TABLE OF CONTENTS. CHAPTER I.-Clinical history of the epidemic of 1873. II.-Etiology of the epidemic of 1873. III.-On the prevention of cholera. IV. On the origin of the epidemic cholera that reached the V. Narrative of the epidemic in Louisiana. XVII.-Narrative of the epidemic in Minnesota. XVIII.-Narrative of the epidemic in Pennsylvania. XIX.-Narrative of the epidemic in Texas. XX.-Narrative of the epidemic in Iowa. XXI.-Narrative of the epidemic in Dakota. XXII.-Narrative of the cholera cases in New York Harbor. XXIII.-Epidemic as it affected the United States Army. ACKNOWLEDGMENTS. In carrying this work through the press, our thanks are due for much courteous consideration to the Hon. A. M. Clapp, Congressional Printer; to Capt. H. T. Brian, Foreman of Printing; and to the compositors and proof-readers of the establishment. From Acting Assistant Surgeon T. W. Wise, United States Army, of the Library of the Surgeon-General's Office, we have received valu. able aid. To Messrs. W. S. McPherson, T. L. Miller, L. M. Penfield, and F. J. Foster, clerks in the Office of the Surgeon-General of the Army, we are indebted for clerical aid. CHAPTER I. CLINICAL HISTORY OF THE EPIDEMIC OF 1873. During the year 1873, cholera prevailed throughout the entire valley of the Mississippi. The early cases of the disease occurred at the city of New Orleans. From that city, the disease was carried northward, when it became epidemic at all points attacked, although it assumed a pandemic form at none. The occurrence of this epidemic gave rise to a most extended discussion in medical circles, during which there was a greater diversity of opinion expressed than had been occasioned by any disease which had appeared upon the American continent during the past century. The vast majority of the medical men of the United States who were engaged in combating the disease during the progress of the epidemic, both in hospitals and in private practice, are unanimous in pronouncing it to have been Asiatic cholera of foreign origin; making use, in their reports of cases, of the synonym which was individually most acceptable, namely, cholera, cholera epidemica, cholera spasmodica, cholera asphyxia, serous cholera, malignant cholera, &c. A second class, composed of a most respectable number of gentlemen, both numerically and intellectually, recognized the disease to have been cholera in a fatal form, but announced it as American cholera, not epidemic but endemic, having its origin in certain local and malarial influences. A third class reject entirely the cholera hypothesis, and pronounce the disease to have been "pernicious bilious fever of an algid type," "congestive malarial fever," etc., and, when pressed by facts, take refuge behind such terms as sporadic or septic cholera. The key-note to this discussion will be found in the obscurity which surrounds the infection of the initial cases, the consideration of which is referred to the narrative of the epidemic. From the study of this demonstration of the disease, in which the writer has been engaged almost constantly since August, 1873, during which time the records of some seven thousand cases have been obtained from physicians at all portions of the field of infection, he does not hesitate in announcing the disease to have been malignant epidemic cholera. During the entire season, the epidemic was governed by the same well-defined laws that have been presented by all other demonstrations of the same disease. That the intensity of the epidemic was modified and its advance checked at most points was due to the general diffusion of sanitary knowledge throughout the country during the past few years, and not to any change of type in the disease itself; but, at the same time, it is shown that whenever the infection of cholera found a fitting and unmolested nidus, then and there the disease exhibited its fatal malignancy. The truths upon which this assertion is based were most vividly impressed upon the mind of the writer by the direct contact in which, from the necessities of his work, he was placed with a very large number of the medical gentlemen residing in the H. Ex. 95-1 great valley of the Mississippi; and the fact that the disease did not assume its accustomed epidemic form in the larger cities, but that its malignant demonstrations were confined to the smaller towns and villages, is robbed of the significance assigned to it by many observers. The narrative demonstrates that cholera was present in the large cities of the Mississippi Valley, but at the greater number of such points the virulence of the epidemic was controlled by the prompt and energetic action of the health-boards, assisted by the active co-operation of the medical profession and municipal authorities. At the present day, almost every village and hamlet throughout the United States contains medical men who are versed in sanitary science, who demand from local authorities that all efforts be made to preserve the public health, and who are engaged in the diffusion of sanitary knowledge among the members of their respective communities. Each year, the suggestions of local medical societies are received as edicts for the public good. It is claimed for the medical men of the Mississippi Valley that, as practical sanitarians, they are the peers of sanitarians in any other section of the country. How great the change effected in the last decade, and how mighty will be the revolution when the state confers upon health-boards autocratic powers upon all points which may influence or affect the public health! Eternal vigilance is the price paid for the safety of the republic; and eternal sanitary vigilance should be exercised by national, State, and municipal authorities. As, in the narrative of the epidemic, space cannot be taken to note in detail individual instances of the disease, it has been thought best, at this time, to present a history of the symptoms and general course of the epidemic, as it occurred in the Mississippi Valley from February to October, 1873. The clinical history demonstrates that no age, sex, color, or condition in life was exempt from its influences. Fatal cases are recorded as having occurred at all ages, from that of one month to that of one hundred and eighteen years; and it is demonstrated that pregnancy affords no immunity to the disease. The greatest mortalities are recorded between the twentieth and fortieth years of age. Males suffered from the disease more severely than females, and, in proportion to their numbers, blacks than whites. A larger number of cases occurred among those who were married than among the single. The disease was most malignant among the lower orders of each community, but the better classes were by no means exempt. Many who lived in healthy localities, who obeyed all obvious sanitary regulations, suffered in their persons and families. During the epidemic of 1873, the disease presented the four distinct stages, and the characteristic symptoms of each stage, which are now so well recognized as pathognomonic of cholera. THE FIRST STAGE: THAT OF THE PRODROMATA.-In the vast majority of cases which have been reported, the disease was ushered in by a distinct stage, which was characterized by general malaise, borborygmi, and diarrhea; the latter passive, painless, but attended with increasing languor and fatigue. This stage, in the greater number of cases, was from one to five days in duration. Exceptions to this are, however, reported, in which the patient, who was apparently in perfect health, after but one dejection passed into the stage of welldefined cholera. This was especially noticeable in the cases of children, many of whom are reported as retiring to bed at night in their usual good health, to be awakened at an early hour of the morning by a strong desire to go to stool. One copious dejection, and the symptoms of the second stage were immediately developed. In these cases, no definition of stages could be determined; the patient after a single profuse dejection becoming exhausted, and collapsed before medical attention could be procured. SECOND STAGE.-In the majority of the reported cases, the attacks of cholera were announced at an early hour of the morning; the largest number having occurred at or about 3 o'clock a. m., the patient awaking with an active desire to go to stool, which was accompanied with more or less nausea. One profuse dejection was generally followed by active vomiting, and together the two symptoms increased in severity. The dejectious were universally described as "rice-water" in character. At first passed with a sensation of relief, from the overdistention of the rectum, they increase 1 rapidly, both as to frequency and quantity, and became at the last involuntary; the exhaustion as becoming more and more profound after each dejection. Fatal cases are recorded in which the diarrhoea had scarcely been present during the attack; but the first handling of the body after death was followed by copious discharges per anum of the "rice-water" fluid. The vomit is described as consisting at first of the contents of the stomach at the moment of attack; but, as the disease pressed, the fluid, diluted by the water which had been drank, or mixed with the substances which had been swallowed, presented the rice-water charac teristics. Some instances are reported in which the vomiting could scarcely be designated as a symptom of the disease, the act consisting in the simple squirting-out of a mouthful of fluid at a time. The thirst in all instances was intense, and the call for cold water incessant. The cramps were confined, in the majority of instances, to the extremities, commencing invariably in the fingers and toes. But few instances are reported of the abdominal or pectoral muscles becoming involved. One terrible instance of cramping of the pectoral muscles was witnessed by the writer. The voice was described as changed, low, husky, lost, or unnatural. Profuse perspiration was present in all cases. A sensation of intense heat, generally referred to the abdomen, while the surface of the body was so benumbed that sacks containing ashes that had been raked from beneath brisk fires and dampened were borne without the least complaint. Intense restlessness was observed. In many instances, it was with difficulty that the patient could be confined to bed. Lividity and shrinking of the skin were present. Change of facial expression was so great that, in many instances, patients who were before the attack in the full vigor of health presented the appearance of being aged and decrepit. Suppression of urine was marked in all cases, and in many instances this symptom was present far into the stage of reaction. Temperature.-Variations of temperature in the second stage are noted, ranging from 98°, the highest, to 95°, the lowest recorded. One interesting case is recorded by Acting Assistant Surgeon S. L. S. Smith, United States Army, in which, during the second stage of a cholera attack, the temperature in the axilla was 970, under the tongue 960. 6, and in the rectum 1020. The fact that the temperature of the body is lowered by severe cramping is especially noted in some reports. The duration of the second stage is noted at from two to six hours, bat many notable instances are recorded of the patient having rapidly passed through the second stage, and one instance exists of the patient being fully collapsed within twenty minutes from the time of the first vomit and dejection. In this case, the blending of the stages was so |