Chapter III: Front Matter (3)

The second stage 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 infrequently 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. 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 hue, 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 found 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. 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.

Much light has been thrown upon Asiatic cholera by Western experience; and the study of the disease by modern methods has resulted in important additions to our previous knowledge of its nature, causation, mode of dissemination and prevention.

Causation

The cause is a micro-organism identified by Koch in 1883 (see PARASITIC DISEASES). For some years it was called the "comma bacillus," from its supposed resemblance in shape to a comma, but it was subsequently found to be a vibrio or spirillum, not a bacillus. The discovery was received with much scepticism in some quarters, and the claim of Koch's vibrio to be the true cause of cholera was long disputed, but is now universally acknowledged. Few micro-organisms have been more elaborately investigated, but very little is known of its natural history, and its epidemiological behaviour is still surrounded by obscurity. At an important discussion on the subject, held at the International Hygienic Congress in 1894, Professor Gruber of Vienna declared that the deeper investigators went the more difficult the problem became, while M. Elie Metschnikoff of the Pasteur Institute made a similar admission. The difficulty lies chiefly in the variable characters assumed by the organism and the variable effects produced by it. The type reached by cultivation through a few generations may differ so widely from the original in appearance and behaviour as to be hardly recognizable, while, on the other hand, of two organisms apparently indistinguishable one may be innocuous and the other give rise to the most violent cholera. This variability offers a possible explanation of the frequent failure to trace the origin of epidemic outbreaks in isolated places. It is commonly assumed that the micro-organism is of a specific character, and always introduced from without, when cholera appears in countries or places where it is not endemic. In some cases such introduction can be proved, and in others it can be inferred with a high degree of probability, but sometimes it is impossible to trace the origin to any possible channel of communication. A remarkable case of this kind occurred at the Nietleben lunatic asylum near Halle, in 1893, in the shape of a sudden, explosive and isolated outbreak of true Asiatic cholera. It was entirely confined to the institution, and the peculiar circumstances enabled a very exact investigation to be made. The facts led Professor Arndt, of Greifswald, to propound a novel and interesting theory. No cholera existed in the surrounding district and no introduction could be traced, but for several months in the previous autumn diarrhoea had prevailed in the asylum. The sewage from the establishment was disposed of on a farm, and the effluent passed into the river Saale above the intake of the water-supply for the asylum. Thus a circulation of morbid material through the persons of the inmates was established. Dr Arndt's theory was that by virtue of this circulation cholera was gradually developed from previously existing intestinal disease of an allied but milder type. The outbreak occurred in winter, and coincided with the freezing of the filter-beds at the waterworks. The theory is worth notice, because a similar relation between the drainage and the water-supply frequently exists in places severely attacked by cholera, and it has repeatedly been observed that the latter is preceded by the prevalence of a milder form of intestinal disease. The inference is not that cholera can be developed _de novo_, but that the type is unstable, and that a virulent form may be evolved under favourable conditions from another so mild as to be unrecognized, and consequently undetected in its origin or introduction. This is quite in keeping with the observed variability of the micro-organism, and with the trend of modern research with regard to the relations between other pathogenic germs and the multifarious gradations of type assumed by other zymotic diseases. The same thing has been suggested of diphtheria.

Epidemicity.

Cholera is endemic in the East over a wide area, ranging from Bombay to southern China, but its chief home is British India. It principally affects the alluvial soil near the mouths of the great rivers, and more particularly the delta of the Ganges. Lower Bengal is pre-eminently the standing focus and centre of diffusion. In some years it is quiescent, though never absent; in others it becomes diffused, for reasons of which nothing is known, and its diffusive activity varies greatly from equally inscrutable causes. At irregular intervals this property becomes so heightened that the disease passes its natural boundaries and is carried east, north and west, it may be to Europe or beyond to the American continent. We must assume that the micro-organism, like those of other epidemic diseases, acquires greater vitality and toxic energy, or greater power of reproduction at some times than at others, but the conditions that govern this behaviour are quite unknown, though no problem has a more important bearing on public health. Bacteriology, as already intimated, has thrown no light upon it, nor has meteorology. Some results of modern research, indeed, tend to assign increasing importance to the relations between surface soil and certain micro-organisms, and suggest that changes in the level of the subsoil water, to which Professor Max von Pettenkoffer long ago drew attention, may be a dominant factor in determining the latency or activity of pathogenic germs. But this is largely a matter of conjecture, and, so far as cholera is concerned, the conditions which turn an endemic into an epidemic disease must be admitted to be still unknown.

On the other hand, the mode of dissemination is now well understood. Diffusion takes place along the lines of human intercourse. The poison is carried chiefly by infected persons moving from place to place; but soiled clothes, rags and other articles that have come into contact with persons suffering from the disease may be the means of conveyance to a distance. There is no reason to suppose that it is air-borne, or that atmospheric influences have anything to do with its spread, except in so far as meteorological conditions may be favourable to the growth and activity of the micro-organisms. Beyond all doubt, the great manufactory of the poison is the human body, and the discharges from it are the great source of contagion. They may infect the ground, the water, or the immediate surroundings of the patient, and so pass from hand to hand, the poison finding entrance into the bodies of the healthy by means of food and drink which have become contaminated in various ways. Flies which feed upon excreta and other foul matters may be carriers of contagion. Of all the means of local dissemination, contaminated water is by far the most important, because it affects the greatest number of people, and this is particularly the case in places which have a public water-supply. A single contaminated source may expose the entire population to danger. All severe outbreaks of an explosive character are due to this cause. It is also possible that the cholera poison multiplies rapidly in water under favourable conditions, and that a reservoir, for instance, may form a sort of forcing-bed. But it would be a mistake to regard cholera as purely a water-borne disease, even locally. It may infect the soil in localities which have a perfectly pure water-supply, but have defective drainage or no drainage at all, and then it will be found more difficult to get rid of, though less formidable in its effects, than when the water alone is the source of mischief. In all these respects it has a great affinity to enteric fever. With regard to locality, no situation can be said to be free from attack if the disease is introduced and the sanitary conditions are bad; but, speaking generally, low-lying places on alluvial soil near rivers are more liable than those standing high or on a rocky foundation. Of meteorological conditions it can only be said with certainty that a high temperature favours the development of cholera, though a low one does not prevent it. In temperate climates the summer months, and particularly August and September, are the season of its greatest activity.

Western diffusion.

Cholera spreads westwards from India by two routes--(1) by sea to the shores of the Red Sea, Egypt and the Mediterranean; and (2) by land to northern India and Afghanistan, thence to Persia and central Asia, and so to Russia. In the great invasions of Europe during the 19th century it sometimes followed one route and sometimes the other. It was not 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 cf the cities and large towns of Great Britain and Ireland. 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 1865-1866, but was on the whole less extensive and destructive than its predecessors.

By some writers the epidemic of 1853 is regarded as a recrudescence of that of 1847. The earlier ones followed the land route by way of Afghanistan and Persia, and took several years to reach Europe. That of 1865 travelled more rapidly, being carried from Bombay by sea to Mecca, from there to Suez and Alexandria, and then on to various Mediterranean ports. Within the year it had not only spread extensively in Europe, but had reached the West Indies. In 1866 it invaded England and the United States, but during the following year it died down in the West. The subsequent history of cholera in Europe may be stated chronologically.

_1860-1874._--This invasion was traced to the great gathering of pilgrims at Hardwar on the Upper Ganges in the month of April 1867. From there the returning pilgrims carried it to the Punjab, Kashmir and Afghanistan, whence it spread to Persia and the Caspian, but it did not reach Russia until 1869. During the next four years a number of outbreaks occurred in central Europe, and notably one at Munich in the winter of 1873. The irregular character of these epidemics suggests that they were rather survivals from the pandemic wave of 1867 than fresh importations, but there is no doubt that cholera was carried overland into Russia in the manner described.

_1883-1887._--This visitation, again, came by the Mediterranean. In 1883 a severe outbreak occurred in Egypt, causing a mortality of above 25,000. Its origin remained unknown. During this epidemic Koch discovered the comma bacillus. The following year cholera appeared at Toulon. It was said to have been brought in a troopship from Saigon in Cochin-China, but it may have been connected with the Egyptian epidemic. A severe outbreak followed and reached Italy, nearly 8000 persons dying in Naples alone. In 1885 the south of France, Italy, Sicily and Spain all suffered, especially the last, where nearly 120,000 deaths occurred. Portugal escaped, and the authorities there attributed their good fortune to the institution of a military cordon, in which they have had implicit confidence ever since. In 1886 the same countries suffered again, and also Austria-Hungary. From Italy the disease was carried to South America, and even travelled as far as Chile, where it had previously been unknown. In 1887 it still lingered in the Mediterranean, causing great mortality in Messina especially. According to Dr A.J. Wall, this epidemic cost 250,000 lives in Europe and at least 50,000 in America. A particular interest attaches to it in the fact that a localized revival of the disease was caused in Spain in 1890 by the disturbance of the graves of some of the victims who had died of cholera four years previously.

_1892-1895._--This great invasion reverted again to the old overland route, but the march of the disease was of unprecedented rapidity. Within less than five months it travelled from the North-West Provinces of India to St Petersburg, and probably to Hamburg, and thence in a few days to England and the United States. This speed, in such striking contrast to the slow advance of former occasions, was attributed, and no doubt rightly, to improved steam transit, and particularly the Transcaspian railway. The progress of the disease was traced from place to place, and almost from day to day, with great precision, showing how it moves along the chief highways and is obviously carried by man. The main facts are as follows:--Cholera was extensively and severely prevalent in India in 1891, causing 601,603 deaths, the highest mortality since 1877. In March 1892 it broke out at the Hardwar fair, a day or two before the pilgrims dispersed; on the 19th of April it was at Kabul, on the 1st of May at Herat, and on the 26th of May at Meshed. From Meshed it moved in three directions--due west to Teheran in Persia, north-east by the Transcaspian railway to Samarkand in Central Asia, and north-west by the same line in the opposite direction to Uzun-ada on the Caspian Sea. It reached Uzun-ada on the 6th of June; crossed to Baku, June 18th; Astrakhan, June 24th; then up the Volga to Nizhniy-Novgorod, arriving at Moscow and St Petersburg early in August. The part played by steam transit is clear from the fact that the disease took no longer to travel all the way from Meshed to St Petersburg by rail and steamboat than to traverse the short distance from Meshed to Teheran by road. On the 16th of August cases began to occur in Hamburg; on the 19th of August a fireman was taken ill at Grangemouth in Scotland, where he had arrived the day before from Hamburg; and on the 31st of August a vessel reached New York from the same port with cholera on board. On the 8th of September the disease appeared in Galicia, having moved somewhat slowly westwards across Russia into Poland, and on the 26th of September it was in Budapest. Holland and Servia were also attacked, while isolated cases were carried to Norway, Denmark and Italy. Meanwhile two entirely separate epidemics were in progress elsewhere. The first was confined to Arabia and the Somali coast of Africa, and was connected with the remains of an outbreak in Syria and Arabia in 1890-1891. The second arose mysteriously in France about the time when the overland invasion started from India. The first known case occurred in the prison at Nanterre, near Paris, on the 31st of March. Paris was affected in April, and Havre in July. The origin of this outbreak, which was of a much less violent character than that which came simultaneously by way of Russia, was never ascertained. Its activity was confined to France, particularly in the neighbourhood of Paris, together with Belgium and Holland, which was placed between two fires, but escaped with but little mortality. The number of persons killed by cholera in 1892, outside of India, was reckoned at 378,449, and the vast majority of those died within six months. The countries which suffered most severely were as follows:--European Russia, 151,626; Caucasus, 69,423; Central Asian Russia, 31,804; Siberia, 15,037--total for Russian empire, 267,890; Persia, 63,982; Somaliland, 10,000; Afghanistan, 7,000; Germany, 9563; France, 4550; Hungary, 1255; Belgium, 961. Curiously enough, the south of Europe, which had been the scene of the previous epidemic visitation, escaped. The disease was of the most virulent character. In European Russia the mortality was 45.8% of the cases, the highest rate ever known in that country; in Germany it was 51.3%; and in Austria-Hungary, 57.5%. Of all the localities attacked, the case of Hamburg was the most remarkable. The presence of cholera was first suspected on the 16th of August, when two cases occurred, but it was not officially declared until the 23rd of August. By that time the daily number of victims had already risen to some hundreds, while the experts and authorities were making up their minds whether they had cholera to deal with or not. Their decision eventually came too late and was superfluous, for by the 27th of August the people were being stricken down at the rate of 1000 a day. This rate was maintained for four days, after which the vehemence of the pestilence began to abate. It gradually declined, and ceased on the 14th of November. During those three months 16,956 persons were attacked and 8605 died, the majority within the space of a few weeks. The town, ordinarily one of the gayest places of business and pleasure on the continent, became a city of the dead. Thousands of persons fled, carrying the disease into all parts of Germany; the rest shut themselves indoors; the shops were closed, the trams ceased to run, the hotels and restaurants were deserted, and few vehicles or pedestrians were seen in the streets. At the cemetery, which lies about 10 m. from the town, some hundreds of men were engaged day and night digging long trenches to hold double rows of coffins, while the funerals formed an almost continuous procession along the roads; even so the victims could not be buried fast enough, and their bodies lay for days in sheds hastily run up as mortuaries. Hamburg had been attacked by cholera on fourteen previous occasions, beginning with 1831, but the mortality had never approached that of 1892; in the worst year, which was 1832, there were only 3687 cases and 1765 deaths. The disease was believed to have been introduced by Jewish emigrants passing through on their way from Russia, but the importation could not be traced. The Jews were segregated and kept under careful supervision from the middle of July onwards, and no recognized case occurred among them. The total number of places in Germany in which cholera appeared in 1892 was 269, but it took no serious hold anywhere save in Hamburg. The distribution was chiefly by the waterways, which seem to affect a larger number of places than the railways as carriers of cholera. In Paris 907 persons died, and in Havre 498. Between the 18th of August and the 21st of October 38 cases were imported into England and Scotland through eleven different ports, but the disease nowhere obtained a footing. Seven vessels brought 72 cases to the United States, and 16 others occurred on shore, but there was no further dissemination.

During the winter of 1892-1893 cholera died down, but never wholly ceased in Russia, Germany, Austria-Hungary and France. With the return of warm weather it showed renewed activity, and prevailed extensively throughout Europe. The recorded mortality for the principal countries was as follows:--Russia (chiefly western provinces), 41,047; Austria-Hungary, 4669; France, 4000; Italy, 3036; Turkey, 1500; Germany, 298; Holland, 376; Belgium, 372; England, 139. Hardly any country escaped altogether; but Europe suffered less than Arabia, Mesopotamia and Persia. Cholera broke out at Mecca in June, and owing to the presence of an exceptionally large number of pilgrims caused an appalling mortality. The chief shereef estimated the mortality at 50,000. The pilgrims carried the disease to Asia Minor and Constantinople. In Persia also a recrudescence took place and proved enormously destructive. Dr. Barry estimated the mortality at 70,000. At Hamburg, where new waterworks had been installed with sand filtration, only a few sporadic cases occurred until the autumn, when a sudden but limited rush took place, which was traced to a defect in the masonry permitting unfiltered Elbe water to pass into the mains. In England cholera obtained a footing on the Humber at Grimsby, and to a lesser extent at Hull, and isolated attacks occurred in some 50 different localities. Excluding a few ship-borne cases the registered number of attacks was 287, with 135 deaths, of which 9 took place in London. It is interesting to compare the mortality from cholera in England and Wales, and in London, for each year in which it has prevailed since registration began:--

+-------+------------------------+-------------------------+
| | England and Wales. | London. |
| +--------+---------------+--------+----------------+
| Year. | | Deaths per | | Deaths per |
| | Deaths.| 10,000 living.| Deaths.| 10,000 living.|
+-------+--------+---------------+--------+----------------+
| | | | | |
| 1848- | 1,908 | 1.1 | 652 | 2.9 |
| 1849 | 53,293 | 30.3 | 14,137 | 61.8 |
| | | | | |
| 1853- | 4,419 | 2.4 | 883 | 3.5 |
| 1854 | 20,097 | 10.9 | 10,738 | 42.8 |
| | | | | |
| 1865- | 1,297 | 0.6 | 196 | 0.6 |
| 1866 | 14,378 | 6.8 | 5,596 | 18.4 |
| | | | | |
| 1893- | 135 | 0.05 | 9 | 0.002 |
| 1894 | nil | nil | nil | nil |
+-------+--------+---------------+--------+----------------+

In 1894 no deaths from cholera were recorded in England, but on the continent it still prevailed over a wide area. In Russia over 30,000 persons died of it, in Germany about 500, but the most violent outbreak was in Galicia, where upwards of 8000 deaths were registered. In 1895 it still lingered, chiefly in Russia and Galicia, but with greatly diminished activity. In that year Egypt, Morocco and Japan were attacked, the last severely. The disease then remained in abeyance until the severe epidemic in India in 1900.

Prevention

The great invasion just described was fruitful in lessons for the prevention of cholera. It proved that the one real and sufficient protection lies in a standing condition of good sanitation backed by an efficient and vigilant sanitary administration. The experience of Great Britain was a remarkable piece of evidence, but that of Berlin was perhaps even more striking, for Berlin lay in the centre of four fires, in direct and frequent communication with Hamburg, Russia, France and Austria, and without the advantage of a sea frontier. Cholera was repeatedly brought into Berlin, but never obtained a footing, and its successful repression was accomplished without any irksome interference with traffic or the ordinary business of life. The general success of Great Britain and Germany in keeping cholera in check by ordinary sanitary means completed the conversion of all enlightened nations to the policy laid down so far back as 1865 by Sir John Simon, and advocated by Great Britain at a series of international congresses--the policy of abandoning quarantine, which Great Britain did in 1873, and trusting to sanitary measures with medical inspection of persons arriving from infected places. This principle was formally adopted at the international conference ference held at Dresden in 1893, at which a convention was signed by the delegates of Germany, Austria, Belgium, France, Great Britain, Italy, Russia, Switzerland, Luxemburg, Montenegro and the Netherlands. Under this instrument the practice is broadly as follows, though the procedure varies a good deal in different countries:--Ships arriving from infected ports are inspected, and if healthy are not detained, but bilge-water and drinking-water are evacuated, and persons landing may be placed under medical supervision without detention; infected ships are detained only for purposes of disinfection; persons suffering from cholera are removed to hospital; other persons landing from an infected ship are placed under medical observation, which may mean detention for five days from the last case, or, as in Great Britain, supervision in their own homes, for which purpose they give their names and places of destination before landing. All goods are freed from restrictions, except rags and articles believed to be contaminated by cholera matters. By land, passengers from infected places are similarly inspected at the frontiers and their luggage "disinfected"--in all cases a pious ceremony of no practical value, involving a short but often a vexatious delay; only those found suffering from cholera can be detained. Each nation is pledged to notify the others of the existence within its own borders of a "foyer" of cholera, by which is meant a focus or centre of infection. The precise interpretation of the term is left to each government, and is treated in a rather elastic fashion by some, but it is generally understood to imply the occurrence of non-imported cases in such a manner as to point to the local presence of infection. The question of guarding Europe generally from the danger of diffusion by pilgrims through the Red Sea was settled at another conference held in Paris in 1894. The provisions agreed on included the inspection of pilgrims at ports of departure, detention of infected or suspected persons, and supervision of pilgrim ships and of pilgrims proceeding overland to Mecca.

The substitution of the procedure above described for the old measures of quarantine and other still more drastic interferences with traffic presupposes the existence of a sanitary service and fairly good sanitary conditions if cholera is to be effectually prevented. No doubt if sanitation were perfect in any place or country, cholera, along with many other diseases, might there be ignored, but sanitation is not perfect anywhere, and therefore it requires to be supplemented by a system of notification with prompt segregation of the sick and destruction of infective material. These things imply a regular organization, and it is to the public health service of Great Britain that the complete mastery of cholera has mainly been due in recent years, and particularly in 1893. Of sanitary conditions the most important is unquestionably the water-supply. So many irrefragable proofs of this fact were given during 1892-1893 that it is no longer necessary to refer to the time-honoured case of the Broad Street pump. At Samarkand three regiments were encamped side by side on a level plain close to a stream of water. The colonel of one regiment took extraordinary precautions, placing a guard over the river, and compelling his men to use boiled water even for washing. Not a single case of cholera occurred in that regiment, while the others, in which only ordinary precautions were taken, lost over 100 men. At Askabad the cholera had almost disappeared, when a banquet was given by the governor in honour of the tsar's name-day. Of the guests one-half died within twenty-four hours; a military band, which was present, lost 40 men out of 50; and one regiment lost half its men and 9 officers. Within forty-eight hours 1300 persons died out of a total population of about 13,000. The water supply came from a small stream, and just before the banquet a heavy rain-storm had occurred, which swept into the stream all surface refuse from an infected village higher up and some distance from the banks. But the classical example was Hamburg. The water-supply is obtained from the Elbe, which became infected by some means not ascertained. The drainage from the town also runs into the river, and the movement of the tide was sufficient to carry the sewage matter up above the water-intake. The water itself, which is no cleaner than that of the Thames at London Bridge, underwent no purification whatever before distribution. It passed through a couple of ponds, supposed to act as settling tanks, but owing to the growth of the town and increased demand for water it was pumped through too rapidly to permit of any subsidence. Eels and other fish constantly found their way into the houses, while the mains were lined with vegetation and crustacea. The water-pipes of Hamburg had a peculiar and abundant fauna and flora of their own, and the water they delivered was commonly called _Fleischbrühe_, from its resemblance to thick soup. On the other hand, at Altona, which is continuous with Hamburg, the water was filtered through sand. In all other respects the conditions were identical, yet in Altona only 328 persons died, against 8605 in Hamburg. In some streets one side lies in Hamburg, the other in Altona, and cholera stopped at the dividing line, the Hamburg side being full of cases and the Altona side untouched. In the following year, when Hamburg had the new filtered supply, it enjoyed equal immunity, save for a short period when, as we have said, raw Elbe water accidentally entered the mains.

But water, though the most important condition, is not the only one affecting the incidence of cholera. The case of Grimsby furnished a striking lesson to the contrary. Here the disease obtained a decided hold, in spite of a pure water-supply, through the fouling of the soil by cesspits and defective drainage. At Havre also its prevalence was due to a similar cause. Further, it was conclusively proved at Grimsby that cholera can be spread by sewage-fed shell-fish. Several of the local outbreaks in England were traced to the ingestion of oysters obtained from the Grimsby beds. In short, it may be said that all insanitary conditions favour the prevalence of cholera in some degree. Preventive inoculation with an attenuated virus was introduced by W.M.W. Haffkine, and has been extensively used in India, with considerable appearance of success so far as the statistical evidence goes.

Treatment.

As already remarked, the latest manifestations of cholera show that it has lost none of its former virulence and fatality. The symptoms are now regarded as the effects of the toxic action of the poison formed by the micro-organisms upon the tissues and especially upon the nervous system. But this theory has not led to any effective treatment. Drugs in great variety were tried in the continental hospitals in 1892, but without any distinct success. The old controversy between the aperient and the astringent treatment reappeared. In Russia the former, which aims at evacuating the poison, was more generally adopted; in Germany the latter, which tries to conserve strength by stopping the flux, found more favour. Two methods of treatment were invariably found to give great relief, if not to prolong life and promote recovery--the hot bath and the injection of normal saline solution into the veins or the subcutaneous tissue. These two should always be tried in the cold and collapsed stages of cholera.

See _Local Government Board Reports, 1892-93-94-95_; Clemow, _The
Cholera Epidemic of 1892 in the Russian Empire_; Wall, _Asiatic
Cholera_; Notter, _Epidemiological Society's Transactions_, vol.
xvii.; Emmerich and Gemünd, _München. med. Wochenschr_. (1904), pp.
1086-1157; Wherry, _Department of the Interior Bureau of Government
Laboratories_, No. 19 (October 1904, Manila); Wherry and M'Dill,
_Ibid._ No. 31 (May 1905, Manila).

CHOLET, a town of western France, capital of an arrondissement in the department of Maine-et-Loire, 41 m. S.E. of Nantes on the Ouest-État railway between that town and Poitiers. Pop. (1906) 16,554. Cholet stands on an eminence on the right bank of the Moine, which is crossed by a bridge of the 15th century. A public garden occupies the site of the old castle; the public buildings and churches, the finest of which is Notre-Dame, are modern. The public institutions include the sub-prefecture, a tribunal of first instance, a chamber of commerce, a board of trade-arbitrators, and a communal college. There are granite quarries in the vicinity of the town. The chief industry is the manufacture of linen and linen handkerchiefs, which is also carried on in the neighbouring communes on a large scale. Woollen and cotton fabrics are also produced, and bleaching and the manufacture of preserved foods are carried on. Cholet is the most important centre in France for the sale of fat cattle, sheep and pigs, for which Paris is the chief market. Megalithic monuments are numerous in the neighbourhood. The town owes the rise of its prosperity to the settlement of weavers there by Edouard Colbert, count of Maulévrier, a brother of the great Colbert. It suffered severely in the War of La Vendée of 1793, insomuch that for years afterwards it was almost without inhabitants.

CHOLON ("great market"), a town of French Indo-China, the largest commercial centre of Cochin China, 3½ m. S.W. of Saigon, with which it is united by railway, steam-tramway and canal. Cholon was founded by Chinese immigrants about 1780, and is situated on the Chinese arroyo at the junction of the Lo-Gom and a canal. Its waterways are frequented by innumerable boats and lined in some places with native dwellings built on piles, in others by quays and houses of French construction. Its population is almost entirely Asiatic, and has more than trebled since 1880. In that year it had only 45,000 inhabitants; in 1907 it numbered about 138,000. Of these, 42,000 were Chinese, 73,000 Annamese, and 155 French (exclusive of a garrison of 92); the remainder consisted of Cambodians and Asiatic foreigners. During the rice season the town is visited by a floating population of 21,000 persons. The Chinese are divided into congregations according to their place of origin. Cholon is administered by a municipal council, composed of French, Annamese and Chinese traders. An administrator of native affairs, nominated by the governor, fills the office of mayor. There are a fine municipal hospital and municipal schools for boys and girls. The principal thoroughfares are lighted by electric light. The rice trade, almost monopolized by the Chinese, is the leading industry, the rice being treated in large steam mills. Tanning, dyeing, copper-founding, glass, brick and pottery manufacture, stone working, timber-sawing and junk building are also included among the industries.

CHOLONES, a tribe of South American Indians living on the left bank of the Huallaga river in the Amazon valley. The name is that given them by the Spanish. They were first met by the Franciscans, who established mission villages among them in 1676. They are a wild race but mild-mannered, very superstitious, and pride themselves on their skill as doctors. Their chief weapon is the blow-pipe, in the use of which they are adepts.

CHOLULA, an ancient town of Mexico, in the state and on the plateau of Puebla, 8 m. by rail W. by N. of the city of that name, and 6912 ft. above sea-level. Pop. (1900, estimate) 9000. The Interoceanic railway passes through Cholula, but the city's commercial and industrial standing is overshadowed by that of its larger and more modern neighbour. At the time of the Spanish Conquest, Cholula--then known as Chololan--was a large and important town, consecrated to the worship of the god Quetzalcoatl, who had here one of the most imposing temples in Anahuac, built on the summit of a truncated pyramid, the largest of its kind in the world. This pyramid, constructed of sun-dried bricks and earth, 177 ft. high, and covering an area of nearly 45 acres, is the most conspicuous object in the town and is surmounted by a chapel dedicated to _Nuestra Señora de los Remedios_. A corner of the lower terrace of this great pyramid was cut through in the construction of the Puebla road, but nothing was discovered to explain its purpose, which was probably that of furnishing an imposing site for a temple. Nothing definite is known of its age and history, as the fanatical zeal of Cortez and his companions destroyed whatever historical data the temple may have contained. Cholula was visited by Cortez in 1519 during his eventful march inland to Montezuma's capital, Tenochtitlan, when he treacherously massacred its inhabitants and pillaged the city, pretending to distrust the hospitable inhabitants. Cortez estimated that the town then had 20,000 habitations, and its suburbs as many more, but this was undoubtedly a deliberate exaggeration. The Cholulans were of Nahuatl origin and were semi-independent, yielding only a nominal allegiance to Montezuma. They were a trading people, holding fairs, and exchanging their manufactures of textiles and pottery for other produce. The pyramid is believed to have been built by a people occupying this region before the Cholulans.

CHOPIN, FREDERIC FRANÇOIS (1810-1849), Polish musical composer and pianist, was born at Zelazowa-Wola, near Warsaw, on the 22nd of February 1810 (_not_ the 1st of March 1809). His father, of French origin, born at Nancy in 1770, had married a Polish lady, Justine Krzyzanowska. Frederic was their third child. His first musical education he received from Adalbert Ziwny, a Czech musician, who is said to have been a passionate admirer of J.S. Bach. He also received a good general education at one of the first colleges of Warsaw, where he was supported by Prince Antoine Radziwill, a generous protector of artistic talent and himself well known as the composer of music to Goethe's _Faust_ and other works. His musical genius opened to Chopin the best circles of Polish society, at that time unrivalled in Europe for its ease of intercourse, the beauty and grace of its women, and its liberal appreciation of artistic gifts. These early impressions were of lasting influence on Chopin's development. While at college he received thorough instruction in the theory of his art from Joseph Elsner, a learned musician and director of the conservatoire at Warsaw. When in 1829 he left his native town for Vienna, where his _début_ as a pianist took place, he was in all respects a perfectly formed and developed artist. There is in his compositions little of that gradual progress which, for instance, in Beethoven necessitates a classification of his works according to different periods. Chopin's individuality and his style were distinctly pronounced in that set of variations on "La ci darem" which excited the wondering enthusiasm of Robert Schumann. In 1831 he left Vienna with the intention of visiting London; but on his way to England he reached Paris and settled there for the rest of his life. Here again he soon became the favourite and musical hero of society. His connexion with Madame Dudevant, better known by her literary pseudonym of George Sand (q.v.), is an important feature of Chopin's life. When in 1839 his health began to fail, George Sand went with him to Majorca, and it was mainly owing to her tender care that the composer recovered his health for a time. Chopin declared that the destruction of his relations with Madame Dudevant in 1847 broke up his life. The association of these two artists has provoked a whole literature on the nature of their relations, of which the novelist's _Un Hiver à Majorque_ was the beginning. The last ten years of Chopin's life were a continual struggle with the pulmonary disease to which he succumbed in Paris on the 17th of October 1849. The year before his death he visited England, where he was received with enthusiasm by his numerous admirers. Chopin died in the arms of his sister, who hastened from Poland to his death-bed. He was buried in the cemetery of Père Lachaise. A small monument was erected to the memory of the composer at Wasswan in 1880. Portraits and medallions of Chopin were executed by Ary Scheffer and Eugène Delacroix, and by the sculptors Bary and Clésinger.

A distinguished English amateur thus records his impressions of Chopin's style of pianoforte-playing compared with those of other masters. "His technical characteristics may be broadly indicated as negation of _bravura_, absolute perfection of finger-play, and of the _legatissimo_ touch, on which no other pianist has ever so entirely leant, to the exclusion of that high relief and point which the modern German school, after the examples of Liszt and Thalberg, has so effectively developed. It is in these feature that we must recognize that _Grundverschiedenheit_ (fundamental difference) which according to Mendelssohn distinguished Chopin's playing from that of these masters, and in no less degree from the example and teaching of Moscheles.... Imagine a delicate man of extreme refinement of mien and manner, sitting at the piano and playing with no sway of the body and scarcely any movement of the arms, depending entirely upon his narrow feminine hands and slender fingers. The wide arpeggios in the left hand, maintained in a continuous stream of tone by the strict legato and fine and constant use of the damper-pedal, formed an harmonious substructure for a wonderfully poetic cantabile. His delicate pianissimo, the ever-changing modifications of tone and time (tempo rubato) were of indescribable effect. Even in energetic passages he scarcely ever exceeded an ordinary mezzoforte. His playing as a whole was unique in its kind, and no traditions of it can remain, for there is no school of Chopin the pianist, for the obvious reason that he could never be regarded as a public player, and his best pupils were nearly all amateurs."

In looking through the list of his compositions, teeming with mazurkas, valses, polonaises, and other forms of national dance music, one could hardly suppose that here one of the most melancholy natures has revealed itself. This seeming paradox is solved by the type of Chopin's nationality, of which it has justly been said that its very dances are sadness intensified. But notwithstanding this strongly pronounced national type of his compositions, his music is always expressive of his individual feelings and sufferings to a degree rarely met with in the annals of the art. He is indeed the lyrical composer _par excellence_ of the modern school, and the intensity of his expression finds its equal in literature only in the songs of Heinrich Heine, to whom Chopin has been justly compared. A sensation of such high-strung passion cannot be prolonged. Hence we see that the shorter forms of music, the étude, the nocturne, besides the national dances already alluded to, are chosen by Chopin in preference. Even when he treats the larger forms of the concerto or the sonata this concentrated, not to say pointed, character of Chopin's style becomes obvious. The more extended dimensions seem to encumber the freedom of his movements. The concerto for pianoforte with accompaniment of the orchestra in E may be instanced. Here the adagio takes the form of a romance, and in the final rondo the rhythm of a Polish dance becomes recognizable while the instrumentation throughout is meagre and wanting in colour. Chopin is out of his element, and even the beauty of his melodies and harmonies cannot wholly banish the impression of incongruity. Fortunately he himself knew the limits of his power, and with very few exceptions his works belong to that class of minor compositions of which he was an unrivalled master. Barring a collection of Polish songs, two concertos, and a very small number of concerted pieces of chamber music, almost all his works are written for the pianoforte solo; the symphony, the oratorio, the opera, he never attempted.

Chopin's works group themselves firstly into the period from Op. 1 to
22, which includes nearly all his attempts at large or classical
forms, e.g. the works with orchestra, Op. 2 (variations on _La ci
darem_), Opp. 11 and 14 (concertos), Op. 13 (Polish fantasia), Op. 14
(_Krakowiak_, a concerto-rondo in mazurka-rhythm), and Op. 22 (Andante
spianato and Polonaise), besides the solo rondos Opp. 1, 5, 16, and
the variations Op. 12 and the essays in chamber music Opp. 3, 8, 65.
Meanwhile, however, the mature lyric style of his second period
already began with Op. 6 (4 mazurkas), and though it is not confined
to small forms, the larger mature works (beginning with the ballade
Op. 23 and excepting only the sonata Op. 58 and the Allegro de Concert
Op. 46) are as independent of tradition as the smallest. It is well to
sift the posthumous works from those published under Chopin's
direction, for the last three mazurkas are the only things he did not
keep back as misrepresenting him. On these principles his mature works
are summed up in the 42 mazurkas (Opp. 6, 7, 17, 24, 30, 33, 41, 50,
56, 59, 63, and the beautiful contribution to the collection _Notre
temps_); 7 polonaises (Opp. 26, 40, 53, 61); 24 preludes (in all the
major and minor keys) Op. 28, and the single larger prelude Op. 45; 27
études (12 in Op. 10, 12 in Op. 25, and 3 written for the _Méthode des
méthodes_); 18 nocturnes (Opp. 9, 15, 27, 32, 37, 48, 55, 62); 4
ballades, in forms of Chopin's own invention (Opp. 23, 38, 47, 52); 4
scherzos (Opp. 20, 31, 39, 54); 8 waltzes (Opp. 18, 34, 42, 64); and
several pieces of various description, notably the great fantasia Op.
49 and the impromptus Opp. 29, 36, 51.

The posthumous works number 35 pieces, besides a small volume of songs
a few of which are of great interest.

Franz Liszt wrote a charming sketch of Chopin's life and art (_F.
Chopin_, par F. Liszt, Paris, 1851), and a very appreciative though
somewhat eccentric analysis of his work appeared anonymously in 1842
(_An Essay on the Works of Frédéric Chopin_, London). The standard
biography is the English work of Professor F. Niecks (Novello, 1888).
See also W.H. Hadow, _Studies in Modern Music_, second series (1908).
The editions of Chopin's works by his pupil Mikuli and by Klindworth
are full of valuable elucidation as to methods of performance, but
unfortunately they do not distinguish the commentary from the text.
The critical edition published by Breitkopf and Härtel, with all its
mistakes, is absolutely necessary for students who wish to know what
Chopin wished to put into the hands of players of independent
judgment.

CHOPSTICKS, the "pidgin-English" name for the pair of small tapering sticks used by the Chinese and Japanese in eating. "Chop" is pidgin-English for "quick," the Chinese word for the articles being _kwai-tsze_, meaning "the quick ones." "Chopsticks" are commonly made of wood, bone or ivory, somewhat longer and slightly thinner than a lead-pencil. Held between the thumb and fingers of the right hand, they are used as tongs to take up portions of the food, which is brought to table cut up into small and convenient pieces, or as means for sweeping the rice and small particles of food into the mouth from the bowl. Many rules of etiquette govern the proper conduct of the chopsticks; laying them across the bowl is a sign that the guest wishes to leave the table; they are not used during a time of mourning, when food is eaten with the fingers; and various methods of handling them form a secret code of signalling.

CHORAGUS (the Lat. form of Gr. [Greek: choragos] or [Greek: chorêgos], leader of the chorus), the citizen chosen to undertake the expense of furnishing and instructing the chorus at the Dionysiac festivals at Athens (see LITURGY and FINANCE). The name is given to an assistant to the professor of music at the university of Oxford, whose office was founded, with that of the professor, in 1626 by Dr William Heather.