surrounding districts, the epidemic widening in all directions. The
pilgrims were almost always the first persons attacked in any
locality, and the cholera attended them on their route wherever they
went. In all the districts where the disease prevailed no cases
occurred until ample time had been given for the pilgrims to reach
them. In a word, "the cholera first showed itself among them; it
followed their lines of route only, and did not outrun them; their
progress was its progress, and their limits its limits." The mortality
caused by this epidemic among the whole civil population of the
North-western Provinces of the Punjâb has been estimated at about
117,181.[7] The history of the religious festival of 1879 {724} was
identical with that just sketched, except that the number of the
pilgrims was smaller and the deaths proportionally less.[8]
[Footnote 7: _Brit. and For. Med. Chir. Rev._, Jan., 1870, p. 137.]
[Footnote 8: Murray, _Practitioner_, xxvi. 309.]
Out of the numberless illustrations of the manner in which cholera is
disseminated by water the following may be cited: In 1865 about
100,000 pilgrims were assembled at Mecca, of whom from 10,000 to
15,000 fell victims to the disease, two-thirds of them within a period
of six days. Some cause acting simultaneously upon the whole number of
persons must be admitted to account for so extraordinary a fact, and
such a cause is not far to seek. At a certain sacred well "one hundred
thousand people had skinfuls of water poured over them at the side of
the well, and every one of them then drank largely of water drawn from
the well. Much of the water poured over the pilgrims must have found
its way by soakage back into the well, and if any of the pilgrims were
at the time suffering from cholera, or had cholera-tainted garments
about them, the well would be exposed to pollution."[9]
[Footnote 9: Christie, _Cholera Epidemics in East Africa_, p. 488.]
In the cholera epidemics of Zanzibar the disease produced the greatest
havoc among the negroes, the Persians, and the East Indians; very few
Europeans were attacked, and quite as few of the sect of the Banyans,
who drank only water drawn from their own wells. The persons among
whom the disease prevailed so fatally used chiefly the water of a
certain well which was highly prized, but which on this occasion had
become polluted by soakage from an adjacent cesspool into which the
dejections of cholera patients had been thrown. It appears, also, that
in Zanzibar the streams are very rarely bridged, and hundreds of
negroes, in passing backward and forward, wade through them and
pollute them. In these streams, also, the negroes wash their clothes
and all the foul clothing of the contiguous town. While this business
is going on "a gang of negroes may be at work at not many hundred
yards' distance filling water-casks for the shipping." Subsequently to
the watering of the ships in this manner sailors were attacked with
cholera, and others who used water drawn from the stream below the
place where it became polluted were attacked, and many of them died;
while Europeans living on shore, and who drank the water of the same
stream, but drawn from a much higher point in its course and after
having been filtered, escaped the disease.[10]
[Footnote 10: _Ibid._, pp. 320, 492.]
The history of the disease in Europe furnishes a multiplicity of
similar cases, and even more distinctly exhibits the dissemination of
cholera by contaminated water.[11] In Holland not less than five
epidemics of the disease occurred between 1832 and 1869, all of them
causing a great mortality, to which the epidemic of 1866 alone
contributed not less than 20,000 deaths. This was about 55 deaths for
every 10,000 inhabitants. Such exceptional mortality over so wide a
territory has been ascribed to the extreme porosity and humidity of
the soil, which is nearly all below the level of the sea. Such a soil
must necessarily retain longer than other soils whatever it absorbs,
and thus tend to render the well-water habitually impure. If, then, to
the ordinary impurities a specific {725} poison is added, its
characteristic effects may assuredly be looked for. The conditions now
stated explain the conclusions of Ballot of Rotterdam, drawn from a
study of the several epidemics referred to. They are as follows: "1.
Holland is highly affected by the cholera at every epidemic, chiefly
in those parts where they drink water directly from the rivers and
canals or from ground saturated with sewage. 2. In places where
rain-water is generally drunk the disease is far less violent. 3.
Places where there is no other drinkable water but rain-water are not
affected by the epidemic; the single cases occurring there are
imported. 4. When places affected by the cholera were supplied with
pure water instead of the vitiated water the disease disappeared."[12]
In like manner, we find that the cholera epidemic of 1873 in Germany
seemed specially to select those situations where the subsoil was
impregnated with decomposing organic matter; and it is evident that,
in cities especially, such situations would include the most
poverty-stricken districts, while the higher, drier, and at all times
more salubrious localities are inhabited by the classes enjoying the
greatest material prosperity.[13]
[Footnote 11: It is of interest to note that on the first appearance
of cholera in England, at Sunderland, in 1831, a surgeon of that
place, Mr. Ainsworth, collected and published conclusive proofs of the
importation of the disease, of its communication from the sick to the
well, "and of its propagation by clothes, and even by emanations, from
the dead" (_Observations on the Pestilential Cholera_, London, 1832).]
[Footnote 12: _Med. Times and Gaz._, May, 1869, p. 459; June, 1869, p.
626.]
[Footnote 13: "Report of the German Imperial Commission,"
_Practitioner_, xxvi. 153.]
This mode of infection has been traced in numberless individual cases
of cholera. In London there was a certain well into which the liquid
contents of a sewer had been percolating for months. Of the water of
this well hundreds of persons had been drinking without obvious
injury. At last a case of cholera occurred hard by; the discharges
were thrown into a privy which communicated with the sewer and
indirectly with the well, whereupon more than 500 persons who drank
water drawn from that particular well were attacked with cholera
within three days. So in 1856 cholera prevailed in the county jail of
Oxford, Eng., the drain from which emptied into a pool from which the
water was drawn to supply the city prison. In the latter institution
cholera began to prevail, but declined as soon as the pipes conveying
the water were cut off, and soon afterward ceased entirely.[14] Again,
in Constantinople in 1865 the clothes, mattrasses, etc. of cholera
patients were washed at a fountain the basin of which was divided into
two parts by a wall; one part was used for washing clothes and the
other for drinking purposes. Unfortunately, the waste-pipe of the
former being obstructed, the foul water of one side communicated with
the clean water of the other, and in one day 60 people died of cholera
in the small portion of the city which was supplied from the infected
source. The striking case has often been cited which occurred at
Epping, Eng., where a woman brought the disease from a distance into a
perfectly healthy house and neighborhood, and of ten persons affected
with it seven died, including a physician in attendance upon one of
them. An examination of the premises "discovered, below the pipes
leading from the water-closet and from the eye-hole of the sink
through which the choleraic dejections had been passed, a leakage
which extended under the foundations of the building and entered the
well. The sewage was distinctly traceable on the side of the well
corresponding with the leakage in the drain." After this discovery and
the disuse of the foul water not another case occurred.[15] In 1868,
Dr. {726} Farr, in his _History of the London Cholera Epidemic of
1866_, showed that water into which cholera dejections find their way
produces cases of cholera all over the district in which it is
distributed for a certain period of time, and that if the distribution
is in any way cut short the deaths from cholera begin to decline
within about three days of the date at which the distribution is
stopped.[16]
[Footnote 14: _Edinb. Med. Jour._, i. 1122.]
[Footnote 15: _Trans. of the Epidemiological Soc._, ii. 428.]
[Footnote 16: _Lancet_, April, 1868, p. 217.]
Analogous instances are furnished by every cholera epidemic of which
the history has been accurately observed, including that which
extended so widely over the United States in 1873. Most of the
following are cited from the official reports prepared, under the
direction of the Surgeon-General of the army, by Surgeon Ely McClellan
and Dr. John C. Peters. Several of the first cases, however, are
foreign.
In 1861, at a station in India, some fresh cholera dejecta found their
way into a vessel of drinking-water. Early on the following morning a
small quantity of this water was swallowed by nineteen persons, five
of whom were attacked with cholera between the first and the third day
afterward.[17] In 1876 an outbreak of cholera took place in a village
in Hindostan, which followed the arrival of wedding-guests, one of
whom was attacked, and from whom it rapidly spread. The soiled clothes
of one or more of the patients were washed in a pool from which all
the villagers obtained their drinking-water, and on the discontinuance
of this source of water-supply cholera speedily diminished in
frequency and fatality.[18] In the German epidemic of 1873 many cases
occurred where persons deriving their drinking-water from special
sources were attacked with cholera, while their neighbors, supplied
from a different source, remained free. Again, it has frequently
happened that outbreaks of cholera have been checked by the
prohibition of the suspected water and the substitution of a pure
supply.[19] It seems probable that a very small portion of cholera
discharges suffices to infect a very large body of water and maintain
its infectiousness for a considerable time.
[Footnote 17: Macnamara, _op. cit._, p. 196.]
[Footnote 18: Surg.-Major Cornish, _Practitioner_, xxiv. 215.]
[Footnote 19: _Practitioner_, xxvi. 159.]
In December, 1871, an outburst of cholera occurred which was confined
to the inmates of three excellent houses in a fine block of buildings
in Calcutta. There had been no cholera in that neighborhood for four
years. Within forty-eight hours a majority of the lodgers were sick,
and on investigation it was found that the disease was carried in the
drinking-water and in the milk diluted with it.[20] The particular
locality in which Dr. Koch made the discovery of the microscopic
representative of cholera furnishes an example of the same nature: "At
Saheb Ragau, a locality which has repeatedly been visited by cholera
during the last hundred years, numerous cases of the disease were
reported, and these, on inquiry, were found exclusively in the huts
situated round a certain tank. Of the few hundred people who dwelt in
these huts, as many as seventeen died of cholera, though the disease
was not at that time prevalent in the neighborhood, or indeed in the
whole police district of Calcutta. It was proved that, as usual in
such cases, the dwellers around the tank used it for bathing, and drew
thence their drinking-water; it was also elicited that the linen of
the first fatal case, befouled with cholera dejections, had been
washed in the tank."[21] In June, 1873, a new {727} hotel was opened
at Vienna, and many of the guests became affected with diarrhoea that
was attributed to the drinking-water, which was offensive to the taste
and smell. After a fortnight a gentleman died of cholera in the hotel,
and two days later several of the guests were attacked with the
disease, of whom fourteen died. The gentleman who first died was
believed to have brought the poison with him into the hotel, so that
the drinking-water, which previously had been polluted with ordinary
fecal discharges, became specifically affected through him.[22] The
discharges of one ill of cholera were thrown into, and the vessels
used by him were washed near, a well from which all the residents of a
farm-house drank. The wooden curbing of the well had rotted, and the
ground immediately around had sunken; a heavy rain burst the curb,
overflowed the well, and washed into it the entire surface-drainage of
the surrounding ground. No attention was paid to this, and the water
was used as before. It became so offensive that its use was forbidden,
but too late to save the family, nine of whom died of cholera.[23]
[Footnote 20: _U.S. Report_, p. 85.]
[Footnote 21: _Times and Gaz._, April, 1884, p. 527.]
[Footnote 22: _Times and Gaz._, p. 86.]
[Footnote 23: _Ibid._, p. 140.]
At Farmington, Tenn., a man arrived who had contracted the cholera at
Nashville; his illness ran its course at a point just forty paces from
a well. Families that obtained their water from this well suffered in
nearly all their members; where only certain members drank of it, they
alone were affected.[24] At Huntsville, Ala., during an epidemic of
cholera, the city authorities forbade the use of well-water, and
supplied pure water from another source, but only for one week. During
this time no new cases of the disease occurred, and the negroes,
thinking themselves secure, resumed the use of the well-water, and
within four days six fatal cases of cholera occurred in the vicinity.
The use of the well-water was again prohibited, and again the progress
of the disease was arrested.[25]
[Footnote 24: _Ibid._, p. 172.]
[Footnote 25: _Ibid._, p. 408. For other examples of the spread of
cholera by means of drinking-water see Macnamara, p. 149 and seq.]
It has already been intimated that the cholera poison may be diffused
through the air from either moist or dry sources, and especially from
contaminated clothing, and then be taken into the throat and
swallowed. Dr. Richardson refers to a local epidemic in England in
which "the persons most constantly and fatally attacked were the women
who washed the clothes of the sick;" and this circumstance has been
largely confirmed by other observers.[26] In a village not far from
Marseilles, and in an isolated place, a peasant and his wife who had
not left the country sickened and died of the disease. The woman, who
was a laundress, had received a bundle of linen belonging to a person
recently arrived from Egypt, and the husband opened the bundle and
unfolded the pieces. During the Crimean War many of the washermen
attending to the washing of the French hospitals were attacked by
cholera. In the post-office at Marseilles none of the clerks who
handled the outgoing mails were attacked, but of those who sorted the
mails coming from the East, where the disease prevailed, one after
another suffered from cholera.[27]
[Footnote 26: _Trans. Epidem. Soc._, ii. 429.]
[Footnote 27: Read, Boston, 1866.]
The cholera was introduced into Guadaloupe by clothing contained in a
trunk belonging to a person who died on the voyage thither from
Marseilles, where the cholera then prevailed. The woman who washed the
clothing died, with all her family. Attracted by the circumstances of
{728} the case, many came to her house, and of these several died.
From this point the disease spread over the island.[28] A sailor died
at some port in Europe of Asiatic cholera in 1832. A chest containing
his personal effects, clothing, etc. was sent home to his family, who
lived in a small straggling village on the Atlantic coast of the State
of Maine. It reached them about Christmas, and was opened on its
arrival. The inmates of the house were all immediately and suddenly
seized with a disease resembling Asiatic cholera in all its malignity,
and died. There had been no cholera in the State. The last case of
cholera that occurred in the garrison at Malta in the epidemic of 1865
was that of a woman who had stolen a chemise the property of one who
had died of the disease. She put on this fatal garment, probably
soiled with cholera discharges, and certainly unwashed, many days
after the death of its former possessor; she took the disease and
died.[29]
[Footnote 28: _Med. Times and Gaz._, April, 1874, p. 387.]
[Footnote 29: _Lancet_, Feb. 17, 1866.]
It is sometimes said, and oftentimes repeated, that cholera is not
directly contagious--is not communicated by the sick to the well. No
statement could be more unfounded. The whole history of cholera proves
that the physicians and nurses of cholera patients are often affected
by the disease. "In Constantinople no less than twenty-seven
physicians and medical assistants were attacked and died during their
attendance on cholera patients; and in Paris and Toulon similar
results followed. At Halifax, N.S., two of the physicians who
volunteered in aid of the steamer England, which put in there disabled
by the ravages of cholera among the officers and crew, as well as
among the steerage passengers, took the disease, and one died" (Read).
In 1832 the cases of cholera in Edinburgh were in the proportion of 1
to every 1200 of the population of the city, while among those in
attendance upon the sick the proportion was 1 to 5. In 1848-49
one-fourth of the nurses employed in the cholera hospital took the
disease, while in the general hospital, only a few paces distant,
where no cholera patients were received, not a single attendant was
attacked. In the London Hospital, in 1866, none of the medical
officers, volunteer nurses, or sisters were attacked. Of the (regular)
nurses five contracted the disease, and of these four died.[30] In
1849 a severe and fatal epidemic broke out in the Philadelphia
Almshouse. The resident physicians of the hospital were abundantly
occupied with the care of the sick of other diseases, and it was
thought prudent not to allow any, even an indirect, communication
between them and the cholera patients. The latter were therefore
removed to an isolated building in the middle of the quadrangle, and
attended by physicians from the city who had volunteered their aid.
Three or four of these physicians had attacks of cholera, and two of
them died.[31] At this time there was no cholera at all in the city,
and the young physicians could not have become infected outside of the
almshouse. They were attacked while attending the sick of cholera, but
the regular house-physicians, who seldom visited the cholera patients,
escaped altogether.
[Footnote 30: _London Hosp. Rep._, iii. 439.]
[Footnote 31: _Philada. Med. Examiner_, Nov., 1849.]
The importance of recognizing the communicability of cholera is so
great that no apology need be made for introducing the following
additional illustrations of it furnished by Griesinger in his article
on the dangers of cholera to medical men. They are the more important
because {729} in many other instances cholera physicians have suffered
little for their devotion to duty: "At Moscow, in 1840, hospital
attendants contracted the disease to the extent of 30 or 40 per cent.,
while in the general population only 3 per cent. were attacked; at
Berlin, in 1831, in Romberg's hospital, 54 out of 115 persons were
attacked: in 1837 one-fifth of the attendants took the disease, and on
one occasion no less than seven of them fell ill on a single day. In
La Charité Hospital in Paris, in 1849, one-sixth of the attendants had
the disease, while only one-twenty-fifth of the general population of
the city suffered from it; at Mittau, in 1848, one-half of the
physicians took the disease; in 1842, at Toulon, ten health officers
out of thirty-five were ill with cholera, and five of them died, while
of thirty workmen who were employed to carry the dead bodies one-third
succumbed; at Stockholm, in 1853, of 536 attendants one-eighth took
the disease, and half of that number died; at Vienna, in 1854, out of
thirty-six nurses, seven caught the disease, and seven men employed in
removing the dead became affected with a prolonged and exhausting
diarrhoea; in 1849, at Strasburg, five nurses out of ten were
attacked, etc." ... "Physicians, nurses, students, etc. are less
frequently affected, however, than patients ill with other diseases
who are lying in the wards where cholera patients are treated, and are
therefore more constantly exposed to the emanations from the
discharges; and physicians usually suffer less than the attendants who
are constantly waiting on the cholera patients."[32]
[Footnote 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]
[Footnote 33: _Practitioner_, xix. 470.]
[Footnote 34: _Med. Times and Gaz._, March, 1884, p. 281.]