scattered in literature of cases in which cholera has been conveyed to distances by undisinfected clothes.

In 1854 cholera broke out in a village in Bedfordshire, two fatal cases occurred. The first case was that of a man whose son had died in London a week or two before of cholera, and whose clothes (undisinfected) were sent down to the country. The man unwrapped the clothes himself, was seized with the disease, and died in a short time. This case was the nucleus from whence the others took their infection.1 At Leistheim, near Munich, the first case of cholera was in the house of a labourer, one of whose daughters was in service at Munich, the latter sent her parents clothes belonging to a family some member of which had died of cholera. These old clothes were at once appropriated and worn. Three days afterwards (September 21st) the father and mother were seized with cholera, and died on the 22nd and 23rd; other members of the family took the disease.2

(397) Pettenkofer's Theory.

Pettenkofer's theory of the spread of cholera is that it is intimately connected with the composition of the soil. The essential elements as to season and locality are:-(1) The physical composition of the earth and subsoil of the dwelling. (2) The moisture of the soil and its changes; this moisture he designates by the collective term "ground water;" to these must be added the presence of nourishing substances in the soil suitable for the nourishment of the lower organisms. (3) The specific germ; he is also inclined to lay stress upon individual predisposition. rise and fall of the ground water is but an index of the moisture of the earth; the most dangerous time for cholera, according to Pettenkofer, is when the ground water, having risen above its usual level, sinks or is sinking. The later epidemics and the outbreaks on vessels at sea, give but moderate support to this theory.

(398) Preventive Measures as formulated by Koch.

The

In the conference on cholera at Berlin, 1885, Koch sketched the following scheme as to preventive measures.3 The preventive

1 On Malaria and Miasmata, by Dr. Barker, F.R.S. Macnamara, p. 162.

2 Quoted by Macnamara.

3 Berliner klinische Wochen., Sept. 21, 1885, No. 37, a. u. b.

measures against cholera must in the first place be referred to the fact that the infection is produced in man, and is contained in the evacuations. In order therefore to make the infectious matter harmless, the dejecta are to be mixed with suitable disinfectants. Carbolic acid is the most suitable, a five per cent. solution, mixed with an equal bulk of either the dejecta or the vomited matters is sufficient to destroy fully the cholera bacillus.

If it were possible to collect all the excreta of the sick in vessels and to immediately treat them with disinfectants, then the destruction of the infectious matter would be simple and certain, and better results would be obtained with disinfectants than now, but any one who has to do with cholera patients knows that only a portion of the excreta actually goes into the vessel, the rest is on the bed, the earth, the clothing, and the hands of the sick and his attendants. Hence all things which either can be soiled or are soiled by the dejecta must be disinfected.

The soiled linen must be put into a solution of 5 per cent. carbolic acid or other disinfecting fluid. Where clothes need not be immediately sent to the wash but may remain several days in the disinfecting fluid, weaker solutions may be used. Clothing, bedding, and mattresses, which cannot well be disinfected by fluid disinfectants, should be submitted to steam in a disinfecting apparatus. Things, as ambulances and the like, which can neither be disinfected with fluid disinfectants nor by steam should not be used for some time, but well aerated, for if the bacillus is dried it is destroyed. Where disinfecting apparatus and appliances are not at hand, things of little value may be burnt, those of more value simply exposed to the air for a long time.

The aeration and drying through heat is the most suitable for the disinfection of the sick room. Disinfection with gaseous reagents especially with sulphurous acid gas, later researches have shown to be uncertain and therefore not desirable. The nurses are to wash their hands often, never to touch the mouth with the hands, and if the hands become soiled with the discharges they must be disinfected with carbolic acid or corrosive sublimate solution. Eating in the same room in which are persons sick of cholera must be specially avoided, as in the dwellings of the poor so often happens.

But with all the above-named precautions complete success may

not be attained because these precautions can only be taken in the serious cases which are recognized as cholera. The numerous slighter attacks which are not recognized as cholera, and which seek no medical aid, are not amenable to these regulations. Like the ambulatory form of scarlet fever, measles, &c., these are probably still more dangerous to the public health than the pronounced cases of cholera, since the dejections of these cases have been ascertained to contain the comma bacilli, yet the sick are enabled to go about their occupations, and to carry from place to place their infection unsuspected.

If we turn now to the accepted English method of prevention as drawn out by the present medical officer to the Local Government Board, the directions only differ as to detail, irrespective of whether Asiatic cholera is produced by "commas " or not; stress is laid by both the English and German school on the special danger of the excreta, the importance of cleanliness, of disinfection, and of general hygiene.

(399) Official Memorandum as to Prevention of Cholera.

PRECAUTIONS AGAINST THE INFECTION OF CHOLERA.

1. The Order of the Local Government Board of July 12th, 1883, now in force, gives certain special powers to the Sanitary Authorities of the sea-coasts, enabling them to deal with any cases of cholera brought into port, so as to prevent as far possible the spread of disease into this country; but as cases of choleraic infection have widely different degrees of severity it is possible that some such cases slightly affected will notwithstanding the vigilance of local authorities be landed without particular notice in English sea-board towns, whence they may advance to other and perhaps inland places.

2. Former experience of cholera in England justifies the belief that the presence of imported cases of the disease at various spots in the country will not be capable of causing much injury to the population if the places receiving the infection have had the advantage of proper sanitary administration, and in order that all local populations may make their self defence as effective as they can, it will be well for them to have regard to the present state of knowledge concerning the mode with which epidemics of cholera at least in this country are produced.

3. Cholera in England shows itself so little contagious in the sense in which smallpox and scarlet fever are commonly called contagious, that if reasonable care be taken where it is present there is almost no risk that the disease will spread to persons that nurse and otherwise attend closely on the sick; but cholera has a certain peculiar infectiveness of its own, which where local conditions assist, can operate with terrible force and at considerable distances from the sick. It is characteristic of cholera (and as much so of the slight cases where diarrhoea is the only symptom, as of the disease in its more developed and alarming forms) that all matters which the patient discharges from his stomach or bowels are or can become infective. Probably, under ordinary circumstances, the patient has no power of infecting other persons except by means of these discharges; nor any power of infecting even by them except in so far as particles of them are enabled to taint the food, water, or air, which people consume. Thus, when a case of cholera is imported into any place,

the disease is not likely to spread unless in proportion as it finds, locally open to it, certain facilities for spreading by indirect infection.

4. In order rightly to appreciate what these facilities must mean, the following conditions have to be borne in mind-first, that any choleraic discharge, cast without previous thorough disinfection, into any cesspool or drain or other depositary or conduit for filth, has a faculty of infecting the excremental matters with which it there mingles, and probably, more or less, the effluvia which those matters evolve; secondly, that the infective power of choleraic discharges attaches to whatever bedding, clothing, towels, and like things, have been imbued with them, and renders these things, if not thoroughly disinfected, as capable of spreading the disease in places to which they are sent (for washing or other purposes) as, in like circumstances, the patient himself would be; thirdly, that if, by leakage or soakage from cesspools or drains, or through reckless casting out of slops and wash-water any taint (however small) of the infective material gets access to wells or other sources of drinking water, it imparts to enormous volumes of water the power of propagating the disease. When due regard is had to these possibilities of indirect infection, there will be no difficulty in understanding that even a single case of cholera, perhaps of the slightest degree, and perhaps quite unsuspected in his neighbourhood, may, if local circumstances co-operate, exert a terribly infective power on considerable masses of population.

5. The dangers which have to be guarded against as favouring the spread of cholera infection, are, particularly, two. First, and above all, there is the danger of water supplies which are in any (even the slightest) degree tainted by house refuse or other like kinds of filth: as where there is outflow, leakage, or filtration from sewers, house drains, privies, cesspools, foul ditches, or the like, into springs, streams, wells, or reservoirs from which the supply is drawn, or into the soil in which the wells are situated a danger which may exist on a small scale (but perhaps, often repeated in the same district) at the pump or dip well of a private house, or, on a large or even vast scale in the source of public water works, and secondly there is the danger of breathing air which is fouled with effluvia from the same source of impurity.

6. Information as to the high degree in which those two dangers affect the public health in ordinary times, and as to the special importance which attaches to them at times when diarrhoeal infection is likely to be introduced, has now for so many years been before the public that the improved systems of refuse removal and water supply by which those dangers are permanently obviated for large populations, and also the minor structural improvements by which separate households are secured against them ought long ago to have come into universal use.

So far, however, as this wiser course has not been adopted in any sanitary district, security must, as far as practicable, be sought in measures of a temporary and palliative kind. (a) Immediate searching examination of sources of water supply should be made in all cases where the source is in any degree open to the suspicion of impurity; and the water both from private and public sources should be examined. Where pollution is discovered, everything practicable should be done to prevent the pollution from continuing, or, if this object cannot be obtained, to prevent the water from being drunk. Cisterns should be cleansed and any connections of waste pipes with drains should be severed. (b) Simultaneously, there should be immediate thorough removal of every sort of house refuse and other filth which has accumulated in neglected places; future accumulations of the same sort should be prevented: attention should be given to all defects of house drains and sinks through which offensive smells are let into houses; thorough washing and lime washing of uncleanly premises, especially of such as are densely occupied, should be practised again and again.

7. It may fairly be believed that, in considerable parts of the country conditions favourable to the spread of cholera are now less abundant than at any former time; and in this connection, the gratifying fact deserves to be recorded that during recent years, enteric fever, the disease that in its method of extension bears the nearest resemblance to cholera, has continuously and notably declined in England. But it is certain that in many places such conditions are present as would, if cholera were introduced, assist in the spread of that disease. It is to be hoped that in all these

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cases the local sanitary authorities will at once do everything that can be done to put their districts into a wholesome state. Measures of cleanliness taken beforehand are of far more importance for the protection of a district against cholera than removal or disinfection of filth after the disease has actually made its appearance.

8. It is important for the public very distinctly to remember that pains taken and costs incurred for the purposes to which this memorandum refers cannot in any event be regarded as wasted. The local conditions which would enable cholera, if imported, to spread its infection in this country, are conditions which, day by day, in the absence of cholera, create and spread other diseases; diseases which, being never absent from the country, are in the long run, far more destructive than cholera, and the sanitary improvements which would justify a sense of security against any appre hended importation of cholera, would to their extent, though cholera should never re-appear in England, give ample remunerative results in the prevention of other diseases. GEORGE BUCHANAN,

Local Government Board, July 21, 1885.

Medical Officer of the Board.

General Cholera Order.

To all Port Sanitary Authorities, except the Port Sanitary Authorities of the Port of London; to all Urban and Rural Sanitary Authorities, whose districts include or abut on any part of a customs port, which port is not within the jurisdiction of any Port Sanitary Authority; to all Officers of Customs; to all Medical Officers of Health of the Sanitary Authorities aforesaid; to all masters of ships; and to all others whom it may concern.

1

Whereas We, the Local Government Board, by an Order bearing date the 17th day of July, 1873, made certain rules and regulations with a view to the treatment of persons affected with cholera, and for preventing the spread of the disease; and whereas cholera is now prevalent in certain parts of Egypt with which this country has communication, and it is expedient that in place of the rules and regulations made by the said Order, other rules and regulations as hereinafter contained should be made :

Now therefore We, the Local Government Board, do hereby rescind the said Order, except in so far as it may apply to any proceedings now pending, and We do, by this our Order, and in exercise of the power conferred on us by section 130 of the Public Health Act 1875, and every other power enabling us in this behalf, make the following rules and regulations, and declare that they shall be enforced and executed by the authorities hereinafter named :

DEFINITIONS.

Article 1. In this Order-The term "ship" includes vessel or boat; the term "officer of customs includes any person acting under the authority of the Commissioners of Customs; the term "master" includes the officer or person for the time being in charge or command of a ship; the term "cholera" includes choleraic diarrhoea; the term "Sanitary Authority means every Port Sanitary Authority except the Port Sanitary Authority for the Port of London, and every Urban or Rural Sanitary Authority whose district includes or abuts on any part of a customs port, which port is not within the jurisdiction of a Port Sanitary Authority; the term "Medical Officer of Health" includes any duly qualified medical practitioner appointed by a Sanitary Authority to act in the execution of this Order.

For the purposes of this Order

(1) So much of a customs port abutting on an Urban or Rural Sanitary District as is nearer to such district than to any other, and is not included within the jurisdiction of any Port Sanitary Authority, shall be deemed to be within such district.

(2) Every ship shall be deemed infected with cholera in which there is or has been during the voyage, or during the stay of such ship in a port in the course of such voyage, any case of cholera.

1 1883.