Volume 1 — GENERAL DISEASES. (continued 18)

³² Traité des Maladies infectieuses, 1868, p. 409.

It may be added that Surgeon-General John Murray, who served continuously for thirty-eight years in British India, caused upward of five hundred circulars to be addressed to the local governments and filled up by the local medical officers. From these returns it appeared that the belief in the communicability of cholera, in one way or another, was practically unanimous; for of the whole number, those who believed that it is conveyed from person to person were 75 per cent.; from place to place, 85 per cent.; through the atmosphere, 80 per cent.; with the drinking-water, 85 per cent.; by the evacuations, 92 per cent.; and by clothing, 98 per cent.³³ This gentleman has more recently furnished additional facts supporting the same conclusion. For example: Out of fourteen cases that occurred at Ramleh during the Egyptian epidemic, eleven occurred in patients already in the hospital for other diseases. In 1856, after visiting the dead-house where the bodies of fourteen cholera patients lay, as he entered the cholera ward he felt a sudden shock in the epigastrium, followed by a deadening sensation that rapidly spread over the whole body. On another occasion he saw a clergyman who was talking to a cholera patient suddenly seized with vomiting of a watery liquid. Several analogous instances are related by him.³⁴

³³ Practitioner, xix. 470.

³⁴ Med. Times and Gaz., March, 1884, p. 281.

It has been objected to the communicability of cholera that its dissemination does not always follow the deposit of cholera discharges in privies, wells, etc., and also that when infection does take place, it may occur between remote extremes as to time, and therefore cannot be attributed to infectious germs. Such objections are frivolous, because we know nothing of the nature or vitality of cholera-germs, and they are, moreover, drawn from exceptional cases. The power of infected fomites to develop the disease has been preserved, in a journey from Arabia into Africa, for at least twelve days, and for even a longer period in passing from Germany to Chicago, as already related. It is true of every infectious and contagious disease that it may possess one or both of these qualities in various degrees—that at one time it is only exceptionally communicated, and that at another time it appears to propagate itself virulently. So the phenomena of cholera may consist of little more than a watery diarrhoea, which may be so mild as hardly to disable the patient from working, while at other times the attack may include all those terrible and fatal symptoms which have won for the disease the name of malignant. That a certain quantity, or "dose," of the cholera poison is required to develop the disease, but one that varies considerably in different cases, may be inferred from these facts: 1. Out of a certain number of persons equally exposed to receive the disease, only a portion may be attacked at all, and these in very unequal degrees. 2. Persons so slightly affected as to be ignorant of the nature of their sickness, and believing it to be an ordinary diarrhoea, may nevertheless become the innocent, because ignorant, disseminators of cholera. The explanation of such facts may be manifold: they may depend upon the dose or upon the energy of the morbid poison, on various possible conditions of its recipient, and so on; but, however explained, their reality is none the less certain. The receptivity of persons exposed to the contagion of cholera is very different. It is well known that some persons appear to be proof against other contagious diseases, while others seem never to acquire an immunity from them. On this very important point the conclusions of Fauvel directly bear.³⁵ They include the following propositions: The East Indian ports where cholera exists as an endemic disease are never the seat of an extensive epidemic among the native population. But strangers to these localities are liable to the disease, and such are the Mussulman pilgrims who come to Bombay to take ship for Mecca. A severe epidemic of cholera confers upon the locality in which it has taken place an immunity which in India appears to be of several years' duration. Such an epidemic in any country is a proof that the cholera is not endemic there.

³⁵ Mémoire lu à l'Académie des Sciences, 1883.

If a contagious disease preserved its virulence undiminished, it might continue to prevail indefinitely. But we know that all other contagious epidemics do come to an end sooner or later, and hence we must conclude that their specific cause progressively loses its virulent qualities. There is every reason, therefore, to believe that the same is true of cholera. Its communicability, and therefore its diffusion, may vary with climatic, seasonal, local, personal, and other conditions; but of what nature those conditions are, and especially of the last and most important, the personal, hardly anything is known. Nor need we too curiously investigate them, so long as the fact remains that outside of, and independent of them all, there is but one essential cause of cholera—a morbid poison as specific in its nature as that of any of the eruptive fevers—a poison which no determinable conjunction of circumstances has ever engendered, and which was unknown in Europe and America before it was carried to them from India. In just such a way did small-pox first arise in the Western World. It had never appeared in Europe until the latter part of the sixth century, when for a short time it prevailed in Marseilles and the neighboring country. Afterward it was not heard of until it was reintroduced by the Crusaders on their return from Palestine in the twelfth century, since which period it has hardly ever ceased. The history of the diffusion of cholera is closely analogous to this in several particulars, and we may reasonably expect that what was in the last generation a new disease will henceforth be liable to prevail again and again as the intercourse increases between the nations of the West and the immemorial source of cholera in Hindostan.³⁶

³⁶ Additional illustrations of the communicability of cholera are contained in the Brit. and For. Med. Chir. Rev., July, 1872, p. 56.

In the preceding discussion of the origin and dissemination of cholera the broad facts of its specific nature and its contagion by means of excreta have been chiefly insisted upon. Little has been said either of the nature of the contagium or of the conditions that modify its activity. These points will be considered hereafter. But it is proper in this place to state that, in the opinion of most investigators, the contagious element has the power of multiplying itself, not only within the body, but wherever it is in contact with decomposing organic matter, provided that the degree of heat and amount of moisture present are adapted to promote such a change, which is certainly analogous to fermentation, if not identical with it. And the facts already mentioned may be recalled, which show that the contagium cannot be a light and subtle substance, since, as has been stated, the immediate attendants upon cholera patients are not as apt as might be expected, on that hypothesis, to contract the disease, while washerwomen inhaling, and probably swallowing, the moist fumes from cholera fomites much more frequently do so; that fomites saturated with the dried discharges are very infectious; and that water is the principal vehicle by which cholera-germs are carried into the stomach.

SYMPTOMATOLOGY.—Like other diseases, cholera occurs under very dissimilar aspects and with various degrees of gravity. Like those especially which are caused by specific morbid poisons, it may be so insignificant as to escape recognition, or, on the other hand, it may give rise to violent and distressing symptoms which come on without warning and hurry the patient to inevitable death. Whenever epidemic diseases present such opposite extremes of severity in their symptoms, it may reasonably be inferred that the differences depend mainly upon the quantity of the poison that has been received into the system, precisely as the dose which has been taken of a narcotic or acrid poison may be estimated by the gravity of its effects. Individual peculiarities, constitutional or acquired, may modify the characteristic phenomena, and sometimes a careful inquiry may be necessary even to detect their existence; but a study of cholera in all its grades shows that its symptoms are all the effects of one and the same cause, and that the cholera poison acts primarily upon the gastro-intestinal mucous membrane. It follows, as a matter of course, that, being thus applied, it will occasion symptoms differing in degree and in kind according to the energy of its action, and that this, again, will depend partly upon the inherent virulence of the agent and partly upon its quantity. In fact, this feature in the clinical history of the disease can be explained only by the operation of a special irritant acting with different degrees of power upon the gastro-intestinal mucous membrane. In other words, the different forms under which it is convenient clinically to recognize and describe cholera are nothing more than different degrees of the operation of one and the same poison, modified more or less by the peculiarities of individual patients. In the most typical of the fully-formed cases of cholera there is a stage of diarrhoea, a stage of cholera morbus—i.e. of vomiting and purging—with more or less evidence of stagnation of the blood, which is followed either by reaction and recovery or collapse and death. The phenomena of those several stages will now be described, after which certain symptoms will be more particularly considered.

It has more than once been pointed out that, however mild an attack of cholera may be, the dejections accompanying it are infectious, and may produce in other persons the gravest types of the disease. Hence the importance, not only to the patients, but also to others, of recognizing it in the earliest stage; for while this knowledge may suggest measures for preventing an extension of the disease, it leads to the prompt use of remedies at the only period in which their success can at all be counted upon. The characteristic of this stage, which has generally been called either choleraic diarrhoea or cholerine, is a diarrhoea remarkable for its profuseness and the frequency and serous quality of the stools, which are, however, of a more or less yellow color. They are preceded by rumbling and gurgling noises in the abdomen, are voided without colic or tenesmus, and are followed by a remarkable sense of exhaustion or faintness, which is sometimes also accompanied with nausea, and, if they are very frequent and copious, cramps are apt to be felt in the calves of the legs. In this variety or stage of the attack, as a rule, there is not any vomiting; there is complete anorexia, but urgent thirst, a white and clammy tongue, and a peculiar alteration of tone, a huskiness, faintness, or hoarseness of the voice. The stools vary from six to twelve a day, and, as above stated, are slightly yellow; they are also alkaline, and on standing deposit a granular sediment which consists largely of the débris of intestinal epithelium. Unless the attack is very severe the temperature is not lowered by much more than 1° F. The symptoms now described, especially in their milder grades, may last for a week or even longer, and then, according to circumstances, end either in cure or in fully-developed cholera; but under appropriate treatment they usually subside in a day or two, and more or less rapidly according to the degree of damage done to the digestive mucous membrane.

Between the above, which is the mildest type of epidemic cholera, and the fully-developed disease must be placed that grade of the disease which is more appropriately called cholerine, comprising cases in which vomiting occurs as well as purging, with increased debility and a tendency, more or less decided, to collapse. The matters vomited, after the rejection of undigested food, are at first bilious, but they gradually become less and less so the longer the attack lasts, and, together with the stools, assume the appearance of rice-water—i.e. they consist of a pale grayish, semi-transparent liquid in which white flocculi are suspended. Its reaction is alkaline, and it has a faint albuminous or spermatic smell. Along with these symptoms the other effects of serous depletion arise—debility with pallor, duskiness, coldness, profuse perspiration, and a sodden condition of the skin, while the secretion of urine is diminished, and all the symptoms that belong to the first stage of cholera are present in an aggravated degree.

A curious feature of this disease is that sometimes the onset even of its graver forms is not attended by any evacuations, although the stomach and intestine may be filled with liquid. It is perhaps chiefly in such cases that the patient experiences a rapid depression of all the mental and physical faculties. The senses are irritable, the head aches and is confused, there is a disinclination to sleep, the limbs totter under the weight of the body, the pulse is frequent and feeble, occasionally fainting takes place; the skin is cool and bedewed with perspiration. In other cases, again, the attack is sudden; the patient is smitten with an unaccountable feebleness, speedily followed by profuse vomiting and purging and general spasms, and dies without any suspension of the symptoms or any tendency to reaction.

But more usually the attack begins with the diarrhoea and vomiting described above, which then assume, more or less rapidly, a high degree of violence, expressed by their frequency and excess. The stools with proportionate rapidity lose all their fecal qualities and acquire the rice-water appearance before mentioned, and the liquid rejected by vomiting in all respects resembles them. It is poured forth less by an ordinary act of vomiting than by gushes, as if it overflowed from the throat and mouth; and it often escapes from the stomach and the bowels at the same instant. Such profuse evacuations necessarily occasion an urgent thirst which cannot be satisfied, for liquids are thrown up immediately on being swallowed. Sometimes a distressing hiccough accompanies these symptoms. It is indeed only one of the many spasms which may affect the muscular system. They generally begin in the fingers and toes, which become bent and stiff; they seize upon the muscles of the calves of the legs, and render the muscular wall of the abdomen as hard as a board. The pain they produce is extremely severe, and unless the patient is exceedingly prostrated he endeavors to assuage it by a constant change of position.

At this period the debility is very great, and progressively increases, and the patient is unable to rise, or even to move at all except under the stimulus of the painful spasms. The features are shrunken; the nose is sharp and pallid, and bent to one side; the dusky, lack-lustre, and sunken eyes, the thin lips, the hollow cheeks, and the contracted muscles that stand out like cords under the tense and clammy skin, present a physiognomy that belongs to no other disease in the same degree. The hands and feet grow cold, and steadily the coldness creeps upward toward the trunk; the temperature falls to 94° or 95° F.; the feeble and even flickering pulse ranges from 100 to 120. The integuments of the limbs are shrivelled and damp, and look as if they had been macerated in water; and if a fold of the skin is pinched up it subsides very slowly indeed. The eyes grow dull and dry, the tongue has a pasty or sticky feel, and the urine is almost suppressed. If any of this excretion can be obtained for examination, it is found to contain both albumen and sugar. As the attack advances the patient falls into a dull, listless, and motionless state, which may be mistaken for insensibility or even unconsciousness but is really due to exhaustion of all the faculties of mind and body. He may express no interest in anything, and hardly notice the attention or the distress of his friends, yet he will generally give clear, although languid, answers to questions, and fall again into an inert and unobservant state.

As these symptoms continue and the fluids of the body decrease, the blood accumulates and stagnates in the veins, giving to the hands and feet, the nose and lips and other features, to the neck, and even to the entire surface of the body, a bluish, leaden, or violet tint, precisely like that of cyanotic children. The pulse, that was already weak and thready, is no longer perceptible; the carotids even and the impulse of the heart cease to be felt, and the second sound of the latter becomes inaudible. The skin is everywhere cold; the hands, feet, and face are sometimes of an icy coldness, and yet the patients seldom perceive that they are so; indeed, complaint is more apt to be made of suffering from internal heat. Even the breath as it issues from the nostrils feels cold. The blood no longer circulates, and the heart seems still. If a vein is opened a few drops of black and viscid blood will trickle from the wound, which if it coagulates, yields but little serum, and in place of a firm clot only a diffluent jelly. The voice has sunk to a mere whisper or is quite extinct. The features assume a distorted and frightful expression; the temples and cheeks are hollowed; the nose is twisted and pointed, and the nostrils are obstructed with dry and powdery crusts; the eyes are also dry, dull, and sunken behind the half-closed and purple lids; the conjunctiva is no longer moistened by its secretion and becomes bloodshot; the temperature in the mouth may fall to 79° or 80° F.; a viscid exhalation bedews the icy and marbled skin; and the whole body is so shrunken from its natural proportions as to lose all the marks by which its identity has been recognized. From this pulseless, exhausted, cold, and cyanotic condition there can be but one step to death. It generally comes on gradually, the patient sinking into the state of apparent insensibility before mentioned; on the other hand, he may expire suddenly on attempting to make some unusual effort.

At any period in the progress of cholera, except that of complete asphyxia, the contest between the system and the disease may be decided in favor of the former. If this occurs before profuse evacuations have taken place or blueness of the skin appeared, the recovery may be gradual and present no special phenomena. The pulse regains by degrees its natural force; the skin grows warm again, first upon the trunk and afterward upon the extremities; the breathing becomes easy, and, the diarrhoea having already ceased, convalescence is established. But in proportion to the severity of the symptoms, the intensity and duration of the cold stage, the cramps, and the evacuations, will there be a tendency to febrile reaction, with more or less passive congestion of the internal organs, and therefore a slower return to health. If the attack has been very severe, and particularly if the algid stage has been prolonged, fever of a low type is apt to occur, and indeed may terminate fatally. This fever presents all the characters of the typhoid state, and is marked by dryness of the tongue, a brown crust upon the teeth and gums, jerking of the tendons, delirium, and coma. These symptoms are partly evidences of exhaustion, of inability of the system to resume its normal action, and perhaps also they denote the retention of the effete products of nutrition in the blood; but sometimes they appear to be associated with, and caused by, a local and latent inflammation of low grade, established usually in the lungs. Again, the nervous system seems to bear the brunt of the reactionary effort, and the patient is attacked by convulsions or perishes in an apoplectic fit. These phenomena appear to be due in most instances, if not in all, to renal obstruction, and, as it is supposed that their immediate cause is the retention of urea in the blood, they have received the title of uræmic. In other cases a wasting diarrhoea, due probably to the damaged state of the intestinal mucous membrane, is superadded to the already existing typhoid state. Occasionally the parotid glands become enlarged and painful, and sometimes a measly or roseolous eruption appears upon the skin.

It frequently happens that the convalescence from cholera is slow and irregular. The system seems to be shattered by the trial it has passed through; the nervous susceptibility is for a long time morbidly increased, or, what is still more usual, the digestive function is greatly impaired. The appetite is capricious and the digestion feeble. The mouth is pasty, the abdomen tympanitic, the bowels are irregular and alternately confined and relaxed. Finally, patients who leave the bed too soon or indulge prematurely in their ordinary diet are liable to a relapse, perhaps fatally, into the original disease. It has sometimes happened that such a relapse has taken place several days after an apparent restoration to perfect health.

COMPLICATIONS AND SEQUELÆ.—In a small proportion of cases, as above stated, cutaneous eruptions have been observed during the attack of cholera, or rather during its decline, for they coincide with the reaction or follow it, and may be regarded as indications of increasing vitality. They belong to the exanthematous class, and comprise roseola, erythema, urticaria, and rarely vesicular eruptions.³⁷ But, instead of them, there may occur destructive tissue-lesions in the form of abscesses or ulcers. These affections are more usual on the limbs than on the trunk or face, but some of them may appear even in the mouth or fauces. Profuse sweats have been noticed elsewhere, and the important fact that they carry off large quantities of urea, which they deposit upon the skin. Diphtherial exudation has also been met with upon tender parts of the skin and in the fauces, as well as in the stomach and intestine. In some epidemics of cholera suppuration of the parotid gland is occasionally observed, while in others it may be entirely absent. Instances have been reported of double parotitis, and in several of them the termination of the attack was fatal. Still more rarely suppuration of the submaxillary or the cervical glands has been met with. Another sequela of cholera is a tetanic contraction of the flexor muscles of the limbs. Between the tenth and fifteenth days of convalescence the patient is attacked with a tearing, rending pain in the hands and forearms, the legs and feet, followed by tonic contraction of the flexor muscles of these parts. The sensibility is not impaired. The attack lasts for one or several days, and seems always to end in recovery (Guterbock).

³⁷ Compare London Hosp. Reports, iii. 457.

Some of the individual symptoms of cholera call for a more detailed notice than they have received in the foregoing epitome, in which the continuity of the narrative could not be interrupted by a description of variations depending upon the stage and grade of the disease.

The first to be considered is the temperature. The animal temperature in cholera varies according to the part of the body at which it is taken more than in any other disease. In cases of average severity it rarely falls below 95° F. in the axilla. The temperature under the tongue does not furnish trustworthy indications. In the stage of asphyxia it seldom exceeds 87.8° F., and even in cases that recover it may fall to about 78.8° F. (Wunderlich). In the cold stage it is not uncommon for a difference of temperature to be noted of nearly ten degrees between the axilla and the rectum. In a female aged thirty-two the temperature in the axilla was 93° F., and that in the vagina 102.8° F. (Mackenzie). In other cases a vaginal temperature of 104° F., and even of 108.32° F., has been reached (Guterbock). Such high temperatures furnish an unfavorable prognosis. As Wunderlich has pointed out, during the algid stage temperatures taken in the mouth do not give an accurate idea of the general temperature; the rectal and vaginal temperatures are more nearly correct. The following are some results of thermometry in 74 cases of cholera: Lorain found the minimum rectal temperature in 1 case 93.2° F., in 2 cases 95°, and in 10 cases 96.8°. In 47 cases the normal temperature was preserved; in 27 it rose to 100.4°; in 15 cases to 102.2°; and in 1 to 104° F. Leubuscher gives the average temperature in the armpit 92.7° F.; under the tongue, 90.5°; upon the tongue, 81.5°, in the nostrils, 79.2°; and on the palm of the hand, 84° F. These numbers, however, only represent averages. It should be noted that the low temperature of the mouth and nostrils is caused not only by the evaporation from the surface of those cavities, but also by the relative coldness of the expired air, due to the partial suspension of the passage of blood through the lungs, and therefore to the heating of the air contained in them. According to Leubuscher also, the lowest temperature is found in the nostrils, and next under the tongue, and at the latter point it may vary from 79° F. to 90.5° F. In death by asphyxia the vaginal and rectal temperatures may rise to 104°-108° F. The axillary fluctuates less than the internal temperature. It is remarkable that during the algid stage the patients, at least before the temperature has reached its minimum, are not conscious of their coldness, but, on the contrary, complain of internal heat, precisely as happens in the congestive forms of periodical fever. When the febrile reaction assumes a typhoid type the temperature in many cases is normal or only slightly elevated, and it is of serious import if the temperature then sinks again below the normal grade (Wunderlich). On the whole, the maintenance of a uniform temperature, neither much above or below 90° F. in the axilla or under the tongue, may be regarded as favorable, yet recoveries have taken place even when the temperature at these points has fallen to 79° F. If the temperature of the parts just mentioned should rise rapidly to 104° F., it may be regarded as a very unfavorable sign.

The skin, as has elsewhere been described, is pallid, bluish, shrunken, and cold, and quite destitute of its natural firmness and elasticity, so that when it is pinched into folds they subside very slowly, as if they had been made on the skin of a corpse. It is curious that, although the drain of liquids through the bowels is so great, the skin not only remains moist, but generally is bathed in a profuse cold sweat. Although the secretion of urine is reduced or quite suspended, that of milk is said to be not always so. Large quantities of urea have been found in the urine, and in some cases it has been visible upon the skin in the form of white scales. During convalescence the skin may be the seat of the various eruptions already enumerated. Of a graver nature, but, fortunately, of rarer occurrence, are erysipelas, boils, abscesses, ulcers, and gangrene. These several affections seem to result from the alternate obstruction and freedom of the cutaneous circulation. They commonly appear first upon the limbs, and afterward upon the face or trunk; they may affect even the cavity of the mouth. Some observers have noted a relatively frequent occurrence of diphtherial exudations in this disease, while others do not allude to their existence. The former describe the false membrane as affecting not only the mouth and fauces, but also the stomach, the intestine, and the female organs of generation. A case is reported by Joseph of a young man who, after an attack of cholera, was affected with a blenorrhoea, due to a diphtherial inflammation of the urethra.

The character of the heart- and pulse-beats in this disease is quite peculiar. Their rate does not increase indefinitely, as it does after hemorrhage; the pulse usually varies from 90 to 110, and indeed seldom exceeds 120, but its volume, tension, and force progressively decline until the beats become imperceptible at the wrist, and even in the brachial and femoral arteries. At the same time, the rhythm of the heart is interrupted, the energy of its impulse declines until it can no longer be felt, and its sounds grow weaker and weaker until they become quite inaudible. Sometimes, it is said, a pericardial friction sound may be heard, which is attributed to the dryness of the pericardium. That the decline and suspension of the heart's sounds and impulse are due not only to the weakness of the cardiac muscle, but also to the lessened volume of the circulating blood, is proved by the fact that they persist, sometimes for many hours, after reaction has commenced, and only become audible again when the arteries have been replenished with blood.

In the description of the symptoms of cholera it has been mentioned that the cyanotic color of the skin is produced by an accumulation of blood in the veins. Many years ago Magendie, and after him Dieffenbach, on examining the arteries of persons in the advanced stage of cholera, found those vessels empty of blood. It might be supposed that, under the circumstances, not only the right side of the heart, but also the lungs, would be gorged with blood, and that extreme dyspnoea would result. But, in point of fact, the respiration in cholera is hurried and shallow rather than oppressed and labored, while after death the lungs are not engorged with blood, but rather in a bloodless condition. The pulmonary artery and its branches are also empty, although the right side of the heart may be filled with dark and soft coagula. These singular conditions seem to be due, on the one hand, to the greatly diminished mass of the blood in the vessels, and to its accumulating and stagnating in various parts of the venous system, and, on the other hand, to the weakness of the heart, which is shown by its suppressed impulse and sounds, and which lessens its power to propel the venous blood into the lungs. The infarction of the systemic veins and the threatening suspension of the circulation necessarily impair the activity of all the functions, including those of nutrition and disintegration, so that the effete detritus of the economy tends to accumulate in the blood. This tendency is doubtless counterbalanced not only by the diarrhoea, but also, more or less, by the almost total suspension of nutrition, due to the inability of the cholera patient to digest or even to retain food, as well as by the diminished oxidation of the blood in the lungs. It has already been observed that, to a certain extent, the impediment to the passage of the blood from the right side of the heart into the ramifications of the pulmonary artery tends to prevent congestion and infarction of the lungs. But this obstruction is precisely what occurs during the stage of reaction in many cases, which then terminate fatally by asphyxia, as in the previous stage still more perish by apnoea.

In the milder attacks of cholera vomiting may not occur, and in the most severe it not unusually is suspended for some time before death, although the diarrhoea may continue. In the most malignant cases, indeed, there may be no vomiting at all, in consequence of the extreme muscular exhaustion, although the stomach may be distended with liquid. When rejected, the liquid has the general aspect of rice-water, which the stools also present. Its reaction is alkaline or neutral, and it is said to contain a less proportion than the stools of solid matter, but a larger proportion of urea. The act of vomiting is strictly one of regurgitation, which is performed without effort or pain. Sometimes, indeed, it seems to relieve the sense of weight caused by the accumulated contents of the stomach. It is readily excited by attempts to drink, and even by slight changes of posture. The vomited liquid at first contains the various articles of food the patient may have eaten. Their half-digested remains have sometimes suggested the announcement of strange specific forms of cholera germs. The liquid, after ceasing to be colored brownish or greenish, becomes gray, and subsequently, in favorable cases, more or less green again; while during the stage of reaction in grave and ultimately fatal cases it is more or less reddened by an admixture of blood. Its most usual and characteristic appearance is that of a grayish liquid containing whitish flocculi. The nature of this liquid, whether discharged by vomiting or by purging, has been variously estimated. Formerly, some persons held the white granules to be leucocytes, but the greater number agree that they are mainly epithelial fragments. When the vomited liquid is allowed to stand, a sediment forms in it which is composed almost entirely of epithelial scales, more or less modified in their appearance by the accidental contents of the stomach, and a film covers its surface in which globules of fat and phosphatic crystals may be detected. They are frequently associated with sarcinæ, produced by fermentation in the contents of the stomach, and after standing for some time the liquid becomes crowded with vibrios (Lindsay).

Although the propensity of the sick to discover a cause for every symptom often leads cholera patients to attribute their diarrhoea to some particular exposure to cold, error of diet, etc., yet, in fact, this symptom, so far as it belongs to cholera, is primarily an effect of the cholera poison alone, although it may be aggravated by causes like those mentioned. It is of great practical importance to bear in mind that a specific choleraic diarrhoea—that is to say, a diarrhoea produced by the cholera poison alone—may continue to be very slight as long as it lasts, which may be for several weeks; and hence, as elsewhere insisted upon, a person who is not suspected of being affected with cholera may, quite ignorantly, sow the seeds of a deadly epidemic of the disease. The danger in cholera is proportioned to the volume of the discharges rather than to their frequency, just as a single profuse hemorrhage is more serious than the loss of an equal amount of blood divided among several successive days. The special danger, however, is not, as in hemorrhage, from syncope, but from the progressive loss by drainage of the water of the blood, rendering it unfit to circulate, and therefore causing it to stagnate in the veins. The spoliative operation of the diarrhoea has occasionally been productive of benefit instead of injury, as in the following case of Barlow: A man suffering from dropsy was attacked with cholera, "and passed gallons of liquid by stool, had cramps, and became livid and clammy, but his pulse did not disappear, as in profound collapse, and he eventually rallied, and left the hospital apparently well. When he began to recover from cholera his appearance was almost ludicrous, from the manner in which the integument hung loosely about him."

The stools pass through a series of changes corresponding to those of the matters vomited, being fecal at first, and then becoming colorless and watery. During reaction, if that occurs, they regain more or less of their proper color, but if typhoid febrile symptoms prevail they are usually bloody. Decomposed blood sometimes renders them dark, tarry, and fetid; this condition has caused them sometimes to be described as being composed of vitiated bile, which is, however, a product not of the liver, but of the imagination.

In the intestine after death considerable quantities of epithelium are found floating in the contained liquid or else loosely adherent to the mucous membrane. It is usually in flocculi, but sometimes in fragments large enough to form a continuous membrane. A microscopic examination of cholera stools shows that their turbidness depends chiefly upon desquamated epithelium, with which is mixed white corpuscles and bacteria. It is remarkable that although the stools are drained directly and so rapidly from the blood-vessels, they nevertheless contain but little albumen, indeed hardly more than a trace of it. If, however, blood is mixed with the stools, as happens in rare instances, more albumen is present. Oil-globules are most abundant in cases that have passed beyond the stage of collapse into that of reaction with fever. In these it is said that oily matter may be found either in concrete masses or as a scum of liquid oil. Of inorganic constituents they contain crystals of the triple phosphate of ammonium and magnesium and chloride of sodium in greatest abundance, but the proportion of ammonium and potassium salts is small. Indeed, the total amount of solids does not exceed 2 per cent. As the quantity of water in the blood and solids is limited, and as in this disease the stomach will not receive nor retain any liquid, it follows that the more profuse the evacuations are, the shorter must be the duration of the attack, for the sooner then does the blood become too thick to circulate.

It has several times been stated that in cholera the urine is diminished, and that, therefore, the blood retains a larger proportion of effete products than in health. But it has also been remarked that the amount of these products is abnormally small, on account of the interference with nutrition of the abnormal state of the circulation. Doubtless, as in other cases of renal obstruction, an increased proportion of effete matter is eliminated by the skin, if not by the bowels. When the amount of urine excreted is only diminished, its specific gravity may vary between remote extremes, as 1.012 and 1.030. Usually, however, when its quantity is very greatly reduced, symptoms which are described as uræmic are apt to arise, and the urine is found to contain the usual products of renal congestion—viz. albumen, sometimes traces of blood, hyaline and granular casts, and epithelial scales, with less chloride of sodium and more urea than normal. It is remarkable that at the beginning of convalescence the urine, which had been suppressed or greatly diminished, may become for a time abnormally abundant. Rarely, if ever, does the derangement of the kidneys now described denote or produce an organic lesion in those organs. Like the disorders elsewhere, these are due to the loss of balance between the arterial and the venous sides of the circulation; both, indeed, have lost their functions more or less, the one by lack of blood, the other by an excess of blood unfit for circulation.

The occurrence of cramps in cholera, which has bestowed upon the disease one of its titles, spasmodic, has, however, no distinctive relation to the Asiatic disease. Spasmodic phenomena occur in many cases of poisoning by corrosive and irritant agents and in ordinary cholera morbus, and in cholera infantum they are among the most alarming symptoms, assuming, as they often do, the character of general convulsions. In most of these cases they are clonic and general, and therefore probably of central origin, primary or reflected; but the spasms of cholera are tonic, and affect the muscles of the upper and lower limbs, and most frequently the flexor muscles of these parts, and especially those of the fingers and toes, which become rigidly bent. The larger muscles contract into hard lumps, and even those of the chest and abdomen do not escape the terrible spasms. When they are severe they extort cries from patients who at other times seem quite apathetic. It is stated by Macnamara that the natives of Southern Bengal and other people of relatively loose fibre are much less apt to be attacked by them than the natives of the upper country or than Europeans. It may be debated whether their immediate cause is a reflex irritation emanating from the gastro-intestinal mucous membrane; or whether it is due to the rapid diminution of the supply of blood to the nervous centres, or to the infarction of those centres with thick and imperfectly oxygenated blood; or, finally, whether it is occasioned by a diminished supply of blood, and that blood of bad quality, to the muscles themselves. Probably all of these factors are associated causes in producing the spasmodic phenomena of cholera. It is well worthy of notice, however, that spasms, which are so frequent in all infantile diseases, and especially in those affecting the stomach and bowels, rarely attack children suffering from cholera. This would seem to prove that the spasms in question are not reflex, but either central and spinal, or else muscular—an inference which is strengthened by their being tonic and not clonic. As stated, the spasms, or cramps, frequently affect the limbs, but comparatively seldom involve the muscles of the chest or abdomen, and those of the face hardly ever. They are almost the only causes of pain in the disease, which in not a few instances runs its whole course, even to a fatal termination, without their occurrence.

As a rule, the abdomen is not so much retracted as might be expected from the profuse discharges. Probably in some degree its form is maintained by the constantly recurring accumulation of liquid in the gastro-intestinal cavity. In protracted cases, however, the abdomen becomes sunken and hollowed. At all stages of the disease it is somewhat sore under pressure, especially at the epigastrium, and it generally has a doughy feel. As to the functions of the digestive organs, they are completely suspended during a typical attack of the disease. Not only are these organs incompetent to digest food, but they cannot even retain it.

Throughout such an attack not only is sleep apt to be prevented by the pain of the cramps and the frequent evacuations, but, as a rule, the patient is wakeful, and yet, apart from the restlessness which accompanies the paroxysms of pain, there is, on the whole, a tendency to a placid quietness. Mental excitement and delirium are probably unknown during the primary attack, but sometimes a degree of somnolence or of apathetic tranquillity exists, which, however, is quite distinct from coma. When the attack is prolonged, and especially when it merges into a typhoid state, the eyes become inflamed by their exposure to the air. The conjunctiva then grows blood-shot, and occasionally the cornea is ulcerated.

MORBID ANATOMY AND PATHOLOGY.—The appearance after death of a person who has died in the collapse of cholera is very characteristic. It comprises a shrunken aspect of the whole body, its prevalent grayish or leaden pallor contrasting with the livid hue of the abdomen and back, the fingers and toes, the lips and eyelids, and ears; the eyes are sunken deeply in their orbits; the nose is sharp and bent, the temples are hollow, and the skin seems to cling tightly to the bones beneath it. The connective tissue is very dry, and the muscles are hard as well as dry, and, owing to the wasting of the softer parts, stand prominently out. In consequence of the absence of moisture decomposition takes place very slowly. Cadaveric rigidity is very marked and persistent. A very notable phenomenon is the occurrence of muscular contraction after death. It may be excited mechanically or may occur spontaneously. A case is related (Eichhorst) in which three hours after death the fibres of the biceps were observed to move tremulously, and then the entire muscle contracted, causing flexion of the forearm. Even the fingers performed movements like those made in piano-playing. The lower jaw has also been observed to move, causing the mouth to open and shut repeatedly. The late Sir Thomas Watson long ago described this singular phenomenon as follows: "A quarter or half an hour, or even longer, after the breathing had ceased, and all other signs of animation had departed, slight, tremulous, spasmodic twitchings and quiverings and vermicular motions of the muscles would take place, and even distinct movements of the limbs, in consequence of these spasms."³⁸ It was carefully studied by Barlow, from whose narrative the following is taken: The patient was a strong man; the course of his attack was rapid, and he suffered most cruelly from cramps. "Within two minutes of his ceasing to breathe muscular contractions began, becoming more and more numerous. The lower extremities were first affected. Not only were the sartorius, rectus, vasti, and other muscles thrown into violent spasmodic movements, but the limbs were rotated forcibly and the toes were frequently bent. The motions ceased and returned; they varied also: now one muscle moved, now many. Quite as remarkable were the movements of the arm: the deltoid and biceps muscles were peculiarly influenced; occasionally the forearm was flexed upon the arm—flexed completely, and when I straightened it, which I did several times, its position was recovered instantly. The fingers and thumbs were now and then contracted, and at times the thumbs were separately moved. The fibres of the pectoral muscles were often in full action; distinct bundles of them were seen at intervals beneath the skin.... After I had taken leave of the body the nurse was horrified by a movement of the lower jaw, which was followed by others; and I thought for a moment that the man was alive. The facial muscles became generally affected, and at length all was still."³⁹ These muscular contractions succeed one another in a regular order, beginning in one lower extremity and extending to the other, then to the upper limbs, and finally to the face. Their degree varies from a slight quivering to a powerful contraction, and their duration from a minute or less to an hour and a quarter. Cases have occurred in which the legs were so forcibly retracted that they could with difficulty be straightened again. In one case, six hours after death movements took place in one leg, and the hand was drawn across the chest; in another, "the forearms were powerfully flexed, and the hands, approximating, gave the attitude of praying to the body."⁴⁰ Again, Mr. Ward reports: "I saw the eyes of my dead patient open and move slowly in a downward direction. This was followed, a minute or two subsequently, by the movement of the right arm (previously lying by the side) across the chest." In the same paper Barlow says: "Mr. Lawrence mentioned to me that a gentleman who died in 1832 of rapid cholera was turned after death completely on the side by a strange and forcible combination of muscular contractions."⁴¹ These muscular phenomena after death form an interesting feature in the history of cholera, but they are by no means peculiar to that disease. They have been observed in other diseases, and especially in yellow fever—an affection in which the pathological condition is quite unlike that of cholera. In both diseases they have been manifested in robust persons and when the course of the fatal attack was both rapid and severe. Thus, Dr. Dowler of New Orleans not only found that they could be developed in such cases of yellow fever by striking the muscles, but he observed their spontaneous occurrence in several, of which the following is a remarkable example: "Not long after the cessation of the respiration the left hand was carried by a regular motion to the throat, and then to the crown of the head; the right arm followed the same route on the right side; the left arm was then carried back to the throat, and thence to the breast, reversing all its original motions, and finally the right hand and arm did exactly the same."⁴² In 1860, Drasche alleged that not unusually the skin covering the contracting muscles became reddish, while the local temperature rose ½°, and that as soon as the contractions ceased the temperature fell below the normal and cadaveric rigidity set in. According to the same observer, analogous contractions affect the unstriped muscular fibres, in those of the skin producing a projection of the papillæ, and in the genital organs a discharge of semen. This phenomenon is said to have occurred an hour and a half after death.

³⁸ Lectures, Am. ed. of 1872.

³⁹ London Med. Gaz., Nov., 1849, p. 798.

⁴⁰ Ibid., Jan., 1850, p. 185.

⁴¹ Ibid., pp. 185, 186.

⁴² Experimental Researches, 1846.

On opening the abdominal cavity of persons who have died in the collapse of cholera one is struck by the general pink or rose tint of the peritoneal coat of the intestines. It is produced by a repletion of the minute branches of the portal venous system. Sometimes the color is rendered very dark by the pitchy blood contained in the veins. The surface of the peritoneum, like all the tissues, is singularly dry, and often has a soapy or sticky feel, caused by a layer of albuminous matter, which forms a lather when rubbed between the fingers, and causes the intestinal folds to adhere to one another. If death takes place during the stage of reaction, these appearances are less distinct, and the intestines, which in collapse are usually retracted, are then somewhat distended.

The stomach generally contains a thin, partially transparent liquid of a greenish or grayish color, and occasionally reddish, holding in suspension portions of coagulated mucus and an unctuous substance of an albuminous nature, which adheres to the walls of the cavity. Fatty globules may be observed floating in the liquid, which under the microscope reveals epithelial débris, granular corpuscles, and fragments of gastric glands. Under heat and nitric acid coagulation of the liquid occurs, and on chemical examination it is found to contain urea. The gastric mucous membrane is of a dark violet or pale pink color, according to the stage of the disease; its follicles are enlarged, and patches of superficial abrasion may be observed on it.

The intestinal canal of those who die during the collapse of cholera is, in the majority of cases, partially filled with liquid which has the aspect of turbid serum, more or less mixed with the previous contents of the bowel if death has taken place very rapidly, but otherwise it is almost colorless. On the whole, however, it is less pale and watery than the stools. It contains, like these discharges, more or less epithelial flocculi, and generally more than were observed during life in the dejections. The mucus scraped from the lining membrane of the intestine and mixed with water renders it turbid with epithelial débris. The same mucus examined microscopically contains fragments, larger or smaller, of epithelium. These conditions are said to predominate in the large intestine. Indeed, the proportion of liquid increases from above downward. Hence in the more prolonged cases the contents of the bowel at its upper part are less liquid and are darker in color. There is, indeed, a striking contrast between the appearance of the intestine in cases which have terminated in collapse and its aspect in persons who have died during the stage of reaction. It has been clearly presented by Dr. Sutton.⁴³ When death took place in "the cold stage the mucous membrane was unusually pale in three cases; in two it was healthy-looking; in other two it was pale throughout, excepting that one or two of Peyer's patches were congested; and in the remaining three there was more or less congestion of the mucous membrane. When the mucous membrane was pale throughout the entire intestine, the valvulæ conniventes looked swollen and oedematous, and the color of the membrane was dead white. The solitary glands were very distinct and prominent. Those of the duodenum were remarkably so. In cases of imperfect reaction the mucous membrane of the intestine was usually found very much congested and ecchymosed. The congested portions were sometimes granular, and apparently denuded of epithelium. The mucous surface had often a dark port-wine color, due to the extravasated blood and the hyperæmia, and here and there the surface was covered with a dirty gray membranous substance, likened to a diphtheritic deposit. I have, however, seen no decided false membrane, such as could be peeled off, as in diphtheria. The surface was also occasionally bile-stained, and the greenish-yellow color of the bile and the deep red color of the congested surface presented a very striking appearance. The solitary glands were very prominent, and in some cases apparently enlarged." The general paleness of the intestinal mucous membrane in the stage of collapse, and its congestive redness whenever the signs of reaction have existed before death, have a very important bearing upon the pathology of this disease, for they demonstrate conclusively that the gastro-intestinal evacuations in cholera have no relation whatever to inflammation. On the other hand, they render it altogether probable that the serous flux is in the nature of a sweat, an intestinal ephidrosis.

⁴³ London Hosp. Clin. Lect. and Reports, iv. 497.

The nature of the exfoliation found in the intestinal canal has been the subject of much discussion. As long ago as the first American epidemic of cholera (1832-35) Dr. W. E. Horner, Professor of Anatomy in the University of Pennsylvania, described an exfoliation of the epithelial lining of the alimentary canal, whereby the extremities of the venous system of the part are denuded, as being characteristic of cholera alone. In 1849, Dr. Samuel Jackson, Professor of the Institutes of Medicine, and Dr. John Neill, Demonstrator of Anatomy in the University, in conjunction with Dr. William Pepper and Dr. Paul B. Goddard, presented a report to the College of Physicians of Philadelphia, in which they, too, showed that the "epithelial layer of the intestinal mucous membrane was either entirely removed or was detached, adhering loosely." This important fact—the most important, perhaps, in the mechanism of cholera—was confirmed seventeen years later by the eminent pathologist Dr. Lionel S. Beale,⁴⁴ who, when referring to "the remarkable characters of the matter discharged from the intestinal tube, and to the fact that the small intestines almost always contain a considerable quantity of pale almost colorless gruel-, rice-, or cream-like matter," added: "This has been proved to consist almost entirely of columnar epithelium, and in very many cases large flakes can be found, consisting of several uninjured epithelial sheaths of the villi.... In bad cases it is probable that almost every villus, from the pylorus to the ilio-cæcal valve, has been stripped of its epithelial coating during life.... These important organs, the villi, are, in a very bad case, all or nearly all left bare, and a very essential part of what constitutes the absorbing apparatus is completely destroyed.... It is probable that the extent of this process of denudation determines the severity or mildness of the attack.... It seems probable also that the epithelium may become detached in consequence of the almost complete cessation of the circulation in the capillaries beneath, but the death of the cells may occur in consequence of their being exposed to the influence of certain matters in the intestine or in the blood, in which case they would simply fall off."

⁴⁴ Med. Times and Gazette, Aug., 1866, p. 109.

In this connection, and as complementary of the statements now made, should be considered the further description by the same author—viz.: "Remarkable changes have occurred in the smaller vessels, especially in the capillaries and small veins of the villi and submucous tissue. The blood-corpuscles appear to have in a great measure been destroyed in the smaller vessels, and in their place are seen clots containing blood-coloring matter, minute granules, and small masses of germinal matter evidently undergoing active multiplication. Some of the arteries are contracted, but here and there small clots destitute of blood-corpuscles may be seen at intervals." Hence, the gastro-intestinal lesions in cholera, according to their extent and degree, they remove the natural obstacles to exhalation in the mucous membrane, and also, and in the same degree, prevent the absorption of the contents of the alimentary canal. It must not, however, be forgotten that this lesion is not altogether peculiar to the intestinal mucous membrane. Dr. Beale long ago called attention to the fact that in this disease there seems to be a tendency to the removal of epithelium from the surface of all soft, moist mucous membranes, but not from the follicles of the glands. The first statement appears to be explicable by the shrinkage of all the mucous membranes during cholera collapse, for by this merely mechanical agency the inelastic epithelium must necessarily become detached. As to the second statement, the remark may be made that the whole follicular structure furnished with columnar epithelium is an absorbing and not an eliminating apparatus, and that, since its functional activity is from the beginning of the disease diminished by an inadequate blood-supply, it can have but a small and indirect share in generating the phenomena of the disease.

In 1884, Dr. Koch, during his investigations of cholera in India, found bacilli in the bowel which he believed to be peculiar to the disease, and which presented the following characters: they were not straight, like other bacilli, but curved or comma-shaped; they proliferated rapidly and displayed very active movements. Bodies of persons who died of various other diseases did not present them, although abounding in different bacteria. The bacilli were not found, or only exceptionally, in the stomach, but abundantly in the intestine, and most so in the diarrhoeal discharges that occurred at the height of the disease. As soon as the stools began to be fecal the specific bacilli disappeared from them. After death at the height of the disease they were most abundant in the intestinal contents, and especially in the lower part of the small intestine. When death took place at a later period none of them might be detected in the liquids in the bowel, but they would still be present, in considerable numbers, in the tubular glands. They were not found at all in cases fatal from some sequela of the disease.⁴⁵

⁴⁵ Times and Gaz., Mar., 1884, p. 398.

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

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

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

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

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

In the state of the respiratory organs the most important facts are that in algid cholera the lungs are always more or less collapsed, "shrunk and small, and lying back in the chest, toward the spine," and that, so far from being congested, they are (with the exception of a small portion of their posterior part rendered dense by hypostasis) singularly bloodless, dry, and tough. As might be inferred from these conditions, they are also lighter in weight than natural. To Dr. Parkes belongs the credit of having first described this very important fact in the morbid anatomy of cholera, as follows: "In fourteen cases the lungs were completely collapsed, appearing in some cases like the lungs of a foetus. In three cases they were considerably, in eight slightly, collapsed, and in the remaining fourteen cases the collapse was in some altogether, and in some partially, prevented by old adhesions."⁴⁶ So Dr. Sutton found that the average weight of the two lungs during collapse was about twenty ounces, and after reaction—that is, after the passage of the blood into the pulmonary artery had become completely re-established—about forty-five ounces. In the latter condition also the lungs presented the usual signs of congestion of those organs, being dark-red throughout or in portions only. Sometimes also they contained masses or nodules of apparent hepatization, and of these some may have undergone partial softening.

⁴⁶ Med. Times, 1848, p. 378.

In absolute conformity with the condition of the lungs that has been described is that of the heart. If the lungs are bloodless, it follows necessarily that the left side of the heart must be empty, and almost as necessarily that the right side of the heart must be distended with blood. All careful investigators of the subject agree that such is the condition of the heart when death takes place in cholera during the stage of asphyxia. All report that the pulmonary artery is either empty or that it contains a small quantity of dark and usually of thick blood; that the right side of the heart and the coronary veins are distended with blood of the same description, while numerous ecchymoses exist along the course of the coronary veins; that the venæ cavæ are filled with half-coagulated blood of a tarry aspect; and that even the femoral and splenic veins contain similar blood. On the other hand, the left ventricle of the heart is usually contracted, and contains a very little semi-fluid blood, with perhaps a small and pale clot. This engorged condition of the right cavities and emptiness of the left cavities of the heart diminish very slowly during the passage from collapse to reaction, during which time the pulmonary blood-vessels are being gradually replenished. Besides the thick and tarry aspect of the blood above described, it has been observed that when the blood is withdrawn by means of a pipette, its globules rapidly subside and are surmounted by a transparent serum, and that such blood may remain for a long time uncoagulated. The red corpuscles are said to be pale and viscous, but not adhesive, and the white corpuscles abnormally numerous and easily crushed. In the free intervals are observed "very pale little objects, slightly elongated and constricted in their middle," which multiplied in blood kept for one or two days at a temperature of 38° C. (100.4° F.).⁴⁷ If death does not take place until reaction is far advanced or has merged into a febrile condition, the left ventricle is usually found not contracted, and it contains a quantity of blood. The term "usually" is employed to show that even to this rule there are some exceptions, and that, as in all other diseases, the issue does not depend absolutely and exclusively upon a definite degree of any anatomical lesion, but upon the aggregate condition of all the functions upon which life depends. The pericardium, like the pleura and the peritoneum, may be covered with a saponaceous film which is albuminous.

⁴⁷ Rapport sur le Cholera d'Égypte en 1883, par M. le Dr. Strauss, etc.

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

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

At the present time (1884) it is the fashion to trace every disease to specific bacteria or analogous organisms. But it may be that the occurrence of cholera only furnishes the occasion for the development of these organisms, just as a certain temperature, hygrometric condition, and deficient light and air will cause mould to form on bread and other organic substances. The judgment pronounced by Dr. Beale in this question as long ago as 1866 appears now, as it did then, to approach the truth upon this point: "There is no good reason for supposing that the bacteria in such numbers in the alimentary canal in cholera have anything to do with this disease or with the falling off of epithelium from the intestinal and other mucous membranes. Bacteria are developed in organic matter which is not traversed and protected by the normal fluids of the body, and they invade the cells and textures in cholera after those cells and textures have undergone serious prior changes, just as they would invade textures removed from the body altogether. Nor would it be in accordance with known facts to infer that cholera was due to the invasion of some peculiar form or species of bacterium."⁴⁸

⁴⁸ Times and Gazette, Aug., 1866, p. 167.

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

The above views regarding the essential cause of cholera were substantially indited before the Egyptian epidemic of 1883, but they are in accord with the more definite conclusions arrived at by the German and French commissions on the subject. Before their reports appeared, however, a communication was made by Dr. Kartulis of the Greek hospital in Alexandria, setting forth that the drinking-water and the stools and blood of the cholera patients contained, the first a mass of micro-organisms, and the others bacteria and micrococci, which, however, presented no distinctive characters.⁴⁹ The German report was prepared by Dr. Koch, the French by Dr. Strauss.⁵⁰ The former, alluding to the enormous quantity of micro-organisms found in the contents of the bowels and in the stools, did not perceive any connection between them and the phenomena of the disease. On the other hand, he did assign this relation to a species of bacterium found in the walls of the intestine, and which he compared to the bacilli of glanders. They were lodged in great quantities within the intestinal glands and behind their epithelium, as well as upon the surface of the villi and within them, and sometimes even in the muscular coat. They were most numerous at the lower end of the small intestine. Dr. Koch concluded that although these bacilli, beyond doubt, are in some manner associated with the development of cholera, they are by no means shown to be its cause, and may indeed be themselves the product of the morbid conditions belonging to cholera. All his attempts at that time to develop cholera in animals by inoculating them with the organisms gave only negative results. The conclusions of Dr. Strauss were in entire conformity with those of Dr. Koch, but involved an additional and very important statement—viz. that the shorter and the more violent were the fatal attacks of cholera the fewer were the bacteria found in the intestine. It is evident that this fact is the very opposite of what should have been found had bacteria been essential in the causation of cholera. The more recent investigations conducted in Calcutta by Dr. Koch, which have already been cited, led him, however, to attribute to bacilli of a specific form the absolute origination of the disease. He poses the question in the following manner: Either these "comma bacilli" are a product of the cholera process, or "the disease only arises when these specific organisms have found their way into the bowel." The former alternative he rejects, because, in his judgment, it assumes that the bodies in question must be pre-existent in every person who becomes affected with the disease—a hypothesis which he rejects, because they have never been found except in cholera. He therefore concludes that they are the cause of cholera. He points out that their first appearance coincides with the commencement of the disease, that they increase with it, and that they disappear with its decline.⁵¹ The statement of Strauss quoted above does not, however, appear to harmonize with this conclusion, since the bacteria are said by him to have been fewest in the more violent and fatal attacks of the disease. Another of Dr. Koch's remarks is also open to criticism. After showing how rapidly the cholera bacteria multiply when kept moist, he states that they die after drying more quickly than almost any other form of bacteria. "As a rule, even after three hours' drying every vestige of life has disappeared." It is evident that this statement is not in harmony with the numerous facts, several of which have been cited, that cholera fomites have preserved their infectious qualities after several weeks. Dr. Koch endeavored to produce in animals, artificially, with these bacteria, a disease analogous to cholera, but without success; and he adds, "If any species of animal whatever could take the cholera, it would surely have been observed in Bengal, but all inquiries directed to this point met with a negative result." Dr. Vincent Edwards, who, however, is of opinion that the cholera poison is "not an organism, but of the nature of a chemical compound of comparatively unstable nature," reports that he produced fatal cholera in pigs by giving them the dejections of cholera patients.⁵² But the Times and Gazette inclines to question that the pigs employed in Dr. Edwards' experiments were affected with true cholera.

⁴⁹ Medical News, xliii. 377.

⁵⁰ Archives gén., Dec., 1883, pp. 713, 722.

⁵¹ Times and Gaz., Mar., 1884, p. 398.

⁵² Notes on the Poison contained in Choleraic Atomic Discharges.

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

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

In illustration may be cited the comparatively familiar description of Sydenham.⁵³ These are his words: "There is vomiting to a great degree, and there are also foul, difficult, and straining motions from the bowels. There is intense pain in the belly, there is wind, and there are distension, heartburn, and thirst. The pulse is quick and frequent, at times small and unequal. The feeling of sickness is most distressing, and is accompanied with heat and disquiet. The perspiration sometimes amounts to absolute sweating. The legs and arms are cramped and the extremities cold. To these symptoms, and to others of a like stamp, we may add faintness." ... "As the summer came to a close the cholera morbus raged epidemically, and, being promoted by the unusual heat of the weather, it brought with it worse symptoms, in the way of cramps and spasms, than I had ever seen. Not only, as is generally the case, was the abdomen afflicted with horrible cramps, but the arms and legs, indeed the muscles in general, were afflicted also." ... At the risk of repetition an additional passage may be quoted from Sydenham's later definition of cholera morbus: "This is limited to the month of August or the first week or two of September. Violent vomiting, accompanied by the dejection of depraved humors, difficulty on passing them, vehement pain, inflation and distension of the bowels, heartburn, thirst, quick, frequent, small, and unequal pulse, heat and anxiety, nausea, sweat, cramps of the legs and arms, faintings, and coldness of the extremities, constitute the true cholera—and it kills within twenty-four hours."

⁵³ Works, Sydenham Soc. ed., i. 163; ii. 8, 266.

In spite of the general likeness between this description and the symptoms of Asiatic cholera, there are differences of considerable importance which have been italicized in the quotations. These differences are such as may be attributed to the action of a harsh irritant in the case of cholera morbus, while in the epidemic (Asiatic) disease the distinctive phenomena are the result of a sudden and profuse intestinal flux. Macpherson, who had a long and extensive experience of epidemic cholera in India, after contrasting in detail its phenomena with those of cholera nostras, sums up the discussion in these words: "Cholera indica is essentially a very fatal disease, while cholera nostras is usually a mild affection and is seldom fatal, although it was called atrocissimus et peracutus, and has undoubtedly killed in from eight to twenty-four hours."⁵⁴ In regard to the individual symptoms this very competent reporter does not recognize a single one as being absolutely peculiar to either disease. Even the ancients, already referred to, after describing bilious evacuations as being characteristic of cholera nostras, add that sometimes also they are whitish; and modern writers, both before and since the advent of Asiatic cholera in Europe, have made a similar observation. Thus, Quinquaud, in his description of cholera nostras, of which a slight epidemic occurred in 1869 at the Hospital St. Antoine in Paris, says: "The principal symptoms were vomiting and purging, sometimes of a bilious and sometimes of a rice-water liquid; a shrivelled and cyanotic skin, the latter appearance being sometimes strongly marked; anxiety, coldness, cramps, altered voice, and suppression of urine."⁵⁵ In 1875 thirty-three cases of this disease occurred at Valenciennes, near Paris, and its symptoms were thus summarized by Manouvriez:⁵⁶ "Repeated vomiting, first of food, and then of a dark-green liquid; diarrhoea, which was at first fecal and then bilious, but afterward serous and like rice-water; painful tension of the epigastrium and tenderness of this part; headache, cramps in the legs, suppression of urine; pallor, coldness, and dryness of the skin, especially of the limbs; pinched features, a blue circle around the eyes, a small and scarcely perceptible pulse, and a faltering and whispering voice." Yet of the thirty-three cases only two were fatal—the one a child of four years and the other an infant of as many months. The substantial identity of nature of these two local epidemics, and the almost equally close relation of their symptoms to those of epidemic cholera, must be quite apparent.

⁵⁴ Times and Gaz., Dec., 1870, p. 725.

⁵⁵ Archives gén., Mars, 1870, p. 308.

⁵⁶ Archives gén., Sept., 1877, p. 298.

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

It is true only in a limited degree, and indeed only upon a superficial survey of the symptoms, that the effects of irritant poisoning are like those produced by Asiatic cholera. The analogy between the two was pointed out, among others, by Sedgwick in 1867.⁵⁷ The resemblance appeared so striking to the vulgar eye that in Paris, and perhaps elsewhere, a popular tumult followed the first violent outbreak of epidemic cholera, and it was charged that the wells had been poisoned. The cases that most resemble cholera are the following: "Acute poisoning by corrosive sublimate, by arsenic, and by mineral acids, especially nitric acid; the effects which follow the eating or drinking of poisonous animal matters, such as tainted or simply unwholesome meat or fish, and milk which has undergone some injurious but yet unknown change, decomposing vegetables and some of the poisonous fungi, and the excessive action of certain drugs, for the most part belonging to the class of drastic purgatives," as elaterium and croton oil. The effects produced by these agents constitute a cholera morbus, and therefore resemble cholera, and have been occasionally, and almost unavoidably, mistaken for it. It is remarkable that suppression of urine may occur among them, as well as vomiting, purging, and collapse. As Griesinger and others have pointed out, the order in which the symptoms occur is a valuable, and generally an available, ground of diagnosis. In cholera, diarrhoea always occurs before vomiting, while in the various irritant poisonings mentioned vomiting precedes diarrhoea. In irritant poisoning also there is generally severe abdominal pain—not so much colicky and paroxysmal as constant and burning; the stools are not so copious as in cholera, and they do not possess the rice-water aspect, but are rather dark, bloody, and fetid, and are voided with tenesmus or with heat in the anus; and even when the urine is suppressed it is less persistently and completely so than in cholera, and attempts to void it are attended with vesical tenesmus and strangury. In a doubtful case it is important to ascertain whether a metallic or other unpleasant taste is perceived in the mouth, whether this cavity or the throat bears marks of corrosion, whether any unusual article of food has been used, etc. Moreover, it is of extreme importance to learn whether Asiatic cholera prevails, not merely in the immediate neighborhood, but at any place from which diseased persons or infected goods may have arrived. The instances should not be forgotten in which cholera-infected clothing from Europe has developed the disease in the valley of the Mississippi. Nor should those still more numerous cases be overlooked in which travellers affected with choleraic diarrhoea have disseminated the disease at great distances from their starting-point, although unconscious of the nature of their own ailment, whose seed they were sowing along their route.

⁵⁷ Med.-Chir. Trans., li. 1.

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

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

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

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

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

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

In regard to the former there would be comparatively little difference of opinion, at least theoretically, if both measures were alike efficacious. But there would seem to have prevailed a tendency in official quarters to undervalue the efficiency of both. Those who made and administered the sanitary laws relating to cholera seem to have forgotten the emphatic question, "What will not a man give for his life?" or at least to have considered that whatever value some men may set upon their own lives, the lives of other men become of no account when balanced against the needs, or even the conveniences, of commerce. The ethics which justified the introduction of opium into China by the English and the American gift of alcohol to the Indian to gratify a lust for lucre or for land is only paralleled by those contained in the official protests against cholera quarantines. At the International Medical Congress held in 1873 at Constantinople, it was almost unanimously resolved that "the practice of (land) quarantine as now carried out ought not to be maintained, because, on the one hand, it does not constitute a real protection, and, on the other hand, it is directly opposed to the interests of commerce and industry." A leading critic, in commenting upon this, remarks that if a quarantine were possible it would give no real security, because it would be evaded, just as customs laws are evaded by smuggling.⁵⁸ A logical deduction from this curious argument would be that customs laws should be abrogated. In 1880 was published the report of the German Imperial Commission on the cholera epidemic of 1873 in Germany, edited by Hirsch, from which we learn that "all the German medical experts agree in condemning the employment of quarantine, for, while largely detrimental to the interests, welfare, convenience, and happiness of a community, it is quite inert and inefficient as a safeguard against the further diffusion of cholera."⁵⁹ Whether this opinion refers only to land quarantine or not is left in doubt, but the spirit of subordinating the lives of the people to the commercial interests of a country is just the same as, and is not less worthy of condemnation than, the spirit which has more than once blinded customs officials to the disease on board of vessels from which it has afterward issued to destroy thousands of lives.

⁵⁸ Practitioner, xii. 226.

⁵⁹ Ibid., xxvi. 159.

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

Probably no sanitary cordon nor any quarantine will invariably and completely exclude cholera, since it is transmissible by living men and by water and by fomites of various descriptions, and, worst of all, by men who neither exhibit its characteristic symptoms nor are conscious of the poison which they conceal and disseminate. But, as has already been urged, it is no argument against preventive measures that they are not absolutely perfect in their efficiency. If they sometimes succeed in arresting the progress of cholera, and if they always, when honestly executed, lessen the number of channels through which the infection can be conveyed, and thereby reduce to a minimum its fatal effects, they ought to be maintained and perfected, and not decried or abolished. It is difficult to characterize that state of mind which concludes against the use of a salutary measure because its efficiency is not absolute, the more so when it is admitted that its inefficiency is not intrinsic, but due to negligent, and even fraudulent, administration. The preponderance of official and personal authority is altogether on the side of the necessity of a quarantine, not in its literal, but in its technical, sense. The International Medical Congress of 1874 declared as follows: "Quarantine ought to be limited to the time requisite for the examination and disinfection of the ship, the crew, and the passengers; and if there be no disease on board the latter should be released immediately after disinfection. But if there be cholera or sickness of a doubtful nature on board, it will be necessary to isolate and disinfect the ship also." The same congress, however, wholly condemned land quarantines, apparently upon the sole ground of the extreme difficulty of rendering them efficient—an argument, as before remarked, that touches not the principle of the measure, but only the manner of its execution. In this respect the congress occupied a lower position than its predecessor of 1866, which held that the futility of quarantine in "arresting the march of cholera" arose "rather from the unintelligent application of the measure than from any fallacy in its principle."⁶⁰