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MALIGNANT CHOLERA (synonyms, Asiatic ...

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Originally appearing in Volume V06, Page 267 of the 1911 Encyclopedia Britannica.
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MALIGNANT See also:CHOLERA (synonyms, See also:Asiatic Cholera, See also:Indian Cholera, Epidemic Cholera, Algide Cholera) is one of the most severe and fatal diseases. In describing the symptoms it is customary to See also:divide them into three stages, but it must be noted that these do not always See also:present themselves in so distinct a See also:form as to be capable of See also:separate recognition. The first or premonitory See also:stage consists in the occurrence of See also:diarrhoea. Frequently of mild and painless See also:character, and coming on after some See also:error in See also:diet, this symptom is See also:apt to be disregarded. The discharges from the bowels are similar to those of See also:ordinary summer cholera, which the attack closely resembles. There is, however, at first the See also:absence of vomiting. This diarrhoea generally lasts for two or three days, and then if it does not gradually subside either may pass into the more severe phenomena characteristic of the second stage of cholera, or on the other See also:hand may itself prove fatal. The second stage is termed the stage of collapse or the algide or asphyxial stage. As above mentioned, this is often preceded by the premonitory diarrhoea, but not infrequently the phenomena attendant upon this stage are the first to See also:manifest them-selves. They come on often suddenly in the See also:night with diarrhoea of the most violent character, the matters discharged being of whey-like See also:appearance, and commonly termed the " See also:rice-See also:water " evacuations. They contain large quantities of disintegrated epithelium from the mucous membrane of the intestines. The See also:discharge, which is at first unattended with See also:pain, is soon succeeded by copious vomiting of matters similar to those passed from the bowels, accompanied with severe pain at the See also:pit of the See also:stomach, and with intense thirst.

The symptoms now advance with rapidity. Cramps of the legs, feet, and muscles of the See also:

abdomen come on and occasion See also:great agony, while the signs of collapse make their appearance. The See also:surface of the See also:body becomes See also:cold and assumes a See also:blue or See also:purple See also:hue, the skin is dry, sodden and wrinkled, indicating the intense draining away of the fluids of the body, the features are pinched and the eyes deeply sunken, the See also:pulse at the See also:wrist is imperceptible, and the See also:voice is reduced to a hoarse whisper (the vox cholerica). There is See also:complete suppression of the urine. In this See also:condition See also:death often takes See also:place in less than one See also:day, but in epidemics cases are frequently observed where the collapse is so sudden and complete as to prove fatal in one or two See also:hours even without any great amount of previous purging or vomiting. In most instances the See also:mental faculties are comparatively unaffected, although in the later stages there is iin See also:general more or less apathy. Reaction, however, may take place, and this constitutes the third stage. It consists in the See also:arrest of the alarming symptoms characterizing the second stage, and the See also:gradual but evident improvement in the patient's condition. The pulse returns, the surface assumes a natural hue, and the bodily See also:heat is restored. Before See also:long the vomiting ceases, and although diarrhoea may continue for a See also:time, it is not of a very severe character and soon subsides, as do also the cramps. The urine mayremain suppressed for some time, and on returning is often found to be albuminous. Even in this stage, however, the danger is not past, for relapses sometimes occur which speedily prove fatal, while again the reaction may be of imperfect character, and there may succeed an exhausting See also:fever (the so-called typhoid stage of cholera) which may greatly retard recovery, and under which the patientmay sink at a See also:period even as See also:late as two or three See also:weeks from the commencement of the illness.

Many other complications are apt to arise during the progress of convalescence from cholera, such as diphtheritic and See also:

local inflammatory affections, all of which are attended with See also:grave danger. When the attack of cholera is of milder character in all its stages than that above described, it has been named Cholerine, but the See also:term is an arbitrary one and the disease is essentially cholera. The bodies of persons dying of cholera are found to remain long warm, and the temperature may even rise after death. See also:Peculiar See also:muscular contractions have been observed to take place after death, so that the position of the limbs may become altered. The soft textures of the body are found to be dry and hard, and the muscles of a dark See also:brown appearance. The See also:blood is of dark See also:colour and tarry consistence. The upper portion of the small intestines is generally found distended with the rice-water discharges, the mucous membrane is swollen, and there is a remarkable loss of its natural epithelium. The kidneys are usually in a See also:state of acute congestion. This form of cholera belongs originally to See also:Asia, more particularly to See also:India, where, as well as in the Indian See also:archipelago, epidemics are known to have occurred at various times for several centuries. Much See also:light has been thrown upon Asiatic cholera by Western experience; and the study of the disease by See also:modern methods has resulted in important additions to our previous knowledge of its nature, See also:causation, mode of dissemination and prevention. The cause is a micro-organism identified by See also:Koch in 1883 (see PARASITIC DISEASES). For some years it was called the " See also:comma bacillus," from its supposed resemblance in shape to a comma, but it was subsequently found Causation. to be a vibrio or spirillum, not a bacillus.

The See also:

discovery was received with much See also:scepticism in some quarters, and the claim of Koch's vibrio to be the true cause of cholera was long disputed, but is now universally acknowledged. Few micro-organisms have been more elaborately investigated, but very little is known of its natural See also:history, and its epidemiological behaviour is still surrounded by obscurity. At an important discussion on the subject, held at the See also:International Hygienic See also:Congress in 1894, See also:Professor See also:Gruber of See also:Vienna declared that the deeper investigators went the more difficult the problem became, while M. See also:Elie Metschnikoff of the See also:Pasteur See also:Institute made a similar See also:admission. The difficultylies chiefly in the variable characters assumed by the organism and the variable effects produced by it. The type reached by cultivation through a few generations may differ so widely from the See also:original in appearance and behaviour as to be hardly recognizable, while, on the other hand, of two organisms apparently indistinguishable one may be innocuous and the other give rise to the most violent cholera. This variability offers a possible explanation of the frequent failure to trace the origin of epidemic outbreaks in isolated places. It is commonly assumed that the micro-organism is of a specific character, and always introduced from without, when cholera appears in countries or places where it is not endemic. In some cases such introduction can be proved, and in others it can he inferred with a high degree of See also:probability, but sometimes it is impossible to trace the origin to any possible channel of communication. A remark-able See also:case of this See also:kind occurred at the Nietleben lunatic See also:asylum near See also:Halle, in 1893, in the shape of a sudden, explosive and isolated outbreak of true Asiatic cholera. It was entirely See also:con-fined to the institution, and the peculiar circumstances enabled a very exact investigation to be made. The facts led Professor See also:Arndt, of Greifswald, to propound a novel .and interesting theory.

No cholera existed in the surrounding See also:

district and no introduction could be traced, but for several months in the previous autumn diarrhoea had prevailed in the asylum. The sewage from the See also:establishment was disposed of on a See also:farm, and the effluent passed into the See also:river See also:Saale above the intake of the water-See also:supply for the asylum. Thus a circulation of morbid material through the persons of the inmates was established. Dr Arndt's theory was that by virtue of this circulation cholera was gradually See also:developed from previously existing intestinal disease of an allied but milder type. The outbreak occurred in See also:winter, and coincided with the freezing of the See also:filter-beds at the water-See also:works. The theory is See also:worth See also:notice, because a similar relation between the drainage and the water-supply frequently exists in places severely attacked by cholera, and it has repeatedly been observed that the latter is preceded by the prevalence of a-milder form of intestinal disease. The inference is not that cholera can be developed de nova, but that the type is unstable, and that a virulent form may be evolved under favourable conditions from another so mild as to be unrecognized, and consequently undetected in its origin or introduction. This is quite in keeping with the observed variability of the micro-organism, and with the trend of modern See also:research with regard to the relations between other pathogenic germs and the multifarious gradations of type assumed by other zymotic diseases. The same thing has been suggested of See also:diphtheria. Cholera is endemic in the See also:East over a wide See also:area, ranging from Bombay to See also:southern See also:China, but its See also:chief See also:home is See also:British India. BpIdem- It principally affects the alluvial See also:soil near the mouths icily. of the great See also:rivers, and more particularly the 'See also:delta of the See also:Ganges. See also:Lower See also:Bengal is pre-eminently the See also:standing See also:focus and centre of See also:diffusion.

In some years it s quiescent, though never absent; in others it becomes diffused, for reasons of which nothing is known, and its diffusive activity varies greatly from equally inscrutable causes. At irregular intervals this See also:

property becomes so heightened that the disease passes its natural boundaries and is carried east, See also:north and See also:west, it may be to See also:Europe or beyond to the See also:American See also:continent. We must assume that the micro-organism, like those of other epidemic diseases, acquires greater vitality and toxic See also:energy, or greater See also:power of See also:reproduction at some times than at others, but the conditions that govern this behaviour are quite unknown, though no problem has a more important bearing on public See also:health. See also:Bacteriology, as already intimated, has thrown no light upon it, nor has See also:meteorology. Some results of modern research, indeed, tend to assign increasing importance to the relations between surface soil and certain micro-organisms, and suggest that changes in the level of the subsoil water, to which Professor Max von Pettenkoffer long ago See also:drew See also:attention, may be a dominant See also:factor in determining the latency or activity of pathogenic germs. But this is largely a See also:matter of conjecture, and, so far as cholera is concerned, the conditions which turn an endemic into an epidemic disease must be admitted to be still unknown. On the other hand, the mode of dissemination is now well understood. Diffusion takes place 'along the lines of human intercourse. The See also:poison is carried chiefly by infected persons moving from place to place; but soiled clothes, rags and other articles that have come into contact with persons suffering from the disease may be the means of See also:conveyance to a distance. There is no See also:reason to suppose that it is See also:air-See also:borne, or that atmospheric influences have anything to do with its spread, except in so far as meteorological conditions may be favourable to the growth and activity of the micro-organisms. Beyond all doubt, the great manufactory of the poison is the human body, and the discharges from it are the great source of contagion. They may infect the ground, the water, or the immediate surroundings of the patient, and so pass from hand to hand, the poison finding en See also:trance into the bodies of the healthy by means of See also:food and drink which have become contaminated in various ways.

Flies which feed upon excreta and other foul matters may be See also:

carriers of contagion. Of all the means of local dissemination, contaminated water is by far the most important, because it affects the greatest number of See also:people, and this is particularly the case in places which have a public water-supply. A single contaminated source may expose the entire See also:population to danger. All severe outbreaks of an explosive character are due to this cause. It is also possible that the cholera poison multiplies rapidly in water under favour-able conditions, and that a See also:reservoir, for instance, may form a sort of forcing-See also:bed. But it would be a See also:mistake to regard cholera as purely a water-borne disease, even locally. It may infect the soil in localities which have a perfectly pure water-• supply, but have defective drainage or no drainage at all, and then it will be found more. difficult to get rid of, though less formidable in its effects, than when the water alone is the source of See also:mischief. In all these respects it has a great See also:affinity to enteric fever. With regard to locality, no situation can be said to be See also:free from attack if the disease is introduced and the sanitary conditions are See also:bad; but, speaking generally, See also:low-lying places on alluvial soil near rivers are more liable than those standing high or on a rocky See also:foundation. Of meteorological conditions it can only be said with certainty that a high temperature favours the development of cholera, though a low one does not prevent it. In temperate climates the summer months, and particularly See also:August and See also:September, are the See also:season of its greatest activity. Cholera spreads westwards from India by two routes—(r) by See also:sea to the shores of the Red Sea, See also:Egypt and the Mediterranean; and (2) by See also:land to See also:northern India and See also:Afghanistan, thence to See also:Persia and central Asia, and so to See also:Russia.

In diWestern Nuslon. the great invasions of Europe during the 19th See also:

century it sometimes followed one route and sometimes the other. It was not till 1817 that the attention of See also:European physicians was specially directed to the disease by the outbreak of a violent epidemic of cholera at See also:Jessore in Bengal. This was followed by its rapid spread over a large portion of British India, where it caused immense destruction of See also:life both among natives and Europeans. During the next three years cholera continued to rage all over India, as well as in See also:Ceylon and others of the Indian islands. The disease now began to spread over a wider extent than hitherto, invading China on the east and Persia on the west. In 1823 it had extended into Asia See also:Minor and Russia in Asia, and it continued to advance steadily though slowly westwards, while at the same time fresh epidemics were appearing at intervals in India. From this period up till 1830 no great See also:extension of cholera took place, but in the latter See also:year it reappeared in Persia and along the shores of the See also:Caspian Sea, and thence entered Russia in Europe. Despite the strictest sanitary precautions, the disease spread rapidly through that whole See also:empire, causing great mortality and exciting consternation everywhere. It ravaged the northern and central. parts of Europe, and spread onwards to See also:England, appearing in See also:Sunderland in See also:October 1831, and in See also:London in See also:January 1832, during which year it continued to prevail in most of the cities and large towns of Great See also:Britain and See also:Ireland. The disease subsequently extended into See also:France, See also:Spain and See also:Italy, and See also:crossing the See also:Atlantic spread through North and Central See also:America. It had previously prevailed in See also:Arabia, See also:Turkey, Egypt and the See also:Nile district, and in 1835 it was general throughout North See also:Africa.

Up till 1837 cholera continued to break out in various parts of the continent of Europe, after which this epidemic disappeared, having thus within twenty years visited a large portion of the See also:

world. About the year 1841 another great epidemic of cholera appeared in India and China, and soon began to extend in the direction traversed by the former, but involving a still wider area. It entered Europe again in 1847, and spread through Russia and See also:Germany on to England, and thence to France, whence it passed to America, and subsequently appeared in the West Indies. This epidemic appears to have been even more deadly than the former, especially as regards Great Britain and France. A third great outbreak of cholera took place in the East in 1850, entering Europe in 1853. During the two succeeding years it prevailed extensively throughout the continent, and See also:fell with severity on the armies engaged in the See also:Crimean See also:War. Although widely prevalent in Great Britain and Ireland it was less destructive than former epidemics. It was specially severe throughout both North and See also:South America. A See also:fourth epidemic visited Europe again in 1865-1866, but was on the whole less extensive and destructive than its predecessors. By some writers the epidemic of 1853 is regarded as a recrudescence of that of 1847. The earlier ones followed the land route by way of Afghanistan and Persia, and took several years to reach Europe. That of 1865 travelled more rapidly, being carried from Bombay by sea to See also:Mecca, from there to See also:Suez and See also:Alexandria, and then on to various Mediterranean ports Within the year it had not only spread extensively in Europe, but had reached the West Indies.

In 1866 it invaded England and the See also:

United States, but during the following year it died down in the West. The subsequent history of cholera in Europe may be stated chronologically. 1869-2874.—This invasion was traced to the great gathering of pilgrims at See also:Hardwar on the Upper Ganges in the See also:month of See also:April 1867. From there the returning pilgrims carried it to the See also:Punjab, See also:Kashmir and Afghanistan, whence it spread to Persia and the Caspian, but it did not reach Russia until 1869. During the next four years a number of outbreaks occurred in central Europe, and notably one at See also:Munich in the winter of 1873. The irregular character of these epidemics suggests that they were rather survivals from the pandemic See also:wave of 1867 than fresh importations, but there is no doubt that cholera was carried overland into Russia in the manner described. 2883-2887.—This visitation, again, came by the Mediterranean. In 1883 a severe outbreak occurred in Egypt, causing a mortality of above 25,000. Its origin remained unknown. During this epidemic Koch discovered the comma bacillus. The following year cholera appeared at See also:Toulon. It was said to have been brought in a troopship from See also:Saigon in See also:Cochin-China, but it may have been connected with the See also:Egyptian epidemic.

A severe outbreak followed and reached Italy, nearly 8000 persons dying in See also:

Naples alone. In 1885 the south of France, Italy, See also:Sicily and Spain all suffered, especially the last, where nearly 120,000 deaths occurred. See also:Portugal escaped, and the authorities there attributed their See also:good See also:fortune to the institution of a military See also:cordon, in which they have had implicit confidence ever since. In 1886 the same countries suffered again, and also See also:Austria-See also:Hungary. From Italy the disease was carried to South America, and even travelled as far as See also:Chile, where it had previously been unknown. In 1887 it still lingered in the Mediterranean, causing great mortality in See also:Messina especially. According to Dr A. J. See also:Wall, this epidemic cost 250,000 lives in Europe and at least 5o,obo in America. A particular See also:interest attaches to it in the fact that a localized revival of the disease was caused in Spain in 1890 by the disturbance of the See also:graves of some of the victims who had died of cholera four years previously. 1892-1895.—This great invasion reverted again to the old overland route, but the See also:march of the disease was of unprecedented rapidity. Within less than five months it travelled from the North-West Provinces of India to St See also:Petersburg, and probably to See also:Hamburg, and thence in a few days to England and the United States.

This See also:

speed, in such striking contrast to the slow advance of former occasions, was attributed, and no doubt rightly, to improved See also:steam transit, and particularly the Transcaspian railway. The progress of the disease was traced from place to place, and almost from day to day, with great precision, showing how it moves along the chief highways and is obviously carried by See also:man. The See also:main facts are as follows:—Cholera was extensively and severely prevalent in India in 1891, causing 601,603 deaths, the highest mortality since 1877. In March 1892 it See also:broke out at the Hardwar See also:fair, a day or two before the pilgrims dispersed; on the 19th of April it was at See also:Kabul, on the 1st of May at See also:Herat, and on the 26th of May at See also:Meshed. From Meshed it moved in three directions—due west to See also:Teheran in Persia, north-east by the Transcaspian railway to See also:Samarkand in Central Asia, and north-west by, the same See also:line in the opposite direction to Uzun-ada on the Caspian Sea. It reached Uzun-ada on the 6th of See also:June; crossed to See also:Baku, June 18th; See also:Astrakhan, June 24th; then up the See also:Volga to Nizhniy-See also:Novgorod, arriving at See also:Moscow and St Petersburg See also:early in August. The See also:part played by steam transit is clear from the fact that the disease took no longer to travel all the way from Meshed to St Petersburg by See also:rail and steamboat than to See also:traverse the See also:short distance from Meshed to Teheran by road. On the 16th of August cases began to occur in Hamburg; on the 19th of August a fireman was taken See also:ill at See also:Grangemouth in See also:Scotland, where he had arrived the day before from Hamburg; and on the 31st of August a See also:vessel reached New See also:York from the same See also:port with cholera on See also:board. On the 8th of September the disease appeared in See also:Galicia,having moved somewhat slowly westwards across Russia into See also:Poland, and on the 26th of September it was in See also:Budapest. See also:Holland and See also:Servia were also attacked, while isolated cases were carried to See also:Norway, See also:Denmark and Italy. Meanwhile two entirely separate epidemics were in progress elsewhere. The first was confined to Arabia and the Somali See also:coast of Africa, and was connected with the remains of an outbreak in See also:Syria and Arabia in 189o-1891.

The second arose mysteriously in France about the time when the overland invasion started from India. The first known case occurred in the See also:

prison at See also:Nanterre, near See also:Paris, on the 31st of March. Paris was affected in April, and See also:Havre in See also:July. The origin of this outbreak, which was of a much less violent character than that which came simultaneously by way of Russia, was never ascertained. Its activity was confined to France, particularly in the neighbourhood of Paris, together with See also:Belgium and Holland, which was placed between two fires, but escaped with but little'mortality. The number of persons killed by cholera in 1892, outside of India, was reckoned at 378,449, and the vast See also:majority of those died within six months. The countries which suffered most severely were as follows:—European Russia, 151,626; See also:Caucasus, 69,423; Central Asian Russia, 31,804; See also:Siberia, 15,037—See also:total for See also:Russian empire, 267,890; Persia, 63,982 See also:Somaliland, 1o,000; Afghanistan, 7,000; Germany, 9563; France, 4550; Hungary, 1255; Belgium, 961. Curiously enough, the south of Europe, which had been the See also:scene of the previous epidemic visitation, escaped. The disease was of the most virulent character. In European Russia the mortality was 45.8% of the cases, the highest See also:rate ever known in that See also:country; in Germany it was 5P3%; and in Austria-Hungary, 57'5%. Of all the localities attacked, the case of Hamburg was the most remarkable. The presence of cholera was first suspected on the 16th of August, when two cases occurred, but it was not officially declared until the 23rd of August.

By that time the daily number of victims had already risen to some hundreds, while the experts and authorities were making up their minds whether they had cholera to See also:

deal with or not. Their decision eventually came too late and was superfluous, for by the 27th of August the people were being stricken down at the rate of r000 a day. This rate was maintained for four days, after which the vehemence of the pestilence began to abate. It gradually declined, and ceased on the 14th of See also:November. During those three months 16,956 persons were attacked and 86o5 died, the majority within the space of a few weeks. The See also:town, ordinarily one of the gayest places of business and See also:pleasure on the continent, became a See also:city of the dead. Thousands of persons fled, carrying the disease into all parts of Germany; the See also:rest shut themselves indoors; the shops were closed, the trams ceased to run, the hotels and restaurants were deserted, and few vehicles or pedestrians were seen in the streets. At the See also:cemetery, which lies about 10 m. from the town, some hundreds of men were engaged day and night digging long trenches to hold See also:double rows of coffins, while the funerals formed an almost continuous procession along the roads; even so the victims could not be buried fast enough, and their bodies See also:lay for days in sheds hastily run up as mortuaries. Hamburg had been attacked by cholera on fourteen previous occasions, beginning with 1831, but the mortality had never approached that of 1892; in the worst year, which was 1832, there were only 3687 cases and 1765 deaths. The disease was believed to have been introduced by Jewish emigrants passing through on their way from Russia, but the importation could not be traced. The See also:Jews were segregated and kept under careful supervision from the See also:middle of July onwards, and no recognized case occurred among them. The total number of places in Germany in which cholera appeared in 1892 was 269, but it took no serious hold anywhere See also:save in Hamburg.

The See also:

distribution was chiefly by the waterways, which seem to affect a larger number of places than the See also:railways as carriers of cholera. In Paris 907 persons died, and in Havre 498. Between the 18th of August and the 21st of October 38 cases were imported into England and Scotland through eleven different ports, but the disease nowhere obtained a footing. Seven vessels brought 72 cases to the United States, and 16 others occurred on See also:shore, but there was no further dissemination. During the winter of 1892-1893 cholera died down, but never wholly ceased in Russia, Germany, Austria-Hungary and France. With the return of warm See also:weather it showed renewed activity, and prevailed extensively throughout Europe. The recorded mortality for the See also:principal countries was as follows:—Russia (chiefly western provinces), 41,047; Austria-Hungary, 4669; France, 4000; Italy, 3036; Turkey, 1500; Germany, 298; Holland, 376; Belgium, 372; England, 139. Hardly any country escaped altogether; but Europe suffered less than Arabia, See also:Mesopotamia and Persia. Cholera broke out at Mecca in June, and owing to the presence of an exceptionally large number of pilgrims caused an appalling mortality. The chief shereef estimated the mortality at 50,000. The pilgrims carried the disease to Asia Minor and See also:Constantinople. In Persia also a recrudescence took place and proved enormously destructive.

Dr See also:

Barry estimated the mortality at 70,000. At Hamburg, where new waterworks had been installed with See also:sand filtration, only a few sporadic cases occurred until the autumn, when a sudden but limited See also:rush took place, which was traced to a defect in the See also:masonry permitting unfiltered See also:Elbe water to pass into the mains. In England cholera obtained a footing on the See also:Humber at See also:Grimsby, and to a lesser extent at See also:Hull, and isolated attacks occurred in some 50 different localities. Excluding a few See also:ship-borne cases the registered number of attacks was 287, with 135 deaths, of which 9 took place in London. It is interesting to compare the mortality from cholera in England and See also:Wales, and in London, for each year in which it has prevailed since See also:registration began: England and Wales. London. Year. Deaths. Deaths per 10,000 Deaths. Deaths per Io,000 living. living. 18¢8 1,908 1.1 652 2.9 1849 53,293 30.3 14,137 6i•8 1853 4,419 2.4 883 3'5 1854 20,097 10.9 10,738 42.8 ,868 1,297 0.6 196 o•6 1866 14,378 6.8 5.596 x8,4 1893 135 0.05 9 0.002 1894 nil nil nil nil In 1894 no deaths from cholera were recorded in England, but on the continent it still prevailed over a wide area.

In Russia over 30,000 persons died of it, in Germany about 500, but the most violent outbreak was in Galicia, where upwards of 8000 deaths were registered. In 1895 it still lingered, chiefly in Russia and Galicia, but with greatly diminished activity. In that year Egypt, See also:

Morocco and See also:Japan were attacked, the last severely. The disease then remained in See also:abeyance until the severe epidemic in India in woo. The great invasion just described was fruitful in lessons for the prevention of cholera. It proved that the one real and sufficient See also:protection lies in a standing condition of Peeven- good sanitation backed by an efficient and vigilant am. sanitary See also:administration. The experience of Great Britain was a remarkable piece of See also:evidence, but that of See also:Berlin was perhaps even more striking, for Berlin lay in the centre of four fires, in See also:direct and frequent communication with Hamburg, Russia, France and Austria, and without the See also:advantage of a sea frontier. Cholera was repeatedly brought into Berlin, but never obtained a footing, and its successful repression was accomplished without any irksome interference with See also:traffic or the ordinary business of life. The general success of Great Britain and Germany in keeping cholera in check by ordinary sanitary means completed the See also:conversion of all enlightened nations to the policy laid down so far back as 1865 by See also:Sir See also:John See also:Simon, and advocated by Great Britain at a See also:series of international congresses—the policy of abandoning See also:quarantine, which Great Britain did in 1873, and trusting to sanitary See also:measures with medical inspection of persons arriving from infected places. This principle was formally adopted at the international con- ference held at See also:Dresden in 1893, at 'which a See also:convention was signed by the delegates of Germany, Austria, Belgium, France, Great Britain, Italy, Russia, See also:Switzerland, See also:Luxemburg, See also:Montenegro and the See also:Netherlands. Under this See also:instrument the practice is broadly as follows, though the See also:procedure varies a good deal in different countries:—See also:Ships arriving from infected ports are inspected, and if healthy are not detained, but See also:bilge-water and drinking-water are evacuated, and persons landing may be placed under medical supervision without detention; infected ships are detained only for purposes of disinfection; persons suffering from cholera are removed to See also:hospital; other persons landing from an infected ship are placed under medical observation, which may mean detention for five days from the last case, or, as in Great Britain, supervision in their own homes, for which purpose they give their names and places of destination before landing.

All goods are freed from restrictions, except rags and articles believed to be contaminated by cholera matters. By land, passengers from infected places are similarly inspected at the frontiers and their luggage " disinfected "—in all cases a pious ceremony of no See also:

practical value, involving a short but often a vexatious delay; only those found suffering from cholera can be detained. Each nation is pledged to notify the others of the existence within its own See also:borders of a " foyer " of cholera, by which is meant a focus or centre of infection. The precise See also:interpretation of the term is See also:left to each See also:government, and is treated in a rather elastic See also:fashion by some, but it is generally understood to imply the occurrence of non-imported cases in such a manner as to point to the local presence of infection. The question of guarding Europe generally from the danger of diffusion by pilgrims through the Red Sea was settled at another See also:conference held in Paris in 1894. The provisions agreed on included the inspection of pilgrims at ports of departure, detention of infected or suspected persons, and supervision of See also:pilgrim ships and of pilgrims proceeding overland to Mecca. The substitution of the procedure above described for the old measures of quarantine and other still more drastic interferences with traffic presupposes the existence of a sanitary service and fairly good sanitary conditions if cholera is to be effectually prevented. No doubt if sanitation were perfect in any place or country, cholera, along with many other diseases, might there be ignored, but sanitation is not perfect anywhere, and therefore it requires to be supplemented by a See also:system of notification with prompt segregation of the sick and destruction of infective material. These things imply a See also:regular organization, and it is to the public health service of Great Britain that the complete mastery of cholera has mainly been due in See also:recent years, and particularly in 1893. Of sanitary conditions the most important is unquestionably the water-supply. So . many irrefragable proofs of this fact were given during 1892-1893 that it is no longer necessary to refer to the time-honoured case of the Broad See also:Street See also:pump. At Samarkand three regiments were encamped See also:side by side on a level See also:plain See also:close to a stream of water.

The See also:

colonel of one See also:regiment took extraordinary precautions, placing a guard over the river, and compelling his men to use boiled water even for washing. Not a single case of cholera occurred in that regiment, while the others, in which only ordinary precautions were taken, lost over roo men. At See also:Askabad the cholera had almost disappeared, when a banquet was given by the See also:governor in See also:honour of the See also:tsar's name-day. Of the guests one-See also:half died within twenty-four hours; a military See also:band, which was present, lost 4o men out of 5o; and one regiment lost half its men and 9 See also:officers. Within See also:forty-eight hours 1300 persons died out of a total population of about 13,000. The water supply came from a small stream, and just before the banquet a heavy See also:rain-See also:storm had occurred, which swept into the stream all surface refuse from an infected See also:village higher up and some distance from the See also:banks. But the classical example was Hamburg. The water-supply is obtained from the Elbe, which became infected by some means not ascertained. The drainage from the town also runs into the river, and the See also:movement of the See also:tide was sufficient to carry the sewage matter up above the water-intake. The water itself, which is no cleaner than that of the See also:Thames at London See also:Bridge, underwent no See also:purification whatever before distribution. It passed through a couple of ponds, supposed to See also:act as settling tanks, but owing to the growth of the town and increased demand for water it was pumped through too rapidly to permit of any subsidence. Eels and other See also:fish constantly found their way into the houses, while the mains were lined with vegetation and See also:crustacea.

The water-pipes of See also:

Ham-See also:burg had a peculiar and abundant See also:fauna and See also:flora of their own, and the water they delivered was commonly called Fleischbruhe, from its resemblance to thick soup. On the other hand, at See also:Altona, which is continuous with Hamburg, the water was filtered through sand. In all other respects the conditions were identical, yet in Altona only 328 persons died, against 86o5 in Hamburg. In some streets one side lies in Hamburg, the other in Altona, and cholera stopped at the dividing line, the Hamburg side being full of cases and the Altona side untouched. In the following year, when Hamburg had the new filtered supply, it enjoyed equal See also:immunity, save for a short period when, as we have said, raw Elbe water accidentally entered the mains. But water, though the most important condition, is not the only one affecting the incidence of cholera. The case of Grimsby furnished a striking See also:lesson to the contrary. Here the disease obtained a decided hold, in spite of a pure water-supply, through the fouling of the soil by cesspits and defective drainage. At Havre also its prevalence was due to a similar cause. Further, it was conclusively proved at Grimsby that cholera can be spread by sewage-fed See also:shell-fish. Several of the local outbreaks in England were traced to the ingestion of oysters obtained from the Grimsby beds. In short, it may be said that all insanitary conditions favour the prevalence of cholera in some degree.

Preventive inoculation with an attenuated See also:

virus was introduced by W. M. W. Haffkine, and has been extensively used in India, with considerable appearance of success so far as the statistical evidence goes. As already remarked, the latest manifestations of cholera show that it has lost none of its former virulence and fatality. Treatment. The symptoms are now regarded as the effects of the toxic See also:action of the poison formed by the micro-organisms upon the tissues and especially upon the See also:nervous system. But this theory has not led to any effective treatment. Drugs in great variety were tried in the See also:continental hospitals in 1892, but without any distinct success. The old controversy between the aperient and the astringent treatment reappeared. In Russia the former, which aims at evacuating the poison, was more generally adopted; in Germany the latter, which tries to conserve strength by stopping the See also:flux, found more favour. Two methods of treatment were invariably found to give great See also:relief, if not to prolong life and promote recovery—the hot See also:bath and the injection of normal saline See also:solution into the See also:veins or the subcutaneous See also:tissue.

These two should always be tried in the cold and collapsed stages of cholera. See Local Government Board Reports, 1892-93-94-95 ; Clemow, The Cholera Epidemic of 5892 in the Russian Empire; Wall, Asiatic Cholera; Notter, Epidemiological Society's Transactions, vol. xvii. ; See also:

Emmerich and Gemund,Munchen. med. Wochenschr. (1904), pp. to86-1157 ; Wherry, See also:Department of the Interior See also:Bureau of Government Laboratories, No. 19 (October 1904, See also:Manila); Wherry and M`See also:Dill, Ibid. No. 31 (May 1905, Manila).

End of Article: MALIGNANT CHOLERA (synonyms, Asiatic Cholera, Indian Cholera, Epidemic Cholera, Algide Cholera)

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