Asiatic cholera

Introduction

The object of this work is to bring together in a condensed form the more prominent views, especially of recent authorities, with regard to this fearfully interesting disease. It is mainly a study of evidence, in which the subject has been considered from many sides, and the result is set down in language as far as possible expressive of the amount of credence to which the different points are entitled.

The communicability of the disease has been dwelt upon at some length, for the adoption of this view is of extreme practical importance ; and it is not a sufficient reply to those facts which are brought forward to prove that cholera is communicable, that in another set of cases, and under circumstances apparently similar, the disease did not extend. It devolves upon those who are unwilling to admit that cholera is transmissible from the sick to the well, to show that the facts in favor of such transmissibility are insufficient evidence. The testimony of the five witnesses who saw the culprit steal the axe, was not weakened by that of the twenty who swore that they did not see the theft. Enough evidence is on record to warrant the assertion, that the connexion between the arrival, from an infected to a healthy and sometimes isolated locality, of those sick with cholera, and the speedy appearance of the disease in that locality, is sufficiently immediate to stand in the relation of cause

IV INTRODUCTION.

and effect. It is also significant that in some cases, as in the ship New York, where it was supposed that no connexion existed with an infected locality, a closer examination has demonstrated that such a connexion did exist, so clear as not to admit of a reasonable doubt.

If a ship laden with poisonous serpents should stop on its passage at different ports, where no such reptiles existed, and soon after its arrival these venomous creatures should be observed in those ports, the natural inference would be that they had been brought thither by that ship ; and it would not be a sufficient reason for disbelieving it, that in some other ports touched by the same vessel, no such reptiles had subsequently made their appearance.

Something has been learned of the characteristics of this pestilence, although very much still remains in obscurity.

It may be claimed as known, that in the large majority of cases the disease is preceded by a premonitory stage which is easily controllable ; that instead of sweeping with the wind over oceans and continents, there is ample reason to believe that human intercourse is the means by which it is propagated, and that the noxious element requires certain foul adjuvants for prolific germination. Accumulating evidence goes to prove that a kind Providence has placed even this great scourge among the number of preventable diseases.

Page 46 — Atlantic should read A talari ta. Page T5— 1855 should read 1865.

ASIATIC CHOLERA.

Chapter I

The successive epidemics of Asiatic Cholera which have prevailed since 1817, when it first left the Delta of the Ganges to become a universal pestilence, have been marked by a striking uniformity in their prominent features. In fact, this uniformity excites a doubt as to whether the destructive epidemics of cholera, which reliable authorities* have described as existing previously to 1817, could have committed such fierce ravages and yet remain within such comparatively narrow limits, if there had been present the same progressive elements which have characterized its subsequent career. It is also remarkable that medical writers of remote antiquity, in describing the cholera as a disease

* Aretseus (A.D. 50) gives an account of cholera, and describes the dejections, loss of voice, general coldness, and suppression of uriue. The disease is also noticed in Sanskrit. From 1^69 to 1190 there are also reliable accounts of cholera (endemic?) by Chisholm, Folly, Curtis, Girdlestone, Jameson, Johnson, Konig, Sonnerat, Thomson, and others. See ''Die Epidemische Cholera. 7 ' Dr. Drasche, Vienna, 1860.

ASIATIC CHOLERA.

indigenous to the banks of the Ganges and detailing its features, do not speak of its epidemic character ; for this is noticed by them as a mark of other pestilential diseases of that period, and is so striking a feature of Asiatic Cholera that it could not have escaped observation if it had been present. The probable inference therefore is, that the cases described were for the most part instances of sporadic cholera, while it is possible that other diseases with somewhat similar symptoms were also described under that name.

From the middle of the eighteenth century to its close, and during the early part of the nineteenth,* there are trustworthy accounts of violent epidemics, yet the disease still remained within its original limits. It is true that epidemics which resembled the Cholera of India prevailed during portions of that period in Madras and Mauritius, also in Pennsylvania (Will. Curie, Philadelphia, 1790) and the Antilles; but it was not until 1817 that the disease displayed those characteristics which have secured for it such a dreadful prominence as the Epidemic Cholera.

It will be interesting to notice the circumstances under which the cholera assumed in 1817 such striking epidemic features, while it may also throw some light upon the nature of the disease.

In the report of Dr. James Jameson,f it is stated that

* Trincomali, 1804; 1814, among the troops at Jaulnah; 1816, in the district of Purneah.

f Eeport on the Epidemic Cholera Morbus as it visited the territories subject to the Presidency of Bengal in the years 181Y, 1818, unusual variations from the ordinary course of the weather were observed in Bengal in February, 1817. This month was more like an autumn one, with rain every third or fourth day. In March there were frequent alternations of clear and cloudy weather with very severe storms. April was more regular, but the rain appeared in May fifteen or twenty days earlier than usual, and then diseases of the bowels made their appearance. June and July were unusually rainy, and there was also much rain in the beginning of August, but in the middle of the month the heat was extreme. Ordinarily the air becomes cooler and more refreshing during the rainy months ; but in 1817 the excessive heat destroyed this beneficial influence. The end of August was accompanied with constant rain, by which the air became suddenly cooled. As a result, while the cases of fever which occurred were mild, there followed severe attacks of diarrhoea and inflammation of the liver, and now cholera made its appearance in a most active form.

The disease had already prevailed during May, June, and July, in Nuddya and Mymunsing, districts far distant from each other, but as it was limited to distinct localities and not often fatal,* no special notice was taken of it until the middle of August, when its virulence and rapid spread caused universal alarm.

and 1819, etc., by James Jameson, Assistant Surgeon and Secretary of the Board. Calcutta, 1820.

* Ueber den Ursprung und die Verhutung der Senchen, &c, von Dr. W. F. P. Kiehl, etc., etc. Berlin, 1865.

It was at this time that Jessore was visited by the disease, and it is a prevalent belief that during this visitation the cholera underwent certain changes, which so modified its character that it became in many respects a new disease, and hence the origin of epidemic cholera has been placed in that town. Previous to the attack upon Jessore the malady had (with the exception of occasional severe local epidemics) prevailed at certain seasons in several places simultaneously, as a disease indigenous to India, apparently produced by atmospheric or malarial causes. It had attacked chiefly the natives, was not greatly feared by foreign residents,* and subsided as the cooler weather came on. But after having appeared as an epidemic in Jessore, it assumed a wandering character, and, as if humanized, passed along the great highways ; stopped at some houses or villages, while capriciously neglecting others ; entered ships, and was carried through rivers and across seas, and followed man all over the world.

Jessore,f a thickly populated town, one hundred miles north-east of Calcutta, is situated in the midst of the Delta of the Ganges, on a flat, reedy bank of the river, slightly elevated above sea-level, on a soil composed of river de-

* Kiehl. "Ueber den Ursprung," &c.

t It was so rare among foreign residents that neither of the physicians who had been connected, one for five, and the other for ten, years, with the General Hospital of the Bengal Presidency for Europeans, had seen a single case of the disease previously to the outbreak of the epidemic.

posits, placed in beds of clay and sand. During August there is little variation in the climate of that vicinity, it having a medium temperature of 81° Fahr., which is the same as that of the river surface. The barometer has a medium height of 29.45. " About eighty miles distant is the tract of Soonderbunds,* and the hot south-west monsoon scatters pestilential vapors over all parts of the Delta for six months of the year. From the 15th July until 15th October, the atmosphere in Bengal possesses all the properties of a filthy vapor bath, producing a sensation of indescribable fatigue and oppression, and an exhausting perspiration.'^ On the north side of Jessore a shallow, almost stagnant, arm of the river extends inwards, having an original bed about seventy-five yards wide. During the rainy season this bed was transformed into a fetid swamp, covered with rank vegetation. By the side of this sluggish water stood the bazaar, and long narrow rows of low, mean huts, surrounded by trees, which afforded shade, but prevented the rapid escape of moisture. The stream was the receptacle for excrementitious matters, and the bodies of partly burned corpses were also thrown into it, in accordance with religious superstition. The water of this stream was also used to some extent for drinking purposes.^

* This is the name given to a large number of low and marshy islands in the Delta, formed by the different channels which the Ganges makes in its course to the ocean.

f Kiehl.

X An estimate has been made that the Granges empties 550.000 cubic feet of sediment every second into the ocean.

In addition to these extremely insalubrious conditions, the rice crop, which furnished the chief subsistence of the natives, had turned out badly in 1817. " Eice is, in consequence of the large proportion of starch and gum which it contains, a good vegetable aliment, but when employed as the sole article of diet, insufficient for the wants of the system. But the blood of the individual depends upon the nature of the food consumed, and therefore the blood of the Bengalese must be of a poor quality, deficient in albumen and fibrin."*

According to an analysis made by J. Moleschott, rice contains, on an average, in 1000 parts :

Gum and Soluble Albumen 50.69

Cellulose 10.18

Starch 822.96

Dextrin 9.84

Sugar 1.73

Salts 5.01

Potash 1.01

Soda 0.13

Lime 0.35

Magnesia 0.21

Oxide of Iron 0.12

Phosphates 3.12

Silicates 0.07

Water 92,04

There are two rice harvests yearly in India. The cho-

* Kiehl.

lera of 1817 occurred about the time of the first harvest, in the rainy season, in August. This first rice is very unwholesome, and the natives consume a third less of it than of the older quality. Sometimes it even produces a fatal disease characterized by vomiting and diarrhoea.* Such food as this would increase any intestinal irritability in a marked degree.

The first cases of cholera noticed in Jessore were in the narrow streets near the swamp, during the rainy season.

On the 19th August, 1817, Dr. Tytler, the physician of the English colony in that city, was called at mid-day by a native physician, to see a middle-aged man who was sick in the bazaar. At first, Dr. Tytler supposed the case to be one of narcotic poisoning, and this suspicion was increased by the fact that the man was to appear as an important witness in a criminal case. The sickness proved fatal on the following day, and then it was discovered that ten others had died with similar symptoms in the same corner of the bazaar, and more lay sick with the disease in other parts of the city.

Now, it does not seem possible that this could have resembled even a severe attack of the ordinary cholera of India ; for Dr. Tytler, who was an intelligent man, and must have seen that disease, considered that this patient was suffering from a specific malady caused by the use of noxious rice.f

* Kiehl.

I Remarks upon Morbus Oryzaeus ; or, Disease occasioned by the

12 ABIATIO CHOLERA.

On the other hand, investigations made after the outbreak of the disease in Jessore, showed that cholera had been prevailing as an epidemic along the Ganges from May until August, and the opinion is quite general that the disease which attacked Jessore was, in its commencement there,, an extension of the epidemic. It is also noticeable that physicians of India who had seen the cholera epidemics of the eighteenth century, and who now saw this later pestilence, considered them as identical diseases. Hence, there is good reason to regard Asiatic cholera not merely as sporadic cholera prevailing epidemically, but as the endemic disease so metamorphosed by some specific influence or agent as to have become what, in the absence of an intimate knowledge of the disease, is termed malignant.* Something similar to this is noticed in the difference between the simple and malignant forms of the exanthemata, and in those throat diseases which assume a grave diphtheritic character.

Why epidemics should be more severe at some periods than at others is a matter of speculation ; yet this is a feature connected with the outbreak of cholera in 181 7 and of subsequent extensive visitations of the disease. They have been preceded by unusual activity of the malady in Hindostan. This was the case with those of 1831 and 1832,

Employment of Noxious Eice as Food. In Two Parts. By Robert Tytler. Calcutta, 1820.

* This term is used to express the effect of certain causes not yet understood.

and in 1860 the epidemic prevailed extensively in the valley of the Ganges between Calcutta and Putna. In 1861 the most serious epidemic since 1846 broke out in and extended over the north-west provinces of India. While pursuing this course it appeared in Candahar and Bagdad, on the western and thrice followed track. In 1863 the mortality of the disease in Bombay was fifty per cent, above the average ; and in March, 1865, the cholera showed itself on the banks of the Ganges, and prevailed as an epidemic for twenty-two days without leaving the country.

A review of the circumstances connected with the outbreak of epidemic cholera presents the following facts. A season of unusual atmospheric changes was accompanied by an earlier and more general visitation of endemic cholera. The fatality was not very marked until August, when, perhaps rendered more active by the advanced season, it visited during the rainy months a locality in the malarious Delta of the Ganges, slightly elevated above sea level, having a fetid swamp beside it which served as a receptacle for excrementitious substances, and the water was also sometimes used for drinking. The inhabitants, degraded and filthy,* were badly nourished or partially poisoned by a defective crop of the staple which formed their principal subsistence. The streets were narrow and dirty, the huts overcrowded, and the air within them poisoned by emanations resulting from excessive crowding. In short, malaria,

* Report of College of Physicians of Philadelphia to Board of Health. Philadelphia, 1832.

9* defective nourishment, and animal filth, stand forth prominently in connexion with the outbreak of the cholera in Jessore.

Such circumstances would be likely to produce disease, or to modify it when originated. The instances are very common in which a low state of the system will render a mild disease severe, and transform even a simple incision into a gangrenous ulcer. Even vaccination, under similar conditions, is followed by very severe inflammation, while the influence of filth and crowding, in giving increased virulence to disease, is generally admitted. Martin notices the effect of these causes, and says : " It was amongst the poor, ill-fed, ill-clothed, and crowded inhabitants of Jessore that epidemic cholera made its first appearance."

In this connexion may be noticed the early cessation of a severe cholera epidemic, which is narrated by Kiehi to show the effect of favorable hygienic conditions in arresting disease.

In 1783 more than a million of pilgrims came to Hurdivar in India, during the time of the April full moon, to bathe in the sacred waters of the Ganges. It was their custom to pass the night near the river with scarce a roof to cover them, or under the open sky. The climate of this vicinity is very changeable ; hot, sultry days, alternated with cold nights and heavy dews, while the proximity of high mountains rendered it liable to sudden blasts of cold mountain air. The cholera broke out soon after the commencement of the ceremonies and destroyed over twenty thousand souls. Yet the town of Juvalapore, ©nly seven miles distant, was not affected by the disease, and the pestilence ceased when the pilgrims separated.

The chief reasons assigned for the cessation of this epidemic are, firstly : That the causes which occasioned it were of a passing or temporary character ; that is, it originated among a transitory population. Secondly : Hurdivar was about seven hundred miles from the mouth of the Ganges, and nine hundred and fifty feet above sea level. Besides, the pilgrims were not in houses, but encamped in the open air, and the disease appeared early in the season, before the protracted summer heat.

Some have considered the different varieties of cholera (cholera morbus, sporadic cholera, endemic cholera, cholera Asiatica) to be varying grades of the same morbid process, depending upon differences in climate and surroundings for the variations in intensity. There is a similarity in the symptoms of each, so great, occasionally, as to cause perplexity in diagnosis, and the post-mortem appearances of sporadic cholera have sufficiently resembled those found in Asiatic cholera to lead some authorities (Andral, Brown, Ferrus, Griesinger*) to regard them as essentially similar. With regard to the distinction drawn between sporadic and epidemic cholera, from the absence of bile in the dejections of Asiatic cholera, Memeyer says : " It must not be inferred from the paleness of the dejections, that the formation or

* Die Epidemische Cholera, von Dr. Drasche. Vienna, 1860. Page 308.

excretion of bile has ceased ; for even if the bile were produced in normal quantity and poured into the intestine, it could not exert any marked effect upon the coloration of such a large quantity of fluid."

Yet, as has been previously said, there is good reason to believe that epidemic cholera is something more than an aggravated form of the endemic variety, but the relations which they bear to each other are at present a matter of opinion on which high authorities differ, and which still waits for a satisfactory solution.

There have also been decided differences in the views taken by able observers, concerning the nature of the ultimate cause of epidemic cholera. Even as early as after the first general invasion of cholera, the theory was advanced that the ultimate cause of the disease was of an animal nature. An infusorial contagion, originating in the swampy districts of Hindostan, while plausible, is thought to explain some of the strong peculiarities of the disease. The almost marvellous vitality of microscopic animalcules, as well as of their germs, is supposed to account for the periodic renewals of the disease at comparatively short intervals—latent germs being quickened — either as the result of fortuitous circumstances, or in consequence of peculiar inherent laws.* The extinction of epidemics also has its

* A distinguished lady of title has lately made a communication to the French Academy of Sciences, in which she declares that she has discovered the cause of cholera in a microscopic insect which she calls the " winged leech," and which, she says, is developed espeanalogue in the entire extermination of myriad swarms of insects; but a thorough examination of the infusorial world during cholera epidemics has given no positive results, so that the question still remains unanswered. The same may he said with regard to the theory that the cholera contagion is of a vegetable nature ; a fungoid growth developing in the cholera dejections. Pettenkofer's opinion is very decided upon this point, and is thus expressed, in a recent journal : " Without the least danger of making an error, we can assert that the substance in question (the ultimate cause of cholera), although quite unknown to us as a separate entity, must be of organic nature, and either a cell or a ferment."*

The solution of these questions would not only be of the greatest importance, as related to cholera, but would, in all probability, throw much light upon many obscure points in other diseases.

cially in marshy and filthy localities. The details she gives in relation to this animalcule and its connexion with cholera, are so minute that the Academy, which commenced by laughing at the first paragraphs of the report, finished by deciding to investigate the matter. — Letter from Paris in New York Times of February bth, 1866. The correspondent, "Malakoff," is an American physician, living in Paris.

* Beilage zur Allgemeinen Zeitung, October 9th, 1865.

Chapter II

The evidence in favor of the contagious nature of cholera is, mostly if not altogether, of a circumstantial character. While the disease is not contagious in the same manner as small-pox and scarlatina, yet the well authenticated cases are so numerous, in which a direct connexion has been traced between the origin of a cholera epidemic, and the arrival of an individual from an infected to a previously healthy neighborhood, that there should be no doubt as to the spread of the disease by human intercourse. This point may be considered as so well established that a practical disregard of it involves the assumption of a grave responsibility.

The evidence which is advanced against the contagiousness of cholera does not weaken the accumulated force of the facts in its favor, some of which do not admit of a reasonable doubt, but it only shows that the liability to contagion is diminished, or strengthened, by certain localizing causes.

Preconceived opinions, although honestly taken, have been in many instances an obstacle to the belief in the communicability of cholera from individual to individual, and the same result has been produced in others from a failure to appreciate the indirect manner in which the disease is believed, on good evidence, to be communicated.

The other methods supposed to account for the extension of cholera are, in general terms : — Progressive atmospheric influence, local atmospheric influence, and terrestrial emanations.* It has been found, however, that as diffusive agents they are insufficient to explain the peculiar features and progress of the malady.

The following opinions, from a distinguished authority, upon certain atmospheric conditions supposed to favor cholera epidemics, are the results of extensive experience, and are entitled to very great respect :

" Great importance has been attached to the meteorological conditions attending an outbreak of cholera ; they do not appear to be very important except in two or three cases.

" 1. Temperature. — High temperature favors spread by increasing the putrefaction of the stools, and by augmenting generally the impurity of the air. When cholera has prevailed at a low temperature (it has been severe at a temperature below freezing), the drinking water has possibly been the cause.

" 2. Pressure. — Pressure has no effect. The old observation of Prout, that the air is heavier in cholera epidemics, has never been confirmed.

" 3. Moisture in Air. — Combined with heat, this seems an accessory cause of importance, probably by aiding transmission.

" 4. Dryness of Air. — Seems decidedly to check it.

" 5. Rain. — Sometimes augments, sometimes checks, it.

* Byrne on Cholera, page 28. Philadelphia, 1854.

This, perhaps, depends on the amount of rain. A very heavy rain is a great purifier.

" 6. Movement of Air. — It is certainly worse in stagnant atmospheres, as in the cases of all the specific poisons.

" 7. Electricity. — Is not known to have any effect. This was particularly examined by M. Lamont, in Munich, one of the most celebrated physical philosophers of our time, but with entirely negative results.

" 8. Ozone — Has no effect on its presence or absence (Schultze, Voltolini, Du Methe, Lamont)."

The history of cholera shows that its usual method of progress is from a centre * in more or less irregular directions ; yet, at the same time, its course has been more strongly imprinted along the chief lines of trade and intercommunication.! The grand routes of travel and traffic have always been especially marked in its progress ; it has followed large bodies of men in motion ; and when it has passed from one continent to another, the first cases have been observed in seaport towns, from which it has spread to the interior.

" Cholera has frequently attached itself to bodies of troops on their march in India, and has remained with

* Reports on Epidemic Cholera, etc., by William Baly, M.D., and William W. Gkill, M.D. Lond. 1854, p. 96.

f " Hastened down the Ohio and Mississippi rivers to New Orleans with the rapidity of a steamboat." — Byrne on Cholera. Pettenkofer explains the prevalence of cholera near rivers by the presence of moisture held by the soil (grundwasser), which he regards as a chief localizing cause.

tliem during many days in their passage over long tracts of country, the inhabitants of which were not suffering from the epidemic. The duration of the epidemic in marching regiments is stated by Dr. Lorimer, who has collected the largest number of instances, to be, in the majority of cases (in 88 out of 121), less than thirty days. It has often, however, been longer, and in the more severe outbreaks, the epidemic reached its climax in the regiment about the eighteenth day. Many points relating to these attacks of marching troops in India are matter of dispute, but the fact that the disease remained with them for many days, when it did not prevail in the country round, seems not to be gainsaid: and here, again, the inference is irresistible that the cause of the disease travelled with the troops, and affected different men in succession."*

Byrne notices the singular circumstance that, although at the date of his writing (1854), thirty-four years since the cholera first reached Canton, it had never crossed the atmosphere of the Pacific ; yet since immigration to America had become very extensive it had crossed the Atlantic a number of times.

Besides, it cannot be regarded as a mere coincidence that the disease should never have been seen on the coast of South Carolina before the arrival of the brig Amelia in October, 1832, at Folly Island ; and that the only cases on the island were of those employed about the vessel ; or that the first cases at Detroit occurred soon after the arrival of the * Baly and Glull, page 135.

Henry Clay, July, 1832, with cholera on board ; or that it never should have appeared at Key West until the arrival of the Ajax, which had sailed from the infected port of New Orleans, and which arrived at Key West with the disease on board ; besides many other well authenticated instances of a similar character.

The present epidemic is consistent with previous ones in affording evidence that the disease has been mainly diffused along the lines of travel by means of human intercourse.*

Dr. Tilbury Fox, who was travelling in Syria at the time when the epidemic prevailed there, states, that numbers of

* Dr. Althaus in a letter to the Medical Times and Gazette, dated October 30th, 1865, writes the following with regard to the recent introduction of cholera into Saxony: "In Berlin, Yienna, and other large towns no case of cholera has as yet occurred. But the disease has been imported into the very heart of Saxony by a few travellers who left Odessa some weeks ago when cholera was at its height there. These gentlemen, a few days after, having arrived at Altenburg, a small town near Leipzig, fell ill and died with all the symptoms of cholera. Several of the inhabitants of Altenburg were subsequently affected and died, and the disease then spread to "Werden, a neighboring town which is in railway communication with Altenburg, and where the epidemic has assumed comparatively large dimensions. Up to October 20th there had been 149 cases of cholera at Werden, of which 52 proved fatal ; and according to the latest accounts the epidemic is by no means decreasing. This insulated outbreak of cholera in a previously healthy country, and which is clearly traced to persons coming from a centre of infection, must prove an important link in the evidence already accumulated to prove the contagious nature of the disease."

pilgrims from Southern India died of cholera during the months of February and March, at the Arabian ports of Djeddah and Moculla, Eighty deaths occurred on one vessel which arrived off Moculla in mid-winter, before the companions of those who had died left the ship for Mecca. Egyptian physicians have also established the fact beyond question, that the disease advanced in the last weeks of May from Arabia along the North African coast, and Egypt was soon visited by the pestilence conveyed thither by the flying pilgrims.* In the report of the chief physician at the Isthmus, it is stated that nearly 20,000 pilgrims, all more or less infected, passed Suez in order to embark at Alexandria for Europe or elsewhere. Suez, Alexandria, and Marseilles were healthy until some pilgrims from Mecca, who had embarked at Djeddah, where the cholera prevailed, arrived at those ports.