Volume 1 — GENERAL DISEASES. (continued 17)

I have referred to these facts with so much emphasis because of late an attempt has been made to introduce chlorate of potassium as the main remedy in bad cases of diphtheria, and, what is worse, in large doses (Seeligmüller, Sachse, L. Weigert, C. Küster, Edlefsen.)

Large doses of chlorate of potassium (2 drachms daily to an adult I claim to be a large dose, particularly when its use is persisted in for many days in succession) are dangerous. In several of my writings I have given instances of its fatal effects.⁴³ I have seen fatal cases since, and scores have been published in different journals. The first effects of a moderately large dose are gastric and, more especially, renal irritation; the latter it was which I experienced when I took half an ounce twenty-five years ago. Fountain of Davenport, Iowa, experienced the same before more serious symptoms developed, of which he died.⁴⁴ The symptoms are those of acute diffuse nephritis, with suppression of urine, or scanty secretion of a little black blood, and uræmia deepening toward death in fatal cases. My earlier cases I considered as primary diffuse nephritis, and I have even been inclined to attribute the frequent appearance of chronic nephritis, amongst all classes and ages, in part to the influence of the chlorates, which have become a popular domestic remedy and are found in every household. But the experimental researches of Marchand⁴⁵ and others prove that, at least in many instances, the extensive destruction of blood-cells is the first and immediate result of the introduction into the circulation of the chlorate, and that the visceral changes are due to embolic processes.

⁴³ C. Gerhardt's Handbuch der Kinderkrankheiten, vol. ii., 1876; Med. Record, March, 1879; Treatise on Diphtheria, 1880.

⁴⁴ Stillé, Therap. and Mat. Med., 2d ed., 1874, p. 922.

⁴⁵ Sitzungsber. d. Naturforsch. Ges. h. u. Halle, Feb. 8, 1879, and Virch. Arch., vol. lxxvii.

Special Treatment.—The first axiom in the treatment of diphtheria is that there is no specific; the second, that in no other disease the individualizing powers of the physician are tested more severely.

The treatment is both internal and external. The local remedies are either such as dissolve the mucous membrane, or such as thoroughly modify the mucous membrane from which the pseudo-membrane has been removed, or real antiseptics, with the power of destroying either chemical or parasitic poisons.

The number of remedies recommended in diphtheria is immense. No other proof of its dangerous nature is needed. In the following I shall review those which I consider it worth while either to reject or to recommend.

Steam is used partly to soften the membranes, but principally to increase the secretion from the mucous membrane, and thereby throw off the superjacent membrane. This can be done to advantage only where there is a natural tendency to it; that is, where there are a great many muciparous follicles under a cylindrical or fimbriated epithelium. This is the condition on part of the pharynx, but not on the tonsils; and in a small portion of the larynx, in the trachea and bronchi, but not on the vocal cords. Wherever there is pavement epithelium on the normal surface, and where the membrane is imbedded into the tissue, steam can hardly be expected to do good. In the other cases it will. Thus, the locality of the diphtheritic process determines to a great extent whether steam is indicated or not. If it be used, the necessity of a full supply of atmospheric air must not be disregarded. Steam, with an overheated room and without pure air, is liable to be as injurious as steam in pure air is beneficial in a number of cases.

There can be no better proof for the necessity of individualizing, and the impossibility of treating all cases alike, than the fact that many will do well under steam treatment, and others are certainly injured by it. I have repeatedly had the joy of seeing children with croup become less cyanotic after their removal from an atmosphere of vapor, and I can readily see that pure atmospheric air would be more agreeable and wholesome to a child with stenosis of the larynx than an atmosphere laden with steam. Of course this remark does not apply to cases of pseudo-croup and bronchitis, which are generally benefited by a warm, moist atmosphere. Those, however, who deem it judicious to employ steam as a vehicle for carbolic acid, salicylic acid, chloride of sodium, chlorate of potassium, or lime, had best resort to the atomizer for applying these remedies. It can be used without trouble; most children are sufficiently intelligent to allow the spray to be directed upon the fauces and larynx every ten or fifteen minutes in case of necessity. When it is deemed advisable to administer steam, I warn against the use of gas stoves. They require a great deal more oxygen than an alcohol lamp, which ought to be preferred when a stove or slaking lime or hot iron or bricks immersed in water are not available.

Water may be made serviceable in different ways. Its effect on the skin, when taken in large quantities, under normal or abnormal circumstances, is a matter of daily experience. Copious perspiration is its immediate result. The very same effect is produced on the mucous membranes. In diphtheria, besides professional hydropathists, I know of but one⁴⁶ who favors the plentiful use of water, 100-200 grammes (3-6 ounces) every hour or oftener, either by itself or mixed with an alcoholic beverage.

⁴⁶ C. Rauchfuss, in C. Gerhardt's Handb. d. Kinderkr., iii. 2, 1878.

Severe inflammatory symptoms, such as redness of the throat, great pain, swelling of the glands, require cold applications, either an ice-bag or ice-cold cloths well pressed out and frequently changed. They must, however, be placed where they can do most good—in laryngeal diphtheria around the neck, in pharyngeal diphtheria with glandular swelling over the affected part. In the latter, therefore, the flannel cloth which covers the whole of the application must be tied over the head, and not behind. When ice-bags are used, care is to be taken lest they should be too large; if so, they will not affect the desired spot at all. Small pieces of ice frequently swallowed are greatly relished by the patient; water-ices in small quantities will render the same service; ice-cream, in half-teaspoon or teaspoon doses every five or ten minutes, adds to the necessary nutriment. When the fever is high and the surface hot, sponging with tepid or cold water, or water and alcohol, will mitigate both. For the cold bath or the cold partial pack (trunk and upper part of the thighs) the general indications hold good. As a rule, I favor the latter, for many cases have such a tendency to debility and collapse that sometimes the circulation of the surface of the body is badly interfered with by cold bathing. Therefore, a contraindication to cold bathing must be found at once in cold feet, either before or after a bath. When, unfortunately, the feet do not recover their normal temperature in a very short time, they ought to be warmed artificially, and the cold bath not repeated. In such cases the cold pack, however, is still indicated. A linen or cotton cloth, large enough to cover the trunk and half of the thighs, is dipped in cold water, well pressed out, and the body of the patient wrapped tightly in it. The arms remain outside; the whole body is then wrapped up in a blanket; the feet may be warmed meanwhile when necessary, and the cold pack repeated as often as required to reduce the temperature—viz. once every five minutes, every half hour, every hour.

The contraindications to the use of cold have in part been alluded to. Very young infants bear it but to a limited extent. The beginning of recovery contraindicates it, unless for some local cause; for instance, an inflamed gland. The extensive use of cold water or ice is also forbidden when there is no fever, where there is perhaps an abnormally low temperature, where we have to deal with the septic or gangrenous form of diphtheria, where the vitality is low and the mucous membranes pale or even cyanotic. In such cases, on the contrary, while unlimited internal stimulation is required, the hot bath, or hot pack and hot injections into the bowel, will be found beneficial.

Lime-water, glycerine, lactic acid, pepsin, neurin, papayotin, chinolin, and pilocarpine are all solvents of pseudo-membrane, but whether there is sufficient time and opportunity to produce a curative effect by every one of them is a question open for discussion. Of lime-water and glycerine I have employed a mixture of equal parts in considerably more than a hundred cases after the completion of tracheotomy, directing the remedy through an atomizer into and below the canula, but cannot say that the descent of the membrane into the trachea or bronchi was prevented by it. Lime-water may be used in the nose and throat as an injection, spray, or gargle, but its solvent effect is greatly diminished by the action of the carbonic acid of the breath on the lime. I have no doubt that if water alone was used with the same persistence as lime-water, its effects would be nearly the same. Still, what little effect the minute dose of lime (1:800) in the lime-water may have may just as well be utilized. What I object to is the omission of more powerful agents. If lime is to be used, slaking lime frequently in the presence of the patient is attended with vastly more benefit, inasmuch as by that proceeding a large amount of powdered lime is projected into the air of the room and the mouth and respiratory organs.

Lactic acid also, in from ten to twenty-five parts of water, has yielded no better results in my hands. Those cases of tracheotomy which I afterward treated with lactic acid spray terminated no better than such as were treated with lime-water and glycerine. Of the solvent effect of pepsin I have not been able to convince myself so as to recommend it. The accounts of neurin have not encouraged me to try it at all. Chinolin (tartrate) has been used locally by O. Seifert,⁴⁷ Müller, and others. It is said to remove the membranes and relieve the fever. For a gargle it is dissolved in five hundred parts of water, or it is mixed with ten parts of water and alcohol each, and applied by means of a sponge. To relieve the burning sensation ice is swallowed afterward. The local applications of alcohol have the same drawback. There are but few patients who do not suffer intensely from its local contact.

⁴⁷ Berl. klin. Woch., Nos. 36, 37, 1883.

Papayotin has been recommended by Rossbach for the purpose of dissolving membranes in a one-half per cent. solution. It peptonizes albuminoids, and macerates meat, intestinal worms, and croup membranes in both neutral and feebly alkaline solution. In concentrated solutions it has a caustic effect. It is recommended, not as an anti-diphtheritic, but merely as a solvent remedy.⁴⁸ Whatever reliance may have been placed upon it has, however, been jeopardized by Rossbach's remarks⁴⁹ on the variability of the preparations in the market. Not only are the specimens very unequal, but each of them is variable, easily spoiled, and particularly affected by moisture.

⁴⁸ Berl. klin. Woch., March 10, 1881.

⁴⁹ Transactions of the Congress for Int. Medicine, 1883, p. 162.

Muriate of pilocarpine was recommended for this purpose three years ago. It was praised by Juttmann as a specific, and has failed. The quackish recommendations of the drug have, indeed, earned for it a certain amount of distrust which it does not deserve in all cases. It is expected to increase the secretion of the mucous membranes to such an extent as to float the pseudo-membranes. It sometimes succeeds in so doing, but only in those cases in which the membrane is deposited upon the mucous membranes. When the tissue is impregnated the drug fails. It also fails in septic cases, and mostly for the reason that it diminishes and paralyzes the heart's action. It ought, therefore, never to be given unaccompanied with large amounts of stimulants. Where the patient is strong, and the heart healthy, it may be tried; I know that a few cases of moderate laryngeal diphtheria improved with pilocarpine, steam, and turpentine inhalations. The dose is 1/30 grain, dissolved in water, every hour.

Turpentine inhalations were recommended by C. Edel.⁵⁰ Fifteen drops of oil of turpentine are inhaled from a common inhalation apparatus, which is placed at a distance of three inches from the mouth of the patient, for a period of ten minutes every hour. He claims recoveries in from twelve to forty-eight hours. I allow the patient to remain in his bed, and keep water boiling constantly on an alcohol lamp, on the stove, or over the gas. A tablespoonful of turpentine, more or less, is poured on the water, care being taken that nothing is spilled in the fire. Thus the room is constantly filled with a penetrating odor of turpentine, which is not at all disagreeable, even when in great concentration. The effects are very satisfactory indeed. Where circumstances allowed or required it I have raised a tent over the bed, large enough not to give inconvenience to the patient and to admit either the whole apparatus or the tube containing the mixed vapor of water and turpentine.

⁵⁰ Med. Rev., Jan. 19, 1878.

Ammonium chloride may sometimes be used to advantage for its softening and liquefying effects. Its internal administration in bronchial and tracheo-laryngeal catarrh is so old that it has several times been obsolete. Of late, more stimulant effects have been attributed to it than it actually possesses. But its liquefying action, in cases where the secretion of mucus is defective and expectoration scanty and viscid, is undoubted. Thus it proves valuable in many cases of simple catarrh, both when administered internally and inhaled. The latter mode I have often resorted to, and believe that its macerating influence has been of service to me in cases of laryngeal diphtheria. Half a teaspoonful of the pure salt is spread on the stove or burned over alcohol or gas. It evaporates immediately, and fills the room or the tent with a white cloud, which, when dense, excites coughing. But it does not irritate to any uncomfortable degree, and the process may be repeated in an interval of an hour or more.

Not all cases of diphtheria are septic or gangrenous, nor are all the cases occurring during an epidemic of the same type. Some have the well-pronounced character of a local disease, either on the tonsils or in the larynx. The cases of sporadic croup met with in the intervals between epidemics present few constitutional symptoms, and assume more the nature of an active inflammatory disease—very much like the sporadic cases of fibrinous tracheo-bronchitis. These are the cases in which mercury deserves to have friends, apologists, and even eulogists. Calomel, 0.5-0.75 gramme (gr. viij-xij), divided into thirty or forty doses, of which one is taken every half hour, is apt to produce a constitutional effect very soon. Such doses, with minute doses, a milligramme or more (gr. 1/60), of tartar emetic, or ten or twenty times that amount of oxysulphuret of antimony, have served me well in fibrinous tracheo-bronchitis. But the mucous membrane of the trachea and bronchi is more apt to submit to such liquefying and macerating treatment than the vocal cords. The latter have no muciparous glands like the former, in which they are very copious. And while the tracheal membrane, even though recent, is apt to be thrown out of a tracheal incision at once, the pseudo-membrane of the vocal cords takes from six days to sixteen or more for complete removal. Still, a certain effect may even here be accomplished, for maceration does not depend only on the local secretion of the muciparous glands, but on the total secretion of the surface, which will be in constant contact with the whole respiratory tract. Thus, either on theoretical principles or on the ground of actual experience, men of learning and judgment have used mercury in such cases as I detailed above, with a certain confidence.

If ever mercury is expected to do any good in cases of suffocation by membrane, it must be made to act promptly. That is what the blue ointment does not. In its place I recommend the oleate, of which ten or twelve drops may be rubbed into the skin along the inside of the forearms or thighs (or anywhere when their surface becomes irritated) every hour or two hours. Or broken doses will be useful, such as given above, or hypodermic injections of corrosive sublimate in ½ or 1 per cent. solution in distilled water, four or five drops from four to six times a day, or more, either by itself or in combination with the extensive use of the oleate, or with calomel internally. Lately, the cyanide of mercury has been recommended very strongly. I hardly believe that it will work more wonders than any other equally soluble preparation. Within the past few years the internal administration of bichloride of mercury has been resorted to more frequently and with greater success than ever before. My own recent experience with it has been encouraging, and so has that of some of my friends. Wm. Pepper⁵¹ gave 1/32 grain of corrosive sublimate every two hours in a bad form of diphtheritic croup, with favorable result. But in this very bad case, desperate though it was—child of five years, resp. 70, pulse 160—large membranes, "evidently from the larynx," had been expelled before the treatment was commenced on the seventh day of the disease. The remedy ought to be given in solution of 1:5000, and in good doses. A baby a year old may take one-half grain every day for many days in succession, with very little if any intestinal disorder and with no stomatitis.⁵² A solution of the corrosive chloride of mercury in water is frequently employed of late as a disinfectant. It acts as such in a dilution of 1:20,000. As healthy mucous membranes bear quite well a proportion of 1:2000-3000, any strength between these extremes maybe utilized. A grain of the sublimate in a pint or more of water, with a drachm of table-salt, will be found both mild and efficient. As a gargle or nasal injection it will be found equally good. But it has appeared to me that frequent applications give rise to a copious mucous discharge; hourly injections into a diphtheritic vagina became quite obnoxious by such over-secretion, which ceased at once when the injections were discontinued. Thus, when it is desirable not only to disinfect but also to cleanse the diseased surface, the injections with corrosive sublimate appear to yield a result inferior to less irritating applications.

⁵¹ Trans. Am. Med. Ass., 1881.

⁵² Med. Record, May 24, 1884.

Chloride of iron is undoubtedly a valuable remedy in diphtheria, but in its administration it must by no means be forgotten that small doses at long intervals are out of the question. I have not the least doubt but that the failure of the remedy may be attributed in most cases to the fact that the doses were too small and administered too seldom. A dose of from five to fifteen drops, properly diluted, every fifteen minutes, half hour, or hour is indispensable for a proper estimation of its effects. Gargles are not of much service, for the simple reason that they do not come into sufficient contact with the affected parts, and reach at the utmost to the anterior pillars of the soft palate. A direct application of the remedy to the mucous membrane of the pharynx may also be desisted from, thereby avoiding any irritation, the internal administration at short intervals causing the pharynx to be sufficiently influenced by local contact with the remedy. It must, of course, not be expected that the chloride will remove the membrane, but it can frequently be seen to reduce the hyperæmia and swelling and prevent the reproduction of exuded material. The chloride of iron exerts a decided influence on the vital contractility of the blood-vessels. This increased contractility certainly assists in diminishing the rapidity of absorption of putrid fluids through the blood-vessels, which constitutes the principal source of danger from the disease.

It cannot yet be positively asserted that the chloride of iron exerts a direct effect on the lymphatic vessels. Naturally, this was claimed when the remedy was recommended, in the treatment of diphtheria, on account of its therapeutic effects in erysipelas, with the accompanying inflammation of the lymphatic vessels of the skin. Although we know of no direct compression of the lymphatic vessels due to the action of the chloride, yet it may be assumed that perhaps the compression of the blood-vessels exerts a similar influence upon the neighboring lymphatics. In consequence of this there would be an impediment to the absorption and further development of poisonous substances in the lymph. The chloride, like the sulphate of iron, is a tolerably powerful disinfecting agent. If this observation be correct, it may go very far toward explaining the action of the chloride of iron in septic diseases, which are accompanied by an exalted activity of the lymphatic vessels and an increase of the white blood-corpuscles. Furthermore, Saase has endeavored to show that the ferrous salts possess the power of converting oxygen into ozone. They share this power with the blood-globules exclusively, and could hence, to a certain degree, supply a deficiency of the latter. Pokrowsky, too, has shown that iron increases the process of oxidation in the body by demonstrating that in health there is an elevation of temperature and an increase of the percentage of urea in the urine during its administration. In anæmic persons, to whom iron has been given for the purpose of increasing the amount of blood, the above phenomena may be observed before this object is accomplished. Thus iron appears to replace the blood-corpuscles to a certain extent. Now, in infectious disorders of the blood, where the red globules are perpetually menaced with destruction, it seems plausible that the preparations of iron should exert an antiseptic action.

Finally, it has been found that of all the preparations of iron the chloride possesses the greatest power of stimulating the nervous system. Possibly this effect may be traced to an increase of the arterial pressure in the nerve-centres. It has been said that this effect has been vividly illustrated in certain forms of chlorosis. If this be true, iron would be all the more indicated in diphtheria, since it would act as a prophylactic against a series of nervous phenomena that so frequently present themselves, both during and subsequently to the diphtheritic process. Thus it is that for many years the muriate of iron has constituted the main element, with me, of internal medication in most cases of diphtheria, both of the mild and the most dangerous septic type. A common formula is, for a child of two years,

Rx. Tinct. Ferri Chloridi drachm ij;

Potass. Chlorat. gr. xx;

Aquæ fl. oz. v;

Glycerin. Pur. fl. oz. j. M.

S. A teaspoonful every fifteen, twenty, or thirty minutes.

Carbolic acid exerts a powerful influence on the vitality of all living elements, and hence also on rapidly proliferating epithelium, which constitutes a part of the diphtheritic membrane. It is of great advantage for local use. Its local effect, undiluted or diluted with equal or larger parts of glycerine or alcohol, in shrinking and removing membranes, is sometimes very useful; in mild solutions in water (½, 1, or 2 per cent.) it is very efficient in nasal injections or for external applications or mouth-washes. Rothe's prescription for external use is carbolic acid and alcohol each 2 parts, water 10, tincture of iodine 1. Its internal administration to the extent of five to twenty grains daily, given largely diluted, in small and frequent doses, is of less positive value.

Salicylic acid, in a solution of 1:30-50, is caustic. A milder solution, 1:200-300 relieves or removes foul odor from the nose or throat, but it does not detach membranes or shorten the duration of the disease, apparently. Internally, it acts no longer as a disinfectant, but is changed into a salicylate and is an antipyretic. It is then better to replace it by the sodium salicylate. With its administration (for a child of 2 years 3 grains every hour until 20 or 25 grains are taken) it ought not to be forgotten that serious brain troubles, collapse, and irregular and paralytic breathing, as well as gastric and intestinal disturbances, may follow its use. It ought not to be given without careful watching and the simultaneous free use of alcoholic stimulants.

Binz found, as the result of experiments with solutions of pure quinia varying from one part in a hundred to one in a thousand, that the latter sufficed to prevent the development of bacteria in fluids capable of undergoing putrefaction; but even estimated thus, a patient with eighteen pounds of blood would require one hundred and thirty-eight grains of quinia circulating therein in order to satisfy the conditions of Binz's experiment. If Binz considers two grammes (half a drachm) of quinia per day sufficient for an individual weighing one hundred and twenty pounds, his calculation is founded on experiments with dogs, in which septicæmia was avoided by the injection of quinia. It is also necessary to bear in mind that Binz makes a distinction with regard to the preparations of quinia employed. He warns against the use of the bisulphate as being the most inactive. No matter which preparations are used—I prefer the muriate—I have come to look upon quinia as of no great service in reducing the temperature in infectious fevers. The main indication for its use can only be found in inflammatory fevers. When it is given, however, salicylate of sodium may be added for a short time to obtain a speedier effect.

On the part of bromine Wm. H. Thompson claims the following advantages: 1. When applied locally, it promptly arrests fetor by arresting directly the gangrenous process, and thus lessens risk from absorption. 2. It acts as an anti-putrefactive likewise in the fluids of the body generally—i.e. blood, interstitial circulation, and secretions—owing to its high rate of diffusibility, equal to that of sodium chloride itself. 3. It locally destroys the communicable property of the discharges, shown by the immunity of attendants from any sore throat when it is used, and from its checking the spread of the disease in the locality. He orders two solutions to be used: the first of equal parts of Lawrence Smith's solutio bromini and of glycerine, applied with a hair pencil to the membrane, as gently as possible. Sometimes he uses the solution full strength. The brush should be washed at once in water, and does not last more than one day, owing to the action of the bromine on the hair. If, however, the membrane be very extensive and the parts much swollen or difficult to reach, he resorts instead to douching with a Davidson syringe, using half a drachm to one drachm of the solution to a pint of warm water. By beginning gently with the stream directed against the buccal mucous membrane, the child soon becomes accustomed to the current and allows it then to play against the deeper parts.

Internally he orders from six to twelve drops of the solution in a half ounce of sweetened water, every hour, two, or three hours, according to the urgency of the case, and continuously.

The most convenient way of making Smith's solution is: Take two ounces of a saturated solution of potassium bromide in water; add to this, very slowly, in a bottle and with constant shaking, one ounce of bromine. It is better to add a part, and then let it stand a while before adding the rest; then fill up gradually, and with constant shaking with water, until it measures four ounces.

Ozone has been used as an anti-fermentative in inhalation during three or five minutes every hour or two, by Jochheim.

Boric (boracic) acid, in saturated (1:25) or milder solutions, has some antiseptic effect. It is mild, and not very injurious when swallowed by necessity or mistake. In diphtheritic conjunctivitis it is valued highly, and in nasal injections I have found it very useful. It is less repugnant than most other substances administered in that way.

Sodium benzoate cannot be relied on either as an anti-diphtheritic nor as an anti-febrile. The doses which were recommended were two scruples or a drachm daily for a child a year old.

Sulphur has been used locally. It gives rise to coughing and vomiting.

Cubebs have been given in incredible doses, two drachms of the powder to a child a year old. The drug disorders the stomach and kidneys.

Local Treatment.—The mechanical removal of the membranes is not permissible unless they are almost detached. It is best to avoid their being cast off, unless partly loosened membranes in the larynx or trachea afford an indication for an emetic. Scratching and eroding the mucous membrane of the neighborhood give rise to new deposits. Even after spontaneous elimination of a membrane a new one may be formed within a few hours.

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

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

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

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

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

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

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

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

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

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

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

CHOLERA.

BY ALFRED STILLÉ, M.D., LL.D.

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

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

HISTORY.—It is sometimes stated that Hippocrates, Galen, Celsus, and the Greek, Roman, and Arabian medical writers generally record "the fact of the presence of cholera in the various countries in which they lived" (Macnamara). Nothing could be more contrary to the truth. All of these writers describe "cholera morbus" in nearly identical terms; they all include bilious discharges among its symptoms, and no one of them speaks of it as a mortal or even as an epidemic disease. (Compare, especially, Celsus, Aretæus, Cælius Aurelianus, and Paulus Ægineta.) Their description of sporadic cholera morbus is very precise. For example, Cælius Aurelianus says: "Cholericam passionem aiunt aliqui nominatam a fluore fellis, per os et ventrem effecto."¹

¹ Acut. Morb., lib. iii. cap. xix.

Asiatic epidemic cholera is a very different disease. It seems to have been known in India from a very remote period, but no detailed account of it was published until the beginning of the sixteenth century. During that century many successive descriptions of the disease exhibited its extreme violence and mortality. It is believed to have occurred repeatedly, if not annually, in the same localities down to the present time. The invasion of India by the Portuguese, and afterward by the English, contributed to spread the disease throughout the Peninsula, partly by military occupation and partly through commercial channels, by which it was also carried to the islands in the Indian Ocean. It prevailed in Batavia in 1629. Between 1768 and 1790 numerous epidemics of cholera occurred. About the former date no less than 60,000 persons are said to have perished near Pondicherry, and in 1783 it is reckoned that 20,000 victims to the disease fell in a single week during the religious gathering at the sacred city of Hurdwâr, where, as will be seen hereafter, it became in later years more fatal still. The English armies extended their conquests in Hindostan, and established commerce between that country and Western Asia and Europe, and by the year 1817 opened new channels of communication in every direction, both within and beyond the Peninsula. Along them the disease was carried; it invaded Ceylon and the Burmese empire, and extended to Batavia, Java, and China on the east, and advanced westward to Persia in 1821. In that year also it was carried from Arabia into Africa, and at various later periods penetrated more and more deeply into the Dark Continent, always following the track of pilgrims returning from Mecca, the routes of armies engaged in war, or those of trading caravans.²

² Christie, Cholera Epidemics in Africa, 1876.

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

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

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

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

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

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

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

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

In 1881 cholera was brought from Hindostan to Arabia by pilgrims on their way to Mecca, where it soon afterward broke out and caused the death of about 8000 persons. In the following year several vessels from Bombay evaded the quarantine and reached Djeddah, the port of Mecca, and the pilgrims on reaching the latter city disseminated the disease. The unusually small number of persons who were there at the time, and their prompt dispersion before the danger, limited the mortality, and gradually cases of cholera ceased to appear. In 1882, the English at that time carrying on war in Egypt, very rigid sanitary precautions against the importation of cholera were enacted and successfully enforced, but in the following year, the same urgent necessity no longer commanding, they were considerably relaxed. At the end of June, 1883, the cholera made its appearance at Damietta (at one of the mouths of the Nile), and soon afterward at Rosetta, Port Said, and Mansourah. During July it spread to various places in direct communication with those named. At Cairo it was peculiarly fatal, and on July 20th it was reported to have caused 600 deaths. For several days the daily mortality varied between 500 and 600. The disease prevailed somewhat in Alexandria during the height of the epidemic, and near the end of October it was fatal to numerous European residents of that city, and some deaths occurred in the British army of occupation. In all Egypt, during the week ending Aug. 13th, the total mortality is said to have been 5000, but in the following week it fell to 2000. It is estimated that the epidemic destroyed at least 20,000 lives. The germ of this epidemic has not been accurately determined. Some regard it as a survival of the cholera of the previous year—a supposition which is at least plausible and sufficient; but certain "sanitarians" have attributed the outbreak to the ordinary causes of disease intensified by the civil war which had recently devastated Egypt. It is sufficient here to say that while such causes have in all ages generated typhus and typhoid fevers and dysentery, they never produced cholera. Some, more unwise than judicious, declared that the Egyptian disease of 1883 was not cholera. It is alleged, on the one hand, that several East Indian merchants from Bombay arrived at Damietta on June 18th, or three days before the disease was recognized in that city. It is also said that a stoker from on board an English steamer from Bombay introduced the cholera into Damietta. But the judgment of Surgeon-General Murray carries with it greater weight.³ He is of the opinion that the Egyptian epidemic of 1883 was simply a revival of the Arabian epidemic of 1882. He shows that cholera existed in several villages on the Damietta branch of the Nile in the latter part of May and during June, and that it broke out in the capital itself, during a fair which had lasted for eight days, on the 22d of June, and was spread by the people on their return from Damietta to their villages. This, adds Mr. Murray, "is a literal transcript of the accounts of many of the severe epidemics that have raged over India." It also appears from M. Proust's narrative⁴ that the Ottoman government had already, as early as April, notified the government of Egypt that certain Indo-Javanese pilgrims were on their way to Mecca, and that ought not to be allowed to land without quarantine. The French delegate to the sanitary council also begged that those of the pilgrims who reached Suez without previous quarantine should be isolated and kept under surveillance for three days. But owing to the opposition of the English delegates these measures were not duly enforced, the council did not meet again, and no protective system was adopted.

³ Times and Gazette, Feb., 1884, p. 209.

⁴ Le Cholera, 1883.

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

Cholera is endemic in no other country than India, and more particularly in Bengal. When it has occurred elsewhere it has invariably been carried from India. The cholera poison has been imagined to be of an aërial nature, but its diffusion has no relation whatever to the velocity or the direction of the wind. In no instance whatever has its rate of progress exceeded that of man on land or water, nor has it ever taken a direction different from that of commercial or military movements. On land it has usually crept from place to place, and if sometimes it has seemed to leap across wide spaces, and even seas and oceans, it has never invaded any inland town or seaport without having been brought thither from a point already affected with the disease. Nor, having once entered an inland or seaboard town, does it spread equally therein in all directions, but prevails chiefly in the quarter immediately surrounding the place of its entrance. If appropriate sanitary measures are enforced, it is sometimes confined to that quarter, and, in the case of quarantine stations, it has repeatedly been prevented from extending beyond them. This statement may be illustrated by the fact that of fourteen epidemics of cholera at Staten Island, the quarantine station of New York, all but four were prevented from reaching that city.⁵ When the disease does overleap the barrier opposed to it, its origin and subsequent course can usually be traced.

⁵ Peters's Notes, etc., 2d ed., p. 94.

A high atmospheric temperature is everywhere associated with the prevalence of cholera. Its origin in the hot climate of Hindostan and its general progress prove this conclusively. In nearly all of the places where a great difference exists between the summer and the winter temperature the disease has disappeared during the cold season, and attained its greatest intensity during the hot months of the year. The only apparent exception to this rule is, that cholera has prevailed in several Russian, Swedish, and Norwegian cities during the winter. But these very exceptions confirm the rule; for in the countries mentioned the intense cold of the winter compels the inhabitants to seal their houses by every possible means, while the atmosphere within them is kept at a high temperature by huge stoves, which hinder ventilation, and indeed render it almost impossible. Difference of temperature likewise explains the fact that of two cholera-ships arriving from Havre, the one at New York and the other at New Orleans, in December, 1848, the former did not disseminate the disease, but the latter formed the starting-point of an epidemic which lasted all the winter.

A good deal has been written of the predisposing causes of cholera, and poverty, crowding, filth, intemperance, and depression of spirits have been given prominent places in the catalogue. But to any one familiar with the history of epidemic diseases it will at once be apparent that every one of these conditions favors the spread of all communicable infectious diseases. There is not the slightest evidence that these agencies, singly or combined, can generate cholera or favor its spread apart from the presence of the specific poison of the disease and the facility with which it is transmitted from the sick to the well whenever the population is crowded, poor, of filthy habits, and weakened by dissipation. Because among such people intemperance prevails, this vice has been regarded as predisposing to cholera. Apart from the brutish mode of living of drunkards, there is nothing to show that they are more liable to cholera than the most abstemious of water-drinkers. On the contrary, it is notorious that during cholera epidemics drunkards in the better classes of society enjoy a certain degree of immunity from the disease; which it is easy to explain on the ground that they imbibe but little water, which is the main channel through which the infectious principle of the disease is spread.

The specific cause of cholera is taken into the alimentary canal, and acts through it to produce the characteristic symptoms of the disease. It is conveyed from the sick to the well by means of the gastro-intestinal discharges, either moist or dry; in the former state, by means of drinking-water, and in the latter through the air, whose suspended noxious particles are received into the fauces and swallowed. There is reason to believe that the poison does not enter the system through the lungs, or through any other channel than the gastro-intestinal canal. W. B. Carpenter⁶ appears to hold, however, that the poison may be absorbed through the lungs. To this view there are two objections: 1, That whatever is taken into the mouth or throat by inspiration may very well be swallowed; and, 2, that all the primary lesions of cholera affect the digestive and not the respiratory apparatus. It is not at all necessary to the propagation of cholera that its excreta should be furnished by persons laboring under the fully-formed disease. A specific choleraic diarrhoea is as infectious as the evacuations which occur in completely developed cholera. But neither will propagate the disease through the air to a distance. The tendency to its propagation in this manner depends chiefly upon the concentration of the poison; thus, it much more frequently occurs in close than in well-ventilated rooms or than in the open air. It has been argued that cholera is not contagious, because so few, comparatively, of the attendants upon cholera patients contract the disease. On the other hand, as some of them are attacked, this positive fact outweighs an indefinite number of negative instances. It should also be noted that different diseases enter the system and infect it through different channels—some through the lungs, others through the alimentary canal, etc. Small-pox, the most contagious of all diseases, is introduced through the air-passages, and is probably harmless when its virus is taken into the stomach. That the converse of this proposition applies to cholera is sustained by the whole history of the disease. Cholera poison may be taken to considerable distances in either a moist or a dry condition. In the former state it is mainly conveyed by water, as in rivers, water-pipes, etc.; in the latter, by fomites and especially by clothing saturated or merely soiled with cholera discharges, and which may retain their infectious quality for an indefinite time.

⁶ The Nineteenth Century, Feb., 1884.

Great stress has been laid upon the humidity and foulness of the soil, a damp atmosphere, filth, crowding, etc., as elements in the production of cholera, but in reality they have no more essential relation to it than to any other disease that occurs epidemically. Cholera may prevail whether they are present or absent. It is evident that from the earliest historical periods all of these causes of disease have existed, and in Europe much more generally and excessively than during the present century, and that they have never been removed in Asia Minor, Egypt, Arabia, and Africa. Yet cholera never was known in any of these countries until it was brought into them about the end of the first third of the present century.

According to Pettenkoffer, cholera is most prevalent when the subsoil water is lowest, and least so when the subsoil water is highest. It would be more descriptive of the fact to say that, so far as cholera has anything to do with the condition of the soil, it is most apt to be severe and prevalent when very dry weather follows a very wet period. Such circumstances are the most favorable to putrefactive fermentation and the dissemination of its products, which thus reach wells of drinking-water, and even rivers, especially when sewers empty into the latter. The identity of this explanation with that which is generally accepted for the dissemination of typhoid fever is too evident to be insisted upon. We might go farther, and say that, in typhoid fever as in cholera, the disease is communicated, although exceptionally, by the air of the sick room and by the exhalations of the soiled fomites of the patient. Now, if typhoid fever resembled cholera not only in being transmitted by means of the dejections, but also in its poison being derived from one primary source only, the analogy between the causes of the two diseases would be very striking indeed. But, in point of fact, the typhoid-fever poison may probably be generated de novo by fecal fermentation and other forms of putrefaction, and the disease is only exceptionally communicable; whereas, the poison of cholera, once received, is conveyed from man to man and far and wide through various channels; but, so far as is known, it has but one primary source, and that is in India. Lebert states that he did not find the localities that are the ordinary seats of typhoid fever peculiarly liable to invasions of cholera. But it must be noted that typhoid fever is very far from being exclusively a disease of the poor, squalid, and vicious. Like death itself, "regum turres pauperumque tabernas æquo pede pulsat;" while cholera much more commonly plants itself and disseminates its seeds in the rank soil of moral and physical degradation.

All morbid causes whatever, derived from race, climate, religion, dwellings, food, clothing, habits of living, etc., have no more to do with the development of cholera than with that of the eruptive fevers, and even less than with the causation of typhus and typhoid fevers and dysentery. The eruptive fevers are caused, as cholera probably is, by specific germs which no known combination of natural causes has ever developed, while the poisons of the other diseases named appear to be generated anew whenever certain more or less definite physicial conditions coexist. It would seem that cholera differs radically from all of these affections by the fact that its cause does not enter the circulation, but confines its direct operation to the gastro-intestinal mucous membrane. In this way it becomes intelligible that while, on the one hand, physicians and nurses of cholera patients, although often, in fact, yet in relation to their numbers, are comparatively seldom infected, provided they duly observe proper sanitary rules, the disease, on the other hand, spreads like wildfire among those who drink water polluted by cholera excretions, and only a little less rapidly among people crowded into ill-ventilated apartments along with cholera patients.

The special fomites of the cholera poison are articles of clothing and furniture soiled with the discharges of the sick, and the emanations from privies, sewers, etc. into which these discharges have been cast. Many considerations render it probable that a very small quantity of cholera matter may suffice to render infectious a very large quantity of liquid, and especially of matters in process of putrefactive fermentation, and that the gaseous or vaporous emanations from them become diffused in the atmosphere and infect all who imbibe them. But water contaminated by cholera discharges is the most rapid and efficient agent in disseminating the disease. Innumerable instances of this mode of action are furnished by its history in Asia and Africa, where water is often scarce, and naturally so impure that its additional defilement by cholera dejections is apt to pass unnoticed. From the illustrations of this proposition which might be adduced only a few of the more striking will here be selected.

Hurdwâr is a town in Northern India at the base of the Himalayas, where the Ganges begins its course in the plains. It is the seat of a great Hindoo pilgrimage, which takes place annually in April, when sometimes from 2,000,000 to 3,000,000 of people occupy an encampment of about twenty-two square miles, comprising a low flat island in the Ganges and the opposite banks of the river. Bathing in the sacred stream on a certain day is the main object of the devotees; which day, in the year 1867, fell on the 12th of April. The bath was taken early in the morning. From noon on that day the pilgrims began to disperse so rapidly that on the morning of the 15th the encampment was quite deserted. It appears that up to the former date the health of the encampment was excellent, and it was the opinion of the reporter (Dr. Cunningham) that cholera was introduced into the camp by pilgrims from the neighboring districts going late to the fair. He believed that the cholera excreta may have been buried in the trenches and carried by a heavy rain into the river, and there swallowed by the pilgrims; for to drink of the water of the Ganges as well as to bathe in it is a religious obligation.

Immediately after the breaking up of the camp cases occurred in the surrounding districts, the epidemic widening in all directions. The pilgrims were almost always the first persons attacked in any locality, and the cholera attended them on their route wherever they went. In all the districts where the disease prevailed no cases occurred until ample time had been given for the pilgrims to reach them. In a word, "the cholera first showed itself among them; it followed their lines of route only, and did not outrun them; their progress was its progress, and their limits its limits." The mortality caused by this epidemic among the whole civil population of the North-western Provinces of the Punjâb has been estimated at about 117,181.⁷ The history of the religious festival of 1879 was identical with that just sketched, except that the number of the pilgrims was smaller and the deaths proportionally less.⁸

⁷ Brit. and For. Med. Chir. Rev., Jan., 1870, p. 137.

⁸ Murray, Practitioner, xxvi. 309.

Out of the numberless illustrations of the manner in which cholera is disseminated by water the following may be cited: In 1865 about 100,000 pilgrims were assembled at Mecca, of whom from 10,000 to 15,000 fell victims to the disease, two-thirds of them within a period of six days. Some cause acting simultaneously upon the whole number of persons must be admitted to account for so extraordinary a fact, and such a cause is not far to seek. At a certain sacred well "one hundred thousand people had skinfuls of water poured over them at the side of the well, and every one of them then drank largely of water drawn from the well. Much of the water poured over the pilgrims must have found its way by soakage back into the well, and if any of the pilgrims were at the time suffering from cholera, or had cholera-tainted garments about them, the well would be exposed to pollution."⁹

⁹ Christie, Cholera Epidemics in East Africa, p. 488.

In the cholera epidemics of Zanzibar the disease produced the greatest havoc among the negroes, the Persians, and the East Indians; very few Europeans were attacked, and quite as few of the sect of the Banyans, who drank only water drawn from their own wells. The persons among whom the disease prevailed so fatally used chiefly the water of a certain well which was highly prized, but which on this occasion had become polluted by soakage from an adjacent cesspool into which the dejections of cholera patients had been thrown. It appears, also, that in Zanzibar the streams are very rarely bridged, and hundreds of negroes, in passing backward and forward, wade through them and pollute them. In these streams, also, the negroes wash their clothes and all the foul clothing of the contiguous town. While this business is going on "a gang of negroes may be at work at not many hundred yards' distance filling water-casks for the shipping." Subsequently to the watering of the ships in this manner sailors were attacked with cholera, and others who used water drawn from the stream below the place where it became polluted were attacked, and many of them died; while Europeans living on shore, and who drank the water of the same stream, but drawn from a much higher point in its course and after having been filtered, escaped the disease.¹⁰

¹⁰ Ibid., pp. 320, 492.

The history of the disease in Europe furnishes a multiplicity of similar cases, and even more distinctly exhibits the dissemination of cholera by contaminated water.¹¹ In Holland not less than five epidemics of the disease occurred between 1832 and 1869, all of them causing a great mortality, to which the epidemic of 1866 alone contributed not less than 20,000 deaths. This was about 55 deaths for every 10,000 inhabitants. Such exceptional mortality over so wide a territory has been ascribed to the extreme porosity and humidity of the soil, which is nearly all below the level of the sea. Such a soil must necessarily retain longer than other soils whatever it absorbs, and thus tend to render the well-water habitually impure. If, then, to the ordinary impurities a specific poison is added, its characteristic effects may assuredly be looked for. The conditions now stated explain the conclusions of Ballot of Rotterdam, drawn from a study of the several epidemics referred to. They are as follows: "1. Holland is highly affected by the cholera at every epidemic, chiefly in those parts where they drink water directly from the rivers and canals or from ground saturated with sewage. 2. In places where rain-water is generally drunk the disease is far less violent. 3. Places where there is no other drinkable water but rain-water are not affected by the epidemic; the single cases occurring there are imported. 4. When places affected by the cholera were supplied with pure water instead of the vitiated water the disease disappeared."¹² In like manner, we find that the cholera epidemic of 1873 in Germany seemed specially to select those situations where the subsoil was impregnated with decomposing organic matter; and it is evident that, in cities especially, such situations would include the most poverty-stricken districts, while the higher, drier, and at all times more salubrious localities are inhabited by the classes enjoying the greatest material prosperity.¹³

¹¹ It is of interest to note that on the first appearance of cholera in England, at Sunderland, in 1831, a surgeon of that place, Mr. Ainsworth, collected and published conclusive proofs of the importation of the disease, of its communication from the sick to the well, "and of its propagation by clothes, and even by emanations, from the dead" (Observations on the Pestilential Cholera, London, 1832).

¹² Med. Times and Gaz., May, 1869, p. 459; June, 1869, p. 626.

¹³ "Report of the German Imperial Commission," Practitioner, xxvi. 153.

This mode of infection has been traced in numberless individual cases of cholera. In London there was a certain well into which the liquid contents of a sewer had been percolating for months. Of the water of this well hundreds of persons had been drinking without obvious injury. At last a case of cholera occurred hard by; the discharges were thrown into a privy which communicated with the sewer and indirectly with the well, whereupon more than 500 persons who drank water drawn from that particular well were attacked with cholera within three days. So in 1856 cholera prevailed in the county jail of Oxford, Eng., the drain from which emptied into a pool from which the water was drawn to supply the city prison. In the latter institution cholera began to prevail, but declined as soon as the pipes conveying the water were cut off, and soon afterward ceased entirely.¹⁴ Again, in Constantinople in 1865 the clothes, mattrasses, etc. of cholera patients were washed at a fountain the basin of which was divided into two parts by a wall; one part was used for washing clothes and the other for drinking purposes. Unfortunately, the waste-pipe of the former being obstructed, the foul water of one side communicated with the clean water of the other, and in one day 60 people died of cholera in the small portion of the city which was supplied from the infected source. The striking case has often been cited which occurred at Epping, Eng., where a woman brought the disease from a distance into a perfectly healthy house and neighborhood, and of ten persons affected with it seven died, including a physician in attendance upon one of them. An examination of the premises "discovered, below the pipes leading from the water-closet and from the eye-hole of the sink through which the choleraic dejections had been passed, a leakage which extended under the foundations of the building and entered the well. The sewage was distinctly traceable on the side of the well corresponding with the leakage in the drain." After this discovery and the disuse of the foul water not another case occurred.¹⁵ In 1868, Dr. Farr, in his History of the London Cholera Epidemic of 1866, showed that water into which cholera dejections find their way produces cases of cholera all over the district in which it is distributed for a certain period of time, and that if the distribution is in any way cut short the deaths from cholera begin to decline within about three days of the date at which the distribution is stopped.¹⁶

¹⁴ Edinb. Med. Jour., i. 1122.

¹⁵ Trans. of the Epidemiological Soc., ii. 428.

¹⁶ Lancet, April, 1868, p. 217.

Analogous instances are furnished by every cholera epidemic of which the history has been accurately observed, including that which extended so widely over the United States in 1873. Most of the following are cited from the official reports prepared, under the direction of the Surgeon-General of the army, by Surgeon Ely McClellan and Dr. John C. Peters. Several of the first cases, however, are foreign.

In 1861, at a station in India, some fresh cholera dejecta found their way into a vessel of drinking-water. Early on the following morning a small quantity of this water was swallowed by nineteen persons, five of whom were attacked with cholera between the first and the third day afterward.¹⁷ In 1876 an outbreak of cholera took place in a village in Hindostan, which followed the arrival of wedding-guests, one of whom was attacked, and from whom it rapidly spread. The soiled clothes of one or more of the patients were washed in a pool from which all the villagers obtained their drinking-water, and on the discontinuance of this source of water-supply cholera speedily diminished in frequency and fatality.¹⁸ In the German epidemic of 1873 many cases occurred where persons deriving their drinking-water from special sources were attacked with cholera, while their neighbors, supplied from a different source, remained free. Again, it has frequently happened that outbreaks of cholera have been checked by the prohibition of the suspected water and the substitution of a pure supply.¹⁹ It seems probable that a very small portion of cholera discharges suffices to infect a very large body of water and maintain its infectiousness for a considerable time.

¹⁷ Macnamara, op. cit., p. 196.

¹⁸ Surg.-Major Cornish, Practitioner, xxiv. 215.

¹⁹ Practitioner, xxvi. 159.

In December, 1871, an outburst of cholera occurred which was confined to the inmates of three excellent houses in a fine block of buildings in Calcutta. There had been no cholera in that neighborhood for four years. Within forty-eight hours a majority of the lodgers were sick, and on investigation it was found that the disease was carried in the drinking-water and in the milk diluted with it.²⁰ The particular locality in which Dr. Koch made the discovery of the microscopic representative of cholera furnishes an example of the same nature: "At Saheb Ragau, a locality which has repeatedly been visited by cholera during the last hundred years, numerous cases of the disease were reported, and these, on inquiry, were found exclusively in the huts situated round a certain tank. Of the few hundred people who dwelt in these huts, as many as seventeen died of cholera, though the disease was not at that time prevalent in the neighborhood, or indeed in the whole police district of Calcutta. It was proved that, as usual in such cases, the dwellers around the tank used it for bathing, and drew thence their drinking-water; it was also elicited that the linen of the first fatal case, befouled with cholera dejections, had been washed in the tank."²¹ In June, 1873, a new hotel was opened at Vienna, and many of the guests became affected with diarrhoea that was attributed to the drinking-water, which was offensive to the taste and smell. After a fortnight a gentleman died of cholera in the hotel, and two days later several of the guests were attacked with the disease, of whom fourteen died. The gentleman who first died was believed to have brought the poison with him into the hotel, so that the drinking-water, which previously had been polluted with ordinary fecal discharges, became specifically affected through him.²² The discharges of one ill of cholera were thrown into, and the vessels used by him were washed near, a well from which all the residents of a farm-house drank. The wooden curbing of the well had rotted, and the ground immediately around had sunken; a heavy rain burst the curb, overflowed the well, and washed into it the entire surface-drainage of the surrounding ground. No attention was paid to this, and the water was used as before. It became so offensive that its use was forbidden, but too late to save the family, nine of whom died of cholera.²³

²⁰ U.S. Report, p. 85.

²¹ Times and Gaz., April, 1884, p. 527.

²² Times and Gaz., p. 86.

²³ Ibid., p. 140.

At Farmington, Tenn., a man arrived who had contracted the cholera at Nashville; his illness ran its course at a point just forty paces from a well. Families that obtained their water from this well suffered in nearly all their members; where only certain members drank of it, they alone were affected.²⁴ At Huntsville, Ala., during an epidemic of cholera, the city authorities forbade the use of well-water, and supplied pure water from another source, but only for one week. During this time no new cases of the disease occurred, and the negroes, thinking themselves secure, resumed the use of the well-water, and within four days six fatal cases of cholera occurred in the vicinity. The use of the well-water was again prohibited, and again the progress of the disease was arrested.²⁵

²⁴ Ibid., p. 172.

²⁵ Ibid., p. 408. For other examples of the spread of cholera by means of drinking-water see Macnamara, p. 149 and seq.

It has already been intimated that the cholera poison may be diffused through the air from either moist or dry sources, and especially from contaminated clothing, and then be taken into the throat and swallowed. Dr. Richardson refers to a local epidemic in England in which "the persons most constantly and fatally attacked were the women who washed the clothes of the sick;" and this circumstance has been largely confirmed by other observers.²⁶ In a village not far from Marseilles, and in an isolated place, a peasant and his wife who had not left the country sickened and died of the disease. The woman, who was a laundress, had received a bundle of linen belonging to a person recently arrived from Egypt, and the husband opened the bundle and unfolded the pieces. During the Crimean War many of the washermen attending to the washing of the French hospitals were attacked by cholera. In the post-office at Marseilles none of the clerks who handled the outgoing mails were attacked, but of those who sorted the mails coming from the East, where the disease prevailed, one after another suffered from cholera.²⁷

²⁶ Trans. Epidem. Soc., ii. 429.

²⁷ Read, Boston, 1866.

The cholera was introduced into Guadaloupe by clothing contained in a trunk belonging to a person who died on the voyage thither from Marseilles, where the cholera then prevailed. The woman who washed the clothing died, with all her family. Attracted by the circumstances of the case, many came to her house, and of these several died. From this point the disease spread over the island.²⁸ A sailor died at some port in Europe of Asiatic cholera in 1832. A chest containing his personal effects, clothing, etc. was sent home to his family, who lived in a small straggling village on the Atlantic coast of the State of Maine. It reached them about Christmas, and was opened on its arrival. The inmates of the house were all immediately and suddenly seized with a disease resembling Asiatic cholera in all its malignity, and died. There had been no cholera in the State. The last case of cholera that occurred in the garrison at Malta in the epidemic of 1865 was that of a woman who had stolen a chemise the property of one who had died of the disease. She put on this fatal garment, probably soiled with cholera discharges, and certainly unwashed, many days after the death of its former possessor; she took the disease and died.²⁹

²⁸ Med. Times and Gaz., April, 1874, p. 387.

²⁹ Lancet, Feb. 17, 1866.

It is sometimes said, and oftentimes repeated, that cholera is not directly contagious—is not communicated by the sick to the well. No statement could be more unfounded. The whole history of cholera proves that the physicians and nurses of cholera patients are often affected by the disease. "In Constantinople no less than twenty-seven physicians and medical assistants were attacked and died during their attendance on cholera patients; and in Paris and Toulon similar results followed. At Halifax, N.S., two of the physicians who volunteered in aid of the steamer England, which put in there disabled by the ravages of cholera among the officers and crew, as well as among the steerage passengers, took the disease, and one died" (Read). In 1832 the cases of cholera in Edinburgh were in the proportion of 1 to every 1200 of the population of the city, while among those in attendance upon the sick the proportion was 1 to 5. In 1848-49 one-fourth of the nurses employed in the cholera hospital took the disease, while in the general hospital, only a few paces distant, where no cholera patients were received, not a single attendant was attacked. In the London Hospital, in 1866, none of the medical officers, volunteer nurses, or sisters were attacked. Of the (regular) nurses five contracted the disease, and of these four died.³⁰ In 1849 a severe and fatal epidemic broke out in the Philadelphia Almshouse. The resident physicians of the hospital were abundantly occupied with the care of the sick of other diseases, and it was thought prudent not to allow any, even an indirect, communication between them and the cholera patients. The latter were therefore removed to an isolated building in the middle of the quadrangle, and attended by physicians from the city who had volunteered their aid. Three or four of these physicians had attacks of cholera, and two of them died.³¹ At this time there was no cholera at all in the city, and the young physicians could not have become infected outside of the almshouse. They were attacked while attending the sick of cholera, but the regular house-physicians, who seldom visited the cholera patients, escaped altogether.

³⁰ London Hosp. Rep., iii. 439.

³¹ Philada. Med. Examiner, Nov., 1849.

The importance of recognizing the communicability of cholera is so great that no apology need be made for introducing the following additional illustrations of it furnished by Griesinger in his article on the dangers of cholera to medical men. They are the more important because in many other instances cholera physicians have suffered little for their devotion to duty: "At Moscow, in 1840, hospital attendants contracted the disease to the extent of 30 or 40 per cent., while in the general population only 3 per cent. were attacked; at Berlin, in 1831, in Romberg's hospital, 54 out of 115 persons were attacked: in 1837 one-fifth of the attendants took the disease, and on one occasion no less than seven of them fell ill on a single day. In La Charité Hospital in Paris, in 1849, one-sixth of the attendants had the disease, while only one-twenty-fifth of the general population of the city suffered from it; at Mittau, in 1848, one-half of the physicians took the disease; in 1842, at Toulon, ten health officers out of thirty-five were ill with cholera, and five of them died, while of thirty workmen who were employed to carry the dead bodies one-third succumbed; at Stockholm, in 1853, of 536 attendants one-eighth took the disease, and half of that number died; at Vienna, in 1854, out of thirty-six nurses, seven caught the disease, and seven men employed in removing the dead became affected with a prolonged and exhausting diarrhoea; in 1849, at Strasburg, five nurses out of ten were attacked, etc." ... "Physicians, nurses, students, etc. are less frequently affected, however, than patients ill with other diseases who are lying in the wards where cholera patients are treated, and are therefore more constantly exposed to the emanations from the discharges; and physicians usually suffer less than the attendants who are constantly waiting on the cholera patients."³²