“ Of all the means of local dissemination, contaminated water is by far the most important, because it affects the greatest number of people, and this is particularly the case in places which have a public water-supply. A single contaminated source may expose the entire population to danger. All severe outbreaks of an explosive character are due to this cause. It is also possible that the cholera poison multiplies rapidly in water under favourable conditions, and that a reservoir, for instance, may form a sort of forcing-bed. ”

“ The general success of Great Britain and Germany in keeping cholera in check by ordinary sanitary means completed the conversion of all enlightened nations to the policy laid down so far back as 1865 by Sir John Simon, and advocated by Great Britain at a series of international congresses—the policy of abandoning quarantine, which Great Britain did in 1873, and trusting to sanitary measures with medical inspection of persons arriving from infected places. ”

“ In 1894 no deaths from cholera were recorded in England, but on the continent it still prevailed over a wide area. In Russia over 30,000 persons died of it, in Germany about 500, but the most violent outbreak was in Galicia, where upwards of 8000 deaths were registered. In 1895 it still lingered, chiefly in Russia and Galicia, but with greatly diminished activity. In that year Egypt, Morocco and Japan were attacked, the last severely. The disease then remained in abeyance until the severe epidemic in India in 1900. ”

“ When the attack of cholera is of milder character in all its stages than that above described, it has been named Cholerine, but the term is an arbitrary one and the disease is essentially cholera.
The bodies of persons dying of cholera are found to remain long warm, and the temperature may even rise after death. Peculiar muscular contractions have been observed to take place after death, so that the position of the limbs may become altered. The soft textures of the body are found to be dry and hard, and the muscles of a dark brown appearance. ”

“ The type reached by cultivation through a few generations may differ so widely from the original in appearance and behaviour as to be hardly recognizable, while, on the other hand, of two organisms apparently indistinguishable one may be innocuous and the other give rise to the most violent cholera. This variability offers a possible explanation of the frequent failure to trace the origin of epidemic outbreaks in isolated places. ”

“ At irregular intervals this property becomes so heightened that the disease passes its natural boundaries and is carried east, north and west, it may be to Europe or beyond to the American continent. We must assume that the micro-organism, like those of other epidemic diseases, acquires greater vitality and toxic energy, or greater power of reproduction at some times than at others, but the conditions that govern this behaviour are quite unknown, though no problem has a more important bearing on public health. ”

“ In the treatment of this disease as it affects young children (Cholera Infantum) , most reliance is to be placed on the administration of chalk and the use of starch enemata. In their case opium in any form cannot be safely employed.
Malignant Cholera (synonyms, Asiatic Cholera, Indian Cholera, Epidemic Cholera, Algide Cholera) is one of the most severe and fatal diseases. In describing the symptoms it is customary to divide them into three stages, but it must be noted that these do not always present themselves in so distinct a form as to be capable of separate recognition. ”

“ Curiously enough, the south of Europe, which had been the scene of the previous epidemic visitation, escaped. The disease was of the most virulent character. In European Russia the mortality was 45.8% of the cases, the highest rate ever known in that country; in Germany it was 51.3%; and in Austria-Hungary, 57.5%. Of all the localities attacked, the case of Hamburg was the most remarkable. The presence of cholera was first suspected on the 16th of August, when two cases occurred, but it was not officially declared until the 23rd of August. ”

“ There is no reason to suppose that it is air-borne, or that atmospheric influences have anything to do with its spread, except in so far as meteorological conditions may be favourable to the growth and activity of the micro-organisms. Beyond all doubt, the great manufactory of the poison is the human body, and the discharges from it are the great source of contagion. ”

“ The diarrhoea which accompanies or succeeds the vomiting, and is likewise of bilious character, is attended with severe griping abdominal pain, while cramps affecting the legs or arms greatly intensify the suffering. The effect upon the system is rapid and alarming, a few hours of such an attack sufficing to reduce the strongest person to a state of extreme prostration. The surface of the body becomes cold, the pulse weak, the voice husky, and the whole symptoms may resemble in a striking manner those of malignant cholera, to be subsequently described. ”

“ Occasionally the disorder prevails so extensively as to constitute an epidemic. The exciting causes of an attack are in many cases errors in diet, particularly the use of unripe fruit and new vegetables, and the excessive drinking of cold liquids during perspiration. Outbreaks of this disorder in a household or community can sometimes be traced to the use of impure water, or to noxious emanations from the sewers.
In the treatment, vomiting should be encouraged so long as it shows the presence of undigested food, after which opiates ought to be administered. ”

“ All goods are freed from restrictions, except rags and articles believed to be contaminated by cholera matters. By land, passengers from infected places are similarly inspected at the frontiers and their luggage “disinfected”—in all cases a pious ceremony of no practical value, involving a short but often a vexatious delay; only those found suffering from cholera can be detained. ”

“ Diffusion takes place along the lines of human intercourse. The poison is carried chiefly by infected persons moving from place to place; but soiled clothes, rags and other articles that have come into contact with persons suffering from the disease may be the means of conveyance to a distance. ”

“ Lower Bengal is pre-eminently the standing focus and centre of diffusion. In some years it is quiescent, though never absent; in others it becomes diffused, for reasons of which nothing is known, and its diffusive activity varies greatly from equally inscrutable causes. ”

“ Cholera spreads westwards from India by two routes— (1) by sea to the shores of the Red Sea, Egypt and the Mediterranean; and (2) by land to northern India and Afghanistan, thence to Persia and central Asia, and so to Russia. In Western diffusion.the great invasions of Europe during the 19th century it sometimes followed one route and sometimes the other. It was not till 1817 that the attention of European physicians was specially directed to the disease by the outbreak of a violent epidemic of cholera at Jessore in Bengal. ”

“ Of meteorological conditions it can only be said with certainty that a high temperature favours the development of cholera, though a low one does not prevent it. In temperate climates the summer months, and particularly August and September, are the season of its greatest activity. ”

“ In this condition death often takes place in less than one day, but in epidemics cases are frequently observed where the collapse is so sudden and complete as to prove fatal in one or two hours even without any great amount of previous purging or vomiting. In most instances the mental faculties are comparatively unaffected, although in the later stages there is in general more or less apathy. ”

“ In Persia also a recrudescence took place and proved enormously destructive. Dr Barry estimated the mortality at 70,000. At Hamburg, where new waterworks had been installed with sand filtration, only a few sporadic cases occurred until the autumn, when a sudden but limited rush took place, which was traced to a defect in the masonry permitting unfiltered Elbe water to pass into the mains. In England cholera obtained a footing on the Humber at Grimsby, and to a lesser extent at Hull, and isolated attacks occurred in some 50 different localities. ”

“ In unfavourable cases, particularly where the disorder is epidemic, death may result within forty-eight hours. Generally, however, the attack is arrested and recovery soon follows, although there may remain for a considerable time a degree of irritability of the alimentary canal, rendering necessary the utmost care in regard to diet. ”

“ These things imply a regular organization, and it is to the public health service of Great Britain that the complete mastery of cholera has mainly been due in recent years, and particularly in 1893. Of sanitary conditions the most important is unquestionably the water-supply. So many irrefragable proofs of this fact were given during 1892–1893 that it is no longer necessary to refer to the time-honoured case of the Broad Street pump. At Samarkand three regiments were encamped side by side on a level plain close to a stream of water. ”

“ They may infect the ground, the water, or the immediate surroundings of the patient, and so pass from hand to hand, the poison finding entrance into the bodies of the healthy by means of food and drink which have become contaminated in various ways. ”

“ The provisions agreed on included the inspection of pilgrims at ports of departure, detention of infected or suspected persons, and supervision of pilgrim ships and of pilgrims proceeding overland to Mecca. ”