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years. Such has not been noticed to the same extent in Scotland, severe as C. was, and destructive as were its ravages. In Edin., in Glasgow, in Dundee, and in Paisley, the mort. during 1847, the year of epidemic typhus fever, greatly exceeded that of the year or years when C. raged. Thus C. raged in Edin. in 1848-9; but the typhus fever epidemic caused the mort. of 1847 to exceed that of 1848 by 1231 deaths, and that of 1849 by no fewer than 1899 deaths. In Glasgow again the typhus fever epidemic caused the mort. of 1837 to exceed that of the C. year 1848 by no fewer than 5606 deaths, and also to exceed the mort. of the C. year 1849 by no fewer than 5850 deaths. Dundee and Paisley, though both very smartly handled by the C., exhibited the same remarkable fact. . . .

In 1852 there was issued from the office of the Reg.-Gen., and from the pen of Dr. Farr, Report on the Mort. of Cholera in England, 1848-9,-a most exhaustive vol., from which many of the preceding details are drawn.

In 1852, also, Dr. William Farr read before the Statistical So. a paper on the Influence of Elevation on the Fatality of Cholera. The paper is printed in the Journal of the So. [vol. xv. p. 155]. It deals with one of the more practical results presented in the special report of this year, already noticed, viz. the influence of locality-particularly of elevation of habitation-on the diseases and characters of men. Here are some of the results: By collecting the districts together in which the mort. was high we find this striking result, that 46,592 of the 53,293 deaths from C. in the year 1849 occurred in 134 of 623 districts; or in less than a seventh part of the area of E. and W. among four parts in ten of the pop. Only 6701 deaths took place out of 10,000,000 of people on 49,228 square miles of territory. In 85 districts of E. and W. no death from C. was regis. in 1849; not a single death from either C. or diarrhoea was regis. in 12 of those districts. The only town of any magnitude in the 85 districts is Hereford. The other districts are made up of villages or small towns. In the county of Hereford only one death from C. was regis. in 1849. This county lies high up the river Wye; the pop. is scattered, and engaged in agriculture: it is out of the line of railways. The common drink of the people is cyder. A straw-bonnet maker, aged 27, died of C. in Kirby Stephen, on July 26, 1849-it was the only death from C. in Westmoreland. The 85 districts which escaped the epidemic C. in 1849 lay in general high, round the sources of rivers, and were thinly peopled. 13 in 208, or 6 p.c. of the districts on the coast escaped, while 72 in 415, or 17 p.c. of the inland districts enjoyed immunity.

The following T. illustrates the mort, from Cholera in the Inland and Coasts districts:

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Thus it appears that the Cholera was three times more fatal on the coast than in the interior of the country. The learned writer proceeds:

The character of the coast varies, and by a further analysis it is found that the fatality of C. on the coast was greatest in the chief seaport districts. Thus 26,773, or more than half the deaths in the country from C., happened in the districts of or about Lond., Liverpool, Hull, Bristol, Plymouth, Portsmouth, Southampton, and Tynemouth. Lond., having a mixed character of a seaport town and an inland city, may, for the present, be set aside: we have then 3 groups of coast districts. The mort. in the great ports was at the rate of 125 in 10,000 inhabitants; in the 125 coast districts with small ports, often inaccessible to ships, the mort. in 10,000 was only 15; which is one-eighth part of the mort. in the great, one-third of the mort. (47) in the secondary ports.

Cholera, we are told, reigned wherever it found a dense pop. on the low alluvial soils of rivers; round the estuaries of the Thames, the Humber, the Mersey, the Severn, the Tamar, and their tributary waters, Certain cities and towns lie on the same rivers at different elevations, and are intimately connected; the one is the port and entrepôt ; the other the manufacturing seat and centre of the surrounding country. Liverpool, Manchester, and other districts åre thus related. It was found that C. prevailed at both extremities of the connecting line; but that it was almost invariably most fatal in the port of the district lying lowest down the river.

For the purposes of more complete obs. two large groups of districts were thrown together: (1) the 47 districts on the river and sea margins, which comprise the principal ports except Lond.; (2) 41 of the large town districts in the interior of the country, seated also on rivers, but nearer their sources and at higher elevations. The inland districts are more densely pop. than the maritime districts; and the mort. in ordinary times, high in both regions, was highest in the inland towns. Yet the C. in the low sea-side districts destroyed 85 in 10,000 of the inhabitants, while in the inland towns it was fatal to 38 in 10,000 of the inhabitants. The fatality was as 24 to 1. The metropolis, with its mixed pop., experienced an intermediate mort.-62 in 10,000 of the inhabitants died of C. The mort. from C. in the rest of the kingdom, on smaller streams and higher ground, was at the rate of only 12 in every 10,000. The mort. from diarrhoea was found to be about the same in these last districts as in the town districts. The want of exact data as to the elevations of certain districts limited the obs. in some respects.

The elevation of the soil in Lond. has, we are told, a more constant relation with the mort. from C. than any other known element. The mort from this epidemic is in the inverse ratio of the elevation. The mort. in the 19 highest districts was at the rate of 33 in 10,000, and of the 19 lowest districts 100 in 10,000. The mean elevation in the two groups was as 71 to 10 feet above the high-water mark of the Thames, or as 7 to 1; while the mort. was as I to 3, or in the inverse ratio. In the two groups of the

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 59 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 1 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


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 diarrhoea 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); 6 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.


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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. 3being 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.

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