March 22, 1894] 



NA TURE 



493 



more cases arose in the town or camp, nor did the disease 

 develop on the track of the dispersing pilgrims. And thus we 

 had the novel experience of a Kumbh fair at Hardwar without 

 an epidemic of cholera spreading all over the surrounding country 

 concurrently with the dispersion of the gathering." 



This is unquestionably one of the most remarkable and 

 brilliant achievemenis of sanitation in the whole history of 

 cholera. Not only in India, but also in Europe, has it been 

 demonstrated that cholera is a preventible disease. The history 

 and character of the epidemic which prevailed in France, Italy, 

 and Spain between 1884 and i885, and in Russia in 1892 and 

 1893, was in no way different from what it used to be thirty 

 years ago in other European countries ; it is expressed by stating 

 that the population of villages and towns of whole districts 

 were smitten by disease and decimated by death. But it was 

 different with England and Germany. In 1892 cholera broke 

 out in Hamburg, and asserted itself witli great severity ; the 

 insanitary conditions of its dock and port population, the 

 neglect in supplying Hamburg with wholesome drinking water 

 — Hamburg being then supplied with unfiltered, polluted Elbe 

 water — brought for Hamburg the long-predicted day of reckon- 

 ing. In former years the establishment of such a focus of 

 cholera as Hamburg, having such vast communications and 

 intercourse with the whole of Germany, would have been 

 followed by innumerable foci of cholera all over Germany ; yet 

 we have the remarkable fact that, with the exception of few 

 cases in a limited number of towns, Germany did not suffer 

 from any further epidemic outbreaks. And in a perhaps more 

 striking manner was the same fact illustrated in 1892, here in 

 England. Grimsby, and Hull also, had cases of cholera in 1893, 

 the former officially at the commencement of September, 

 unofficially some weeks before. The sanitary condition of 

 Grimsby, as revealed at the time by inquiry, and published by 

 the Ti?nes and the British Medical journal, remind us, in some 

 respects, almost of the times and conditions of a former genera- 

 tion, and the result, as was to be expected, was an unnecessary 

 loss of life through cholera. But although Grimsby carries on 

 a considerable trade by*rail and sea with the rest of England, 

 and is in notoriously extensive personal railway communication 

 with the rest of the northern and midland counlies [vide the 

 enormous fish and oyster trade of Grimsby and Cleethorpes, 

 and the extensive tourist communication with Cleethorpes), with 

 two or three exceptions in which a small local outbreak occurred 

 (Ashbourne, Derbyshire ; Rotherham, Yorkshire ; North 

 JBierley, Staffordshire), only isolated cases of cholera were 

 noticed in the rest of England. What is this comparative 

 immunity due to, what is the cause of the conspicuous 

 limitation of cholera, that has been experienced lately both in 

 England and Germany ? In both countries foci of cholera had 

 been established, sufficient, judging from former experience, 

 for the dissemination and production of cholera in an epidemic 

 form in numbers of localities, and although the transmission 

 and spread of cholera from the first foci, owing to the 

 increased facilities of human intercourse, was possible in a 

 greater degree than in former periods, yet the country remained 

 practically free from cholera epidemics. 



Sir John Simon has years back insisted on the importance 

 of considering cholera, as also typhoid fever, as a "filth dis- 

 ease ' ; that is to say, both in cholera and in typhoid fever the 

 contagium voided with the dejecta of a patient, affected with 

 the one or the other disease, is capable of setting up the dis- 

 ease, if it finds access to the alimentary canal of a susceptible 

 person, either by specifically polluted drinking water or 

 articles of food, or by the instrumentality of the hands that 

 had been in contact with specifically soiled linen or other textile 

 articles. 



Since the recognition of these facts it has become an axiom 

 insanitary science to isolate the patient, to disinfect or destroy 

 not only the dejecta, but all articles that may have become 

 soiled by the dejecta of a patient affected with cholera, to pre- 

 vent such filth from gaining access to drinking water and to 

 articles of food, and to insist that the hands that have been in 

 contact with such soiled articles ought to be scrupulously 

 cleansed in order to avoid self-infection ; in short, to prevent 

 and to avoid the contagium being "swallowed."' By carrying 

 out these precepts it has become possible, and, as events proved, 

 it has been successfully accomplished that cholera'did not spread 

 epidemically either at the last Kumbh fair at Hardwar, or in 

 England or in Germany. This success implies two things : (i) 

 the locality, prior to the introduction of a case of cnolera, should 



NO. 1273. VOL. 49] 



be in a proper sanitary condition, and (2) on the appearance of 

 a case of cho'era the measures for isolation and disinfection 

 should at once be put in practice ; there should be no attempt 

 at hiding or ignoring, but boldly and openly the fact should be 

 recognised, and action taken accciJingly ; for if in any locality 

 even a few cases are allowed to pass undealt with, and supposing 

 the sanitary conditions of that locality be of an inferior char- 

 acter, the dissemination of the contagium and the creation of a 

 number of further and independent foci may in a short time 

 bring about a state of things in which the check of the epidemic 

 spread of the disease becomes a matter of the greatest difficulty 

 — an occurrence which had its illustration both in Hamburg and 

 in Grimsby. Though a great portion of England may claim to 

 be fairly well prepared, as far as general sanitation, drinking- 

 water, drainage, and general cleanliness are concerned, it is 

 notorious that there remain localities which escaped a visitation 

 by cholera during last year ; but their luck may not hold out on 

 a second occasion, and a day of reckoning may arrive on which 

 they will be rudely awakened, like Hamburg, to the fact that 

 by their negligence in the past they have to pay a heavy penalty 

 in human life. 



Now, it will be asked, is it a fact that those isolated cases 

 which occurred in different localities in England during the 

 last autumn were really cases of true or Asiatic cholera, and 

 that owing to the better preparation and stricter execution in 

 regard to sanitary measures, insisted on by our Public Health 

 authorities, those isolated cases did not spread, and were not 

 followed by further outbreaks of the disease? It must be evi- 

 dent that if those cases were not cases of true cholera — that 

 is to say, if they were of the character of that disease 

 which occurs in each year during the summer and autumn in a 

 sporadic form, known as English cholera or cholera nostras, then 

 the above proposition as to the supposed superiority of our sani- 

 tation for the prevention of the spread of epidemic or Asiatic 

 cholera remains as yet untried and has still to be proved. No 

 one, I presume, will deny that we had in September, 1893, true 

 or Asiatic cholera in Hull, Grimsby, and certain other places ; 

 the character of the disease, the grouping of the cases, and the 

 high percentage of mortality prove this ; besides, it is known 

 that cases of cholera have reached our shores both in 1892 and 

 1893. Similarly, it will not be denied that the cases that oc- 

 curred in Rotherham, Ashbourne, and North Bierley were of the 

 same nature ; the symptoms, the epidemic character, and the 

 high fatality alone prove this. But what has been questioned is 

 whether the isolated cases which occurred in Retford, Leicester, 

 Derby, Doncaster, Yarmouth, London, and other places, were 

 true cholera. Now, it is agreed that as regards their clinical 

 history and mortality (these were all fatal cases) a distinction be- 

 tween them and typical true cholera could not be drawn. But 

 it is said that {a) on account of their occurring as isolated cases, 

 and (l>) on account of the impossibility of tracing the way in 

 which the infection had been imported, the proof that they were 

 cases of true cholera has not been satisfactorily established. 



As to {a). If in any locality after the appearance of one or 

 more suspicious choleraic cases there should follow, sooner or 

 later, a gradually increasing number of similar cases with high 

 fatality, the preliminary conclusion that these are cases of true 

 cholera is justified. But whether in any locality one case is 

 followed by others, or remains an isolated one, obviously depends 

 on the condition whether the contagium, either by the prevailing 

 insanitary conditions, or by the laxity of the application of 

 sanitary measures, has or has not been allowed to take a footing 

 and to spread ; for if, as stated above, the conditions as to drink- 

 ing water, drainage, &c. are satisfactory, and if on the intro- 

 duction of the first case this is at once isolated, its dejecta 

 disinfected and destroyed, and infection from it therefore pre- 

 vented from being disseminated, it is clear that no further cases 

 would be forthcoming. The epidemic diffusion of the disease 

 depends then on deficient sanitation, and cannot therefore be a 

 distinguishing character between what is true and what is not 

 true cholera. No one doubts that the few cases that were im- 

 ported from cholera-infected districts in 1891 into Hardwar were 

 cases of true cholera, yet we saw that owing to the excellent and 

 thorough sanitary measures taken before and during the fair no 

 epidemic occurred ; those few cases therefore remain cases of 

 true cholera, notwithstanding the unwonted absence of an 

 epidemic outbreak. 



In a like manner it must be evident that numbers of persons 

 that contracted the infection in Hamburg in 1892 travelled to 

 many places in Germany where they sickened of, and some of 



