CHOLERA 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. Bacteriology, as already intimated, has thrown no light upon it, nor has meteorology. Some results of modern research, indeed, tend to assign increasing importance to the relations between surface soil and certain micro-organisms, and suggest that changes in the level of the subsoil water, to which Pettenkofer long ago drew attention, may be a dominant factor in determining the latency or activity of pathogenic germs. But this is largely a matter of conjecture, and, so far as cholera is concerned, the conditions which turn an endemic into an epidemic diease must be admitted to be still unknown. On the other hand, the mode of dissemination is now well understood. 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. 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. 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. Flies which feed upon excreta and other foul matters may be carriers of contagion. 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 watersupply. 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. But it would be a mistake to regard cholera as purely a waterborne disease, even locally. It may infect the soil in localities which have a perfectly pure water-supply, but have defective drainage or no drainage at all, and then it will be found more difficult to get rid of, though less formidable in its effects, than when the water alone is the source of mischief. In all these respects it has a great affinity to enteric fever. With regard to locality, no situation can be said to be free from attack if the disease is introduced and the sanitary conditions are bad; but, speaking generally, low-lying places on alluvial soil near rivers are more liable than those standing high or on a rocky foundation. 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. • 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 'diffusion. Int^a and Afghanistan, thence to Persia and Central Asia, and so to Russia. In the great invasions of Europe during the 19th century it sometimes followed one route and sometimes the other. Four
49
such invasions are mentioned in the article in the ninth edition of the Encyclopaedia—those of 1830-39, 1847-49, 1853-54, and 1865-67—but by some writers the epidemic of 1853 is regarded as a recrudescence of that of 1847. The earlier ones followed the land route by way of Afghanistan and Persia, and took several years to reach Europe. That of 1865 travelled more rapidly, being carried from Bombay by sea to Mecca, from there to Suez and Alexandria, and then on to various Mediterranean ports. Within the year it had not only spread extensively in Europe, but had reached the West Indies. In 1866 it invaded England and the United States, but during the following year it died down in the West. The subsequent history of cholera in Europe may be stated chronologically. 1869-74.—This invasion was traced to the great gathering of pilgrims at Hardwar on the Upper Ganges in the month of April 1867. From there the returning pilgrims carried it to the Punjab, Cashmere, and Afghanistan, whence it spread to Persia and the Caspian, but it did not reach Russia until 1869. During the next four years a number of outbreaks occurred in Central Europe, and notably one at Munich in the winter of 1873. The irregular character of these epidemics suggests that they were rather survivals from the pandemic wave of 1867 than fresh importations, but there is no doubt that cholera was carried overland into Russia in the manner described. 1883-87.—This visitation, again, came by the Mediterranean. In 1883 a severe outbreak occurred in Egypt, causing a mortality of above 25,000. Its origin remained unknown. During this epidemic Koch discovered the comma bacillus. The following year cholera appeared at Toulon. It was said to have been brought in a troopship from Saigon in Cochin China, but it may have been connected with the' Egyptian epidemic. A severe outbreak followed and reached Italy, nearly 8000 persons dying in Naples alone. In 1885 the south of France, Italy, Sicily, and Spain all suffered, especially the last, where nearly 120,000 deaths occurred. Portugal escaped, and the authorities there attributed their good fortune to the institution of a military cordon, in which they have had implicit confidence ever since. In 1886 the same countries suffered again, and also Austria-Hungary. From Italy the disease was carried to South America, and even travelled as far as Chile, where it had previously been unknown. In 1887 it still lingered in the Mediterranean, causing great mortality in Messina especially. According to Dr Wall, this epidemic cost 250,000 lives in Europe and at least 50,000 in America. A particular interest attaches to it in the fact that a localized revival of the disease was caused in Spain in 1890 by the disturbance of the graves of some of the victims who had died of cholera four years previously. 1892-95.—This great invasion reverted again to the old overland route, but the march of the disease was of unprecedented rapidity. Within less than five months it travelled from the North-West Provinces of India to St1 Petersburg, and probably to Hamburg, and thence in a few days to England and the United States. This speed, in such striking contrast to the slow advance of former occasions, was attributed, and no doubt rightly, to improved steam transit, and particularly the Transcaspian railway. The progress of the disease was traced from place to place, and almost from day to day, with great precision, showing how it moves along the chief highways and is obviously carried by man. The main facts are as follows :—Cholera was extensively and severely prevalent in India in 1891, causing 601,603 deaths, the highest mortality since 1877. In March 1892 it broke out at the Hardwar fair, a day or two before the pilgrims dispersed; on 19th April it was at Kabul, on 1st May at Herat, and 26th May at Meshed. From Meshed it moved in S. III. — 7
