorless and 
 slightly opaline— except as, at the outset, they might 
 become mixed with material still remaining within the 
 gut, — which precipitated flocculi of organic matter on 
 boiling.* Transudation of watery fluid into the in- 
 testines, due to capillary diffusion, takes place as the 
 result of paralysis of the sympathetic; the occur- 
 rence of sudden hypersemias, transudations, and 
 ecchymoses, in some thoracic or abdominal organ, 
 may have a neurotic basis, f 
 
 Paralysis or hyperaethesia of the sympathetic — 
 conditions that differ physiologically only in degreeX — 
 induce vomiting, retching, etc. When the nerves are 
 divided below the solar plexus, which is situated in 
 most intimate relation with the splanchnic area, the 
 
 *Vide Flint's " Physiology of Man." New York, 1874. 
 
 f Vide Carpenter, Dalton, Draper, Kirk, Paget, Landois 
 and Sterling, Foster. 
 
 |:There are several circumstances that support this 
 view, chief of which are, the association of pain with both 
 hyperffithesia and numbness, especially in highly sensitive 
 parts, and the difficulty of differentiating the condition pro- 
 ducing the one from the other. "It is clear," says Dr. C. 
 
— io6 — 
 
 secretion of urine and urea sinks quickly to a minimum, 
 and may perhaps cease entirely, as shown by Coni 
 Peyrani, who is corroborated by Brown-S^quard and 
 Claude Bernard. These latter authors, moreover^ 
 further observed that partial segregation of the sym- 
 pathetic below the inferior cervical ganglion induced 
 marked depression of temperature, made more mani- 
 fest toward the surface and in the cutaneous area, but 
 succeeded by rapid increase of temperature after 
 death. " Paralysis of vaso-motor nerves decreases 
 temperature," says James Kirk; and the sympathetic 
 pertains to the vaso-motoric system. 
 
 Lebert declares that while the most important 
 and constant anatomical clinical localization of the 
 disease occurs in the small intestines, there " is a pos- 
 sibility the often so violent discharges of serum are 
 incited by the central nervous system, the excitement 
 originating in the vaso-motor centres.''' Again: " The 
 cerebro-spinal fluid is entirely absent in cases where 
 death occurs at an early period, or is present only in 
 slight quantity and of almost pasty consistence. But 
 I have seen it more copious when death has occurred 
 
 Handifield Jones, "there is no opposition between them: 
 all are present together. Now paralysis, numbness, anaes- 
 thesia, hyperaesthesia are evidently failure of functional 
 power; and of the same import is the occurrence of various 
 degrees of paralysis, or of paresis, paraesthesia, analgesia, 
 which may be, and are, associated as analogous affections of 
 he motor and sensory nerves." — S. 
 
— I07 — 
 
 at the end of thirty-six hours; and, where death oc- 
 curs still later, it may even exceed the normal amount. 
 The pia mater loses its marked hypersemia in a more 
 protracted course of the disease, and becomes dry, 
 perhaps icteric. The fluid of the ventricles remains 
 scanty even when death occurs at later periods. 
 * . * * Ecchymoses of the external surface of the 
 brain (pia), or on the internal surface (ependyma) 
 are not rare. There may be capillary effusion into 
 the pons, and once I saw a fresh effusion of blood 
 between the dura and arachnioid." — All this is cer- 
 tainly suggestive. 
 
 Again, it must be borne in mind that while " rice- 
 water " stools accrue to all choleraic attacks, except the 
 most pronounced and violent form known as cholera 
 asphyxia, cholera siderans or cholera sicca, they are, per 
 se, by no means pathognomonic, but result always 
 from influences of the most powerful character brought 
 to bear upon the central nervous system. They are 
 a concomitant of terror and mental purturbation; of 
 heat apoplexy; of arsenical poisoning;* of autogenetic 
 
 * How probable it is that a swiftly fatal attack is de- 
 veloped through nerve irritation manifested in a portion of 
 the small intestine, is shown by the action of arsenic, which 
 may induce fatal poisoning in a few hours, with symptoms 
 perfectly resembling those of cholera. Late in the autumn 
 of 1854, a woman who had been suddenly taken sick during 
 a criminal trial, entered Lebert's Clinic in Zurich. She died 
 in hospital after a number of violent, perfectly colorless, 
 
— io8 — 
 
 toxication by specific ptomaines; of toxication by cer- 
 tain alkaloids, etc.; and, moreover, the dejections, as in 
 cholera, hold a profusion of material commonly sup- 
 posed to be intestinal epithelium (but which is really 
 the result of transformation taking place in the effusion 
 of blood plasma), and likewise contain serum-albumen, 
 mucin, and a large amount of salts, chloride of so- 
 dium preponderating to such an extent as often to 
 exceed in amount all organic matters.* But the 
 blood in cholera, as an almost invariable rule, is free 
 from bacteria, either actual or potential ; this is the 
 case as well shortly after death as during life, and 
 holds in regard to every stage of the disease. 
 
 Further, choleraic, arsenical, and alkaloidal poison- 
 ings, of a particular class, likewise thermic apoplexy, 
 alike induce a high specific gravity of the blood — an 
 
 very copious discharges. The small intestine showed an 
 immense accumulation of colorless fluid, and clinical ex- 
 amination of the contents of the stomach revealed unmis- 
 takable evidences of arsenical poisoning. Lebert further 
 adds: " In the summer of 1847 I was told by Louis, in the 
 Hotel Dieu, that the Duke of Choiseul, who had been ar- 
 rested the day before for the murder of his wife, died sud- 
 denly of cholera, and he wondered at it greatly, because 
 cholera was nowhere prevalent. Louis was the Duke's 
 physician and, as is well known, one of the greatest 
 diagnosticians of our time; nevertheless it soon turned out 
 the Duke had poisoned himself with arsenic." — S. 
 
 * The proportion of solid constituents in all, varies from 
 i.20to 2.40. — S. 
 
— 109 — 
 
 average of 1.0701, against 1.0503 in health, — which is 
 remarkably tough and viscid, the corpuscles increased 
 in number but abnormally impoverished as to salts; 
 the amount of fibrin is unaffected, but the serum is 
 very dense, extremely rich in albumen, and contains 
 more phosphates and potash salts (though less col- 
 lectively) than normal; moreover, contains some urea, 
 together with extractive matters that seem to possess 
 the quality of rapidly converting the former into car- 
 bonate of ammonia (Day, Hoppe-Seyler, C. Schmid). 
 Draper also remark: " In cholera the constitution of 
 the blood is so changed that the cells can no longer 
 carry oxygen into the system; the heat-making pro- 
 cesses are put a stop to, and the temperature declining, 
 the body becomes of marble coldness characteristic 
 of this terrible disease,"— phenomena that accrue to 
 muscarine and certain other alkaloidal poisonings. 
 
 Armand Trousseau says the varied and peculiar 
 symptoms exhibited by asphyctic cholera, can be ex- 
 plained only by referring to a poison having specific 
 effect upon the nervous system; and Wilhelm Erb 
 adds,* refering to poisons as a class: " They cause 
 lasting paralysis, as a rule, only when their action is 
 slow and repeated, more rarely when they are acute; 
 they cause the most varied forms of paralysis and 
 paraplegia, from simple weakness and paresis to com- 
 
 * Ziemssen's " Cyclopoedia of the Practice of Medicine." 
 New York, 1874. 
 
plete paralysis, . . with or without disturbance of 
 sensibility. 
 
 One of the functions of the sympathetic, if the 
 deductions of Jno. W. Draper maybe accepted, is " the 
 equalization or balancing of nerve force, storing up 
 all transient excesses, and providing for all transient 
 deficiences." 
 
 This sympathetic nerve system, too, transmits sen- 
 sations so tardily that the economy may be violently, 
 even fatally poisoned through the central nerve organs, 
 long before the customary effects are manifested by 
 the usual symptomatology. Says Jno. C. Dalton :* 
 " Evidences of sensibility are much less acute than in 
 other nerves, and show themselves only after prolonged 
 application of the exciting cause''! 
 
 Damp, cold, malaria, chorea, and certain poisons, 
 all act in the same precise way by deranging mole- 
 cular nutritive actions of the nerve structure, and so 
 unfitting the latter to fulfil its function : and anaesthe- 
 sia and hypersesthesia are alike failures of func- 
 tional power, varying only in degree. Again hyper- 
 sesthesia and irritation may be the result of dual 
 action, viz : Of poisoning of cerebral centers, and of 
 local irritation. 
 
 The foregoing most certainly sheds new and most 
 welcome light on the pathology of cholera, especially 
 the frequent steady march to fatality during moments 
 
 "Human Physiology." New York, i8go. 
 
that promise so much in the way of amendment as to 
 mislead the most astute observer. 
 
 And herein perhaps Hes the arrow that fatally 
 pierces the joints of our therapeutic armor, when is 
 sought to oppose the disease by treating that which 
 is most apparent — the local manifestation; the evil 
 has been wrought long before its faintest symptom- 
 atology is made appreciable to human understanding, 
 and consequently is apt to be beyond the power of 
 any method or theory of antagonism or revulsion, 
 however perfect. In cholera, then, often the patient 
 may be fatally poisoned before the presence of the 
 disease can be detected or even surmised. 
 
 In fades cholerica is observed a condition that 
 may be duplicated by segregation of the superior 
 cervical ganglion of the sympathetic, or by its extir- 
 pation; the eyeball is drawn back into the orbit, 
 causing partial closure of the upper and lower lids 
 and flattening of the corneas; the countenance be- 
 comes withered and ghastly; in short, is brought 
 about a cadaverous aspect that sometimes precedes 
 death in long-standing disease, but here supervenes 
 in an hour or two. 
 
 When death occurs during the invasion of the 
 disease or in the stage of collapse, in the more marked 
 cases the appearances, as previously shown, are: The 
 bodies remain warm for some time — the temperature 
 may rise after death, perhaps even to 103° Farh., and 
 so continue for several hours (note the observations 
 
of Brown-Sequard and Claude Bernard, before cited); 
 the rigor mortis* soon appears and is extended over a 
 preternaturally long period of time; the muscles (par- 
 ticularly of hands, arms, and legs) sometimes exhibit 
 a peculiar spasmodic twitching before rigor mortis 
 sets in, so much so that the Cholera Gazette for 1832 
 
 * Professor A. Paltauf read a paper before the Associa- 
 tion of German Physicians, at Prague, on some experiments 
 made to show the causal connection between rigor mortis and 
 deaths from poison. For the purpose of these experiments 
 such poisons were used as were known to exert a certain in- 
 fluence on the muscular system, either by acting directly 
 on the muscle substance, or indirectly by affecting the ner- 
 vous system. Amongst the poisons belonging to the first series , 
 curare always considerably delays the occurrence of rigor mor- 
 tis. Amongst those acting on the central nervous system, 
 strychnine, picrotoxin, camphor, and the salts of ammonium 
 and arsenic, accelerate the occurrence of rigor mortis. The 
 aceleration is still more increased by artificially prolonging 
 the stimulation of the muscular system, but is again arrested 
 on the occurrence of paralysis. Veratrine and physostig- 
 mine cause only a slight acceleration of the rigor mortis, but 
 with caffeine and its chemical derivatives — the rhodan salts 
 — this acceleration becomes considerable. To study the in- 
 fluence of the nervous system at the time of occurrence of 
 the rigor mortis, Paltauf divided the nerves and the spinal 
 cord, with the result that the more a muscle had been stimu- 
 lated by the poison the sooner was the rigor mortis observed, 
 independently of its connection with the spine, if such con- 
 nection existed. The reaction of the rigid muscles was in 
 the case of many poisons, as has been generally believed, 
 acid. Other poisons, however (such as camphor, ethyl-theo- 
 
— 113 — 
 
 declares the soldiers were accustomed to bind the 
 limbs of their dead comrades to the bed-frames in 
 order to prevent shocking the more timid of the 
 living.* All these manifestations point indubitably 
 
 bromine and the rhodan salts), gave, contrary to the general 
 assumption, an alkaline reaction. This alkaline reaction 
 affected, however, only the anterior portion of art animal in 
 which, after the poisoning, the cord had been divided. The 
 posterior part of the animal, in which the rigor mortis was' 
 delayed, showed the usual acid reaction until the alkaline 
 reaction of putrescence took place. Where the reaction of 
 the anterior portion of the animal was alkaline it often be- 
 came, after the reduction of the rigidity had passed off, 
 neutral or slightly acid before putrescence once more made 
 it alkaline. Division of a single nerve had the same result,, 
 and it was possible to cause either alkaline or acid reaction of 
 the various muscles of one extremity by respectively leaving. 
 the nerve entire or by dividing it. Paltauf also approached the' 
 solution of the question of the existence of a cataleptic rigor 
 mortis. He found that the convulsive muscular contractions 
 of an animal poisoned by camphor and suddenly killed by 
 strangling led to immediate rigor mortis, and he therefore 
 believes in a cataleptic rigor mortis. — VVeiner Med'chiische 
 Presse. 
 
 Some time previous to this paper, Prof. Paltauf an- 
 nounced he had observed " the greater the hypersesthesia 
 of the sympathetic, the. greater the rigor mortis; but if the 
 sympathetic had only attained a condition of paralysis, the 
 rigor mortis was very greatly delayed." — .S. 
 
 * Bodies of those who died from cholera, on resurrec- 
 tion after burial were sometimes found turned and twisted 
 in their coffins; and this accrues often to those that have suC' 
 
 8 KKK 
 
— 114 — 
 
 to poisoned nerve centres, being phenomena especially 
 apt to follow upon specific toxic fatality. And long 
 since T. Lauder Brunton recognized the symptoms of 
 cholera were precisely paralleled by those of mus- 
 carine poisoning. Muscarine, though an alkaloidal 
 product of Agaricus inuscarius (fly agaric), is also a 
 ptomaine, and consequently of animal as well as 
 vegetable origin, and one of the most powerful nerve- 
 poisons known. Its specific action is upon the sym- 
 pathetic, inducing either paralysis or hypersesthesia 
 according to the degree of toxicity; it induces, as just 
 remarked, all the phenomena of cholera, even to stop- 
 page of the heart in diastole, and reflex derangement 
 of kidneys with suppression of urine; moreover, its 
 toxic manifestations are exceedingly dilatory for the 
 same reason. 
 
 Another point of moment to be recalled is that 
 the functions of the sympathetic, which belong to the 
 vaso-motor group, are adjuvant to the cerebro-spinal 
 system. 
 
 Carpenter appears also to have had a partial in- 
 sight into the workings of the sympathetic, for he 
 says:f The nerves of this system — "in which tubu- 
 
 cumbed to other specific poisons, as the result of decomposi- 
 tion and stimulus of nerve centres by the formation of cada- 
 veric alkaloids that seem to have the power of inducing in 
 dead tissue the same phenomena that result upon galvanic 
 stimulus. — S. 
 
 ■["Principles of Comparative Physiology." London, 
 
— 115 — 
 
 iar fibres derived from the cerebro-spinal system are 
 combined in various proportions with those gray or 
 organic fibres which have their centres in the proper 
 sympathetic ganglia, — possess a certain degree of 
 power of exciting muscular contraction in the various 
 parts to which they are distributed. Thus by irritat-' 
 ing them, contraction may be excited in any part of 
 the alimentary canal from the pharynx to the rectum, 
 according to the trunks that are irritated; in the 
 heart after the ordinary movements have ceased; in 
 the aorta, vena cava, and thoracic duct; in the ductus 
 choledochus, uterus. Fallopian tubes, vas deferens, 
 and vesiculse seminales; and the very same contrac- 
 tions may be excited by irritating the roots of the 
 spinal nerves from which the sympathetic trunks 
 receive their white fibres; and there is strong reason 
 to believe that the motor power of the latter is entirely 
 dependent upon the cerebro-spinal system. That 
 even the sensory endowments the sympathetic trunks 
 possess, are probably to be referred to the same con- 
 nection. The parts exclusively supplied by the sym- 
 pathetic trunks do not appear to be in the least degree 
 sensible; and no sign of pain is given when the sym- 
 pathetic trunks themselves are irritated. But under 
 certain diseased conditions of these organs, violent 
 pains, are felt in them; and these pains can only be 
 produced through the medium of fibres communicating 
 with the sensorium through the spinal nerves. . . . 
 There is much reason to believe, however, that it (the 
 
— ii6 — 
 
 sympathetic system) constitutes the channel througb 
 which the passions and emotions of the mind affect 
 the organic functions; and this especially through the 
 power of regulating the calibre of arteries. We have 
 examples of the influence of these states upon the 
 circulation in the palpitation of the heart which is 
 produced by an agitated state of feeling; in the syn- 
 cope or suspension of the heart's action which some- 
 times comes from sudden shock; in the act of blush- 
 ing or turning pale, which consists in the dilatation or 
 contraction of the small arteries (arterioles); in the 
 sudden increase of the salivary, lachrymal, mammary, 
 gastric and intestinal secretions under the influence 
 of particular states of the mind, which increase is 
 probably due to the temporary dilatation of the 
 arteries that supply these organs.* It is probable that 
 the sympathetic system not only brings the organic 
 functions into relation with the animal, but also that it 
 tends to harmonize the former with the latter, so as 
 to bring the various acts of secretion, nutrition, etc, 
 into mutual conformity. The distinctive functions of 
 the gray or organic fibres, and of their ganglionic 
 centres, constituting the proper visceral system . . 
 not improbably have some direct influence upon the 
 chemical processes which are involved in such changes, 
 and may thus affect the quantity of such secretions; 
 whilst the office of the tubular fibres may be rather to- 
 
 *Also in the enuresis and diarrhcea that supervenes 
 upon fright. — S. 
 
— 117 — 
 
 regulate the diameter of the blood-vessels supplying 
 the organ, and thus to determine the quality of their 
 products." 
 
 At the risk of prolixity, since the point to be 
 made is of the utmost importance, I may repeat it is 
 essential to the better understanding of the pathology 
 of cholera to note that the phenomena peculiar to the 
 malady, and the symptoms and manifestations relied 
 upon for both ante-mortem and post-mortem diagno- 
 sis, are conclusive evidences of its neurotic origin, 
 and of profound toxicity by some agent closely allied 
 to certam alkaloids and acting upon the central nerv- 
 ous system, fatality being hastened'by predisposing 
 ■causes that induce depression of such nerve centres.* 
 
 * Toxic alkaloids as the cause of many cases of acci- 
 dental poisoning have come into prominence of late years, and 
 every summer instances of ptomaine poisoning are reported. 
 An interesting article on this subject appears in the "Boston 
 Medical and Surgical Journal" of August 4th, 1892. Much 
 remains to be discovered relative to the kinds of ptomaines 
 that may develop in both animal and vegetable substances 
 out of the body, as well as of the toxines that may form in 
 food after its ingestion. Doubtless the possibilities of 
 ptomaine formation are very great, and under unusual con- 
 ditions of insalubrity — hot, damp weather, sewage emana- 
 tions, etc., — the work of decomposition may goon with extra- 
 ordinary rapidity, and, under such influence, tox-albumens of 
 great power may form in food that to the eye and taste 
 is still wholesome. There is accumulative evidence to 
 show that this is so. .... Cases 
 
— ii8 — 
 
 — That we do not know the poison specifically, is of 
 little matter; neither do we know whether this poison 
 is developed external to the economy, or induced 
 within the body through miasmatic, bacillar, telluric, 
 meteorologic or physiologic metabolism: 
 
 1. Watery diarrhoea and vomiting, both fluids 
 being odorless and colorless: 
 
 2. Tetanic convulsions or cramps, followed hy 
 muscular flaccidity and lack of cutaneous sensibility 
 and elasticity: 
 
 3. Diminished respiration; spasmodic contrac- 
 
 of poisoning by food of a relatively innocuous character are 
 not uncommon. Some portion of the ingesta becomes an 
 irritant poison, a fit of indigestion ensues, and often the 
 offending substance is speedily expelled by vomiting. The 
 matter of idiosyncrasy need not detain us here;' it is known 
 that certain articles of diet, such as cheese and shell-fish, are 
 toxic to some persons. Generally the state of the alimentary 
 canal at the time is responsible. The most common and 
 best known of the various forms of indigestion is that in 
 which, from the absence or the deficiency of gastric juice 
 and other digestive fluids, the alimetitary bolus becomes a 
 gastro-intestinal irritant, provoking vomiting, purging, and 
 a catarrhal condition of the digestive tract. A second stage 
 in the process of acute indigestion arises from the presence 
 of abnormal fermentations and decompositions in the 
 alimentary canal. The food substances break up into 
 organic acids and alkaloidal products of a lower order, 
 which are in part absorbed and produce constitutional 
 disturbances. This stage borders very closely on that of 
 ptomaine formation. There is good reason to regard cholera 
 
— 119 — 
 
 tion of circular fibres of bronchi, proximate and ulti- 
 mate; flagging circulation, with more rapid heart- 
 beat: 
 
 4. Depression of temperature below normal — 
 perhaps from five to twenty and more degrees: 
 
 5. vSuppressed urinary secretion without sufficient 
 pathological manifestation — manifestly due to power- 
 ful reflex causes: 
 
 nostras and the gastro-intestinal catarrh of infants as kinds 
 of ptomaine poisoning due to multiple causes, of which 
 weakening of the alimentary canal and consequent poverty 
 of digestive fluids, the ingestion of food of an indigestible 
 character, the putrefaction of the latter and the formation of 
 toxines, are the principal factors. That a considerable num- 
 ber of persons may simultaneously be attacked with ill- 
 ness after a large meal, owing to the influence of causes such 
 as have been above mentioned, cannot be a matter of serious 
 doubt. Similar conditions of faulty hygiene produce, in in- 
 dividuals with similar organic susceptibility, results essenti- 
 ally the same. A remarkable case of this kind occurred in 
 America on July 23d of this year. Out of a total of seventy 
 persons who dined together, about fifteen became more or 
 less violently ill within a few hours, exhibiting the symp- 
 toms of cholera. The general opinion, as advanced by 
 physicians who had opportunities of studying the facts is, 
 that the sufferers were persons who had eaten rather im- 
 moderately of indigestible dishes; that the hot weather, the 
 bad air, and the bad water of the place, co-operated in bringing 
 about the necessary predisposition in the guests, and that 
 therefore the " Salisbury sickness " was a local and limited 
 epidemic of cholera nostras. — 77if /.a/we/ (London), Sept. 
 17th, 1892. 
 
6. Intense thirst — an evidence of functional dis- 
 turbance and vicarious nourishment: 
 
 7. Immediate disorganization of blood cor- 
 puscles, similar in character but slower in degree to 
 that supervening upon serpent poisoning: 
 
 8. After death an abnormal persistent increase 
 of temperature, reaching 103° Farh. perhaps: 
 
 9. Speedy post-mortem desquamation of epithe- 
 lium: 
 
 10. Post-mortem spasmodic muscular contrac- 
 tions such as follow upon galvanic stimulus: 
 
 11. Speedy rigor mortis persisting for an abnor- 
 mally long period, and in proportion to the hyperses- 
 thesia of the sympathetic: 
 
 12. The most virulent symptoms may usually be 
 mitigated by antagonizing the sympathetic: 
 
 13. One attack of cholera seems to protect the 
 individual against a second, in greater or less degree, 
 since recurrences of the malady are not frequent: 
 
 14. Everything that induces shock (a purely 
 nervous condition), or reduces muscle and nerve 
 vitality — the two being in a measure physiologically 
 synonymous and inter-dependent — increases predis- 
 position: 
 
 15. Other epidemics, as influenza, that have a 
 depressing effect upon the nervous system, promote 
 cholera.— All other diseases during cholera epidemics 
 become more aggravated and more fatal :* 
 
 "'See observations on pages 10, il and 127. 
 
i6. Severe attacks of cholera are especially apt 
 to follow wine suppers and debauches of all kinds — 
 from depressed or deficient nerve tone: 
 
 17. Fear is often a prime factor in promoting 
 the spread of the malady. — Though Lebert thinks 
 this has obtained undue evidence, because "the 
 greater the fear, the more minutely are all prelimin- 
 ary measures carried out." Manifestly Lebert's pro- 
 position is more true in abstract than in reality. 
 
CHAPTER IX. 
 
 PROPHYLAXIS. 
 
 The cause of cholera has been shown, then, to be 
 some morbid agent exercising a toxic effect through 
 the central nervous system. The precise nature of the 
 agent is unknown, but its effects are only too appar- 
 ent; and experience has taught that it attacks the 
 poor in a much larger proportion than the rich, the 
 unclean rather than those practicing sanitation and 
 the laws of hygiene. 
 
 It is also well known that in proportion to the 
 prevention of distribution of water fouled with sewage, 
 and to the removal of destitution, filth, foul air, and 
 other great factors of disease, so, generally, is de- 
 stroyed the agency through which the cholera poison 
 operates. — Thos. Hawkes Tanner, especially remarks 
 the lesson taught by the epidemics of 1853-54 and 
 1865-66 in England, viz., that even poverty-stricken 
 denizens of an unhealthy neighborhood, supplied with 
 pure water, are more certam to escape than the 
 wealthy residents of fashionable parks and squares 
 when the latter consume bad water. Still, that over- 
 crowding is an important factor in disseminating the 
 malady — probably through re-consumption of exhaled 
 gases of respiration, tending to poisoning of the cir- 
 culation and central nervous system with carbonic 
 oxide — is not to be denied. Within the walls of an 
 
— 123 — 
 
 establishment for pauper orphans at Tooting, Eng- 
 land, in 1853-54 there were assembled 1,395 children, 
 little more than one hundred cubic feet of breathing 
 space being available for each child, against a require- 
 ment of 1,500 (and 500 is the very smallest com- 
 patible with health). Here, in a single night, the 
 epidemic seized sixty-four of the inmates, 300 bemg 
 laid low within a week, during which time 180 died. 
 Again, in the workhouse at Taunton, with 276 occu- 
 pants, and with breathing space in many of the rooms 
 not exceeding sixty-eight cubic feet for each person, 
 cholera swept away nearly twenty-four per cent, in the 
 brief period of six days; while in the gaol of the 
 same town, where each prisoner had a breathing 
 space of nearly 900 cubic feet (and in some instances 
 more), not a single case of cholera or diarrhoea oc- 
 curred ! 
 
 When an epidemic is prevalent, there are also 
 certam conditions other than filthy surroundings, bad 
 water, and foul air, that render individuals liable to 
 the disease, such as unwholesome, indigestible food — 
 stale meat and fish, game that is "high," butcher- 
 made sausages (since these latter are largely worked 
 up from scraps and unsold remnants at the spoiling 
 turn), withered vegetables, over- or under-ripe fruit, 
 etc. Other predisposing causes are vitiated damp air; 
 exposure to all forms of miasm; intemperance; insuffi- 
 cient protection from cold and inclement weather; 
 excessive fatigue; long abstinence from food; diar- 
 
124 — 
 
 rhoea; in fact all irregular habits, including loss of 
 sleep, excessive venery, et al. 
 
 Hence the old maxim of an ounce of prevention 
 vs. a pound of cure, in this malady receives apt illus- 
 tration. To secure immunity it is essential to form 
 regular habits of life — to live by rule, in a measure, 
 for sudden radical changes, even if for the better in 
 a general way, are sometimes prone to work an effect 
 quite the reverse of that sought. It is important the 
 residence should be in a clean, dry, airy locality, in a 
 house that has no defects in sanitation, whether from 
 plumbing, from decaying wood, or from water beneath 
 the floors; to avoid the use of purgatives, especially 
 of an acrid or drastic nature — the patent liver-pills, 
 "pleasant" pellets and other nostrums, are extremely 
 pernicious, the larger containing aloes, the smaller 
 aloin, croton oil, or elaterium; to check any manifest 
 laxity of the prima vice by rest in the recumbent pos- 
 ture and employment of plain farinaceous foods; 
 to use for drinking purposes only water that has been 
 boiled, and when cold filtered through a mixture of 
 sand and charcoal — I may state a personal preference 
 for rain water filtered through the Kedzie filter, which 
 I employed for many years. 
 
 If there is matter within the intestines tending 
 to irritation, this should be gotten rid of by means 
 of a simple aperient — Hunyadi Janos water, the effer- 
 vescing draughts, castor oil, or the like; or if there 
 are loose, watery evacuations, modification of the 
 
— 125 — 
 secretions may be obtained by small and repeated' 
 doses of leptandrin, bismuth or cerium oxalate, 
 ipecac, and camphor monobromide, combined; or 
 by chloroform water or spirit; by coto; by chlor- 
 anodyne; these may be employed either with or 
 without aromatics. The tendency to intestinal flux, 
 even if not choleraic, is necessarily a source of 
 danger in that it must needs be more or less de- 
 bilitating, thus inducing a condition that pre- 
 disposes the individual to receive the cholera 
 virus. It is obvious that conservation of the vital 
 powers is of the utmost importance; but that an 
 ordinary diarrhoea, the result of indiscretion in eating, 
 of " taking cold," etc., can,/<?r se, produce the specific 
 germ of cholera, as some seem to imagine, is ridicu- 
 lous to the extreme of absurdity. 
 
 But right here let it again be impressed that dur- 
 ing a cholera epidemic the precise character of any 
 diarrhoea must necessarily be difficult of determina- 
 tion ; it may be truly choleraic, yet never manifest its 
 real nature, and thus become a source of infection. 
 For this reason, on such occasions all stools should be 
 carefully gathered and cremated— no other measure 
 is positively safe, — not emptied into the closet or 
 privy; and these latter receptacles should be carefully 
 disinfected. Again, no traveler or stranger should 
 be permitted to use such closets— not even a neigh- 
 bor; and no person should ever venture to enter a 
 strange closet, privy, or latrine, since, as has already 
 
126 
 
 been shown, the emanations therefrom may communi- 
 cate the infection. No device of sanitary expert, or 
 care of plumber, has yet sufficed to render a closet 
 perfectly safe. The practice of wearing a broad, 
 thick web of flannel as a belt, snugly embracing the 
 abdomen, as a prophylactic against intestinal disturb- 
 ances, far from being reprobated should be encour- 
 aged, especially among those of advanced life or 
 sedentary habits. 
 
 Clothing soiled by diarrhceaic evacuations, whether 
 the linen of the person or of the bed, should at least 
 be subjected to the prolonged action of intensely hot 
 water — be boiled, in fact, — and also of strong antisep- 
 tics, as measures of safety;* and if there is any suspi- 
 cion of choleraic tendency, it is greatly to be preferred 
 they too go to the fire. With all our boasted knowl- 
 edge of antiseptics and antisepsis, we are as greatly 
 in the dark as to what is available in destroying the 
 poison of cholera, the element of fire excepted, as we 
 are regarding the precise nature of the virus. 
 
 Finally, it may not be generally known that there 
 is no disease in the whole nosological record that is 
 more aided in the onset, and the fatal tendencies of 
 
 ^I have already shown that Zehnder ascribed the origin 
 of two cholera centres in Zurich in 1867, to an accumulation 
 of bedding, mattresses, pillows, etc., which had been used 
 on the beds of cholera patients, and which before disinfec- 
 tion were piled up in the neighborhood of the houses af- 
 fected! — S. 
 
127 — 
 
 which are more vigorously promoted and hastened by 
 mental depression and fear, than cholera — less fear of 
 cholera itself, however, than developed through other 
 sources. The fact is, this malady in the main claims 
 far fewer victims in proportion to the general popula- 
 lation of any one country than many others that are 
 regarded with comparative complaisance and often 
 receive scarce passing attention save from medical 
 men and those whose homes are directly invaded. 
 Yearly whole districts are ravaged by typhoid fever, 
 diphtheria, scarlatina, etc., to a greater degree than 
 cholera is apt to do; further, I believe there are no 
 valid reasons, other than the rapidity of the attack 
 and the brief period that may elapse between incep- 
 tion and fatality, for regarding this disease, in fairly 
 sanitary localities, as ultimately more dangerous, 
 taking into consideration all results, than epidemic 
 influenza. Again, it is notable that on every occasion 
 when it assumes its most malignant and epidemic 
 form, and spreads beyond the boundaries of the 
 regions where it is endemic, there have been me- 
 teorologic or telluric conditions, or both, favorable 
 to its dissemination; that generally throughout the 
 temperate regions of the globe, as well as in the 
 tropics, a marked tendency to enteric disease pre- 
 vails*. In the present year (1892), as in 1891, this 
 
 * As early as the beginning of 1827 cholera appeared 
 with renewed intensity at Calcutta, and here it is mentioned 
 for the first time that many animals also showed the influ- 
 
— 128 — 
 
 latter fact has been most manifest, and never for 
 twenty-five years has the diarrhoeaic mortality of^ 
 London, Paris, Berlin, and other European cities 
 reached greater height than during the past summer. 
 The present epidemic, as has been shown, readily 
 found its way into Russia, where, by reason of the 
 
 ence of the disease (p. 365). ... It was observed in 
 North Germany at that time (1831) that chickens and pigeons, 
 and in many instances fishes, perished in great numbers 
 (p. 359). — Ziemssen's "Cyclopaedia of Practical Medicine," 
 vol. i. — See Appendix A. 
 
 Even in India the development of cholera demands a 
 medium degree of humidity of the soil and air. Great and 
 protracted dryness, as well as excessive long-continued 
 moisture of the soil, are alike unfavorable; therefore it is 
 that in the hot regions of the East Indies, where dryness 
 predominates and rainfalls are scanty, the cholera breaks 
 out, as a rule, in the rainy season; while in the hot regions 
 of lower Bengal, wher^ wet weather predominates and rain- 
 falls are abundant, the malady prevails in spring seasons 
 which lack their usual rain. Great weight is attached to the 
 monsoon season by Indian physicians, who for the most part 
 in past years have been upholders of the miasmatic theory. 
 Von Pettenkofer undoubtedly states the truth when he ex- 
 plains the influence of the monsoon by the saturation of the 
 soil. Again, in Paris in 1849, after a wet spring, cholera 
 reached an unusual degree of fatality in the first eight days, 
 of June, which were very warm; on the ninth, however, 
 occurred a violent storm, when the number of new attacks 
 diminished one-third as compared with the days of the pre- 
 ceeding week. The same was true in the same year at 
 Vienna, in Austria, and Christiania, in Denmark.— S. 
 
— 129 — 
 famine and the consequent train of circumstances 
 which make an entire population susceptible to ad- 
 ditional scourge, it obtained firm foothold, and thence, 
 in spite of sanitary barriers, reached the more civilized 
 portions of Europe; the same circumstances, precisely, 
 existed in Southern Ireland prior to and during the 
 epidemic of 1834, in which locality the malady was 
 exceptionally fatal until the famine was in great 
 measure relieved, and wholesome food became the rule 
 rather than the exception — thanks to the bounties of 
 the world. 
 
 This with reference to the epidemic form of chol- 
 era; for it must be remembered that sporadic cholera 
 like the poor, is "always with us" to greater or less 
 extent, and constantly exists in the Levant, in Southern 
 Europe along the Mediterranean, and occasionally ap- 
 pears as an endemic even on the borders of the Ger- 
 man Ocean, and in the far interiors of Canada and the 
 United States: The fact these sporadic cases are 
 generally classed as aggravated cholera morbus, chol- 
 era nostras, English cholera, cholera infantum, etc., 
 matters little, since they are pathologically one and 
 the same, differing only in degree — an opinion that 
 is upheld by the very highest authorities in India and 
 Europe.* And I here insist, taking every feature 
 
 *See " Pathological Researches" of T. R. Lewis; Lon- 
 •don, 188S. " Nature and Treatment of Sporadic and Epi- 
 demic Cholera," by Alex. Harkin, London, 1885. "On the Ori- 
 gin, Habits, and Diffusion of Cholera," by Sir J. Fayrer, K, 
 C. S. L, M. D., F. R. S. 
 
 9 KKK. 
 
— I30 — 
 
 into consideration, and giving all negative evidence 
 due weight, that cholera is cholera wherever it occurs, 
 and its epidemic prevalence and intensity are phases 
 or accidents in its history. Surgeon-Majors D. D. 
 Cunningham, and J. M. Cunningham, the latter the 
 Health Commissioner of India, and many others who 
 are very properly considered as expert authorities on 
 Asiatic cholera, believe that cholera nostras is the 
 same precise malady, " exhibited under conditions 
 unfavorable for its perfect expression — that at times 
 the conditions may and do become favorable, and 
 then an epidemic results." The disease occurring 
 in the deltas of the Ganges and Trawadi, in Moscow, 
 Hamburg, London, New York or Winnipeg, is practi- 
 cally the same; and within a quarter of a century 
 I have seen numerous cases in the Great Lake region 
 of North America as serious as any that ever bore 
 the name Asiatic, two that would have been pro- 
 nounced asphyctic had the malady only been raging^ 
 as an epidemic ! 
 
 [Since the above was written, it has been my lot 
 to see three other cases of cholera nostras (morbus) in 
 Detroit, either of which was so virulent there would 
 have been not the least hesitancy on the part of any- 
 one viewing in pronouncing true Asiatic cholera, had 
 there been the slightest chance of infectious origin. 
 I may further add, the bacillus of Koch was specifically 
 identified in the dejections of all three; also, that all 
 were speedily relieved by inhibition of the sympa- 
 thetic] 
 
— 13' — 
 Owing, presumably, to the utter failure of rem- 
 edies, external or internal, to check the march of this 
 dire disorder, the efforts of medical men for the most 
 part — almost exclusively, I should say — have been 
 directed to measures of prevention; and it is perhaps 
 for this as well as for other reasons, that the therapeu- 
 sis of cholera has not kept pace with that of other 
 diseases. Sanitary measures have almost wholly 
 superseded sanatory considerations, and to such an 
 extent that in most dissertations of the leading advo- 
 cates of State Medicine, the former are gravely 
 heralded as panaceas for all epidemic disorders, and 
 sure, in course of time, to eliminate from the nosologi- 
 cal record the whole train of such accidents. Says 
 Dr. Alex. Harkin:* 
 
 "These enthusiasts seem to have adopted for 
 their motto, and emblazoned on their 'banner 
 with the strange device,' Sanitas Sanitattim, et o?nnia 
 Sanitasj and yet I fear the saying of the Wise Man, 
 Va?iitas Vanitatuni, et omnia Vanitas, is not alto- 
 gether obsolete in their regard, but fairly applicable 
 to many of their most confident vaticinations. I 
 am not one unfairly to decry the value of sanitation 
 or scientific hygiene — I should rather prefer that san- 
 itary and therapeutic measures should go hand-in- 
 hand; but in the recent experience of a fatal form of 
 typhoid fever, which numbered many victims in some 
 
 * Dublin Journal of Medical Sciences March, 1890. 
 
— 132 — 
 of the finest cities of America, France, and Ireland, 
 and in the actual presence of epidemic influenza which 
 has prostrated thousands in the British Isles and on 
 the continents of Europe and America, the impotence 
 of sanitary arrangements to alone repel an attack 
 of infectious disorder must be hopelessly apparent."* 
 Looking at the history of cholera in Malta ante- 
 cedent to 1887, we find after the epidemic of 1865, 
 considered the most fatal up to that date on record, 
 every measure that sanitary science, or engineering 
 skill could effect was carried out; yet, notwithstand- 
 ing, the cholera unheeding swept down upon the 
 Island in 1887 in a more malignant form than ever, for 
 out of 626 cases only 164 recovered — a death rate of 
 73.5 per cent. In 1865, after which Dr. Sutherland 
 and the eminent engineer Osbert Chadwick visited 
 the Island, the mortality stood at 60 per cent.; while 
 in 1867, an intermediate visitation, there was a mor- 
 tality of only 64 per cent., and this before the sani- 
 tary improvements were complete. In the presence 
 of such adverse statistics it is difficult to agree wholly 
 with sanitary scientists. 
 
 "'This conviction appears to be entertained by some of 
 the most enlightened organs of public opinion, as I find in 
 an able article on Influenza in the Standard (London) this 
 sentence: "And those who hoped that in the case of this, as 
 of more serious scourges, the comparative excellence of 
 sanitation would secure an absolute immunity, have to con- 
 fess they have carried their faith in drainage a little too far!" 
 
Antiseptics and Disinfectants 
 
 FOR THE PREVENTION OF CHOLERA. 
 
 We desire to call attention to the following antiseptic and disinfectant 
 preparations: 
 
 Ethereal Antiseptic Soap (Johnston's) is a hydro-alcoholic solution 
 of Castile soap which was devised by an experienced nurse in the surgi- 
 cal clinic of the Jefferson Medical College. It may be made weak or 
 strong in antiseptic value by dissolving mercuric chloride in it in propor- 
 tions indicated in the case in hand. Since its introduction its use has 
 been extended to the treatment of parasitic affections with much success. 
 
 Antiseptic Liquid arrests decomposition and destroys noxious 
 gases that emanate from organic matter in sewers and elsewhere, and 
 may be used in cellars, barns, outhouses, and the sick-room. (Send for 
 Note on the Disinfectant of the Future, by Prof. Alfred L. Loomis.) 
 
 Antiseptic Tablets are convenient for the extemporaneous prepa- 
 ration of antiseptic solutions of definite strength for disinfectant purposes 
 and for antiseptic sprays. 
 
 Eucalyptus and Thymol Antiseptic is adapted for use as an anti- 
 septic internally, externally, hypodermatically, as a douche, a spray, by 
 atomization, and as a deodorant. Its application in surgery is unlimited. 
 It combines the antiseptic virtues of benzoic acid, boric acid, oil pepper- 
 mint, oil eucalyptus, oil wintergreeti, oil thyme and thymol. 
 
 Disinfectant Po'wder possesses in a high degree disinfectant, ab- 
 .sorbent, and antiseptic properties. It is admirably adapted for the dis- 
 infection of excreta in cholera, yellow fever, and typhoid fever, and in 
 all diseases in which such an agent is indicated for the purpose specified, 
 
 Labarraque's Solution we supply for the use of those who desire 
 to employ it for its local or internal antiseptic action. It may be diluted 
 to suit the indications. 
 
 Sulphur Candles thoroughly employed are effectual in the fumiga- 
 tion and disinfecting of rooms after infectious diseases. 
 
 fVe shall he pleased to forward, on request, any information desired con- 
 cerning these products. 
 
 PARKE, DAVIS & COMPANY, 
 
 DETROIT, NEW YORK, AND KANSAS CITY. 
 
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 GEORGE S. DAVIS, Publislier. 
 
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 By Beverley Robinson, M. D. 
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 Diseases of the Liver- 
 
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 Hysteria and Epilepsy. 
 
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 Diseases of the Kidney. 
 
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 Nervous Syphilis. 
 
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 Education and Culture as correlated to 
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 Diabetes. 
 
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 A Treatise on Fractures. 
 
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 Some Major and Minor Fallacies concern- 
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 Hypodermic Medication. 
 
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 Practical Points in the Management of 
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 Neuralgia. 
 
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 Rheumatism and Gout. 
 
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 Practical Notes on Urinary Analysis. 
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 Pulmonary Consumption, a Nervous Dis- 
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 Insomnia and Hypnotics. 
 
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 Treatise on Diphtheria. 
 
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