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to peculiarly favor their rapid and virulent multiplication. Badly drained and badly ventilated localities excluded from the purifying influences of fresh air and sunshine, which go hand in hand with filth and insanitation, furnish the best possible condi. tion for the growth and multiplication of these germs when placed in such localities.
Observation and experiments have also established the fact that cholera bacilli do not and cannot flourish in an acid medium, and that the most minute quantity of mineral acid will destroy their vitality.
This corresponds with the observation of all who have participated in cholera epidemics. It is those persons with lowered vitality, poor digestion, with alkaline stomachs from abnormal gastric secretions, and especially old alcohol habitues whose stomachs are of typical alkalinity, who first fall victims to the disease ; while those with normal digestion and physiologically acid gastric juices, if prudent in eating and drinking, seldom if ever yield to the infection.
Then, the conclusions from these accepted theories are that cholera, to gain access to a locality, must be brought thence in the system of persons, or by means of clothing or fomites soiled by cholera dejection, in which the vitality of the germs still survives ; that it always follows in the line of human travel, commerce, and traffic ; that the matter containing the vitalized cholera bacilli must find a lodgment in some suitable medium, place, and temperature, when they multiply and increase rapidly, with all the conditions for infection. They do not sporillate, and, as before stated, are not susceptible of being borne through the air by wind currents ; therefore contaminated air and mephitic gases may be eliminated from the list of exciting causative factors.
Drinking water has long been regarded as a conspicuous agent in the spread of the disease, and the theories of the day retain this idea in all its conspicuousness. Just how this occurs has never been quite clear to my mind, as cholera bacilli do not live and multiply in pure water, and were only found by Dr. Koch in the filthy bathing-pools along the lower Ganges in Asia. The theory, however, is that these germs, by various methods, enter the drinking water, and thus clandestinely find their way into
the stomachs of their victims. It is claimed that the teeming myriads of these organisms which swarm upon a soil when once infected by them are washed with the water which percolates through the earth's surface, and thus drift into springs, wells, and other receptacles from which drinking water is obtained. This is favored by the geological formation of limestone regions, and if true may account for the popular idea that limestone water invites the disease.
There are other and many methods and avenues by and through which these germs might find their way into drinking water, milk, and other fluids consumed. They also gain access into the human stomach upon vegetables, fruits, eating and drinking utensils, and perhaps hundreds of other ways. There can be no question but that flies and other insects are the frequent carriers of these as well as other pathogenic germs.
These are the popular and dominant theories of the day, and upon their accuracy the sanitary world is staking the lives and hopes of the people. They constitute the tactics by which we are disputing the power of this foreign enemy to invade our continent and unfurl its sable banners upon our shores.
As before stated, there are a few who do not accede to these views. Prof. Von Pettenkoffer has long entertained and promulgated a theory which he and his few but prominent followers have not yielded to the more popular and recent Koch idea of the origin of cholera. He disputes the popular drinking-water theory of the origin of the disease, and does not believe that it is absolutely essential that cholera bacilli should enter the intestines from without to develop the disease, but that the organisms (the omnipresence of which in the intestines of cholera patients cannot be disputed), are but the innocent denizens always existing in the intestines, stimulated into pathological activity and modified somewhat in characteristics by a principle of some kind borne through the atmosphere, a kind of miasm cultivated and intensified by certain soil conditions, giving to the disease endemic characteristics. These soil conditions are contamination and what he terms grund wasser, or wet soil. Prof. Pettenkoffer's theory is that such a soil, so wetted and contaminated, becomes a hot-bed for cholera infection ; and, when once inoculated by cholera influences at a proper temperature, the atmosphere becomes contaminated by an infectious principle, which may gain access into the human economy through the lungs as well as stomach, and there arouse the usually harmless comma bacillus into pathological activity.
Prof. Pettenkoffer, to show the sincerity of his convictions in this matter, has recently made some important experiments upon himself, which he published in a lecture recently delivered at Munich. He took into his stomach, probably on several occasions, cubic centimeter doses of pure agar cultures of cholera bacilli obtained from Hamburg, after having placed the organ in the most receptive condition by selecting a time sufficiently long after eating to insure the minimum of gastric juice and hydrochloric acid, and, to further insure alkalinity, taking bicarbonate of sodium in alkaline water. This procedure, while filling the intestines with cholera bacilli, did not produce the characteristic disease ; from which he argues that some other cholera epidemic influence is essential to develop the disease besides the Koch bacilli.
All must concede that, during epidemics of this disease (if the Koch theory be accepted), nearly everyone who is not exceptionally cautious must receive cholera germs into the intestines. This is confirmed by microscopic examinations of excreta during epidemics showing that many persons who have no disease mani. festations yet have cholera bacilli in the intestines. It fortunately requires a certain amount of predisponent influences, & receptivity of person, to yield to the influence, which probably Dr. Pettenkoffer did not at that time possess ; so that his experiments are really barren of decided and convincing significance.
The theory of the atmospheric conveyance of the infection is controverted in India, the home of the disease, where its spread or advance is clearly not controlled by the monsoon or prevailing wind of that country, but often pursues a diametrically opposite direction from the air currents, following the lines of travel, traffic, and individual communication. So that, while probably the Koch theory of the origin of cholera may not harmonize to our liking in its every feature, it certainly is the best we have up to the present time; and from its teachings and the legitimate deductions therefrom I propose to argue my theories of treatment, and, if occasion shall require, to erect my defenses and give battle to the enemy, unless more rational methods shall be devised.
Preventives.—Unquestionably the most effective preventive is national exclusion, which comes properly under the province of quarantine, and forms no part of my subject. But should the scourge succeed in crossing our borders, then the line of duty of the intelligent physician (for, no matter how indifferent legislators and public functionaries may be to his suggestions and appeals in times of health and prosperity, in occasions of great calamity, when death stalks abroad in the land, all eyes are turned to him for advice and counsel), consists in measures of prevention and cure. The former may be divided into Public Sanitation, Individual Sanitation, and Therapeutic Prevention.
Observations in the various outbreaks of cholera in this country, as well as in the East, have established one fact beyond the possibility of controversion, that it is in those localities where filth and bad hygienic regulations exist that the disease makes it worst ravages, and that it is in those particular localities in cities noted for the neglect of the laws of public and private decency and police regulations that the death rate is highest during the prevalence of the disease. Therefore, it matters but little whether we accept the Koch theory that the pathogenic germs must be cultivated under favorable conditions and afterward find their way into the human intestines, or the Pettenkoffer grund wasser idea that some mephitic or miasmatic principle must be generated in a contaminated soil, under pretty much the same conditions, and enter the human economy in some way to arouse the innocent and formerly harmless germ parasites into virulent pathological activity ; or yet the theory of Klein who maintains in a recent production that the cholera spirillum, so called, is not the effective factor in the etiology of Asiatic cholera ; all agree that these conditions do invite and favor the spread of the disease. Therefore, intelligent public sanitation consists in correcting and destroying these conditions, in watching vigilantly for foci of infection and in circumscribing the same. Dryness of soil is attained in small towns and rural localities by intelligent ditching and drainage of damp and humid localities. In cities, the whole subject may nearly be embraced in thorough sewerage and enforced employment of the same. Where this is done the amount of moisture necessary to maintain a favorable culture field for sensitive cholera germs cannot exist; the ground water level sinks below the culture range. Next, all portions of the city, especially the lowest and most neglected, should be thoroughly cleaused of surface contaminations. Surface privies should be abolished. The throwing of slops of whatsoever kind upon the ground should be prohibited, and all existing débris should be carted off and consumed by fire. In a word, the soil should be made and retained clean and dry. The sunlight and air should be admitted to every available spot. There is no germicide or antiseptic so effective as this. · The too common practice of sprinkling dry lime upon damp and filthy spots, hoping thereby to render them non-infective, is a delusion and a snare. It covers up for a time but protects nothing. It is a useless and expensive fallacy. In cities, a house-to-house inspection of prem ises and back-yards should be rigorously, intelligently, and impartially carried out in time of threatened epidemics, and the strictest sanitary rules enforced.
The first case should be vigilantly watched for, and every physician should constitute himself a committee of one to perform this duty. It is the first doubtful case, over which doctors often dispute and wrangle, which does the mischief and sows the seeds of infection. Give the public the benefit of the doubt. All questionable cases (and many such occur every summer), should be watched and guarded, and the excreta disinfected and destroyed until after careful microscopic examination can be made and diagnosis rendered. If the disease should obtain a foothold, and a focus of infection become established, it should be isolated and quarantined, and when practicable the buildings where it occurred burned.
The sanitary report of Dr. Biggs shows that not less than ten cases of genuine Asiatic cholera occurred in the city of New York last fall, and but for the fact that the vigilant health department of that city pursued the course indicated, the disease would in all probability have become epidemic, not only there but over the whole country. Contamination of water supply should be looked to most sedulously. Spring or well water, where there exists a possibility of sipage or drainage from infected localities, should be prohibited. The restriction or prohibition of the sale