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, {751} 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."
[Footnote 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 {752}
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.
[Footnote 54: _Times and Gaz._, Dec., 1870, p. 725.]
[Footnote 55: _Archives gén._, Mars, 1870, p. 308.]
[Footnote 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 {753}
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.
[Footnote 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 {754} 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
{755} 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.
[Footnote 58: _Practitioner_, xii. 226.]
[Footnote 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, {756} 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 {757} quarantine
in "arresting the march of cholera" arose "rather from the
unintelligent application of the measure than from any fallacy in its
principle."[60]
[Footnote 60: _Practitioner_, xxviii. 393.]