Popular Science Monthly/Volume 27/May 1885/Cholera IV
By Dr. MAX VON PETTENKOFER.
THE last sheet-anchor of the contagionists is always the linen of cholera-patients. But this view rests on such debatable ground that in the end it may prove to be fallacious. If cholera is really spread through human intercourse, then it is clear that the unknown specific something must accompany other vehicles, which may be man himself; and if this something can cause illness in man, then it must reside in the system of the patient, and ought to be found there. There can be no doubt of this; and I am prepared to admit as much. Thirty years ago I began my investigations on cholera in the belief that the germs of cholera were contained in the stools; but afterward, having made sure that cholera was dependent on locality as well as human intercourse, I endeavored to see how this relationship obtained by asking myself what was brought to the soil by man in his journeyings. The reply was, urine and stools—his excrements and nothing else. This view ripened into the belief that disinfection of the excreta and their receptacles ought to be a prophylactic measure against the spread of cholera, and excreta which had not been disinfected constituted a source of danger. These thoughts occupied me up to April, 1866, when I published with my lamented friends, Griesinger and Wunderlich, some regulations on cholera; and I first relinquished these views when further study showed the uselessness of measures of disinfection as well as the harmlessness of the undisinfected excreta of cholera-patients. If the poison of cholera be contained in the excreta, then, individual predisposition aside, those who mostly come in contact with the excreta ought to be most frequently affected. And these should be the various physicians and nurses in hospitals devoted to the care of cholera-patients. But experience has clearly shown that the medical attendants in cases of cholera are not more prone to take the disease than others. The like holds good of nurses. Let us first of all consider how the facts stand in the home of cholera, in India. During 1867, in which the epidemic at Hurdwar prevailed, James Cuningham investigated the relationship of cholera to nurses in forty garrison towns containing sixty-seven hospitals; of the sixty-seven hospitals only eight gave instances of cholera in the nurses; the largest number of cases occurred at Dharmsala, where there were eleven, Kasanli had three, Muttra and Moradabad each two, Fazabacl, Lakknau, Mirat, and two others one each. An epidemic among the nurses can therefore only be spoken of in the hospital of the First Ghorka Regiment stationed at Dharmsala, where eight nurses, two porters, and one other officer were taken ill of the disease. These statements show how exceptional such occurrences are. Why should not a hospital as well as a garrison now and again be a center of infection? Closer investigation proves, however, that the personnel of the hospital at Dharmsala was not affected in a greater degree than the population outside the hospitals. It may be shown that the percentage of cases of cholera among the outside population was 8·01; in other words, that eighty-six cases occurred out of 1,073, while of the hospital staff of 127 eleven fell ill, or a percentage of 8·66. Cuningham also inquired whether the immunity enjoyed by nurses could be explained by disinfection. He found from ancient sources that this striking immunity of nurses was by no means a new thing, and had certainly obtained before the days of disinfection. He draws attention, among other writings, to an experience of Dr. Bruce, who wrote: "In 1848 cholera broke out among the infantry at Caenpur from May to September. During the whole time the hospital was never free from single cases of cholera, and at times it was overfilled with them. The whole institution may be said to have lived in the rooms of the sick; the coolies did not leave the beds of the sick for an hour together, the physicians had much to do with the treatment of the patients; and yet not a man, whether European, half-caste, or native, showed a single symptom of cholera. I took the greatest pains to collect and sift these circumstances, but in this year not a single instance occurred." In India a practical use is made of this knowledge under the exceptional circumstances of the nurses being attacked. Nothing is said of isolation and disinfection; but the site on which the hospital stands is looked upon as unfavorable, and a change is made. This change of place is called by the English a movement, and as a prophylactic measure comes within the first ranks. If the site to which a movement has been made prove to be more unfavorable than that which was quitted from the frying-pan into the fire the movement has not availed anything. No good comes of the movement if the personnel has been already infected as much as possible. The Sixty-sixth Ghorka Regiment in its march through Tarai was not spared when it reached the Naini Valley; but, probably, if it had stayed a day longer in Tarai, the percentage of illness, instead of being ten, would have been twenty. It is the same as regards nurses and hospitals in Europe. I shall refer to Munich intentionally, not because it had so frequently been the seat of cholera (Munich had cholera once to Berlin's twelve times), but because I am better acquainted with the particulars. During the epidemic of 1873-'74 we had three hospitals —the hospital on the left bank of the Isar, in Lindwurmstrasse, and that on the right bank of the river in Ismaningenstrasse, and the military hospital in Oberwiesenfeld. Cholera behaved in each hospital just as it behaved in the houses in their immediate neighborhood. Cases of cholera appeared in all three hospitals. In that on the left bank of the Isar there was rejoicing on account of the supposed success of isolation and disinfection until August 10th, when the summer epidemic reached its height; then an epidemic suddenly broke out. This was at the time that the epidemic developed in Lindwurmstrasse, in which the hospital was situate, and the epidemic in the hospital subsided as the epidemic in the street gave way. In the hospital on the right bank of the Isar the rejoicings lasted longer. The Ismaningenstrasse took no part in the summer epidemic, and neither did the residents of the hospital. But in the winter epidemic the same course of affairs took place as had occurred on the left bank of the river. The military hospital escaped all along. Of the seven barracks in Munich any cases or suspected cases of cholera were immediately sent to the military hospital. Now and again a surgical patient or a patient suffering from other illness than cholera was put among other patients, and later on suffered from cholera. Such cases were of course removed to the cholera division as soon as the stools betrayed the case. At times the cholera division was very full, and many nurses were employed therein; but none of these fell ill or gave the least indication of cholera, though many of them must have come in very close relation with the cholera stools. In the military hospital in Müllerstrasse the same facts were observed as were met with in the case of the other hospitals. Seeing how little contagious cholera is among the nurses, it appears very remarkable that the washers of cholera-linen should suffer so much. I think I hear a contagionist say that why nurses of cholera-patients in hospitals are not infected may be easily explained when it is borne in mind that great cleanliness exists, that there is much washing of hands, that they do not eat with unwashed hands, and that whatever spurts on their clothes is rapidly dried, and dryness kills the bacillus. On the contrary, among the washers of cholera-linen it is easy to imagine that drops may be spurted into the mouth, or that infective material may be conveyed on wet fingers to the lips, and if a solitary bacillus gets into the intestines cholera may occur. How can this be seriously discussed? Can it be supposed that the nurses wash their hands only in certain hospitals, and during certain times, and that the chances of taking in the bacilli are less during the cleansing and attention to a patient than in washing the clothes? Do such nurses never put the moistened fingers to their lips? Do their noses never itch? The explanation of the contagionists appears to me to be very comical. And yet there are cases in which the infection must have been derived from the linen soiled by cholera-stools. A very interesting case came under my observation at Lyons in the washing-village of Craponne. In the "Gazette Médicale de Lyon" for 1854, page 252, we read from a letter by Dr. Gensoul: "In the month of July, 1854, two fugitives, a man and his wife, from cholera, alighted from Marseilles at the Milanese court. They had hardly arrived before they were attacked by cholera, the germs of which they had brought with them, and both died on July 17th. Some days later the washers of the Gasthof Bouchard in Craponne, a village about twelve kilometres from Lyons, came to fetch the linen for the wash. The soiled clothes and linen of the cases of cholera were given out in a separate bundle, placed in a separate part of the cart, and finally given to a washerwoman to clean. The washer-woman was struck down by a rapidly fatal cholera, and the washer's daughter shared the same fate. No other cases of cholera existed in the district on which the blame could be thrown. Such a choice of victims needs no comment." The cholera was not limited to the two cases. J. Garin ("Gazette Médicale," p. 309) says that eight cases of death followed in Craponne, and among them the washer's wife. From the statistics of Dr. Garin it is gathered that the disease attacked almost exclusively the washing-folk and their children. The population of Craponne numbers about 1,600 inhabitants, several families of which have charge of the washing for the hotels of Lyons. As a later report of Dr. Bouchet showed, there were besides twenty-five other cases of cholera, with fifteen recoveries and ten deaths, which occurred in the course of two months. The year 1854 was that in which the lower-lying parts of Lyons were invaded by an epidemic. It remains a striking fact that in the fair-sized village of Craponne cholera attacked almost exclusively the laundry-workers. With the exception of the washers, Craponne might be regarded as a place free from cholera. In 1855 severe epidemics prevailed in villages near Lyons—e. g., St. Bonnet and St. Laurent de Mure—though the outlying districts always enjoyed immunity from cholera. The same held good of other exempt districts. A very instructive example of this kind is furnished by Stuttgart in 1854, which is usually exempt from cholera. At the time when the severe epidemic prevailed at Munich an inhabitant of Stuttgart left Munich while he was suffering from diarrhœa, and arrived at Stuttgart, where he became worse and died of cholera. A few days later a case occurred in the person of a woman who had never left Stuttgart. She was the nurse of the case which had come from Munich. This case might be quoted as one of direct contagion. Again, after some days, a third case appeared, and this time it was the washer-woman who had cleaned the clothes of the first case. Finally, the washer-woman's husband suffered from cholerine. But no further cases appeared. Such cases are always wrongly interpreted by the contagionists as examples of direct infection, and such, at first sight, appears to be the case. If the case from Munich had infected the three at Stuttgart, how was it that none of the three infected other individuals? For it must be remembered that the cases at Stuttgart and at Craponne must have been tended and their linen washed. How was it that no further cases occurred, and that an epidemic was not started? The linen of the case from Munich was poisonous, but not that from the cases at Stuttgart! Must we not also suppose that another factor is necessary to explain the further spread of cases introduced from without? And this local factor was wanting at Craponne and Stuttgart. If a case from Munich caused three at Stuttgart, then the latter ought to produce nine. In places which enjoy immunity from epidemics it is conceivable that sporadic cases may occur, but, the conditions which are necessary for the production of an epidemic being wanting, no further development can take place. The soiled linen appears to me to be infective not because it comes from cases of cholera, but on account of its arrival from a locality where cholera prevails. Perhaps linen is a good vehicle for transmitting the infective material produced in a locality under the necessary circumstances of time and place. Man is the only creature that wears linen, and perhaps he alone spreads cholera, and it is possible that whether he were clothed or naked he would spread it just as much and no more. But, if we accept this doubtful solution of the Gordian knot, still the views of the contagionists on the dejecta of cholera and the soiled linen would not stand on a firmer basis, since we see not only individual cases but actual epidemics arising without the introduction of soiled linen. The infective material which produces cholera may be transmitted at all events in other ways along the paths of human intercourse. The germs of cholera may be brought from a locality to a place where the necessary relations of time and place are not favorable for the epidemic development of cholera, and they may there slumber for a month before they develop. There is every chance for the propagation of cholera in India, and yet cholera only shows itself fitfully in districts lying outside the endemic area. If the intercourse with India be reduced to the least possible, as it was in the last century, yet cholera might still at times visit us.
Finally, I shall ask myself what can be done to ward off cholera? The measures to be adopted will be very different according to the theory adopted. According to the contagionists, the spread of epidemic cholera depends on personal and material intercourse, as well as on conditions of time and space when the germs arrive at certain localities. Moreover, the severity of the epidemic is supposed to depend on the individual susceptibility. If one of these three factors be wanting, an epidemic of cholera can not develop. Preventive measures against cholera may be devised in one of three directions: (1) intercourse; (2) disposition in time and place; (3) individual predisposition. Measures to prevent the spread of cholera by interfering with human intercourse are, for many reasons, impracticable. If we ask ourselves what good has resulted from sanitary cordons, inspection, and quarantine, we are bound to answer, None. All these measures have failed because they simply treat the individual, the possible case of cholera. But the germs of cholera may be transmitted in the absence of the disease as manifested by illness. Even perfect sanitary cordons and quarantine would be also valueless, for the reason that they are commenced too late. It is true that quarantine and cordons may prevent a certain quantity of the germs of cholera from entering a country, so that it will serve as much purpose as a good custom-house against smuggling. But there is a great difference between articles of commerce and germs of cholera. The germs of disease are capable of multiplication, and so the smuggling through of a few may, under suitable circumstances, be the means for the development of millions and billions. The epidemics at Toulon and Marseilles afford excellent illustrations of my argument. Paris has not yet been attacked, while all the regulations have failed to prevent the appearance of cholera at Naples. No doubt inspection of ships is a good regulation as tending to discover unhygienic conditions, but it is useless as preventing the transmission of cholera. Inspection of places where cholera prevails, the disinfection of articles coming from localities where cholera is, as well also as the places where the dead are laid, are important matters, but too much is not to be expected from these measures. The prevalence of contagious diseases like small-pox can not be much diminished by attempts to limit intercommunication. Protection from small-pox by vaccination, which leaves human intercourse free, has been followed by success. But we have not at our command a simple and sovereign remedy by means of which the individual predisposition to cholera may be done away with, and yet we can do something in this direction. Everything which tends to lower the general health and cause depression, but especially those conditions which induce diarrhœa, predisposes to cholera. To these matters every one must look for himself, and his own efforts may be aided by the advice of doctors. The organs of public health may also effect much. Medical treatment should be obtained for the earliest cases of cholera and of diarrhœa. Care must be taken by the authorities and by the community to take measures for the treatment of the sick. But the difficult point in the prevention of cholera is the predisposition in time and place. It is no use urging, as the contagionists do, that we can not change the nature of the soil. One of the established facts concerning epidemics of cholera is the tendency of the disease to rage in those quarters where the greatest filth prevails. All towns which have been provided with good drainage and water-supply have lost their susceptibility to cholera. England affords the best example of this fact. In 1849 there were recorded 53,237 deaths from cholera, in 1854 the numbers were 20,097, and in 1866 only 14,378, while from 1872 to 1874, when several epidemics prevailed on the Continent, cholera did not reach England. I do not imagine that this immunity was due to the want of predisposition to cholera as regards conditions of time. The case of Fort William in Calcutta may be again referred to, as there, I believe, the immunity from cholera now enjoyed was due not merely to the introduction of a better supply of water, but largely also to the improvement in the other matters of hygiene.