CHAPTER XXV.

THE CONTAGIOUSNESS OF CHOLERA.

WE have already expressed our conviction to the effect that cholera is a specific infectious disease, and, though contagious, that it is not so in the sense, for example, of the acute exanthemata. That the peculiar contagion of cholera resides in the dejections is no longer doubtful. That it is not a volatile substance emanating from the sick is also certain. It is shown by the fact that the immediate attendants upon cholera patients are less liable to contract the disease than, for example, the washerwomen and others engaged in handling the soiled linen, and than we should expect to observe if it partook of the nature of a volatile poison.

In the opinion of the editor, a practical disregard of the contagiousness of cholera (though, as previously stated, this is not as direct as in the case of small-pox and similar affections) involves, both in the presence of an epidemic and during the time of its expected arrival, graver responsibilities than we have any right to assume. Burrall says truly in this connection:

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

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

It is proper to state, however, that even at the present day many physicians in India, long familiar with cholera, still doubt its specific contagiousness. Thus Dr. Morehead's observations apparently support the view of the non-spreading of cholera in hospitals through contagion. They were conducted with care through three epidemics in Bombay, and though he refrains from drawing positive conclusions, his experience is not in favor of contagion. Sir Joseph Fayrer states that he has seen hundreds. of cases of sporadic and epidemic cholera, but has seen nothing to make him believe there is anything of contagion in connection with the disease. Dr. J. R. Lewis writes that for fourteen years he has studied cholera, and has never seen anything to lead him to think it contagious. It was the custom in India to treat cholera in the same wards as other diseases, and no evil resulted.

1 Asiatic Cholera. By F. A. Burrall, M. D. New York: W. Wood & Co., 1866.

Among those who maintain that cholera is a non-contagious disease, Dr. J. M. Cunningham, the surgeon-general and sanitary commissioner to the government of India, occupies a prominent place. His opinions, as laid down in a work that has just appeared,' are diametrically opposed to those of the contagionists, and especially the positive assertions of Koch and his followers as regards the etiology of this disease.

He makes this sweeping assertion concerning the doctrine of Koch: "The whole superstructure which the German. Cholera Commission raised on the supposition that the comma-bacillus is an organism peculiar to cholera, and which was viewed with such ready approval both by the public and a great part of the medical profession, has in fact tumbled to the ground." Elsewhere he declares that "from the record of about 8,000 attendants on cases of cholera in India it is proved that they suffer no more than other people living in the same place. There is no danger in attendance on cholera cases. Surgeon-General Hunter, in his report on the recent cholera epidemic in Egypt, after quoting the above, adds:

My personal experience of cholera in India is in accordance with the opinions above expressed. The professional staff, a large body of students and attendants of the Medical College and Hospital, Bombay, who were more or less in frequent communication with cases of cholera, and many of whom were also engaged from time to time in performing post-mortem examinations, appeared to enjoy comparative immunity from the disease without any special precautions being taken. Experience gained during the recent epidemic in Egypt confirms still further these facts. It was no uncommon thing to hear from medical officers and others that their clothing and persons had been covered with the discharges from cholera patients, which had been allowed to become dry, yet no evil results followed. Circumstances rendered it necessary that the British officers serving with the Egyptian army should attend on the cholera sick, wash the bodies after death, according to Moslem usage, and afterward bury them, and yet in no single instance, if I am correctly informed, did they contract the disease.

The Recent Discussions on Cholera before the Paris Academy of Medicine.-Allusion must here be made to the prolonged discussions which took place at many successive meetings of the Paris Academy of Medicine during the summer and fall of 1884. Two principal theories were enunciated as to the nature of cholera. M. Jules Rochard, and a majority of the members of the Academy, held to the theory of personal contagion and the importation of the disease through human intercourse and the medium of fomites. M. Jules Guérin, on the other hand, championed the cause of the believers in the spontaneous origin of cholera. Although an able orator, a learned physician, and a gentleman of unquestionable sincerity, he received but slight support from his fellow members. On the other hand his views were shared by many of those who had recently been brought into personal contact with the disease in the south of France.

In reviewing the Academy discussions, Dr. J. P. Bonnafont recalls the oscillations regarding the doctrine of contagion, in the last half century.

From 1830 to 1849 nineteen-twentieths of the physicians in France were noncontagionists. From 1850 to 1880 almost the exact opposite prevailed. And in 1884 he states that there were as many or more non-contagionists as believers in contagion, and the indications were that the pendulum would soon swing well

Cholera: What can the State do to Prevent it? By J. M. Cunningham, M.D., Surgeon-General Indian Medical Department, and Sanitary Commissioner with the Government of India. Calcutta, 1884.

Le Choléra devant l'Académie de Médecine. La Contagiosité et les QuaranParis: J. B. Baillière et Fils. 1885.

taines.

over to the negative side. The contagionists of late years have attempted to effect a sort of compromise with their opponents by maintaining that there are two kinds of cholera-one contagious, the imported or Asiatic cholera; the other non-contagious, sporadic cholera, or as Fauvel called it, cholera nostras. This new doctrine is the one which seemed to be most in favor among the members of the Academy of Medicine. At the beginning of the epidemic M. Fauvel, in an endeavor to calm the excited fears of the public, declared before the Academy that the disease was of the sporadic variety, and was consequently not contagious, and would remain limited to the two cities in which it then was. But when the disease passed the bounds set for it by M. Fauvel, MM. Brouardel and Proust were dispatched by the Minister of Commerce, and M. Rochard by the Minister of Marine, to study the progress and the character of the disease. These three reported, contrary to the opinion put forth by M. Fauvel, that the epidemic was one presenting all the characteristics of Asiatic cholera, and that the disease was therefore highly contagious. The first, while avowing that quarantine alone could hinder the spread of the disease, stated squarely that it was impossible to maintain a quarantine by land. There were then two opposite systems in force-one on the side of the sea condemning the unfortunate travelers to a long period of detention; the other on land allowing the inhabitants of the infected districts to go forth freely, sowing the epidemic along their route, without fear of the bullets of the sanitary guards.

The advocates of the spontaneous theory, who believe that cholera may arise and be propagated in any locality without being contagious, assert also that the atmosphere may undergo changes rendering it capable of producing the disease. But they believe that the air is always the medium of transmission, and on this point they are in accord with some partisans of the importation theory. It is very evident, M. Bonnafont asserts, that the air is the only vehicle which can transport to great distances from its point of origin any infectious principle whatever; but it could never be the generator of this principle. In support of this assertion that it is possible for the contagion to be transported through great distances by the air, he mentions the carrying of the ashes thrown out by the recent volcanic eruption in Java.

M. Jules Guérin supported the doctrine of the spontaneous origin of cholera, maintaining that it can originate and be reproduced in any country whatever. And M. Bonnafont agrees with him in so far as he denies the contagiousness of the disease, citing numerous facts and authorities in his support. He asserts that "the transmission of cholera from one individual to another is scientifically impossible." And he asks how it is possible to believe that one person can introduce the disease into a previously healthy district, when, as in the hospital of the military school at Constantinople, in 1855, nearly 1,500 cholera patients were treated during the course of a year, and not one of the attendants suffered from the first symptom of the disease. He quotes M. Cazalas as asserting most emphatically that cholera, which is contracted by infection in a cholera district just as intermittent fever is contracted by infection in a malarious region, is neither directly nor indirectly contagious. M. Bonnafont concludes his monograph by the statement that he opposes most strenuously every form of quarantine as useless, since, as he believes, the atmosphere is the sole vehicle for the transmission of the cholera poison, and the air cannot be made subject to quarantine regulations.

Goodeve's Opinion.-Goodeve, an English writer of large experience in India, says:

A volatile poison, at all strong in its action, would be most dangerous to all about the sick, and yet in India the medical men, nurses, hospital coolies, sweepers, and others who are constantly engaged about the sick do not appear to be more liable than the rest of the population. The disease seldom spreads from bed to bed in a ward; on the contrary, when people are attacked in hospital they lie generally in a distant corner, or in another ward. I have noticed this over and over again, and though I have been connected with the larger hospital of the medical college at Calcutta for many years, I do not recollect any spreading to the nearest or neighboring patients. I should, as far as my own experience goes, say that cholera does not spread from the sick to the whole by any rapidly acting emanation.

Other Views.-Against the foregoing and many similar statements

from far less competent writers, we have the positive evidence of a large number of accurate observers. Only a few illustrations in point are here introduced.

From the epidemic of 1861 the India commission found that for the whole of the troops attacked in thirteen stations, the "virulence of the disease among hospital patients was clearly more than twice as great as it was among the healthy strength of the regiments."

Writing in 1866, Burrall states that

The opinion of physicians in Europe has been tending toward a belief in the contagious nature of cholera. During the last epidemic in Paris, the cholera patients were treated in separate wards, and the administration ordered the immediate removal, cleansing and disinfection of the bedding used by cholera patients, as well as the washing and fumigation of the personal clothing.

M. Velpeau considers the contagious character of the disease proved to a certainty, and the same is true of other prominent European physicians.

The views of M. Jules Worms,' who has had a very large personal experience with cholera, may also be cited in this connection. He stated at a meeting of the Paris Academy of Medicine that

On the banks of the Ganges, and under conditions which are not well understood, a special agent, poisonous to a large number of individuals, is produced. This agent shows itself among individuals who are collected together in rest or motion, but always presents an uninterrupted connection. The cholera is a malady transmissible by man. This agent manifests its influence on certain human beings (probably also on certain animals) by mild or severe effects. The proportion of individuals liable to the poison can only be approximately estimated, and is under all circumstances very small. The human system may become a fruitful field for the multiplication of this agent as soon as its poisonous effects are manifested. The multiplication of this poisonous agent takes place chiefly in the alimentary canal. The vomitings and dejections of cholera patients contain the active agent of the transmission of the disease. This communicability does not correspond to the time when the dejections are voided, but is developed a few days subsequently, and seems to be exhausted at the end of from fifteen days to three weeks. The corpses of cholera patients emit the toxic agent in a greater degree than the bodies of the sick. Persons attacked merely with choleraic diarrhoea (cholerine) void with their dejections the agent which is capable of producing confirmed cholera in their vicinity. The greater or less density of the soil on which the dejections are cast diminishes or favors the propagation of the disease.

The late lamented Dr. Elisha Harris, in 1865 made the following statements embodying his experience at the Staten Island quarantine, with regard to the contagiousness of choleraic dejections:

In studying the history of fourteen epidemics of cholera that have occurred within the walls of our New York quarantine establishment, the writer has seen abundant evidence of the infectious agency of the sick and their “rice-water" evacuations. Ten of these epidemics at Quarantine unquestionably depended upon cholera patients from ships, and in six instances, at a time when there was no cholera upon our Atlantic coast. These sudden outbursts of cholera, as a general rule, occurred within a period of four days from the disembarkation of the sick; and whenever cholera was not generally epidemic in this country, these epidemics at Quarantine ceased as suddenly as they came, after sweeping off a portion of the convalescents and patients that were in other hospital buildings, having other diseases. The cholera patients were kept as remote from other patients as possible.

Concerning these repeated outbreaks of cholera at Quarantine, it should be stated, that while they prove how fatally infectious the cholera poison may become in the midst of crowded hospitals and public institutions, they utterly failed

1 Archives générales de Médecine, Nov., 1865, p. 623.

Report on Epidemic Cholera by the Council of Hygiene and Public Health of the Citizens' Association of New York. New York, November, 1865.

202

to prove that from the same exclusive cause-viz., the contagion of the cholera evacuations-a world-wide epidemic could be caused. These outbreaks did prove, however, that the stools and besmeared clothing of the sick with cholera can, under certain circumstances, propagate the disease; while, on the other hand, a series of events at Quarantine and in the city demonstrated that, for the production of a wide-spread epidemic, other important causes than the presence of the "rice-water" stools and vomitings must be present.

Dr. Budd' has also collected a number of instances in which the spread of cholera was apparently prevented by an immediate disinfection of the discharges. Some of these instances are here reproduced:

Immediate disinfection was tried, at his suggestion, in the year 1854, at Fishponds, in the workhouse situated there for the reception of the Bristol poor. In 1849, cholera, brought in by a woman coming from an infected quarter in Bristol, killed, in this same workhouse, more than 130 out of less than 600 inmates.

In 1854, although the pest was introduced into the workhouse three separate times, only eight died of it, and the total number of attacks was under thirty.

In the prison of Kaisheim cholera was introduced by a prisoner who died there. The sanitary conditions of the prison were as bad as possible, but the choleraic discharges were disinfected, and the result was, that only one of the 500 other prisoners took the disease. In the prison of Elrach, on the contrary, where no measures of this kind were taken, of 350 prisoners, fifteen per cent. perished.

At Traunstein, in Bavaria, in every case in which the rice-water discharges were disinfected the disease ceased with the person first seized.

In conclusion, he mentions the case of a planter in the Island of St. Vincent, who ascribes the almost entire escape of his laborers from cholera in the great epidemic of 1853 to similar measures. encamped all his negroes on open ground, and by the advice of one of his friends, When cholera broke out on his estate, he had a pit dug in the earth and deeply charged with chloride of lime, to serve as a receptacle for all discharges from the sick. boring estates were all decimated by cholera, and some almost depopulated by it, The result was, that while the neighthis gentleman's estate escaped with only a slight outbreak.

Lebert's views are very much in accordance with our own conceptions concerning the point under consideration. He has found many examples showing rapid contagion by means of fresh excretions. The manner in which cholera attacks those who come in contact with patients, their discharges, linen, or dead bodies is, he explains, quite in harmony with the parasitic doctrine.

He says:

I have noticed in all epidemics, and have seen it mentioned in the writings of many authors, that practicing physicians, even hospital physicians, are seldom attacked with cholera, because, although they come in contact with many patients, their stay with each is short, and because, when themselves attacked, they immediately treat the prodromic diarrhoea. But the resident physicians, and more especially the assistants and nurses, are much more frequently attacked. Their contact with the sick is much more protracted, and not unfrequently local epidemics are developed in hospitals which effect transient visitors rarely or but slightly, while residents, or those whose stay is longer, are attacked much more frequently and intensely.

Finally he gives the following unequivocal expression to his convictions: The much-agitated question concerning the contagion of cholera, whether, if it be considered contagious, it is spread by a miasma or contagium, must be considered, under the light we now possess, as follows: That cholera can be spread only by contagion, i.e., by germs which are carried from a diseased to a healthy person; but that these disease germs infect only comparatively rarely by intercourse or contact with cholera patients, since they possess relatively but little vitality in the air of the sick room, and are present mostly in inconsiderable quantity. On the other hand, a certain number of the germs and a given vitality

Memoranda on Asiatic Cholera; its Mode of Spreading and its Prevention. By William Budd, M.D., etc. Bristol, 1865.