War Department Received July 18, 1885. Surgeon General's Dept. July 16, '85. State Dept. Transmit copy of report from U.S. Consul at Marseilles, France. (Frank H. Mason) on Cholera during the nine years, since 1835 that that city has been afflicted with the disease. Department of State Washington, July 16, 1885 To the Honorable William C. Endicott, Secretary of War. Sir: I have the honor to enclose review for your information a copy of a dispatch from the Consul at Marseilles, Frank H. Mason, Esquire, under date of the 23rd of June last, numbered 60 in which he has submitted a report on cholera at Marseilles During the nine years since 1835 that the City has been afflicted with the Cholera. I have the honor to be Sir, Your obedient servant, T. F. Bayard [?] Enclosure: Mr. Mason to Mr. Porter No. 60 June 23rd 1885 Copy Copy No. 60 United States Consulate, Marseilles, June 23, 1885. Hon. James D. Porter, Assistant Secretary of State, Washington, DC Sir: I have the honor to submit herewith a report, in which the attempt has been made to condense into practical form various facts which are suggested by the experience of the medical and municipal authorities of Marseilles during the nine years of cholera which have afflicted this city since 1835. No other European city has had a larger experience or attained greater skill in the management of Cholera than Marseilles, and it is thought that the Department may wish to utilize the results of this experience for the benefit of such American communities as may unfortunately be threatened by Epidemic. In a report of this character, no originality of course has been attempted, the purpose being rather to avoid all mere theories or disputed points, and give only facts which are fully established by experience and so plain and practical as to be useful for public information. A large part of the misfortune of a cholera epidemic is always averted when people generally understand the mature and limitations of the disease and the best methods of avoiding and treating it. I am, Sir, Very respectfully, Your obedient servant, Frank H. Mason, Consul. Enclosure: Report as above. 3 Copy Asiatic Cholera A Resume of the practical conclusions concerning its nature and the best methods of prevention and treatment as derived from studies of the Epidemics of 1884 and preceeding [sic] years at Marseilles. Report by Consul Mason. During nine years since 1835, Marseilles has been visited by Asiatic Cholera. The outbreak of 1834 was aggravated by a recurrence of the epidemic in 1835, and those of 1854 and 1865 respectively were each followed by a reappearance of the scourge during the summer of the following year. With one exception - that of 1834-35- the cholera death-rate of these second seasons was somewhat less than half that of the year preceeding [sic], and the diminution is attributed largely to the fact that, after a year of pestilence, the municipal 4 and sanitary authorities, the physicians and the people generally have been able to meet the recurring epidemic more intelligently and with much less of the panic and trepidation that are usually caused by an outbreak of cholera in an inexperienced community. In view of the present steady increase of Asiatic Cholera throughout various provinces of Spain, and the extraordinary efforts that are made to prevent its transfer to other countries and to limit and restrain its ravages in case such preventive measures should fail, it would seen timely and provident to utilize, as far as possible, the experience of Marseilles in the interest of other threatened communities. In the following report, it has been sought to condense as far as practicable within reasonable limits, the more important facts concerning the nature of cholera, the methods of its transmission 5 and the measures have here been found most effective in preventing its spread and treating those attacked by the dreaded malady. I. The Nature of Cholera. Leaving aside all merely abstract theories concerning the origin of the disease or its precise point of attack upon the system, it is important to observe that its symptoms, its methods of attack, differ greatly in neighboring cases during the same epidemic. Sometime[s] preceded by diarrhea, the cholera develops only after several day[s] of such premonitory illness; again, it strikes its victim while asleep after a day of apparently perfect health; in one case, it produces profuse vomitings and dejections, in another, neither of these symptoms; one victim is stricken with intense chills, suppression of urine, loss of voice and violent cramps, while another 6 feels only a painful compression of the chest; here, a case which begins with violent symptoms soon yields to treatment, then another which from a mild and nearly painless beginning proceeds irresistibly to complications which result in death. In no previous epidemic at Marseilles were these manifestations of the disease so various, so complicated and perplexing to physicians as during that of 1884. In its choice of victims, cholera is more precise and definite. With rare exceptions, they belong to one of the four following classes of persons: 1. Those who live under bad hygienic conditions in respect to food and lodging. 2. Those who are imprudent in respect to eating, drinking and exposure. 3. Those who [sic] weakened and debilitated by alcoholic excesses. 4. Those who suffer from chronic digestive weakness or derangement. 7 Among the imprudences which have become dangerous in presence of cholera, are overeating to the extent of producing lethargy or indigestion, drinking any liquid so cold as to check the process of digestion, the easting of raw vegetables in the form of salads, and in general the use of raw fruits unless they are perfectly fresh and ripe. Drinking cold water or beer after having eaten raw fruit is a direct challenge to cholera which no person, however strong and healthy, can afford to risk. The susceptibility of drunkards to choleraic influences is proven by abundant evidence, among which may be cited the sweeping fatality of the disease wherever it has attacked the inmates of an Inebriate Asylum. Anything in fact, whether of a temporary nature or chronic nature, which impairs the rigor of the digestive organs, exposes the person 8 thus weakened to choleraic attack. II. Methods of Transmission The evidence of last year's epidemic seems to prove conclusively that the contagion of cholera is transmitted both by the inhalation of air infected by clothing, rags, wool, etc. which has been tainted by contact with the disease, -- and by water. In proof of the first proposition may be cited the case of a man who in July last left one of the worst affected quarters of Marseilles for his native village of Vogne, in the department of Ardeche. He remained there in perfect health until he opened his trunk, which had been packed at Marseilles, and wore a suit of clothing that it contained. Immediately thereupon he and several persons with whom he was living were fatally attacked and with [sic] twenty days fifty-four of the 630 inhabitants 9 of the village had perished. To this may be added the conclusive fact that the epidemic of 1884 was kindled at Marseilles by the clothing brought to this city in the trunk of a young student com from the Lycee at Toulon. Equally striking as an example of the power of water to diffuse the contagion was the case of the village of Omergues in the Department of Basses-Alpes . On the 10th of July, there arrived at Omergues a young servant girl who had been in service at Marseilles. Soon after her arrival, she washed home linen which had been in contact with a cholera patient at Marseilles, in the Jabron- a creek which supplies the village with water. From that imprudence sprang the contagion which decimated that unfortunate community and spread death throughout the entire valley of the Jabron below Omergues, while 10 the inhabitants of the same valley above the village escaped. Concerning the general question of transmission of cholera, the medical authorities of Marseilles are united in the following conclusions: 1. The disease does not transmit itself directly from a cholera patient to a person in good health, neither by contact nor by inhalation. 2. The dijections and vomit of a cholera patient usually contain the germ of contagion, which, although not immediately transmissable itself, yet when placed under favorable conditions quickly breeds and develops the contagious principle by means of which cholera always operates, whether through the medium of air or water. 3. Clothing and textile merchandise are far more dangerous as vehicles of this contagious principle than individuals. 4. This choleraic poison attacks only persons who are in a greater or less degree prepared 11 for its reception, and, in proportion to the degree of this receptive condition, its produces cholera or cholerine. In other words, cholera is not directly contagious like scarlatina, small-pox or diphtheria, but is a disease producing a germ which, in order to become contagious, requires to pass through a certain process of development. As this germ is contained in dijections and vomited matter of cholera patients, it is of the first importance to immediately neutralize such matter by contact with powerful antiseptics. For this purpose the five antiseptics which have been cound most effective are: 1. Solution of sulphate of copper in the proportion of not less than - 2 ounces to a quart of water 2. Liquid chloride of zinc- 1 1/2 " " " " " 3. Bichloride of mercury- 1/6 " " " " " 4. " " copper- 2 " " " " " Sulphuric Acid- 4 " " " " ". The same chemicals are used for the disinfection of water- 12 -closets, sinks and all other seats of decay or infection. For washing streets and drains, sulphate of iron 10 lbs. in 220 gallons of water, or the liquid chloride of zinc - 20 lbs. in 220 gallons of water - have been found most effective and practicable. Phuric acid, in proportion of ten pounds to 220 gallons of water was largely used at Marseilles last year, but the results were less satisfactory than was effected, some experts even going so far as to affirm that the Phuric principle preserved rather than destroyed the germs of contagion. Cholera on ship-board was notably fatal and violent, not less than twenty-seven of the thirty-six cases of sailors attacked on vessels in this port having resulted fatally. Nearly all these cases were of the "foudroyant" or rapid, unmanageable type. The holds of ships, tainted with bilge water and the miscellaneous leakage and refuse of previous 13 cargoes, are fertile hot-beds of choleraic atmosphere and only the most scrupulous cleanliness and careful ventilation can avert this danger in presence of an epidemic. For the disinfection of ships a strong solution of chloride of zinc, liberally used, has been found most effective. III. The care of Barracks, Asylums and Hospitals. One of the grave problems of civic administration, during \ a period of epidemic, is the care of Barracks, Prisons, Asylums and other public institutions in which large numbers of persons are detained more or less against their will. The garrison of Marseilles, during the summer of 1884, included an average of 5000 men. Although two of the casernes occupied by this force were situated in the most infected portions of the city, the entire military death-toll from choleraic disease amounted to only 14 twelve person, one of whom committed practical suicide by drinking on a wager a quart of sea-water from the port and following this influence with a libation of milk. The regimen of the military department which produced these excellent results was the result of long and careful experience and consisted in the strict enforcement of the following rules: - 1. The wearing of a broad belt of girdle of flannel to protect the stomach and bowels from sudden chill. 2. White linen or cotton "Havelocks" to be worn during all out door exercises. 3. Absolute interdiction of green fruits. 4. The use of rice in all soups. 5. A quart of wine daily to each man. 6. Variation of food as often as practicable. 7. Suspencion [sic] of military exercises. 8. A walk for exercise from 6 to 7 1/2 A.M. each alternate day. 15 9. Music morning and evening in the barrack yard. 10. Frequent washing of rooms and halls with a solution of Phuric acid. 11. Stewards were required to have constantly ready tea, sugar and rum to be administered immediately in all cases of colic. Also "Liquor of Batavia" to be given (20 drops in a quart of water) upon the appearance of choleraic symptoms. The "Liquor of Batavia" is thus constituted - Laudanum of Sydenham 6 grammes Sulphuric ether 2 1/2 " Water of orange flowers 6 ". IV. Subsistence In presence of Epidemic cholera, the question of subsistence becomes one of vital importance. No amount of cleansing and dosing with medicines can eradicate the cholera from a community which is badly fed. It was found necessary in Marseilles to prohibit the entry 16 and sale of melons, cucumbers, and most of the summer fruits and to open at various places in the city soup kitchens where the poor could be supplied with properly cooked food. The code of instructions issued by the Health Authorities for the guidance of all classes, embodied in substance the following points: - 1. Avoid all excess, whether of eating or drinking. 2. Drink as little as possible of anything during the interval between meals. 3. Avoid the use of raw fruits and vegetables. 4. Drink mineral or boiled water, mixed with a small proportion of wine. 5. Avoid exposure to the chill air of morning and evening. 6. Wear a wide belt or girdle of flannel. 7. Liquors and cordials taken in moderation after meals may be beneficial; but when taken at other times, or in excess, they intestinal inflammation 17 which is an invitation to cholera. 8. Beef and mutton are the best meals in time of cholera and fresh fish should be used with extreme caution. All stale vegetables and fruits should be rigidly prohibited. V. Clothing and Bathing. Any sudden change of temperature, particularly cooling of the body after violent exercise or exposure to heat, should be carefully avoided. Accordingly, woolen clothing for every part of the body is preferable to cotton or linen. While the strictest personal cleanliness is essential, it is not considered advisable for any but persons in full physical vigor and accustomed to regular cold baths, to continue them in presence of cholera. Daily tepid baths, taken with careful reference to hours of meals, are advised. Such baths should always be followed by rigorous rubbing of the skin and the usual measures to restore rigorous and healthy circulation. 18 A few drops of a mixture of 1 gramme bichloride of mercury in a quart of Cologne poured into the wash-bowl before bathing the hands and face, is highly recommended for persons living in an infected atmosphere or who are engaged in the care of cholera patients. Mercury, although a remedy to be used with great care, seems to possess many of the qualities of an antidote to choleraic poison. In the hospitals of Marseilles, patients who had been previously treated with calomel for other diseases were found to be almost exempt from choleraic attack. VI. Moral Conditions. The actual dangers of a cholera Epidemic are enormously increased and complicated by the terror and demoralization which the presence of the dreaded malady invariably inspires. Simple fear, of course, does not produce cholera, but it often checks and deranges 19 the vital functions to a degree which may weaken the patient and greatly increase his susceptibility to choleraic influences. Beyond question, it is best for those who feel this terror, and for all thus who can conveniently do so, to leave a city infected with cholera as quickly as possible after the epidemic is declared. The presence of one terrified person is often sufficient to greatly increase the peril of an entire family. The deadly attack of last year upon the unclean and crowded city of Arles was only checked by the emigration of three fourths of its inhabitants. Whatever reduces the population of crowded streets and precincts diminishes the danger. There remains the often perplexing problem of keeping the fugitives away until the danger is really past, for nothing is more perilous than for persons who have once left an infected atmosphere to return before the pestilence 20 is completely suppressed. At this stage of an epidemic physicians and city authorities have a great responsibility. In all years of pestilence at Marseilles, the premature return of the people who left hastily at the outbreak of the disease has produced a more or less serious aggravation of the scourge. The hygiene of this stage of the epidemic is as follows: 1. No person should return to an infected city unless in a condition of good health, particularly in respect to all the functions of nutrition. 2. Whenever possible, persons so returning should stop for at least forty-eight hours in a suburb or other locality as near as possible to the infected city without being itself actually infected. This modifies the abrupt transition from a healthy atmosphere to an unwholesome one. 3. Before returning to a house which has been closed 21 during an epidemic, the occupant should be sure that the premises have been thoroughly prepared. The neglect of this precaution has cost the lives of entire families whose houses were in the best quarters of this city. For at least a week before the re-occupation of a dwelling under such circumstances, it should be kept open daily during several hours, fires built in the chimneys, the walls brushed and the floors washed with solutions of Sal soda, sinks and closets washed thoroughly, disinfected with copperas or chlorides, and, as far as possible, ceilings and walls whitewashed. Carpets and curtains should be aired and dusted and all decaying vegetation or garbage burned. Upon closing the house at evening, the person in charge of these preparations should burn in each room from two to four ounces of sulphur, the fumes of which 22 should permeate every crevice of the building during the night. Nothing short of a repetition of these measures during several successive days can render absolutely safe a house which has remained closed during summer in a city infected by cholera. Unless compelled by urgent reasons, no person who has been absent from a city during a cholera epidemic should return after the last fatal case has been reported. It was clearly demonstrated during the epidemic of last year that the fumigation system, under which railway passengers were cooped up with their baggage in close rooms and exposed for some minutes to the fumes of phuric acid and other anticeptics, was a worse than useless barbarism, and was soon abandoned by the French Authorities. There is , in fact, grave reason to suspect that 23 the quarantine system, as practiced by several Mediterranean comities, creates more danger than it obviates. The cholera was carried into Italy by some returning Italian workmen who, with their families, underwent the prescribed fifteen days detention in the lazaret at Vintimiglia under conditions that might well have generated cholera, without previous exposure to contagion. Closely connected with What has been designated the "Moral conditions" of a cholera epidemic, is the part played by the public press. After thorough experience, it has been found best and wisest for the authorities to publish daily and without reserve the precise facts. As long as the disease has shown only a sporadic character and epidemic conditions have not been developed, there may be reasons which fairly dictate concealment of the truth, but, when once the existence of 24 the epidemic becomes known, all evasion is worse than useless. The presence of a malady which can kill a strong man in five or six hours so excites public feeling that rumor invariably far outruns the truth and panic takes the place of reason. The fact should be urged that, during an epidemic, public apprehension is always out of all proportion to the real danger, and that a person with a cool head and Good digestion, who lives carefully, sleeps regularly and avoids the every day imprudences which are always more or less injurious, can live amidst cholera patients indefinitely without serious danger. During the whole of last year's experience, not a single nurse at the Pharo Hospital, not one of the workmen at the cemetery where the dead were buried, was stricken with cholera. At the close of the ordeal, thousands of persons who had remained in the city during 25 the entire summer found themselves in more perfect health than they had known for years, by reason simply of their regular, abstemious living during the months of peril. On the other hand, a young physician, who ate half a dozen apricots and afterwards drank several glasses of cold beer at noon, was dead and buried before midnight. The Subject of Remedies and Methods of Treatment Belongs to medical science, and is mainly outside the scope of this report. There has been formed as yet no positive specific for cholera, and nearly every physician of ability and experience has his own remedies and system of treatment. Ether, Mercury, Picrotoxine, Iodine, Nitro-glycerine, Camphor, Morphia and other drugs all have their advocates. The practitioners of Homoeopathy claim to have attained great success in visiting the earlier stages 26 of cholera with camphor and cuprum. The methods of treatment practiced at the Pharo Hospital and, in general, by the physicians officially in charge of the various "Bureaus of Assistance," throughout the city are briefly described in the excellent report of Dr. H. Mireur , from which many of the facts in this synopsis are derived. To arrest the diarrhea, check vomiting, subdue the cramps, raise the temperature, and sustain the strength of the patient, these are essential things to be done, so that the first step in the treatment of a case must depend on the stage of the malady in which the physician finds his patient. 1. To arrest diarrhea, opium, in the form of Laudanum of Sydenham; is the standard specific, although tannin, ratanhia, and cachon were used with greater or less success. 2. In the first stage of premonitory vomiting, ipecac 27 was administered; later on, as the symptoms became more complicated, recourse was had to aerated drinks, ice and strong hypodermic injections of morphine. 3. For the suppression of cramps and contortions which characterize violent cases, various exciting liniments, vigorous rubbing, and acetate of ammonia were used, but physicians generally preferred hypodermic injections of morphine as the most certain remedy. 4. In the "algide" or collapse stage, when the patient seems stricken with cold of death, the usual exterior applications were muscular friction, turpentine liniments, sinapisms, wrappings of hot linen, and flannels spread with mustard. To these were added doses of alcoholic liquors, ether, acetate of ammonia, picrotoxine or concentrated camphor of Hahnemann. 5. The cyanose stage, in which the stagnation of blood 28 in the capillary vessels causes the skin to assume - a brown, blue or purple tinge, was successfully treated by inhalations of oxygen and with caffeine administered rapidly in large doses to restore action of the heart. As a popular remedy to be kept at hand for immediate use, nothing has been found superior to Chlorodyne, which is sold by most druggists, or may be prepared after the following formula: Chloroform 3 parts Sulphuric ether 2 " Perchloric Acid 3 " Spirit of Cannabis Indica 3 " Molasses 20 " Spirits of Capsicum 3 " Morphine 1 " Cyanhidric acid a 1/50 1 " Essence of peppermint 5 Carried in the pocket and administered at the first symptom of attack; it has saved thousands of cases which might have been beyond rescue before 29 a physician could be summoned. No country is better equipped than the United States with able, zealous, intelligent physicians who know by practice or theory the most of what has been proven concerning the best remedies for cholera. Should the occasion unfortunately arise, they will doubtless be found equal to every emergency. The important thing is that people of all classes should realize, first, the importance of cleanliness and correct living; secondly, that Cholera from its first stage is a disease which requires the best professional attention, and finally, that in presence of the Asiatic scourge, an ordinary diarrhea is a serious illness and should be treated accordingly. Frank H. Mason, Consul. United States Consulate, Marseilles, June 23, 1885 July 20, 85 Sir: I have the honor to acknowledge the receipt of a copy of a dispatch dated the 23rd ultimo from the United States Consul at Marseilles, in which he submits a report on cholera in that city during the nine years, since 1835, that it has been afflicted with the disease, kindly transmitted in your letter of the 16th instant, and to advise you that the document in question has this day been sent to the Surgeon General of the Army for his information. Very respectfully Your obedient servant, James Hodgkiss Acting Chief Clerk, In the absence of the Secretary of War. The Honorable The Secretary of State.