Report on Epidemic Cholera, in the Army of the United States during the Year 1866. We have been favoured with a Report on the Epidemic of Cholera in the Army of the United States during the year 1866, which report being published for the information and guidance of medical officers, merits from us at least a passing notice. It is interesting mainly in relation to the important question of , and of public hygiene?points on which medical authorities are somewhat at variance. Some there are who contend that cholera is essentially a non-contagious disease, and that it is invariably transmitted from one locality to another through the medium of atmospheric air. An In- spector General of hospitals writing on this subject, in a recent number of our contemporary, the Lancet, defends this theory, backed up as he is by an extensive experience. In this, as in not a few other matters, the adage in medio tutissimus ibis holds good. If the above views are adopted we are necessarily forced, we submit, to the following conclusions:?In the first place, that if cholera is not contagious, quarantine must be useless for the prevention of its propagation, and secondly, that if conveyed exclusively by particular winds, as some maintain, from place to place, it should attack indiscriminately and irrespective of insanitary conditions. Denying these conclu- sions then in a qualified manner, as contrary to experience and observation, we incline to the belief that cholera is contagious, or in other words, that it reproduces its poison in and around REPORT ON EPIDEMIC CHOLERA. 2G9

the individual affected, and that consequently it may be thus propagated to susceptible persons who come within the foci of infection, as we understand the term, through the medium of the atmospheric air, or of contagion, or touch, to which we think the term fomites should exclusively be applied; and further, we believe, that insanitary conditions are favourable to the development of the disease wherever the specific element of cholera is present. We have said we have given a qualified denial to the above conclusions, for, admitting the existence of a specific element so erratic in its operations, we must admit that the cholera poison seems wafted to and from certain localities through atmospheric influence. It is well known and universally admitted that such causes as depress vitality, render individuals so influenced more susceptible to disease, and this unquestionably obtains in cases of the disease of which the report under consideration treats, and whose particulars furnish corroborative testimony to the opinions submitted. With reference to the outbreak of the cholera epidemic, this excellent report informs us that the first reported case of cholera in the occurred at Fort Columbus, Governor's Island, Harbour, on the evening of July 3d, previous history and exposure of patient unknown; about an hour afterwards a second case occurred in a recruit also of unknown previous history and exposure, cholera being then prevalent in New York . From this early stage the subsequent pro- gress of the disease can be traced in a most interesting and instructive manner. Recruits from Governor's Island carried cholera to Hart's Island, where the first case occurred on the 8th July, and here, the disease becoming severe, the troops were on the 20th sent to David's Island, "where the disease sub- sequently prevailed to a limited extent among the troops thus transferred." A case is reported as having occurred in Boston, the patient arriving on the same day from Hart's Island where he had been on duty in connection with the cholera hospital. The case of the steam ship San Salvador is particularly interest- ing. This vessel left New York on the 14th July, touching at Governor's Island, where she took on board 476 recruits. These recruits were lodged, we are told, between decks, and were greatly overcrowded. Two days out, cholera made its appear- ance, and on reaching Savannah, Georgia, three deaths had occurred, and twenty-five were ill of the disease. From this case it is worthy of observation that these inferences are de- ducible, viz., that there must be a period of incubation in cholera as in many other diseases, or that cholera may originate under such circumstances de novo, or else that individuals may carry about them the germs of choleraic disease susceptible of 270 REVIEW.

development under the conditions first mentioned, the same holding good of the poison of typhus and other zymotic affec- tions. To the latter opinion we decidedly incline. The period of incubation, if indeed there be any, understanding by that a progressive stage of the disease unrecognizable by ordinary signs, must be extremely short. The cabin passengers, be it observed, escaped the disease, ventilation and cleanliness, we may presume, being in their case unfavourable to its develop- ment. The troops were landed at Tybee Island, where an hospital was extemporized, cholera prevailing during July and August to the extent of 202 cases, 116 of that number proving fatal. Of ten white citizens resident on this island nine were seized with cholera, shortly after the arrival of the infected ship, of 'whom five died, and the tenth, who fled from the island, was also reported to have died. In like manner recruits from New York Harbour conveyed the disease to New Orleans. Thus can the dissemination of cholera in the army be traced to two centres. As it would serve no practical purpose on our part to follow succinctly the different stages of transmission, the may be quoted by way of summary:?The following " epidemic originated in the overcrowded barracks of Governor's Island, New York Harbour, in the immediate vicinity of an infected city, through which troops passed with more or less delay before arrival. The infection spread by readily traceable steps to Hart's Island, and other parts in the Harbour; to Tybee Island, Georgia; to Louisiana by way of New Orleans; to Texas by way of Galveston; to Louisville, Kentucky; to Richmond, Virginia; and to La Virgin, Nicaragua Bay. From Richmond it was carried to Norfolk, Virginia ; from Louisville to Bowling Green, Kentucky. The probabilities appear to be that the disease was carried from New Orleans up the Missis- sippi River to various ports on that stream (as our friends put it), and west of it; and, though the whole chain of evidence is not complete, yet there are a sufficient number 01 known cases of the transfer of the epidemic from one part to another in this region to put this view of the whole movement beyond a reasonable doubt." With these facts to judge from, it would require a very accommodating belief to suppose that, however erratic cholera may be, the disease should by such singular coinci- dences be thus transferred from one part to another through the medium of the atmosphere; and it is further clearly demon- strated that cholera is a contagious disease, and, consequently, its spread preventible by strict quarantine. Further, this report before us shows that in cases of overcrowding cholera broke out, and the practical lesson thus conveyed is, that in REPORT ON EPIDEMIC CHOLERA. 271

cases where troops have been previously exposed to infection, overcrowding should be guarded against; the troops, in short, should be disseminated over a large area, and good food and water furnished. It is interesting to observe the difference in the death ratio in the white and coloured troops. While in the former the number of cases reported during the six months was 192*6, with 77*7 deaths per 1000 of strength, the number in the latter was 259*4, with 135*5 deaths per 1000 of strength; while, curiously enough, the reverse obtains with diarrhoeal and other diseases. In the white troops there were 741*8 cases and 7*5 deaths per 1000 of diarrhoeal diseases, and of all other diseases 1328 cases and 15*5 deaths per 1000. In the coloured troops there were of diarrhoeal diseases 574 5 cases and 3*5 deaths per 1000; of all other diseases 833*9 cases and 11*4 deaths per 1000. With regard to the important question of the Therapeutics of Cholera, we are candidly informed that no new light has been shed upon the existing obscurity of the subject by the army experience; the tendency of the facts recorded being towards the adoption of prevention by hy- measures. The diarrhoea was treated gienic " preliminary by the exhibition of Squib's Mixture," some compound, foreign to our Pharmacopoeia, and of whose virtues Ave must confess ignorance ; but the well-known paregoric, and aromatic spirits of ammonia were also administered. The stage of incipient collapse was promptly met by the exhibition of large doses of calomel. No benefit, we are told, was derived from opium or alcoholic stimulants, and their use was conse- abandoned. Several deaths occurred after recovery quently " from the collapse stage, two of them being well-marked cases of ursemia from total and persistent suppression of the secre- tion of urine." Recollecting the excellent results obtained in such cases at the .London Hospital irom the salmo-alcoholic injections, to which we recently had the pleasure of ad- verting, we regret that this treatment had not been tested in such favourable cases; and, if our recommendation be of any avail, we honestly suggest a trial of this method of treatment by our Transatlantic brethren, should occasion unfortunately transpire. In the statistical tables we find that a distinction is drawn between cholera and cholera morbus?on what grounds we are certainly at a loss to understand. The multi- plication of diseases is much to be deplored, as there is certainly few things more detrimental to any science, more particularly to such a comprehensive one as that of medicine, than unjusti- fiable discriminations. As precautionary measures, cleanliness, the use of disinfec- 272 CLINICAL RECORD. tants, ventilation, and proper air space, are correctly enjoined ; while, with regard to the important element of pure water, its efficacy has been shown in arresting the spread of the disease after it had made its appearance. For the purification of water from organic impurities the use of permanganate of potash accords with experience in this country. On the whole this report is very carefully compiled, and seems a most reliable document. It will be found particularly interesting to statis- ticians and etiologists.