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6 districts supplied with the water of the Thames at Kew and Hammersmith, the mean elevation was 35 and 175 feet; the mort. from C. was 19 and II in 10,000. In the two groups of 12 districts supplied with the Thames water between the Battersea and Waterloo Bridges, the mean elevations were foot and 10 feet; the mort. 168 and 77 in 10,000. In the two groups of 20 districts supplied with the waters of the New River and the Lea, the mean elevation was 24 and 593 feet; the mort. from C. was 59 and 37. "While (says Dr. Farr) the effects of the water and of the wealth of the districts are apparent, they do not, in this analysis, conceal the effects of the elevation." He asks, Why is the C. fatal in low places? and answers the question as follows:

C. has not only been most fatal in the low, and least fatal in the high, parts of the country but the fatality has diminished proportionably as the dwellings of the pop. have been raised above the sea-level. The epidemic began and was most fatal in the ports on the coast; and in ascending the rivers step by step, we saw it grow less and less fatal. This made it prob. that a certain relation existed between elevation and the power of the C. to destroy life. The more exact information which we possess respecting the Lond. districts estab. this connexion beyond doubt. The relation may not be expressed by the same figures in other places, or in Lond. at other times, but it will always be the general rule that the mort. of C. is inversely as the elevation of the people assailed above the sea-level. Mere density of pop. has not, we are told, the same direct effect of increasing the mort. in this disease as in others; for in many inland towns and in high dense parts of Lond. the mort. was slight or inconsiderable. Neither does the mort. from C. vary in the Lond. districts in any ratio of density. Still density and numbers of the people are not be lost sight of; for the cholera was not fatal to many inhabitants of thinly-populated though low and marshy parts; while in such localities it was very fatal in nearly all towns. The law is that the mort. in towns of some extent and density is inversely as the elevation.

There are one or two other notable incidents to be mentioned. Cholera attacked the greater part of the districts on the coal-fields of England, and was most fatal in the denser masses of the mining pop. Dr. Farr says: "The ground on the coal-formation may have lent the epidemic fatality." [MINERS.] A few scattered cases occurred in the marshy districts of Lincolnshire; but the mort. was inconsiderable. The marsh districts in the interior of Cambridgeshire also escaped down to the Ely district; North Witchford, Whittlesey, and Wisbeach suffered. So did some of the marsh districts of Essex and Kent, on the estuary of the Thames. In the Romney marsh district only one death from Cholera occurred.

Finally we arrive at the learned Doctor's generalization of this portion of his subject, which goes to this extent that the cause of Cholera is some chemical modification of organic matter; and-here is the great practical fact-that although elevation of habitation, with purity of air, and purity of water, does not shut out the cause of C., it reduces its effects to insignificance.

We shall have to return to this important paper under other heads. [FEVERS.] [LoCALITY.] [PLAGUE.]

Between 1850 and 1852 there was pub., Report of the General Board of Health on the Epidemic C. of 1848-9, with three Appendixes. There was also pub. in 1852, Report on the Epidemic C. in Germany in 1852, by R. D. Grainger.

In 1853 Sweden, Norway and Denmark suffered severely from the Cholera. Between June and the middle of October no less than 15,000 persons died.

At the meeting of the Brit. Asso. held in Hull in 1853, Dr. Henry Cooper, M.D., read a paper: On the Cholera Mort. of Hull during the Epidemic of 1849. In this borough the mort. on this outbreak was at the rate of 241 deaths to every 10,000 of the pop. ; while in the adjoining parish of Sculcoates it was at the rate of 152 to every 10,000. The Reg.-Gen. stated that Hull, in proportion to its pop., suffered more severely than any town in the kingdom. The total deaths were 1860-males 885, females 975-being at the rate of I in 43 01.

The Reg.-Gen. said in his 12th Report (1853):

C. is a disease well calculated to excite alarm by its wide, well-marked march over the world, the suddenness of its invasions, the sufferings it awakens, the fatality of its attacks, the helplessness of medicine, and the hopelessness of its victims. But it cannot be denied that the epidemic of C. in 1832 aroused the attention, and led the way to sanatory inquiries and ameliorations, which, however imperfect, have saved more lives than C. destroyed. For C. is a health inspector that speaks in language which nobody can misunderstand; it visits the prisoner in the hulk on the polluted river, the neglected lunatic in his cell, the crowded workhouse, the estab. for pauper children, the sides of stagnant sewers, the undrained city, the uncleansed street, the cellar and the attic; as well as the fair open quarters which strangers frequent and admire. The oversights, the errors, the crimes, of persons who in responsible offices have charge of the health and life of men, are proclaimed aloud by this inexorable

voice.

It was in the autumn of 1853 that the following incident occurred. The Presbytery of Edin. recommended as an infallible specific for C. the expedient of fasting and humiliation. Lord Palmerston was at the time Home Sec. It fell to his lot to direct the correspondence. He caused a letter to be addressed to that devout body, to the effect that the affairs of this world are regulated by natural laws, on the observance of which the weal or woe of mankind depends. One of those laws connects disease with the emanations from bodies, and it is by virtue of this law that infection spreads in crowded cities, and, indeed, wherever animal and vegetable decomposition is going on. Therefore it is better to cleanse than to fast. The presence of the plague renders activity

preferable to humiliation. The concluding sentence of the letter deserves to be reproduced. Lord Palmerston advises that the winter should be employed in "planning and executing measures by which those portions of our towns and cities which are inhabited by the poorest classes, and which from the nature of things must most need purification and improvement, may be freed from those causes and sources of contagion which, if allowed to remain, will infallibly breed pestilence, and be fruitful in death, in spite of all the prayers and fastings of a united but inactive nation." Mr. Buckle says, in his History of Civilization, that this paper will "in future ages be quoted as an interesting State paper for illustrating the hist. of public opinion."

In 1853 Dr. Begbie pub. in the Edin. Medical Journ. a second Report on the mort. of the Scottish Widows Fund, embracing 7 years' experience, from 1845 to 1853. The mort. from C. during that period was at the rate of 3'91. (See 1860.)

In the report of an investigation into the deaths of the Standard L. office during the quinquennium 1845-50, by Dr. Christison, the able examiner for that co., and pub. in the Monthly Journal of Medical Science for August, 1853 [since reprinted in a separate form], we find the following:

Of 20 deaths from malignant C., 9 occurred in Scotland, 8 in Ireland, and 3 in England. The number would prob. have been larger had not the previous epidemic fever led to a limitation of bus. in Ireland among professions now known to be apt to suffer from C. as well as fever. The deaths have chiefly occurred at an unfavourable period of life. One half of the number occurred before the age of 50, and 8 of them indeed before 40; so that, like fever, this epidemic not only adds to the average deaths, but likewise does so at an age peculiarly unfavourable to assu. cos. The ages of the whole at death were as follows: 2 died between 20 and 30, 6 between 30 and 40, 2 between 40 and 50, 5 between 50 and 60, 3 between 60 and 70, and 2 above 70. The unfavourable influence, however, of epidemic C. on the bus. of an assu. co., will be most clearly seen from its destructive effect upon the expectations of life among the deceased. One with another they survived acceptance only 123 years, while their conjoint expectation of life was 520 years, or more than four times the actual survivancy. Not a single individual of the whole 20 reached his expected term, and only 1 lived two-thirds of it.

The lives which have fallen a sacrifice to C. have evidently belonged, for the most part, to the class of assu. risks which were of the most favourable denomination at the commencement. One, indeed, would now be considered a doubtful risk in the circumstances at the date of entry, as he was an aged officer of the army, who had repeatedly had West India fever, and several times gout, after retiring from service. A second was barely an average risk, because, when accepted at 34, the individual had successively suffered from dysentery, lumbago, and sciatica, and not long before acceptance, from headache so severe as to require the use of leeches. A third appears not to have undergone a medical examination on the part of the Co., but presents no other objection. These however are all the risks to which any exception can be taken. The remaining 17, both in respect of family hist. and personal particulars, must be regarded as above the average at entry, and many as first-rate lives for assu. The mort. from C. has not fallen heavily on any particular profession. On the whole a scrutiny of this section of the emerged risks is far from satisfactory. No foresight can materially reduce

the loss from C.

In reference to the belief that C. only attacked unsound or enfeebled constitutions, the writer says: "This opinion, which was rather supported by fact in 1832, was on the contrary opposed to medical experience in 1849; and it is quite at variance with the tresults of a scrutiny into the C. deaths of 1849 among persons insured in the Standard Life Assu. Co."

The C. outbreak in Gt. Brit. which was supposed to have subsided in 1849 did not in reality do so; for the deaths from this disease regis. in 1850 were 887; while in 1851 no less than 1132 deaths were attributed to it; and in 1852 the still larger number of 1381. In 1853 it proclaimed its existence in an epidemic form, attacking Lond. and some other places slightly, and ravaging Newcastle-upon-Tyne-the deaths in which town and Gateshead in that year were returned as 1927, out of a total mort. from C. of 4419 persons. In 1854 it presented, as on former occasions, a second eruption, and carried off no less than 20,097 persons.

This Third Cholera Epidemic in Gt. Brit. [1854] was not nearly so severe as that of 1849. The mort. from C. and diarrhoea in 1848-9 was at the rate of 41 in 10,000; while the mort. in 1854 was at the rate of 22 in 10,000 of the pop., or but a little more than half. The rate of mort. by diarrhoea in the two epidemics were equal, viz. 11 in 10,000 of the pop. Thus in 1854 the mortality from Cholera and diarrhoea were equal; while in 1849 the mortality from Cholera had been 30 in 10,000, or nearly three times its force in 1854.

The following is a Table of the Districts and Towns which suffered most severely from the C. epidemic of 1854, arranged in the order of the rate of mort. experienced :

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The following T. shows the geographical similarities of the disease of 1854 as compared with that of 1849:

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A person living in the coast districts in the same conditions as the coast pop. was thus in 1854 more likely to die of C. in the proportion of 20 to 4 (or 5 to 1) than a person living inland. In 1849 these ratios were 50 to 17 (or 3 to 1). If the coasts are divided into 3 classes, the mort., it will be found, was at the rate of 30 on the E. coast facing the Continent, 10 on the W. coast, and 5 on the S. coast, out of every 10,000 of the pop. Exclusive of the Lond. districts, the mort. by C. in the districts of the E. coast was at the rate of 12 in 10,000. In 1849 the rates of mort. on the E. coast were 53; on the W. coast 49; on the S. coast 39. The 42 districts on the coal-fields of E. and W. suffered severely from the epidemic in 1849, where to 10,000 living the deaths were 46 by C. and 13 by D.; while in 1854 the deaths to 10,000 were 12 by C. and 14 by D. The latter rates include the deaths from C. and D. in Newcastle and Gateshead during the year 1853. Males suffered more than females from C. and D. in 1854, at all ages under 25; at the ages 25 to 45 the females suffered more than the males; at 45 to 55 the mort. rate of males was greater than the mort. rate of females in 1849; but in 1854 the rates were nearly equal. From the ages of 55 to 85 the old women suffered more than the old men ; at the age of 85 and upwards the facts became too few to yield certain results; but they seem to show that proportionably more old men of 85 and upwards die of C. and D. than old women at the same advanced age. The deaths of males from C. in England in 1854 were 9860; of females 10,237. The deaths from D. in the same year were: males 10,211; females 9841. But adding C. and D. together, the following result, remarkable for its uniformity, was obtained: males 20,071; females 20,078.

During this visitation great ravages were committed in Broad-street, Westminster. It was discovered to arise from the impurity of the water in a well in that street. The discovery was in the first instance accidental; but more complete investigation showed that the well was simply poisoned by an influx of sewage and of surface drainage, percolating through the crevices of the bricks forming the lining of the well. It was also very fatal in Soho, and in some of the south parts of Lond.

Dr. Farr, reviewing, in the 17th R. of Reg.-Gen., the rise and progress of the C. outbreak of 1854, says:

It is impossible to overlook the diarrhea which has gone on gradually increasing in fatality since the year 1838, when 2482 deaths were referred to that cause; while in 1847 the deaths by diarrhoea were 11,595; in 1848 nearly the same number; in 1849 the deaths by diarrhoea were 17,831; thus making the deaths by C. and D. in the epidemic year 71,104, or 72,180 if we add the cases of persons attacked while labouring under other fatal diseases. Diarrhoea did not discontinue its ravages after 1849; the deaths in the 3 following years were 11,468, 14,728, and 17,617; in 1853, when C. appeared in the epidemic form, the deaths from diarrhoea fell to 14,192; but in 1854 their number was 20,052. Thus the deaths by C. and D. in this year were 40,149, exclusive of a certain number of deaths which epidemic diarrhoea caused in conjunction with other diseases. Diarrhoea is often a symptom of other well-marked diseases; and it is also the effect of a class of medicines; but this diarrhoea which always prevails in hot weather, and has been so common since the year 1846, is evidently a variety of C., proving fatal chiefly to young children and to old people, who do not so commonly exhibit the spasms of C., but have nearly all the other symptoms.

In 1854 there were also pub.: (1) Report on Epidemic Cholera, drawn up, by desire of the Cholera Committee of the College of Physicians, by Drs. W. Baly and W. W. Gull; (2) Minute on Preventative Measures in relation to Epidemic Cholera.

In this year also the C. raged in Italy and Sicily; above 10,000 are said to have died in Naples. It was also very fatal to the allied troops at Varna in the autumn of this year. In 1855 Dr. Sutherland addressed a Letter to the General Board of Health on Epidemic Cholera in the Metropolis in 1854. There was also pub. in this year: (1) Report [to General Board of Health] on the Results of the Different Methods of Treatment pursued in Epidemic Cholera; (2) Report on the Cholera Patients admitted into the Middlesex Hospital during the Year 1854, by Dr. S. W. Sibley; (3) Report on the Cholera Outbreak in the Parish of St. James, Westminster, during the Autumn of 1854; (4) in Stockholm, a Report on the Cholera outbreak in that city in 1853; (5) in Copenhagen, a Report on the Cholera outbreak in that city in 1853.

Dr. Farr says in the 17th R. of Reg.-Gen. pub. 1856:-"Cholera has prob. always

existed in England, and it was well described by Sydenham in the 17th century; but the epidemic form presents some differences in the symptoms as well as in the extent of its ravages. The chief characteristic is found in the duration of the fatal cases, half of which terminate within one day (24 hours) of the first appearance of decisive symptoms, while half of the cases of common C. terminate in three days, and half the cases of diarrhoea extend over six days."

In 1860 Dr. Begbie pub. in the Edin. Med. Journ. a further Report on the mort. experience of the Scottish Widows Fund, for the 7 years ending 1859. The mort. from C. during that period was at the rate of 1'47 p.c. or less than one-half of that of the previous septennium. Over the entire period of 44 years it had averaged 2'11 p.c. (See 1847 and 1853.)

In 1861 the late Mr. Spens pub. Tables of the Mort. Experience of the Scottish Amicable Life Assu. So. from 1826 to 1860. There were included therein 24 deaths from C., of which 4 occurred between the ages 25 and 35; 8 between 35 and 45 (of which 3 had been insured as hazardous); 5 between 45 and 55 (of which I was a female, and I had been insured as hazardous); between 55 and 65 (of which I had been ins. as hazardous);

I in class 75 and upwards.

In 1862 Dr. J. G. Fleming, M.D., the medical adviser of the Scottish Amicable, supplemented the preceding by his useful little book, Medical Statistics of Life Assu., etc. He says, "So far as I am aware, no Brit. assu. co. has pub. any T. or statement to show the proportionate mort. from classes of disease, or from particular diseases, to the number of lives it had at risk." He shows that Mr. Spens's C. statistics relate to 10,255 individuals, "and the sums of the number of lives exposed to risk during each year of age amount to 56,300." He endeavours to construct some such a table as he speaks of, but finds the difficulties insuperable. We have tried, with a.like result. He succeeded, however, in constructing the following T., which presents some important points for comparison; but it includes "Dysentery" with C. and D.

TABLE OF DEATHS FROM CHOLERA, DIARRHOEA, AND DYSENTERY, AT SIX GROUPS OF AGES:

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41

*104 *064 072 6'67 3'44 5'30 4'07

6.83

3'99 | 1'48

Total... 11880 85 The Standard column did not embrace the then last quinquennium. The Equitable So. C. experience only embraced the outbreak of 1832. [See details at close of this art.] In 1862 Dr. J. G. M. Burt pub. in the Edin. Medical Journ., A Report of the Causes of Death in the North Brit. Life Assu. Co. from the Commencement up to 1860. During this period of 37 years, 1823-60, only 16 cases of C. had arisen. The average duration of life after ins. was 8 years. The per-centage of mort. from C. was 1'22.

In 1864 Dr. Farr pub. the English Mort. T. (No. 3). It had been the subject of remark that no previous mort. T. in Gt. Brit. had embraced mort. results in which epidemic C. had taken any part. It was so. The English tables, Nos. 1 and 2, had been based upon periods remarkably free from the mort. of C. But T. No. 3— being based upon the two censuses of 1841 and 1851, and upon the returns of deaths over a period of 17 years [1838-54] extending to 6,470, 720 deaths-embraced not only the mort. of 1849, which was the most fatal year in regard to C. which has been experienced in Gt. Brit. (as will be seen by reference to the T. at the end of this art.), but also the deaths of 1854, the next severe visitation.

The Reg.-Gen. in his 25th R., pub. 1864, says :-"Women of the age of 15 and under 45 were cut off in great numbers in the C. years.' Regarding its effect upon men, the following figures are given. Over a period of 25 years the mean ann. mort. of men of the age of 25-35 was '975, but the mort of men of that age in 1849 (C. year) was 1236, and in 1850 it was as low as '877 p.c. The range (of variation) was 359. In the one case it was more than 26 p.c. above 975, and in the other 10 p.c. below that mort. rate. Again, at age 55-65 the mean ann. rate for men was 3′136, but in 1849 the rate was 3653; in 1850 it was 2'979: thus the range was 674 at that age.

In June, 1865, the C. was reported to be raging in Alexandria. In July it had materially abated. In Aug. of that year it was very severe in Constantinople; more than 50,000 cases were estimated to have occurred. It subsided after the great fire of 6th Sept. that year. In Aug. 843 deaths were reported from Ancona. Between July and Oct. Marseilles, Paris, and Madrid suffered greatly. In Sept. Toulon and Southampton each suffered. In Germany the epidemic was very severe, and also in Naples.

In 1865 Mr. John Mann, the medical adviser of the Brit. Empire Mut. L., pub. the mort. experience of that office for the first 10 years of its existence-that is, down to 1857 -wherein he says:—“We have to report 13 deaths from C. ; yet the experience of the so. includes not only one great epidemic visitation of the scourge, but a second of smaller proportions. Only two of these deaths were females. Of the total number 2 occurred between 20 and 30 years of age; 2 between 30 and 40; 4 between 40 and 50; 3 between 50 and 60; and 2 between 60 and 70." The rate of mort. was 5'06 p.c.; but it was rendered high by embracing two epidemics, viz. 1849 and 1854.

In 1865 there was pub. in N. Y. Report by the Council of Hygiène and Public Health of the Citizens Association of New York upon Epidemic Cholera and Preventative Measures, which contains much information of a practical character.

In Feb. and March, 1866, an International Congress (proposed in the preceding Oct.) was held in Constantinople, for the purpose of considering epidemic C. in its various aspects. Seventeen States took part in the Conference, viz. :-England, France, Prussia, Austria, Russia, Belgium, Holland, Denmark, Sweden, Italy, Greece, Spain, Portugal, the Papal States, Persia, Turkey, and Egypt. These States were represented by 36 delegates. His Highness Aali Pasha, Minister of Foreign Affairs, presided. The points discussed were: (1) the origin and development of C.; (2) the mode of its propagation; (3) measures of preservation-hygiène-restriction; (4) form of resolutions. The conclusion finally adopted was that C. may be propagated, and from great distances; and a number of preventive measures were recommended.

We now reach what may be termed the Fourth Great Cholera Epidemic in Gt. Brit. Asiatic C. had hovered over Europe in 1865, settling down with some severity upon Paris, Marseilles, and some other Continental cities. It also prevailed in England, the regis. deaths from it in the year being 2191; those from diarrhoea reaching the large number of 23,531. On Wednesday the 11th July, 1866, the epidemic began to show itself in an aggravated form in Lond. It continued severe during the remainder of that month, and in Aug. The total deaths from it regis. in Lond., including West Ham and Stratford (not embraced in the Lond. district), were 5973; and from diarrhoea, 3197-total 9170 by the two maladies.

The epidemic was felt all over the kingdom, and while the deaths by it in the Lond. district proper were 5596, the deaths in the other ten divisions of E. and W. were 8782. The pop. of the ten divisions is six times the pop. of Lond., and at the Lond. rates the deaths by C. would have amounted to 33,576. The mort. in the ten divisions was at the rate of 5 in 10,000 against 18 in Lond. The disease, says Dr. Farr, "was only fatal to any considerable extent in certain regions, which may be called Cholera-fields, as here the centres of activity were all in direct communication with each other, and were surrounded by free border-lands." The mort. of all England was at the rate of 7 deaths by C. in 10,000 persons living. In the three Midland divisions-the S. Midland, N. Midland and W. Midland-the deaths by C. were at the rate of 1 in 10,000; in Yorkshire, 2; in the S. Western division, 3; in the S. Eastern and the Eastern divisions, 4; in the Northern division, 5; in the N. Western division (Lancashire and Cheshire), 9; in Lond. 18; in the Welsh division (Wales and Monmouthshire), 18 in every 10,000. It was only in Wales that the disease was to any extent more fatal in 1866 than it was in 1854.

The deaths in the U. K. were about 17,793; and the mort. by the disease in the year 1866 was at the rate of 6 deaths in every 10,000 inhabitants. The following are the exact returns for each division of the U. K. :

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C. was very unequally distributed over England. 14,378 people were slain by the disease in 641 districts; and of that number 10,889 fell in 37 districts of Lond. and in 24 other town districts; 3489 in 342 districts; while in 238 districts no death from C. was recorded. All the districts, with the exception of Wigan and Merthyr Tydfil, were seaport towns or districts in their immediate neighbourhood; the pop. were dense, and were nearly all dwelling on the lower alluvial soils of the kingdom. These correlations have been observed in all the epidemics. The exceptions are accounted for by such peculiar circumstances as the mort. around the Broad-st. Pump [Westminster], in 1854; and in St. Giles', Lond., in 1849; where either the people were excessively dirty and crowded, or took in water large doses of C. matter in a very active state.

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