cholera on the American continent are described by Dr. Peters as
follows: "All these ships and their passengers were quarantined at
Grosse Isle, a few miles below Quebec. On June 7th the St. Lawrence
steamer Voyageur conveyed a load of these emigrants and their baggage,
some to Quebec, but the majority to Montreal on the 10th. The first
cases of cholera occurred in emigrant boarding-houses in Quebec on the
8th, and the same pest-steamboat, the Voyageur, landed persons dead
and dying of cholera at Montreal, a distance of two hundred miles, in
less than thirty hours. Over this long distance, thickly inhabited on
both shores of the St. Lawrence, cholera made a single leap, without
infecting a single village or a single house between the two cities,
with the following exceptions. A man picked up a mattress thrown from
the Voyageur, and he and his wife died of cholera; another man,
fishing on the St. Lawrence, was requested to bury a dead man from the
Voyageur, and he and his wife and nephew died. The captain of a
passing boat requested an Indian to bury a man from on board; this man
and five other Indians were attacked {717} and died. The town of Three
Rivers, halfway between Quebec and Montreal, forbade steamers to land,
and escaped for a long time. From Montreal the great influx of
emigrants were forwarded away, by the Emigrant Society, as fast as
they arrived, and by them the pestilence was sown at each
stopping-place. Kingston, Toronto, and Niagara soon became affected.
In the end, over 4000 persons died of cholera in Montreal, and more
than an equal number in Quebec. The epidemic reached Detroit in the
same way, ... and continued west along the Great Lakes, until in
September it reached our military posts on the Upper Mississippi....
Fort Dearborn, near Chicago, was temporarily reoccupied in 1832, and
it was here that epidemic cholera displayed its most fatal effects
among our troops. Out of 1000 men, over 200 cases were admitted into
hospitals in the course of seven or eight days.... When these troops
again marched for the Mississippi, they appeared in perfect health,
yet the cholera broke out again on the way, and when the command
reached the Mississippi it had been as fatal as it had been at Fort
Dearborn."
Meanwhile, an emigrant ship with cholera on board reached New York,
whence the disease spread up the Hudson River, and was also carried
southwardly to Philadelphia and the West. The mortality in New York
City from this epidemic is stated at 3500. In 1833 the disease broke
out in the cities of Havana and Matanzas in Cuba, and is said to have
destroyed one-tenth of the entire population. Hence it was carried to
Mexican and American towns on the Gulf of Mexico, and up the
Mississippi and Ohio as far as the western border of Pennsylvania. In
the following year it was again introduced at the port of Quebec by a
vessel filled with emigrants, of whom many had died during the
passage. It prevailed in Canada and the State of New York and spread
over the whole country in 1835 and 1836. In the former of these two
years it was confined to several Southern cities, whither it was
brought, as on a former occasion, directly from Cuba. It then
gradually subsided, and at last disappeared for the space of nearly
ten years.
But in 1845 it was known to be advancing on its former path, which it
steadily pursued, and entered England in October, 1848, at Sunderland,
the very town at which it first appeared in 1831. "During the second
epidemic in Europe, in 1848, two vessels sailed from Havre, where
cholera prevailed--one, the New York, for New York, and the other, the
Swanton, for New Orleans. Both contained large numbers of German
emigrants. On one vessel the cholera appeared when it was sixteen days
out, with fourteen deaths; on the other, in twenty-six days, with
thirteen deaths. The New York arrived at Staten Island Dec. 2, 1848,
and a severe epidemic broke out, but was confined to the quarantine
grounds. The Swanton arrived at New Orleans Dec. 11th; no quarantine
was instituted, and in two days its sick were taken into the Charity
Hospital. This was the beginning of a severe epidemic, which increased
in power all winter, till, in June, 1849, 2500 died of it in New
Orleans. December 20, 1848, it reached Memphis by steamboat from New
Orleans, and for twenty-five days was confined to the landing-place of
the former city, whence it afterward spread. In the spring it was
carried to St. Louis and Cincinnati and the whole Mississippi Valley.
In October it reached Sacramento, Cal., by means of overland
emigrants, and, almost at the same time, San Francisco, by the U.S.
steamer Northerner from {718} Panama. The Chinese of California
suffered most severely" (Peters). In April, 1849, cholera reappeared
in the public stores at the quarantine station, Staten Island, N.Y.,
and in the city of New York, where it was fatal to 5000 persons.
A pause now took place in the ravages of the disease which lasted
until 1853. In that year it destroyed no less than 11,000 persons in
the Persian city of Teheran. At Messina its victims numbered 12,000,
in France 114,000, and in England about 16,000. In 1854 it was
introduced by emigrant ships into New York, causing a mortality of
2000 persons, and was carried to Philadelphia, where its victims
numbered 500. It extended to many towns in New England and westward
along the great channels of emigration. In Montreal the deaths were
1300, and in the then small town of Detroit, 1000.
After an interval of quiescence longer than any previous one the
cholera again broke out among the pilgrims to Mecca in December, 1864.
It appeared in Alexandria during May, 1865, and thence was carried to
many parts of Europe, and from them to North America and the West
Indies. This period of exemption included that of the Civil War in the
United States, when, if ever, the local causes which have been
erroneously assigned to the disease existed in all their forms and in
the most intense degree. It was only when its specific germs were once
more imported that cholera began to prevail again. Official records
show that in 1866 it was introduced from Europe into Halifax, N.S.,
the city of New York, and the military posts of New York harbor.
Thence it was carried in troop-ships to various Southern ports, from
which its progress could be traced to Texas and other Gulf States, and
to the towns on the Mississippi and Missouri Rivers. From New York,
also, the disease travelled westward to Cincinnati and the U.S.
barracks at Newport, on the opposite side of the Ohio River, whence it
advanced in a south-westerly direction to meet the trail that, coming
from the South, followed the great rivers of the Mississippi Valley.
During the summer of 1867 cholera again prevailed, although less
fatally, at most of the points, especially of the Mississippi Valley,
which had been invaded the previous year, and some cases occurred at
the military posts around New York in recruits who had shortly before
arrived from places in the West where cholera prevailed. Thus did the
disease complete the circuit of the United States.
Meanwhile, cholera prevailed to a greater or less extent in the east
of Europe between 1865 and 1874. After the latter date it seems to
have been confined to Syria, Arabia, and the African shore of the
Mediterranean. In 1877-78 it existed to a limited extent among the
pilgrims at Mecca, and since then it has not been known in Europe. The
latest appearance of cholera in the United States was in 1873, when it
occurred at three points far distant from one another. It was
introduced in the effects of immigrants. The vessels that brought them
were in a perfect sanitary condition. The passengers themselves were
healthy, and remained so after landing and until they reached the
distant points of Carthage, Ohio, Crow River, Minn., and Yankton,
Dak., where their goods were unpacked. At each place, "within
twenty-four hours after the poison particles were liberated, the first
cases of the disease appeared, and the unfortunates were almost
literally swept from the face of the earth" (E. McClellan).
{719} In 1881 cholera was brought from Hindostan to Arabia by pilgrims
on their way to Mecca, where it soon afterward broke out and caused
the death of about 8000 persons. In the following year several vessels
from Bombay evaded the quarantine and reached Djeddah, the port of
Mecca, and the pilgrims on reaching the latter city disseminated the
disease. The unusually small number of persons who were there at the
time, and their prompt dispersion before the danger, limited the
mortality, and gradually cases of cholera ceased to appear. In 1882,
the English at that time carrying on war in Egypt, very rigid sanitary
precautions against the importation of cholera were enacted and
successfully enforced, but in the following year, the same urgent
necessity no longer commanding, they were considerably relaxed. At the
end of June, 1883, the cholera made its appearance at Damietta (at one
of the mouths of the Nile), and soon afterward at Rosetta, Port Said,
and Mansourah. During July it spread to various places in direct
communication with those named. At Cairo it was peculiarly fatal, and
on July 20th it was reported to have caused 600 deaths. For several
days the daily mortality varied between 500 and 600. The disease
prevailed somewhat in Alexandria during the height of the epidemic,
and near the end of October it was fatal to numerous European
residents of that city, and some deaths occurred in the British army
of occupation. In all Egypt, during the week ending Aug. 13th, the
total mortality is said to have been 5000, but in the following week
it fell to 2000. It is estimated that the epidemic destroyed at least
20,000 lives. The germ of this epidemic has not been accurately
determined. Some regard it as a survival of the cholera of the
previous year--a supposition which is at least plausible and
sufficient; but certain "sanitarians" have attributed the outbreak to
the ordinary causes of disease intensified by the civil war which had
recently devastated Egypt. It is sufficient here to say that while
such causes have in all ages generated typhus and typhoid fevers and
dysentery, they never produced cholera. Some, more unwise than
judicious, declared that the Egyptian disease of 1883 was not cholera.
It is alleged, on the one hand, that several East Indian merchants
from Bombay arrived at Damietta on June 18th, or three days before the
disease was recognized in that city. It is also said that a stoker
from on board an English steamer from Bombay introduced the cholera
into Damietta. But the judgment of Surgeon-General Murray carries with
it greater weight.[3] He is of the opinion that the Egyptian epidemic
of 1883 was simply a revival of the Arabian epidemic of 1882. He shows
that cholera existed in several villages on the Damietta branch of the
Nile in the latter part of May and during June, and that it broke out
in the capital itself, during a fair which had lasted for eight days,
on the 22d of June, and was spread by the people on their return from
Damietta to their villages. This, adds Mr. Murray, "is a literal
transcript of the accounts of many of the severe epidemics that have
raged over India." It also appears from M. Proust's narrative[4] that
the Ottoman government had already, as early as April, notified the
government of Egypt that certain Indo-Javanese pilgrims were on their
way to Mecca, and that ought not to be allowed to land without
quarantine. The French delegate to the sanitary council also begged
that those of the pilgrims who reached Suez without previous
quarantine should be isolated and kept under {720} surveillance for
three days. But owing to the opposition of the English delegates these
measures were not duly enforced, the council did not meet again, and
no protective system was adopted.
[Footnote 3: _Times and Gazette_, Feb., 1884, p. 209.]
[Footnote 4: _Le Cholera_, 1883.]
ETIOLOGY.--The essential cause of cholera is unknown, unless the
investigations of Koch, described below, may have revealed it. Its
secondary causes, or the conditions of its dissemination, are better
understood. Some general propositions concerning them will here be
laid down, and illustrated so far as the argument requires and the
available space will allow.
Cholera is endemic in no other country than India, and more
particularly in Bengal. When it has occurred elsewhere it has
invariably been carried from India. The cholera poison has been
imagined to be of an aërial nature, but its diffusion has no relation
whatever to the velocity or the direction of the wind. In no instance
whatever has its rate of progress exceeded that of man on land or
water, nor has it ever taken a direction different from that of
commercial or military movements. On land it has usually crept from
place to place, and if sometimes it has seemed to leap across wide
spaces, and even seas and oceans, it has never invaded any inland town
or seaport without having been brought thither from a point already
affected with the disease. Nor, having once entered an inland or
seaboard town, does it spread equally therein in all directions, but
prevails chiefly in the quarter immediately surrounding the place of
its entrance. If appropriate sanitary measures are enforced, it is
sometimes confined to that quarter, and, in the case of quarantine
stations, it has repeatedly been prevented from extending beyond them.
This statement may be illustrated by the fact that of fourteen
epidemics of cholera at Staten Island, the quarantine station of New
York, all but four were prevented from reaching that city.[5] When the
disease does overleap the barrier opposed to it, its origin and
subsequent course can usually be traced.
[Footnote 5: Peters's _Notes, etc._, 2d ed., p. 94.]
A high atmospheric temperature is everywhere associated with the
prevalence of cholera. Its origin in the hot climate of Hindostan and
its general progress prove this conclusively. In nearly all of the
places where a great difference exists between the summer and the
winter temperature the disease has disappeared during the cold season,
and attained its greatest intensity during the hot months of the year.
The only apparent exception to this rule is, that cholera has
prevailed in several Russian, Swedish, and Norwegian cities during the
winter. But these very exceptions confirm the rule; for in the
countries mentioned the intense cold of the winter compels the
inhabitants to seal their houses by every possible means, while the
atmosphere within them is kept at a high temperature by huge stoves,
which hinder ventilation, and indeed render it almost impossible.
Difference of temperature likewise explains the fact that of two
cholera-ships arriving from Havre, the one at New York and the other
at New Orleans, in December, 1848, the former did not disseminate the
disease, but the latter formed the starting-point of an epidemic which
lasted all the winter.
A good deal has been written of the predisposing causes of cholera,
and poverty, crowding, filth, intemperance, and depression of spirits
have been given prominent places in the catalogue. But to any one
familiar {721} with the history of epidemic diseases it will at once
be apparent that every one of these conditions favors the spread of
all communicable infectious diseases. There is not the slightest
evidence that these agencies, singly or combined, can generate cholera
or favor its spread apart from the presence of the specific poison of
the disease and the facility with which it is transmitted from the
sick to the well whenever the population is crowded, poor, of filthy
habits, and weakened by dissipation. Because among such people
intemperance prevails, this vice has been regarded as predisposing to
cholera. Apart from the brutish mode of living of drunkards, there is
nothing to show that they are more liable to cholera than the most
abstemious of water-drinkers. On the contrary, it is notorious that
during cholera epidemics drunkards in the better classes of society
enjoy a certain degree of immunity from the disease; which it is easy
to explain on the ground that they imbibe but little water, which is
the main channel through which the infectious principle of the disease
is spread.
The specific cause of cholera is taken into the alimentary canal, and
acts through it to produce the characteristic symptoms of the disease.
It is conveyed from the sick to the well by means of the
gastro-intestinal discharges, either moist or dry; in the former
state, by means of drinking-water, and in the latter through the air,
whose suspended noxious particles are received into the fauces and
swallowed. There is reason to believe that the poison does not enter
the system through the lungs, or through any other channel than the
gastro-intestinal canal. W. B. Carpenter[6] appears to hold, however,
that the poison may be absorbed through the lungs. To this view there
are two objections: 1, That whatever is taken into the mouth or throat
by inspiration may very well be swallowed; and, 2, that all the
primary lesions of cholera affect the digestive and not the
respiratory apparatus. It is not at all necessary to the propagation
of cholera that its excreta should be furnished by persons laboring
under the fully-formed disease. A specific choleraic diarrhoea is as
infectious as the evacuations which occur in completely developed
cholera. But neither will propagate the disease through the air to a
distance. The tendency to its propagation in this manner depends
chiefly upon the concentration of the poison; thus, it much more
frequently occurs in close than in well-ventilated rooms or than in
the open air. It has been argued that cholera is not contagious,
because so few, comparatively, of the attendants upon cholera patients
contract the disease. On the other hand, as some of them are attacked,
this positive fact outweighs an indefinite number of negative
instances. It should also be noted that different diseases enter the
system and infect it through different channels--some through the
lungs, others through the alimentary canal, etc. Small-pox, the most
contagious of all diseases, is introduced through the air-passages,
and is probably harmless when its virus is taken into the stomach.
That the converse of this proposition applies to cholera is sustained
by the whole history of the disease. Cholera poison may be taken to
considerable distances in either a moist or a dry condition. In the
former state it is mainly conveyed by water, as in rivers,
water-pipes, etc.; in the latter, by fomites and especially by
clothing saturated or merely soiled with cholera discharges, and which
may retain their infectious quality for an indefinite time.
[Footnote 6: _The Nineteenth Century_, Feb., 1884.]
{722} Great stress has been laid upon the humidity and foulness of the
soil, a damp atmosphere, filth, crowding, etc., as elements in the
production of cholera, but in reality they have no more essential
relation to it than to any other disease that occurs epidemically.
Cholera may prevail whether they are present or absent. It is evident
that from the earliest historical periods all of these causes of
disease have existed, and in Europe much more generally and
excessively than during the present century, and that they have never
been removed in Asia Minor, Egypt, Arabia, and Africa. Yet cholera
never was known in any of these countries until it was brought into
them about the end of the first third of the present century.
According to Pettenkoffer, cholera is most prevalent when the subsoil
water is lowest, and least so when the subsoil water is highest. It
would be more descriptive of the fact to say that, so far as cholera
has anything to do with the condition of the soil, it is most apt to
be severe and prevalent when very dry weather follows a very wet
period. Such circumstances are the most favorable to putrefactive
fermentation and the dissemination of its products, which thus reach
wells of drinking-water, and even rivers, especially when sewers empty
into the latter. The identity of this explanation with that which is
generally accepted for the dissemination of typhoid fever is too
evident to be insisted upon. We might go farther, and say that, in
typhoid fever as in cholera, the disease is communicated, although
exceptionally, by the air of the sick room and by the exhalations of
the soiled fomites of the patient. Now, if typhoid fever resembled
cholera not only in being transmitted by means of the dejections, but
also in its poison being derived from one primary source only, the
analogy between the causes of the two diseases would be very striking
indeed. But, in point of fact, the typhoid-fever poison may probably
be generated de novo by fecal fermentation and other forms of
putrefaction, and the disease is only exceptionally communicable;
whereas, the poison of cholera, once received, is conveyed from man to
man and far and wide through various channels; but, so far as is
known, it has but one primary source, and that is in India. Lebert
states that he did not find the localities that are the ordinary seats
of typhoid fever peculiarly liable to invasions of cholera. But it
must be noted that typhoid fever is very far from being exclusively a
disease of the poor, squalid, and vicious. Like death itself, "regum
turres pauperumque tabernas æquo pede pulsat;" while cholera much more
commonly plants itself and disseminates its seeds in the rank soil of
moral and physical degradation.
All morbid causes whatever, derived from race, climate, religion,
dwellings, food, clothing, habits of living, etc., have no more to do
with the development of cholera than with that of the eruptive fevers,
and even less than with the causation of typhus and typhoid fevers and
dysentery. The eruptive fevers are caused, as cholera probably is, by
specific germs which no known combination of natural causes has ever
developed, while the poisons of the other diseases named appear to be
generated anew whenever certain more or less definite physicial
conditions coexist. It would seem that cholera differs radically from
all of these affections by the fact that its cause does not enter the
circulation, but confines its direct operation to the
gastro-intestinal mucous membrane. In this way it becomes intelligible
that while, on the one hand, physicians and nurses of {723} cholera
patients, although often, in fact, yet in relation to their numbers,
are comparatively seldom infected, provided they duly observe proper
sanitary rules, the disease, on the other hand, spreads like wildfire
among those who drink water polluted by cholera excretions, and only a
little less rapidly among people crowded into ill-ventilated
apartments along with cholera patients.
The special fomites of the cholera poison are articles of clothing and
furniture soiled with the discharges of the sick, and the emanations
from privies, sewers, etc. into which these discharges have been cast.
Many considerations render it probable that a very small quantity of
cholera matter may suffice to render infectious a very large quantity
of liquid, and especially of matters in process of putrefactive
fermentation, and that the gaseous or vaporous emanations from them
become diffused in the atmosphere and infect all who imbibe them. But
water contaminated by cholera discharges is the most rapid and
efficient agent in disseminating the disease. Innumerable instances of
this mode of action are furnished by its history in Asia and Africa,
where water is often scarce, and naturally so impure that its
additional defilement by cholera dejections is apt to pass unnoticed.
From the illustrations of this proposition which might be adduced only
a few of the more striking will here be selected.
Hurdwâr is a town in Northern India at the base of the Himalayas,
where the Ganges begins its course in the plains. It is the seat of a
great Hindoo pilgrimage, which takes place annually in April, when
sometimes from 2,000,000 to 3,000,000 of people occupy an encampment
of about twenty-two square miles, comprising a low flat island in the
Ganges and the opposite banks of the river. Bathing in the sacred
stream on a certain day is the main object of the devotees; which day,
in the year 1867, fell on the 12th of April. The bath was taken early
in the morning. From noon on that day the pilgrims began to disperse
so rapidly that on the morning of the 15th the encampment was quite
deserted. It appears that up to the former date the health of the
encampment was excellent, and it was the opinion of the reporter (Dr.
Cunningham) that cholera was introduced into the camp by pilgrims from
the neighboring districts going late to the fair. He believed that the
cholera excreta may have been buried in the trenches and carried by a
heavy rain into the river, and there swallowed by the pilgrims; for to
drink of the water of the Ganges as well as to bathe in it is a
religious obligation.