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Full text of "Asiatic cholera: its genesis, etiological factors, clinical history, pathology and treatment"

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Spirillum Choleras Asiatics. X - iooo. 
From a photo-micrograph. (Koch.) 


Colonies of the Cholera Spirillum. 
End of twenty hours. 2. End of thirty hours. 3. End 
of forty-eight hours. .). After liquefaction of the 
gelatine. (FLUEGGE.) 

Dried and Stained Preparation of Cholera Spiri 
(x 950), from an eight- day old gelatine culture. 


urn (x 950^ 
1 at 37° C. 

id Stained Preparation of the Cholera 

Attention is called to the fact that the Spirillum Cholera' Asiatics is very variable in its appearance and 
physical characteristics. Specimens from a fresh and vigorous culture may be so short and thick, that only a 
slightly greater curvature of one side of the vibrio is to be noted as a sign of the characteristic curvature. 
Specimens made from the same culture a few days later, when the rate of division is less rapid, will show the 
curved form of the microbe in a clear and striking degree. Their curvature is also liable to be masked if the 
films on the cover glasses are dried too quickly. It is advisable to always allow the films to become air dry, 
and then pass through the flame. (Hart.) 


i. Gelatine culture of the Finkler-Prior vibrio, grown at the temperature 
of the room, four days after inoculation. A large quantity of the gelatine is 
liquefied and uniformly turbid. 

2. Gelatine culture of the vibrio isolated by Deneke from cheese, grown at 
the temperature of the room, four days after inoculation. A smaller quantity 
of the nutrient medium is liquefied than is the case with the Finkler-Prior vibrio 
when grown under similar conditions. 

3. Gelatine culture of the spirillum cholerae Asiatics, grown at the temper- 
ature of the room, four days after inoculation. In the small quantity of gelatine 
that has been liquefied along the track of the needle, a quantity of whitish 
granular matter can be found. Owing to the evaporation at the surface of the 
liquefied gelatine, a bubble of air has been drawn below the surface. The for- 
mation of such an air bubble occasionally takes place in cultures of the 
Finkler-Prior vibrio and other microbes. 







pOCl 16 1 393 J 























These Lectures were delivered at the College of 
Physicians and Surgeons of Chicago, as part of a 
course on the Practice of Medicine, in the winter of 
1892-3, in addition to the lectures belonging to my 
own Chair; that of Physiology. The subject matter 
was compiled from a great number of sources. The 
lectures were never intended for publication, and 
while they represent a considerable amount of work F 
no one recognizes more completely than myself,, 
their imperfections and short-comings. My only 
excuse in giving them publicity is an invitation to 
that effect, which I received from the Graduation 
Class of '93, a request which I felt it to be a duty as 
well as a privilege to favorably respond to. 

245 Warren Avenue, Chicago, Illinois, May 25th, 1893. 


Lecture 1 13 

Special interest in the study of cholera; Commercial rea- 
sons; Epidemic of 1882 in Europe; Chivalrous philan- 
thropy and bravery of the King of Italy ; Heroes who have 
not been gazetted; History of early epidemics, their mor-, 
tality, the "pestis;" Influence of superstition on the peo- 
ple; Labors of the early physicians, their theory of spe- 
cific poison ; Draining the Pontine Marshes ; Neglect of 
public health; Tribute to Dr. Jno. M. Woodworth; Emas- 
culation of National Quarantine Bill in the last Congress ; 
Locality of the birthplace of the epidemic of 1629; Ba- 
tavia, Isle of Java, Jacatra river; Insalubrity of the climate 
and surroundings; Tendencies of all severe diseases in 
India; Origin of epidemic of 1817; Description of Delta 
of Ganges; The pilgrimages to the Holy River; Filthy 
state of the river and surrounding country; Genesis of 
Asiatic cholera ; Birth of the Spirillum Cholerse Asiaticae; 
Course and mortality of the epidemic of 1817; Reminis- 
cences of Alonzo Clark. 

Lecture II. . . . . ... . .36 

Mortality of epidemic of 1817; Epidemics in the United 
States ; Sanitary services of Surgeon-General John B. Ham- 
ilton; Route of the epidemic of 1892; Dawson Williams 7 
remarks ; Cholera routes from India to Western Europe; 
Rapidity of travel in later times; Deductions made from 
the study of the epidemic of 1892; Inefficiency of local 
quarantine ; Good effects of medical inspections ; Impor- 
tance of establishment of Portfolio of Public Health in 
Cabinet of the Chief Executive; Relationship of financial 
interests and sanitation; Definition of Asiatic cholera; Le- 
gend of the wise man of Bagdad; Etiology; Koch's dis- 
covery, and observations ; Sternberg's nomenclature; Chol- 
era micro-biology ; Etiological relation of the comma 


bacillus to the disease; Sternberg's experiments ; Nencki's 
observations; Aid from Prince Alexander of Oldenburg; 
Blachstein and Shubenko; Bacterium caspicum, etc.; 
Mixed infection, and cultures; Micro-biological chemistry; 
Toxines, etc. ; Symptomatology of cadaverin poisoning ; 
Kobert and the salts of cadaverin; Location of spirillum 
in body; Accidental infection in Berlin laboratory in 1884. 

Lecture III 63 

Cholera bacteriology; Ferran on micro- biological chem- 
istry ; De Giaxa, behavior bacillus in sea water, etc. ; Ther- 
mal death point; Dunham on spirillum viability, feces, 
clothing, fruits and vegetables; Amounts of different 
reagents required to destroy the spirillum; Hueppe on 
arthrospores ; Gehrmann's rules for demonstration of the 
spirillum; Technique of test- making; Hints for the ne- 
cropsy hall. 

Lecture IV . . , 7& 

Modes of infection ; How spread ; Nitrifying power of spir- 
illum ; Pettenkofer's theory ; Supposed immunity of Jews ; 
What must take place in order that the disease should be 
produced in a given person ; Predisposing causes ; The 
emotional factor; First effect ii; bowel; Pathology, mor- 
bid anatomy; Post-mortem movements; Pathological find- 
ings in the disease. 

Lecture V 92 

Symptomatology; Varieties; Mild, medium and of great 
intensity; Choiera-bicca; Cholera foudroyant; Incuba- 
tion; Stages; Description of an attack; Sudden change in 
appearance of the sufferer; Varieties of cholera typhoid ; 
Connection between the morbid anatomy and the clinical 
picture; Diagnosis; Prognosis; Cholera in literature. 

Lecture VI 106 

Treatment; Prophylaxis; National and municipal prophy- 
lactic measures; Duties of physicians as health officers; 
Raymond's excerpts; Sanitary condition of Chicago; 


Drinking water supply; Sewage; The Chicago river; 
Never place ice in direct contact with drinking water; 
Milk ordinance; Public and personal cleanliness; Dis- 
posal of the dead ; Cremation ; Flies as carriers of conta- 
gion; Edict condemning flies to death; Prophylactic meas- 
ures connected with the individual; Milk, how to sterilize; 
Butter; Foodstuffs; Beer; Wine as a bactericide; Ad- 
vice as to conduct of the healthy during an epidemic; 
Water regime; Duties of the medical profession in as- 
sociation with the laity; Advice of the New York City 
Board of Health. 

Lecture VII 121 

General managment of a case of cholera; Prevention of 
the spread of the disease; Disinfecting solutions; Treat- 
ment of the dejections ; Care of the dead body ; House and 
room disinfection; General outline of treatment; Results 
to be sought for; Conditions to which attention is called; 
Literature of cholera treatment; Treatment of preliminary 
diarrhoea; Artificial oyster; Arrest of diarrhea; Objec- 
tions to use of opium; Camphor; Camphor wine; Bis- 
muth and benzo-naphthol ; Acid drinks; Salol ; Chola- 
gogues ; Action of bile ; Neutralization of toxines ; Cantani's 
enteroklysis; How performed; Objections to the opera- 
tion; Nicholas Senn's experiments as to effect on peri- 
toneum of forcing the colic valve; As to permeability of 
the valve; Hare and Martin on enteroklysis; Purvis on 
sulphur dioxide; Surgeon-Major Brown's plan of treat- 
ment; Latest reagent in treatment; Blisters over pneu- 
mogastric; Hydrotherapeutic measures; Winternitz; Ful- 
lerton on quinine treatment; Cramps; Vomiting; Glonoin; 
Hot drinks; As to exhibition of liquids; General manage- 
ment of case. 

Lecture VIII .... 145 

Recommendations as to treatment first stage; Attempts 
to neutralize noxa in gut, tissues, in blood; Ciaramelli's 
method; That of Maestre, Semmola's hot baths; Peters' 
method of warming patient with unslaked lime ; Modes of 


heading off the algid stage; Wendt on the energetic doctor 
and his efforts to keep his patient warm ; Chloroform ; 
Chloric ether; Strychnine; Chapman on strychnine dos- 
age; Singultus; Exhibition of fluids; Pachysemia ; Hy- 
podermoklysis; Intravenous transfusion; How to per- 
form ; Samuel's continued infusion ; Keppler's mode of 
procedure; Hayem's operation; Effects produced by these 
measures; Cantani's conclusions as to hypodermoklysis; 
How I would desire to be treated, if I suffered from 

Lecture IX 163 

Treatment of stage of reaction ; Management of simple 
cholera-typhoid ; Of the variety in which diverse compli- 
cations occur ; Of uremic cholera-typhoid ; Macnamara's 
plan of treating anuria ; Transmission of the disease to 
lower animals; Immunization; Interdependence and dove- 
tailing of different modes of study ; Observations of Nicati 
and Rietsch ; Koch's experiments ; Old attempts to render 
the body immune; Jenner; Haffkine on cholera vaccina- 
tion; Heroic confidence of E. H. Hankin; Brieger's ex- 
periments; Vincenzi's observations; Those of Klemperer; 
Metchnikoff on phagocytosis in immunization; Value of 
laboratory work ; Detail description of Haffkine's method, 
and his deductions therefrom ; Basis of anticholeraic vac- 
cination ; Results on animals ; Application of operation to 
man; How long immunity may last; Does protection pro- 
tect; Dangers of reasoning by analogy. 

Prescriptions that have been recommended in cholera. . 187 
Appendices and Illustrations 199 



The study of the disease that we to-day com- 
mence, is exceptionally interesting on account of 
the fact that even now its shadow can be seen upon 
our shores, and for the past few months its ravages 
in the Eastern Continent have almost struck terror 
into the heart of civilization. Within a few months, 
Chicago will open her doors to the inhabitants of the 
globe, all nations have been invited to accept our 
hospitality; already the brains of architects are plan- 
ning the erection of suitable buildings; already are 
cunning and skillful artisans at work for the Great 
Exposition, but vain and futile will have been our 
efforts, if in addition to the golden stream of wealth, 
that will flow from every point of the compass to- 
wards our gates, there comes the dark, noisome cur- 
rent of disease and death. It behooves us therefore 
to pay especial attention to this subject, lest per- 
adventure the enemy steal among us and catch us 
unawares. You may recollect that about ten years 
ago, cholera swept over Asia, and Europe; you may 
remember its devastations in Southern France and 
Italy; you may bring to mind how the gallant 
Humbert, king of Italy, and his lovely Consort bound 
themselves more closely than ever to their subjects 
by their care and solicitude for the sick and suffer- 


ing; how the King, proving himself regal by nature 
as well as by rank, went bravely into the infected 
districts and ministered to the wants of the afflicted 
and dying. But you do not remember, for the 
world does not know, the names of that host of 
noble men and women who as physicians and nurses 
not only visited, but lived in the hovels of the sick 
and poor, and sacrificed life itself on the altar of 

In reading the history of man, we find records of 
epidemics that at various periods, have prevailed. 
Sometimes these epidemics have been circumscribed 
in their influence, and limited to special localities; 
while again they have taken a wider range and ex- 
tended over large sections of the earth, inflicting 
most lamentable results and increasing to a most 
alarming degree, the mortality bills of the inhabit- 

For obvious reasons in studying these early epi- 
demics it is very difficult for us to identify the 
special character of the condition or disease that 
flourished during a given time. The earlier writers 
who have described them, speak in terms more or 
less vague, uniting however in ascribing to them 
fatal and devastating attributes, surpassing all other 
maladies by their rapid, uncontrollable advance and 
extension, and in the duration of their prevalence. 
In the Orient, — in Egypt, and along the eastern 
shore of the Mediterranean sea, fearful epidemics 
have occurred from time immemorial. They have 
often proved very destructive, especially in the mid- 
dle ages, and as late as the sixteenth and seven- 


teenth centuries. During the prevalence of the 
pestis, which raged throughout Europe between the 
years 1347 and 1350, according to computation, a 
fourth part of the inhabitants of that section of the 
globe was carried off. The estimates of the vast 
numbers swept away by its repeated occurrence and 
prevalence appear quite incredible. For example: 
during the time it ravaged Marseilles in 1720 it is 
reported that in the Charity Hospital there were 
admitted from October 3rd to February 28th, 1013 
patients, of whom 585 died; and during the same 
period in another hospital, there were admitted from 
October to July 3rd, 15 12 patients, of whom 820 
died. The population of Marseilles previous to the 
occurrence of the disease was estimated at about 
90,000, of whom 40,000 died; leaving only about 
10,000 of the whole population who had not been at- 
tacked or in any way affected; so that the record 
shows the appalling mortality of fifty per centum of 
those who were attacked. 

The bills of mortality in the years of 1770 and 
1771 were as appalling as any arising from epidemics 
of later dates. Mons. Geradin investigated the 
"pestis" as it raged in Moscow in the year 1771, and 
quoting from the published statistics, observes: in 
April the deaths were 744; May, 851; June, 1099; 
July, 1708; August, 7268; September, 21401; October, 
17561; November, 5235; December, 805; making a 
total in nine months of 56,672, which is considerably 
less than the estimate given by De Mertens, who 
thinks the whole number carried off by this pesti- 
lence, from the city alone, can not be less than 


80,000. In comparing these statistics with those of 
epidemics of Asiatic cholera in our own time we 
notice a striking similarity between them; thus in 
Asiatic cholera the intensity of the disease varies in 
a given epidemic, with the season of the year; the 
greatest fatality being usually at the close of sum- 
mer and at the beginning of autumn. We find in 
short many points of resemblance in this and former 
epidemics to that of cholera, and this naturally 
leads us to look upon the "pestis" as being phy- 
logenetically related to, if not identical with chol- 
era. While in noting the characteristics of the 
various diseases referred to, that in earlier times 
have afflicted the sons of men, we can recognize 
syphilis and small-pox, among others; there is no 
doubt in our minds as to the identity of "the white 
and cold death" of the earlier chroniclers with 
Asiatic cholera. 

We are not at all surprised at the fearful moral 
influence these epidemics had upon the minds of 
the people. Their pestilential character, their ex- 
tended influence, their great fatality, and their 
sudden appearance and uncontrollable advance ren- 
dered their presence and progress a special terror to 
physicians, and melancholy apprehension to the 
populace. They seem to have been regarded as the 
manifestation of an invisible power, which directed 
and guided "the pestilence that walketh in dark- 
ness" and "the destruction that wasteth at noon- 
day;" a visitation or chastisement over which human 
ingenuity and medical skill had little, if any control. 
And this belief was fostered in the people, who were 


taught that the epidemic was a punishment from 
God-Almighty, for sins, and was to be submitted to 
in sorrow and with patient resignation, and to be 
shortened or averted only by prayer, fasting and 
pilgrimages. In this way, during such epidemics, 
the spread would be aided, as people would congre- 
gate together, and headed by priests and church 
dignitaries would march in solemn procession, calling 
upon God and his saints to withdraw the dread af- 
fliction. Under these conditions, it is not remark- 
able that no rational, reasonable measures could be 
adopted to prevent the occurrence of the malady. 
But our forefathers in medicine were far in advance 
of the rest of the people, and we find them laboring 
and endeavoring to satisfy the great mass of mind 
that these occasional and special developments of 
disease arose from natural causes and were subject to 
certain natural laws. They ascribed their origin to 
the commingling of some specific poison, in the 
food, and drink, and air, which through these 
"media" was received into the system. But in spite 
of all their efforts, we find them making but little 
headway. The obstacles they had to overcome were 
too numerous and too formidable. Superstition 
fostered and nurtured by interest and ignorance, con- 
stantly and most energetically led her forces against 
scientific medicine. Menaced on the one hand by 
the churchmen as being "heretics," and threatened 
with the direst punishments, both of this and the 
world to come, unflinchingly these pioneers in the 
art and science of our profession "kept on the even 
tenor of their way," and laid the foundations of the 


magnificent superstructure it is our privilege today 
to contemplate. Even in those days though, we find 
men outside of the medical profession, advanced 
enough to recognize natural factors in connection 
with disease-causation, thus when Rinaldo,, prince- 
archbishop of Cologne and Chancellor of the Ger- 
man empire, accompanying the Emperor Barba- 
rossa to the siege of Rome, was interviewed by an 
Italian delegation friendly to the Germans, warned 
(Of the pestilential fever that every year afflicted the 
Romans, and asked to have public prayers offered 
up that it might be averted, he replied by informing 
them that if they would drain the Pontine marshes, 
and cultivate the marsh land around the Paternal 
City, the visitations of the Lord would soon cease. 

The specific poison theory was elaborated upon 
by the followers of the medical art, and advances 
made on this line. They considered the extreme 
summer heat — especially the intense heat of the sun 
in a dry season — the emanations from stagnant 
waters, and the miasm exhaled from the soil, and 
from putrid bodies of animals, as the chief causes of 
all epidemics. These views prevailed for a very 
long period and have really undergone no very re- 
markable change down almost to our own time. 

Modern writers advanced nearly the same doc- 
trines, embracing however the principal sources of 
insalubrity — the malarious and miasmatic influences; 
and have assigned as the cause of epidemics, es- 
pecially that of cholera, a peculiar constitution of 
the atmosphere, and certain predisposing causes 
combining with each other, so that an association or 


union of these two independent and individual 
causes are necessary and essential to the production 
of the disease. Eminent scholars and pathologists 
have during the past century, patiently searched for 
its final cause, without arriving at any better, wiser, 
or more satisfactory conclusion than the earlier 
writers, who regarded it as a poison, commingled 
with the food they ate, the water they drank, and 
the air they breathed. The more modern writers 
almost universally adopted the hypothesis that the 
remote or final cause of cholera is a specific poison; 
for says one eminent authority: At no period has a 
person in good health in this or any other country 
been known in a few minutes to be shrivelled up, his 
face and extremities to turn purple, his whole body 
to become of an icy coldness, and with or without 
vomiting a peculiar fluid, like rice-water, to die in a 
few r hours, except under the influence of poison. 
That this disease, so appalling and destructive in 
its effects and so mysterious in its wanderings, 
should spread over countries in respect to climate, 
soil, geological formations, and as to the moral and 
physical habits of the population, so utterly op- 
posite to those where it first originated, is only ex- 
plicable on the hypothesis of its propagation on the 
principle of a specific disease — poison. Such was 
the knowledge of the scientific world concerning the 
causation of cholera up to 1884, when the great 
Robert Koch discovered and described the specific, 
morbific, exciting etiological factor of the disease— 
the Spirillum Cholerae Asiaticae. 

You have noticed with me, the important part 


played by our profession from earliest times, in 
educating the masses, and in determining the ex- 
act causes of disease as far as possible. You 
have seen how they had every obstruction put in 
their way, and I would here say to you that the end 
is not yet come, but an almost similar condition 
exists even today. It is surprising how careless men 
are of that priceless boon, good health, and how 
they will fight against all endeavors on our part to 
place their surroundings in the best possible sanitary 
condition. Look for a moment at our own country, 
and see how the various interests of the business 
w r orld are cared for. The financial element has the 
Secretary of the Treasury; defensive principles are 
represented by the departments of War and the 
Navy, other interests come under the Interior de- 
partment, and our foreign relations are cared for by 
the portfolio of State. Of late even the down trod- 
den farmer has representation in the Cabinet; but 
let an attempt be made to elevate to a proper posi- 
tion the Department of Public Health, and irrespec- 
tive of party, a host of objections will arise and 
certain defeat is the sure outcome. I would here 
pay tribute to Dr. John M. Woodworth, the organizer 
of the U. S. Marine-Hospital Service, who for years 
labored with this end in view, gallantly coming 
afresh to the attack after each defeat, until at last 
death overtook him with his much desired object as 
far from accomplishment as at first. And here now 
with cholera knocking at our doors, when a National 
Quarantine Bill of value was introduced into our 
National Legislature, instead of its being submitted 


to the American Medical Association, it was given 
over to the representative of a local political organi- 
zation, to be emasculated and cut and slashed to 
suit the exigencies of partisan interests. The same 
fight of ignorance and self-interests against know- 
ledge and science, that prevailed during the middle 
ages is on to-day, you will find the same obstructions 
in your path, as did your forefathers, and in your 
labors and travels for the bettering of man, you will 
need the confidence of the knowledge of the im- 
pregnability of your position, for you will be repaid 
by those for whom you are working, by ingratitude 
and contempt. 

Perhaps some idea of the character of Asiatic 
cholera may be obtained from a view of its birth- 
place and surroundings, and whether the locality of 
its irruption in 1629, or that of 1817, whence it spread 
over the greater part of the globe, be entitled to the 
unenviable distinction of fostering its gestation, con- 
cealing and protecting its birth, and nursing its 
infancy, is immaterial — since the similarity of these 
localities strikingly illustrates its cause and ultimate 

On the north side of the Island of Java, about 6° 
S. Lat. and 107 E. Long., near where Jacatra 
belches forth her waters to join the stream of the 
Sundaian Straits, is situated Batavia, in the midst of 
swamps and marshes, surrounded by trees, dense 
under-growth and jungle, which prevent the ex- 
halations from being carried off by a free circulation 
of the air, and render the town peculiarly obnoxious 
from marsh miasmata. Pass with me into the town, 


and we notice all the principal streets traversed by 
canals planted on each side with rows of trees, and 
over the canals there are bridges at the end of al- 
most every street. Into these waters is poured the 
filth of the entire town. In the dry season their 
stagnant and diminished streams emit a most intoler- 
able stench, while in the wet season they overflow 
their banks, and as the waters subside they leave 
behind a quantity of excessively offensive slime. 
From these united causes you are not at all surprised 
to hear that Batavia has been considered the most 
unhealthy spot in the world, and has received the 
name of the store-house of disease. According to 
Raynal, the number of sailors and soldiers alone who 
died in the hospitals averaged 1,400 annually for 
sixty years, and the total number of deaths in twenty- 
two years exceeded a million of souls. The city was 
inclosed by a wall of coral rock, with a stream of 
water on each side within and without. Few Euro- 
peans, however, sleep within the town, as the night 
air is considered very baneful. The inhabitants, 
possibly as an antidote against the noxious effluvia 
arising from the swamps and canals, continually burn 
aromatic woods and resins, and scatter about a pro- 
fusion of odoriferous flowers, of which there are 
great abundance and variety. During the period of 
prosperity of the Dutch East India Company, 
Batavia obtained the title of "Queen of the Orient," 
as the resources of all other districts were sacrificed 
to her exclusive commerce. Here in this noted 
locality, was the cholera bred and reared in 1629, 
under circumstances of great significance, admirably 


adapted to convey some idea of its cause and char- 
acter. But while in this delectable place the epi- 
demic of 1629 apparently had its origin, it is in India, 
the land of mystery, of dense superstition and ignor- 
ance that we must look for the seeming origin of 
subsequent outbreaks. Since 1817, it has been 
endemic in India, annually reoccurring at various 
points, -commencing generally at the beginning of 
the hot season, but sometimes occurring in the rainy 
and cold season. Its greatest proclivity to propaga- 
tion is amongst populations living in low, damp 
situations, where people are crowded together, where 
from any cause their powers of resistance are re- 
duced and especially w 7 here is impure or vitiated 
water-supply. Nearly all the diseases fatal in India 
are accompanied by profuse discharges w r ith which 
the air, water, linen, bedding, closets, walls of hos- 
pitals and barracks become more or less infected; so 
that the "materies morbi" come into contact with all 
the inmates of buildings where the disease prevails. 
Its origin or reappearance in 18 17, is not in any 
respect essentially different from its earlier develop- 
ment on the Jacatra. You are acquainted with the 
course of the River Ganges; you know that like the 
Nile in Egypt, it flows for a long distance through a 
low, level country which it annually inundates. Di- 
viding its waters about 200 miles from the sea, the 
delta of the Ganges commences and continues its 
variegated and checkered surface, until approaching 
the borders of the Bay of Bengal, it presents a pe- 
culiar aspect, being composed of a labyrinth of 
creeks and rivers, called "The Sunderbunds," with 


numerous islands, covered with the profuse and rank 
vegetation called "jungle," affording haunts to 
tigers and various beasts and birds of prey. This 
large river, sacred to the Hindoos, is subject to an 
annual freshet* often rising to the height of thirty- 
two feet in the month of July; when all the 
lower parts of the country adjoining to the Ganges, 
as well as to the Burrumpootre, are overflowed for 
a width of one hundred miles; nothing appearing but 
villages, trees, and sites of some places that have 
been deserted. Now this river is a deity to the 
Hindoos, and its personality is to them a powerful 
god, and as the one longing of the true Mussulman 
is to make a visit to his Holy City — Mecca, so does 
the faithful Hindoo endeavor once in his life to 
make a pilgrimage to his sacred river, drink of its 
waters, wash away sin in its stream, and find salva- 
tion on its bosom. The Hindoo therefore saves all he 
can, and joining a caravan of those like unto him- 
self, journeys across desert and plain towards the 
Ganges. With its members reduced by privation, 
enfeebled by want, hardship and colliquative diar- 
rheas, the caravan at last halts on the shore of the 
Holy River. At various intervals along the banks 
there are wells, near to the river and filled with its 
waters. These wells receive the dejecta of man and 
beast and a portion of the filth that is poured into 
the main stream, and of this water the Hindoo de- 
voutly drinks, with it he laves himself and with it he 
fills goat-skin bags to transport some of the bene- 
ficial fluid back to his native town for the edification 
and delectation of those compatriots less fortunate 


that he in not having made the pilgrimage. But not 
only in the wells do the pilgrims bathe, but also in 
the river itself, and should the current wash some 
wight away, or should some sinner over anxious to 
be cleansed from sin, venture out too far in the 
stream, or peradventure should some one already 
sick and depressed, be seized with cramp and be 
drowned, thrice happy is his lot and his body must 
be left in the embraces of the River-God. It would 
be sacrilegious to remove the corpses of such lucky 
individuals from the stream, and they float along 
beneath the burning noon-day sun, and rot and 
putrefy and still further taint the water. And should 
pilgrims, as they do, die by dozens and by tens of 
dozens on the borders of the Ganges, there un- 
covered except by the canopy of Heaven itself, are 
the bodies left. And the living drink of, and bathe in 
this same water, and carry of it back to their homes. 
Up from the dark Plutonian caverns of Erebus, up 
from the clouded Stygian valley, up from the depths 
of hell, in the early part of this century, arose the 
Goddess of Filth, and she wandered around over 
the face of the globe, seeking for a home to her 
liking. And coming to the delta of the Ganges, in 
this low, insalubrious and festering locality, where so 
many noxious and noisome diseases are generated, 
and where so many epidemics have arisen and so 
often swept over the earth with most fatal and deso- 
lating effects, — here she met, one dark and stifling 
night, with gaunt Despair. And surrounding her 
with his bony arms, Despair threw her on the foul, 
dark and slimy ground, and had his will of her. 


And when the day of her reckoning was reached, 
here in the neighborhood of Jessore — a town in the 
centre of the delta — in agony and in shame and in 
desolation, Filth gave birth to the monstrosity yclept, 
— Asiatic Cholera. And here she nurtured and fed 
him, here in this vast pest-house where every con- 
ceivable vegetable and animal substance is left upon 
the soil to rot in the heat and dews of a tropical 
climate, — here Filth feet her offspring from her own 
breasts, and as he grew and waxed strong, and his 
tusks and teeth appeared so that he would chew and 
tear her dugs, she longed to wean him, and one day 
as he ferociously fastened himself upon her, she cast 
him away on the mud, and as his mouth was forcibly 
torn from the dug, some of her foul milk was scat- 
tered around, and falling into the water of the Gan- 
ges, as drops, was at once coagulated by the water, 
and became — the Spirilla Cholerae Asiaticse. 

Lei us now take up the consideration of the great 
epidemic of 1817, and after viewing in a more or less 
cursory manner its track and mortality, I will call 
your attention to some points connected with the 
epidemic of last year. The disease in 1817 appeared 
on the delta of the Ganges, and gradually extending 
its influence, swept over various countries with ter- 
rible severity. Having here acquired its full de- 
velopment, and manifesting an indomitable deter- 
mination to itinerate, it started upon its lethean er- 
rand, and soon showed both capacity and power to 
overcome every obstacle opposed to its progress,, 
and to pursue its course unchecked and even un- 
retarded by any natural or artificial barrier. It soon 


traversed India, and in the succeeding season spread 
over adjacent countries, visiting in 1-818 the Indian 
Peninsula, the Burmese Empire, the Kingdom of 
Aracan, and the Peninsula of "Malacca. In 1819 it 
reached Sumatra, Singapore, and various other 
islands situated along the coast on either border of 
this vast peninsula. 

During the year 1820, pursuing steadily its pro- 
gress eastward, it reached Tonquin, Southern China, 
Canton, the Philippine and numerous other places 
and islands in that direction. In 1821 it visited Java 
— the place of its earlier nativity — Maduro, Borneo, 
and many other places in the Indian Archipelago. 
During the years 1822, 1823 and 1824, it continued to 
spread over the vast and populous regions of Cen- 
tral and Northern China and the numerous islands 
upon the coast, and in 1827 prevailed in Chinese 
Tartary, leaving few places in all these different 
countries on the continent, or even on the islands 
bordering on the eastern coast, unscathed by its 
terrible ravages and depopulating influence. 

During the same period, its progress westward 
was uninterrupted, and attended with results no less 
remarkable. It baffled all attempts to check or even 
retard its outward course, or mitigate its appalling 
effects. In July, 1821, it had reached Muscat in 
Arabia, and thence extended its influence to the 
populous cities and villages along the Persian Gulf. 
During the same season it appeared in Persia and 
continued to ravage the principal cities and towns of 
that empire for four successive years. At Bassorah 
and Bagdad it broke out in July, 182 1, and thence 


extended its desolations westward to the Red and 
Mediterranean Seas, carrying off vast numbers of the 
inhabitants of the populous cities of Mesopotamia, 
Syria and Judea. 

In 1822 it prevailed among the nomadic tribes in 
Central Asia and in the northern Persian provinces, 
and in 1823 broke out on the Georgian frontiers of 
Russia, at Orenburg on the River Ural, and at As- 
trachan on the Volga. Here its western course was 
apparently interrupted. There was for a short 
period an interval of comparative immunity from its 
presence. Along the border of the Russian Pro- 
vinces the disease had entirely disappeared, and 
seemed inclined to retrace its course and return to 
the home of its birth. But the fond anticipations of 
Europeans were disappointed; the destroyer was not 
to be arrested and turned back in his progress over 
the earth; his march was onward, his demands im- 
perative. Hence, in the month of June, 1830, the 
scourge reappeared in a Persian province on the 
southern shore of the Caspian, and again at Astra- 
chan, on the Volga in July, where it raged with such 
unwonted violence, that before the close of August, 
more than four thousand persons had fallen victims 
to its maleficience in the city, and twenty-one thou- 
sand, two hundred and seventy in the province. 
From its interval of repose, it recuperated its 
strength and vigor and with renewed energy, as- 
cended the Volga, reached Moscow, became epi- 
demic there in September, and continued with great 
severity until February, 1831. Here it attacked in 
the city about nine thousand of the inhabitants, of 


whom more than one-half died. Continuing its ad- 
vance, it reached Riga about the middle of May, and 
St. Petersburg on the 26th of June. 

From Astrachan it also directed its course to- 
wards the northern coast of the Black Sea, and 
thence along the course of the rivers into the cen- 
tral parts of Russia. It reached Poland in January, 
183 1, accompanied the army of the Tsar, in its 
various marches and encampments during the dis- 
memberment and subjugation of that country, and 
proved very destructive in Warsaw and many other 
places during April and May. It appeared at Dant- 
zic in May, and in June at Lemburg, Cracow and 
various other places and sections of country, extend- 
ing through Gallicia and Hungary, and reaching 
Berlin and Hamburg in August and September, and 
Vienna about the same time. Smyrna was visited in 
September and Constantinople soon afterward. From 
Mecca to Cairo the pestilence was conveyed in Aug- 
ust, 1 83 1, by a caravan, which was known to the sur- 
vivors as the "Caravan of the Path of Death," as its 
track was marked across the sands by some thou- 
sands of its members, who died, and whose bodies 
were left by the roadside; and by the middle of 
September, ten thousand, four hundred Moham- 
medans, besides Jews and Christians, had died of it 
in this latter city. Passing from the western coast of 
the Continent, on nearly the same parallels of lati- 
tude, it found its way over the north sea to the 
British Isles, and making a lodgement first on the 
northeastern coast of England, in October, 1831, 
appeared at Sunderland, situated in latitude 55° 


north, whence it prevailed and extended its influence 
over this section, evincing the same malignant char- 
acter it had manifested in its progress over the 
Continent. It made its first appearance in Scotland, 
at Haddington in December, 1831, and at Edinburgh 
in January. In these and various other places it 
manifested its energy, and warm w r eather coming on, 
it increased in severity, and carried off a large per- 
centage of those attacked. After spreading thus 
over the northern section, and rioting for months in 
the more populous cities and towns, it made its entry 
into London on the 14th of February, 1832, where it 
found abundance of material for recuperating its 
strength and multiplying its forces, and soon after 
spread over various other places in the United King- 
dom, inflicting the most appalling consequences upon 
the people. In short, all along we find its progress 
attended with most lamentable consequences and 
destructive influences, both on the Continent and in 
the British Isles. No change, modification or soften- 
ing of its disposition or character had arisen from its 
passage over the Northern Sea, nor from the re- 
freshing influences of a purer atmosphere. 

It appeared in Calais on the 12th, and at Paris on 
the 26th of March, 1832, where it continued in these 
and other neighboring cities and towns and villages, 
with its accustomed vigor, for some months. During 
the season it raged throughout the vast empire, swept 
away an immense number of its inhabitants, and dur- 
ing the succeeding years, 1833 and 1834 it traversed 
Spain and severely scourged her sons and daughters. 

In the meantime, continuing its course from Great 


Britain westward unchecked by the prevailing west- 
ern winds and the broad expanse of the Atlantic 
Ocean, over which it passed a distance of nearly three 
thousand miles, it made its first appearance on the 
American Continent at Quebec, Lower Canada, on 
the 8th of June, 1832, and arrived at Montreal on the 
tenth day of the same month. From here it rapidly 
spread in all directions, invading the towns and vil- 
lages on the St. Lawrence and its tributaries, and 
soon extended along the chain of lakes that divides 
the English possessions from the United States, visit- 
ing with great impartiality, the principal ports on 
either shore. In all these places it exhibited the 
same virulence of character we have before noticed, 
and proved itself severe and fatal where ever it 

Sixteen days after its appearance in Quebec, on 
the 24th of June, 1832, it broke out in New York, and 
at Albany, midway between the two former cities, 
cases were reported on the 3d of July. From New 
York it extended to Flatbush and Gravesend, Lone 
Island, where it appeared on the 5th of July, and on 
tRe same day and date at the city of Philadelphia. 
Shortly after it was passing through New Jersey, and 
on the 1 2th of July reached Rochester, and a few 
days later, Buffalo, N. Y. 

Thus while it was making its way westward along 
the great lakes, towards the arteries of the great West, 
it was at the same time, pursuing its course steadily 
along the Coast, visiting the main cities and spread- 
ing from these as from common centres over the in- 
termediate towns and villages. In its progress it 


reached Baltimore on the 22d of August and the city 
of Washington on the 28th of the same month. 
Thence it continued its course to Richmond, Nor- 
folk, Edenton and various other cities along the 
Atlantic and Gulf Coast. 

It appeared at New Orleans in the Autumn of 1832, 
during the existence of a severe epidemic of yellow 
fever, and apparently subsided on the disappearance 
of the fever. Sporadic cases, however, occurred dur- 
ing the Winter, and with the opening of Spring it 
broke out with unwonted intensity and severity, and 
thence spread according to its accustomed laws of 
itineracy, along the rivers into the interior of the 
States bordering upon the Mississippi and the Gulf 
Coast, and raged throughout Louisiana and Texas. 

In 1832, 1833 and 1834 it prevailed along the Mis- 
sissippi valley with great fatality, especially in the 
principal cities, villages and towms situated upon its 
navigable waters. Here after intervals of entire 
immunity from its presence, it occasionally reap- 
peared in some of the larger cities with increased 
intensity and in short spaces of time, swept away 
great numbers of people. In no section of the United 
States did greater numbers, compared with the whole 
population, fall victims to it than in the fertile and 
sparsely settled prairies of the South and West. 

Thus from the North, and at a later date from the 
South, extending its influence along the principal 
rivers into the interior, it swept over the country, 
being found in some places in the valley of the Father 
of Waters as late as 1836. In short, it reappeared in 
1834 in many cities and places where it had before 


prevailed, and again spread over a considerable 
portion of the country with unprecedented fatality. 

In 1833, cholera appeared at Havana in Cuba, 
and in Matanzas, lasting on the island for several 
months with great severity, especially among the 
colored people. During the same season it appeared 
in August at Tampico, Campeachy, Vera Cruz and 
the city of Mexico, proving particularly violent. 
In Central America it is said to have attacked the 
army, and in a short period to have wiped out of ex- 
istence a very large proportion of its officers and 

Thus it appears that this epidemic from its first 
irruption on the Northern Coast, spread over the 
greater part of the North American Continent in the 
space of two years, and that it several times reap- 
peared in different parts of the country spreading on 
each occasion over a greater or lesser extent of ter- 
ritory, with the same uniform and destructive influ- 
ence. For years and years after its final departure, 
this epidemic left a cloud over the country, and for 
a long time old inhabitants spoke with bated breath 
of its devastations. I remember hearing Prof. Alonzo 
Clark, tell of its invasion of New York; how business 
was suspended, how the streets were deserted, how 
between the cobble stones on Broadway blades of 
grass put up their little heads into the sunshine, how 
houses were closed, and a funereal pall seemed to 
hang over the Empire City. Then one could walk 
out in the early morning, when the air would be 
bright and cool and pure and apparently salubrious, 
and security and peace seemed to hover over the 


city; but reminders of the true condition would be 
noticed in the appearance of carriages loaded with 
household utensils tending toward the country, by 
the odor of vinegar with which every passer by was 
accompanied, and by the mournful creaking of the 
wagon conveying some one to the small and narrow 
house. The public parks were cool and fragrant as 
of yore, skirted by verdure as bright and shaded by 
foliage as luxuriant, but no longer frequented by 
lively steps and cheerful countenances. Every day ad- 
ded to the devastation and confusion of the city. The 
most populous streets were deserted and silent. The 
greater number of the inhabitants had fled, and the 
ones who remained were occupied with no cares but 
those which related to their own safety The work 
of the artisan and the speculations of the merchant 
were suspended, but the labors of the physician were 
increased many hundred-fold. All shops, but those 
of the apothecaries, were closed. The hearse was 
now the only carriage seen, and this was employed, 
night and day, in the removal of the dead The 
customary sources of subsistance were cut off. Those, 
whose fortunes enabled them, had left the city, 
and those who lived by the fruits of their daily 
labor were subjected, in this total inactivity, to the 
alternative of starving, or of subsisting upon public 
charity. I remember hearing the Doctor tell of one 
particular day when he walked forth in a residence 
street, which was as quiet almost as a grave-yard, the 
only sound heard being the rattle of the dead wagon 
stopping at one house or another for its ghastly 
freight. Slowly he strolled along, feeling intensely 


the deep solemnity of his surroundings, when the 
door of one of the houses opened, and a young 
woman came out talking to a companion, and sud- 
denly laughe'd. At any other time her laugh would^ 
have been called soft and musical, but now it 
sounded harsh, and wanton and weird. And Clark 
said he thought of the words of the Prophet: "I 
also will laugh at your calamity; I will mock when 
your fear cometh. When your fear cometh as deso- 
lation, and your destruction cometh as a whirlwind; 
when distress and anguish cometh upon you." 


At my last lecture, I outlined to you, some mat- 
ters connected with the history of great epidemics 
that in earlier times, have visited our planet, and the 
course of the great cholera epidemic of 1817. This 
plague, as we have already noticed, was marked by 
great severity'and high rate of mortality. Accord- 
ing to the most reliable reports, the cases occurring 
in the earlier periods of an irruption are generally 
fatal, few only surviving the attack; while of those 
occurring when the disease is on the decline, a 
greater number recover. Some observers have di- 
vided epidemics in three subdivisions; the first, in 
which the majority of the cases die; the middle third, 
in which many die and many recover; and the last 
third, in which the larger number of the attacked, 
recover. This arbitrary rule however can not be 
looked upon as being generally applicable, as you 
will find in studying the various outbreaks of cholera, 
that often the disease will seemingly be of equal 
virulence all throughout an epidemic, and will sud- 
denly disappear, to re-appear perhaps in a week or a 
month, as malignant as in the first invasion. 

We read of numerous instances where one-third, 
one-half, two-thirds and even nine-tenths of those 
seized with cholera have perished, and again of 
some places where one-fifth, one-fourth, and in some 
attacks one-third of entire populations have been cut 
off in a very short period by it. But without attempt- 


ing to burden your minds with statistics of cholera, 
in this part of the world, or even in Europe, I will 
present to you a few instances of mortality, in order 
to show the severity of the disease and the necessity 
for prophylactic study. 

During the epidemic of 1817, in Siam, it is said, 
20,000 persons fell victims to it in twelve days. The 
Siamese are remarkable for their disregard of 

In Sicily, 16,000 died of cholera in 1832, at Cata- 
ria; in Palermo, 40,000. In Bassorah and Bagdad, 
situate in low, unhealthy localities, and exposed to 
a damp, insalubrious atmosphere, which in the 
warmer season is often essentially impregnated with 
miasmata and offensive exhalations from animal and 
vegetable decomposition, both within and without 
their inclosures, it is affirmed that more than one- 
third of their entire populations were carried off in 
less than a month. 

In the province of Caucassus, out of 16,000 at- 
tacked by the disease 10,000 died. In Russia, out of 
54,000 attacked in 1830, it is said more than 31,000 

In Hungary, it is reported that the whole number 
affected by the disease was about 400,000, of whom 
more than one-half died. 

It is officially reported that the total number — 
the military excepted — of those affected with cholera 
in France, from its first appearance at Calais, March 
15th, 1832, to January 1st, 1833, was 230,000, and the 
deaths were 95,000. 

In England, the whole number of cases of cholera 


was reported to have been 49,594 and the number of 
deaths 14,807. In the City of London there were 
1 1,020 cases, of which 5,274 proved fatal. In Wales 
there were 1,436 cases, of which 498 died. In Ire- 
land, from its first appearance in 1832 to March, 1833, 
there had occurred 54,552 cases of which 21,171 
were fatal. 

In Quebec, from June 9th to September 2nd, 
1832, there had occurred in that city alone no less 
than 5,783 cases, of which 2,218 were fatal. In Mon- 
treal from June 10th to September 21st, there were 
4,440 cases, and 1,904 deaths reported. 

In New York, from July 4th to August 28 in 1832, 
there had occurred 5,814 cases, and 2,935 deaths. 
In Philadelphia, from July 4th, to August 28th, 1832, 
there were reported 2,314 cases of cholera, of which 
935 were fatal. 

In many particular portions of the United States, 
the percentage of loss from cholera, during this and 
other epidemics, was considerably higher than the 
general average compared with the data I have 
given you. The mortality varies materially in 
different localities, and indeed, I feel safe in saying, is 
in direct ratio with the sanitary condition, of the 
locality in question. 

Since the occurrence of the epidemic whose course 
and peculiarities, we have just reviewed, this part of 
the world has been visited at various intervals by 
Asiatic cholera. Prominent periods were the years 
1848, 1854 and 1866. It is now almost ten years 
since we have been threatened by it. You recollect 
that then it was endemic in several portions of the 


country, and I believe would have become generally 
epidemic, had it not been for the promptness and 
energy of Surgeon-General John B. Hamilton, who 
proved himself to be a sanitarian and hygienist of 
great skill, by the manner in which he handled the 
threatening danger. The route of the epidemic of 
1892 has been carefully traced by Dr. Dawson Wil- 
liams, of London, from whose paper read before the 
annual congress of the Sanitary Institute, September 
1892, we learn as follows: In tracing the progress of 
the present epidemic of cholera, it does not appear 
to be necessary to include a consideration of the 
occurrence of the disease in Syria in 1891, or its 
subsequent recrudescence. There is no evidence of 
any spread from Syria either northward or westward; 
on the contrary, all the evidence goes to show that 
Asiatic cholera reached Europe in 1892 by a track 
differing altogether from the paths followed in the 
last half century, though nearly approaching the 
route taken by the earliest epidemics which reached 

Speaking broadly, Asiatic cholera has followed 
three main routes from India to Western Europe: 
1. It has passed through the north-west provinces of 
India into Afghanistan, and thence along the caravan 
routes by way of Balkh, Bokhara and Khiva to 
Orenburg in Russia (1829, 1843-44); 2. It has spread 
from Southern India up the Gulf to Persia, and 
radiated south-westward to Syria and Egypt, and 
north-westward across Persia to the Caspian Sea, 
thence to Astrakhan on its western shore, and from 
that port up the Volga to Saratov and Kasan (1830); 

■ * 


3. It has been transported, mainly in relation with the 
pilgrim traffic, to Red Sea ports, has gained Egypt, 
and spread thence to the Mediterranean basin. 
Since 1865 the epidemic has always, until 1892 taken 
the last mentioned route, and the attention of inter- 
national conferences has been, in the main, confined 
to devising precautions for protecting Europe from 
invasion by way of the Red Sea and Egypt. 

In 1892, the epidemic once more followed a north- 
ern course, and . has afforded one more striking 
illustration of the readiness with which Asiatic 
cholera can be conveyed along a trade route. 

Late in 1891, cholera appeared in Afghanistan, and 
caused a considerable mortality in Cabul. During 
the winter months, January and February, the 
epidemic died down, but in March there was a severe 
outburst, and the disease continued to be epidemic 
for several months. In March the disease had 
reached Herat, in north-western Afghanistan, and 
was causing several hundred deaths a day. Two 
months later it had become established in Meshed, 
in north-eastern Persia, and spread slowly thence to 
Nishapur, Gabzawar, Abbasad and Sharud, only 
becoming epidemic at Teheran some two or three 
months after its appearance in Meshed. 

Very different from this slow march of the epi- 
demic westward through Persia, was its swift progress 
once it touched Russian territory. The disease was 
recognized at Askabad during the first day of June, 
having in all probability spread there from Meshed 
a little earlier. At Askabad the epidemic touched 
the Trans-Caspian Railway, which runs from the 


eastern shore of the Caspian Sea, through Askabad 
and Merv to Bokhara and Samarkand. Cholera 
spread eastward and westward along the course of 
the railway with great rapidity, nor was its progress 
arrested or even checked by the Caspian Sea, for its 
presence in Baku on the western shore was admitted 
officially within a fortnight of its recognition in 
Askabad, and private telegrams show that it had 
undoubtedly been present for a week or ten days 
before this. Baku is an important trade centre. It is 
the terminus of the Trans-Caucasian Railway, which 
brings it into direct communication with Black Sea 
ports, while steamboats on the Caspian connect it 
with the terminus of the Trans-Caspian Railway, and 
with Astrakhan, the southern outlet of the trade of the 
Volga. The spread of the epidemic in Baku itself, 
favored by the existence of gross sanitary defects, 
and by the want of competent municipal government, 
was rapid; and even the brief telegraphic despatches 
have given a picture of social disorganization which 
can hardly be equalled in the whole terrible gallery 
which Asiatic cholera has provided for the warning 
and instruction of mankind. 

With cholera raging in Baku, and with an inept 
administration relying entirely upon quarantine 
regulations illogically planned and imperfectly 
carried out, it was no matter of surprise that the 
epidemic found its way eastward along the Trans- 
Caspian Railway as far as Tiflis, and northward by 
the Caspian boats to Astrakhan. How early the 
last named city was infected is not, and probably 
never will be, known; when the presence of the 


epidemic was recognized officially, it was already 
prevailing in Saratov, some 500 miles higher up the 
river, and a week later was reported from Kostroma 
to the north-east of Moscow. 

Within a month, therefore, of the recognition of 
cholera at a town on the Trans-Caspian Railway, it 
had penetrated to the heart of Russia in Europe, the 
transit from Central Asia having taken as many 
days as, before the creation of railroads and steam- 
boat lines, it took months. The recognition of the 
significance of this fact is one of the most important 
lessons which this epidemic has as yet afforded. 

Having traced the progress of the epidemic from 
Afghanistan to Persia with great probability, and 
from Persia to Russia in Asia, and from Russia in 
Asia to Russia in Europe with precision, it remains 
to enquire how the infection reached Afghanistan. 
As to this there is room for some difference of 
opinion. It is natural in the first place, to turn our 
thoughts to the Hurdwar Fair, the continuance of 
which the Indian Government found it advisable 
last year to prohibit, on account of the danger of the 
dissemination of cholera. This great assembly of 
people, brought together primarily by a religious 
object, is frequented by pilgrims and traders from 
the north-west provinces, by Kashmirees and border 
men. The prohibition was not completely effective, 
and many of those w T ho reached Hurdwar at an early 
date, or eluded the vigilance of the officials at a later, 
undoubtedly carried cholera for considerable dis- 
tances. There is strong reason to believe, though the 
fact cannot be affirmed positively, that the disease 


was thus conveyed to Srinagar, the capital of Kash- 
mir, where a severe outbreak began in May. While 
it will be admitted that the accumulation of a huge 
multitude of people at Hurdwar in the early Spring, 
and their dispersal in every direction throughout 
north-western India and the frontier countries, is a 
fact, the significance of which for Europe is greatly 
increased by the proof now afforded that cholera 
may be carried in a few weeks from the confines of 
Afghanistan to European Russia, yet it appears that 
the Hurdwar Fair is not in any way responsible for 
the movement of cholera last year. 

As we have already seen, cholera was epidemic in 
Afghanistan at the end of 1891. A month or two 
earlier — in September — an outbreak had occurred 
among laborers in the Hoti Mardan district of the 
Peshawar division. There appears to be little doubt 
that this outbreak was originated by men coming 
from Swat and other independent territories to the 
north-east of Peshawar. The laborers immediately 
dispersed, many fleeing to Peshawar, where an epi- 
demic of a peculiarly fatal character subsequently 
occurred, both in the town and in the Pathan villages 
in the immediate neighborhood. The mortality in 
some of the villages in the valleys toward the eastern 
mouth of the Khyber Pass was particularly severe. 
At an later date many villages in the Shinwarri 
-country lying to the north of the western end of 
the Pass were ravaged, and toward the end of the 
year Cabul itself was attacked, as already said. 

It does not seem to be necessary to refer at any 
length, to the spread of the epidemic at Hamburg; 


its dependence upon the line of emigration from 
Russia appears to be obvious, and the probability of 
the occurrence of cases among emigrants arriving at 
that port from infected districts en route for England 
and America ought to have been foreseen and pro- 
vided for by the authorities in Hamburg. This does 
not seem to have been the case and insanitary con- 
ditions appear to have been allowed to prevail, of 
which we now see the inevitable consequences. 
Neither does it come within the scope of our 
present studies to discuss the nature of the choleraic 
disease which began to prevail in Paris in the 
early Summer. Its epidemiological characters were 
not those of Asiatic cholera. 

From our studies of this epidemic, the following 
deductions maybe made: 1st. The greater rapidity 
of transit has increased the probability of the im- 
portation of cholera and other epidemic diseases 
from central Asian countries to European Russia, 
and thence to Europe in general. By extension of 
commerce, and the building of railways, and steamer 
lines, the land of dense religious superstition, of un- 
qualified ignorance, and of total disregard for sani- 
tary laws, has been brought in close and intimate 
relations with the civilized world. This condition is 
well exemplified by the fact that a trip from Chicago 
to Irkoutsk, is thought less of to-day by us than was 
a journey from Philadelphia to Washington, less than, 
a hundred years ago, by our forefathers. 

2nd. Asiatic cholera, in traveling by land routes, 
depends for its power of continued progress mainly 
upon the existence of insanitary conditions in towns 


in which traffic is temporarily arrested for trans- 
shipment or otherwise. The necessary delay affords 
time for persons from infected districts to be at- 
tacked by the disease, and so to infect the place at 
which the halt is made. Such places become fresh 
centres from which the disease spreads along lines of 
traffic. This fact is well illustrated by the history of 
the epidemic in Baku and in Hamburg. Cholera 
spreads to an extent and with a rapidity directly pro- 
portionate to the march of commerce and the facili- 
ties afforded for intercommunication. Its intensity 
and reactionary strength are in direct ratio to the 
sanitary condition of the locality, and the manner in 
which hygienic laws are obeyed, or disregarded, and 
in this connection let me call your attention to the 
parable spoken of in the Scriptures, of the sower and 
his seed, and of the different results obtained in ac- 
cordance with the condition of the receiving ground; 
so with cholera, and all filth diseases, let the territory 
be acceptable and the harvest will be plenteous. Let 
the ground be nutritious and the disease germs will 
take root rapidly, and grow and develop with malig- 
nant luxuriance. 

3rd. Quarantine has once more shown itself to 
be a most ineffectual method of checking the spread 
of cholera. Quarantine for instance, between Baku 
and Astrakhan utterly failed to prevent the spread of 
the infection to the latter town. Quarantine is there- 
fore in one way, dangerous, because it leads to a 
sense of false security. That is, quarantine alone, 
and without other precautions. 

4th. On the other hand, medical inspection of 


travelers, especially of those of the poorer emigrant 
class, combined with isolation of doubtful cases, ap- 
pears to be once more showing itself to be an 
effectual method. At the same time, it must be 
recognized that no method can be effectual in the 
absence of good sanitary conditions in ports or other 
centres of trans-shipment or temporary arrest of 
trade. In fact, it may truthfully be said that the 
only effectual method of excluding cholera from a 
country is to exclude the infectious principles from 
its water supplies. 

5th. There is great need for more precise, 
earlier, and more authoritative information as to the 
existence of epidemic diseases in all civilized coun- 
tries. Such information, is at present, as it has been 
in the past, eminently unsatisfactory. Information 
coming from scientific journals, from government re- 
ports, while precise and authoritative, comes too late 
to be of service during a given epidemic. News- 
paper reports, on the other hand, while prompt, are 
not reliable, as they usually are founded on either 
popular rumor, or on official statistics which are not 
always entirely trustworthy. 

I will consider that these lectures have not been 
delivered in vain if I can indelibly impress upon 
your memories the following facts: Local quaran- 
tine is an absurdity. The quarantine regulations and 
public health laws, should be in the hands of 
National authority, to be of value to the country, or 
in fact to any part of it. Chicago and Omaha are, 
from a commercial standpoint, as much seaports as 
New York or Boston. Denver is as near to the 


Orient as is San Francisco, and it is just as nonsensi- 
cal for the State of Illinois to have charge of quaran- 
tine regulations concerning her own territory, as it 
would be for her to declare war against the German 
Empire. But in order to attain the much desired 
end, we must continue the campaign of educa- 
tion, that was begun when the first physician com- 
menced to practice medicine. On you, the phy- 
sicians of the future, will devolve the task that we of 
to-day will be obliged to resign as our strength 
wanes, and your first step will be to show clearly to 
mankind that financial interests require the observ- 
ance of sanitary laws. It is therefore to the advance- 
ment of commerce to enforce hygienic regulations. 
Of what benefit would it be to the Garden-City, with 
the Exposition in full blast, with great expectations 
and hopes not only to be immediately realized, but 
to be felt in both near and distant future, if the 
pestilence should come among us? It is to our 
financial and commercial interests therefore to be 
clean physically as well as morally. The wise man 
hath said: "Cleanliness is next to Godliness," but I 
place cleanliness first. How can a pure spirit reside 
in a foul and filthy body? How can a virtuous maid 
make her home in a brothel? We should, irrespec- 
tive of political belief or partisan prejudice, bend our 
energies in this direction; to have all quarantine and 
public health matters under the control of the 
Federal Government; to endeavor to have a Portfolio 
of Public Health attached to the Cabinet of the 
Chief Executive of the Nation, in charge of a medi- 
cal man whose recommendation for the position 


must be that he is a scientific physician and a skillful 
sanitarian. When this condition of affairs shall 
come to pass, then we can absolutely prevent inva- 
sion of the Commonwealth by foreign epidemics, 
and quickly stamp out those due to auto-infection. 

Asiatic cholera is, a specific, infectious disease, 
induced by a specific, exciting etiological factor, 
acting under the influence of favorable contributory 
conditions, and characterized clinically by violent 
purging, great dessication of the system, and rapid 
collapse. You will note that in this definition I 
make mention of a particular cause, which we have 
before referred to as the spirillum cholerae Asiaticae — 
Koch's comma bacillus, and I would accentuate the 
value of our knowledge in this direction, as without 
such information, prophylactic measures would be 
entirely empirical, and could not be scientifically ap- 
plied. An old and trite proverb says: "You must 
first catch your hare before you can cook him," but 
in order to catch the aforesaid hare, you must first 
know something concerning his habits and mode of 
life, his peculiarities and characteristics. In the 
chronicles of Ibrahim El Mured, I find the following 
legend: During the reign of the great and good 
Caliph Haroun-Al-Raschid of happy memory, there 
dwelt in the city of Bagdad, a follower of the 
Prophet who was renow r ned far and near for his 
wisdom, so that even from the most distant portions 
of the Caliph's dominions, people would come to 
Bagdad to consult the wise-man. Now it happened 
that in a far and distant city, the inhabitants were 
sorely afflicted on account of a certain monster 


which for many months had been ravaging the 
vineyards and grain fields, working grievous damage 
and occasioning great distress. The people of this 
city having heard of the wizard at Bagdad, came 
together and sent a messenger with presents, to ob- 
tain instruction as to how they might best free them- 
selves from the monster who was plagueing them. 
Arid after forty days' journey, the envoy arrived at 
Bagdad, and having performed his ablutions, he 
presented himself before the man of wisdom, and 
stated his case. Then said the philosopher: "What 
manner of beast is this that you complain of?" and the 
youth blushingly acknowledged that neither he nor 
any in the city had as yet laid eyes upon it. "Then, by 
the beard of the Prophet," exclaimed the wiseman, 
"how T can I instruct thee how to rid thy town of its 
persecutor. Go back, Oh, most foolish of messen- 
gers, and acquaint thyself with what manner of beast 
this may be, and then when thou shalt come and tell 
me whether it flieth in the air, or walketh on the 
ground, or swimmeth in the water, then can I tell of 
cunning means I will devise for its destruction." 
And the messenger departed, a sadder and a wiser 

Following out this mode, or plan, we will now 
commence the study of the etiology of cholera. In 
1883, Robert Koch went out to Egypt as chief of a 
commission sent by the German government to in- 
vestigate the causative factors of cholera. From 
Egypt, the commission subsequently went to India, 
continuing their observations, and in 1884, Koch an- 
nounced to the world his discovery of the "Comma- 


Bacillus." That this micro-organism is the exciting 
cause of the disease, there is no doubt. It responds 
to all the tests to which a micro-organism must re- 
spond before it can be called "specific." It is always 
found in the bodies of those suffering from Asiatic 
cholera; it will grow and develop in culture-media 
outside the body; from these media, the disease can 
be reproduced; and in those animals in which \he 
malady has been reproduced, the specific morbific, 
micro-organism, can be found. 

Koch was first struck by the discrepancies be- 
tween the descriptions given in the text-books of the 
post-mortem appearances of the disease, and the ap- 
pearances he actually found. He noticed that it was 
rare to find the intestinal mucous membrane simply 
opaque with slightly swelled follicles and the tube 
containing gruel-like material. This condition he 
found only in the most acute cases, and the gruel- 
like matter presented the characteristics of an al- 
most pure cultivation of the bacillus. Very excep- 
tionally did he find fluid in the intestines, comparable 
with rice-water. In cases where the disease had 
lasted somewhat longer, he noticed that the follicular 
masse's and Peyerian patches were surrounded by 
hyperemic rings or zones, having a tendency to run 
together into red patches; and in the cases where the 
disease had lasted the longest, he found the small 
intestine congested, most marked above the valve, 
the contents becoming bloody, exhaling a putrefac- 
tive odor, and with the replacement of the before- 
referred to bacillus, by other bacterial forms. 

If, in the stage of patchy redness, sections were 


made of the mucosa parallel to its surface, it was 
shown that the redness corresponded to an invasion 
of the tubular glandular structures, by the bacillus 
found in the contents of the intestine in the more 
acute cases, and the parasite was found lying be- 
tween the epithelium and the basement membrane. 
On account of its definite form, and its apparent 
constant presence, the parasite soon attracted atten- 
tion. When he wrote his early papers on this sub- 
ject, Koch named the parasite "the comma-bacillus," 
and he believed that its form was quite characteristic. 
Some bacteriologists speak of it as the cholera 
"vibrio," but Sternberg following Flugge's nomen- 
clature calls it the "spirillum cholerae Asiaticse," and 
it is by this name, we shall study and recognize it. 
This micro-organism is about one-half to two-thirds 
the length of a tubercle bacillus, but much thicker 
(about .5 m.m.m.)and it presents a curve, usually about 
equal to that of a comma (hence the first name — 
comma bacillus), but sometimes amounting to a semi- 
circle. It multiplies by transverse division, and the 
segments separate from each other at once upon 
gelatinous media or in the intestine mucosa; if two 
remain united they form an "S," their curves being 
in opposite directions. Under certain circumstances 
it grows out into long spiral filaments, and the so- 
called "commas" have a spiral twist which may be 
recognized in drop cultures, especially in the longer 
elements which in stained preparations present an 
"S" shape. When development is rapid the short 
curved rods and "S" shaped spirals only are seen; 
but in hanging drop cultures, or in media in which 


the development is retarded by unfavorable condi- 
tions, such as low temperature or the presence of a 
small amount of alcohol, long spiral filaments are 
quite numerous. In old cultures, the involution 
forms — or distorted forms, are often seen. The 
curved rods have rounded ends and are about 0.3 to 
0.4 m.m.m. in diameter. They are actively motile, and 
are provided with a single terminal flagellum, which 
however can only be demonstrated by Loffier's 
staining methods. The above mentioned spirals 
resemble very much the spirillum of Obermeier, in 
fact side by side under the microscope, Koch found 
it difficult, if not impossible, to distinguish between 
them. The cholera spirillum grows well upon all 
the ordinary media, and its rapid multiplication can 
be watched in a drop of meat-infusion upon the 
under surface of a cover glass. In stains of cholera 
dejecta upon linen, kept moist and exposed to the air, 
growth is quite free for several days. The colonies 
upon nutrient gelatine or agar begin as very tiny, 
pale spots, which, as they get larger, present a 
slightly irregular outline and a finely granular sur- 
face; Koch compares them to heaps of fine bits of 
glass. Then the gelatine (not agar) around for about 
one millimeter liquefies and the colony sinks down 
into a funnel-shaped depression with an apical white 
point. This appearance of a long narrow funnel 
is typical when a tube is inoculated by puncture. 
The growth of this spirillum is unusually rapid; it 
reaches its limit in a few days, remaining a short 
time stationary, and then begins to decline, the 
spirilla either shrivelling or swelling up centrally or 


terminally, and staining more or less imperfectly. 
Concerning the etiological relation of the spirillum 
to the disease with which it is associated, I have 
already commented. So eminent an authority as 
Surgeon-General Sternberg of the U. S. Army, states 
that so far as his information extends, there has been 
no failure to find it in the characteristic discharges 
of cholera patients when these have been collected 
at an early period of the attack and have been ex- 
amined by competent bacteriologists. On the other- 
hand, this particular micro-organism has never 
been obtained from the alvine discharges of persons 
suffering from other diseases, or of healthy individu- 
als, although very extended observations have been 
made on this line, since the announcement of Koch's 
discovery. Prominent among these are the re- 
searches of Finkler and Prior, of Weisser, of Es- 
cherich, of Booker, of Jeffries and of Sternberg. For 
full information in this connection I must refer you 
to Geo. M. Sternberg's works, from which I largely 
quote. Examinations have been made of the dejecta 
of those suffering from enteric fever, and of well and 
river water from various sources, but no one has met 
a spirillum which is identical with the "comma- 
bacillus" of Koch. This subject is, at the same time, 
one of public health and of microbiology, and noth- 
ing is more attractive to-day than microbiology, 
especially that of all those maladies which are 
variously termed Asiatic cholera, cholera nostras, 
cholerine, choleriform diarrhea. The intestine is, in 
all of these different cases, infected by microbes to 
which are attributed cholerigenic properties. And 



here I will enumerate these bacilli, which are in 
brief: 1st. The comma-bacillus of Dr. Koch dis- 
covered by him at the time of the Egyptian epidemic 
in 1883, and the existence of which has been recently 
confirmed at Hamburg; 2nd. The bacillus which 
Emmerich observed in 1884, during the epidemic at 
Naples; 3rd. The bacillus of Drs. Finkler and Prior; 
4th. The bacillus which Drs. Gilbert and Girode 
observed in several cases of cholera alleged to be 
nostras and which in the opinion of many bacteriolo- 
gists, is no other than the bacterium coli commune; 
5th. The micro-organism obtained in 1885, by Den- 
eke, from a piece of old cheese. Of these, two are 
in some ways, found to be closely allied to the Koch 
spirillum; one, the spirillum of Finkler and Prior, and 
the other, the spirillum of Deneke; but both of these 
have been show r n to present constant characters by 
which they may be differentiated from the spirillum 
cholerae Asiaticae. Cunningham, as a result of recent 
researches made in Calcutta, states that he has failed 
to find comma bacilli in undoubted cases of cholera, 
and that in certain cases in which they were present 
he was able to differentiate several varieties. The 
question of cholera microbiology, is not by any means 
as yet entirely settled, although there is no doubt of 
the specific value of the comma-bacillus. 

Professor M. N.encki reports under date of Janu- 
ary 7th, 1893, on the work accomplished in the St. 
Petersburg Imperial Institute of Experimental Medi- 
cine during the cholera epidemic of last year. At 
the very beginning of the outbreak the institute was 
enabled, by the kindness of Prince Alexander of 


Oldenburg, to establish two temporary branches for 
practical work at Baku and at Astrakhan, and to 
furnish them with the necessary apparatus and instru- 
ments for bacteriological investigation, as well as 
with a large supply of old and new remedies for the 
disease. As a result of these investigations, Dr. 
Blachstein and Dr. Shubenko advance the following: 
They found in the stools of a large number of 
patients suffering from typhoid-cholera, and some- 
times also in cases of typical cholera three kinds of 
short bacilli, which they named bacterium caspicum 
alpha, beta primus, and beta secundus. The bac- 
terium caspicum alpha does not liquefy gelatine. It 
is very difficult to distinguish this bacterium from 
the bacterium coli commune and from the bacillus of 
enteric fever. The bacterium caspicum beta primus is 
chiefly found in cases of typhoid cholera, but now and 
then also in typical cases of cholera Asiatica. It lique- 
fies gelatine. The bacterium caspicum beta secun- 
dus was obtained from the contents of the small intes- 
tine of a person who died from typical cholera. It acts 
on gelatine like the foregoing, from which it differs 
very little, and it is possible that both the kinds last 
mentioned are identical. Dr. Blachstein states that, 
after subcutaneous injections of bouillon inoculated 
with the discharges of a cholera patient, mice and 
rabbits died in twenty-four to thirty-six hours. On 
the other hand f injections of a pure culture of comma 
bacilli or of pure cultures of the three species of 
caspic bacilli, taken separately, did not cause death. 
This observation is in accordance with that pre- 
viously made by Bouchard. Dr. Blachstein prepared 


artificially pathogenic mixtures in which the comma 
bacillus and some of the other kinds of intestinal 
bacilli were present. These mixed cultures were ob- 
tained either by inoculating a twenty-four hours' old 
culture of one of the other microbes with the comma 
bacillus, or by placing one of the other bacilli in a 
culture of comma bacillus, and it was observed 
that mixtures obtained in the former way were 
more virulent than those prepared in the 
latter. Experiments on mice always gave uniform 
and positive results, illustrating the fact that 
the comma bacillus, in combination with some of 
a large number of other bacteria, is able to kill 
mice, while, in the same animals, pure cultures of 
any single kind give negative results. 

The caspic bacillus alpha, plus comma bacillus, 
kills rabbits and pigeons; bacillus caspicus beta 
secundus plus comma bacillus kills only mice and 
guinea-pigs. The mixed cultures were generally 
injected in the quantity of 0.1 cubic centimetre into 
the mice; the rabbits were inoculated with two cubic 
centimetres. Death quickly ensued, generally with- 
in twenty-four hours. 

Dr. Blachstein, in collaboration with Dr. Zunft, 
succeeded in obtaining from the water supply of St. 
Petersburg a bacterium which by itself was quite in- 
nocuous, but which mixed with the comma bacillus 
caused the death of animals. A mixture of comma 
bacillus with the bacterium coli commune obtained 
from the contents of the intestines of a cow, killed 
pigeons. The comma bacillus grows very well in a 
pure culture of bacterium coli, and in growing dis- 


places the latter so effectually that within a week no 
trace whatever of it remains. 

With regard to the other mixed cultures, it was 
found that the comma bacillus entirely disappears 
in a culture of bacterium caspicum, and within thirty- 
six to forty-eight hours; on the other hand, trans- 
ferred into a culture of bacterium beta primus, it 
first develops abundantly, but soon stops in its de- 
velopment, and after two to three days disappears, 
and leaves the place to its companion. A growth of 
the inoculated comma bacillus in the bodies of 
animals was not observed by them; on one occasion 
only, Blachstein and Zunft succeeded in recovering 
the cholera bacillus from the place of inoculation. 

In Professor Nencki's opinion, too much atten- 
tion can not be given to the question of mixed in- 
fection in studying the microbiological aspect of 
cholera etiology. He thinks it clear that other 
bacteria in some way or the other increase the viru- 
lence of the comma bacillus. Nehcki believes that 
if Pettenkofer and Emmerich, instead of drinking a 
pure culture of comma bacilli, had taken one of the 
mixtures mentioned above, they would not have 
escaped with so light a form of cholera. 

A very interesting portion of our subject, is the 
study of the noxa that appear in connection with the 
processes that belong to the growth and develop- 
ment of the cholera spirilli. Brieger has succeeded 
in isolating several toxic ptomaines from cultures of 
the cholera bacillus, some of which had previously 
been obtained from other sources — cadaverin, putres- 
cin, creatinin, methyl-guanidin. In addition to 


these he obtained two toxic substances not pre 
viously known. One of these is a diamin, resembl- 
ing trimethylenediamin; it gave rise to cramps and 
muscular tremor in inoculated animals. The other 
poison reduced the frequency of the heart's action 
and the temperature of the body in the animals 
subjected to experiment. In more recent researches 
made by Brieger and Fraenkel, a toxalbumin was 
obtained from cholera cultures, which, when injected 
subcutaneously into guinea-pigs, caused their death 
in two or three days, but had no effect on 

Pfeiffer finds that recent aerobic cultures of the 
cholera spirillum contain a specific toxic substance 
which is fatal to guinea-pigs in extremely small 
doses. This substance holds a most intimate relation 
to the bacterial cells themselves, and is perhaps an 
integral part of the same. The spirilla may be killed 
by chloroform, thymol, or by desiccation without 
apparently injuring the toxicity of this substance. It 
is destroyed however, by absolute alcohol, by con- 
centrated solutions of neutral salts, and by the boil- 
ing temperature, and secondary poisonous products 
are formed which have a similar physiological action, 
but are from ten to twenty times less potent. Similar 
toxic materials were obtained by Pfeiffer from cul- 
tures of Finkler-Prior's spirillum, and from the spir- 
illum Metschnikovi. From France comes the des- 
cription of two dangerous toxines; the one considered 
as a neucleine, the other as a neucleo-albuminine, 
but which are probably identical with the toxines 
already described. Cadaverin was thoroughly 


studied in 1886 by Brieger, and later on by Robert 
of Dorpat. These authors agree on its action as that 
of one of the most powerful central poisons. 

With cadaverin-injections, Behring succeeded in 
producing symptoms in mammalia, identical with 
those of Asiatic cholera. This powerful product of 
bacterial life is described as a most prominent cause 
of symptoms in the disease. The irritation in the 
bowel is ascribed mostly to this ptomaine; and 
when the epithelial destruction is started and the 
osmotic disorder breaks out, great amounts of cadav- 
erin seem to be taken up in the blood. 

Once introduced into the circulation, it is able to 
attack the very finest and most important parts of 
the system: the vaso-motor and respiratory centres, 
the ganglia of the heart, the centre of the temperature 
mechanism, and the kidneys. According to Brieger 
and Bocklisch, this alkaloid is composed of C 5 H u 
N 20 . Being thus isomerous with saprine and neuridine, 
it is a diamine, and makes its appearance in animal 
putrefaction after the disappearance of choline. 
Patients, with cystinuria produce cadaverin by the 
kidneys. It is also produced by micro-organisms 
other than the cholera spirillum. Scheuerlen and 
Grawitz found by experimental observation: a. That 
it produces suppuration (denied by Robert); b. That 
it interferes with blood coagulation; c. That it acts 
deleteriously on other bacilli; d. That it poisons 
homoiothermal animals. According to Behring: a. 
It decreases the bodily temperature; b. Produces 
death under tonic spasms, paralyzing the respiratory 
centre; c. Produces desquamation of the epithelium 


of the bowel-mucosa, with gathering of rice-water- 
like fluids in the cavity of the gut; d. Causes ex- 
travasations in several organs. 

Later on, Kobert experimented with the muriate 
of cadaverin on various animals, with the result that 
this salt may be considered as a very mild poison, if 
any poison at all. The same may be said of other 
salts of the alkaloid; for instance, the tannate, lac- 
tate, and citrate. I ask you now to mak£ a mental 
note of these statements as shortly, when we come 
to study treatment, we shall find them of interest. 

The spirillum is not found in the blood or in the 
various organs or other tissues of individuals who 
have succumbed to the disease; but it is constantly 
found in the alvine discharges "during life, and in the 
contents of the intestine examined immediately 
after death; frequently in almost a pure culture in 
the colorless "rice-water" discharges. It is evident, 
therefore, that if we accept it as tho» exciting etio- 
logical factor in producing the disease, the general 
systemic morbid phenomena must be ascribed to the 
absorption of toxic substances formed during its 
multiplication in the bowel-tube. We have already 
studied various toxic substances, produced in these 
developmental processes, and have seen what symp- 
toms they produce, in the animal economy. In 
studying symptomatology, we shall note certain 
symptoms of cholera, which are identical with those 
we have seen produced by these toxines. In cases 
which terminated fatally after a very short illness, 
Koch found but slight changes in the mucous mem- 
brane of the intestine, which was but slightly swollen 


and reddened; but in more protracted cases the 
follicles and Peyerian agmina were reddened around 
their margins, and an invasion of the mucous mem- 
brane by the spirilla was observed, as before shown. 
They penetrated especially the follicles of Lieber- 
kuhn, and were seen between the epithelial cells and 
the membrana propria. Rarely is the spirillum pres- 
ent in vomited material, Koch having fourld it in but 
two cases, and Nicati and Rietsch in three. In about 
one hundred cases in which Koch examined the 
excreta or the contents of the gut of recent cadavers, 
during his stay in Egypt, in India, and in Toulon, his 
"comma-bacillus" was invariably found, and these 
observations were verified last year in Hamburg, but 
the most satisfactory evidence that this spirillum is 
able to produce the disease in man was afforded by 
an accidental infection which occurred in Berlin, 
in 1884, in the case of a young man who was 
one of the attendants at the Imperial Board of 
Health, when cholera cultures were being made for 
purposes of instruction. Through an accident, the 
spirillum appears to have been introduced into his 
intestine, for he suffered a typical attack of cholera, 
attended by thirst, frequent watery discharges, 
cramps in the extremities and partial anuria. For- 
tunately he recovered, but the genuine nature of the 
attack, was shown by the symptoms, and by the 
abundant presence of the "comma-bacillus" in the 
colorless, watery discharges from the bowels. 

The experiments of Pettenkofer and Emmerich of 
Munich and of Hasserlik of Vienna, on their own 
persons are so recent and so fresh in your memories 


that a mention of them on my part will be sufficient. 
These observers swallowed cholera cultures and sub- 
sequently suffered from classical cholera symptoms 
Prof. Emmerich's case being the most severe. Pet- 
tenkofer took one cubic centimetre of fresh bouillon 
culture containing living cholera and at the same 
time to neutralize the acidity of his gastric juice, 
he swallowed one gramme of sodium bicarbonate. 
Thirty hours afterwards a diarrhea set in, which 
lasted eight days and which on the second day was 
marked by nearly colorless stools. There was no 
nausea, no change was made in the diet, but there 
was a good deal of rumbling in the bowels and now 
and then an imperative call to stool. In Emmerich's 
experiment the results were more pronounced. There 
were rice-water discharges and prostration. In both 
instances the stools contained large numbers of the 
specific pathogenic bacilli. 

Finally I would sum up by saying that the spiril- 
lum is found in the bowel and the discharges there- 
from, in every case of Asiatic cholera, but not al- 
ways at all times throughout the course of every 
case. Thus you will often find it difficult or im- 
possible to discover in the later stages of well-marked 
and even severe cases. Drasche reports its disap- 
pearance in fatal cases. On the other hand you will 
find it to persist in the discharges from the bowels 
for two and even three weeks after recovery. 


Resuming our studies of the micro-biology of 
the comma bacillus, to-day I will call your attention 
to certain characteristics which are of great interest 
to us from a practical standpoint, as furnishing us 
with a scientific basis for measures of prophylaxis, 
disinfection, etc. 

The cholera spirillum grows readily in a great 
variety of organic" media, either in the presence or 
in the absence of oxygen. In other words it is an 
aerobic and facultative anaerobic spirillum. 

In bouillon the development is rapid and abun- 
dant, especially in the incubating oven; the fluid is 
only slightly clouded, but the spirilla accumulate at 
the surface, forming a wrinkled membranous layer. 
Sterilized milk is also a favorable culture medium. 
In general this micro-organism grows in any liquid 
containing a small quantity of organic pabulum and 
having a slightly alkaline reaction. It is however 
essentially a "protective tariff" bacillus, and can not 
compete with foreign labor, for in media containing 
other active micro-organisms, it languishes and loses 
strength and vitality. An acid reaction of the cul- 
ture medium prevents its development, as a rule, but 
it has the power of gradually accommodating itself 
to the presence of vegetable acids, and grows upon 
potatoes — in the incubator only — which have a 
slightly acid reaction. Abundant development oc- 
curs in beef -tea which has been diluted with eight or 


ten parts of water, and the experiments of Wolff- 
huegel and Riedel show that it also multiplies to 
some extent in sterilized river and well water, and 
that it preserves its vitality in such water for several 
months. According to Kinyoun it may preserve its 
vitality in sterilized sea-water, taken from New York 
Bay, for a considerable time, but not for a longer 
period than sixty days. 

In an interesting article on the chemistry of the 
cholera bacillus, Ferran states that when it is culti- 
vated in a slightly alkaline bouillon, containing 
lactose, paralactic acid is produced in quantity suf- 
ficient to render the liquid distinctly acid. When 
this microbe is sown upon agar that is slightly alka- 
line, and containing lactose as well as litmus, the 
medium becomes red from the formation of para- 
lactic acid. A cultivation in a slightly alkaline bouil- 
lon containing lactose presents, after being left at 
rest at 30 C. (86° F.) for five days, a floating my- 
coderm, consisting of large comma bacilli, in the 
interior of which may be seen one or two very small 
granulations analogous to spores; eventually all the 
protoplasm of the bacilli disappears, leaving ex- 
posed these small granulations which are readily 
colored by methyl-violet. The same bacillus sown 
in a small quantity of alkaline bouillon, contained in 
a capacious flask, may remain alive for more than 
three years, provided that the flask is closed by 
cotton wool, which will allow of the renewal of the 
air. Under the very same conditions, and with the 
sole difference that the bouillon contains some lac- 
tose, the vitality of the microphyte is rapidly extin- 


guished by reason of the acid character com- 
municated to the medium by its own action. In 
ordinary culture bouillons the growth of this microbe 
is always rapid and luxuriant; but when the bouillon 
contains lactose it is disproportionately less prolific. 
The colonies become very numerous in consequence 
of the addition of that substance, withifi a few hours; 
but the growth ceases completely as soon as the 
medium becomes acid, and before long the vitality 
of the microbe is destroyed. Ferran calls attention 
to the resemblances between the chemical function 
of this microbe and that of the bacillus coli com- 
munis. In many particulars their pathogenic func- 
tions are also similar. Paralactic acid paralyses the 
chemical activity of both, a fact to which we will 
later refer when studying treatment. 

In an extended experimental research made by 
De Giaxa, in 1889, it was' found that in sterilized sea- 
water the cholera spirillum multiplied abundantly for 
a time, and retained its vitality for a considerable 
period; but in non-sterilized sea-water it died out 
within two or three days, the rapidity with which it 
disappeared being in direct ratio to the number of 
common saprophytes in the water. It has also been 
found that it dies out within a few days in milk or in 
river water, which contains numerous saprophytic 

Gruber and Schottelius have shown that in bouil- 
lon which is greatly diluted the cholera spirilla may 
take the precedence of the common saprophytic 
bacteria, and that they form upon the surface of such 
a medium the characteristic wrinkled film. Koch 



found in his early investigations that rapid multipli- 
cation may occur upon the surface of moist linen, 
and also demonstrated the presence of this spirillum 
in the foul water of a "tank" in India, which was 
used by the natives for drinking purposes. Mac- 
namara reported the vitiation of certain drinking- 
water by cholera dejecta, and the production of the 
disease in individuals using the fluid for drinking 
purposes, the water having acted as a culture 
medium. In Bolton's experiments in 1886, the 
spirillum was found to multiply abundantly in dis- 
tilled w T ater to which bouillon was added in the 
proportion of fifteen to twenty-five parts in one 

An interesting question is the ascertaining of the 
thermal death-point of the spirillum. In recent 
cultures in flesh-peptone-gelatine, Sternberg found it 
to be 52 C. (125.6 F.), the time of exposure being 
four minutes; a few colonies only developed after 
exposure to a temperature of 50 C. (122 F.) for ten 
minutes. In Kitasato's experiments in 1889, ten or 
even fifteen minutes' exposure to a temperature of 
55 C. ( 131 ° F.) was not always successful in destroy- 
ing the vitality of the spirillum, although in certain 
cultures exposure to 50 C. (122 F.) for fifteen min- 
utes was successful. He was not, however, able to find 
any difference between old and recent cultures 
as regards resistance to heat or to desiccation. In a 
moist condition this spirillum retains its vitality for 
months — as much as nine months in agar and about 
two months in liquefied gelatine. It is quickly des- 
troyed by desiccation, as first determined by Koch, 


who found that it did not grow after two or three 
hours when dried in a thin film on a glass cover. In 
Kitasato's experiments in 1889, the duration of 
vitality was found to vary from a few hours to thir- 
teen days, the difference depending largely upon the 
thickness of the film. When dried upon silk threads 
it may retain its vitality for a considerably longer 
time. Most interesting observations have been made 
by Dunham of New York, under the direction of Dr. 
Koch, concerning the viability of the bacillus, and 
such experiments prove valuable in throwing light 
upon the way in which cholera may spread from 
place to place during an epidemic. In agar-agar 
cultures this observer found that it is possible for 
the bacillus to retain its viability in a single culture, 
without transplantation, for six-hundred and eighty- 
one days; one year, ten months and ten days. He 
also found that cholera may live in agar culture, 
three hundred and eighteen days, at a temperature 
closely approximating that of the human body. In 
fecal matter, four experiments were made, and the 
mixture examined daily for living cholera bacilli. 
In no case were they found after the sixth day. The 
difficulty of finding the bacillus in such a mixture 
increases with the age of the mixture, so that the 
failure to find them on a given day can not be taken 
as proof that there were none present. When, how- 
ever, as in these cases, a rapid diminution in the 
number present in equal bulks of the mixture ex- 
amined from day to day is observed, and afterward, 
for a number of successive days, none can be found, 
the presumption seems reasonable that the bacillus 


gradually dies out and is no longer present in a liv- 
ing state, soon after all efforts to detect it, fail. 
Dunham experimented with, among other materials, 
urine, dirty water and sewage. In the latter he 
found that a sample of neutral reaction collected at 
the Berlin city pumping station, inoculated with 
cholera from agar and kept at the room temperature, 
contained living cholera bacilli after twenty-four ' 
hours, but after forty-eight hours none could be de- 
tected nor could any be found on the first, third, and 
sixth day thereafter. 

In river water, nine experiments were made in 
which water from the Spree was inoculated with 
cholera bacilli and then examined from day to day 
to determine the presence and number of cholera 
bacilli in known quantities of the water. The water 
was not sterilized before the cholera was added to it, 
and the conditions of the experiment were varied 
with respect to the access of air, agitation, and ad- 
dition of fresh water from the river. For details of 
the experiments, I must refer you to Professor Dun- 
ham's original article, suffice it now to say, that in 
no case could living cholera bacilli be found after 
the sixth day. These results must, of course, be 
taken w r ith the same allowance as those derived 
from the experiments with fecal matter. Of the 
experiments on textile fabrics, I will quote two: 
A piece of flannel was soaked in blood-serum mixed 
with cholera from an agar culture, and kept in a 
lightly covered glass dish at the room temperature. 
Examined almost daily, by means of plate culture, 
for sixteen days. Living cholera found up to and 


including the ninth day; after which a contamination 
with rapidly liquefying bacteria rendered the ex- 
aminations negative. In another, a piece of old 
sheeting was used. This was soaked in soapy water, 
and after having been dried, was dipped in bouillon 
containing cholera from an agar culture. Part of 
the cloth was kept in a loosely covered glass dish. 
In this, living cholera was found after forty-eight 
hours, but none on the sixth or seventh days. Other 
portions of the cloth were rapidly dried in the air, 
and on these no cholera was found after forty-eight 
hours, and seventy-two hours. A very large number 
of observations were made in connection with fruits 
and vegetables, such as cauliflower, cucumber, straw- 
berry, onion, tomato, grape, peach and cabbage, and 
they go to show, that while most of these substances 
can not be regarded as media suitable for the in- 
definite maintenance of the life of the bacillus, they 
are not so unfavorable to its existence that they 
might not readily serve as vehicles for the distribu- 
tion of the germ. It appears that the most destruc- 
tive influence is exerted by other bacteria, which take 
possession of the substratum to the exclusion of the 
cholera bacillus. But by the time this has taken 
place such substances as are articles of food would 
no longer be regarded as fit for consumption. 

Very many experiments have been made to deter- 
mine the amount of various disinfecting agents re- 
quired to destroy the vitality of this micro-organism. 
I quote for you here the results of Boer's observa- 
tions, made in Koch's laboratory, on a culture in 
bouillon kept in the incubating oven, for twenty-four 


hours, time of exposure, two hours: — hydrocyanic 
acid, I to 1350; sulphuric acid, 1 to 1300; caustic 
soda, I to 150; ammonia 1 to 350; mercuric cyanide, 
1 to 60,000; gold and sodium chloride, 1 to 1000; 
silver nitrate, 1 to 4000; arseniate of soda, I to 400; 
carbolic acid, 1 to 400; lysol, 1 to 500. In Bolton's 
experiments, mercuric chloride was effective in two 
hours in the proportion of 1 to 10,000; cupric sul 
phate, 1 to 500. 

The low thermal death-point and comparatively 
slight resisting power for desiccation and chemical 
agents, indicate that this spirillum does not form 
spores, and most bacteriologists agree that this is 
the case. Hueppe, however reports a mode of spore 
formation which is different from that which occurs 
among the bacilli, to-wit: the formation of so-called 
arthrospores; these are said to be developed in the 
course of the spiral threads, not as endogenous re- 
fractive spores, but as spherical bodies which have 
a somewhat greater diameter than the filament and 
are somewhat more refractive. Hueppe describes a 
splitting up of vegetative cells into small fragments, 
which become rounded like spores, and when trans- 
planted grow into spirilla. This mode of spore for- 
mation has not been observed by Kitasato and other 
bacteriologists who have given attention to the sub- 
ject, and can not be considered as established. In 
competition with the ordinary putrefactive bacteria 
the cholera spirillum soon disappears, and Neffelman 
and Kitasato have determined, what we have already 
noticed by Dunham's experiments, that they only sur- 
vive for a few days when mixed with normal feces. 


The cholera spirillum grows best at a temperatnre 
of 30 to 35 C. (86° to 95 F.) and ceases to grow 
at a temperature above 42 C. (107.6 F.), or below 
14 C. (57. 2° F.) Like other micro-organis,ms of 
this class, it is not destroyed by a freezing tempera- 
ture. Your attention is called to this fact, for it is 
extremely valuable from a practical point of view, 
as many times drinking water that had been rendered 
pure (or being previously pure) has been inoculated 
by vitiated ice, which melting in the water, has set 
free living cholera. 

For various reasons, obvious without detailed ex- 
planation, you must be able to differentiate between 
true cholera, and the local form; again there will be 
occasions when it will be necessary for you to de- 
termine as to the existence or non-existence in fluids, 
in perhaps dejecta material, or on clothing, of the 
cholera germ. This you can not do, unless you 
are familiar with the physical characteristics and 
habits of the comma-bacillus. My esteemed friend 
and learned colleague, Professor Adolph Gehrmann, 
has furnished me with a very clear and explicit set of 
rules for this operation, which I now tabulate for 
your information: 


We have to consider: 

a. The collection of the material. 

b. The preservation a?id transport of the material. 

c. The exami?iation of the ?naterial. 

d. The differentiation of the spirillum. 


a. The cholera spirillum may be demonstrated in 
the feces, vomit, or in the intestinal contents of 
cholera suspects. Only fluid feces or vomit should 
be investigated. The material is best collected in a 
vessel that has been thoroughly scalded with boiling 
water, from which it^is poured into flasks or morphine 
bottles, that have been sterilized by dry heat at 
i6o G C. (288° F.), for one hour. After the bottles 
have been filled and closed they must be washed in 
a one to one-thousand solution of mercury bichloride, 
to avoid accidental infection of persons during trans 
portation to the laboratory. When the intestinal 
contents are desired, it is best to make a small open- 
ing into the intestine and allow the material to flow 
directly into the bottle. 

b. The material should always be examined as 
quickly as possible, as cholera soon loses its vitality 
when in contact with actively growing saprophytes. 
The bottles should therefore be packed in ice and 
taken to the laboratory. When it is necessary to 
use the mails, the greatest care must be taken. Only 
strong, tightly corked bottles must be used, these are 
to be packed in regulation mailing cases with suffi- 
cient absorbent cotton to absorb all of the contained 
fluid. If the mailing case is then in turn, packed in 
a tin or metal case or can, it may be sent without 
danger. When the laboratory is more than twenty- 
four hours distant, pieces of thin cloth should be 
saturated with the material and dried at a tempera- 
ture not exceeding 45° C. (113° F.) These are 
placed in bottles and packed as before. 

c. In the laboratory the bottles are again washed 


in bichloride solution and then opened. The con- 
tents are examined as follows: A number of test 
tubes are prepared, each containing fifty per cent, 
beef bouillon which has been diluted with eight or 
ten volumes of sterilized water. Ten per cent, 
nutrient gelatine is also ready, and this must have a 
reaction that is positively alkaline. In these are the 
best conditions for growth; in dilute bouillon they 
grow much more rapidly than the accompanying 
saprophytes, especially at 37 C. (98. 6° F.), and in 
the gelatine they are favored by the alkaline reac- 
tion. The bouillon tubes are inoculated with the 
straight inoculating rod and placed in the incubator. 
At the same time, several plate cultures are made on 
gelatine in Petri dishes. Lastly slides are prepared 
from the fluid remaining. At the end of twenty- 
four hours, the cultures are examined. If there is 
any growth at all, upon the surface of the bouillon, 
other tubes are immediately inoculated from it. The 
fluid is also examined microscopically for character- 
istic organisms. The plate cultures will show, at 
the end of twenty-four hours numerous whitish col- 
onies, that liquefy the gelatine. From these, bouillon 
and plate cultures and slides are prepared. This 
must be continued until some definite characters 
either for or against the presence of cholera, are 
observed. When cultures presumably cholera are 
obtained they must be differentiated. 

d. In the bouillon tubes, at 37° C. (98.6 F.), 
cholera grows quickly, producing a film upon the 
surface. From this, pure cultures may sometimes be 
obtained. In addition the indol reaction should be 


tried upon the bouillon cultures. This consists in 
the addition of a small quanity (five drops) of pure 
sulphuric acid, when, in several hours a reddish 
violet or purplish color will develop. If litmus blue, 
sufficient to color, is added it will be decolorized at 
incubator temperature, which does not occur with 
allied organisms. Upon the gelatine plate cholera 
appears at first as small white granular colonies, and 
the gelatine is liquefied in funnel form. The indol 
reaction may be tried here. In the gelatine test tube 
it liquefies just below the surface, below which the 
inoculation streak remains finely granular for some 
time. Later the gelatine is entirely liquefied and the 
usual film is seen upon the surface. Upon agar-agar 
it produces a whitish smooth film. The growth upon 
potatoes is not characteristic. Under the micro- 
scope it appears, in the hanging drop, as a small 
bacillus or spirillum, having an extremely active 
motion. Long spirils are seen at times. Cover 
glass preparations may be stained with any stain. 

When soiled linen or cloth saturated with material, 
is examined the same method is used. The cloth is 
moistened with water and scrapings from the surface 
are used to inoculate diluted bouillon. From these, 
gelatine plate cultures and slides are made. 

I have tabulated on the board, the following 
simple rules for your guidance, in testing for the 
spirillum cholerae Asiaticae. 

In making the test, you will require the following 
articles: a. One microscope with Abbe's condenser; 
b. A solution composed of fifteen grains of fuchsin 
in three ounces of water plus two-and-a-half drachms 


of alcohol; c. Some pipettes, a couple of glass rods 
and object and cover glasses; d. A couple of glass 
rods with a piece of platinum wire soldered in one 
end; e. Several hollow slides; f. About a dozen glass 
plates about five or six inches by three or four 
inches in size; g. About a dozen ordinary glass 
plates; h. An alcohol lamp or Bunsen burner; i. Test 
tubes with sterilized gelatine; j. Test tubes with 
sterilized nutrient bouillon; k. Two Erlanger's glasses 
one-third filled with a solution made as follows: 
Fifteen grains of peptone, seven-and-a-half grains of 
sodium chloride, in three ounces of water; /. Some 
concentrated sulphuric acid. 

We will suppose now that you desire to examine 
some material from a rice-water stool of a cholera- 
suspect. Scatter a little of the dejection matter on 
a glass plate, in a thin film, and with a platinum loop 
isolate some flaky material on the edge of the plate. 
From this take a piece the size of a pin head and 
with a sterilized platinum wire loop evenly divide it 
by rubbing on a cover glass. Remove all superfluous 
matter by pressure with another cover glass, and let 
it get air dry. Now draw it three times through the 
flame of your alcohol lamp or Bunsen burner (as in 
tubercle-bacillus preparation) and with a pipette, 
add a few drops of the fuchsin solution. Then wash 
with distilled water, add a couple of drops of water 
to the cover glass and lay it on a slide. Examine 
with oil-immersion system. To make a permanent 
preparation, after staining, wash off all excess of 
stain, let it get air dry and mount in Canada balsam. 

Where the stool is bloody and dysenteric in char- 


acter, it is best at once to proceed to culture making 
Take a hollow slide and along the border run a thin 
edge of vaseline. Then with a platinum loop bring 
a drop of sterilized bouillon into the hollow groove 
and inoculate it with a little of the suspected mate- 
rial. Lay a cover glass on so that its rim rests on the 
vaseline edge, and set the whole aside in a tempera- 
ture of from 22° to 23 C. (71.6 to 73.4 F.) In 
twenty-four hours the bouillon becomes turbid and 
the slide can then be examined under the microscope 
by the oil-immersion system. Examine along the 

Schottelius' method is as follows: Take about 
three ounces of the stool-matter and put it in a 
beaker glass with about eight ounces of meat bouil- 
lon of a mild alkaline reaction. Let the mixture 
stand for from twelve to tw T enty-four hours at a 
temperature of from 30 to 40 C. (86° to 104 F.) 
At the end of the time mentioned, cholera spirilla 
will be found in the upper layer. In this layer in- 
troduce your wire loop, draw out a drop and prepare 
it for examination in the hollow slide as just 

In the necropsy hall in making a post-mortem ex- 
amination, open the abdominal cavity and isolate a 
piece of the ileum about two or three inches in 
length near the cecum, with four stout twine liga- 
tures, as shown in figure. 


After the ligatures have been tied, then with knife 
or scissors, cut through the gut at the points indi- 
cated in the diagram by the dotted lines, and remove 
the separated piece. In the same way take away a 
piece from the upper part of the ileum. Handle the 
intestine very gently, so as not to empty of its 
contents, the section you desire to remove. By 
leaving tied the cut ends of the tube remaining in 
the body, you prevent the contents of the bowels 
being emptied into the peritoneal cavity, which is 
a desideratum. Now you can treat the more or less 
fluid matter you will find in the isolated sections of 
the gut, by the modes just described. Make sections 
of the gut-wall parallel to its surface, and examine 
them under the microscope, paying especial atten- 
tion to the epithelial structures. 

Make potato cultures, stroke and stick gelatine 
cultures, and cultures in blood-serum and agar-agar. 


Having thoroughly studied the microbiology of 
the specific exciting etiological factor of Asiatic 
cholera, and learned how to seek for and recognize 
it; we find the following question facing us for solu- 
tion: Under what circumstances and through what 
channel do the comma bacilli penetrate into the 
human system, and in what manner do they there 
excite the characteristic processes of the disease? 
There can be no manner of doubt whatever but that 
here in America the disease is not indigenous, but 
is always imported. It is not an air-traveler, but as 
we have seen, follows the lines of human traffic, pro- 
gressing along the world's most frequented highways, 
with a rate of speed that is in direct ratio with that 
afforded by the means of human intercommunication. 
We are equally certain that the main, if not the only 
agent for the spread of the malady is the dejection 
material from cholera patients, which w r e find to be 
rich in cholera spirilla. In this connection we must 
also consider the pathogenic value of vomited 
matters. These bacilli escaping from the interior of 
the body, into the external world, find abundant 
means to prolong their life and existence, exemplify- 
ing the words found in Holy Writ, "That it is that 
which cometh out of a man which defileth a man." 
They grow and develop upon moistened bed-cloth- 
ing, or in water, or in food, either solid or fluid, or in 
moist earth. Of course, in order that the disease 


may be induced in a given individual, conditions 
favorable to the reception, growth and multiplica- 
tion of the bacillus, must exist. These conditions are 
known as contributory causes, or predisposing fac- 
tors, and when they are propitious, and the exciting 
factor is present, the disease is produced. In rela- 
tion to its growing and living in moist earth I would 
call your attention to a very interesting characteristic 
of the spirillum, and that is its nitrifying power. 
Franklin, in England, and Wynogradsky, in France 
have recently described certain minute bacilli or 
cocci which are found in the soil, and which possess 
the power of oxidizing ammonia to nitrites. These 
nitrifying bacilli play an important part in rendering 
the soil s fit for the growth of plants, and the pos- 
session of this power by the comma-bacillus may be 
regarded as an indication of its fitness to live in the 
soil, and thus lead to a non-parasitic mode of ex- 
istence. Let us look now at the modes of infection. 
It would seem as if cholera is not highly contagious 
in the same sense as variola and scarlet fever, but 
resembles enteric fever, in this respect. The im- 
pression that physicians, nurses and others in close 
contact with the patients, are not often affected, did 
not prove to be correct in the epidemic last year at 
Hamburg, where the medical attendants and nurses 
suffered quite severely. It is reported that of the 
fifty doctors who went to that city to assist in the 
work there, hardly one escaped a more or less severe 
choleraic attack, It is easy to understand why 
certain persons, as washer-women, laundresses and 
nurses, are more liable to infection than others, and 


the spread of the disease, is often explained by 
certain outward circumstances. 

The concensus of opinion on the part of the lead- 
ing authorities, is that the disease is propagated 
chiefly, if not entirely, by the contamination of water 
used for drinking, washing and cooking. It is easy 
to believe that contaminated food may prove a factor 
n this connection, but to a lesser degree than drink- 
ng water. We have seen that the bacilli can and do 
develop in water-supply reservoirs, as tanks, etc., and 
Osier's pithy expression, that the virulence of an 
epidemic in any region is generally in direct propor- 
tion to the imperfection of the water-supply, ex- 
presses volumes. So emphatic is this statement in 
its truth, that we cannot devote too much labor and 
attention to our water-supplies. It has been proven 
time and time again, by the fact that where there 
have been improvements and perfection in the water- 
works of a locality, the epidemics have been re- 
duced in intensity, and immunity even has been ob- 
tained. You remember in studying the etiology of 
enteric fever, we found Pettenkofer placing great 
value on the condition of the ground-soil, and in 
cholera transmission we find him denying the truth 
of the drinking water theory, and maintaining the 
importance of the conditions of the soil, especially 
as regards porosity, moisture and contamination with 
organic matter. This authority claims that the germs 
develop in the sub-soil moisture during the warm 
months, and that they rise into the atmosphere as a 
miasm. To assume the absolute correctness of 
Pettenkofer's theory, and to deny the possibility of 


infection in any other way, would be to accept a 
statement entirely at variance with many observed 
facts, and one that is not borne out by the charac- 
teristics of many studied epidemics and outbreaks of 
the disease. 

Cholera is more liable to occur in places at the 
sea level, than in those situated inland, and does not 
prevail so extensively in high altitudes. A high 
temperature favors the development of the disease, 
but in our country and in Europe, the epidemics 
usually take place in the late Summer and Autumn. 

It is no respecter of person, age or sex, but is 
particularly prone to attack those in whom for any 
reason whatever, the normal powers of resistance 
are, lowered. Reducing psychical emotions, as fear 
and anxiety, beyond a doubt have a most marked 
influence. It is very doubtful whether one attack 
confers immunity from a second. In an interesting 
manner Dr. Alexander, quoting Hough, Richardson, 
Neusville, Billings and others has discussed the 
causes that partially exempt Jews as a race from 
cholera and other epidemics. 

In order that the disease should be produced, the 
spirilla must gain access to the alimentary canal, 
must reach the mouth, pharynx, gullet, etc., before 
they can start on their career. The comma-bacillus 
is never found in the human economy except in the 
digestive tube, never in the blood, never in the 
glandular system, nor in the secretions — only in the 
bowels, and what they contain. It is not at all an easy 
matter for the bacillus to reach the bowels belong- 
ing to a healthy person provided with a good diges- 


tion. A healthy stomach has the best safe-guard 
against it, in the free acid of the gastric juice. We 
have seen that small traces of acid will interfere with 
the life of the bacilli, and the normal stomach secre- 
tion is acid enough to kill them, should they re- 
main even for a short time in the functionating 
organ. But we know that the resting stomach does 
not contain any of this juice, and we also know from 
the experiments of Kuehne, Richet, Beaumont and 
Ewald, that fluids can pass the pylorus within a few 
minutes; and if a large amount of water, for instance, 
is swallowed at once, part of it will pass the pyloric 
junction the very next minute. It has also been shown 
that draughts of water taken into the stomach do not 
excite its functional activity, but uncontaminated 
by gastric secretion, pass into the duodenum.* 

In such a case even the healthiest man could get 
some germs unhurt into the bowels; and that is all 
that is needed, to have the disease developed in 
perhaps a few hours. 

It is stated that the period of incubation, is from 
one to three days, but there is no doubt in my mind 
but that it may be shorter than even one day. 

We can easily understand why it is that dyspeptics, 
or those in whom the gastric function is below par, 
are liable to suffer. Beaumont has shown that a 
decrease of acidity of the stomach secretion is the 

*1 have repeatedly verified Ewald's observation m this respect, on my own 
person, both by drinking large quantities of water, at various periods of time 
emptying the stomach by a syphon tube or by inducing' emesis mechanically; 
and by swallowing small pieces of clean sponge to which were attached strings 
of surgical silk, by which, after they had been allowed for varying periods of 
time to remain in the stomach, they would be pulled up. The reaction of all 
being carefully tested before and after exposure in the stomach. 


result of febrile disturbance. Manassein and Hoppe- 
Seyler have demonstrated that such a gastric juice is 
weak and deficient in action; and Beaumont's obser- 
vations indicate that acute or chronic disturbances of 
the gastric glandular apparatus, partly or fully inter- 
fere with the production of a normal succus gastricus. 
In these cases it is the lack of acid that is the cause 
of trouble. 

Let me call your attention to the emotional factor 
in etiology. The secretion of gastric juice is much 
influenced by nervous conditions. It was noticed by 
Dr. Beaumont, in his observations upon Alexis St. 
Martin, that irritation of the temper or other moral 
causes would diminish or suspend the supply of the 
gastric fluids. Any febrile action or unusual fatigue 
would exert a similar effect. Every" one is aware 
how readily mental disturbances, such as anxiety, 
fear, anger or vexation, will take away the appetite 
and interfere with digestion. Impressions of this 
kind, especially at the commencement of the process, 
seem liable to produce a lasting effect and to disturb 
digestion for the entire day. In order, therefore, 
that the function may be properly performed, food 
should be taken when the appetite demands it; it 
should be thoroughly masticated, as a wise man of 
our time has said, there being thirty-two teeth in the 
head, each mouthful should be chewed thirty-two 
times; and, finally, both mind and body should be 
free from unusual or disagreeable excitement. 

Were it not for this protective acid gastric solution, 
on the first tour of Asiatic cholera, it would have 
almost depopulated the globe. 


Let us now see what would be the result, should 
any of these bacilli pass unchallenged through the 
pylorus, and enter the cavity of the duodenum. 

It has been noticed by us that a fluid of alkaline 
reaction highly favors the vitality and action of the 
comma-bacillus; moreover that the bodily tempera- 
ture is the best for its development. Consequently, a 
better soil than the intestinal fluids could not be 
found for their growth; and they will at once begin 
to develop their immense fecundity, and multiply 
with a rapidity that startles human comprehension. 

The first sign of their existence in the bowel, 
anatomically, seems to be an increased flow to the 
vascular parts of the gut-wall, due to irritation. 
Very soon the signs of catarrhal inflammation 
develop; the solitary follicles and Peyerian patches 
begin to swell and become peripherally congested. 
All the intestinal glands increase their work, and 
soon a slippery layer of tough and glassy mucous 
covers the epithelium all over. Hemorrhagic spots 
appear in the submucous strata. The slender delicate 
epithelial cells cannot any longer bear the enormous 
over-irritation; they begin to stagger, loosen their 
foothold, and become swept away from large surfaces. 
Soon the interior of the intestine becomes filled with 
an abundant transudation, the gut-coils containing a 
large amount of clear fluid, resembling gruel or rice-" 
water, and so devoid of biliary matters as to indicate 
the suspension of hepatic activity. This fluid con- 
sists of the results of hyper-secretion of the glands of 
the small intestine, and plasma-sanguinis, alkaline 
and blood-warm, from the interior of the vessels, 


forming a culture medium in the highest degree 
favorable for the multiplication of the spirilla. As 
time goes on the signs of inflammation of the mu- 
cous membrane become more pronounced. The 
processes already noticed in the patches and follicles 
advance, the epithelial desquamation becomes more 
extensive, and later on the intestinal trouble fre- 
quently assumes a croupous-diphtheritic character. 
The surface becomes necrosed and ulcerated in many 
places, and the contents change from the rice-water 
containing immense numbers of cholera spirilla, to a 
bloody, foul-smelling liquid containing fewer cholera 
germs but large numbers of other morbific micro- 
organisms. According to Cohnheim, the fluid found 
in the gut-cavity, is not due to transudation from the 
blood vessels at all, but is entirely caused by an 
extraordinary profuse secretion from the intestinal 
glands; while others place the source as being from 
the circulatory apparatus. In all probability both 
factors are potent in the affair. 

Let us look at this condition closely for a moment; 
the bowel, being deprived of its osmotic regulators, 
and having lost the lymphatic aids in the follicles 
and agminate glands, will soon become over-filled. 
The choleraic poison stimulating to hyper-activity the 
glandular mechanism in the gut-wall, and liquor 
sanguinis freely passing into the bore of the tube, on 
account of the blocking of the lymphatic channels, 
over-distension must occur unless the bowel can 
relieve itself by catharsis. In sudden cases, where 
the individual has been quickly overpowered by the 
intense virulence of the poison, death will take place 


without there having been a single passage or stool. 
In these instances the intestinal tube will be found 
enormously distended, with the contained fluid. 

So far we have studied the process entirely from 
a local standpoint, but soon after the beginning 
of the development of the bacilli, we find that there 
is a general or systemic element that is pronounced 
and prominent. Closely connected with the vital 
processes of the spirilla there is the creation of the 
toxines which we have touched upon in our consid- 
eration of micro-biological chemistry. These toxines 
are very soluble and highly diffusible. They pass 
into the life stream of the blood and circulating 
through the vessels with it, they produce general or 
constitutional and special local symptoms, whose 
degree is in direct ratio to the amount and intensity 
of the absorbed noxa. From our knowledge of the 
physiology of the digestive tube, and from our 
acquaintance with the cholera spirillum, we are pre- 
pared for the recognition of the fact that the growth 
of the comma bacillus, is limited as far as time is 
concerned, in the intestinal cavity. We know that 
the cholera germ will not thrive in media where- 
in other micro-organisms are growing or living. 
Now in the bowel of the healthy, normal man, there 
are going on processes, which are to be regarded as 
fermentations or putrefactions, and which are quite 
different from those caused by the digestive enzymes 
or ferments. These putrefative changes are connected 
with the presence of low organisms, the fermentation 
or putrefaction-producers; and they may develop as 
you know, in suitable media outside of the body. 


They are wanting during fetal life, but are numerous 
a few days after birth. They have been found in 
the saliva, stomach and intestine. From the normal 
intestinal mucus Babes has isolated five species of 
bacteria, while an enormous number of micro- 
organisms exist in the large intestine and feces, 
Vignal calculating their number at twenty millions 
per decigram of feces. The activities of these, and 
of other forms that following closely upon the comma 
bacillus, gain entrance to the system by treading in 
its footsteps, ultimately interfere with cholera growth. 
On post-mortem examination, you will find the ap- 
pearances that are associated with profound collapse. 
There is often well-marked post-mortem elevation 
of temperature. Rigor mortis sets in early, is pro- 
nounced and disappears late, being an exception to 
the general rule that when it occurs soon after death 
it disappears quickly, and when its onset is late, its 
disappearance is deferred. Post-mortem movements 
of the various portions of the body are noticedr after 
death by cholera. Displacements of the body, 
movement of the lower jaw, rotation of the eyes, and 
changes of position of the arms and legs have been 
described. Dr. Edward Vanderpoel, of New York, 
in an interesting communication to the Medical 
Record, last fall, describing the epidemic of 1832, says 
that it was a common thing for those who died during 
the day and who were put in a coffin at night, to be 
found the next morning with their arms out of the 
coffin, or their hands up to their heads.* 

♦Professor Eichhorst also relates that on one occasion he had left a patient 
for dead, when, three hours later he was told that the dead man had revived. 


All the internal organs are dry, pale and anemic. 
The left ventricle is usually contracted, and the blood 
lies mostly in the great veins, the right heart, and 
the cerebral sinuses. It is thickened, dark-colored, 
but little clotted, and there is a remarkable diminu- 
tion in the amount of water and salts. The peri- 
toneum is sticky, and the coils of intestine are 
congested and look thin and shrunken. The spleen 
is usually small — an exception to the rule in infectious 
diseases. The kidneys present marked passive 
congestion, and if the subject has suffered for any 
lenghth of time from the disease, may show cloudy 
swelling, a greater or lesser degree of parenchyma- 
tous nephritis, and destruction of the epithelium. 
Cloudy swelling of the hepatic cells, or more pro- 
nounced changes, depending upon the length of time 
the individual had lived with the disease, are noticed. 
The lungs are collapsed, and congested at their 
bases. When death takes place late, or at an 
advanced stage of the malady, the tissues have lost 
their characteristic dryness, and the most diverse 
local lesions, may be found to have caused death. 
In these advanced cases the condition of the small 
intestine, will often be found to simulate very closely 
that of the small intestine of an individual dying in 
the third week qi enteric fever. 

To recapitulate, I would call attention to Van 

He found that the muscles of the upper arm were giving' short, quick motions, 
following- each other rapidly, which were interrupted by contractions of the 
whole group of muscles, whereby the forearm was visibly contracted. The 
fingers were also distinctly observed to be moving, as though playing a piano. 
It was only after three hours that the movement of the muscles stopped. 


Cott's excellent resume of the pathological findings 
in cholera. 

R. Pfeiffer has shown that the specific toxine of 
cholera is a ptomaine which is probably incapable of 
complete isolation from the germ, without losing 
much of its toxic force. He believes that either the 
ptomaine is in intimate atomic association with the 
actual protoplasmic atoms of the germ, or that the 
protoplasm of the germ itself is a rank intoxicant. 
In any event, dead bacilli in sufficient quantities 
produce the characteristic semiology of cholera. 

Subcutaneous injections of the cholera virus are 
far less toxic in animals than intra-peritoneal injec- 
tions. Both are followed by marked fall of tempera- 
ture, great prostration, muscular spasm and cramps. 

Transplantations and successive cultivations, weak- 
en the potency of the spirilla. 

Koch showed in 1884 that the intestine and stools 
were loaded down with his bacillus. 

Nicati and Ritsch found the germ in the follicles 
of Lieberkuhn, and positively assert that it obtains 
in the intestinal wall, (supposably the mucosa and 
sub-mueosa). They also succeeded in inducing 
cholera at once in animals, by injecting pure cultures 
of the comma bacillus into the intestine, after ligature 
of the ductus communis choledochos, 

x^ccording to Eisenberg, no cholera germs have 
been determined in the blood of human cholera 

These data simplify the pathology of cholera. Local 
intestinal irritation, with doubtless general intoxica- 
tion through absorption of a toxine into both the 


blood and lymph, are productive of profound consti- 
tutional and local symptoms, thermal depression, 
nervous phenomena, profuse diarrhea. In general 
the serous surfaces are dull, and often covered with 
a gluey deposit. The blood is anhydremic, dark- 
colored, thick, tarry and coagulates imperfectly. 

Rigor mortis occurs early and lasts unusually long. 
The arteries are empty, the veins generally filled, 
while the heart may be either full or empty. Some- 
times the left ventricle is found contracted, at other 
times the whole heart is found quite flabby. There 
is great general emaciation. The Peyerian patches 
are reddened, slightly swollen, and sometimes 
necrotic. Complete epithelial desquamation from 
the intestine occurs, to some extent post-mortem, 
and there is sometimes intestinal hemorrhage. 

In the kidneys, the cortex is usually found swollen 
and pale; and the medulla congested on the venous 
side. Anuria probably due to water abstraction. 
The spleen and liver are not markedly affected, 
although the liver is changed in protracted cases. 
The brain and cord are said to be much firmer than 
normal. Bartholow describes a congested state of 
the bulb, which bears relation to the intensity of 
certain of the symptoms; noticeably the muscular 
cramps. These are the findings in death during the 
algid stage. 

The reactionary stage presents lesions of inflam- 
matory and hemorrhagic nature. Hemorrhages, 
usually petechial, may be exceedingly numerous, 
or profuse hemorrhage may obtain. Meningitis and 
peritonitis may supervene. 


The exact reason for the development of the 
hemorrhagic and inflammatory tendencies is not 
stated; probably the toxic action of the poison on 
the vessels predisposes to their rupture, especially 
the smaller ones. Analysis of stools reveals large 
quantities of blood serum, myriads of epithelial cells 
and leucocytes, and abundant supply of the specific 
organism. These ingredients explain the color and 
other gross appearances of the dejecta. 

To sum up, there is rapid emaciation from loss of 
water, which is held by some to account for the 
muscular cramps, which are so distressing a symptom. 
Hyperemesis and hypercatharsis due to local irrita- 
tion and to central excitation. We can conceive of 
the poisoned blood irritating the nuclei in the floor 
of the fourth ventricle, and producing excessive 
vomiting. Cyanosis due to the disturbance of the 
physiological equilibrium of the blood, and to ner- 
vous and cardiac depression. The hemorrhage and 
inflammatory tendency in the reaction stage, are not 
definitely explained. 


Together you and I have studied the causative 
factors of cholera; together we have been taught 
how to search for and how to recognize the comma- 
bacillus; together we have gone down into the 
charnel house and looked at the dead; we have 
opened the body and examined the morbid changes 
produced by the disease; but to-day, I ask you to 
accompany me to the bedside and watch the sick 
man, and we will now take up the study of symp- 
tomatology, and gaze at the clinical picture. 

As in nearly all the infectious diseases, so in 
cholera, the intensity of the illness varies between 
the extremes of mildness and severity, so that in a 
great number of cases a correct diagnosis of the 
mildest forms, can only be made, by the fact of the 
existence of an epidemic. These simple cases are 
called "choleraic diarrhea/' and resemble in a 
marked manner, cases of ordinary summer-cholera. 
The symptoms are those belonging to an attack of 
violent, acute catarrhal enteritis; during the twenty- 
four hours, there are from three to ten large, watery 
and usually painless stools. There is loss of appetite, 
more or less thirst, and general malaise, some times 
even now there may appear choleraic symptoms, such 
as vomiting, pains in the calves of the legs and diminu- 
tion in the amount of urine voided. Many cases re- 
cover after a few days, but in others, after from one 
to three days, there comes on a severe attack of 


In gradual transition, these mild forms, are suc- 
ceeded by more pronounced ones, which are called 
"cholerine." Cholerine comes on very much like a 
sudden and severe attack of cholera-morbus, often 
beginning at night. There may be a severe diarrhea, 
which may assume the characteristics quite early of 
pronounced cholera. Vomiting soon comes on, and 
there are more or less violent constitutional symp- 
toms. We find languor and depression, the voice 
becomes weak, the extremities cold, the heart's 
action is hurried and feeble the pulse being quick 
and small, muscular spasms and painful cramps oc- 
cur in the bellies of the gastrocnemei, the urine be- 
comes decreased in amount, and examination per- 
haps reveals the presence of albumen. The whole 
attack may last a week or two, until recovery be 
complete, but the course is not infrequently varied 
by repeated improvements and relapses. From these 
cases of medium intensity, we find gradations until 
we reach the severe forms of cholera proper. In the 
most intense form, "cholera-foudroyant," the patient 
may be stricken down, and die overcome by the 
virulence of the poison, in a few hours without 
having had a single stool. 

Ordinarily three stages may be recognized in the 
attack, which is preceded by a period of incubation 
of uncertain length, but which is probably from one 
to three (or perhaps four) days in duration. 

The stages referred to, are: the preliminary diar- 
rhea, the algid stage, and the period of reaction. 

A true attack of cholera may begin very suddenly, 
and without any preliminary diarrhea, but with 


severe symptoms. As a rule, however, the first stage 
appears, and after from one to three days, is replaced 
quickly and suddenly by the pronounced symptoms 
of the algid stage, or cholera asphyxia. This stage 
is ushered in with abrupt bodily weakness, chilliness, 
and vertigo. Shortly after, the gastro-intestinal symp- 
toms declare themselves. The diarrhea becomes dis- 
tressing. At short intervals, the patient has copious 
painless dejections, at first of a feculent, bilious char- 
acter, but soon changing, present the appear- 
ance of the "rice-water" or "gruel-whey" fluid, or 
the rice-water characteristic may be prominent 
from the beginning. A single stool will measure 
about a half a pint, or two hundred grams. The 
stools are colorless and odorless. They are watery, 
alkaline or neutral in reaction, and on stand- 
ing usually deposit a finely granular, grayish- 
white sediment. Examination shows the following 
composition: about one or two per cent, is solid 
matter, with a small amount of albumen and a large 
quantity of sodium chloride. In severe cases, and 
especially in the later stages of the disease, there is 
more or less blood, or saigneous matter. Under the 
microscope we find epithelial cells, triple-phosphate, 
and numerous micro-organisms, consisting of the 
comma-bacillus, and bacteria of putrefaction. Of a 
certainty as soon as the cholera spirillum is de- 
monstrated, the diagnosis is absolute, I have al- 
ready shown you how to find the exciting causative 
factor of cholera, which you must always look for, if 
there is any element of doubt as regards diagnosis, 
unless it be during an epidemic, when I think it to be 


perfectly correct to treat every case of diarrhea as 
the first stage of a cholera attack. 

These excessive evacuations are almost pathogno- 
monic of the disease, but there are cases in which 
death will occur without their having been present, 
these are cases of "cholera-sicca," or dry cholera. 

Soon after the onset of the diarrhea, there is fre- 
quent vomiting, which rarely though becomes dis- 
tressing. Sometimes late in the disease, the vomit- 
ing becomes "projectile," such as is found connected 
with meningeal disturbance. The vomited matters 
consist partly of ingested material and partly of fluid 
that has transuded through the gastric and intestinal 
mucosa. Accompanying and following the emesis, 
there may be spasmodic contractions of the dia- 
phragm, constituting hiccough. This often becomes 
a very annoying symptom. 

In addition to these digestive symptoms there is 
anorexia, and also great thirst. The tongue is thick, 
dry and coated. The belly is as a rule soft and flat, 
but occasionally it may be concave and quite hard. 
By palpation we can often make out fluctuation in 
the bowels, due to their being filled with fluid. In 
some instances there is acute abdominal pain,' in the 
majority of cases however, the sensation described 
is one of heat and pressure around the umbilicus. 

At the same time other portions of the economy 
are affected, the circulatory apparatus being pro- 
foundly involved. 

At the onset of the attack there may be accelera- 
tion of the heart's action, amounting almost to 
tachycardia. The patient will complain of palpita- 


tion and a feeling of weight at the precordia, causing 
him anxiety. Soon however progressive heart fa- 
tigue comes on, which becomes more and more pro- 
nounced until there is decided cardiac enfeeblement, 
and on auscultation, the heart-sounds are faint, so 
faint indeed may they become, as to be almost in- 
audible. The radial pulse becomes very quick and 
small, and in a severe case may, after a few hours, 
entirely disappear. 

This functional reduction of the circulatory ap- 
paratus, is quickly evidenced in the general condi- 
tion of the patient, and his appearance. The face 
and extremities grow cool and then ice-cold, and 
this change will extend to the whole body. Put 
your hand into the bed and feel the patient's feet, 
and they will be cold as any stone; then feel to the 
knees, and so upward, and upward, and all will be 
cold as any stone; and his countenance and expres- 
sion will in a most marked manner, change and ex- 
hibit the pencilled tracings of the stark and evil 
genius of the white and cold death. You know how 
years and trouble can alter expression; you remem- 
ber how eloquently Sir Walter Scott speaks of this 
in "Marmion:" how 

"Danger, long travel, want and woe 

Soon change the form that best we know ; 

For deadly fear can time outgo, 

And blanch at once the hair: 

Hard toil can roughen form and face, 

And want can quench the eye's bright grace, 

Nor does old age a wrinkle trace 
More deeply than despair." 

But what want and woe and despair, would require 


perhaps years to accomplish, cholera will do in as 
many hours. You know of the horrible deformities, 
that cancers will produce; you know of the great 
facial tumefaction that small-pox induces; but Asia- 
tic cholera does not deform, and there is no condi- 
tion that not deforming, can so thoroughly change 
the lineaments of the face, so completely alter ex- 
pression, in a short period of time, as does cholera. 
Almost as you gaze upon him, the stout, healthy- 
looking, rosy-cheeked, handsome youth becomes 
changed into a thin, cadaverous, ashen-hued old man. 
The complexion becomes livid, and bluish-gray; with 
lips dry, cracked and almost black, so dark are they. 
The mouth is sore, often bleeding, the tongue is 
coated, and the patient will complain of intense thirst. 
The eyes sink back into the cavity of the orbit and are 
partially open, with often a thin film seen covering 
the lower half, while the cheeks become hollow and 
fall in towards the mouth. The skin loses its elasti- 
city, becomes shrivelled and wrinkled and is bathed 
in a cold, clammy sweat. Sometimes the lips are 
drawn into a spectral, sardonic smile, and a ghastly 
expression, the shadow of death, comes over the 
whole face. The depressed surface temperature is not 
only appreciable but is demonstrable by the ther- 
mometer, which may indicate a reduction to 35 C. 
(95 ° F.,) and even lower, while there may be at the 
same time febrile temperature in the rectum. The 
mental field may remain unclouded to the end, but 
as a rule there is great apathy, and perceptive acuity 
is much impaired. Few patients are restless and 
active, more or less hebetude being the rule. Reflex 


action is impaired, the voice becomes husky and 
hoarse and weak, and respiration becomes laborious 
and more and more superficial. In this state it is 
often difficult to determine whether in a given case, 
the individual belongs to the quick or the dead. Dr. 
Vanderpoel relates that a girl apparently dead, dur- 
ing the epidemic in New York, of 1832, was left in the 
dead house for some undefined reason, when the 
other bodies were removed. Her appearance did 
not change, and so she remained for five days. On 
the sixth day there was some sign of life, and she 
recovered, but with ulcerated corneas. 

A characteristic symptom of cholera is muscular 
cramps. These are very painful, and consist of 
tonic contractions of the muscles, especially those of 
the calf of the leg, but involving also those of the 
toes, thighs, arms and hands. These cramps may 
occur spontaneously, or upon the slightest provo- 

We may find the skin affected, with an eruption 
which assumes various characteristics. Most fre- 
quently it resembles that of measles, and is more 
abundant about the forehead, eyelids and forearms 
than elsewhere. When pustular, the back in its 
lower half, or reaching as high as the shoulders, is 
.most often involved. 

In a well developed case of cholera there is a de- 
cided lessening of secretory power. The mouth is 
dry from deficiency of saliva, and there is oliguria or 
veven anuria. What urine is secreted, is highly con- 
centrated, with abundant sediment and is often al- 
buminous, sometimes days will pass without the 


secretion of a drop of urine, and this condition will 
persist until death or recovery. In cases that ter- 
minate fatally, we find a peculiar dusky look, less 
bluish than heart cases, in fact really blackish. This 
is especially noticeable about the extremities. The 
appearance of the hands and feet may remind us of 
gangrene, but yet it differs in that there is a shrivel- 
led, shrunken look, and no purpling, the flesh tints 
showing as through coal dust. Bed sores may be 
present, and may spread with alarming rapidity after 
their appearance. Death gradually steals in upon 
the scene, and the end is usually peaceful; apathy 
deepening into lethargy, lethargy passing into sleep, 
sleep into coma, and coma merging almost imper- 
ceptibly into dissolution. 

The picture I have just given you, taken as a 
whole, represents the algid period, or stage of col- 
lapse, which rarely lasts more than one or two days, 
usually terminating in some way within from three 
to eight hours. In many cases death occurs 
during this stage, and may take place in a few 
hours, or more frequently in the second half 
of the first day. Dissolution may be ushered 
in by deepening of the general prostration, and 
as we have seen, it may be impossible for us to 
draw a dividing line between life and the occurrence 
of somatic death. But in other cases there may be 
a true compensatory period, leading to convales- 
cence; the stage of reaction. The bowel discharges 
become less frequent and more feculent, and the 
vomiting is arrested. The pulse is once more felt at 
the wrist. The heart's action becomes stronger, the 


peripheral circulation is again made manifest, here 
and there little patches of dilated capillaries will be 
visible, giving the patient a somewhat mottled ap- 
pearance, the skin resumes its normal color and soft 
velvety feel, and not infrequently breaks out in an 
abundant perspiration. The breathing becomes nat- 
ural, the mental attributes are brightened, and after a 
time, the kidneys begin to secrete urine which is 
almost always quite albuminous and contains casts 
and discoid blood corpuscles. The appetite re- 
turns and the patient is sometimes absolutely 
ravenous for food. If there be no interference 
with convalescence, in a few days the urine be- 
comes normal, and after a week or two the patient 
may be discharged as being perfectly recovered. 

Not always however, in this favorable manner, do 
our patients pass to recovery, but there may be re- 
peated relapses into the previous condition, and 
sometimes unfortunately with fatal result. Or in- 
stead of the convalescent period, the patient will 
pass into a condition resembling very strongly the 
third week of enteric fever, and called cholera-typhoid. 
This stage is subject to manifold variations in its 
clinical manifestations and exciting causes. 

As I have said, cholera-typhoid may present all the 
appearances of enteric fever, with a severe febrile 
movement, headache and mental dulness. The pulse 
is full and rapid, the expression is heavy and the face 
flushed, the lips and tongue are dry, and there may 
be abdominal tenderness and tympanites. The chol- 
eraic-eruption may be present on the skin, especially 
of the extremities, and assumes the form perhaps 


of an erythema, a roseola or an urticaria. In severe 
cases there may be insomnia, coma-vigil, and del- 
irium, especially at night. This condition may per- 
sist for a longer or shorter period of time, when re- 
covery may ensue, or the patient may pass into one ot 
the following states. 

In the first of these conditions (the second variety 
of cholera-typhoid), we find the development of the 
most diverse local inflammatory processes. There 
may be a severe dysentery or a violent diphtheritic 
inflammation of the wall of both large and small 
intestine, . accompanied by numerous painful dis- 
charges of purulent and bloody material. There 
may be pneumonitis, or purulent bronchitis, or serous 
or purulent pleuritis, diphtheritic laryngitis, phar- 
yngitis, cystitis and extensive inflammation of the 
genitalia, particularly of the female. You will now 
and then find parotitis, and sometimes erysipelas and 
general pyemia. Occasionally there will be ophthal- 
mia, keratitis and corneal ulceration, and inflamma- 
tion of the meninges of cord and brain. Cases that 
recover are often troubled by, and for a long time 
have to be treated for, otitis media suppurans. In ad- 
dition to any of these symptoms, or varied groupings 
of the same, you will remember that intestinal symp- 
toms, and those of inflammation of the kidneys, may 
co-exist, and you have a clinical picture of great 
complexity. Should death not supervene, any or 
many of these complications may cause future 
trouble, constituting prominent sequelae. 

The third variety of cholera-typhoid, is the uremic 
form. Here the patient exhibits all, or nearly all, 


the special symptoms of a severe nephritis. There 
may be absolute anuria, or if any urine be secreted, 
it is small in amount and contains numerous casts, is 
albuminous, and you will find on examination renal 
epithelium and leucocytes and discoid corpuscles. 
Earlier or later, but usually near the end of the first 
week, grave nervous symptoms supervene which must 
be regarded as uremic. These are the classical 
manifestations of removal of the kidney function 
from the economy, and we find headache, vomiting, 
somnolence deepening into coma, or delirium and 
convulsions. As a rule these cases are fatal. 

Before leaving this portion of our subject, let me 
ask you to look for a moment at the connection be- 
tween the morbid anatomy and the exciting causa- 
tive factor of the disease, or again between the 
pathological changes and the clinical aspect. First — 
Remember that the comma-bacillus is found only in 
the cavity of the intestine and its wall, never in the 
blood or other portions of the body. The extra- 
physiological state of the intestine so produced, ex- 
plains the intestinal symptoms, but not the general 
ones. Second — As a result of the great drain of water 
from the system, caused by the profuse colliquative 
discharges, there is a positive desiccation of the body 
which can not fail to cause most profound changes 
in the tissues; which can not fail to cause a most 
intense disturbance of the general processes of 
nutrition. A special disarrangment is that of the 
heart, one factor in the production of which is the 
decreased amount of liquid on which it has to act, 
and the decided departure from the normal stan- 


dard of the blood. But this explanation will not 
suffice for all the symptoms, for circulatory disturb- 
ances and cardiac failure may occur in the most 
intense forms of cholera, before large evacuations 
have appeared, nay as we have noted, death may 
supervene without the occurrence of a single stool. 
You will bear in mind in this connection, the close 
sympathetic relation that exists between the heart 
and the abdominal viscera. Third — You recollect 
the toxines we have studied in connection with the 
vital processes of bacterial life, which when isolated 
and injected into animals produce disturbances iden- 
tical with the general symptomatology of cholera. 
We can account for these symptoms therefore, by 
assuming the absorption by the blood and lymphatic 
vessels, of these noxa, of their coursing through the 
delicate capillaries and producing their fell effects 
on the tissues, and here I would have you remember 
that the blood itself is a highly complex and com- 
plicated tissue, and suffers pari passu with the other 

As to the complications that we have found in the 
later stages of the disease, and that we have studied 
under the name of cholera-typhoid, I may say that 
they are secondary, and are not caused by the chol- 
era process, which is however the occasion for their 

The diagnosis of a case of cholera has no difficul- 
ties at all during the prevalence of an epidemic. The 
only affection with which it could be confounded is 
cholera nostras or cholera morbus, the severe sum- 
mer choleraic diarrhea of our own climate. The 


clinical manifestations of the two maladies are iden- 
tical. We have the collapse, vomiting, the rice- 
water discharges, the muscular cramps, and cyanosis 
in both disturbances. In enfeebled persons, the 
very young and the very old, cholera morbus may 
kill in twelve hours, and there will be the same 
pinched, peaked expression seen as in true cholera. 
For various reasons it is necessary to differentiate 
between the two conditions. This can only be done 
by one, cunning and skillful in technique, well versed 
in methods and thoroughly acquainted with the 
diversified bacteriological botany of the bowels. Of 
course as soon as Koch's comma-bacillus has been 
found, the diagnosis is complete. 

From your studies in general toxicology, you will 
recollect that arsenic, corrosive sublimate, and cer- 
tain fungi produce a symptomatological grouping 
that in many respects resembles cholera, but the 
difficulties in differentiation are slight. 

The prognosis varies with the intensity of the 
disease in a given epidemic, with the age, previous 
condition of the individual and his surroundings. 
Intemperance, pre-existent disease of any kind, de- 
bility and old age are unfavorable conditions. The 
disease is also very fatal in childhood, and amongst 
those whose previous diet has been improper and 
whose hygienic surroundings have been bad. The 
prognosis is always uncertain, as the mortality ranges 
in different epidemics from thirty to eighty per cent. 
During the occurrence of a given attack, the prog- 
nosis becomes graver in direct proportion with the 
development of the characteristics of asphyxia and 


cyanosis. The more rapidly the collapse sets in, the 
greater is the danger. In about two-thirds of the 
fatal cases death occurs during the first days of the 
algid stage, and about one-third during the period of 
cholera-typhoid. Cases with marked cyanosis and 
very low temperature rarely recover. 

To recapitulate; as to the preliminary diarrhea, 
the patient may recover from it, or from six to 
twelve, or twenty-four hours, or even two to three 
days it may persist and then be succeeded by the 
algid period. Its average duration is about twelve 
hours, while the average duration of the stage of 
cholera asphyxia is from three to six hours. Con- 
valescence sets in usually from twelve hours to four 
days after the appearance of the first manifestations. 
The typhoid period is very variable as to length, 
lasting from five days to two weeks, and even 

In studying the history of cholera epidemics, we 
have seen how frightful the mortality may be, and 
novelists and artists and writers have drawn on these 
scenes, to describe some of the most fearful and 
gloomy pictures ever portrayed by pen or pencil, to 
human understanding. 


At our last meeting, we studied the symptom- 
atology of cholera, we stood by the patient's bedside 
and contemplated his sufferings, and to-day it be- 
comes our duty to note what can be done to alleviate 
the pains of the disease and relieve the sick-man. 

An old, pithy proverb of our fore-fathers is, "An 
ounce of prevention is worth a pound of cure." 
This saw is very applicable to our subject, but I 
would modify it by saying, "A grain of prevention is 
worth many tons of cure." It is our prime duty to 
prevent disease, not to wait for its onset, and then 
try curative measures, and you must never consider 
your work as being circumscribed by narrow boun- 
daries, or as being confined to the mere administra- 
tion of physic. Far broader must your horizon be,, 
far wider your scope; you are high priests of health, 
you are teachers of men, and as members of the great 
faculty of medicine, your first duty will be to preach 
and practice physical and moral cleanliness. 

Cholera being an infectious disease characterized 
by the constant presence of the Koch-comma-bacillus 
in the intestine and its contents, any measures used 
to destroy this specific, morbific micro-organism, to 
prevent its development, or to preclude its introduc- 
tion into the animal economy, are of essential im- 
portance in connection with prophylaxis. Certainty 
as to results of prophylactic measures postulates 
the strictest detail attention to the hygienic and 
sanitary surroundings of the community, the family 


and the individual. In this age, with the aids given 
by bacteriology and sanitary science, an outbreak of 
Asiatic cholera is crimi?ial and is a blot upon the 
escutcheon of nineteenth century civilization. 

Commencing our study of treatment, by consider- 
ing prevention, I now invite your attention to the 
question of prophylaxis. 

Municipal and National authorities should en- 
deavor to combat contagion: 1st. By not furnish- 
ing to the scourge a favorable field for its develop- 
ment. 2nd. By preventing the development and 
propagation of the malady, once it has infected a 

The general measures to be put into execution in 
such cases may be summed up as follows: 

a. Fecal discharges must never be allowed to, in 
the slightest way, infect or vitiate drinking-water 

b. Unhealthy, dirty lodging houses must not be 

c. For drinking purposes, use only water that you 
are absolutely sure is pure, and never vitiate pure 
water by direct contact with ice. 

d. Disinfect properly, or destroy, all clothing, 
utensils, and apparatus used by a cholera-patient, or 
in the management of cholera cases. 

e. Do not place cholera patients in the wards of 
general hospitals, they must be isolated in especial 

Remember, that in the event of cholera ever visit- 
ing the locality in which you might be living, that 
you and your colleagues in the medical profession, 


will all be medical officers of health; that you will 
be, by virtue of your profession, aids to the sanitary 
authorities, and that it behooves you to prepare 
yourselves, and be ready, and able and willing, to 
do your utmost towards the preservation of trie 
integrity and good health of the commonwealth. 
In connection with municipal measures, the follow- 
ing excerpts of Dr. Raymond, cover so thoroughly 
the ground, that I would ask you to transcribe them 
in your note books for future reference. 

All surface wells should be closed at the earliest 
possible moment; and great care should be taken 
that the water supply of all cities, towns and villages 
shall be of tmdonbted purity. In cities or towns 
where the water supply comes from the country, at a 
distance from the city or town, and where there is 
always danger of contamination from stables, slaugh- 
ter-houses and privies along the banks of streams; 
special inspection must be made of these sources of 
danger, and where ever a nuisance is found, it must 
be promptly and positively abated. 

All privy vaults should be abolished wherever 
water-closets can be supplied; and wherever the ex- 
istence of such vaults- is necessary they must be 
rendered water-tight in such manner as to prevent 
saturation, not only of the grounds surrounding them, 
but also of the materials of which they are built; and 
the contents of such vaults must be kept constantly 
disinfected, and removed to a proper place at fre- 
quent intervals. Too much attention can not be 
paid to the disposal of the contents of privy vaults. 
During the existence of an epidemic, or if there be 


suspicious cases in the town or neighborhood, under 
no consideration should night-soil be removed to 
farm lands or used as fertilizer, but the material 
should be absolutely destroyed. 

In city, surburb, town or country, all stagnant 
ponds should be disinfected, and when possible the 
water should be removed by drainage or pumping, 
and the further accumulation prevented by filling 
with fresh earth or other material free from garbage 
or other filth. 

Great care should at all times be exercised to keep 
all sewers which receive refuse from dwellings, fac- 
tories and other buildings, clear and free from ob- 
struction; and examinations should be made as to the 
plumbing in all buildings, and any defects discovered 
should at once, be corrected. The sewage and 
water-supply questions, are burning ones, and de- 
mand careful consideration. Taking our own city 
for example; let us see from whence we get our 
drinking water, and where do we pour our refuse mat- 
ters. Leaving out our artesian well waters, and those 
of various springs, whose waters brought to Chicago 
are used by only a comparatively small fraction of 
the entire population, the source of the water sup- 
plied for domestic and other use is from the Lake, 
which laves the feet of our right royal city. We 
have two main outlets for our sewage; Lake Mich- 
igan, and — through the Chicago River — the Missis- 
sippi River. In its state of nature, the Chicago 
River was wont to flow into the Lake, but as it re- 
ceives a very large proportion of the city's filth, in 
order to prevent all of its vitiated stream from pour- 


ing into the drinking-water source, our municipal 
authorities have attempted to cause its current to 
flow backward, by building a powerful pumping 
station some distance up, on its southern fork. Here 
over a lock into a canal, the river water is pumped, 
and after a devious and variegated course, it ulti- 
mately reaches the Mississippi River. But while the 
great bulk of the liquid sewage is thus .disposed of, 
there are a number of sewers serving the shore dis- 
tricts of the city, that open directly into the lake, 
and while their total output is relatively small, it is 
absolutely large. The current in the Chicago River is 
very sluggish and lazy, for the greater portion of the 
time, and there is therefore a continual deposit of 
suspended matter on the river bottom. This sludge 
is removed by dredging and carried out and dumped 
into the Lake, which thus receives effete material in 
addition to the discharge of the sewers serving the 
Lake Shore districts. From various points out in 
the Lake lying at no great distances from the sources 
of pollution, water is taken, and by means of sub- 
terranean aqueducts beneath the floor of the lake, is 
conveyed to pumping stations in different parts of 
the city, to be distributed through the city mains, to 
the consumers' houses without having undergone 
filtration or any treatment whatever. Now, unfiltered, 
this water is absolutely unfit for consumption, on ac- 
count of its suspended matter, and our security from 
epidemics depends entirely on the thoroughness 
with which the Lake water is filtered or otherwise 
purified before being used. No matter how carefully 
this may be done, it is of no value, if after purifica- 


tion the water is allowed to be exposed to the air for 
a considerable length of time, or vitiated by direct 
contact with ice. I have shown you in one of my 
€arly lectures, that the spirillum cholerse Asiaticse is 
not destroyed by freezing, and it can be imprisoned in 
a block of ice, set free by the melting of its jail, and 
exhibit its pristine vitality, to the fullest extent. 
Those of you who are at all familiar with the facts, 
will bear me out in my statement that the condition 
of the Chicago River, is positively disgusting. The 
degree of pollution that is found in its waters, is 
alarming, the stream being really nothing more than 
animal refuse mixed with common sewage, and its 
condition demands immediate attention. The ques- 
tion here to be answered is: "Does this state of 
affairs affect the health of the city?" To this I 
will not attempt to give an answer, but will simply 
make the following remark: In the year 1890, 
Chicago suffered nearly eight times as much as Lon- 
don, from typhoid fever, and nearly twelve times as 
much as London in 1891. 

Extraordinary care should be exercised in refer- 
ence to all tenement houses, lodging houses, and in 
general all places where large numbers of human 
beings congregate; frequent and thorough cleaning 
and whitewashing of such structures should be re- 
quired; no accumulation of garbage or other filth 
ought to be permitted in cellars or yards; and house- 
holders should frequently and thoroughly examine 
their yards, cellars, closets and other out of the wax- 
places, to see that no filth of any kind has been de- 
posited therein. There is some difference of opinion 


concerning the specific value of rags, as etiological 
factors in spreading cholera. Dr. Allan McLane 
Hamilton, of New York, places stress on their im- 
portance in this respect, while Dr. S. T. Armstrong 
of the same city claims that not a single instance can 
be given wherein it can be shown that rags have 
spread or conveyed the disease in this country. 

The food supply should be vigorously watched to 
exclude from the market all unwholesome meat; all 
milk adulterated, or from diseased animals; all un- 
ripe fruit and vegetables; and cow stables should be 
kept at all times, clean, well whitewashed and free 
from all excremental accumulations. 

Here in Chicago we have little, if any, complaint 
to make in this regard. A short time ago our City 
Council passed an ordinance with reference to milk 
inspection, that in all probability is the most perfect 
measure of its kind, to-day in force. 

All garbage, kitchen and household refuse should 
be promptly removed from dwellings, stores and 
other buildings to a proper place where it may be 
destroyed by fire or otherwise disposed of in such 
manner as to occasion no nuisance; and such material 
should never be used in the filling of lots or thrown 
in streets or vacant property to decompose and. ex- 
hale offensive and deleterious gases. 

Too much attention can not be given to the in- 
struction of the public as to personal cleanliness. 
You must remember that the most effective pre- 
ventives of cholera are the effectual cleansing of 
places and of persons. 

A very important question, that I feel it to be a 


duty to touch upon here, is as to the disposal of the 
dead. As you are aware, to-day the method in vogue 
is that of earth-burial. Now while this mode was 
correct in days gone by, I am forced to say that in 
our time, it looks to me like a relic of medieval 
barbarism. This is not the occasion, nor have we 
the time to thoroughly review the merits of crema- 
tion or of inhumation; but I desire to direct your 
observation to some salient points connected with 
the matter. 

Dr. Petrie, of the Department of the Interior in 
Berlin, not long ago published a paper in which he 
claimed that cemeteries were perfectly safe if situated 
in proper soil and managed correctly, but in the 
discussion of his paper it was shown that pathogenic 
bacilli had been found in the earth three years after 
bodies had been buried. It has also been shown 
that in places where persons dying of yellow fever 
had been buried, bacilli identical with those found 
in the excretions of the yellow-fever patients have 
been discovered only a few inches below the surface 
of the ground. In the Sa?titarian you will find a 
most thorough and scientific paper on this subject 
from the pen of Dr. Robert Newman, who favors 
cremation in a most decided manner as a prophy- 
lactic measure against epidemic diseases. 

Nothing can be found in the bible which can be 
construed as opposed to cremation, and many 
ministers of the gospel now favor it. "He who can 
make men from the dust can bring them from ovens 
as well as from graves." 

Newman quotes the fact that anyone who drank 


water from the Elbe, during the last epidemic in 
Hamburg, was looked upon as being a cholera-sus- 
pect. Biernacki found in the well in Lubin, a suburb 
of Hamburg, cholera spirilla. That well was near a 
single house, in which in a few days twelve persons 
were seized with cholera. All these had been drink- 
ing from that well. Professor Frenkel, of Magde- 
burg, found comma bacilli in the Rhine-Ruhr Canal 
where a boat had been anchored whose owner had 
died of cholera, and where his excretions had been 

Earth in graves through burials, may cause a new 

Sanitary Commissioner Doering in Berlin, has de- 
monstrated the existence of living cholera in graves, 
and has shown that the germs may be liberated by 
water, and thereby create the disease. 

A proof of this can be adduced in an incident 
which occurred in New York during the epidemic of 
1866, when some emigrants dying of the disease, 
were buried in Ward's Island, and shortly after a 
new epidemic appeared in the city opposite the 
Island, in Ninety-Third Street, near Third Avenue 
for which no explanation could be given except of 
infection from the graves. 

From the standpoint of the sanitarian, therefore, 
the correct mode of disposing of our dead, is by 

*In a late number of the Revue des Deux Motides, M. Deherain con- 
tributes a paper entitled "Fermentation of the Earth," in which he discusses 
the question, "Can earth give infection?" He points out that "Those who are 
acquainted with Eure-et- Loire, with Oise, or Seine-et-Marne, have heard of 
the accursed fields on which the shepards refuse to feed their flocks. It will 


Another point of interest, is that contagion may 
be carried by flies. Gatti, Grassi, Koch, Simmonds 
and others authorize the statement that flies have 
transmitted cholera. They kept flies that had been 
seen sitting on cholera corpses, at their laboratories, 
and demonstrated to their satisfaction that flies can 
carry comma bacilli. The police authorities of a 
town in Prussia are said to have issued a proclama- 
tion against flies. The decree states that, inasmuch 
as flies contribute to the spreading of cholera, citizens 
are commanded to exert themselves to the utmost 
to destroy all flies within their houses. The pro 
prietors of beer saloons are ordered to keep fly- 
catchers on their counters, and penalties are pro- 
vided for neglect or disobedience of the order. 

During an epidemic of cholera, milk is one of the 
means by which the disease is propagated, the germs 
being carried by the water used to contaminate that 
fluid-food. It has been found that the bacillus of 
cholera thrives in milk as well as it does in water. 
To purify the milk it is not enough to filtrate it, nor 
is it advisable to add to it alum or an acid, because 
the fluid must be pure, particularly when it is to be 
given to children and sick people. The milk should 
be boiled. It is then destitute of all microbes and 
never produces diarrhea. 

The best and easiest method of sterilizing milk is 
that proposed by Soxhlet. The amount necessary 
to use for once, is placed in a bottle, and is then 

be found on investigation that animals stricken with disease have been at a 
former time buried there, and that a direct infection can and has been passed 
through the vegetation growing up above." 


heated by means of boiling water (water-bath) for 
a period of from thirty to forty minutes. The bot- 
tle is then taken out, and corked with a rubber stop- 
per and metal covering, in order to avoid the en- 
trance of outside air. 

Butter should be avoided during an epidemic, 
since the bacillus of cholera lives in this article of 
food for from thirty to forty days. 

Meats, vegetables and fruits should never be eaten 
raw, but should always be thoroughly cooked before 
being used as food. 

Coffee, tea, boiled water and milk, beer, and wine 
and water, are recommended as beverages, during an 
epidemic, also acid drinks, lemonades, etc. 

Theodor Weyle, of Berlin, found that the comma- 
bacillus does not thrive well in beer. This result 
Weyle attributes to the acid reaction of beer. It is, 
however, important during a cholera epidemic to 
cleanse the beer-glasses with sterilized, or boiled, or 
hot water. Weyle examined various brands of beer 
during his investigations. 

Pick has demonstrated the inhibitory action of 
wine, or wine and water, upon the cholera spirillum, 
for after an exposure of but from ten to fifteen 
minutes, no living germs could be found. The same 
result followed twenty-four hours' exposure. During 
the prevalence of a cholera epidemic, it is, therefore, 
advisable to add to the drinking water an equal 
quantity of wine, and it will be an object of further 
investigation to determine how far the thinning of 
the wine may be carried, and how long these mix- 
tures should be allowed to stand, in order to be cer- 


tain that the germs of the disease contained in the 
water are entirely destroyed. It will also be advis- 
able only to drink the wine from vessels in which it 
has already stood for twenty-four hours, and to mix 
the water and wine twenty-four hours before its use. 
There were various good reasons for Paul the Apostle 
to advise his colleague, Titus, to 'Take a little wine 
for the stomach's sake," and his advice holds good 
to this day especially during the existence of an 
epidemic. v 

During an epidemic, do nothing that could pos- 
sibly disturb the equilibrium of your economy, es- 
pecially of your digestive tract. Therefore, avoid 
excessive fatigue, and all depressing passions, for 
they are injurious. Do not suddenly check per- 
spiration, and if overheated, beware of a sudden 
chill, and keep the skin comfortably warm. Suf- 
ficient covers should be made use of at night, and it 
is advisable to wear flannel under-clothes. Even in 
summer it is a good plan to wear a wide flannel belt 
round the body, covering t*he stomach and bowels. 
Diet must be carefully attended to. Bad digestion 
diminishes the secretion of normal gastric juice, the 
acid of which is essential to counteract the baneful 
activity of the comma bacillus. I would not make 
any change in my usual diet, if cholera invaded 
Chicago, but would see that it was simple and easy 
of digestion; you should eat moderately, and at 
regular intervals, as long fasting is injurious, and 
you must carefully avoid excess in intoxicating 

The idea so prevalent among the laity, that brandy 


and whiskey are prophylactic agents against cholera, 
is a false one; they are not preventives and unless 
carefully used, may do serious harm by disordering 
the action of the stomach and bowels. 

Contact favors the transmission of cholera. Thus, 
members of the family, nurses, physicians who 
attend cholera patients and touch the bodies of 
these, as well as the utensils employed, clothing, 
articles of food, matters vomited, the dejections, and 
so forth; are all apt to carry about the germs of the 
disease. The scourge may be transmitted by plac- 
ing a soiled hand to the face, by handshaking, by a 
cigar, in the simplest way imaginable, and thus con- 
stant washing of the hands at such times is of the 
utmost importance. 

Not only the home-dwellings, but also public 
places, like hotels, should be kept scrupulously clean, 
and the removal of all sources of infection should be 
similarly supervised, suppressing even the slightest 
bad odors from stairs, corridors and particularly 

The mouth being a common source of infection, 
it and the teeth should be frequently washed and 
brushed during the day with boiled water, pure or 
mixed with soap; after which the mouth should be 
rinsed with a solution containing citric acid, an acid 
which is inimical to the cholera germ. As a fluid 
dentifrice and wash for the mouth, Listerine is ex- 
cellent. The nasal cavities should likewise be 
treated with disinfected water, since infection may 
be transmitted through the mucous lining of the 


Finally, living near by, or even frequenting, the 
vicinity of sewers or filthy water streams, ponds, 
marshy districts, etc., should be avoided. 

As a purely prophylactic measure, Winternitz 
recommends w^tQr regime. It acts in two ways; it 
furthers cleanliness, serving to disinfect the person, 
and it has a tonic, hardening effect, which improves 
digestion. Winternitz pursues the following course. 
When the skin is dry, sluggish and neglected, he 
has the individual well rubbed down with moist or 
dripping cloths wrung out in water at about 10° C. 
(50 F.) Where the person is more robust, a half 
bath at 20° C. (68° F.), lasting two minutes, may be 
given; or in a well developed, strong man, a general 
shower-bath, even quite cold, lasting a half to a 
whole minute, may be indulged in. These baths 
should always be followed by brisk rubbing down 
with coarse towels, or flesh brush, and a normal re- 
action induced. They are best taken in the morning, 
and exercise in the fresh air, or room gymnastics 
must be attended to. In some cases the procedure 
may be repeated in the evening. Care must always 
be taken that the individual does not bathe in such 
a manner as to cause depression; but bathe he 
should, for as we have already seen, strict personal 
cleanliness is absolutely a necessity. If weakness, 
or disturbances of digestion of a trifling nature are 
present, Winternitz advises the application before 
retiring, of a Priessnitz bandage, an irritating ap- 
plication, about the abdomen. 

The medical profession has been accused of pes- 
simism, and its members rated as alarmists. By 


your actions you must prove the falsity of these ac- 
cusations. Do not be afraid of cholera, or make it 
the subject of conversation, especially with the laity; 
do not allow interviews to be published in the daily 
press expressing opinions as coming from you of a 
gloomy nature, but do not shut your eyes to danger, 
do not say there is safety, when there is no safety; 
but remember that if eternal vigilance is the price of 
liberty; unremitting, unsleeping, eternal vigilance is 
what we must also give for health. 

I have only outlined to you in a general way, 
prophylactic measures against cholera. From works 
on hygiene, from comprehensive text-books you 
will glean fuller and more complete information, and 
every hour so spent, is an hour well spent. For I 
am certain you appreciate that the key-note to the 
medical practice of the future, is the word "Preven- 
tion" and in conclusion let me quote the epigram- 
matic advice of the New York Board of Health, 
which you will do well to bear in mind and live up 
to, should you ever pass through a cholera epidemic, 
"Don't be frightened, but do be cautious and avoid 
excesses and unnecessary exposures of every kind." 


After having considered all that can be done to 
prevent the occurrence of cholera, we pass to the 
study of the treatment of the disease once, it has ap- 

On being called to a house to attend a case of 
cholera, in your anxiety for the salvation or cure of 
the sick man, you must not forget your duty to the 
community. You must bear in mind that the sick 
man is a poison-producer, and on this account, is in a 
certain sense, a foe to the commonwealth Your 
treatment must therefore be directed along the two 
following lines: 1st. That which concerns the pa- 
tient as an individual. 2nd. That which is connected 
with the prevention of the spread of the disease. The 
Committee on Disinfectants of the International San- 
itary Conference of Rome, recommends, as a means 
of disinfection against cholera, besides destruction: 
I. Steam at ioo° C; 2. Carbolic acid or chloride of 
of lime. 3. Aeration. 

Sternberg directs the use of two solutions, one 
weak, the other strong, of carbolic acid and lime 
chloride in water, as follows: 

Weak Solutions: Carbolic acid, two per cent.; lime 
chloride, one per cent. 

Strong Solutions: Carbolic acid, five per cent.; lime 
chloride, four per cent. These solutions should be 
kept in large blue glass bottles, plainly labeled, with 
directions and formula written thereon, and the word 
"poison" in good-sized letters. They should always 


be kept in the same place, not changed from one part 
of the room, to another part of the room, nor 
from room to room. In addition there should be 
kept in the water-closet, a very large bottle or jug, 
which should be constantly filled with strong chlorine 
water. You must impress upon everyone connected 
with the case, the necessity of obeying your orders 
and you will see that the following measures are. put 
into practice: Dejections must be received in a por- 
celain bed-pan or pot-de-chambre ■, the patient not being 
permitted, even in the earliest stage, to use the closet. 
Into the vessel there must then be poured one of the 
strong disinfectant solutions, in quantity at least 
equal to the amount of material to be disinfected; the 
whole mixed carefully but thoroughly by shaking, al- 
lowed to stand about ten minutes, and then poured into 
the hopper. Then into the hopper there must be im- 
mediately thrown about two quarts of the strong 
chlorine water. In the same manner must vomited 
materials be treated, and in both instances when the 
foul matter has been cast out, the vessel must be 
scalded with boiling hot water and then rinsed 
with one of the weak solutions, before being returned 
to the bed room. All feeding utensils used by the 
patient, such as spoons, glasses, dishes, basins, must 
be at once washed in boiling water, then rinsed in 
one of the weak solutions, and then cleansed in pure 
water. All linen, clothing, bedding, etc., which can 
not be immediately subjected to the action of steam, 
should at once be immersed in one of the strong so- 
lutions, left there for from four to six hours, then 
boiled for at least thirty minutes, well washed 


with soft soap, and then hung in the open air for 
from 12 to 24 hours. Physicians and attendants should 
wash their hands with one of the weak disinfecting 
solutions every time they touch or handle a cholera 
patient or his clothing, etc. Especially must atten- 
tion be directed to care in this respect, with those 
who handle soiled linen and bed clothes. 

Should the patient die, the body must be enveloped 
in a sheet, satured in one of the strong solutions, 
without previous washing of the corpse, and at once 
placed in a coffin. 

Whether the patient lives or dies, at the termina- 
tion of the case the mattress, carpetings, tapestry and 
hangings of the room occupied by him, as well as the 
coverings, must be destroyed by fire. The sick room 
and adjoining chambers should be well sprinkled with 
one of the strong disinfecting solutions, the floors 
and walls washed jwith one of the weak solutions, and 
then freely ventilated, cleansed and repainted. 
• In connection with treatment the following outline 
has been prepared by me and is offered only as a 
suggestion of modes or plans to be followed. 

First. You are to endeavor to prevent, in every way 
possible, the admission of the germ into the system; 
and with this end in view, you will pay attention to 
— prophylactic measures connected with the com- 
munity, and— prophylactic measures connected with 
the individual. 

Second. Inhibit the growth and development of the 
spirilla in the intestinal cavity. 

Third. Obviate the local and general specific effects 
of the germ and produced toxines on the system, 


such as diarrhea, emesis, collapse, anuria and arrest 
of secretion generally, coma, cramps, singultus, and 
so forth. Important conditions to be considered are 
the dessication of the system and the pachyemia that 
occur as results of the enormous flow of water from 
the economy. 

Fourth. Promote free and thorough elimination. 

Fifth. Sustain vitality. In order to do this you will 
supply warmth, stimulation and nutrition, and en- 
deavor to render fluid the thickened blood. 

Sixth. Obviate as far as possible complications and 
treat them as they arise. 

Bucquoy points out that three results are to be 
sought after in each case: 1st, To maintain the bod- 
ily temperature of the patient at normal; 2d. To 
combat the diarrhea; and 3d. To arrest the vomiting. 
Now there are three things to which I particularly 
direct your attention: 1st. During a cholera epidemic 
every case of diarrhea should be treated as the first 
stage of an attack of cholera, and the fact that the 
preliminary diarrhea is mild does not indicate a cor- 
responding mild attack of the disease, for sometimes 
a very severe algid period will suddenly follow on the 
heels of a rather ordinary diarrhea. Do not wait un- 
til the stage of collapse has arrived before you think 
of doing something for it, it may then be too late. 
All through the first stage, your treatment must more 
or less trend in the direction of collapse obviation, 
and bear in mind that cholera asphyxia comes on 
often like a stroke of lightning. A patient in the 
initial stage of true cholera, may be likened unto a 
man blindfolded and walking along a level plot to- 


wards a steep, precipitous inclined plane of slippery 
ice. If he is to be saved, it must be before he reaches 
the edge of the precipice. If he comes to the edge, 
his feet slip out from under him, and he falls to de- 
struction with terrible rapidity. So in cholera, it is 
surprising at what a frightful rate of speed these pa- 
tients will pass from a condition of health to a mori- 
bund state. 2nd. In treating an individual in the per- 
iod of collapse of Asiatic cholera, remember that the 
normal absorbent functions of the gastro-intestinal 
surfaces are arrested, and that therefore it is worse 
than useless to pour powerful drugs into the patient's 
alimentary canal, as they will not be absorbed, and 
cannot therefore produce effect. Should the sick 
man recover from the cholera asphyxia and. pass on 
into the reaction stage, when the absorptive mechan- 
ism would once more return to its condition of ac- 
tivity, and the stomach and gut of the patient be filled 
with strong drugs, sudden death might occur caused 
by the overwhelming effects of various potent agents 
quickly thrown into the system. 3d. Bear in mind 
that a man in the condition known as cholera-typhoid 
must be treated in just the same way that you would 
treat a patient in the third week of enteric fever, and 
that many of the accidents met with in the third week 
of enteric fever, are often to be encountered in chol- 

The literature of the treatment of cholera is exces- 
sively interesting, and extends from the description 
of the most superstitious rites, and the proposal of 
the most ridiculous practices, to the laying down of 
the most finical rules that have ever been outlined by 


theoretical dreamers, in connection with hyperbolic 
antiseptic performances or surgical interferences. 

From far Russia comes the account of how the in- 
habitants of a certain village tried to protect their 
homes from epidemic invasion. How at dead of night 
a troop of maidens walked in procession around the 
hamlet, dragging a plough and intoning invocations, 
and if after this an epidemic should come, it was a cer- 
tain proof that one, at least of the maidens, had sur- 
reptitiously offered up sacrifice at the altar of the 
Cytherian Goddess. Hardly less remarkable was the 
proposition of a physician during one of the earlier 
epidemics in this country to check the diarrhea by 
stopping up the anal orifice with a properly con- 
structed cork. 

At the other end of the scale, we read of an ambi- 
tious individual who has of late proposed surgical in- 
vasion of the abdominal cavity. As his percentage 
of deaths, was an even one hundred, his plan could 
hardly become popular. 

It will require a great deal of tact to enable you to 
safely steer between the Scylla of carelessness on the 
one hand, and the Charybdis of unnecessary alarm on 
the other,duringan epidemic of cholera. I have already 
told you that, during such an epidemic, every case of 
diarrhea, no matter how slight, should receive the ut- 
most care, and be treated on the principle that it may 
be premonitory of an attack of the disease, and this 
you must do without causing unnecessary apprehen- 
sion, or spreading alarm among your circle. You 
will cultivate yourselves to act "Snaviter in rnodo, forti- 
ter in re" and inform the members of the various 


families composing your practice, of the urgent 
necessity of immediately paying attention to slight 
intestinal derangements, that under ordinary circum- 
stances might be considered insignificant and disre- 

Very eminent authorities say that if a slight diar- 
rhea occurs, and it is clearly traceable to errors or 
excess in eating, and if there is reason to believe that 
undigested food is still irritating the bowels, a mild 
laxative may safely be given. No possible harm, 
says one distinguished author, can result from this 
treatment, and even should the sequel show that the 
case was one of choleraic diarrhea, the physician 
may rest assured that the attack was not aggravated 
by his remedy. But, continues this same authority, 
if there is no distinct evidence pointing to the pres- 
ence of irritating bowel contents, the preliminary lax- 
ative is contra-indicated, and treatment by opium 
may at once be begun. Now I assure you I cannot 
see the force of this method of argument, and my be- 
lief is to treat every case on the plan of bowel irrita- 
tion. Whether it be undigested food-stuff or a mor- 
bific micro-organism that is producing the irritation, 
my plan would be the same; give a mild laxative, 
such as castor oil, or a dose of salts. In either case, 
follow up the laxative, with a little opium, syrup of 
ginger and tincture of capsicum as a corrective. The 
mildest and most pleasant laxative you can exhibit is 
castor-oil, but you must thoroughly disguise its naus- 
eating taste, and give it in a rather small dose. I do 
not believe in large doses of this drug, they are apt 
to gripe and cause a good deal of discomfort. One 


drachm you will find quite sufficient in a very large 
majority of cases. I never find it necessary to ad- 
minister over two drachms, and this rarely, as half 
this quantity usually is enough. But you must dis- 
guise the taste of the oil, or give it so that it can not 
stimulate the gustatory terminal bulbs in the mouth. 
Now there are numerous methods prescribed for dis- 
guising the taste of castor-oil and they are all perfect 
successes in every way except that they do not dis- 
guise, on the contrary they accentuate. Castor-oil 
has a very self-asserting taste, it is like Mark Twain's 
story about the smell of the Limburger cheese in the 
baggage car, it uses the various tastes of the adju- 
vants as a background and stands out more pro- 
nounced than ever. I have never had any difficulty 
in giving castor-oil under the form of an "artificial 
oyster," which I do as follows: Take a soft elastic 
capsule holding a drachm, and lay it on ice until 
cold. Then put it in a tablespoon and cover with 
catsup, lemon juice, vinegar and a little horse radish, 
and have your patient swallow it as he would an oys- 
ter. In this way I have given this sickening drug 
safely to people with very squeamish stomachs. 

No sooner, however, has the laxative produced its 
effect of cleaning out the bowels, than any persis- 
tence of diarrhea should be immediately arrested. If 
there should be stomach distress, an emetic dose of 
ipecac is highly recommended by Professor Fabre, 
of Marseilles, who exhibits it not only in the pre- 
monitory stage of an attack, but also even when 
grave phenomena already exist, should the tongue 
demonstrate gastric disturbance. Fabre remarks that 


it is surprising to witness the calm that follows on the 
vomiting, to observe the pulse rise, a moisture bedew- 
ing the limbs, the cramps to cease, the countenance 
to lose its pinched appearance and the general con- 
dition of the patient to improve. 

For the arrest of the diarrhea, many authors still 
seem to be in favor of the exhibition of some form of 
opium. Very eminent authorities, however, severely 
condemn its use. The distinguished therapeuticiari>, 
'Dr. Hare, of Philadelphia, says that we should not' 
give opium for the diarrhea, but only for the cramps 
and pain, and he recommends its use by the rectum. 
When it is necessary to use it perorem, Hare advises 
the employment of the denarcotized laudanum. Hare 
goes on to state that as the bacilli find a strong bar- 
rier in the acid secretion of the stomach, and as 
opium tends to inhibit the secretion of the gastric 
juice; that therefore opium is contra-indicated. This 
mode of reasoning is, with all due respect to the 
quoted authority, to my mind hardly logical. When 
in the premonitory diarrhea, or first stage of cholera, 
we are called upon to give opium, the enemy has 
passed the outposts and is already in the citadel. The 
spirilla have escaped the action of the gastric free 
acid and are now where the secretion of the gastric 
glandular apparatus can not disturb them. I would 
call your attention to the fact that there is but little 
use in locking the stable door after the horse, harness 
and buggy have been stolen. Constantine Paul, in a 
paper read by him before the Societe Therapeutique, 
advances a most excellent reason for the non-use of 
opium in chplera. He shows that the kidneys suffer 


in this disease, that they rapidly become unable to 
eliminate the drug, which then becomes a poisonous 
substance, and adds just that much more to the load 
of toxic matters the system has to carry. 

Hare speaks highly of a drug that I recommend 
to you for use in this connection, and that is camphor. 
I exhibit it habitually in cases of cholera-morbus, 
and it tends to stop the diarrhea and relieve the 
cramps from the beginning to the end of the attack. 
It is a general systemic stimulant, and is useful as- 
preparatory treatment looking towards the onset of 
the algid stage. Particularly beneficial is camphor 
when used in connection with alcoholic preparations, 
as it not only tends to control the diarrhea, but also 
stimulates the torpid kidneys. A much lauded mix- 
ture is camphor wine, which is made by adding sev- 
enty-five grains of finely powdered camphor to a bot- 
tle of strong reel wine, to which are also added gum 
arabic and alcohol. The camphor is first dissolved 
in the alcohol and then thoroughly mixed with the 
wine, and the dose is a teaspoonful in peppermint- 
tea every hour, to a child of six years, while to an 
older child a dessertspoonful may be given, and to an 
adult a wineglassful. This mixture is not only valu- 
able on account of the camphor it contains, but also 
on account of the red w T ine, which is, as we have seen, 
of bactericidal importance. 

For the diarrhea, a powder composed of fifteen 
grains of subnitrate of bismuth and ten grains of 
benzo-naphthol given three times in the course of 
the day s has been found efficient. Hayem has confi- 
dence in lactic acid as an intestinal disinfectant. 


Take three drachms of lactic acid; six of simple 
syrup and thirty drops of tincture of lemon, which 
are to be mixed and placed in a quart of distilled 
water. Of this the patient is to receive from one to 
to three dessertspoonsful every quarter of an hour. 
A few drops of some mineral acid (preferably sul- 
phuric) very largely diluted with, water, may be given 
frequently with advantage; not only with the hope 
of interfering, by the acid solution, with the morbific 
processes in the gut, but also on account of the grate- 
ful, soothing effect on the patient. In cholera-mor- 
bus, ten drop doses of aromatic sulphuric acid in 
water frequently repeated, are of great benefit, and 
would, I believe, be useful in true cholera. Most re- 
markable results are reported from the use of salol 
in doses of from fifteen to twenty-five grains every 
three or four hours for a day or two. Lowenthal 
finds it very antagonistic to the comma bacillus, and 
Hueppe is authority for the statement that its use 
prevents the development of anuria by inhibiting mi- 
crobic grow T th and preventing the diarrhea and the 
appearance of the toxic materials, both of which in- 
fluence the blood. I believe that a good practice is 
to administer early in the first stage, a cholagogue. 
You will find as the diarrhea assumes choleriform as- 
pects that there is an entire absence of biliary pig- 
ment in the stools, which are whitish in color. We 
have already seen that in order to produce the disease 
in animals, it has been found necessary to tie the 
bile-duct. Bidder and Schmidt describe bile as di- 
minishing putrefactive decomposition of the intesti- 
nal contents, and ascribe to it slight antiseptic quali- 


ties, although this is doubted by von Voit. Any- 
such virtues that bile may possess are due to its 
interference with bacterial development in the intes- 
tinal tube cavity. Dalton found that the feces of a 
dog with permanent biliary fistula, were much more 
stinking than ordinary, while Bidder and Schmidt 
noticed abnormal discharges of flatus. I believe it 
to be of advantage in the early history of the disease 
to favor intestinal antisepsis, by inducing hepatic ac- 
tivity, causing a free out-pouring of bile into the 
bowel and then cleaning out the tube. For this pur- 
pose I would recommend the administration of small 
doses of podophyllin, aloes, euonymin, iridin or blue 
mass. A five grain blue mass pill given in the neigh- 
borhood of three or four hours before a dose of cas 
tor-oil, is good treatment. 

In studying the chemistry of cholera micro-biol- 
ogy, you recollect we found that certain noxa were 
produced during the processes connected with the 
growth and development of the cholera germ in the 
bowels. Turn back to your notes and read the symp- 
tomatology of cadaverin-poisoning, as tabulated by 
Scheuerlin and Grawitz. Read further and note Ro- 
bert's observations on the muriate of cadaverin, 
which he found to be a very mild kind of poison, if 
indeed a poison at all. A similar attribute he noticed 
as belonging to other salts of the alkaloid; as for in 
stance, the tannate, lactate and citrate. A question 
to be answered" in relation to treatment, is how to 
convert the produced cadaverin into a harmless salt. 
There are three localities in which we find this tox- 
ine, and in which we have to attack it. These are: in 


the bowel, in the blood, and in the tissues of the system. 

Dr. Heir in Hyderabad, believes that the best re- 
sults can be obtained from the use of salol, which 
in the bowels becomes split up into carbolic acid and 
salicylic acid. He recommends the administration 
of nine grains four times a day. This is also the ra- 
tionale of the acid treatment which I have before 
spoken of, the conversion of the toxic animal alka- 
loid into a lactate, a citrate or a sulphate. In these 
methods two ends are aimed at: 1st. To so alter the 
medium in which the bacilli are growing and living 
in the bowel as to render it inimical to them; and 2d. 
To convert the toxine (or toxines) into harmless 

Cantani believes that the best means at our dis- 
posal for accomplishing the two results above men- 
tioned, are included in the method of enteroklysis, 
or washing out the bowel, introduced by him within 
the last decade. This mode yielded such brilliant 
results in his hands that he enthusiastically employed 
it in a very large number of cases, and induced many 
other physicians to try it. He holds that for the op- 
eration to be successful, it must be performed rather 
early in the history of the disease in a given case, and 
it must be performed as directed by him. The mo- 
dus operandi consists in the slow irrigation of the large 
and small bowel by way of the rectum, with a solu- 
tion urged on by the hydrostatic pressure of a foun- 
tain syringe. The solution is composed of: infusion 
of chamomile flowers, two thousand parts; tannic 
acid, ten to twenty parts; gum arabic, thirty parts; 
and tincture of opium, two parts. 


Cantani insists that in order that the operation 
should be successful, the ileo-cecal valve must be 
passed, and that in favorable cases where the opera- 
tion was a failure, no more was done than to irrigate 
the colon. The importance of irrigating the ileum is 
very great, since it is here the disease is most active. 
He uses for each injection two quarts of his injection 
fluid at a temperature of from ioi° to 105 ° F., and 
gives it so slowly that the bowel hardly appreciates 
that it is being distended. The beneficent effects 
claimed are; contraction of the leaking vessels, 
inhibition of the growing of the bacilli, lessening of 
the absorptive capability of toxines, the changing of 
at least a portion, of the toxic alkaloids into compar- 
atively harmless salts, the acidulation of the intesti- 
nal contents, the warming of the body, the preven- 
vention of anuria and desiccation of the tissues, and 
the obviation of collapse. Theoretically, could any 
treatment be more perfect, and if practical results 
only bore out the theory, we would have almost, if not 
absolutely, a specific treatment for cholera. 

Oser thinks the enthusiasm of Cantani and his dis- 
ciples to be premature, for he asserts that the death 
rate has remained as high in Naples since the method 
of enteroklysis was introduced, as before. Oser 
states that he cannot say whether or not the ileo-ce- 
cal valve is paralyzed in cholera, as he has not made 
any experiments in this direction, but he is inclined 
to the opinion that under ordinary circumstances the 
valve is impassable. He feels certain that with only 
two quarts of fluid, it is impossible to wash out the 
whole small intestine and sterilize the bacilli in the 


upper part. Bull has found that in the adult a little 
over a quart of water injected by the rectum will 
reach the cecum, but that the entire capacity of the 
Jarge intestine is from four to somewhat over five 
quarts. He is of the opinion that in the living body 
fluid can not be forced beyond the ileo-cecal valve, 
although ancient and modern experimenters claim to 
have succeeded in the cadaver. He affirms that when 
the large intestine is distended by air the ileo-cecal 
valve is rendered incompetent and the air passes into 
the small intestines. Heschl has made numerous ob- 
servations and declares himself as being satisfied that 
the valve is an absolute barrier against regurgitation 
from the large into the small intestine. In experi- 
menting as to the resistance afforded by the various 
coats of the bowel, to pressure, he found that the 
peritoneal coat of the colon yielded first to over-dis- 
tension, the remaining portions of the wall giving 
way subsequently to a somewhat slighter force. On 
being subjected to hyper-distension, the small intes- 
tine of a child ruptured first on the mesenteric side, 
the place where acquired diverticular are found. 
Other opposition to Cantani's procedure comes from 
the authorities of the Moabit Hospital in Berlin, who 
have no confidence in it whatever. 

Probably the highest authority in the world on this 
question is Nicholas Senn. This brilliant investiga- 
tor asserts that the results of carefully conducted ex- 
periments combined with clinical experience leave no 
further doubt that, practically, the ileo-cecal valve is 
not permeable to fluids from below 7 , and that for di- 
agnostic and therapeutic uses it is unsafe and unjust- 


ifiable to attempt to force fluids beyond the ileo- 
cecal valve. There is no gainsaying such a positive 
statement from such a careful observer and eminent 
author as Professor Senn, and I would sum up by 
saying that my belief is that the valve of Bauhin is 
impassable to fluids from below, that any attempt to 
overcome its integrity would necessitate the employ- 
ment of force that would, beyond the peradventure of 
a doubt, materially injure the intestinal structure, and 
that any how it would seem as if two quarts of fluid 
were rather a small amount to irrigate the tube in al- 
most its entire length. 

Hare and Martin, basing their opinion on experi- 
ments made by themselves during the past two or 
three years, coincide with Cantani in his conclusions, 
and acknowledge his claims. Hare insists on the 
following requirements receiving due attention in 
performing the operation: Give the injection slowly 
and with great care, never use a pumping syringe but 
let the fluid be forced onwards by gravity, always 
therefore use a fountain syringe; to fill the colon use 
a pressure of from one to two pounds, and to force 
the injection into the small intestine do not allow the 
pressure to pass above six pounds. As a rule twenty 
minutes suffices for the operation, but if after forty- 
five minutes of gentle but constant pressure, the valve 
has not been opened, it is advisable to stop, at least 
for the time being. 

But in spite of the difficulties that we have so far 
met with in our endeavors to put into practice a 
theory that is in every way correct, we are not dis- 
heartened, and I believe that in the near future we 


will be enabled to perfect some such a plan. Dr. 
Senn assures me that he believes the intelligent and 
. scientific mode of treatment of cholera, to be the 
early disinfection of the intestinal tract with some 
gas inimical to the cholera spirillum. He advises me 
that chlorine gas would probably meet the require- 
ments. Further experimentation will have to be 
made before we can decide as to the amount of this 
gas to be used, and exactly how it is to be employed. 
With respect to the irritating properties of chlorine, 
I would remark that since Shurley has introduced it 
into the intrapulmonary cavity, which is lined by a 
mucous membrane very sensitive and antagonistic to 
it, I believe it to be feasible to introduce this gas 
into the intestinal cavity. Perhaps hydrogen would 
be indicated, as so far as I know the microbe of tet- 
anus is the only pathogenic micro-organism that can 
live and develop in this gas. 

But at this point, and with good reason, you ask 
me: "Can we disinfect in any way both large and 
small intestine? Can we pass the boundary line that" 
is guarded by the colic valve?" In answer, I would 
refer you to the results of a large number of experi- 
ments made by Dr. Senn with regards to rectal insuf- 
flation of hydrogen gas, as a test in the diagnosis of 
visceral injury of the gastro-intestinal canal in pene- 
trating wounds of the abdomen. After careful and 
painstaking observation, Senn makes the following 

The entire alimentary canal is permeable to rectal 
insufflation of air or gas. 

The ileo-cecal valve is rendered incompetent and 


permeable by rectal insufflation of air or gas under a 
pressure varying from one-fourth of a pound to two 

Air or gas can be forced through the whole ali- 
mentary canal from anus to mouth, under a pressure 
varying from one-third of a pound to two pounds 
and a half. 

Rectal insufflation of air or gas to be both safe and 
effective must be done very slowly and without 
interruptions. Therefore inflate slowly, as long con- 
tinued, uninterrupted pressure accomplishes most 
effectually lateral and longitudinal dilatation of the 
cecum, conditions which render the ileo-cecal valve 
incompetent, and which must be secured before infla- 
tion of the small intestines is possible. 

The safest and most effective rectal insufflator is a 
rubber balloon large enough to hold sixteen quarts 
of air or gas. The filled balloon is to be connected 
by means of a rubber tube with the rectal tip of an 
ordinary syringe, and between the tip and the bal- 
loon, there should be a stop-cock, so that the escape 
of gas can be prevented whenever necessary. The 
return of gas along the sides of the rectal tip can be 
readily prevented by an assistant pressing the anal 
margins firmly against it. 

The entrance of gas from the colon into the ileum 
is always attended by a diminution of pressure, and its 
occurrence can invariably be recognized by gurgling 
or bubbling sounds heard over the ileo-cecal valve, 
and sometimes the sounds are sufficiently loud to be 
appreciated at some distance. 

The resisting power of the intestinal wall is nearly 


the same throughout the entire length of the canal, 
and in a normal condition yields to diastaltic force of 
from eight to twelve pounds of pressure. When rup- 
ture takes place it either occurs as a longitudinal lac- 
eration of the peritoneum on the convex surface of 
the bowel, or as multiple ruptures from within 
outwards at the mesenteric attachment. The 
former result follows rapid, and the latter slow, 

Dr. G. C. Purvis suggests the employment of a so- 
lution of sulphur dioxide by rectal injection, as in 
Cantani's method of tannin enteroklysis, to destroy 
the cholera germ, in those portions of the intestinal 
tube reached by the solution of the gas. The sul- 
phur dioxide may be prepared by acting on crystal- 
ine sodium sulphate by either hydrochloric acid or 
sulphuric acid, in water that has been boiled. 

Surgeon-Major Brown, U. S. A., speaks highly 
of the rectal injection of solution of hydrogen per- 
oxide, in the proportion of two teaspoonsful to a 
quart of hot water, but I need not call to your mind 
reasons why these procedures would have the same 
objections offered to their use, as we have advanced 
against Cantani's. Brown recommends the hypoder 
mic injection into the abdominal wall of the whole 
of the following formula: Sulphate of strychnine, 
about one-sixteenth of a grain; sulphate of morphine, 
about one-third of a grain; ergotine of Yvon-Sick, 
about five grains; and distilled water about one tea- 
spoonful. This injection to be repeated in an hour. 
In succeeding injections the strychnine to be omitted, 
and the morphine also if there be the slightest signs 


of narcotism. Half hourly doses of the ergotin, may 
be given, and if the diarrhea does not improve, larger 
quantities may be exhibited. 

I would suggest the administration of an "enteric" 
pill of inspissated and purified bile, or the conjugate 
acids,. at regular intervals of time. 

The very latest reagent proposed for attacking the 
cholera spirilla in the intestine, is ammonio-tetrasul- 
phate of potassium, which is endowed with the remark- 
able property of remaining neutral in reaction at 
ordinary temperatures, but resolving itself into an acid 
sulphate at blood heat. It is claimed, with what truth 
I can not say, that this drug, when taken with food, 
remains neutral in the stomach, but gives off its acid 
combination in the intestine. The powder is odor- 
less and tasteless and a dose of ninety grains is 
reported as having been well borne by a dog. In 
theory this is all right, but we will have to await 
practical tests, before deciding as to practical 

Hare quoting Harkin and Groneman, speaks of 
the extraordinary results produced by the applica- 
tion of blisters over the pneumogastric nerve in the 
neck, a therapeutic measure to which I simply refer. 

Some little time ago, I told you of the hydrothera- 
peutic regime recommended by Winternitz in connec- 
tion with prophylaxis. With even more confidence, 
this observer advises hydrotherapy in the first stage 
of the malady. He declares the action of this treat- 
ment to be, that through thermic irritation a stronger 
contraction of the intestinal blood vessels is produced 
and greater resistance is thereby afforded to the trans- 


udation of fluids. The results to be expected are: 
Peristaltic movement is slowed, the excretion into the 
intestine is diminished, and absorption is increased. 
Winternitz holds that by his methods the peripheral 
circulation is enlarged and accelerated, the nervous 
system is aroused to meet the requirements of the 
body, and the patient's vitality is given an impetus 
to activity. The simplest method by which these 
results are to be attained, the one most easily carried 
out anywhere, and without exception the most effec- 
tive is an energetic rubbing off of the patient's body 
with towels wrung out in ice-cold water, followed at 
once without the patient being dried, by a sitz-bath 
at from 43.3 to 51.6 C. (no° to 125 F.), lasting 
from fifteen or twenty, to thirty minutes, according 
to effect produced. In this sitz-bath all of the pa- 
tient's body not immersed in the water, must be cov- 
ered by a blanket. Should the patient be strong 
enough he must be required to energetically rub his 
belly with his hands; if not, two nurses should kneel 
beside him, one on either side, and reaching under 
the cover, rub his abdomen. After the bath the pa- 
tient is to be wrapped up in a hot dry blanket, put to 
bed, and his extremities well rubbed beneath the 
covers. In place of these procedures, a sharp sprink- 
ling of cold water, or a movable fan douche directed 
against the abdomen for from half a minute to a 
minute and a half, followed by the sitz-bath, will ful- 
fil the indications very well The treatment is us- 
ually succeeded by a complete reaction, and the pa- 
tient breaks out in a profuse, grateful perspiration. 
Fullerton, of Columbus, Ohio, speaks in terms of 


praise concerning the exhibition of quinine. He 
suggests that one drachm of the drug be dissolved 
in three ounces of water by means of sufficient aro- 
matic sulphuric acid, and that of this solution a table- 
spoonful should be administered and at once repeated 
should vomiting occur, and afterwards at intervals 
of an hour and half until thirty grains have been 
taken, and thereafter pro re nata. 

For the muscular cramps, should they persist after 
the exhibition of camphor and salol, or the use of the 
bath, you had better exhibit morphine hypodermati- 
cally, as occasion may require. If the vomiting be 
present, the patient may be given "ice-pills," small 
pieces of cracked ice which he should swallow whole 
and not allow to melt in the mouth, cold champagne, 
seltzer or carbonic-acid water. Wine of ipecac given 
in drop doses, and oxalate of cerium in doses of 
from one to three grains, are recommended, but the 
drug that I place the most reliance on in controlling 
vomiting from any cause whatever, is glonoin. A 
nitro-glycerine pellet of the one-hundred and fiftieth . 
of a grain, repeated as occasion may demand, is a 
very potent remedial agent. Of the anti-emetics, 
Bucquoy places the greatest value on menthol, while 
in combating the vomiting Laussedat uses a mixture 
composed of seventy-five minims of ethereal tincture 
of valerian; fifteen minims of Sydenham's laudanum; 
five minims of essence of peppermint and seventy- 
five minims of Hoffman's anodyne. Of this the 
patient is to receive twenty-five drops every few min- 
utes until the tendency to vomit is relieved. In this 
period Hare states that the following prescription is 


very efficacious: Half an ounce of aromatic sul- 
phuric acid; fifteen drops of cajuputoil; two drachms 
of fluid extract of hematoxylin; one drachm of spirits 
of chloroform; and three ounces of syrup of ginger. 
Of this a teaspoonful is to be given in water every 
two hours. To the question as to whether the patient 
is to be allowed to quench his thirst, I would unhesi- 
tatingly answer, yes. Let him drink plain water, 
previously boiled, then placed in a bottle and put on 
ice. Claret, or small quantities of brandy or whiskey, 
or vermouth, or Rhine wine may be added to the 
water with excellent effect. Do not allow the patient 
to drink much at a time, Give him small quantities 
at a dose frequently repeated. A tablespoonful of 
fluid given every ten or fifteen minutes, is much bet- 
ter for him than larger amounts, at longer intervals. 
Cold tea and coffee are often relished, but while 
cold drinks are as a rule craved, you will frequently 
find that hot drinks will be better borne and produc- 
tive of better results. Before leaving this portion of 
our subject, I would say that too much stress can not 
be laid on the general management of the case. 
As soon as the diarrhea manifests itself the patient 
should be ordered to cease immediately his work, 
and lie down in bed between blankets. For several 
hours he should eat nothing, and a flannel bandage 
should be applied over the abdomen. About eight 
or nine hours after the subsidence of the diarrhea he 
may be allowed egg-white, mucilaginous drinks, 
scalded. foast, gruels, wine-whey, arrowroot, farina or 
rice. Beef-tea, soup and all meat broths must be 
excluded from the bill-of-fare. After recovery, for 



several days the patient must be very conservative, 
and gradually return to his usual vocation and nor- 
mal diet. 


At my last lecture I outlined to you the treatment 
of the first stage of cholera; and of the plans sug- 
gested, I would recommend the internal exhibition 
of salol and wine of camphor, the giving of acidu- 
lated drinks, the administration of small quantities of 
various liquids as occasion requires at short intervals 
of time, the careful and intelligent appplication of 
Winternitz's hydrotherapeutic measures, and the 
early performance of Senn's operation of gaseous 
intestinal disinfection.* As an initial step, I would 
give a cholagogue, followed by a dose of cas- 
tor-oil, and then check any subsequent diarrhea. If 
muscular cramps persisted I would use morphine 
hypodermatically. If there was much abdominal 
pain, I would use hot applications over the belly, and 
I would have you understand now, that I condemn in 
a most unqualified manner, the routine use of opium. 
When this drug of necessity must be used, the de- 
narcotized opium or the deodorized laudanum, prefer- 
ably in acidulated solution, ought to be employed. 
Hare's ruling in this connection should be followed; 
never use opium, in cholera, to arrest diarrhea, but 
exhibit it only to diminish pain. At the risk of being 
considered tautological, I will repeat that you must 
watch your patient very carefully during the first 
stage, remembering that the onset of the second stage 

*In the near future a report will be made giving positive details as to this 
mode of treatment. As yet it is too early to be specific about details. The 
question is one that requires further investigation. 



is excessively rapid and that your treatment in this 
initial stage must be largely expectant. If, there- 
fore, your patient does not soon improve, if the 
diarrhea persists, I would begin quickly to take 
measures to head off the cholera asphyxia. I think 
that here Winternitz's or Semmola's hydrotherapeusis 
is excellent treatment, and I would not delay, but 
would take advantage of the acceptable time before 
the hour of salvation had passed. If vomiting con- 
tinues, I would rely largely on the use of nitro-glyc- 
erine to control it. I have seen severe, uncontrolable, 
incessant attacks of vomiting completely subjugated 
by from two to three doses of a hundred-and-fiftieth 
of a grain of this drug, given per orem at intervals of 
from half-an-hour to ^n hour. 

If the first stage continues, you must bear in mind 
what is going on in the interior of your patient's 
body: — The bacilli are growing and multiplying 
enormously in the bowel, the toxic materials are 
being elaborated, are being absorbed, are coursing in 
the blood, and ultimately will reach the various 
tissues of the economy. The blood is being drained 
of its w T ater and the soluble, diffusible matters there- 
in dissolved; this is thickening the blood, decreasing 
its volume, and will in the end change it into a viscid, 
almost grumous liquid that can scarcely be forced 
through the smaller blood vessels. We have seen 
that we can reach and attack the cholera germ in the 
intestinal cavity, and if we succeed in devitalizing 
it~there, we have done our full duty in this regard, 
for the germ is not found in the body outside of this 
location; we have seen that we can reach the toxines 


in the intestine, but we know that these poisons pass 
into the blood and tissues. Therefore we ask, can 
we neutralize them after they have left the bowel? 
When they have reached the tissues? While still in 
the blood? 

In answer to this, I would say that it is impossible 
to stop the action of these noxa if once taken up in 
the system in doses large enough to interfere with 
the central functions. 

We can, peradventure, keep up the strength of our 
patient with stimulants and proper nourishment; we 
can excite or arouse nervous activity; but if the 
amount of virus be but sufficient, our endeavors will 
very soon be of little service. 

But now you ask me: can we interfere with the 
poison while yet in the blood stream? So far we 
know nothing positive concerning such treatment. 
Prophylactic inoculations with this end in view, have 
been proposed; but the results are very doubtful and 

Ciaramelli, in 1885, reported magnificent results in 
treating cholera by hypodermic injections of the 
citrate of iron, in the stage of collapse. His method 
was to inject three times a day a syringeful of a ten 
or twelve per cent, solution of this salt, representing 
three grains of iron, and his results in all probability 
were due to the action of the acid component of the 
iron salt on the absorbed poisons. 

Maestre's treatment of cholera collapse with 
chloral injections, seems to be valuable, according to 
report. In this case again in all probability we are 
dealing with a neutralizing of the cadaverin, when 


we are told that chloral in the blood is changed into 
an acid product, — afterwards visible in the urine as 
uro-chloralic acid, and later as glycuronic acid. 

You recollect that one of the conditions I have laid 
stress upon in the disease we are considering, is the 
absence of absorptive power during the algid 
stage; you remember I have warned you how danger- 
ous it is, and how useless, to pour drugs into the 
digestive tract of an individual at this time, and I 
would now advise you to bear in mind, that the ex- 
hibition of medicinal agents by the mouth, is there- 
fore, only correct while intestinal absorption lasts. 
Whenever, during cholera asphyxia, drugs are posi- 
tively and quickly required, hypodermatic adminis- 
tration affords a much better chance of effective 
action than swallowing, even although the absorptive 
functions of the subcutaneous connective tissue are 
reduced or suspended by desiccation and shrinking 
during collapse. 

When the algid stage is feared, but has not as yet, 
arrived, Semmola's plan of administering repeated 
hot baths (from ioo° to 104 F.) I imagine would be 
efficacious. It is useless to w 7 ait for collapse to set 
in, for then the hot bath would have but little more 
effect than with a corpse. This authority describes 
the bath as having a calmative effect and a pro- 
nounced rallying influence. 

In incipient collapse, Dr. J. C. Peters recommends 
the use of pieces of unslacked lime, wrapped in wet 
cloths and put in bowls around the patient's body, 
under the bed-clothing. The heat so produced is 
very gratifying. Packing the patient in blankets 


wrung out in hot cayenne or mustard water is useful; 
and as the blankets become cool or dry, hot water 
may be poured upon them, without disturbing the 
sick man. Sinapisms applied to the abdomen, and 
hot flaxseed poultices with a little mustard mixed 
with the meal are grateful. 

Wendt, in his excellent treatise on cholera, de- 
scribes how an energetic doctor once gave his 
collapse patients a hot bath, made them drink all the 
hot water their stomachs would hold, and then 
pumped not only their bowels but their bladder full 
of hot water, and complacently said if any one could 
do more to warm a patient up he would like to hear 
of it. 

Maclean, Macnamara, Parrot, Hartshorne, Desprez, 
and Wendt all speak favorably of the use of chloro- 
form both internally and by inhalation. Desprez 
claims that by its use from eighty to ninety out of 
every hundred persons in the algid stage can be 
saved. His formula is: 

R Chloroform 15 minims 

Alcohol 2 drachms 

Syrup of hydrochlorate of morphia 1 ounce 
Acetate of ammonia 2 drachms 

Distilled water 3 ounces 

Misce et signa: — A tablespoonful every half hour. 

Chloric ether is valuable given hypodermatically, 
and T. Ffrench-Mullen states that he has given in 
the same manner strychnine in some hundreds of 
cases of cholera, with very satisfactory results. He 
uses the method in every case in which collapse has 
set in or seems to be coming on. He gives five 
minims of liquor strychnise in an equal quantity of 


water. As his patients were almost all seen in their 
own homes, and there were so many to be visited, it 
was as a rule, only possible to give two injections in 
the day (morning and evening) to any one case. He 
has, however, given five injections in twenty-four 
hours, and two more during the following twelve 
hours in the case of a prisoner where the effects could 
be watched, and has no doubt the man owed his 
recovery to the remedy.* When the urinary secre- 
tion has not been re-established within twelve hours 
or so of the cessation of the other symptoms, hypo- 
dermic injections of pilocarpine have produced ex- 
cellent results. In many cases urine appeared within 
less than five minutes aftei the use of the syringe. 
A symptom that sometime becomes very distressing 
is singultus or hiccough. It can usually be arrested 
by a hypodermic injection of morphine, an epigastric 
sinapism, or a blister. Should these means fail, it 
may be necessary to give a few whiffs of chloroform. 
I do not wish to have you .understand me as advis- 
ing you to withhold all fluids from your patient in 
the second stage. Stimulants may be given, Bur- 
gundy or Tokey wine, port or sherry wine, brandy 
and soda water, or champagne. The ammoniacal 
preparations, and camphor and musk, may be used, 
but, as previously remarked, when the algid stage once 
becomes pronounced in spite of attention, to con- 
tinue giving medicine by the mouth is worse than 
useless. In mild cases you will find that hot water 

*Dr. Chauncey F. Chapman informs me that in certain cases he has ex- 
hibited without untoward effects, one -twelfth of a grain of strychnine, eight 
times in the course of a single day. The patient being all the time under ob- 


bottles applied around the body, sinapisms, hot 
drinks, and so forth, will do; if not, you must not 
procrastinate, but adopt some more energetic meas- 
ures, and one of the best measures for ordinary 
use, is the one proposed by Dr. Peters, and which has 
been detailed to you. 

In addition to the various pathological conditions 
that we have been endeavoring to obviate, there is a 
group to which I now direct your observation; com- 
prising the thickening of the blood, the decrease in 
its volume, the drying up or desiccation of the tissues 
and the pretty general arrest of secretion, that of the 
kidneys being the most important. These conditions 
are in the main due to the enormous and rapid drain 
that is made on the system by the colliquative intes- 
tinal discharges. Our first indication is to prevent 
the loss of water, but failing in this we must try and 
make good the loss. We can accomplish this latter 
end by intravenous and subcutaneous transfusion of 
fluids, resembling to a certain extent, the physiolo- 
gical plasma sanguinis.* 

This brings us to the study of hypodermoklysis, 
a procedure introduced by Cantani, and first used in 
cholera by Oser. 

As its name indicates, this operation consists in the 
injection of fluid under the skin, in order to flush 
the system. About three or four years ago Dastre 

*Dr. C Barth suggests that the absorbent surface of the mucous membrane 
of the bladder should be utilized for the introduction of water into the anhy- 
dremic cholera system. According to this observer, the scanty concentrated 
urine found in the bladder after death in cholera seems to indicate the reab- 
sorption of urinary water, under the influence of the increased density of the 
blood in the vessels. Copious injections of saline fluid into the urinary bladder 
may therefore aid in fulfilling the main indication of the choleraic state. 


and Love in experimenting on dogs and rabbits, in 
jected a seven-tenth per cent, solution of chloride of 
sodium directly into the animals' veins. They found 
that they could without any danger to the life of the 
animal, transfuse in this manner four times the 
amount of the normal quantity of the blood. 

A remarkable fact noticed by these observers was 
that the blood tension, which could reasonably be 
expected, on account of the plethora induced by the 
operation, to be much elevated, was no higher than 

Again, they noticed that about two or three hours 
after the operation a well-marked diuresis was 
induced. Continuing their studies, they ultimately 
fixed the unit of transfusional capacity which they 
found to be a flow of one drachm of the solution 
into the blood current, in fifteen minutes, for a pound 
weight of the animal's body. Thus for an ordinary 
dog, weighing about twenty pounds, the maximum 
harmless quantity of saltwater infused into his sys- 
tem would be about two drachms per minute, and if 
this ratio were kept up, the operation might last for 
hours, with the result that a balance would be struck, 
just as much fluid flowing out of the system, in a 
given space of time, as was poured in. If however 
4 the rate of speed of the inflowing current, was in- 
creased over and above that which kept up the con- 
dition of equilibrium, then, fluid would accumulate in 
the system, and produce a fatal result, because the 
kidneys would not be able to remove the fluid as 
fast as it was injected. 

During the time that the infusion is going on, it is 


noticed that the urine of the animal becomes paler 
and paler, losing in specific gravity, until at last it 
becomes very similar to the fluid injected. In this 
way there is induced a flushing out, or washing of 
the body tissues, and very much more urine is passed 
than would have been possible without the injection. 
Albumen does not appear as a result. This opera- 
tion is safe only with an absolutely healthy heart, for 
in a diseased organ the increase in tension of the 
fluid in the right heart, might prove serious. 

On the other hand, Roux and Yersin have not 
obtained good results with this mode of treating 
animals poisoned with different bacterial products. 
The operation was considered for various reasons 
dangerous as applied to man, and methods were 
sought for that would produce its beneficial effects 
and obviate its dangers. 

Such a method was discovered by Cantani, who 
first conceived the idea of injecting the physiological 
solution hypodermatically, and who named the 
operation "hypodermoklysis." He recommended it 
in two different conditions: post-hemorrhagic ex- 
haustion, and in cholera; although to Oser, by some 
is given the credit of first adopting the procedure 
in the latter condition. Cantani's purpose was to 
overcome the desiccation of the tissues, by replacing 
the water that had been removed. But he builded 
even better than he knew, and more advantages are 
now claimed for the operation, than were ascribed to 
it by its discoverer. We recognize today that many 
diseases are caused either by materials resulting from 
metabolic processes connected with microbic life in 



our bodies; or, are induced by the physiological 
waste-matters of the body itself. The investigations 
of Brieger and of Vaughn leave no doubt but that in 
both instances there appear varieties of highly pois- 
onous substances, which are either alkaloidal, pro- 
duced by decompositions and called ptomaines or 
toxines; or, are derivatives of pathogenic bacteria, 
and called toxalbumines. Now when these bodies 
are introduced into or retained in the circulation, 
they produce deleterious effects, which are known as 
"intoxications." It has been proven, that, in various 
diseased conditions — especially those accompanied 
by a febrile movement, these noxa circulating in 
the blood stream, are removed from the economy 
largely by the kidneys; and it is a well-recognized 
clinical fact that in these infectious diseases, the 
reappearance of a copious flow of urine is a most 
favorable sign. Now by the method we are describ- 
ing — if there have not been pre-existent renal disease 
— such a flow can be established, and the poisonous 
matter washed out of the system. 

The technique necessary for the performance of 
hypodermoklysis, is comparatively simple. A glass 
vessel, containing about thirty to forty ounces, is 
filled with a sterilized solution of seven parts of 
sodium chloride, and one-thousand parts of water 
(about three and one half grains to the ounce). The 
temperature should be in the neighboorhod of 43°C. 
(uo° F.). Leading through a tight stopper from the 
vessel to an india rubber tube which is to be attached 
to a large-sized canula, there is a glass syphon; while 
leading to the bottom of the vessel for the purpose 


of admitting the necessary air, is a glass pipe, filled 
at the upper end with sterilized cotton. It is hardly 
necessary for me to remark that every part of the 
apparatus should be absolutely sterilized. The best 
place for administering the injection, is in the abdo- 
men. The trocar is to be pushed through the skin 
into the subcutaneous connective tissue, then with- 
drawn, the tube connected to the canula and the 
fluid injected by holding the glass vessel about four 
or five feet above the patient's abdomen. The time 
required for infusing thirty ounces is about five 
minutes. While the fluid is flowing a tumor is 
slowly formed, which is gradually absorbed in about 
three hours and which may be slowly and carefully 
kneaded by the fingers of one hand during formation. 
While it is a fact that this tumor is painful, yet it 
disappears in from two to three hours, and its dis- 
comfort can be reduced by making two injections, 
one on either side. 

During the operation hold the canula parallel with 
the surface of the body, or rather incline its point a 
very little toward the skin. While'the fluid is flowing 
in, the canula should be pressed slowly forward, in 
order to distribute the solution in a greater space, 
and to prevent its regurgitating outward from the 
point of entrance. After the withdrawal of the can- 
ula, the puncture is to be immediately closed with 
rubber plaster. It is not unlikely that in a consid- 
erable number of cases an abscess will follow, but 
this need not cause any alarm. 

In private practice the apparatus required need 
not be as complicated as I have described. In a 


clean tea-kettle, boil a measured amount of water, 
forirom ten to fifteen minutes. Towards the end of 
this time, shake in some table salt in the proportion 
of one heaping teaspoonful to a quart of water. Al- 
low the water in the kettle to cool to the proper 
temperature point, place it on a step-ladder, or hang it 
at the correct height, attach one end of a disinfected 
or sterilized rubber tube to the kettle nozzle, and 
the other end to a canula which has been pushed in- 
to the areolar tissue beneath the skin, and the trocar 
pulled out. 

Samuel's continued subcutaneous infusion, as per- 
formed by Kutner, is somewhat different as regards 
technique. Kutner operates in the infraclavicular 
fossa, on each side alternately, and eventually in the 
supraclavicular fossa. He stops the inflow, or re- 
tards the ingoing current very materially, if absorp- 
tion be slow. He injects continuously during the 
whole duration of the stage of asphyxia, to deep in 
the typhoid period, even after the secretion of urine 
has recommenced. 

Keppler advises an injection at first on both sides, 
of fifteen and one-half fluid drachms; as soon as this is 
absorbed (about one minute), thirteen and one-half 
drachms more, and so on until the pulse improves. 
When a swelling forms, its disappearance is awaited. 
As soon as the pulse shows improvement, five min- 
utes are allowed to lapse between injections; when 
the pulse becomes full, intermissions of thirty min- 
utes, are permitted. Keppler stops the injection as 
soon as renal activity is made manifest, but repeats 
it at once on the occurrence of a new attack. He 


uses usually from eight to twelve quarts of fluid, 
which is a solution of common salt in the proportion 
of one drachm to the quart, at a temperature of from 
102° to 104 F. He uses several canulas, leaving 
each canula in situ even after the infusion at that 
point is, for the time being, completed. Neumann 
recommends the addition to the salt solution, of one- 
tenth of one per cent, of sodium carbonate. 

In desperate or well-nigh hopeless cases, Hayem's 
intravenous transfusion may be performed, a much 
more difficult and dangerous operation than hypo- 
dermoklysis; but one whose action is often instanta- 
neous. The fluid is a sterilized solution composed of 
one and one-quarter drachms of common salt; thirty- 
four ounces of distilled water;- and enough sulphate 
of sodium added to increase the solid matter to six 
and one-half drachms to the quart. The operation is 
performed with a Collins' transfuser, and two to two- 
and-one-half quarts are injected in a quarter of an 
hour. Should the pulse again become thready, then 
a second injection follows ten to twelve hours after 
the first. 

The injection fluid is drawn from the funnel of the 
transfuser into the pump, and from the pump into 
the tube. The distributing chamber of the transfuser 
is a cylinder, which communicates through three 
openings with the funnel. It contains a round ball 
of aluminum, whose specific gravity is arranged so 
that it will be less than that of the solution to be in- 
jected. In this way it serves as a valve, and prevents 
the fluid from flowing back into the funnel, or air 
from entering the veins. 


The effect of either hypodermoklysis or intraven- 
ous transfusion, in some cases, is simply marvelous. 
Where, only a few moments previously, circulation 
and respiration had ceased, and where hope was lost, 
a striking change will be noticeable, and an abrupt 
and deep inspiration indicates a return to life. In 
other cases the benefits are appreciated much more 
slowly and are sometimes initiated by increased kid- 
ney activity. Vanderpoel describes the case of a 
man. who after passing through all the routine of 
treatment, was left to breathe his last, resembling a 
terribly emaciated corpse. He then had a quart of 
bicarbonate of soda solution thrown into his veins at 
the bend of the arm. It was strange to see him revive 
from an immovable, shrunken, death-like condition, 
the veins on his nose becoming filled, the skin redden- 
ing and expanding, then his limbs beginning to move, 
and he to survive.* 

Cantani's summing up with regard to the value of 
hypodermoklysis, is as follows: 

The hypodermic injection is an invaluable thera- 
peutic remedy in the treatment of cholera. 

*Dr. Silbermann, whilst recognizing the yaJue of subcutaneous and intra- 
venous injections of saline fluids in cholera, points out that owing to stagna- 
tion of the thickened blood in the venous system, it may be far better some- 
times to inject the fluid into the arterial system in a manner similar to the form 
of arterial tiansfusion introduced by Landors and Ungar. The radial artery is 
laid bare for a short distance, the peripheral end of the exposed artery secured 
by a ligature and the central by the forceps. The apparatus consists of a fur- 
nel-shaped receiver of from five to six hundred cubic centimetres' capacity, ter- 
minating in a T-shaped tube with which is connected a syringe, the vertical 
limb being attached to the rubber tube which ends in the nozzle that is afterwards 
inserted into the arteiy above the point of ligature. This insertion does not 
take place until the tube and syringe have been filled with fluid and all the air 
driven out. The fluid is then pumped into the artery toward the heart, by 
means of the syringe; and the process of filling the syringe and repeating the 
injection is readily affeded without any risk. 


In order to be of value it must take place under 
conditions which render absorption possible. In or- 
der to obtain these it should immediately follow a 
warm mustard bath of about 40 C. (104 F.). 

The hypodermic injection, as an absolutely harm- 
less remedy, should be put in use as soon as the case 
of cholera comes to the physician's notice, and should 
be methodically repeated every four hours. 

To further the absorption, it is well to apply the 
injection at several, or at least, at two places. 

The hypodermic injection is not to be regarded as 
an exclusive remedy for cholera, but it can remove 
the symptoms accompanying the disturbances in cir- 
culation, and following this the imperfect formation 
of the blood. 

During the later periods of the Hamburg epidemic, 
the per-iodates were used with, it is stated, marked 
advantage and noticeable decrease in the mortality. 

At the Seamen's Hospital, the following plan is 
carried out: There are two principal drugs employed 
— the crystals of per-iodate, which are powdered, and 
a per-iodate of iron. The last named is used in such 
cases as demand an extra strong nerve or cardiac 
stimulant, and where there are severe neuralgic symp- 
toms. The first named is used in several ways. First, 
as a powder to disinfect the alimentary tract. Second, 
as a plain water solution, prepared by boiling, and 
used by patients as a beverage to wash out the stom- 
ach in severe vomiting, which abates as soon as the 
walls of the stomach begin to absorb the fluid, 
whereby the nervous energy is stimulated in from a 
few minutes to an hour or two; it is used for hypoder- 


mic transfusion, and in cases of collapse for intra-ve- 
nous injection for restoration of the suspended circu- 
lation of the blood. Third, an acid solution of the 
powdered crystals of much greater strength than the 
plain water solution is found to stimulate the liver 
and kidneys and gall bladder, promoting a free flow 
of bile. The effect of this treatment in cholera is al- 
leged to be very marked and speedy. In a case of 
collapse with all the severest symptoms present, the 
patient is placed upon the bed and copious draughts 
of per-iodate are given and repeated until a sufficient 
quantity is retained. Meanwhile the transfusion so- 
lutions are ready in the hot water bath, and usually 
within five to ten minutes, one to two quarts are run 
under the skin by a double canula. In about fifteen 
minutes the fluid is absorbed into the tissues and 
passes into the circulation, which is thereby restored, 
and the pulse and the heart beats return. In some 
cases the fluid is run direct into a vein, usually of 
the arm, but where this is so far contracted as not to 
admit of the smallest canula, a vein of the thigh is 
opened. But even the larger veins will sometimes 
not receive the instrument, and such cases are hope- 

Recently Mr. Weaver gave a demonstration of the 
chemical and physiological actions of the per-iodates 
before the hospital staff and several visitors, includ- 
ing Dr. Cornel, Prof. Koch's confidential assistant, 
and a well known bacteriologist. During the lecture 
several severe cases were admitted into the ward, 
practical illustrations were given of the method of 
physiological examination of new patients and of 


those who had been under treatment for some days. 
From the new patients Dr. Cornel showed the pres- 
ence of swarms of cholera bacilli possessed of in- 
tensely active movements when shown under a glass 
magnifying iooo diameters. From the patients who 
had been under treatment, neither toxines nor bacilli 
were obtained. From the experience gained in the 
treatment of cholera, Mr. Weaver is of the opinion 
that the cure of the disease necessarily implies its 
prevention by the same means. 

In closing this portion of our subject, it might not 
be out of place for me to indicate to you what partic- 
ular plan of treatment I look upon as being best. 
But in outlining the form of management that ap- 
peals to me the most forcibly, I would first warn you 
against becoming routinists. Every case you have 
may demand some special attention, and a good 
general rule to be remembered, is, that every case of 
a given disease, must be treated on its own merits. 
But to resume: Should I be attacked by Asiatic 
cholera, I would, as soon as the first symptoms de- 
clared themselves, take to my bed. I would follow 
Olliffe's suggestion, and immediately take a chola- 
gogue, either blue mass or calomel, and repeat in two 
hours or until some green appeared in the stools. I 
would then take from one to two drachms of castor 
oil, and if required would repeat this dose in about an 
hour. I would subject myself to Winternitz's hydro- 
therapeutic measures, from the very first I would use 
full doses of salol and wine of camphor, every now and 
then would drink a small quantity of a mixture of equal 
parts of red-wine and water, and at short intervals of 


time, I would take a little water acidulated with sul- 
phuric or lactic acid. I would insist on my attendants 
resorting, at once, to the careful and thorough perfor- 
mance of Senn's gaseous intestinal insufflation, and un- 
less improvement was quickly evidenced, I would be- 
gin the use of Desprez's chloroform mixture, and per- 
haps hypodermic injections of chloric ether. Should 
there be early symptoms of cardiacenfe eblement, I 
would request the hypodermatic exhibition of strych- 
nine, and if muscular cramps and pain were marked, 
the injection of morphine. I would beg my attendants 
to surround me in bed with bowls containing unslacked 
lime wrapped up in wet cloths, and if amelioration 
were not rapid, to administer a hot bath, with con- 
comitant massage and rubbing of my body with a 
flesh brush. Then I would ask to be put to bed, 
wrapped up in a hot dry blanket, and have a good 
sized sinapism applied to my abdomen. Should pro- 
nounced purging thicken my blood I would demand 
the employment of hypodermoklysis of normal salt 
solution, and should all efforts prove unavailing, I 
would at least feel as if the evil genius of the White 
Death had, in me, met a foeman worthy of his steel, 
and one who had not succumbed until overpowered 
by superior strength. And I would further ask that 
after my death had been positively assured, my body 
should be securely and quickly covered with a sheet 
soaked in a disinfectant solution, and as soon as pos- 
sible, cremated, so that I, who had in life been a 
friend to humanity, should not after my death, be 
come a foe. 


There remains yet for consideration the question 
of the treatment of the stage of reaction of cholera, 
and the condition known as cholera-typhoid. If your 
patient rallies from his collapsed state and enters 
upon the reactionary period, not by any means is he 
yet out of danger. You must still consider his con- 
dition critical, and pay him attention. You must 
also remember that relapses not infrequently occur, 
and when such an accident takes place, you will treat 
it with the same caution and on the same principles 
as the primary attack. When you recollect that the 
fury of the storm has been largely spent on the gas- 
trointestinal tract, you will appreciate the necessity 
for the strictest supervision of the patient's diet. It 
is during this period of reaction, that we recognize 
the value of good nursing and diet. Drugs are of 
but little if any value, and the sick man is better off 
without medication. Solid food-stuffs are absolutely 
dangerous. If you have studied carefully the morbid 
anatomy of the disease, you will appreciate how 
cruel it would be to subject the tender, ulcerated and 
inflamed bowel to the effects of the ingestion of solid 
food. Fluid nourishment however should be freely 
given. Milk, at first diluted with plain or preferably 
with carbonic acid or seltzer water, egg-white, gruels, 
wine-whey, sago, rice, or arrowroot decoction, well 
seasoned and strained, constitute a pretty good slop 
bill of fare. Coffee, tea and chocolate or cocoa may 
be gradually added, although coffee is well borne 


nearly all through the disease. This is the time when 
wines are of great benefit, and small quantities of rich, 
generous wines, given often are advantageous. Broths 
and soups should not be allowed early, but their use 
must be deferred. Very excellent authority has ad- 
vised me that often in this stage, a patient will be 
progressing in a very favorable manner, when the ex- 
hibition of some broth or soup, has been followed by 
a diarrhea. Gradually a diet made up of soft-boiled 
eggs, soups, broths, bread, potatoes, and meats can 
be resumed. In a majority of instances the kidneys 
will need some attention. Plenty of clean, pure 
drinking-water will stimulate them sufficiently in 
mild cases. 

In the first variety of cholera-typhoid the treat- 
ment should be identical with that belonging to the 
third week of enteric fever. The patient should be 
in a well ventilated room, kept in the prone position, 
not allowed to sit up or make any exertion, and 
maintained on liquid diet. Naturally milk is the 
most suitable food. At least three pints should be 
given to a grown person during the twenty-four 
hours, always somewhat diluted as previously des- 
cribed. Partially peptonized milk is serviceable, but 
it tastes so badly, that as a rule the patient will ob- 
ject to it. The general treatment described for the 
stage of reaction, is here applicable. The patient 
should be encouraged to drink freely and the fluids 
given him, may be pleasantly cold. Iced tea, barley 
water and lemonade are grateful. Sponging the 
body off with alcohol or whiskey, once or twice a 
day, is productive of good results. There is no 



necessity of reviewing in its entirety the treatment 
of this condition. It suffices to draw a comparison 
between it and the management of the period in 
enteric fever, to which I have already drawn your 

The second form of cholera-typhoid is the con- 
dition wherein we find the most diverse complica- 
tions. We may have dysentery, or a violent inflam- 
mation of a diphtheritic character of the large and 
small intestine, or pneumonitis or pleuritis or laryn- 
gitis, and so forth. Your treatment will have to be 
symptomatic, but you will bear in mind that in ad- 
dition to any of the symptoms, or groupings of the 
same, that may characterize this condition, there may 
also be intestinal and renal lesions of considerable 
intensity. You will recollect that these people are 
very apt if they do recover, to suffer from trouble- 
some sequelae. 

The third variety of cholera-typhoid that you may 
have to treat, is the uremic type, the most severe of 
all. Here we find the symptoms of a severe nephri- 
tis. You will rarely if ever, meet with anasarca in 
these cases, but you know a most intense inflamma- 
tion of the kidneys may exist without any dropsy. 
The rules as regards diet and the use of dituen 
drinks previously given, apply all the more forcibly 
to this class of patients. Where there are pains in 
the back and hematuria, dry cups followed by hot 
poultices are grateful and relieving. The wet pack 
or hot-vapor bath are measures that are indicated. 
The wet pack is given by wringing a blanket out in 
hot water, wrapping the patient up in it, covering 


this with a dry blanket and the whole with a rubber 
cloth. In this the individual may remain for a 
longer or shorter period of time, according to the 
effect produced, and while in the pack, he should be 
watched. The hot air or vapor bath may be given 
by allowing the heated air or vapor to pass from a 
funnel beneath the bed clothing, which is raised on a 
low scaffolding. If the patient is able to bear it, an 
excellent treatment is a hot water bath, of from ten 
to twenty minutes, after which he is immediately to 
be wrapped up in blankets. A portable bath (as 
shown in the appendix) should be brought close to 
the bed, so as to cause the least possible disturbance 
to the patient. Very profuse sweating can usually 
be produced by some of these procedures, and 
they are very rarely exhausting. Sometimes, how- 
ever, the skin will not react, sweating can not be in- 
duced and then we must resort to medicinal reagents. 
Diuretics may be exhibited, or a sixth to an eighth 
of a grain of pilocarpine may be given hypodermati- 
cally. I must confess though that I am afraid of pilo- 
carpine. On several occasions I have seen great 
depression following its exhibition, and on more than 
one instance a very distressing bronchorrhea. If anuria 
exists thirty-six hours after reaction has set in, Macna- 
mara is in the habit of administering the tincture of 
cantharides. He gives ten minims in an ounce of water 
every half-hour until six doses have been taken. He 
then, if the treatment has not excited renal activity, 
discontinues the medicine for twelve hours, and re- 
peats in precisely the same way, giving six doses 


Following this plan, most satisfactory results have 
been reported. 

Heart tonics, such as digitalis, strophanthus and 
strychnine should not be neglected. 

I have now in a general way, outlined to you the 
treatment of Asiatic cholera, without having exhaust- 
ed the literature of the subject, which is very vol- 
uminous. As the pest progresses in different sec- 
tions of the world, if you will follow closely both the 
medical and secular press, you will notice the sug- 
gestion of innumerable remedies, many of which will 
be absolutely ridiculous. I desire now to call your 
attention for a short time to a most valuable and 
interesting portion of the study-subject-matter of the 
disease, and will review some of the work that has 
been done in connection with the transmission of the 
malady to the lower animals, and to their immuniza- 
tion from future attacks. I would ask you in these 
studies to note how perfectly the various subdivisions 
into which our art and science are divided, dove- 
tail into each other. We have seen this in studying 
other infectious diseases — notably enteric fever, and 
we have noticed that there is a gradual evolution of 
development, or passage from the simpler forms to the 
more complex, of the subdivisions. Thus the clini- 
cian studies the symptomatology; the pathologist 
teaches us the damage to the economy; the thera- 
peutician delves into the lore of treatment; and the 
bacteriologist demonstrates to us the causative 
factors. But the territory of each one of these 
workers, overlaps that of every other, and he who 
would endeavor to separate the ultimate object of 


any one, from those of the others, would fall into 
error. As bacteriologists, I would require of you 
that you look not upon the human body as a large 
test-tube containing culture media for the growth 
and development of various microganisms, and to be 
subjected to the same treatment as such media would 
receive in your laboratory. To do this would be as 
incorrect as to look upon the processes of nutrition 
as being identical with the chemical processes you 
note in your beaker jars, your retorts or filtration 
stands. The interdependence of these apparently 
different sections, and their fusion the one into the 
other, are well shown in connection with the study 
of cholera. Thus the bacteriologist having dis- 
covered the specific, exciting, etiological factor of 
the disease, introduces morbific material into the 
bodies of some of the lower animals, in order to re- 
produce the disease. At first he fails, and in endeavor- 
ing to discover the reason therefor, he notices that 
the germ is prevented from growth by the acid re- 
action of a secretion of the body. He has here noted 
an important fact connected with prevention and 
with treatment, and the bacteriologist, the therapeu- 
tician and the sanitarian become merged into one. 
Continuing his experiments, he finds that under 
certain circumstances animals are poison-proof, and 
a new field is opened up, that of immunization. 
There is no disease which has been as thoroughly 
mastered by bacteriology, as cholera, and it will be 
excessively instructive and interesting to watch the 
bombardment which the morbid citadel will receive 
in the near future, from the combined prophylactic 
engines of war. 


The limited time at my disposal, will not allow me 
to give this matter the attention it deserves, and I 
can simply erect for you a scaffolding on which you 
will subsequently build the more pretentious super- 
structure. I will only outline the picture, you will 
put in the high-lights and the varied shadows. 

After the discovery and study of the spirillum 
cholerse Asiaticae, it became a question as to whether 
the disease could be transmitted to the lower 
animals. At first the experiments made in this 
direction, were failures, but before long, Nicati and 
Rietsch, at Marseilles, reported that they had suc- 
ceeded in producing in dogs and guinea-pigs, symp- 
toms pretty nearly identical with those of cholera, 
by injecting cultivations of the comma-bacillus di- 
rectly into the duodenum. Their experiments were 
repeated and their observations confirmed, by Koch 
and others in Europe, and subsequently similar ex- 
periments were performed in this country. These 
authorities found they could produce the malady in 
the lower animals by first tying the common bile 
duct, thus cutting off the hepatic secretion from ad- 
mission into the bowel, and Koch demonstrated the 
inability of the germs to retain their vitality after 
passing the acid gastric juice, when given by the 
stomach. He therefore neutralized the gastric juice 
for about three hours by a suitable injection of carbo- 
nate of soda, and later injected spirilla in meat in- 
fusion. Of nineteen animals, only one sickened and 
died with symptoms corresponding to those pro- 
duced when the injections were made directly into 
the duodenum — and this was an animal which a short 


time previously, had suffered from an abortion, an 
accident that with the existence of lax abdominal 
walls, suggested the possibility of delayed peristalsis. 
In a subsequent series of experiments, aperistalsis 
was induced by the exhibition of opium, with the re- 
sult that of thirty-five guinea-pigs infected by way of 
the stomach, thirty died of "choleriform" attacks. 

From the observations of Ewald, it would seem as 
if it would be comparatively easy under ordinary cir- 
cumstances for the human animal to be infected. We 
have already seen that the most frequent mode by 
which infection occurs in human beings is through 
drinking water; and we have also noticed that water 
introduced into the empty stomach does not excite 
gastric activity, and that the fluid does not become 
acid in reaction; under these circumstances you can 
easily appreciate that it is not difficult for the bacilli 
to reach the small intestine, in the full preservation 
of their maleficent integrity. 

Attempts to render the body immune against dis- 
ease, have been made from time immemorial, but 
they were weak and empirical until bacteriology and 
micro-biological chemistry showed the way clear to 
positive results. In the writings of a chronicler in 
the middle ages, we read: "Philosophers have often 
searched for a fluid of such power, that rubbed on 
the skin, or incorporated with the juices of the body, 
would render the one so treated, proof against all 

It is incorrect to state that the history of attempts 
at immunization is co-eval with the history of bacter- 
iology, for attempts in this connection have not only 


been made, but accomplished while the science of 
bacteriology was yet in the womb of the future. I 
need only call to your minds the labors and discov- 
ery of the immortal Jenner. But a short time ago, 
Pasteur began his admirable work; in Berlin, Brieger, 
Kitasato and Wasserman have made researches in- 
dicating that some of the lower animals can be pro- 
tected against inoculations that in control animals 
would cause cholera; while at Paris, M. Haffkine has 
been experimenting with and perfecting his cholera 
"vaccine," on almost the identical lines that Pasteur 
followed in securing the protection virus of rabies. 

In The British Medical Journal for September ioth, 
1892, you will find a most delectable article from the 
pen of Mr. E. H. Hankin, who submitted himself per- 
sonally to Haffkine's operation of "cholera-vaccina- 
tion," and who discourses most interestingly there- 

Brieger reports as to his method which originally 
depended on the breeding of cholera bacilli in a 
watery extract of an organ rich in cells, such as the 
thymus. All his researches were, he states, carried on 
with a "Massowah" original culture, and at first 
with a thymus extract, proceeding in the following 
manner: The bacilli were allowed to develop for 
twenty-four hours on the surface of the thymus ex- 
tract; they were then warmed to 65 ° C. for fifteen 
minutes, or to 8o° C. for ten minutes. For twenty- 
four hours, they were left in a refrigerator, and then 
used on the animals that were to be subjected to the 
preparatory treatment. Guinea-pigs were exclus- 
ively made use of, and these creatures received four 


cubic centimetres intraperitoneally for four succes- 
sive days. The animals were then, but particularly 
after the primary injection, taken quite decidedly 
sick, but would be improved, if not entirely recov- 
ered, by the next day. Thermometric observations 
indicated during this time, very striking fluctuations. 
In slight cases, in from three to five hours, there 
would be a febrile movement reaching perhaps to 
40 C. The normal temperature of these little ani- 
mals lies between 38 and 39 C. If, on the other 
hand, severe symptoms set in, the temperature would 
fall for some hours, two or three degrees below the 
abscissa. By the next day the guinea-pigs would 
have returned to health, and further use of the injec- 
tion would present the same effects, in however a 
much slighter degree. 

At once after the last injection, or about four or 
five days after the first one, these animals possessed 
special resisting power sufficient to withstand the 
specific effects of the cholera spirilla, and in very 
truth, could take without bad or untoward symptoms, 
three times the amount which, in twelve or fifteen 
hours, would kill unprepared animals. Right after 
the injection of virulent cholera cultures, in the 
treated animals, the temperature rose above the nor- 
mal, and then in the course of a few hours, fell from 
two to three degrees. On the other hand, the com- 
pared animals by this time were suffering from the 
toxic effects of the injection, were relaxed, laid on 
their sides, had frequent convulsions, and their tem- 
perature had fallen to 32 C These animals died, 
while the prepared ones would recover by the follow- 
ing day. 


The minimum quantity of the fluid requisite to 
produce the desired effect, is one cubic centimetre, 
injected each day for two days, in a guinea-pig weigh- 
ing between three and four hundred grams. 

A much simpler mode of preparation has been sug- 
gested by Koch, which consists in breeding the ba- 
cilli in peptonized meat-broth and then heating the 
cultures on the next day for fifteen minutes to65° C. 
'Animals protected with this fluid have withstood a 
dose of poisonous cholera culture, half of which would 
kill the control animal. The minimum dose capable 
of exerting protective effect in this case was also two 
cubic-centimetres,' and the protection followed in 
forty-eight hours after the first injection, lasting 
about two months. It should be remarked that not 
only is the comma bacillus changed by heating so as 
to apparently lose its poisonousness, while retaining 
the immunizing properties, but a similar effect seems 
to be produced by the passage of the electric current. 

Vincenzi has made experiments on animals with 
cultures of the comma bacillus isolated at Massowah. 
By injecting a minute quantity of such cultures in 
guinea-pigs, he produced acute subcutaneous edema 
followed by the characteristic phenomena of cholera 
intoxication and a fatal termination in less than 
twenty-four hours. On injecting a few drops of cul- 
ture into the peritoneal or pleural cavity, death 
quickly followed. Attempts to produce the infection 
by introducing the virus into the stomach, were fol- 
lowed by failure. By inoculating pigeons and guinea- 
pigs with cultures grown in broth and filtered by the 
method of Kitasato, Vincenzi succeeded in making 


them immune, and the protection was very speedily 
conferred. The serum of immunized animals was 
found to have the property of being inimical to the 
cholera germ, and subcutaneous injections of the same, 
instead of being followed by edematous infiltration 
accompanied by but few leucocytes, caused edema- 
tous inflammation with rapid and effective phagocy- 
tosis. Vincenzi also made guinea-pigs insusceptible 
by inoculating them with a few centimetres of blood 
drawn from a guinea-pig rendered immune in the 
way just described, but this protection lasts only a 
very short time. 

Klemperer reports even more astonishing results. 
This observer has been able, by using intra-periton- 
eal injections of heated cultures, to rescue animals 
which had previously received a deadly dose of 

Those of you who have in previous years attended 
my physiological lectures, remember without doubt, 
the stress I have laid on the Metchnikoffian attri- 
butes of the leucocytes, and while the remarks I am 
about to make refer to a disease different from the 
condition we have been studying, still I think they 
will be of interest in connection with our present 
subject-matter. In investigating as to the immunity 
of rabbits vaccinated against the microbe of hog-chol- 
era, Metchnikoff arrived at certain conclusions, 
among which were: ist. The bactericidal properties 
in vaccinated rabbits reside in the phagocytes; 2d. 
The phagocytes play an important part in the resist- 
ance of vaccinated rabbits; 3d. They play an equally 
important role in the resistance of non-vaccinated 


rabbits which have been treated with the preventive 
serum. It is probable that this liquid exercises, under 
these conditions, a stimulating effect upon the phag- 

Elaborating upon this subject, the Klemperers 
show the great practical value of laboratory work in 
connection with the study of the cure and prevention 
of disease, especially infectious diseases, the experi- 
ments upon animals serving to test the value of var- 
ious modes of inducing immunity. 

These observers remark that the value of any sys- 
tem of producing immunity depends first upon the 
degree of immunity obtained by its use; but when it 
is also used as a cure, the question of rate of speed 
of action, has weight. The infection which is to be 
overcome does not present itself in full vigor at the 
onset, but gradually culminates, so, the greater the 
rate of speed at which the inoculation acts, the less 
serious is the disease which is to be overthrown. For 
the practical value of this method, it becomes of 
great importance to know whether it acts specifically 
— that is, whether the immunity produced by it, has 
a specific limit. To this we are not yet able to give 
a positive answer. 

Prominent among the great workers in this, as yet, 
hazy and uncertain field, is M. Haffkine, of the Pas- 
teur Institute, from whose admirable lecture on 
"Anti-Choleraic Inoculation, " delivered at the labora- 
tories of the Royal Colleges, I quote almost verbatim, 
as follows: The experience acquired in the preven- 
tion of hydrophobia by preventive inoculation — the 
first human disease treated according to the new 


method — gave observers a perfectly clear plan which 
they might follow for other human diseases. It was 
shown that in order to be successful it was necessary 
to prepare a series of virus, gradually increasing in 
strength until they reached a fixed degree of viru- 
lence greater than that of the ordinary virus, which 
when used, should permit the organism to become 
accustomed to a poison more virulent than that 
which it has to fight against at the moment when in- 
fection takes place. The traitement intensif 'of hydro- 
phobia, based upon virus of a maximum strength, has 
inaugurated the method, and has shown the true role 
of the virus kept in a fixed state of exaltation by ap- 
propriate experiments. 

The acquisition of an exalted virus and the estab- 
lishment of a method suitable to keep it in a fixed 
state is, then, -the starting point and the final aim in 
the research of a vaccine, for as before stated, it is 
necessary gradually to accustom the organism under 
treatment to this fixed virus. It is known that this 
task may be accomplished by the passing of the in- 
fectious organism through a series of animals, and 
that the microbe would acquire the maximum of its 
contagious power by cultivating it through a long 
series of living beings. 

Now let us look at this problem as applied to chol- 
era. In the case of this disease the first attempts 
towards the end in view, were made by trying to in- 
fect animals through the digestive canal. In this way 
the culture of the cholera microbe took place in a 
medium occupied by a number of foreign microbes, 
which from the first rendered the means employed 


uncertain. The result of the introduction of a mi- 
crobe into a medium already occupied by other 
microbes depends upon the nature of the latter, and 
their presence renders its development sometimes 
more easy, sometimes, on the contrary, impossible. 
Besides the purification of the microbe by artificial 
culture, made with virus transmitted through two 
animals, is a source of. -weakness which counterbal- 
ances the exaltation. 

This explains how Messieurs Pfeiffer and Nocht, 
in seeking to strengthen the cholera microbe by pas- 
sing it alternately through animals and cultures, 
have not been able to obtain a microbe capable of 
overpowering the natural resistance of birds; and. 
this is the reason why Messieurs Roux and Haffkine,, 
in trying to transfer the intestinal contents from one 
animal to another, according to the method used by 
Gamaleia, have seen their series interrupted after the 
third or fourth transference. 

There is no necessity of our going into the discus- 
sion of the modes of Gamaleia, of Roux, of Hueppe, 
or of Pfeiffer, but we will pass at once to the consid- 
eration of the Haffkine method, and the experiments 
of this observer on animals. In the Haffkine re- 
searches at the Pasteur Institute, on vaccination 
against Asiatic cholera, the initial point chosen was 
the inoculation of the animal into the peritoneal cavity, 
and starting from this point a method was worked 
out which permits the culture of the microbe in the 
animal organism in a state of purity during indefinite 
generations, the exaltation of it to a determined max- 
imum of strength, and the keeping it at the same 


degree of virulence for an unlimited period of time. 

This method can be illustrated by three series of 
experiments, which are: 

1st. Giving the first animal a dose larger than the 
fatal dose, and killing this animal in a sufficiently 
short space of time to be able to find the more re- 
sisting microbes. 

2nd. Exposing the exudation taken from the peri- 
toneal cavity, to the air for several hours. 

3rd. Then the transferring of this exudation to the 
next animal, of large or small size, according to the 
concentration of the exudation. 

In the hands of a number of experimenters this 
method has given the same results and showed a per- 
fect consistency. 

The properties of the virus so obtained are as fol- 
lows: Upon intraperitoneal inoculation it kills 
guinea-pigs regularly in the space of about eight 
hours, and the fatal dose for this animal is reduced 
to about twenty times less than that which it would 
have been necessary to take, for the microbe with 
which the start was made. The same inoculation 
kills rabbits and pigeons with a dose which would 
have been perfectly harmless at the beginning of the 
experiments, and kills guinea-pigs by intra-muscular 
inoculation. The subcutaneous inoculation brings 
about the formation of a large edema, which tends 
towards the sequestration of a whole part of the cutan- 
eous tissues, and to the formation of a wide open 
wound which is cured in from two to three w 7 eeks. 

The basis of anticholeraic vaccination is founded 
on the virus obtained in the manner just described. 


This virus, when injected under the skin of a 
healthy animal, gives it after several days, complete 
immunity from all choleraic contamination, no mat- 
ter in whatever manner such contamination may 

Anticholeraic vaccination of animals in this man- 
ner is definitely established, but the operation is not 
suitable as applied to human beings. The wound 
following a subcutaneous inoculation is terrible to 
look at, and in all probability, extremely painful. 
Besides, although it does not in itself present any 
danger to the health of the individual, it exposes him 
to all the complications inseparable from an open 

This power of inducing necrosis of the cutaneous 
tissues may be removed from the exalted vaccine by 
cultivating it in a temperature of 39 C, and in an 
atmosphere constantly aerated. Under these condi- 
tions the first generations of the cholera microbe 
would die rapidly, in an interval of two to three 
days, and therefore care must be taken to sow them 
again in new media immediately before death, and 
after a series of generations of this kind a culture is 
obtained which, if injected under the skin of animals, 
even in exaggerated doses, only produces a passing 
edema, and prepares the organism in such a manner 
that the injection of exalted virus, the definitive vac- 
cine, only produces a local reaction of slightest 

The method of vaccination thv.s worked out com- 
prises then two vaccines — a mild vaccine, obtained 
by weakening the fixed virus; and a strengthened 


vaccine, which is presented by the virus itself. 
It is easy to understand why to obtain the weak- 
ened vaccine we do not use an ordinary virus, 
but a virus the nature of which has been pre- 
viously fixed in the laboratory. It is because the 
virus such as is found in the natural state, especially 
when it has a saprophytic phase of development, 
presents such pathogenic differences that there is 
no certainty in its application. Respecting this, you 
may recall to mind the attempt made in 1885 by Dr. 
Ferran, of Barcelona, who, with the object of preserv- 
ing the population of the Peninsula from cholera, 
made injections in his patients of the ordinary virus 
taken from dead bodies and cultivated in his labora- 
tory. The statistics of the results obtained by this 
means showed such uncertainty that no one dared to 
recommend this operation to his country in spite of 
the very many trials made in Spain. 

The possibility of treating the animal organism by 
vaccines of an absolutely fixed nature, prepared by 
means of special operations, constitutes, on the other 
hand, the basis of the Pasteurian method, and here 
lies the whole secret and the sole guarantee of the 
success of its application. 

The method of anticholeraic vaccination worked 
out by experiments on guinea-pigs, was tried upon 
rabbits and pigeons before it was applied to men. 
These animals were chosen in order to have subjects 
very differently organized, and in order to be able to 
generalize the conclusions, and to be able to extend 
them to the human organism. 

The results obtained on all these animals being ab- 


solutely the same, it was decided to apply the oper- 
ation to man. 

The method has been tried at Paris, at Cherbourg, 
and at Moscow, on about fifty persons of both sexes, 
between the ages of nineteen and sixty-eight, of 
French, Swiss, Russian, English and American nat- 

In every instance the method has shown itself ab- 
solutely harmless to health, and the symptoms that 
it evokes are, a rise in temperature, a local sensitive- 
ness at the place of inoculation, and the formation 
of a transitory edema at the same place. The first 
sensations are felt about two or three hours after in- 
oculation; fever and general indisposition disappear 
after twenty-four to thirty-six hours; the sensitive- 
ness and edema last, gradually dying away in from 
three to four days. The symptoms following the 
second inoculation are generally rather more marked 
but of shorter duration. The whole recalls the sen- 
sation of a bad cold lasting about one or two days. 
The microbes introduced under the skin do not prop- 
agate, but after a short time they die and disappear. 
It is the substances which they contain, and which 
are set free when they die, that act upon the animal 
organism and confer immunity upon it. It is found 
that the same result can be obtained if the microbes 
be killed before inoculation, and if their dead bodies 
only be injected. Thus vaccines have been prepared 
and preserved in weak solutions of carbolic acid. In 
this the microbes die at the end of several hours, and 
the vaccine so prepared has been found still effica- 
cious six months after its preparation. 


Haffkine is not able to speak as to the length of 
the period that immunity lasts, and sufficient time 
really has hardly elapsed to answer this question 
intelligently. This much can be said, and that is, the 
inoculations upon man added to the hundreds of 
experiments that have been made upon animals, testify 
to the perfect harmlessness of these operations, and 
Haffkine states positively, there is no difficulty in 
proving their efficacy by experiment, no matter on 
what species of animal.* 

The test question that faces us for reply now is: 
Does the protection that we have seen given to the 
lower animals, become applicable to human beings? 
This fact as yet has not been positively demon- 
strated, and more observation is required before we 
can speak definitely. In the first place, are we doing 
right in reasoning that because a given method pro- 
duces certain results in guinea-pigs and rabbits, that 
it will induce the same effects in man? Is not this 
argument a very weak one? On the other hand is it 
possible that a process that renders so many of the 

* Under date of May 3rd, 1S93, M. Haffkine reports from Agra that up to 
that time S36 persons had been vaccinated against cholera, and from this num- 
ber, the most important groups are represented by 51 children, from the age of 
6 years from St. Peter's College, which was done with the Archbishop's per- 
mission; 230 men of the transport lines of Agra, and 120 men from the 
police force. At the same time preparations have been made for the vaccina- 
tion of soldiers, permission having been granted by the commander-in-chief 
from Simla. At Aligarh 55 persons had been vaccinated. While these groups 
are of interest in studying the value of the method, the number is yet too 
small, and it must also be taken into consideration that in the district in which 
M. Haffkine has been working, the cholera mortality is not very large. Larger 
groups must be operated on, and the lower provinces at the mouth of the 
Ganges, where cholera thrives plentifully, must be invaded. M. Haffkine 
states that so far his vacrinations have been performed without the occurrence 
of anv inconvenience or accident. 


lower animals resistant to the cholera poison, would 
have no such power in man, an animal high in the 
scale? It is very, very dangerous to reason by analT 
ogy. Just because in one family of animals a certain- 
series of tubes being found normally straight, does 
not indicate that in another species of animals the 
finding of the corresponding tubules in a convoluted 
condition would be pathological. Haffkine has 
demonstrated however that his virus does confer 
topical immunity upon human beings. For instance, 
if an individual be inoculated in subcutaneous tissue 
with active choleraic germs, there results an edema- 
tous tumefaction and injection which remains for 
several days, and which leaves behind a hard nodular 
mass. No such condition or reaction takes place in 
persons who have received the protective inocu- 

The field is so far a comparatively unexplored one; 
there is much room therein for future work. Perad- 
venture there is some one here listening to me at 
this very time who will solve the many problems that 
now seem so difficult; some one here with us to-day 
who will perhaps in the near future, lift another one 
of the many veils that are hanging between us and 
the glories of truth and knowledge and light. 

And now, I must needs come to a close, for my 
task is finished. Here ends my course. And if I had 
no more than this to say, I would say it with something 
like pleasure, and you, as well as myself, would be 
glad that at length a resting time and breathing-space 
had come. But it is with deep regret that I am 


forced to announce that this is not only the last lec- 
ture of this course, but also the last lecture on any 
subject that I shall ever probably deliver in this 

No one is more fully aware, than myself, of the 
imperfections of these lectures. I have had no offic- 
ial connection with the Chair of Practice of Medicine 
but have delivered these lectures to you on account 
of a personal request from the distinguished gentle- 
man and learned physician who is its honored incum- 
bent; and this in addition to the regular work 
belonging to my own chair. And I confess to you, 
that I began my course with a certain amount of 
trepidation, on account of being brought into direct 
comparison with so eminent a teacher as Professor 
Quine. Reluctantly leaving the work that for the past 
two years, I have done in this branch, it is a source 
of the most profound gratification to me, that my 
relations with yourselves have always been pleasant; 
from you I have never received any but the kindest 
greeting, and the most courteous and respectful at- 
tention, and for this I thank you most sincerely. 
And now, in almost a few short hours you will go 
forth from the halls of your Alma Mater, to put into 
practice, what you have been taught concerning 
medicine and surgery. 

From other members of this Faculty, more capable 
of giving it than myself, you will receive advice that 
will be of value to you. But you will permit me to 
say that in commencing your career you will do well 
to bear this admonition in mind: Be pure, be hon- 
est, be conscientious, be studious and be brave. Be 


not afraid of doing that which your conscience tells 
you is right, because it may not be popular. Be pa- 
tient, and lay in a good supply of what is called 
"grit." Believe me, he who strikes the iron long 
enough and hard enough, will be sure ultimately to 
make it hot; and the faculty of stick-to-it-iveness in 
the long run, will more than compensate for perhaps 
a lack of genius, or a deficiency as to brilliancy of 
intellect. It has been said that many a noble idea 
is clothed in humble language, and this I thought a 
few days ago on reading an unpretentious verse, 
Avhich I will here repeat: 

I observed a locomotive in a railroad yard one day, 
It was waiting in the round-house, where the locomotives stay; 
It was panting for the journey, it was coaled and fully manned, 
And it had a box the fireman was filling full of sand. 

It appears that locomotives can not always get a grip 
On their slender iron pavement, 'cause the wheels are apt to slip ; 
And when they reach a slippery spot, their tactics they command, 
And to get a grip upon the rail, they sprinkle it with sand. 

It's about this way with travel along life's slippery track, 
If jour load is rather heavy and you're always sliding back; 
So, if a common locomotive you completely understand, 
You'll provide yourself on starting, with a good supply of sand. 

If your track is steep and hilly and you have a heavy grade, 
And if those who've gone before you, have the rails quite slippery 

If you ever reach the summit of the upper table land, 
You'll find you'll have to do it with a liberal use of sand. 

If you strike some frigid weather and discover to your cost 
That you're liable to slip on a heavy coat of frost, 
Then some prompt, decided action will be called into demand, 
And you'll slip 'way to the bottom if you havn't any sand. 


You can get to any station that is on life's schedule seen 
If there's fire beneath the boiler of ambition's strong machine, 
And you'll reach a place called Flushtown at a rate of speed that's- 

If for all the slippery places you've a good supply of sand. 


Inosemzeff s Anti- Cholera Mixture. 

5 Tinct. rhei composite, m. v 

Tinct. rhei spirituosae, m. ij 

Tinct. opii, 

Tinct. valerian, setherosi, 

Tinct. menthae piper., 

Spts. aetheris comp., aa ?ij 

Olei menth. piper, m. xxjv 

Extract, nucis vomicae, gr. jvss 

M. sig. — Fifteen to twenty drops at a dose. 

Hamlin's Cholera Mixture. 

No. i. 
]£ Tinct. opii, 

Tinct. camph. aa i part 

Tinct. rhei, . 2 parts 

Misce. — 

No. 2. 
^ Tinct. opii, 

Tinct. capsici, 

Tinct. cardam. co. 

Ginger, aa equal parts 

Misce. — 

Ruschenberger 's Cholera Mixture. 

3 Tinct. zingiberis, 
Tinct. capsici, 
Tinct. piperitae, 
Tinct. opii, aa equal parts 

Misce. — 


^ Choloroform, § ss 

Spts. aetheris sulph., 3 iss 

Ol. menth. pip., gtt. viij 

Olei-resin. capsici, gtt. ij 

Ext. cannabis ind., gr. vj 

Morphiae muriatis, gr. xvj 

Acid, hydrocyanic, dil. m. lxv 

Acid, hydrochloric, dil., 3 j 

Glycerine, et mellis. q. s., ad § jv 

M. sig. — Dose, fifteen to twenty drops. 


Bengal Cholera Pill. 

^ Pulveris piper, niger., 

Assafoetidae aa gr. j 

Camphorae, gr. ij 

M.— et ft. pil. No. i. 

Macnamarc? s Pill. 

^ Pulv. opii, gr. j 

Plumbi acet. gr. ij 
M.— etft. Pil. No. i. 
Sig. — One pill pro re nata. 

Hope's Mixture. 

IJ Tinct. opii, 

Acid, nitrici dil., aa 3 ss 
Aquae camph., 3 jv 

M. sig. — Teaspoonful as occasion requires. 

For Vomiting. 

R Cocaini hydrochlor., gr. iij 

Tinct. menth., 3 ij 

M. sig. — Ten drops every half hour until vomiting 
is arrested. — Lazaraff-Przedborski. 

Camphor Wine. 

^ Finely powdered camphor, gr. lxxv 
Gum arabic, q. s., 
Alcohol, q. s., 

Strong red wine, 1 bottle 

Use enough of alcohol to dissolve the camphor, 
then add to the wine. 

Sig. — Teaspoonful in peppermint tea every hour to a 
child of six years; for an older child a dessertspoonful; and for 
an adult a wineglassful. — Hare. 

5 Acid, lactic, 3 iij 

Syrupi simpl., 3 vj 

Tinct. limonis gtt. xxx 
M. sig. — Place in a quart of water, and give from one to 
three dessertspoonsful every quarter of an hour.^ — Bucquoy. 


fy Ethereal tinct, of valerian, m. lxxv 
Sydenham's laudanum, rh, xv 

Essence of peppermint, m. v 

Hoffman's anodyne, m. lxxv 

M. sig. — Twenty- five drops every few minutes until 
tendency to vomit is relieved. — Laussedat. 

^ Tinct. cinnamon, 3 iij 

Bismuth, subnitr., 3 j 

Sydenham's laudanum, m. xij 

Syrup, acaciae, J iijss 

M. sig. — Teaspoonful every two hours. — Bucquoy. 

]£ Acid, sulph.aromat, 3 ss 

Ol. cajuputi, gtt. xv 

Ext. haematoxyli fid, 3 ij 

Spts. chloroform., 3 j 

Syr. zingiber., § iij 

M. sig. — Teaspoonful in water every two hours.— Hare, 

Disinfecting Washes. 

. ^ Hydrarg. chlorid, corrosiv., gr. xv 
Acid, hydrochloric!, 3 ijss 

Aquae destil., O xx 

M. sig. — Poison, use as a wash. — G. Daremberg. 

]£. Acid.phenic, 3 ij 

Acid, salicyl., gr, xv 

Acid, lastic, gr. xxx 

Aquae destil., O xx 
M. sig. — Poison, use as a wash. — G. Daremberg. 

Sun Cholera Mixture. 

^ Tinct. rhei, 

Tinct. opii, 
Tinct. capsici, 
Spts. camph., 
Spts. menth. pip., 

aa 3 j 

Misce. — 

Thiehnann 's Mixture. 

fy Vini opii, 

Tinct. valerian, 

I )% 


5 jv 

Ol. menth. pip, 
Ext. ipecac, fid. 
Alcohol, q. s., ad. 

5 J 

111. XV 

5 jv 



Looynis 1 Mixture. 

^ Tinct. opii, 3 jv 

Tinct. rhei, 3 jv 

Tinct. catechu, co., § j 

Ol. sassafras, m. xx 

Tinct. lavend. co., q. s., ad, J jv 

Misce. — 

VelpeaiCs Mixture. 

]£ Tinct. opii, 

Tinct. catechu, co, 

Spts. camph, aa 3 j 

Misce. — 

Diarrhea Powder. 

^ Bismuth, subnitr., gr. xv 

Benzo-naphthol, gr. x 

M.— et ft. chart. No. 1. 

Sig. — Give a powder as above, three times a day. — 
G. Daremberg. 

Solution for Hypodermoklysis or Intravenous Transfusion. 

\\ Aquae destil., O ij 

Sod. chlorid., gr. lxxv to c 

Sod. sulphat, 3 ijss 
M. — et ft. solut. — Hayem Cantani. 

CantanVs Enteroklysis Solution. 
IJ. Acid, tannic, 3j to iij 

Aquae destil, O jv 

Gum.acaciae 3 xjv 

Tinct. opii, gtt. xxx to 1 

M. — et ft. enema. 

Sig. — Inject the above quantity as high up in the bow- 
els ns possible. Do this four or five times a day. 

]£ Strychninae sulph., gr. 116 
Morph. sulph., gr. */$ 

Ergotine — Yvon-sick., gr. v 
Aquae destil., 3 j 

M.— et ft. solut. 

.Sig. — Inject hypodermically in abdominal wall. Re- 
peat in an hour, in succeeding injections the strychnine 
may be omitted, and if narcotism be shown, omit the 
morphine. — P. R. Brown. 


fy Argenti nitras., gr. ss 
Confectio. rosae, q. s 

M. — et sec. art, ft. pil. No. xv. 

Sig. — From one to three pills in water, several times 
a day. Begin with a large dose, which is to be lessened 
as patient improves. — Odartchenko 

3 Sulphuris praeciptati. 

Sodii. bicararbonas, aa 3 jv 
Spts. lavendulae comp, 5 xxj v 

Aquae, § Ixxij 

M. — Triturate the soda and sulphur together in a 
mortar, then add gradually the spirit of lavender, till the 
whole is well mixed, when the water is poured in. 

Sig. — Dose, two teaspoonsful in a little water, every 
two, three, or four hours, in simple choleraic diarrhea; but 
when urgent, every ten or fifteen minutes. — J. Grove. 

J£ Plumbi acetatis, gr. xxx 

Acidi acetici, m. x 

Aquae destillatae, J vj 

M. — Sig. — Two to three tablespoonsful every half-hour 
or hour. — Fleming. 


ty Tinct. opii, § ij 

Lin. saponis, J J 

Aq. cologniensis, § ij 
M. — et ft. liniment. 

Sig. — For external use only. Rub extremities gentlv 

with some of the lininent poured into palm of hand 
— Wendt. 

1^ Chloroform, 3 i-ij 

Syr. quiniae, § ss 
Aquae destil, J Wj 
M. sig. — Give a tablespoonful every half hour in tea. 
— Parrot. 



m. xv 


3 ij 

Ammon. acetat, 

3 ij*s 

Syr. morpn. hydrochlor, 

3 \% 

Aquae destil., 

. I i'j^s 

M. sig. — Tablespoonful every half-hour. — M. Desi>rez. 


3 Acid, sulph. aromat, I jv 

Magnes. sulph., 3 jv 

Tinct. opii, 3 jv 

Elixir, Simp]., 3 j 

Aquae, 3 ij 

M. sig. — Teaspoonful in a little water every three,four 
or six hours according to the frequency of the stools — 
N. S. Davis. 

fy Quiniae sulphat., §j 

Acid, sulph. aromat, q. s., ad solv. 
Aquae destil , 3 iij 

M. sig. — -Give one tablespoonful, repeat at once 
should vomiting occur, and afterwards at intervals of an 
hour and a half, until thirty grains have been given, and 
thereafter pro re nata. — Fullerton. 

I£ Acid, lactic, ~ ij 

Syr. limonis, § jv 

Aquae destil., 3 xxxiij 
M. sig. — To be taken through the day — Medical 



3 ij 

Spts. camphor, 

Tinct. opii, 


: jss 

Ol. cinnamon, 

gtt. V 



3 iij 

-Et ft. tinctura 


Sig. — Dose, from five to thirty minims, or more as 
required. — We.ndt. 

Voronefs Anti-Cholera Elixir. 

T£ Amnion. Muriat, 

I X 

Olei naphthae, 

3 vj 

Oiei caryophilli, 

3 x 

Acid nitrici, 

3 vj 

Potass, nitrat., 

Turkey pepper, 

aa 3 jss 

Menth. virid., 

5 viij 


6 j 

Sprts. vini gallici 

O jv 

Misce. — 


fy Acid sulphurici, 5 ss 

Morphiae sulph., gr. % 

Spts. vini gallici, 3 iss 

Aquae destil., 3 iij 

M. sig. — Inject under skin of arms, legs, and over 
stomach every hour, until symptoms are relieved. — R. W. 

Ext. cannabis ir 


gr. xvj 


5 ss 


3 ss 

Olei terebinth, 

3 ij 

Mucil. acacias, 

Syr. simplicis, 

aa § ss 

Aq. cinnamon, 

5 j 

M. sig. — Tablespoonful every one or two hours. — G. 
B. Thurston. 

I£ Creasoti, gt. j 

Aq. camphor, 
Infus. gent, co., aa ~ vj 
M. sig. — At a dose, and -repeat every two hours. — J. 
T. Jones. 

3 Sodii chloridi, 3 ij 

Sodii carbonatis, 3 ij 

Potassii chloratis, 3 ij 

Aquae destil., § vj 

M. sig. — Two tablespoonsful in water every half-hour. 
— Wm. Stevens. 

Murray 's Cholera Pill. 
I£ Puiveris opii, gr. j 

Pi peris, gr. ij 

Assafcetidae, gr. iij 

M. — et ft. pil. No 1. — John Murray. 

Edward R. Squibb } s Mixture. 

1£ Tinct. opii. depurat., 
Spts. camphorae, 

Tinct. capsici, aa 3 j 

Chloroformi purif., 3 iij 

Alcohol — 95 per cent. q. s , ad, 3 v 
M. — Each fid. drachm or teaspoonful contains about 
100 drops, and consists of twelve minims of each of the fii>t 


three ingredients, and four and a half minims or eighteen 
drops of the chloroform.— Dose, is one teaspoonful for 
persons over 18 years of age; a small teaspoonful for per- 
sons 14 to 18 years; for those 10 to 14 years, a half tea- 
spoonful; for those 6 to 10 years, thirty drops; for those 2 
to 6 years, ten to thirty drops; for infants, one to ten 
.drops. To be taken in water. 

^ Chloroform, m. xv-xx 

Tinct. opii, m. x-xv 

Spts. vini, 3 i 

Aquae destil., § j 
Misce. — T. M. Lowndes. 

^ Acid, sulphuric, aromat, 3 j 

Tinct. opii deodorat, 3 ss 

M. sig. — Ten to twenty drops every half hour or long- 
er as required, in some cold water. — Roberts Bartholow. 

3 Acid, hydrochloric, 3 ss 

Cocaine hydrochlorat, gr. ij 

Tinct. opii, 3 ss 

Aq. dest., J v 

Syr. simpl., ? vjss 

M.sig. — Teaspoonful every two hours. — Mendel and 


fy Acid, tannici, 

Plumbi acetat., aa gr. xij 

Opii, gr. ij 

Oleoresinae capsici, gr. iij 

M, —Ft. pilul. No. xij 

Sig. — One pill every one, two, three, or four hours. — 
Roberts Bartholow. 

I£ Acid, tannic, 3 j 

Camphorae, gr. x 

Opii, gr. ij 
M.— Ft. pil. No. xx 

Sig. — One pill even hour or two. — Roberts Barth- 

]£ Bismuth subnitrat, 3 ij 

Plumbi acetat. gr. xij 

Camphorae gr. vj 

Oleoresinae capsici gr. iij 


M. — Ft. chart. No. xij 

Sig. — One powder every hour or two. — From Barth- 
olow's "Cholera." 

^ Iodoformi 3 j 

Naphthalin 3 ij 

Bismuth, salicylat. 3 ij 
M. — et ft. chart. No. xx. 
Sig. — One every hour or two in milk. — Bujwid. 

5 Sod. phosph. (cryst.) 5 parts 

Sod. sulph. 10 " 

Aq. destil. 100 " 

M. — Boil and filter. 
Sig. — For subcutaneous injection. — Luton, (of Rheims.) 

ty Acid boric (seu Lactic) 3j 3tj 
Aq. ferventis O ij 

M. s. — For stomach lavage.-HAYEM-LESAGE-DELPECH. 

^ Hydrarg. chlor. cor. gr. j 

Aq. dest. § j 

M. sig. — For hypodermatic use — m xx for initial 
dose, and m. x every half hour or hour. — Roberts 

3 Caffein 3 ss 

Sod. Benzoat. gr. xl to 1 
Aq. dest. 3 ijss 

M. S. — m. xx (a hypodermic syringeful) equal nearly 
gr. v of caffein. This can be repeated every 2, 3 or 4 
hours. — Paris Formula from Bartholow's "Cholera." 

In Threatened Collapse. 

^ Strychnine sulphatis, gr. % 

Acidi sulphurici diluti, § ss 

Morphinse sulphatis, , gr. ij 

Aqua? camphorse, § iijss 

M. sig. — A teaspoonful well diluted, every hour or 
two. — Roberts Bartholow. 

CantanPs Solution for Hypodermoklysis. 

^ Water, sterilized O ij 

Salt 3 ijss 

Carbonate of sodium grs. lxxvij 
M.~ et ft. solut. 


Samuel's Solution for Hypodermoklysis. 

ff Water, sterilized O ij 
Sodium chloride 3 j 

M.— et. ft. solut. To be used at 104 Q F. To this solu- 
tion Rumff adds hydrogen dioxide, Heyse, alcohol, and 
other authorities add, thymol, or boric acid, etc. 

NothnageVs Solution for Hypodermoklysis. 

5. Water, sterilized O ij 

Sodium chloride I ij 

Sodium carbonate gr. xciij 

M.— et ft. solut. 

/;/ Algid Stage. 
B Quiniae hjdrochlorat, 3 j 

Aq. dest., ~ iij 

Sod. chlorid, gr. x 

M. sig. — Inject two syringesful, carrying about gr. 
xviij of the quinine. — Nedzwedzki. 

3 Chloroform, 

Spts setheris comp., 
Spts. camphorae, aa equal parts 

M. sig. — Teaspoonful now and then in water, as oc- 
casion may require. — Chauxcey F. Chapman. 

New 2'ork Quarantine Plan of Treatment. 

Patients and suspects are required to drink freely of hy- 
drochloric acid lemonade, 1 to 1000, and stomach lavage is 
practised every two hours with tannin solution or solution of 
hydrochloric acid, 1 to 1000. Cantani's enteroklysis is per- 
formed every two hours, with a 2 per cent, aqueous solution 
of tannic acid, half a gallon being used at a time at a temperature 
of 108.9 F. A rectal tube, two feet long, is introduced as far as 
possible, and passage through the colic valve is aided by external 
manipulation, massage. At the outset gr. x of calomel are exhib- 
ited, and repeated every hou^r until three doses have been given 
or until free purgation has been induced. Then gr. ss is exhibited 
every two hours. Stimulants are used pro re nata, preferably 
brandy, and usually hypodermatically. As soon as cholera 
asphyxia appears hypodermoclysis is resorted to, the solution used 
being 3 parts of sodium chloride, 10 parts of brandy to 1000 parts 
of sterilized water at a temperature of 104° F. One quart is the 
amount used for an adult, and it is injected into the flanks at about 
the level of the eighth rib, and repeated every second to fifth hour, 
according to urgency of the case. The largest amount reported 
used in any one case, is eleven quarts. 

Bronze Medal cast by the City of Paris to commemorate the invasion 
of that city by cholera in 1832. The original, of which the above is an 
exact reproduction, is in the possession of Dr. Joseph H. Hunt, of 
Brooklyn, N. Y. 


Appendix A. 

Too much attention can hardly be paid to the Bacteriological 
Subdivision of our subject-matter. Before Koch's discovery of the 
specific, exciting etiological factor of the disease, there were no 
means whereby a local epidemic of true cholera could be recognized 
with certainty in the early stage, or of ascertaining whether the dis- 
ease had left a given locality or not. As a result, the requisite sani- 
tary precautions were either adopted too late or abandoned too soon. 
Now, however, we are acquainted with almost every detail of the 
development and progress of the disease. 

In certain cases of true cholera the clinical picture does not per- 
mit the phj sician to make a diagnosis on account of the resemblance 
of the symptoms to those of cholera nostras, cholera infantum, cer- 
tain forms of peritonitis, poisoning with arsenic and various organic 
substances. The only distinguishing feature between true cholera 
and the affections above mentioned, may be the highly infectious 
and fatal character of the malady. During an epidemic when per- 
haps proper bacteriological examinations can not be had, all such 
cases should be in every way treated on the basis of true cholera. 
In both hospital and private practice though, bacteriological exam- 
ination should be resorted to as a routine measure. Such examina- 
tions should be made of the stools of individuals recovering from 
cholera, as the bacilli in a most virulent form, are apt to persist in the 
motions long after the choleraic symptoms have subsided. 

Accurateand rapid diagnosis, and the adoption of prophylactic 
measures are always questions of paramount importance, but be- 
come especially so at the beginning and toward the end of an epi- 

Bacteriological diagnosis must be prompt, and of unsuspected 
accuracy to be of real service, as so rapid is the spread of the dis- 
ease that the delay of a single day may lead to disaster. For this 


reason those making the examinations must be of undoubted skill, 
as the interests involved are too great to be imperilled by amateurs or 
careless operators. 

Appendix B. 
Prof. Koctfs Instructions for Bacteriological Examinations. 

i. Microscopical. — This consists in the examination of cover- 
glass preparations obtained from fecal material and alvine dis- 
charges. The mucoid concretions found in the stools, or after 
death, in the intestines, should be selected. Ziehl's dilute f uchsine 
solution is the best staining reagent. 

These slides vary in appearance according to the severity of the 
case and the stage of the attack. They may either show pure — or 
nearly so — cultures of cholera spirilla, or mixed cultures in which 
the spirillum is found associated in variable proportions with the 
micro-organisms found in the intestine, especially the bacterium 
coli commune. Sometimes the slide will not reveal the presence 
of any comma-shaped organisms. (At Massaouah the bacillus is 
met with in the form of straight rods. — Liebreich.) 

In a preparation showing a pure culture, or in one in which the 
bacterium coli commune is the only other organism present, the 
cholera bacilli appear in clusters, which are especially characteristic 
where the mucus has been drawn out in filaments. This arrange- 
ment is peculiar, inasmuch as the bacilli all point in the same direc- 
tion and resemble a file of fishes swimming one behind the other, 
in a slowly flowing stream of water. (Koch looks upon this as being 
specific, characteristic and indicative of Asiatic cholera.) This feat- 
ure may be absent, and in spite of its absence, the diagnosis is just 
as certain when the only organism found in the preparation is the 
bacterium coli commune mixed with a large number of bacilli pre- 
senting the physical characteristics of cholera organisms. The ex- 
istence of other bacteria introduces an element of doubt as to diag- 
nosis. The value of microscopical examinations is in direct ratio 
to the skill of the operator. With one trained and able to recog- 
nize cholera bacilli at a glance, by thorough acquaintance with the 
morphological appearances of the organisms, the method is a great 
aid to rapid diagnosis, and the advantages of a rapid diagnosis from 
a prophylactic point of view, are obvious to those who know that 


precautionary measures against cholera can never be adopted too 
soon. (In a case in which culture experiments had been unsuc- 
cessfully performed for four days, Koch discovered that the very 
first microscopic preparation might have enabled the physician to 
form a correct diagnosis.) 

2. Cultures on Peptone Solutions. — Dunham observed that the 
bacilli of cholera grow and increase with great rapidity in a steril- 
ized one per cent, peptone solution, to which five-tenths percent of 
chloride of sodium has been added, and kept at the temperature of the 
blood. The fluid show T s turbidity six hours after inoculation, and on 
the addition of sulphuric acid a red color is produced. The reaction 
is more delicate and the red color more intense under these circum- 
stances than when the bacilli are grown in broth with, or without the 
addition of peptone. Dunbar at the Public Health Institute, in 
Hamburg in the last epidemic, used this test with success. The 
technique is as follows: 

To a test tube containing a sterilized one per cent, solution of 
peptone, a few r drops of choleraic dejections, or a small quantity of 
mucus from the stools, are added by means of a looped platinum 
wire. The tube is then kept at a temperature of 57° C. Hesse 
shows that cholera bacilli are essentially aerobic. They have a tend- 
ency to rise to the surface of the solution where they are able to 
multiply, away from the disturbing influence of the other organ- 
isms normally present in the feces. At any rate, during the early 
stages of the process, the latter remain in the deeper parts of the 
fluid. If a few drops of the peptone solution are taken from the 
surface with the platinum loop and examined under the microscope, 
as soon as some turbidity appears, the fluid is found to contain a 
pure culture of cholera bacilli, provided these organisms were pres- 
ent in sufficiently large numbers in the dejections or mucus origin- 
ally employed, In cases in which the latter contain but few bacilli 
these take a longer time to rise to the surface, and they are then us- 
ually mixed in variable proportions with the ordinary intestinal 
micro-organisms, especially with the bacterium coli-commune. 
Under these circumstances the element of doubt exists as to the 
real nature of the curved bacilli that are present. 

Positive results may be obtained by means of peptone cultures, 
where plate cultures entirely fail. In all probability this is owing 
to the fact that on gelatine plates the cholera spirilla are overcome 


by the saprophytic bacteria present from which they cannot escape 
as in peptone solution, and their development is interfered with and 
their presence obscured. Valuable as the peptone cultures are,. 
they only afford positive evidence in cases in which the surface 
of the fluid yields a pure culture of the organism under consideration. 
The culture should be examined between six and twelve hours after 
inoculation. Sometimes, however, a longer period must be allowed 
to elapse. Now and then a few drops must be examined so as to 
determine the exact time w T hen the culture reaches its maximum 
development. Care must be exercised as to the grade of peptone 
employed. At the Berlin Institute for the Study of Infectious Dis- 
eases, that prepared by Witte (Rostock) is used in preference to all 
others. The peptone should contain twenty-five milligrammes of 
carbonate of soda to each cubic centimetre, the amount being de- 
termined by volumetric analysis, with litmus paper as an indicator. 
(Peptone is a substance of very unstable composition, in spite of the 
most careful preparation, and the peptones of commerce are not all 
suitable for purposes of experiment.) 

3. Cultures on Gelatine Plates. — Although less delicate than 
peptone cultures, the plate cultures confirm and complete the latter. 
In the course of a few hours in using a peptone culture, bacilli are 
present in sufficient numbers to permit of successful inoculation on 
gelatine plates. Three solutions of gelatine are prepared in the 
ordinary way, and poured into covered glass dishes, The higher 
the temperature, the more rapid is the development of the colonies 
on the plates. The. best temperature is about 22 C. for a properly 
prepared ten per cent, solution of gelatine. At the end of from fif- 
teen to twenty hours, under these conditions, the plates will show 
characteristic colonies. When the temperature rises above 22 Q C, 
the gelatine liquefies and the colonies break up. It is therefore nec- 
essary to use an auto-regulating incubator, which will maintain the 
temperature standard, variations never to exceed half a degree above 
or below 22 C. When the cultures are exposed to a higher tem- 
perature or when an inferior gelatine solution fusing at 22 is used,, 
the cholera colonies rapidly liquefy the medium of culture and they 
then closely resemble the spirillum of Finkler, for which, indeed, 
they may be mistaken by inexperienced investigators. Under or- 
dinary conditions, cholera colonies obtained from freshly isolated 
organisms, on properly prepared gelatine kept at a moderately high 




>4* <.f^ ~f 

Spirilla Cholerae Asiaticae, pure culture (prepared by Franklyn J. Tower), 

Leitz Oil Immersion Lens i-i2th, ocular No. 5, 

magnified 1200 times. 


temperature, present characteristic and easily recognizable appear- 
ances; but it must be borne in mind that such appearances may be 
modified to a greater or lesser degree, as for instance by the fact 
that the bacilli had been isolated a long time before inoculation, by 
changes in the composition of the gelatine, a low temperature, etc. ; 
these cases are, however, exceptional. When they occur, other 
methods of investigation will always permit accurate diagnosis. 

4. Cultures on Agar Plates. — While these may be looked upon 
as being simply a modification of the method of cultivation on gel- 
atine plates, they differ in several important particulars. The agar 
colonies are not so characteristic in appearance as those on gela- 
tine. They form medium sized transparent aggregations of a pe- 
culiar brownish-gray color. An advantage possessed by the agar cul- 
tures is that they can be exposed safely to a high temperature (37° 
C.) with the result that in from eight to ten hours the plate shows a 
sufficient number of colonies to permit of further study. In using 
agar the colonies must develop on the surface, for they grow but 
slowly in the depth of the nutrient medium, where they never reach 
any considerable size. For this reason the agar must first be al- 
lowed to solidify and it is then to be inoculated on the surface with 
the help of a platinum loop. In order to prevent the surface of the 
agar during the process of setting from becoming covered with a 
film of water, it should be kept for a few days in the incubator un- 
til the fluid has entirely evaporated . After inoculation the plates 
are to be kept in the incubator at a constant temperature of from 
37° to 38° C. Agar cultures are not well adapted for purposes 
of experiment, when the fluid to be experimented with contains but 
few cholera organisms. When the bacilli have multiplied for from 
six to ten hours in peptone solution and are then transplanted to 
agar plates, after another period of from six to ten hours, a compar- 
atively large number of pure colonies are produced. After micro- 
scopical examination these agar cultures are valuable for use in 
inoculating fresh peptone tubes which very soon w T ill exhibit the 
red cholera reaction, or for experiments on the lower animals. 

5. Red Cholera Reaction. — Discovered almost simultaneously 
by Bujwid and Dunham, consists of the appearance of a red color 
on the addition of sulphuric acid to cholera cultures, which always 
contain a certain quantity of indol and nitrous acid. Indol is like- 
wise produced by other bacteria, and a third group of organisms is 



Spirilla Cholerae Asiaticas, sediment of bouillon culture, (Franklyn J.. 
Tower). Leitz i-8th, ocular No. 5, magnified about 600 times. 


capable of reducing nitric to nitrous acid. Moreover it is possible 
that there are other micro-organisms, which like 'the cholera spirilla 
can produce both indol and nitrous acid, but this power is not pos- 
sessed by any of the known species of comma-shaped organisms 
capable morphologically of being confounded with cholera bacilli. 
For success in performing this test the following conditions must 
be attended to: 

ist. Care must be exercised to select a good preparation of pep- 
tone, and the delicacy of the reaction can be increased by raising or 
lowering the proportion of nitrates present in the peptone solution. 
2nd. The sulphuric acid used should be absolutely free from all 
trace of nitric acid. 3rd. The cultures of cholera bacilli should be 
perfectly pure, so as to remove all elements of doubt as to what or- 
ganism has produced the reaction, a doubt which might easily ex- 
ist should a mixed culture be employed. 4th. - The test should 
only be employed with pure culture of bacilli in sterilized peptone 

6. Experiments 011 Animals. — It has been for some time known 
that cultures of cholera bacilli injected into the peritoneal cavity of 
guinea pigs produce a toxic effect on these animals. Constant and 
definite results can only be obtained with cultures of cholera organ- 
isms on agar. R. Pfeiffer takes with a looped wire about fifteen 
decimill'grammes (as much as the loop can hold) of cholera culture 
from the surface of the agar. This is diluted in about one cubic 
centimetre of broth and injected into the peritoneal cavity. Care 
must be exercised that the fluid be not injected into the intestine 
by pushing the needle through the intestinal wall. To cause effect 
the ahiount of the culture injected must bear a certain relation to 
the size of the animal. For a guinea pig weighing from three hum 
. dred to three hundred and fifty grams, the quantity of cholera cul- 
ture, which can be held in the loop of a platinum wire, is usually a 
fatal dose. Soon after injection the phenomena of intoxication ap- 
pear, prominent among these being a fall of the temperature, cul- 
minating rapidty in death. A few agar colonies are sufficient for 
this experiment. 

By means of the various methods of investigation above de- 
scribed, we are enabled in ^^'y case rapidly to form an accurate 
opinion of the exact nature of the disease. The secret of success 
lies in their rational application, that is to say, in combining them 



Spirilla Cholerae As"aticae, pure culture, (prepared by Frankly n J. 
Towei). Leitz Oil Immersion Lens i-i2th, ocular No. 5, magnified 
about 1200 times. 


so as to obtain the maximum amonnt of information therefrorru 
They may with advantage be substituted for the older methods of 
cultivation on potatoes, in gelatine tubes, etc., which may now be 
dispensed with. 

Appendix C. 
Prof. R. Koch's Rules for the Examination of Water. 
To a large quantity (ioo c.c.) of the water to be examined, add 
one per cent, of peptone and one per cent, of sodium chloride, and 
keep the mixture at a temperature of 37° C. At the end of ten, 
fifteen or twenty hours, a number of peptone tubes and agar plates 
are inoculated with this culture. Under these circumstances the 
microscopic examination of the peptone cultures is of but secondary 
importance, seeing that comma-shaped bacilli resembling cholera 
spirilla are almost always to be found in water from whatever 
source. On the other hand, all suspicious colonies on the agar 
plate must be carefully examined under the microscope; should 
they be found to consist of comma organisms, the latter should be 
transferred to fresh culture media for the red cholera test and ex- 
periments on animals. No examination of water is complete which 
is not confirmed by experiments on animals. 

Appendix D. 

At the Moabit Hospital in Berlin, the authorities have no con- 
fidence in the treatment of cholera by salol, by creoiin, or by the use 
of Cantani's tannic acid intestinal flushing. They use and recom- 
mend subcutaneous saline injections. 

Appendix E. 
M. Giaard, chief of the Paris Municipal Laboratory, reports 
concerning the value of citric acid as a microbicide. He finds it to 
be a useful and efficient purifier of water, effectually destroying 
various morbific micro organisms in solutions of one grain of the 
acid to a quart of water. 

Appendix F. 

Sterilization of Water by Heat. 

Hygienists have in all times recommended the use of boiled 

water when there was reason to suspect the water employed for 

drinking purposes. This precaution is still among those that the 


attention of the public is earnestly called to, as soon as an epidemic 
of diarrhea, cholera, etc., is threatened or develops itself. But, al- 
though so general a measure is easy to indicate to private individuals, 
it is more difficult of application to the population in general of a 
crovvded locality. This is the raison cVetre of Messrs. Rouart, Gen- 
este & Herscher's new apparatus for sterilizing water by heat. This 
ingenious apparatus furnishes the solution of a problem which has 
for many years occupied the attention of the Consulting Committee 
of Public Hygiene of France, and particularly of its eminent pres- 
ident, Prof. Brouardel. There is not a week passes in which the 
committee is not informed of the existence at some point in France 
of some epidemic or other, such as of typhoid fever, for which there 
is reason to recommend the use of boiled water to the population 
attacked. The same is the case in the army at every instant. 

Now the French Board of Health, which possesses a most re- 
markable material of disinfection, has for a long time desired to add 
thereto some apparatus designed for the sterilization of water by 
heat, and which it might induce cities to procure, or which it might 
send to localities visited by an epidemic when the necessity there- 
for should be demonstrated. This project has just been put in exe-- 
cution after numerous tentatives, by Messrs. Rouart, Geneste & 
Herscher, in the following way : The drinking water is led into a 
pump, whence it is sent to the lower part of a metallic cylinder con- 
taining a worm. When this cylinder is filled, the water reaches 
the bottom of a second cylinder constructed in the same way, and. 
then it is finally led to a receiver, in which it is heated to 120 C 
under pressure, in contact with steam pipes connected with a boiler 
(Fig. 1). After the water has boiled for a certain length of time it. 
is forced into the worms of the two cylinders designed for the re- 
ception, in the first, of the pure water; then after cooling, and a sub- 
sequent filtration through a layer of silicious sand, it flows outside. 

The boiled water must be promptly consumed, for, like all pure 
water, it possesses the singular power of becoming rapidly, but 
temporarily, self infected. Whatever may have been said of it, it 
is easily digestible after it has been sufficiently aerated. It would 
be well, then, to obtain it in sufficient quantity, at least, for drinking 

Fig. 2 gives a diagram of this ingenious apparatus, which com- 
prises, essentially: A boiler with an independent steam reservoir, 

1 trl 







one or more exchangers, and a filter. The exchangers, which are 
cylinders provided with worms, constitute the most interesting and 
original part. The impure cold water that they receive is heated by the 
temperature of the boiled water circulating in the return worms, and 
this same boiled water becomes cooled therein by giving up its heat 
to the water which goes to the boiler. In this way the exchange of 
temperature is effected without expense, and it is possible to easily 
furnish on its exit from the apparatus, water sufficiently cool to be 
used at once. 

In fact, experience has proved that water that has been sub- 
mitted in this apparatus for at least fifteen minutes, to a minimum 
temperature of i20 Q may make its exit therefrom with a tempera- 
ture but 2° degrees higher than that which it had when it entered. 
As for the microorganisms that it contained, there no longer re- 
main any trace of them. It is absolutely sterilized. The state- 
ments of Messrs. Miquel, Pouchet & Charrin are very precise and 
demonstrative on this point. It remains to be known how such an 
apparatus can be put in use. Messrs. Rouart, Geneste & Herscher 
have devised several arrangements to this effect. In one, it is by 
the aid of a # hand pump that the water is introduced; in another, 
much larger, a pump fed by the boiler allows the impure water to 
circulate in the various parts. 

These different models are mounted upon wheels, so that they 
can be moved about and installed in situ in communities visited by 
epidemics. Fig. i represents an installation of this kind upon a 
village square, whither the inhabitants are coming to fill their pails 
and pitchers with water that has been sterilized by boiling, that is 
exempt from germs, and that is without a disagreeable taste. They 
obtain the water from a tube, whose extremity they lift up, so as 
not to soil it. 

The low net cost of water thus boiled favors the application 
of this industrial process, which has already rendered signal services 
in the barracks of the marine at Brest, where typhoid fever pre- 
vailed for many years almost in an epidemic state. — Scientific 

Appendix G. 

The specific value of contaminated drinking water in spreading 
cholera is very noticeable and striking, in studying epidemics and 
outbreaks of the disease. Visitations in the City of London have been 


remarkable on account of the differences in mortality tables in dif- 
ferent parts of the city, similar in surroundings and general condi- 
tions, except as to supply of drinking water. In those districts 
drawing water from the river Thames, the deaths from the disease 
varied according to the amount of sewage, from 8 to 163 per 10,000 
of population. During the epidemic of 1866 in London, the mortal- 
ity in the district supplied from the river Lea was 63 to n 1 per 
10,000 of population, while in other sections the rate was only 2 to 
12 per 10,000. The Broad Street epidemic in London has been 
very graphically described by the eminent sanitarian, Mr. Ernest 
Hart, in a recent address. In this case, the cholera was almost, if 
not entirely, circumscribed to the people using the water of a par- 
ticular well, and the spread of the disease was checked on closing 
the well. A similar example can be found in the Konigsberg epi- 
demic in 1866, when the disease raged amongst those using water 
from the river Pregel, while but few cases occurred among those 
obtaining water from a distant source. Wherever cholera has ex- 
isted, similar conditions are observed; cesspools containing 
cholera dejecta caused to overflow by sudden falls of rain, as a con- 
sequence wells in the vicinity becoming infected and cholera ravag- 
ing the families using the contaminated water. The history of the 
late epidemic at Hamburg is very interesting in this regard. Sim- 
ultaneously in different parts of the city at the beginning of the 
epidemic, cases would occur and yet the lines of demarkation of the 
infected areas were well defined. Near Hamburg, and having the same 
general conditions of soil and climate, but with separate water sources 
are the cities of Altona and Waldeck. From the river Elbe, just above 
the harbor, Hamburg receives her water, which is delivered unfil- 
tered throughout the city, and which is contaminated by sewage 
and refuse of all kinds on account of the tidal current reaching the 
source of supply. Higher up the stream in the same river, but 
above the contaminating influences of Hamburg's source, Altona 
draws her drinking water, which is treated by a system of sand fil- 
tration before distribution, while Waldeck is supplied from an in- 
land sea. Attention is called to the fact that the two latter cities es- 
caped the plague, while the former was severely scourged. Last 
year the pestilence stalked along the water courses — the Volga, the 
Don, the Dneiper and others — and in St. Petersburg nearly every 
case that occurred could be traced to the use of polluted water. 


Very instructive facts are to be gleaned from the report of Dr. F. 
Clemon, taken from the London Lancet of May 16, 1893. He saj's: 
In the village of Ulybyshef (Vladimir Government) a laboring 
man arrived on the 29th of June from Kazan, where he had at- 
tended the funeral of his brother who had died from cholera. 
Three days later he sickened from the disease in the morning and 
died the same evening. The clothes he had worn remained in an 
out-building for a week. They were then washed in a stream from 
which the village drew its water supply. In a very short time cholera 
became epidemic throughout the village. In the Government of 
Viatka five villages situated 'along the banks of the same stream 
were invaded by cholera. The infection was traced to the syste- 
matic washing of linen belonging to the early cases, in the stream 
which provided the inhabitants of the five villages with their drink- 
ing water. No sooner was this practice forbidden than the epi- 
demic began to abate. In the village of Upper Moulla (Perneskoy 
Government) the linen of cholera patients was washed in a pond. 
From the same pond the inhabitants drew their supply of drinking 
water, with the result that cholera raged throughout the village. 
As soon as the washing of linen in the pond was put a stop to, the 
number of cases of cholera began to diminish. In the Indian Med- 
ical Gazette, in the half-yearly report of sickness and mortality 
among the servants of the East India Railway Company, for the 
first half of the current year, an instructive instance of infection by 
cholera stools is reported. Dr. Bathe reports that there can be no 
doubt that the milk diluted with impure water was the cause of the 
outbreak of cholera among the European employees and their fam- 
ilies stationed at Asanol. The milk supply was not equal to the 
demand, and the only water available for its dilution was procured 
by digging holes in the bed of a small river at a spot where the ex- 
creta of several cholera patients had only a day or two previously 
been thrown. Almost all those who suffered from cholera had 
partaken of this milk. At Jamalpur, a native child, suffering from 
cholera, was -seen by Dr. Brooke lying on a bag full of rice, and the 
choleraic dejecta were soaking through the gunny bag into the rice. 
Had this rice been sent to some distant place where no cholera ex- 
isted, and had cholera supervened on this rice being distributed and 
eaten, we might have been treated to various theories as to the ori- 
gin of the epidemic ; but it is very doubtful if the simple explana- 


tion of the choleraic dejecta of the child would have been hit on. 
Public Health quoting the special correspondent of the Times, Sep- 
tember 17, gives the following: In the town of Askhabad the 
cholera was already nearly extinguished when it suddenly blazed 
up again with extraordinary violence. On August 3rd there were 
only eleven patients left in the hospital and they were convalescent; 
a few soldiers also remained in the same state in the barracks. On that 
night twelve more soldiers were taken violently ill, and within a few 
hours a fresh outbreak appeared among the townspeople. On the fol- 
lowing day four hundred were down with cholera. Energetic meas- 
ures were taken, and the course of the disease was stajed,or stayed 
itself in three days, but during that time eight hundred persons took 
it, and about half of them died. It appeared that the soldiers who 
were first taken ill had gone down to a stream with their soiled 
linen and had washed it there, drinking also from the same water. 
The occurrence is very instructive from several points of view; but 
it certainly shows that the poison can be conveyed by clothes, and 
as such things can, apart from travelers, be absolutely excluded 
without any trouble whatever, it is wiser to exclude them. Dr. H. 
B. Millard reports facts of interest relative to the mortality from 
cholera in Paris last summer. The water supply of Paris has been 
for several years insufficient, and so costly that many arrondisse- 
ments (or wards) have been obliged to drink the water of the Seine 
(boiled or not as they chose), which in 1892 was unusually low and 
dirty. It was in these arrondissements that the greatest mortality 
prevailed. In the three quarters, that of the Louvre, the Champs 
Elysees, and the 14th arrondissement (on the left bank of the Seine) 
which are the healthiest of Paris, there were not altogether more 
than nine or ten deaths. The next smallest mortality was in the 
9th (Montmartre), which is on a height and very clean. The great- 
est was in La Villette (the 19th), the ragpickers' quarter. Every 
avenue must be guarded against in aiming to arrest cholera or pre- 
vent its entrance, and many curious and unlooked for sources of 
infection meet us when we study the subject closely. The Lancet, 
quoting the Musical Times, calls attention to the piano-forte as a fo- 
cus of infection. A garment exposed to infection, says the writer, 
can be quickly disinfected, but it is far more difficult to fumigate all 
the multitudinous cloths,baizes, felts and woolen materials which the 
complex mechanism of a piano contains. It is questionable, indeed, 


whether this is ever properly done. (It is questionable whether such 
a thing was ever thought of). Few pianos are regularly cleaned 
out. Dust accumulates in them and they become receptacles for 
all kinds of dangerous germs. Among musicians it is well known 
that one of the chief centres in Germany of cheap piano making is 
Hamburg; and especially in the slums of St. Pauli, where the chol- 
era has been rife — thousands of pianos are in course of construction, 
the majority of which are destined for the English market. 

Appendix H. 

The most popular place in New York, says the Medical Rec- 
ord, if the cholera comes, should be Shanty Town, and the proudest 
animal on this land will be the goat. For Dr. Klemperer, of Ber- 
lin, after going over the subject of securing immunity against chol- 
era, and after trying all methods of protection, including the 
swallowing of a pint of cholera bouillon, finds that the milk of an 
immunized goat does the work best and most easily. Subcutaneous 
injection of the milk from the goat artificially made immune, was 
given to a man (who had volunteered). The injection of 5 c.c. of 
this milk produced such a degree of immunity that 0.25 c.c. of 
his blood serum protected a guinea pig against choleraic intoxica- 
tion. There is hardly any doubt, says Klemperer, that goats may 
be made more resistant by further injection, and thus their milk 
will have greater anti-toxic properties. The author thinks it per- 
missible to hope that 1 c.c. of such goat milk will protect men not 
oniy against the intoxication of cholera, but also against the infec- 
tion. The price of goats has been five dollars and upward. When 
the cholera comes, this much ridiculed animal will take a position in 
history higher than the sacred bull of Egypt or the vaccinated calf 
of jenner. Harlem, too, will become the centre of New York and 
not an uptown annex. 

Appendix I. 

Should cholera invade the country, attention must be paid to 
Railway Hygiene. An individual suffering from cholera and trav- 
eling on a railroad, by means of his dejecta could infect a large ex- 
tent of territory. The Annals of Hygiene, quoting from The Sanitary 
Inspector, furnishes us with the Swiss regulations, promulgated 


August 15, 1892, against the danger from cholera. These rules 
prescribe that the closets in railway carriages shall not discharge 
upon the ground, but shall be provided with a receiver securely at- 
tached to the lower end of the soil pipe, or by a removal of a por- 
tion of the pipe and the fixing of a vessel directly below the seat. 
Whatever form of catch basin is used, each must receive at least 
two quarts of milk of lime just before :he train starts, and when the 
destination of the car is reached there shall be poured into each ves- 
sel a quantity of milk of lime equal to the quantity of its contents. 
After the vessels are emptied, they are to be abundantly rinsed 
outside and inside with the milk of lime. 

Appendix J. 

The Annals of Hygiene notes the character of butter as a bac- 
illus medium. It is generally known that milk affords a dangerous 
vehicle for the dissemination of disease, but that this undesirable 
property is shared by butter is information at once of a novel and 
startling kind, and such as should put us on our guard. Yet, ac- 
cording to recent researches, there are contained in one gram of 
butter (as much as would go on the point of a knife) 2,465,555 mi- 
<:ro-organisms from the centre of the pat, and as many as 47,250,000 
on the outside. In fact, in some cases it is tolerably certain, it is 
stated, that the number of micro-organisms swallowed with a mod- 
erately large piece of bread and butter may excel that of the whole 
population of Europe. Butter kept in a refrigerator showed a 
marked reduction in the number of bacteria — a result which is also 
obtained by the addition of common salt. Samples of artificial but- 
ter, curiously enough, were invariably found to be much poorer in 
bacteria than ordinary butter; thus, while the smallest number found 
in one gram was 746,069, in real butter considerably over two mil- 
lion microbes was the minimum. Two varieties of bacilli have been 
isolated and described, and inasmuch as they were found to be con- 
stantly present in butter they were probably specific micro-organ- 
isms of a non-pathogenic character. But at anj' rate, it seems clear 
that butter as well as milk is capable of carrying and fostering or- 
ganisms, and on this account it behooves us, under certain circum- 
stances to melt our butter to boiling point in addition to boiling the 


Appendix K. 

Quoting the Pharmaceutische Zeitung, The Annals of Hygiene 
describes the German savant as being eminently practical when it 
comes to beer, and as soon as the cholera assumed noteworthy pro- 
portions in Europe, he set about determining the duration of life of 
the bacillus in his — the savant's — pet beverage. He found that the ba- 
cillus does not live beyond three hours in Pilsener, Patzenhofer or 
Munich beer; two hours in Berlin white beer; five minutes in white 
and fifteen in red wine, and twenty minutes in cider. Two hours 
in cold coffee decoction (six per cent.) was too much for the bacil- 
lus; but it needed five hours of rye-and-chickory imitation to kill 
it. In milk which had been boiled for an hour the bacilli lived for 
nine days, but the tenth brought them to the end of their career. 
Cold tea was much the same, i. e., a one per cent, brew, but a two 
per cent, tea cleared the field in four days, three per cent, in one 
day and four per cent, in an hour. The bacilli were most partial to 
cocoa; they did not appear to die off in that at all. 

Appendix L. 

From a most instructive, interesting and elegant monograph 
on the "Prevention of Cholera," by Prof. Daniel R. Brower, I make 
the following extracts, and hope in this way to extend more widely 
the valuable advice of this eminent author: "The principal vehicle 
for the spread of cholera infection is ivater. Germs that escape 
from the patient in the ways suggested, passing into the source of 
water supply, there thrive with great rapidity. It is our duty, there- 
fore, to see to it that the water consumed by our patients is not only 
filtered, but boiled, and the boiling should be done recently. There 
is no filter, I have reason to suppose on the market, that is proof 
against the cholera germ. We should urge a thorough cleansing 
of the hands before eating, and should see to it that those domestics 
who are engaged in the preparation of our food, take the same pre- 
cautions against the propagation of the disease. In the matter of diet, 
it should be simple, nourishing, ample and well cooked. Every- 
thing of doubtful propriety should be avoided, such as canned 
goods of all kinds, preserved meats, raw vegetables and fruits, pas- 
try, cheese and nuts. Special attention should be paid to the milk. 
All the milk consumed should be boiled immediately before being 


used. Particular attention should be paid to the cooking utensils. 
We should impress upon our patients the very important fact that 
cholera germs that have been properly cooked are just as harmless 
as any other vegetable. If a case of cholera occur among our pa- 
tients it should be isolated. If the isolation can be made in their 
own home, there it should be done; but if it is not possible, by rea- 
son of circumstances, to secure this isolation, then they should be 
taken from their dwelling place to some hospital provided for the 
purpose. Then every effort should be made to avoid panic. Those 
who must be in attendance must be told that there is no danger of 
cholera attacking them unless the germs enter their bodies by their 
mouths; that cleanliness of hands and of person, and the proper de- 
struction of germs by the processes already stated, will make this 
entrance impossible. We should give to our patients instructions 
as to what to do before the doctor arrives. On the first appearance 
of diarrhea they should goto bed at once; they should be kept 
warm ; artificial heat applied to the extremities and to the abdomen. 
There should be administered as speedily as possible, either a mod- 
erate dose of castor oil in hot milk, or a moderate dose of calomel. 
They should be instructed to sip water slightly acidulated with sul- 
phuric acid. If the looseness of the bowels continues, they should 
be instructed to inject at least a quart of hot water, containing about 
thirty grains of tannin and thirty drops of Jaudanum; ar.d whatever 
is discharged from the patients by stool or vomit should at once be 
destroyed, either by heat or by someone of the disinfectants already 

These instructions are full, complete and to the point, yet 
while I yield to no one as far as respect for the skill of Dr. Brower is 
concerned, I must take issue with him in regard to his recommenda- 
tion as to enteroklysis. If the injection prescribed by Dr. Brower 
be intended by him to merely flush the large intestine, I subscribe 
to it unhesitatingly. But if the Doctor intends that any attempt be 
made to violate the integrity of the colic valve, I just as unhesitat- 
ingly pronounce against it. Such an attempt I believe would be 
dangerous, in the hands of the laity. I do not believe that Cantani's 
enteroklysis is a feasible operation, but any attempt made to flush 
the small intestine should never be made by any other than aphy 


Appendix M. 

In considering the operation or procedure of Cantani — entero- 
klysis — in the treatment of cholera, the following points present 

i. Is the small intestine flushed by the fluid, oris the large 
intestine only involved ; in other words, does the fluid pass the 
valve of Bauhin? 

2. What are the main dangers to be feared in attempting to 
overcome the integrity of the valve? 

In answer to the first question I would say, that depending on 
the observations of many eminent investigators, prominent among 
these being Senn and Oser,and on the results of experiments made 
by myself on the lower animals and on cadavers, there is no doubt 
in my mind whatever, but that in the very large majority of those 
on whom the method is used, the fluid washes out only the large 
intestine and does not reach the small intestine. The colic valve is 
intended to prevent material from passing out of the large intestine 
back into the small. The material that the ileum throws into the 
cecum is quite fluid or pultaceous, and a careful anatomical examin- 
. ation of the structures at this point will show that on account of the 
mechanism of the valve any attempt to produce regurgitation, but 
more tightly seals the opening. It is true in a few cases, by careful 
technique, in either the living or dead subject, fluid can be coaxed 
to trickle through the opening, but these instances are few, and in 
a given case it can not be prognosticated as to whether this result 
can be obtained. On the contrary, air or gas, introduced as de- 
scribed in the body of the text, will invariably pass the valve, pro- 
ducing incompetency by a lateral and longitudinal distension of 
the cecum, mechanically separating the valve margins. I have no 
doubt but that during life and in the healthy individual, a gaseous- 
hyper-distended colon can relieve itself in this manner. From per- 
sonal observation I am satisfied that gaseous regurgitation occurs 
in cases of enteric fever accompanied by pronounced colic meteor- 
ism. In the cadaver, in cases in which the valve prevented the 
passage of fluid into the ileum when the intestinal tube was coiled 
up in its normal position, I have found fluid would pass, under the 
same pressure on attempting to straighten out the gut at the junc- 
tion of the ileum and cecum. 



Rubber Bag- and Tube, with Rectal Tip, for performance of Entero- 
klysis. By replacing- the rectal tip with an aspirator needle or tapping- 
canula, the apparatus will serve for the performance of Hypodermoklysis. 


With reference to the second question I would state that the 
danger par excellence that threatens us in endeavoring to flush the 
small intestine from below, is, injury to the bowel. As before seen, 
this injury may be a longitudinal laceration of the peritoneum on 
the convex surface of the bowel, or multiple ruptures from within 
outwards at the mesenteric attachment. But it must be borne in 
mind that under certain conditions, stretching the cecum may be a 
factor in producing ileo-cecal intussussception. 

Appendix N. 

Very interesting matters for consideration are connected with 
the entrance of the germ into the system and of its subsequent growth 
or destruction. We have already noted the antagonistic qualities 
of the normal gastric juice to the cholera spirillum; w r e have seen 
that should there be a deterioration of the stomach secretion, how 
ingested germs could safely pass the stomach and reach the intes- 
tine, where all conditions are favorable for growth and develop- 
ment. The reaction of the interior of the small intestine is always 
alkaline, there is no real need of any catarrhal process to produce 
such a condition ; even when the acid contents of the stomach dur- 
ing digestion are poured into the duodenum, the alkaline bile, pan- 
creatic juice and intestinal secretion rapidly and thoroughly neu- 
tralize and render decidedly alkaline the mixture. We have seen 
that water can enter the stomach and be emptied into the bowel 
without gastric functional activity being awakened, without any 
acid reaction being induced. In this case therefore, contaminated 
water could convey living cholera to the intestine. But even with 
a deteriorated state of the gastric juice, if infected food were taken, 
and the activity of the alimentary system called into play, even if 
living cholera unchallenged passed into the stomach and entered 
the gut, are there any conditions whereby the individual could es- 
cape the disease? Yes, there are; a prominent one being as follows: 

It is a well understood fact, how the different portions of the 
economy are brought into relation with each other, and by means 
of the nervous system the various subdivisions associated in such 
a manner that stimulus applied to one organ may excite the activity 
of another. An excellent example of this is to be found in the di- 
gestive mechanism. Just as soon as we begin a meal, with the 
swallowing of the first bolus of food, the digestive system awakens 


as it were from sleep. The musculature of the gall bladder con- 
tracts and bile is poured into the duodenum, the pancreas becomes 
rosy red and takes on functional activity, the stomach elaborates 
its juice, the glandular apparatus of the intestine increases its work, 
and peristaltic waves, quicker and mere pronounced above, slower 
and less marked below, pass from above downwards. Sometimes these 
waves are continued rather forcibly over on to the large intestine. 
There are some people who have an urgent call to go to stool im- 
mediately after eating, and the desire begins to be appreciated be- 
fore the individual leaves the table, before the meal is over. I 
am acquainted wtih a bon vivant who tells me he always wants to 
<l defecate just before dessert." Now the substratum of the intesti- 
nal mucosa is adenoid tissue. We find a sustentacular framework of 
connective tissue with the interstices packed with leucocytes, which 
are accumulating in the intervals between meals. This tissue takes 
on activity as well as the other parts above mentioned. The leuco- 
cytes wander out of their prison cells and play an important part in 
nutrition. Employing their attributes as phagocytes, they seize on 
pabulum and at once dive deep into the tissues, entering lym- 
phatics and blood-vessels and everywhere give up their precious 
freight. There is an enormous ..increase at this time in the body 
of these wandering cells, w r hich gradually decrease in number un- 
til a little time after completion of digestion, when a condition of 
equilibrium is once more assumed. If, when these cells are swarm- 
ing out of their nests into the cavity of the gut ; if, when they are 
engaged in loading up with food soluti&n, there should be cholera 
bacilli in this food solution, exemption from the disease might be 
produced by the destruction of the spirilla on the part of the phag- 
ocytes. If there were but a few morbific germs, the 'army of 
phagocytes would quickly overpower them, and the general econ- 
omy would never know there had been any invasion. If, however, 
the invading troops were more numerous, the battle might be fierce 
and stormy, many on each side would be slain, the field of battle all 
torn up, but the phagocytes victorious. Then there might be a ca- 
tarrhal enteritis of greater or lesser severity set up, and after the 
debris had all been expelled and removed from the bowel, the man 
would be again in full health and would refer his diarrhea, perhaps, 
to some indiscretion in diet. The subject is of the deepest interest, 
and I have not space here to continue further, but would simply 


direct attention to protection from invasion from this point of 

Appendix O. 

In Science, Dr. A.S. Ashmead pleads for general asepsis, holding 
prevention to be better than cure. There is, says this author, a 
singular agreement of precept between some of our new philoso- 
phical schools and the doctrine of the Orientals as to our duty to 
the race in case of disease. The doctrine of our philosophers, 
teaching the survival of the fittest, and our duty to the race, not to 
interfere with the eliminating operations of nature, is not put into 
practice, and considering that Christianity is our religion, and is 
not looking forward at present to any imminent decline, it is not 
likely to pass into practice for some time to come. The Orientals 
criticize Christianity because it seems unduly and undutifully oc- 
cupied in counteracting the decrees of nature, by saving, w r ith 
fostering care, individuals of the race, preserving in hospitals all 
that ought to perish, and heaping up, so to speak, the sweepings of 
nature, to perpetuate moral and physical uncleanness. True, they 
also are anxious to build hospitals ; but if they were let alone per- 
haps they might build them only for animals, whose races are not 
important enough to make it a pity that disease and vice should be 
allowed to be transmitted among them from generation to genera- 
tion. Wherever the Oriental spirit has developed on its own lines,, 
it has endeavored to eradicate the human weed, to sweep away all 
human influences detrimental to mankind, whether they be rep- 
resented by disease or by crime, always ready to sacrifice any man 
to the interest of men. The leper was cast out to die with his 
disease in unpitied misery and solitude; the beggar, uiable to earn 
his bread or support his family, was excluded from help and inter- 
course of any kind; what could the race expect from his seed? 
What is the use of amputating a limb which tuberculosis or syphilis 
or leprosy is gnawing at? Why should his seed be preserved to 
perpetuate his rottenness? Why should we so tenderly humor 
the madman, use infinite care and infinite treasures of knowledge, 
and miracles of skill, to bring the diseased brain into a condition 
which makes the man innocuous, tolerable, while yet he can 
never be normal, rational, useful; his brain fibre is degenerated 
and should not be transmitted to future generations. 


When we Westerners discovered the bacterium we thought 
that here we had the cursed cause of all disease, and forthwith 
began to give her chase or to lay siege to her citadel. The Ori- 
ental may have thought dimly: Wherever you are, O, Microbe, 
you are in the state where Providence has placed you, and must do„ 
His behests. Yours is the empire of the abnormous, the morbid,, 
the destructive. Whatever part of creation you establish your- 
self upon is by your very presence stamped as bad, unhealthy, un- . 
deserving of existence. Therefore stay in your domain, we do -. 
not envy it to you. Eat up, what belongs to you, it can do us only 
harm. These Eastern populations believe in fate; they are the 
true Stoics. What is written, is written, Kismet, If we are 
doomed to be cut off by cholera, we shall not escape it, and the . 
fear of the inevitable shall not prevent us from plunging our limbs • 
into the lethal waters of the Ganges, or quenching our thirst in , 
the Mecca pools. And what does it mean, that our own people, 
not very long ago, considered the use of vaccine as being an inter-, 
ference with the will of Providence. They called Providence 
what in the Orient we call fate. It would seem that medicine in 
general is just the opposite of this magnificent supineness: the 
physician tries to save his individual, let what may become of the 
race; there is another kind of recklessness, not supine like the 
Oriental, but busy and officious. It would be a much higher task % 
if, instead of waging war against the bacillus, who has invaded an 
individual, medicine should find means to obviate and suppress 
the bacillus, or its development, or its culture, before it invades the 
race by the individual, that is, should create in the organism such 
conditions, should produce such constitutions, as would not allow 7 
of the existence of these microscopical pestilences. That would 
be asepsis instead of antisepsis. Here is what asepsis has to do. 
It stands at the fountain head, its mission is to keep the spring of 
life free from impurity. Let a commission, or whatever body of 
scientific information and action, go to Russia, to the original 
habitat of the typhus germ, and oppose the development of its colon- 
ies before they begin their trip around the world. The first thing to 
do will probably be to improve the condition of the Russian Jew. 
Prevent the Hindoos from poisoning themselves with their holy 
water, with which they drink the blessing of cholera. Enact laws 
to isolate the syphilitic and the tuberculous. Prohibit the marriage 


of such. Let the congenitally incurable die before puberty : it is 
better that the offending limb should be lost than that tuberculosis, 
syphilis, leprosy, etc., should spread through the whole body. 
Let the healthy, the temperate, the moral, alone have the in- 
heritance. A correct life is the most perfect asepsis, and insures 
an immunity with which the burnt infant's immunity, known as 
such, cannot compare. 

Appendix P. 

Hare, in the Therapeutic Gazette, quoting Arthur Klein, re- 
views the present status of blood-serum therapy. According to 
these authorities, recent advances in this direction may affect the 
whole future of medicine. These show the blood in the light of a 
protecting organ for the rest of the organism. Much investigation 
remains to be made, especially as to the conditions of immunity 
from infectious diseases. Behring's blood-serum therapy is the 
most recent of these important discoveries, and has already found 
its way to the bedside. 

By immunity we understand the power of an organ to defend 
itself successfully against the entrance of an infection. This im- 
imunity may be congenital or acquired. The congenital is peculiar 
to the animal genus, the acquired is the special acquisition of an 
individual; in both forms the immunity is specific, i. e. y for certain 
infectious diseases, but by no means for all. The rabbit appears to 
be non-inoculable by the bacillus Friedlander, the dog by the diplo- 
coccus pneumoniae, the rat by anthrax. If we see a horse survive a 
deadly dose of a tetanus culture, we know that he must have ac- 
quired the immunity artificially. 

The methods of producing artificial immunity are numerous, 
but in general, they seek to follow the natural way as much as pos- 
sible. There are two diverse views as to the manner in which the 
organism protects itself against disease. One view is that there 
are cellular portions of the blood — the leucocytes — which render 
the organism immune, by forming a wall against the causes of in- 
fection, taking them up and destroying them (as scavenger cells). 
One must imagine that the mobilizing of the white blood-corpuscles 
at the point of the outbreak of infection (local inflammation) is due 
to a chemical irritation, which proceeds from the infectious germs, 
attracting the white cells. Opposed to this theory are equally acute 


observations, which see that the means of protection of the organ- 
isms consists in substances dissolved in the blood. (Neither of these 
theories alone will explain all the phenomena noticed hi various 
instances. The recognition of both seems to be necessary.) The 
excitants of infection known to us may be divided into two cate- 
gories. One kind is excessively increased in the body, growing 
through the tissues, pressing into the circulation, and threatening 
the organism by the very great hordes of parasites which are able 
to disturb or entirely stop the normal functions of the organs. 
These infections may be grouped under the general idea of septi- 
cemia (as anthrax, diplococcus infection). 

Another portion of infectious germs increase but little in the 
infected animals, or at least remain confined to the infected place; 
the pathogenic micro-organisms which belong to these (as tetanus, 
diphtheria, cholera) do not enter the circulation, but they produce 
an intensely active poison, which is absorbed by the organism at- 
tacked, and thereby develops an activity injurious to the organism. 
This must be distinguished as an entirely different mode of infec- 
tion from the former, and is designated as intoxication. 

If it is possible to render animals immune against the toxines, 
there must exist anti-toxines. 

If it is possible to produce a protective body of such power 
that it is able suddenly to render immune an organism where infec- 
tion already exists, then the protective has become the healing 
substance, and the method of rendering immune, a healing method. 
For the congenital immunity, no general explanation of its origin is 
yet possessed. For that artificially produced, we are able to trace 
it confidently to a property of the cell-free blood. But in no dis- 
ease against which a sufficiently high degree of immunity has been 
produced in an animal of originally light receptive powers, has any 
one been able to prove the absence of the bodies conferring immun- 
ity in the extravascular blood of the individuals rendered immune. 

First, a high degree of immunity is to be produced in a recep- 
tive individual, and then trial is to be made to see whether the blood 
of the animal rendered immune produces a preventive and healing 
action upon othere. Behring has tried to render rabbits immune 
from a tetanus infection. The culture, bred in meat broth, is re- 
duced with carbolic acid to five per cent, which is now administered 
n five increasing doses, given by intraperitoneal injection. The 


doses follow each other at intervals of from three to five days. If 
the injection is not well borne by the rabbit, instead of increasing 
the dose, the last dose given is repeated. The animal acquires a 
correspondingly increased degree of immunity, as examination of its 
blood-serum shows. It is also tested by ascertaining what quan- 
tity of the serum will render a white mouse of a given weight im- 
mune. After receiving the last of the five injections, the injections 
are of the culture in its full virulence, always increasing from very 
small to larger doses. 

But for large and susceptible animals we must have either a 
blood-serum of enormous power to render immune, or use it in 
enormous quantities. This shows that larger animals must be 
chosen for the treatment, which can endure the loss of larger 
quantities of blood without injury to their health, and are able to 
supply the necessary quantities of blood-serum. Sheep are suit- 
able, but above all horses, which Behring regards as the "travelling 
apothecaries of the future." The method used for rabbits needs 
only slight modifications to be applied to horses. Behring has al- 
ready cured large animals with this, and Rotter reports one man 
successfully treated for tetanus; of course further experiment will 
develop a more potent cure. 

Pawlowsky and Buchstab have made many experiments in this 
direction, alter Pasteur's method. 

A quantity of pure culture was injected into the blood of an 
animal and gave a negative result. By transmission of the pepto- 
toxine through a serious of rabbits and guinea-pigs a culture of 
great virulence was obtained. A dose of from three to five cubic 
centimetres killed the animals in from twelve to twenty hours. A 
very weak culture is injected into the blood or the peritoneal cavity 
and gradually increased up to the very powerful cultures. In the 
course of a month many animals were rendered immune. Five 
cubic centimetres of the virulent culture were injected into the per- 
itoneal cavity, and in from one to five hours blood-serum from an 
immune animal w 7 as injected under the skin. Seventy-five per 
cent. of the animals lived. All the control animals died. The 
authors claim to have isolated a substance from the blood-serum 
of immune animals which possesses as much power to render 
animals immune as the blood-serum. They experimented upon 


themselves with the serum from immune animals but no changes 
were noted. 

Appendix Q. 
A fact of great value that we have to notice is the advanced 
position taken by many theologians in these later times. Dr. 
Briggs' courage and his manly stand in defense of his conscience 
have now become matters of history. It is lucky for the Doctor 
that he lives in the nineteenth century. In earlier times the 
officers of the Holy Inquisition would have paid special attention 
to his soul's welfare (at the expense of his physical integrity), or 
he might have shared the fate of the monk Servetus, who at 
p Calvin's instigation, was burned at Geneva in 1553. A remark of 
the Right Reverend Dr. Potter, Protestant Episcopal Bishop of 
New York, may be cited as an example of this newer and broader 
theological thought. When, last summer, this distinguished, en- 
lightened and learned prelate was memorialized by members of his 
flock to issue a circular letter to all the churches in his diocese 
calling tor general supplication to the Most High to avert the 
plague from the Empire City? he consented, but advised his 
petitioners to gird up their loins and cleanse the city. 

Appendix R. 

The Practitioner quotes Pettenkofer at length concerning 
cholera etiology. This authority believes that cholera is impos- 
sible without the simultaneous action of three etiological factors: — 
X, the specific germ of cholera disseminated by man ; 2~, the pecu- 
liar and subtle influence of place and season; and Z, the personal 
equation as represented by the individual predisposition. These 
three factors, he thinks are equally potent and equally necessary. 
To the majority of those who have studied cholera epidemics, the 
factor T, or the influence of place and season, is a negligeable 
quantity, and quite subsidiary to the . Jf, or specific germ which, 
unless the organism be in a state of absolute immunity, once hav- 
ing gained access to the body is alone sufficient to give rise to 
cholera. On the other hand, von Pettenkofer attaches the 
greatest value of importance to the Y; to him the X and Z are not 
enough, and unless supported by the presence or existence of his 
factor Y, are unimportant. 

On October 7th, 1892, von Pettenkofer swallowed one cubic 


centimetre of a fresh bouillon cholera culture; and moreover, to 
guard against any possible antagonistic or protective influence of 
the acid gastric juice, he neutralized it by taking at the same time 
one gramme of bicarbonate of sodium dissolved in 100 cubic 
centimetres of Munich water. In order to give the experiment 
every chance, von Pettenkofer in no way altered his manner of 
living, or his habits. At noon the same day he consumed soup, 
eggs, black bread, a salad, some rice-cake, prunes, and coffee with 
milk. Similarly in the evening he partook of meat, potatoes, 
cheese, bread and butter, as well as a litre of beer and some alka- 
line water. 

On October 9th, or some forty-eight hours after taking the 
cholera-broth culture, the first symptoms of intestinal irritation 
appeared. These consisted of borborygmi and some six to eight 
liquid motions, the appetite, power of working and sleeping, re- 
maining, however, good. His condition remained the same during 
the next three days, the only marked discomfort being some 
flatulence and looseness of the bowels. So far no remedial meas- 
ures were adopted; but on the 13th a warm cordial of wine was 
taken. The diarrhea gradually abated and entirely ceased on the 

All the excreta were carefully submitted to a microbiological 
examination by competent experts, with the result that comma- 
bacilli were found in large numbers — some of the motions consist- 
ing almost of pure cultures, but no commas were noted after the 
1 6th. Von Pettenkofer's own words regarding his experiment upon 
himself are worth recording at this point. He said: "Nearly all bac- 
teriologists are agreed that the comma bacilli cause Asiatic cholera, 
not by penetrating into the general organism through the intestinal 
walls, but by remaining in the bowel, and there elaborating certain 
products which on absorption give rise to the infection. 

What a quantity of poisonous products must have accumulated 
during those eight days in my intestines from those millions of 
comma bacilli! And yet I enjoyed good health, I had a good 
appetite, I experienced no symptoms of auto-intoxication, I had 
neither sickness, albuminuria, nor collapse; I was able each day to 
fulfil my duties. I concluded that the comma bacilli certainly 
give rise to diarrhea, but they do not cause either European or 
Asiatic cholera. Had my experiment been performed in Hamburg 


it might have been, and probably would have been fatal because 
on that day, October 7th, there existed in Hamburg 2" in sufficient 
quantity to cause cholera, even with a minute quantity of said X" 
(It seems to me as if Prof, von Pettenkofer's reasoning were not 
perfectly logical. In the first place the germs swallowed by him 
had been sent to him from Hamburg, and were cultivated in bouil- 
lon, before being swallowed by him. This virus might there- 
fore be looked upon as having been attenuated. Again it 
seems to me as if the learned Doctor places too much 
stress on his Y, to the neglect of his Z\ T he describes 
as the peculiar and subtle influence of place and season, 
while by Z he indicates the personal equation as repres- 
ented by the individual predisposition. It appears to me as if Z 
were just as valuable as Y, and were I a believer in von Petten- 


\\ II 

kofer's theory, I would describe cholera as -JC_ = Z. Not every 
one swallowing the specific exciting cause of cholera, will suffer 
from the disease; not every one taking into his digestive tract 
the bacillus typhosus, will have enteric fever; not even will every 
unprotected person exposed to variola contagion, contract small- 
pox. In order that one should contract one of these diseases, the 
exciting factor must be present, and contributory conditions must 
be favorable. Now of these predisposing causes the most import- 
ant is the personal equation before mentioned. In Pettenkofer's 
case, his powers of resistance were normal, his vitality was at par, 
the Metchnikoffian attributes of his mesodermic cellular elements 
were active, and he escaped. 

Still cholera microbiology is not yet absolutely understood and 
the reader is again referred to Prof. Nencki's observations on 
mixed infection — (Lecture II.) 

Appendix S. 
At the fifth meeting of 1893 of the Calcutta Medical Society, 
held in the medical college hospital theatre on Wednesday, May 
the 10th, the chairman, Dr. C. K, Bose, read a paper on "Some 
Points Connected with Cholera." He first dealt with the obscure 
listory of cholera, referred to allusions made by the Chinese and 
Mahomedans in their sacred writings, to the writings of Casperez, 





H E 



Dugot's Combined Bed Par. This contrivance is far in advance of 
anv similar invention. 

Bed Pan for use in bowel flushing - . At one end is seen an exhaust tip 
to which a rubber tube may be attached, and the returned fluid carried off 
to a pail, or other suitable receptacle on the floor. 


Sydenham and MacNamara. Cholera, he said, had selected 
Calcutta as a centre of infection and from there it was transferred 
to different parts of the world. The reason why it was so, was 
interesting. The soil of Calcutta was soft, the summer was a 
prolonged one, and the winter comparatively short, the rainy 
weather extending from June 15th to the end of August, the 
average rain fall being 66 inches. The highest temperature ioo°, 
and the lowest 6o° F. The climate was hot and moist, and there- 
fore favorable to the growth of the micro-organism. The northern 
portion of the cit} T was occupied mostly by natives, the houses and 
locality being in a very insanitary condition, while the southern part 
which w T as healthy and well looked after, was occupied by Euro- 
peans. Of the population of Calcutta, only twenty-nine per cent, 
belonged to the place, this number being born there, the rest com- 
ing to it from other parts. In the northern part of the town, the 
building arrangements were very bad, the very poor lived in 
bustees, each bustee having a tank in the centre. The water from 
these tanks is used for cleansing cooking utensils, purposes of 
ablution, and what is most revolting, this same water is used for 
drinking purposes, owing to the occupants of the bustees being too 
lazy to get water from the taps near by. From these bustees the, 
infection begins in many outbreaks of zymotic diseases. The 
sources of access into the town are very often very difficult to trace; 
the sources of conveyance are twofold, those within the town, and 
those from without. Those within are mainly sanitary defects. 
In the native portion of the town, the streets are very much neg- 
lected, for instance in Burra Bazar, the streets are not even cleaned 
once a week. Cholera and typhoid may arise from the under- 
ground system, and the system as it is, can not be properly carried 
out in the native part of the town without danger to the health of 
the people. While much improvement has been done, still until 
direct information is lodged with the health officer, very little care 
is bestowed on the native portion of the town ; debris and other re- 
fuse lie about the lanes for many days, and very often in a state of 
putrefaction. In case of death from cholera, small-pox, etc., the bed- 
ding, pieces of rags, etc., are thrown into the streets, blown around 
by the winds and very often stick near a water-pipe, till the domes 
come to collect old rags, etc., for the purpose of sending to Eng- 
land, to the paper factories, and thus the disease is carried with all 



its mischievous results. Another source of mischief to be found in 
some of the native houses is that the tap with filtered water is near 
the latrine, and a drive to the neighborhood I have referred to, 
would convince the most sceptical. The bhistees and goalahas with 
their adulterated supplies, are sources of mischief from without the 
town, and if the germ theory of infection be correct with reference 
to cholera, then milk is the best medium for the bacilli. Of course 
many use boiled milk, and others use raw milk. • • • • It is 
known that ignorant confectioners who come into town bring 
cholera with their milk. 

So far the factors of infection and spread of cholera have been 
noticed, and in passing I may mention, that good filtered water is 
of more value than one hundred therapeutical agents, which article 
is in many instances denied by the Corporation. As an instance of 
their procedures, I will mention one case of cholera which hap- 
pened the other day at Manicktollah, and the cause was traced to 
the consumption of foul water, the municipality having disconnected 
the filtered supply owing to the municipal water rate not having been 
paid. The medical attendant made an application to have the 
connection restored, but it coidd not be done without payment of the 

While cholera may appear at any season, the summer seems 
to be the most favorable time. In March, April and May, the 
mortality is high. During the holi festival the natives take in all 
kinds of food and drinks, they use opium, bhang and sweetmeats, 
and these with debauchery and irregular meals. They cover their 
bodies with red paint, and at this time cholera generally breaks 
out and dozens die. In Orissa during the rath fathra festival, 
many deaths occur, also at the kumbh mela and the ardohya fog, 
while the disease abates after the festival is over. In different sec- 
tions of the town, when there is a case of cholera, the discharges, 
soiled rags, etc., are very often thrown into the streets, or if 
the stools happen to fall upon the floor of the house, they are 
covered with ashes, and then removed to be thrown outside of the 
door of the house. In houses of the poor, or in places where gun- 
nies are piled for sale, if a case of cholera occur pieces of gunny 
are used to wipe up the stools and vomit of the patient, which are 
afterwards^ sent to the dhoby, and then used for making gunny 
bags. With regard to the contagiousness of cholera, a case was 


mentioned where a native mother had been nursing her child 
who was suffering from cholera, and although contact could be no 
more pronounced than in this case, as the child was in her arms all 
through, and her hands were simply soaking with the cholera 
stools, etc., yet she escaped. 

A peculiar circumstance was reported where a party of 
twenty-two men went to Kalighat and stayed near a filthy tank ; 
they all ate and drank equally, and after performing their rites they 
returned home. Nine of these men were attacked with cholera 
and died, the other thirteen were opium eaters and were not at- 
tacked. Dr. Bose then concluded by referring to immunity from 
cholera after one attack in connection with recovered cases of 
cholera in native houses. 

Appendix T. 

J. G. Santchenckoo, in the Wratch. Annates, de VInstitut 
Pasteur discusses the part played by flies in the propagation of 
cholera epidemics. The recognition of this fact is not new. In 
1884, in a report to the French Government, Dr. Paul Gibier 
called attention to the dangers which flies cause, by saying that 
these insects, which are so numerous in summer, impregnate their 
bodies with germs caught in contaminated places and transport 
them into our houses and victuals. But Santchenckoo has sought to 
study the minute mechanism of the transportation of germs. He 
has fed flies with a liquid culture of choleraic bacilli. Then he 
has searched for the microbe in the excrements of the insects. At 
the end of two hours he had already obtained colonies of comma- 
bacilli among other and different bacteria. Twenty-four hours 
later the number of choleraic bacilli was much more considerable. 
From these observations the investigator concludes that the part 
of flies is not limited to the expansion of microbes which they may 
have swallowed, but that the bacilli are easily propagated in the 
intestinal canal of this insect. 

Klebs has been studying the therapeutics of a re-agent which 
he calls "Anticholerine." He prepares it by concentrating large 
quantities of sterilized cholera cultures over a water bath, and 
removing the toxic substances by means of absolute alcohol. The 
residue possesses bactericidal and immunizing powers. .By adding 
a few drops of a concentrated solution of anticholerine to agar, we 


produce a culture medium which is antagonistic to the develop- 
ment of the comma-bacillus, and if to a rapidly growing culture, a 
few drops of anticholerine be added, the development ceases and 
the culture dies, while streptococci grow freely in the medium. 

The non-toxicity of anticholerine was demonstrated by inject- 
ing guinea-pigs and especially those in a tubercular condition, 
which are peculiarly susceptible to cholera. Klebs and Schnei- 
der have injected themselves with quantities corresponding to 
eight cubic centimeters of filtered culture without any evil effects. 
Two guinea-pigs were inoculated intraperitoneally with 0.8 cc. of 
pure culture of comma-bacilli. One, which had received an injec- 
tion of anticholerine, remained in perfect health. The other 
Avhich was not protected, had a rise of 9 F. in temperature and 
lost much weight, but it finally recovered. 

Of two other guinea-pigs, the control animal died of cholera, 
while the one that had been treated with anticholerine two hours 
after the injection of the pure culture, remained in good health for 
six days, when it died of a prolapse of the intestine through the 
operation wound. 

Notwithstanding the small number of experiments he had 
made, Prof, Klebs did not hesitate to use his remedy in Hamburg. 
The patients were inmates of barrack F , where the severest cases 
were admitted, among whom the mean death rate was 80 per cent. 
The result was that the mortality fell from 80 per cent to 63 per 
cent, and Dr. Manchot of the Eppendorf Hospital considered that 
the anticholerine prevented the febrile reaction. Among many 
similar cases, was that of a young man who was stricken with 
cholera at an early hour and was admitted to the hospital at 11 a. 
m. On the first day, five, and on the second day, six cubic centi- 
metres of anticholerine were injected. The temperature, which 
was only 35 0.(95° F.) on admission, rose the same day to 36.7 Q C, 
and the next day oscillated between 37. 2° and 38°C. (90°-i00 4° F.) 

Appendix U. 
Carried away by zeal and a desire to benefit mankind the 
worker in practical preventive medicine may be tempted to de- 
pend too much on analogy or unsupported theory in forming de- 
ductions, if he neglect consideration of known physiological data. 
The questions of immunization against cholera, of hvpodermo- 


clysis, and intra- vascular transfusion are all of potent and engross- 
ing interest, and the special physiological fact to which I would call 
the attention of observers in this field, is as follows — heterogeneous 
blood plasma or serum should never be used, in other w-ords the 
blood (or serum) of the lower animals ought never to be transfused 
into the blood vessels of man. As a general rule the blood serum of 
one mammal will dissolve the blood corpuscles of another mammal. 

When foreign or heterogeneous blood is transfused, two 
dangerous and serious phenomena occur: 1st. The corpuscles 
undergo solution. Before they are dissolved they run together and 
form sticky masses, consisting of ten to twelve corpuscles, which 
are apt to occlude capillaries and even arterioles. After a time the 
zooid is separated from the oekoid or stroma, which yields a sticky, 
fibrin-like mass that may occlude fine vessels. 2nd. As a result of the 
solution of the discoid corpuscles, hemoglobin is set free, which red- 
dening the plasma and appearing in the urine constitutes hemoglo- 
binuria. The presence of a large amount of dissolved hemoglobin 
causes extensive coagulations within the blood vessels, usually in 
the venous system and in the large vessels, and death may 
ensue immediately, or after a longer or shorter period of time. Dis- 
solved hemoglobin seems to increase in a most marked manner the 
activity of the fibrin ferment. There is no necessity of my touch- 
ing upon the clinical picture involved, which for obvious reasons 
is complex. 

Other fluids have been transfused, normal saline solution 
(0.6 per cent. NaCl) aids the circulation in a purely mechanical way, 
and even excites the circulation. In severe spansemia this fluid can 
not maintain life. The injection of fluids containing peptone, even 
in moderate amount, is dangerous, as paralysis of the vessels re- 
sults. The injection of milk is fraught with either immediate or 
ultimate danger; fever follows the operation, and the milk gobules 
cause the occlusion of many vessels, producing subsequent de- 
generations. Fat may appear in the urine and there may be fatty 
infiltration of the uriniferous tubules. The urine contains sugar 
and albumin, the liver cells often contain fatty granules, and the 
weight of the body diminishes. If too large a quantity of milk be 
transfused, death occurs, and when unboiled milk is injected, numer- 
ous bacteria are developed in the blood. 

These facts (as to heterogeneous serum) must be borne in 




mind in connection with the hypodermic injection into man of 
pre-immunized goat's or horse's serum. Should this method be 
used the minimum amount of the serum must be determined that 
will produce the looked-for therapeutic result without disturbing 
to a too serious an extent, the physiological integrity of the blood. 

Appendix V. 
The "Elmer Lee" table for the performance of enteroklysis, 
designed by Dr. Elmer Lee of Chicago, and intended principally 
for hospital service. Dr. Lee sums up the minutiae of detail as re- 
gards the technique of bowel flushing as follows: "Irrigation of 
the bowels is to be accomplished with warm water, made soapy with 
some neutral liquid soap, or a good Castile soap, — using from 1 
to 3 gallons (say 4 to 12 litres) at a time, twice a day for the first 
and second days, and once a day afterwards if required. The 
operation is performed with a soft rubber tube one metre (39 
inches) in length, and of suitable size to be introduced into the 
rectum, in front of the promontory of the sacrum, into and up 
through the sigmoid flexure, and into the descending colon. This 
tube which is connected with a reservoir, should not be too small 
nor too large, in order to facilitate its introduction through the 
folds of the sigmoid portion of the lower bowel. In fact the great- 
est difficulty to be encountered, is to successfully pass the tube in 
front of the promontory of the sacrum, and enter it into the sig- 
moid flexure. The tube should be of proper firmness to prevent 
it from bending or buckling upon itself when the end (which in 
all cases should be rounded) comes into contact with the obstruct- 
ing folds of the intestine." 

Appendix W. 
The late Prof. Peter, of Paris, insisted that cholera nostras or 
cholerine and Indian cholera are for all practical purposes one and 
the same malady. He believed that cholera nostras is contagious 
like cholera, and that under favorable conditions it may become 
epidemic. He reported a rapidly fatal case occurring in France 
where no other cases existed, in which the symptoms were the 
same as in Indian cholera, and in which the autopsy showed the same 
changes as are found in true cholera. Many examples are recorded 
by Prof. Peter showing how what at first seems simple cholerine 








Canula in situ in intra- venous transfusion. 


may rapidly become an epidemic of true cholera; and it is there- 
fore on every ground desirable that cholera nostras should be 
looked upon as true cholera, and the same precautions taken to 
prevent further cases as have been found effective in preventing 
the spread of the more severe disease. 

Appendix X. 

An official report of the Governor- General of Turkestan, 
which has recently been published in St. Petersburg, according to 
the British Medical Journal, states that the province has been 
severely visited by an epidemic of the "black death" which fol- 
lowed on the footsteps of cholera. It appeared suddenly at Aska- 
bad, and in six days killed 1303 persons in a population of 30,000. 
"Black death" has been long known in Western Asia as a scourge 
more deadly than cholera or the plague. It comes suddenly, 
sweeping over a whole district like a pestilential simoon, striking 
down animals as well as men, and vanishes as suddenly as it came, 
before there is time to ascertain its nature or its mode of diffusion. 
The visit here referred to was no exception to this rule. After 
raging in Askabad for six days, the epidemic ceased, leaving no 
trace of its presence save the corpses of its victims. These putrefied 
so rapidly that no proper post-mortem examination could be made. 
The Governor-General giyes some details as to the symptoms and 
course of the disease, which though interesting as far as they go, 
do not throw much light on its pathology. The attack begins 
with rigors of intense severity, the patient shivering literally from 
head to foot; the rigors occur every five minutes for about an hour. 
Next an unendurable feeling of heat is complained of; the arteries 
become tense and the pulse more and more rapid, while the tem- 
perature steadily rises. Unfortunately no thermometric readings 
or other precise data are given. Neither diarrhea nor vomiting 
has been observed. Convulsions alternate with syncopal attacks, 
and the patients suffer intense pain. Suddenly the extremities be- 
come stiff and cold, and in from ten to twenty minutes the patient 
sinks into a comatose state, which speedily ends in death. Im- 
mediately after he has ceased to breathe large black bullae form on 
the body, and quickly spread over its surface. Decomposition 
takes place in a few minutes. 


Appendix Y. 

Dr. James F. Hibberd, in an address on cholera, remarks: 
The comma bacillus is a small microbe about the 1 -25000th of an 
inch in length and one-third of that in transverse diameter. We 
can hardly conceive of a living thing so minute. It would require 
1000 of them placed end to end, to extend 1 — 25 of an inch, and a 
sphere of the size of an ordinary drop of fluid would contain 52 V 
600,000 of them. . . . It breeds by each spirillum dividing its- 
self into two spirilla and each of these into two more, and so on. 
This division has been seen to take place in the laboratory in twenty 
minutes after a spirillum had been planted, or placed in a suitable 
culture medium ; but let us suppose such division to be complete 
once an hour, a simple calculation will demonstrate that at the end 
of twenty-four hours the descendants of this one microbe would 
number 16.777,216. As it must be a rare thing for a person who 
swallows such a microbe to swallow only one, when a drop of fluid 
may contain millions, we can readily understand why, when a 
person becomes affected with cholera, he is so quickly, so severely, 
and so dangerously diseased. 

Appendix Z 

Dr. Wm. Henry Porter, in the American Medico- Surgical Bul- 
letin reports concerning Uffelman and Neisser's observations as to 
whether living cholera bacilli can be brought into the air by dust 
or garbage. 

It is generally accepted that cholera bacilli can not be trans- 
ferred by air. This statement is based on the belief that the vitality 
of the bacilli is soon destroyed by desiccation and that they can 
only be brought into the air when in a dry condition. 

The latest experiments have shown that the vitality of the 
bacilli is not so readily destroyed by desiccation as it is generally 
thought. If this is the case, the important question comes up: 
whether the air can not be infected with living cholera bacilli by 
dust charged with them. To come as near as possible to the truth, 
Uffelman has carefully conducted some experiments to ascertain 
how long cholera bacilli retain their vitality in dried ground or 
dust, and whether they are brought into contact with air while 

Neisser has experimented to some extent in this field. He satu- 



Hutchinson's Transfusion Instrument. 



Reservoir with pump attachment to insure the passage of the fluid, 
Uged in Geimany. (Bartholow.) 


rated a piece of linen with cholera bacilli, and after drying it he 
passed over it a current of air which was brought into contact with 
a nourishing medium. He failed in producing any results. Had 
he however reduced the linen to powder, his observations might 
have shown different results. 

Uffelman's experiments with garden ground- dust and garbage 
were conducted in the following manner: After previous steriliza- 
tion he took a small portion of the dried substance, and saturated 
it with water charged with cholera bacilli, under exclusion of sun- 
light and at a temperature of 15 C. (59° F.) He kept it until 
perfectly dry again. It took from sixteen to twenty hours to dry. 
Then he took a small portion of the dried substances, reduced 
them to a powder, and made some cultures on gelatine 
medium. Numerous experiments showed the following results: 
At sixteen and one-half hours, or just after complete dryness, 
thirty to forty cholera colonies were found; after twenty-four 
hours, three colonies; after forty-eight hours, one colony ; and after 
seventy-two and ninety-six hours, no cholera colonies were 
found. In another experiment, Uffelman- blew a small portion of 
the pulverized infected material, eight hours after it was dried, on 
a gelatine plate. He found six cholera colonies; after forty-eight 
hours no bacilli were developed. 

From these experiments, Uffelman comes to the conclusion 
that most of the cholera bacilli lose their vitality in dried ground- 
dust or garbage within twenty-four hours, but in some cases they 
retain their vital activity for a much longer time, and in excep- 
tional cases, for three days. These experiments tend to prove that 
these bacilli can become intermingled with the air before they have 
lost their vitality.