MALIGNANT CHOLERA (synonyms, Asiatic Cholera, Indian Cholera, _Epidemic Cholera, Algide Cholera) is probably the most severe and fatal of all diseases. This form of cholera belongs originally to Asia, more particularly to India, where, as well as in the Indian Archipelago, epidemics are known to have occurred at various times for several centuries. It was not, however, till 1817 that the attention of European physicians was specially directed to the disease by the outbreak of a violent epidemic of cholera at Jessore in Bengal. This was followed by its rapid spread over a large portion of British India, where it caused immense destruction of life both among natives and Europeans. During the next three years cholera continued to rage all over India, as well as in Ceylon and others of the Indian islands. The disease now began to spread over a wider extent than hitherto, invading China on the east, and Persia on the west. In 1823 it had extended into Asia Minor and Russia in Asia, and it continued to advance steadily though slowly westwards, while at the same time fresh epidemics were appearing at intervals in India. From this period up till 1830 no great extension of cholera took place, but in the latter year it reappeared in Persia and along the shores of the Caspian Sea, and thence entered Russia in Europe. Despite the strictest sanitary precautions, the disease spread rapidly through that whole empire, causing great mortality and exciting consternation everywhere. It ravaged the northern and central parts of Europe, and spread onwards to England, appearing in Sunderland in October 1831, and in London in January 1832, during which year it continued to prevail in most of the cities and large towns of Great Britain and Ireland, and its disastrous effects are still in the recollection of many persons. The disease subsequently extended into France, Spain, and Italy, and crossing the Atlantic spread through North and Central America. It had previously prevailed in Arabia, Turkey, Egypt, and the Nile district, and in 1835 it was general throughout North Africa. Up till 1837 cholera continued to break out in various parts of the Continent of Europe, after which this epidemic disappeared, having thus within twenty years visited a large portion of the world.

About the year 1841 another great epidemic of cholera appeared in India and China, and soon began to extend in the direction traversed by the former, but involving a still wider area. It entered Europe again in 1847, and spread through Russia and Germany on to England, and thence to France, whence it passed to America, and subsequently appeared in the West Indies. This epidemic appears to have been even more deadly than the former, especially as regards Great Britain and France. A third great outbreak of cholera took place in the East in 1850, entering Europe in 1853. During the two succeeding years it prevailed extensively throughout the Continent, and fell with severity on the armies engaged in the Crimean War. Although widely prevalent in Great Britain and Ireland it was less destructive than former epidemics. It was specially severe throughout both North and South America. A fourth epidemic visited Europe again in 1865-66, but was on the whole less extensive and destrnelive than its predecessors. Cholera has since appeared in the form of limited epidemics in various districts of Russia, Turkey, and Western Asia, while it still continues to maintain its footing in India, where sudden outbreaks are of frequent occurrence, being often connected with the assembling of crowds at native festivals.

A disease so widespread in its distribution and deadly in its effects has naturally engaged the attention of scientific physicians in all countries. Investigations into the nature of cholera and the conditions favouring its propagation have been extensively carried on in England, in Germany, and in India, not merely by those whose opportunities of observing and treating the disease have been numerous, but by others specially undertaking such inquiries at the suggestion of Governments or other public authorities. Although many conflicting views have been propounded on the above-named points, the result of these investigations has been the collection of an amount of information sufficient to form the basis of a rational theory of cholera., and which may be expected yet to lead to the discovery of means to counteract the spread of this pestilence.

The following points respecting the nature and mode of propagation of cholera are generally admitted by the best authorities :- That cholera is a specific disease depending upon the action in the human system of a morbid material (whether of the nature of a parasitic germ or a poisonous ndasm being still undetermined) which is originally generated in certain parts of India, particularly in the delta of the Ganges and the flat lands around Madras and Bombay ; That this infective material is capable of spreading from its centre of origin indefinitely, and thus cholera has appeared in an epidemic form in almost all countries ; and further that the disease may become acclimatized (endemic) in some places ; That when it spreads abroad the vehicle of its transmission is the discharges from the bowels of persons already affected ; and that from these the cholera-infecting matter is exceedingly apt to be diffused through the air, to contaminate water, and to become attached to clothing, bedding, furniture, &c., and in these various ways to find ready entrance through the lungs or alimentary canal into the bodies of healthy persons, where it is capable of developing the disease in a more or less severe form according to the quantity introduced ; That cholera is thus in a certain sense contagious ; That overcrowding and other insanitary conditions, particularly the presence of decomposing organic matter, afford the conditions favourable to the multiplication of the cholera matter, and thus tend to spread the disease, although of themselves incapable of originating it.

But even admitting these propositions, it is obvious that they are insufficient to explain the intense tendency of cholera to spread widely at some times more than others. Without alluding to the various hypotheses which have been advanced on this point, it seems probable, from the history of the disease as exhibited both in Europe and in India, that various factors may alone or together be concerned in the rise and spread of epidemics of cholera. It is stated that a high temperature favours the development of cholera, and in general this appears to be the case, but it is by no means invariable, as some of the most severe epidemics raged with greatest fury in winter. That cholera might be carried by the agency of winds from one country to another must be held as a possibility, although no satisfactory evidence exists upon the point. More probable are the theories which assign to local conditions an important part in the propagation of cholera. With regard to mere locality it appears that the disease has been generally found to prevail more extensively and with greater virulence in low-lying districts than in elevated situations. In connection with this, the relation of the character of the soil to the propagation of cholera has been elaborately investigated by Professor Pettenkofer of Munich, whose work in this department has attained world-wide reputation, and who ascribes a powerful influence in the diffusion of the disease to the ground-water of a locality where cholera is prevailing, - shallow, porous soils affording, according to his views, special facilities for the reception, proliferation, and distribution of the so-called cholera germs. Further, the observations of Dr Snow, Dr Frankland, and Mr Simon in certain epidemics of cholera in London have conclusively connected outbreaks of the disease in various districts with the use of drinking-water contaminated with the discharges from cholera patients. All investigations appear clearly to show that the prime factor, and that without which no other conditions can take effect, is the introduction into the locality of the specific infecting matter, this being accomplished in general by the arrival of infected persons, for cholera epidemics, as is well known, spread mostly in the lines of human intercourse and travel. But further, in this as in other acute infectious diseases, a special liability of individuals must be admitted, as is proved by the fact that among persons living under precisely the same conditions some will suffer while others escape, and likewise that persons inhabiting cholera districts may come to enjoy an immunity from attacks of the disease. Among known predisposing causes, the incautious employment of purgative medicines, the use of unripe fruit, bad and insufficient food, intemperance, personal uncleanliness, overcrowding, and all kinds of unfavourable hygienic surroundings play an important part during the course of any epidemic of cholera.

In describing the symptoms of cholera it is customary to divide them into three stages, but it must be noted that these do not always present themselves in so distinct a form as to be capable of separate recognition. The first or premonitory stage consists in the occurrence of diarrhoea. Frequently of mild and painless character, and coming on after some error in diet, this symptom is apt to be disregarded. The discharges from the bowels are similar to those of ordinary summer cholera, which the attack closely resembles. There is, however, at first the absence of vomiting. This diarrhoea generally lasts for two or three days, and then if it does not gradually subside either may pass into the more severe phenomena characteristic of the second stage of cholera, or on the other hand may itself prove fatal, The second stage of cholera is termed the stage of collapse or the algide or asphyxial stage. As above mentioned, this is often preceded by the premonitory diarrhoea, but not unfrequently the phenomena attendant upon this stage are the first to manifest themselves. They come on often suddenly in the night with diarrhoea of the most violent character, the matters discharged being of whey-like appearance, and commonly termed the "rice-water" evacuations. They contain large quantities of disintegrated epithelium from the mucous membrane of the intestines. The discharge, which is at first unattended with pain, is soon succeeded by copious vomiting of matters similar to those passed from the bowels, accompanied with severe pain at the pit of the stomach, and with intense thirst. The symptoms now advance with rapidity. Cramps of the legs, feet, and muscles of the abdomen come on and occasion great agony, while the signs of collapse make their appearance. The surface of the body becomes cold and assumes a blue or purple hue, the skin is dry, sodden, and wrinkled, indicating the intense draining away of the fluids of the body, the features are pinched and the eyes deeply sunken, the pulse at the wrist is imperceptible, and the voice is reduced to a hoarse whisper (the vox cholerica). There is complete suppression of the urine.

In this condition death often takes place in less than one day, but in epidemics cases are frequently observed where the collapse is so sudden and complete as to prove fatal in one or two hours even without any great amount of previous purging or vomiting. In most instances the mental faculties are comparatively unaffected, although in the later stages there is in general more or less apathy.

Reaction, however, may take place, and this constitutes the third stage of cholera. It consists in the arrest of the alarming symptoms characterizing the second stage, and the gradual but evident improvement in the patient's condition. The pulse returns, the surface assumes a natural line, and the bodily heat is restored. Before long the vomiting ceases, and although diarrhoea may continue for a time, it is not of a very severe character and soon subsides as do also the cramps. The urine may remain suppressed for some time, and on returning is often found to be albuminous. Even in this stage, however, the danger is not past, for relapses sometimes occur which speedily prove fatal, while again the reaction may be of imperfect character, and there may succeed an exhausting fever (the so-called typhoid stage of cholera) which may greatly retard recovery, and under which the patient may sink at a period even as late as two or three weeks from the commencement of the illness.

Many other complications are apt to arise during the progress of convalescence from cholera, such as diphtheritic and local inflammatory affections, all of which are attended with grave danger.

When the attack of cholera is of milder character in all its stages than that above described, it has been named Cholerine, but the term is an arbitrary one and the disease is essentially cholera.

The bodies of persons dying of cholera are found to remain long warm, and the temperature may even rise after death. Peculiar muscular contractions have been observed to take place after death, so that the position of the limbs may become altered. The soft textures of the body are found to be dry and hard, and the muscles of a dark brown appearance. The blood is of dark colour and tarry consistence. The upper portion of the small intestines is generally fouud distended with the rice-water discharges, the mucous membrane is swollen, and there is a remarkable loss of its natural epithelium. The kidneys are usually in a state of acute congestion.

With respect to the mortality from cholera no very accurate estimate can be formed, since during the prevalence of the disease the milder cases are apt to escape notice, and it is certain that some epidemics are of a more virulent character than others. It is generally reckoned, however, that about one-half the cases of fully developed cholera prove fatal, death taking place in a large proportion of instances in from twenty-four to forty-eight hours. It has been noticed that in cholera epidemics the mortality is relatively greater at the commencement of the outbreak. The disease appears to be most fatal in children and aged persons.

As illustrating the destructive effects of cholera, it may be mentioned that in the first epidemic in England and Wales 52,517 deaths were reported to the Board of Health, but this number was doubtless below the actual amount. In the second epidemic (1848-9) there were 55,181 deaths from cholera in England alone, besides 28,900 from diarrhcea. The subsequent epidemics in this country have been much less fatal.

The treatment of cholera embraces those sanitary measures requisite to be adopted with the view of preventing as far as possible the introduction of the disease into localities previously unaffected, or of checking its spread when introduced, as well as the special medical management of those who have been attacked. These topics can be alluded to only in general terms.

When cholera threatens to invade any place, however favourably circumstanced as to its hygienic condition, increased vigilance will be requisite on the part of those entrusted with the care of the public health. Where the disease is likely to be imported by ships, quarantine regulations will be necessary, and, where practicable, measures of isolation should be adopted in the case of individuals or companies of people coming from infected localities, more i may be introduced into a community by one or more individuals who have themselves only suffered from the first or milder stage of the disease (cholera diarrhoea), since the discharges from the bowels abound in the infective matter, and where sanitary arrangements are deficient may readily contaminate the water or air of a locality.

The utmost care will be demanded, particularly in populous districts, in cleansing and disinfecting places where accumulations of animal refuse are apt to occur. The condition of the drinking water and of the wells in which it is collected will always require inspection, as will also the quality of the food supplied, more especially to the poor. Where suspicion attaches to the water, it should be boiled before being used, and the same holds true of the milk. The establishment of cholera hospitals, with a thoroughly equipped staff of medical attendants and nurses, is one of the first and most important steps to be taken in any threatened epidemic, as affording opportunity for the removal and isolation of those attacked at an early period, while every facility should be given to the poorer classes of obtain. ing medical aid. Instructions should be issued by the authorities warning all persons against the use of unwholesome food, unripe fruit, and excesses of every kind, and recommending early application for medical advice where there is any tendency to diarrhoea. House to house visitation by members of a sanitary staff will be of great service, not merely in discovering cases of the disease, but in the important work of disinfection, which should not be left entirely to the inhabitants, but be done systematically by the authorities. The discharges from cholera patients should be disinfected with such substances as carbolic acid or sulphate of iron before removal, and special care be taken that they are not disposed of in places where they may contaminate drinking water. Every article of clothing which has been in contact with a cholera patient should if possible be burnt, while infected apartments should be thoroughly disinfected with carbolic acid or by fumigation with sulphur. The early burial of those dying from cholera is obviously a matter of urgent necessity.

The influence of fear in predisposing to attacks of cholera has been greatlyexaggerated and is nowgenerally discredited. But apart from such considerations there can be no doub of the wisdom of those to whom it is practicable in removing from a place where cholera is raging.

With respect to the treatment of cholera, it may be safely affirmed, that as to no disease has so much difference of opinion prevailed or so many extravagant notions been entertained regarding the value of remedies. There is a want of agreement as to fundamental principles of treatment ; for while astringents have been regarded by some as their sheet anchor, others have condemned them as worse than useless, and rely on the elimination of the materies morti by means of laxatives. Much evil has been done by the manner in which various systems of treatment have been extolled by over-sanguine practitioners as possessing special curative value. Indeed to enumerate the different medicines winch have been suggested and employed for the treatment of this disease would be a work of no little difficulty. It is sufficient to state that no medicinal agent has yet been found to be of infallible efficacy in the treatment of cholera. Nevertheless, much may be done, and many lives saved, by the timely application of certain well-approved remedies. The various stages of the disease demand special treatment. In the earlier period of the attack for the cholera-diarrhcea the use of opium is of undoubted value. Given alone in small and oft-repeated doses, or in combination with other astringents, such as catechu, tannin, bismuth, nitrate of silver, or acetate of lead, it frequently succeeds in quelling this symptom, and thus arresting the disease at the outset.

Strict confinement to bed and the administration of bland drinks such as milk, barley-water, and beef-tea, along with counter-irritation to the abdomen, will be found valuable adjuvants to treatment. In the second stage of cholera opium is of less value, and other remedies are called for. The violent vomiting and purging and the intense thirst may be relieved by iced effervescing drinks, while at the same time endeavours should be made to maintain the heat of the body by friction with stimulating liniments or mustard to the surface, and by enveloping the body in flannel and surrounding it with hot bottles. For the relief of the cramps the inhalation of chloroform is recommended, and probably chloral would be found of equal value. Stimulants such as ammonia and brandy must be had recourse to where these measures fail to establish reaction and the patient threatens to sink. When reaction occurs and the vomiting ceases, liquid food in small quantities should be cautiously administered.

Report on Epidemic Cholera Morlats . . . in Bengal, 1817, 1818, 1819, by J. Jameson, Calcutta, 1820 ; Official Reports on Cholera, by Drs Russell and Barry, London, 1S32 ; Researches into the Pathology and Treatment of Asiatic Cholera, by E. A. Parkes, M.D., London, 1347 ; Report of the General Board of Health on the Epidemic Cholera, 1848-49, London, 1850 ; Report on the Mortality 7f Cholera in, England in 1S48-49, by Dr W. Farr ; Reports on Epidemic Cholera, by Drs Baly and Gull, London, 1854 ; Unto-- sachem unel Beobachtungen Giber die Vcrbreitungsart der Cholera, by Dr Max Pettenkofer, Munich, 1855 ; Reports to the Privy Council on the two last Cholera Epidemics, by Mr J. Simon, London, 1856 ; Mode of Communicating Cholera, by Dr J. Snow, 2d ed., London, 1855 ; Report on the Constantinople Cholera Conference in 1866, Calcutta, 136S ; Reports of Medical Officer of Privy Council from 1865 upwards; A Treatise on Asiatic Cholera, by C. Macnamara, London, 1870 ; Ziemssen's Cyclopedia of Practical Medicine, article "Cholera," by Prof. H. Lebert, Engl. Trans., London, 1875 ; A History of Asiatic Cholera, by C. Macnamara, London, 1S76. (J. 0. A.)