These considerations help to explain the extreme diversities of mortality in different epidemics. The extremes may be stated at 10 and 90 per cent., and they would perhaps be still wider apart if all the mild cases, which are never reported—many of which, indeed, do not even fall under medical observation—were included in the reckoning. The general or average mortality of cholera is about 50 per cent. According to Allbu, the epidemics in Berlin from 1831 to 1873 gave a total of 28,753 cases and 18,916 deaths; that is, a mortality of 65.8 per cent. (Eichhorst). It should be noted that, as in other epidemic diseases, there is no uniform proportion between the extent and the mortality of cholera epidemics. Some of very limited extent have been proportionally the most destructive. It should also be remembered that the disease is far more fatal in infancy and old age than at any other period of life, and for a similar reason it is very dangerous to all who are weakened by any cause, such as an inherited morbid diathesis, a chronic debilitating disease, etc. There seems to be a doubt whether its male or female victims are the more numerous. In this connection it may be suggested that while males are more likely to contract the disease by drinking contaminated water, etc., more women are exposed to its contagion by their intimate relations with the sick, by their handling and washing infected fomites, by carrying away the cholera discharges, etc.
Undoubtedly, the class of society to which cholera patients belong is not without influence on its prognosis. Not only is the total mortality greater among the laboring classes, but the individual belonging to those classes has a less chance of recovery, because he is not apt to resort to treatment on the appearance of the premonitory signs of the disease, and because the treatment he receives is less intelligently and sedulously pursued by his physicians and friends.
In regard to the particular symptoms which are favorable or unfavorable, nothing need be added to what has already been stated in detail, unless it be that during the height of the attack the danger is to be measured by the degree of prostration and of the stasis of the blood, and, during reaction, by the grade of the typhoid state. Gradual reaction, as denoted by the state of the skin and the pulse and a more natural aspect of the stools, is generally indicative of improvement.
Finally, a word of caution may be given to those who are apt to attribute all the favorable changes in the conditions of an epidemic to the sanitary or medicinal measures they have instituted. Cholera epidemics are remarkable for the comparatively short period of their duration, which may be stated at less than a month in the same place. Doubtless, judicious sanitation and timely treatment save a great many lives, but the qualifying fact, already insisted upon, must not be overlooked, that the mortality occasioned by the disease in a given place is greatest during the first period of its prevalence, and that thenceforth it gradually declines. Yet it is of essential significance that the disease rarely attacks a large number of persons simultaneously; the epidemic proper is usually preceded by a few scattering cases which are apt to become foci of ignition that presently unite to form a widespread conflagration. The recognition of these cases, their isolation, and the proper treatment of the localities where they occurred have frequently stamped out what might have been the commencement of a deadly epidemic.
PREVENTION.—The history of cholera demonstrates conclusively that since the disease, outside of India, never arises spontaneously, it must be more or less preventible, partly by excluding its seeds and partly by rendering the soil in which they are planted more or less unfit for their development; in other words, by quarantines and sanitary cordons and by various measures of local sanitation.
In regard to the former there would be comparatively little difference of opinion, at least theoretically, if both measures were alike efficacious. But there would seem to have prevailed a tendency in official quarters to undervalue the efficiency of both. Those who made and administered the sanitary laws relating to cholera seem to have forgotten the emphatic question, "What will not a man give for his life?" or at least to have considered that whatever value some men may set upon their own lives, the lives of other men become of no account when balanced against the needs, or even the conveniences, of commerce. The ethics which justified the introduction of opium into China by the English and the American gift of alcohol to the Indian to gratify a lust for lucre or for land is only paralleled by those contained in the official protests against cholera quarantines. At the International Medical Congress held in 1873 at Constantinople, it was almost unanimously resolved that "the practice of (land) quarantine as now carried out ought not to be maintained, because, on the one hand, it does not constitute a real protection, and, on the other hand, it is directly opposed to the interests of commerce and industry." A leading critic, in commenting upon this, remarks that if a quarantine were possible it would give no real security, because it would be evaded, just as customs laws are evaded by smuggling.58 A logical deduction from this curious argument would be that customs laws should be abrogated. In 1880 was published the report of the German Imperial Commission on the cholera epidemic of 1873 in Germany, edited by Hirsch, from which we learn that "all the German medical experts agree in condemning the employment of quarantine, for, while largely detrimental to the interests, welfare, convenience, and happiness of a community, it is quite inert and inefficient as a safeguard against the further diffusion of cholera."59 Whether this opinion refers only to land quarantine or not is left in doubt, but the spirit of subordinating the lives of the people to the commercial interests of a country is just the same as, and is not less worthy of condemnation than, the spirit which has more than once blinded customs officials to the disease on board of vessels from which it has afterward issued to destroy thousands of lives.
58 Practitioner, xii. 226.
59 Ibid., xxvi. 159.
It seems to be overlooked that in national as well as in personal affairs "honesty is the best policy," and that if, instead of concealment or false statements regarding the sanitary state of ships, their passengers, and cargoes, and equally false assertions respecting the contagiousness of cholera, and a contemptuous neglect of well-tried preventive measures,—if, instead of this delusive and disastrous policy, all nations had honestly carried out the rules prescribed by experience for the exclusion of the disease, and for its management after it had passed the frontiers of a country, there can be little doubt that its ravages would ere this have been confined to the region in which it originated. As we have seen, there is urged against the enforcement of a rigid quarantine by land or sea the singular argument that it has not always excluded the disease. A more logical inference would seem to be that since it succeeded, not completely, but yet partially, its inefficiency should be charged to its imperfect execution; or, even granting that the absolute exclusion of cholera is impracticable in every instance, including cases of choleraic diarrhoea, contaminated clothing and merchandise, does it therefore follow that the transit of men and things should be unimpeded? As well might it be maintained that because one or more houses cannot escape destruction by fire, therefore no effort should be made to save the remainder of a threatened city; as well might it be argued that because some men must be killed in battle, no precautions should therefore be used to preserve the rest of the army; as well abstain from all local sanitation intended to mitigate the ravages of the disease, because, do what we may, some victims it will surely have. This is taking counsel from despair; is a stupid fatalism which one might imagine to have been imported with the disease from the East; or it may be a sign of the unconscious blindness of Mammon-worshippers, who, neither fearing God nor regarding man, have as little pity for the victims of cholera, permitted, if not invited, by them to scourge the nations, as devout Christians once felt for the negroes who were bought or kidnapped in Africa to toil and die under the lash of the slave-driver.
Probably no sanitary cordon nor any quarantine will invariably and completely exclude cholera, since it is transmissible by living men and by water and by fomites of various descriptions, and, worst of all, by men who neither exhibit its characteristic symptoms nor are conscious of the poison which they conceal and disseminate. But, as has already been urged, it is no argument against preventive measures that they are not absolutely perfect in their efficiency. If they sometimes succeed in arresting the progress of cholera, and if they always, when honestly executed, lessen the number of channels through which the infection can be conveyed, and thereby reduce to a minimum its fatal effects, they ought to be maintained and perfected, and not decried or abolished. It is difficult to characterize that state of mind which concludes against the use of a salutary measure because its efficiency is not absolute, the more so when it is admitted that its inefficiency is not intrinsic, but due to negligent, and even fraudulent, administration. The preponderance of official and personal authority is altogether on the side of the necessity of a quarantine, not in its literal, but in its technical, sense. The International Medical Congress of 1874 declared as follows: "Quarantine ought to be limited to the time requisite for the examination and disinfection of the ship, the crew, and the passengers; and if there be no disease on board the latter should be released immediately after disinfection. But if there be cholera or sickness of a doubtful nature on board, it will be necessary to isolate and disinfect the ship also." The same congress, however, wholly condemned land quarantines, apparently upon the sole ground of the extreme difficulty of rendering them efficient—an argument, as before remarked, that touches not the principle of the measure, but only the manner of its execution. In this respect the congress occupied a lower position than its predecessor of 1866, which held that the futility of quarantine in "arresting the march of cholera" arose "rather from the unintelligent application of the measure than from any fallacy in its principle."60