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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 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. :
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.
Regarding sex and age, the following details will prove interesting :-Deaths 14,378— males, 6995; females, 7383. Of the males 356 died under 1 year, and 1517 under 5; 772 between 5 and 10; 395 between 10 and 15; 229 between 15 and 20; 318 between 20 and 25; 824 between 25 and 35; 894 between 35 and 45; 887 between 45 and 55 ; 647 between 55 and 65; 380 between 65 and 75; 122 between 75 and 85; 9 between 85 and 95; and I over 95. Of the females 305 died under 1 year and 1361 under 5; 692 between 5 and 10; 311 between 10 and 15; 223 between 15 and 20; 364 between 20 and 25; 1043 between 25 and 35; 1100 between 35 and 45; 883 between 45 and 55; 704 between 55 and 65; 478 between 65 and 75; 187 between 75 and 85; 34 between 85 and 95; and 3 over 95.
The following T. shows the districts and towns which suffered most severely from the C. epidemic of 1866, arranged in the order of the rate of mort. experienced :
In a Special Supplement to the Weekly Bills, pub. in Dec., 1866, the Reg.-Gen. furnished the following important details regarding this last C. outbreak :-The French returns show that in Paris the epidemic of 1865 reached its maximum in Oct., in which month 4653 deaths were recorded. In the first six months of 1866 only 69 deaths occurred, but in July the deaths suddenly rose to 1743. The proportional number of deaths by C. to every 10,000 of the pop. of Paris in 1865 was 39; in the first seven months of 1866 it was II. In Lond. the deaths by C. in the year 1866 were in the proportion of 18, in Liverpool, of 36 to 10,000 living. In Italy the epidemic began on the 25th of June, 1865, in the province of Turin, and destroyed 12,901 lives during that year, or to every 10,000 of the pop. living in the 35 provinces and the 349 communes that were attacked by C. 35 deaths occurred. It appears that in Italy the town pop. suffered less severely than that of the country, the number of deaths to 10,000 living being 38 in the former and 56 in the latter case. In Naples 2301 deaths are recorded in 1865 out of 446,931 inhabitants, being in the proportion of 52 deaths by C. to 10,000 living. In Vienna the returns date from the 11th Aug. to the 10th of Nov., 1866 -the ratio was 51. In seven Belgian towns, comprising Antwerp, Brussels, Bruges, Ghent, Mons, Liège, and Namur, no less than 11,771 deaths occurred from May 1st to Oct. 15th of the year 1866, out of a pop. of 553,377; or the deaths by C. were in the proportion of 186 to 10,000 living. In Brussels the proportion was 164. In Holland 18,547 deaths occurred in 1866. Taking 15 Dutch cities and towns, including Amsterdam, it appears that 8872 deaths by C. were recorded in the five months from June to Oct. of 1866, being in the proportion of 107 deaths to 10,000 living. In Amsterdam the ratio was 42, while in Utrecht it was 271. Norway, it appears, suffered but slightly from the epidemic in 1866, only 48 deaths are recorded out of a pop. of 1,701,478.
In 1866 the United States, or rather some of the principal cities in the States, suffered from a severe visitation of Asiatic C. In St. Louis, a considerable city on the Mississippi -which by the way sustains some deaths by C. almost every summer-the deaths in that year are said to have reached 200 per day in a pop. diminished by flight to 180,000. During this year there was pub. in Boston, U.S., A Communication from the City Physician on Asiatic Cholera. Is it a Contagious Disease? This report, which is an official document, contains a great deal of valuable information.
In 1867 a "Cholera Conference" was held at Weimar, and there were present many of the leading epidemologists and mycologists, including some from England. An opportunity was afforded for "the interchange of ideas," as the diplomatists say, on this and other important theories, such as the local relations of Cholera to soil as regards its geological character and its conditions of moisture, and the alleged efficacy of dis
infection, the communicability of C., the meteorological aspects of the case, and the like. Whether C. is a fermentation of infinite microscopic self-multiplying organisms in the bowels, drawing the serum from the blood with excruciating spasms, leaving the clot to coagulate throughout the body as in a bruised surface, and thus producing the blue and livid colour which marks the fatal stage of this terrible malady, or whether any other theory be preferred, the practical effects as regards the human subject and the practical means of prevention are in the present state of our knowledge the same. Be the cause of C. what it may, excremental pollution of air and water will develope it anywhere and everywhere, and the abolition of these will remove it.-Vide Dr. Simon's Report to the Privy Council, 1867. In 1867 C. prevailed in Rome, Naples and Sicily in Aug. and Sept., and in some parts of Switzerland in Oct.
In the 28th R. of Reg.-Gen., pub. 1867, Dr. Farr uttered the following words of wisdom and warning-wonderfully applicable to the present moment:
C., like smallpox, is one of those zymotic diseases which exist in all climates: under favourable conditions their products assume an active form, capable of inducing in other bodies the same morbid changes by which they were generated. They estab. the kinship of the human race. Every nation is vitally interested in the sanitary condition of every other nation. Hence the endless discussions about contagion, and as regards C. the futile vexations of quarantine. There are difficulties in the hypothesis, because experiments cannot be performed on human beings as they are in the laboratory of the chemist, or as they may be in veterinary hospitals; but for all practical purposes it may be assumed that the discharges of patients in the epidemic, either casually touching the mouth, or entering in dust and vapour through air or water, induce diarrhoea or C. in a certain proportion of those exposed to their influence. Now Lond. was supplied with the sewage water of a river by several cos. in 1848-49; all, except one, got their water beyond the reach of the Lond. sewage in 1853-54, and the mort. fell proportionally as the water became purer. At the present time the water of all the cos. is comparatively little contaminated by zymotic pollution. The Lond. pumps have also been placed under inspection. The drainage is in rapid progress. Analogy justifies the hope that as the city is purified, and as the means of diffusion are cut off, the destructiveness of the disease will be diminished.
The detection since 1849 of the mode of propagation and of the premonitory stage of C. by English practitioners are among the greatest triumphs of medical science. For as the surgeon cannot restore. the shed blood to the heart, but can tie a ligature round an artery, and stop bleeding, so the physician cannot revivify a man in collapse, or restore the serum of his blood, but he can in nine cases out of ten check diarrhoea turning into C.
C. throws men into terrible convulsions, and kills half of its victims in twenty-four hours; but there is a merciful warning of its approaches in probably every instance, the neglect of which is fatal. So it is with the epidemic itself in England. It has hitherto commenced generally about Oct., and has only proved excessively fatal in the following summer. Thus all our towns have six months' notice, and the whole winter for the preparation of defensive works. Every district in the kingdom should at once appoint its health officer.
In 1868 there was pub. by way of supplement to the 29th R. of Reg.-Gen., but in a separate vol., Report on the Cholera Epidemic of 1866 in England. This Report was prepared by Dr. Farr under direction of the Reg.-Gen., and is a most valuable and exhaustive work. Dr. Farr says:
Thus, by the year 1866, from the obs. of the three great plagues, we had learned enough of the causation of C. to justify us in believing that in Lond. it could be confined within narrow limits-in the first place, by preventing any extensive distribution of the C. stuff through water, as the cos., in compliance with the Water Act of 1852, had, it was believed, since 1854 carried out all their purifying filtering works; and in the second place, by the organization of health officers, who could secure attention to the early treatment of premonitory diarrhoea, and to the destruction by disinfectants of the C. flux.
These anticipations, from various causes, were not realized, as we have already shown. Dr. Farr deals with these causes individually and collectively, in a most masterly and comprehensive manner. This learned writer says:
It may be stated first simply as hypothesis, that the C. is propagated epidemically by a material substance. This matter may be called cholrine. [CHOLRINE.] Then the elements of the disease must either have been diffused (1) by personal contact; (2) by transmission through the air; (3) or by dissemination in vapour of sewers; or (4) by the various waters. Now the evidence that C. can be communicated in these ways by cholrine is conclusive. Instances of a C. patient brought to a distant house and communicating forthwith the disease to an inmate are too numerous to be mere coincidences; as the chances by the doctrines of prob. against such numerous coincidences are inconceivably great. But it is evident that as the pop. of every district of Lond. is in free communication with every other district, and is constantly interchanging its residents on both sides of the river, so by this mode of communication cases would be, as indeed they were to a limited extent, freely distributed all over Lond. . . .
I now proceed to call attention to the mort. from C. in the various water-fields of Lond. As their areas correspond with none of the other recognized divisions of Lond., the 135 sub-districts have been distributed into 15 groups, with the various heads corresponding as nearly as possible with the various water-fields. It will be seen that while there is a certain mort. from C. in every condition, the excess above this standard is constantly in proportion to the impurities of the water during the epidemic period. Lond. is now supplied with water by 8 cos. South of the Thames it is supplied by 3 cos.. North of the Thames by 5 cos... The proportion of deaths by C. to 10,000 inhabitants in 1866 will show the relative fatality of the disease.
These deaths were found to be as follows:-Chelsea Co., 4; West Middlesex, 4; Grand Junction, 3; New River, 8; East Lond., 72; Southwark, 7; Kent, 15; Lambeth, 6. Some of the cos.-especially those on the south side of Lond.-overlap each other considerably; and it has been found very difficult to apply this test in such cases. Again, "As water conveys C. matter which multiplies and reproduces itself in the pop., it often opens fresh fountains of disease, which extend their operations beyond the direct limits of the water supply, either through the medium of well-water, or personal contamination, or linen, or sewer vapours.
The Report says: Cholera in an individual goes commonly through a regular series of development; commences with diarrhoea, grows hourly more violent, until the crisis is
past, and then, if death intervene not, subsides slowly in consecutive fever, lingering until the danger is over, and the patient restored to health. This is a type of the course which the epidemic takes in a community. The rapidity both of growth and decline here depends on the means of diffusion, as well as on the activity of the diffused cholrine. High temperature has a sensible effect. The duration of the epidemic also depends on the magnitude of the community; thus it goes through a house in less time than through a great inst. ; in less time through a small town than through a large city. It may in this respect be compared with a conflagration, which spreads rapidly through houses put in communication with each other by inflammable materials, and dies out sooner in a small than in a great city-where the embers smoulder for a long time, and unless extinguished are liable to break out in successive eruptions.
It contains a T. showing the occupations of many who died from C. in 1866. From this T. is taken the following list of professions and trades, and the numbers belonging to them who died :
1 clergyman, 4 Protestant ministers, and 2 other religious teachers; 3 solicitors, but no barrister; 2 physicians, 3 surgeons, 7 druggists; 2 authors, editors, or writers; 2 artists; 10 musicians; 4 schoolmasters; 9 hotel-keepers, 27 publicans, 6 beersellers; 3 merchants, 1 banker; 41 clerks, 31 commercial travellers; 36 railway officers and men; 12 cabmen, 18 carriers, carters, or draymen; 56 barge, lighter, watermen; 203 seamen in merchant service; 4 land proprietors, 58 farmers, 152 agricultural labourers; 27 gardeners; 3 booksellers, 10 printsellers; 3 watchmakers; 47 engine and machine makers; 14 coachmakers; 21 builders, 116 carpenters, 67 bricklayers, 49 masons, 18 plasterers, 47 plumbers, 34 cabinet makers; 3 undertakers; 10 wheelwrights; 7 woollen cloth manufacturers; 10 hairdressers, 62 tailors, 111 shoemakers, 10 ropemakers; 9 cowkeepers or milksellers, 45 butchers, 10 fishmongers, 21 bakers, 14 greengrocers; 10 sugar-refiners, 19 grocers; 6 tallow-chandlers; 9 curriers; 40 sawyers, 23 coopers; 254 coal miners, 3 copper or tin miners, 12 iron miners; 22 coalheavers, 13 gas-works servants; 25 brickmakers, 36 railway labourers, 16 navvies; 6 earthenware makers, 4 glassmakers; 15 salt manufacturers; 23 copper manufacturers, 17 tin manufacturers; 5 lead manufacturers; 147 iron manufacturers, 89 blacksmiths, 22 boiler makers; 689 labourers; 17 emigrants; 14 gentlemen; 5 prisoners. In reference to 2960 male deaths no occupation was stated.
Regarding the female deaths, the great majority were returned as wives, daughters, widows, etc.; but among those in which the occupation was stated were the following: 10 innkeepers' wives, 35 publicans' wives, 20 farmers' wives, 15 butchers' wives, 85 shoemakers' wives; 5 were schoolmistresses; 147 domestic servants; 24 nurses, 63 charwomen; 10 hawkers and pedlars, 14 cotton manufacturers, II milliners, 49 seamstresses; 19 laundresses. The real test of relative mort. can only be applied where the number of persons engaged in any particular occupation is known. Such a T. is furnished in the Report. The range of mort. is considerable, and Dr. Farr considers this to be mainly due to the sanitary condition of the locality in which the occupation is carried on.' He adds:
The mort. of salt-workers, copper-workers, and sugar-refiners was high. Now of 2016 men engaged in the salt manufactures of Eng. 1237 live in Northwich; 2236 of 3827 copper manufacturers live in Swansea, Neath, and Llanelly; and 1373 out of 2790 sugar-refiners live in the heart of East Lond. In all these districts the epidemic raged with great severity among all classes of the pop.; and it is clear that if the occupations had been pursued in other places no such mort. would have occurred. The comfortable English clergymen, the farmers, and the agricultural labourers in open districts suffer little, because they live in happier sanitary regions.
Some curious facts are given regarding sex and age, in relation to deaths from Cholera. "The fatality of an epidemic depends not only on external conditions, but also on the internal organization. It is found by experience that the two sexes at different ages are not affected to the same extent by all diseases, either because by the habits of life they are not exposed to the same extent to the causes of disease, or because the power of resisting the operation of those causes varies." The 3 epidemics of Cholera (including that of 1831-2) supply data for determining the mort. of C. at different ages in the two sexes: for the deaths have amounted to 102, 186, inclusive of about 14,418 deaths by the epidemic, which were regis. under the head of diarrhoea. "It is important to include these outside deaths in estimating the effect of age, inasmuch as the occult form of the disease is not met with in equal proportions at all ages. The characteristic symptoms are not so well marked in early infancy or in the second infancy of old age; and "the reason of this is, that the muscular and nervous systems being then less active, and giving rise to less convulsive and violent symptoms, the medical attendants return the cases as diarrhoea." At all ages above 5 and under 55, the number of such cases of occult choleraic diarrhoea is not considerable; while under the age of 5 years, according to this estimate, 4 cases of diarrhoea must be added to every 6 deaths regis. from C., to get the actual deaths by the epidemic. At the age of 75 and upwards also there is a large addition of these occult cases. correction we find the mean mort. in the 3 epidemics was, of males 18′0, females 17.8, to 10,000 living at all ages." The addition for occult cases was nearly the same, or 2.6 to the male, and 25 to the female mort.
The mort. is higher in boys than in girls at all ages under 15; at the ages of reproduction, 25-45, the mort. of women, many of them pregnant, exceeds the mort. of men; but at the ages after 65 the mort. of men exceeds the mort. of women. Dr. Farr considers there is evidently a law of mort. involved in the age, independently of the sex. Thus in the first three lustres of life, the deaths of boys to 10,000 living were 31.8, 13.2, and 7'6; of girls, 284, 126, 64; and the mean mort. of the two sexes at the same ages were 30*1, 129, and 70, which differ little from the series 30'1, 14'5, and 70,-numbers obtained by assuming that the mort. is inversely as the age, and decreases about 14 p.c. for every year
of age, or is less than half at 5-10, and less than a fourth at 10-15, what it was in the first
Thus, to 10,000 men living at the age 25 and under 35, the deaths by C. and choleraic
We are told that the resistance which the body offers at different ages may be of two
The Deaths in relation to the attacks are shown in the following T. :
This T. is partly based upon the observations of the Scientific Committee of the Board
of Health on the epidemic of 1854.
Regarding the duration of fatal cases, Dr. Farr remarks, that "the greater the dose of