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: in 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., 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 : I 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; IO 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. After 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 2.5 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 318, 132, and 7·6; of girls, 284, 126, 6'4; 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 7·0,-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 CHO any poison, the more fatal it is, and the more rapidly it is fatal. By parity of reasoning Regarding the days of the week most fatal in C. during the epidemic of 1866, the fewest deaths occurred on Saturday; the next fewer on Sunday. The greatest number occurred on Wednesday, and the next greater on Tuesday. In 1849 the deaths on Tuesday and Saturday stood highest; on Thursday and Friday lowest. The popular belief as to unlucky Friday did not apply, as Dr. Farr has already pointed out, to either of these epidemics. He adds, with great sagacity, "If the temperate or intemperate habits of any of the working classes of Lond. had any effect on this series of facts, they therefore raised the deaths on Monday, lowered them on Friday." We cannot follow this able and instructive Report further. We have indeed quoted from it in several other portions of this art. ; and we shall quote from it in other parts of this work. Its learned author concludes: "To render the generation of great epidemics of C. rare, nay, impossible, India has only to carry out the measures which have proved efficacious in England." In Dec., 1868, the Scientific Reviw contained the following: Cholera Fungus-After a long series of botanical researches, Prof. Ernest Hallier, of the University of Jena, has convinced himself of the presence in the excreta of C. patients of a microscopic fungus which exist in them in considerable quantities. On submitting this minute plant to a careful microscopical examination, the distinguished botanist found that it has all the characters of Urocistus oryza, which in India is found sometimes in the rice plantations. Prof. Hallier then manured some rice plants with the excreta in question, and finds that they perish rapidly. A whole plantation may be thus destroyed by the Urocistus in a very short space of time. In 1869 the Experience T. No. 2 was pub. This being based upon the mort. experience of a number of Brit. ins. offices, will also embrace the mort from C., as also from D., so far as these diseases affected the class of lives ins. in the offices contributing their experience. Sir William Jenner said before the Brit. Medical Asso. in 1869 : With reference to C., the special facts collected by Dr. Snow prove that one of the great agents in the diffusion of C. was drinking water; that every virulent local outbreak in a limited district was clearly coincident with the pollution of the drinking water supply of that district; and that persons living at a distance, if by accident they drank of the polluted water, suffered as certainly as if they dwelt in the district specially affected. The conclusion which follows from the facts collected by Dr. Snow is that, the conditions existing, be they atmospheric or other, which determine the epidemic disposition to C., the presence of minute portions of C. excreta in the water supplied to a district for drinking purposes will be followed by an outbreak of C. in that district. Careful investigations into the circumstances attending local virulent outbreaks of C. during the last epidemic have proved the truth of that conclusion. I will refer to two such investigations only, namely, Mr. Netten Radcliffe's admirable researches into the relation between the water supply and the spread of C. in Lond., and to Dr. Bellot's most conclusive obs. on impure water as a cause of C. in Holland. Dr. Snow's investigations traced special individual cases and local outbreaks to one existing cause. Mr. Radcliffe's researches bear especially on the influence of the polluted water in determining excess of mort. in a large district of a great city. Dr. Bellot's facts show that those towns and those parts of a town in Holland in which there was the greatest facility for the contamination of the water supply by C. dejections were those which suffered by far the most severely. The spread of typhoid fever by contamination of the drinking water supply is, if possible, less disputable than is the spread of C. by the same means. Dr. Guy, in his valuable work, Public Health, pub. 1870, has pointed out that between the epidemics of Cholera and plague there is an unmistakable resemblance. They are, he says, evidently diseases of the same class. The figures on the death registers rise to an They harmonize with the theory of an imported unwonted height in certain years only. disease. But there is this difference. The C. of 1854 attained its maximum in 8 weeks, and subsided in 13; while the plague (of 1665) took 22 weeks and 17 weeks to accomplish the same feats. The figures for the C. are suggestive of a disease carried chiefly in currents of air; those for the plague of one spreading more slowly by direct contact, He adds: and exposure of the healthy to the sick. This disease too, like others of its class, is most fatal when it first breaks out, least fatal when it is passing away. How it selects its victims we do not know, and cannot expect to learn. Some whom it kills quickly seem in the rudest health, others who are longer dying are obviously less vigorous. Whether a man is to succumb or recover probably depends in part on the strength of the dose, but in part upon his having or not having some unsound organ which will not bear the congestion of the cold, or the quickened circulation of the hot, stage. The intemperate man is taken always at a disadvantage, and the chances of escape lessen with age. Another fact must be specially noted, as common to all epidemics-the poison, when it does not kill by sudden shock, remains for a variable period, in some shorter, in others longer, inert. The seed is sown, but takes time to germinate. The interval of real or apparent inaction is known as the period of incubation. It is not easy to fix the limits in these maladies. In C. it is thought to extend from three days to a week; in typhus fever from a few minutes or hours to a few weeks or months. The fact that there is this period of inaction, or incubation, helps to explain some apparent anomalies. The C., considered as a type of the class to which it belongs, has one or two other characters worth noting. It has been more than once preceded by the milder epidemic, influenza; it has given something of its own character to other diseases prevailing before, during, and after its own visitations; it has seemed to require time to develope itself in the several places which it attacks, for several weeks will sometimes elapse before the weekly deaths exceed one or two; and it is certainly, as a general rule, fostered and promoted by overcrowding and uncleanliness. Regarding the alleged similarity of C. to the plague, leaving the medical aspect of the case out of consideration, the statistical results hardly justify this view. The four great outbreaks of the plague of the 17th century in Lond. were: 1603, when the deaths from Plague were 36,269; from all causes, 42,042 1625 1636 1665 Mean of those years 54,265 37,671 The great outbreaks of the Cholera (excluding that of 1831-32, of which we have not authentic returns) have been : 1849, when deaths in Lond. were Cholera 14, 125; from all causes, 68,755 1854 1866 Mean of those years Ditto ditto (including diarrhoea)... 13,550 As compared with the deaths from all causes, those from the plague were 69 p.c. Those from C. are less than 14 p. c., and with diarrhoea included less than 18 p.c. Nearly as many died from the plague in 1666 as from all causes (cholera included) in 1849. The Gresham L. has made a contribution to the statistics of mort. of ins. lives as arising from C. Out of the first 1000 deaths among the ins. in that Co., 7 were reported as having died from C. Out of the second 1000, no less than 32 were attributed to C. In the report of the med. officer of the Co., Mr. A. H. Smee, presented in 1871, it is stated:-"This large increase is no doubt partly due to the epidemic of C. which swept along the shores of the Mediterranean during the summer of 1866." In 1871, also, Mr. Harben pub. the mort. experience of the Prudential Life during the 4 years 1867-70. The deaths from Diarrhoea, Dysentery and Cholera (classified together) were at the rate of 413 to 10,000 male, and 420 in the like number of female, lives ins. It is said to have been remarked in Paris and elsewhere, that copper-workers had a remarkable immunity in respect to the C. At a serious outbreak at Bagdad in 1871, all classes are said to have suffered except the workers in copper. We have already shown that copper-smelters suffered severely in Gt. Brit. in 1866. In the summer of 1872 Mr. John Netten Radcliffe, one of the medical inspectors who has for some years been charged with the duty of examining the communications with the Lords of the Council, as administrators of the Quarantine Act, and till recently of the Diseases Prevention Act," submitted to Mr. Simon, the medical officer of the Privy Council, a Report upon the Recent Diffusion of Cholera in Europe. This Report, which the Times designates as "a very remarkable one, proves, almost to demonstration, that the C. epidemic which has been displaying itself in eruptions more or less serious in Persia, Russia, and other parts of Continental Europe, originated at the annual religious Hindu Fair at Hurdwar, in 1867, at which, it was calculated, "not less than 2,800,000 were present on the great day of the festival," and was carried by or through personal communication with the pilgrims to the various localities in which it has since been heard of. [PLAGUE SPOTS.] In the Appendix to 33rd R. of Reg.-Gen., pub. 1872, Dr. Farr says: No greater mistake can be made than to assert of Asiatic C., as is done with a kind of Oriental fatalism, by some popular writers, that C. is under no kind of control. Now it is, I believe, more completely under medical control than any other known epidemic disease; in the first place its propagating fluid is tangible, and can be destroyed; and in the second place the disease almost invariably begins as diarrhoea, which can, in the great majority of cases, be stopped by simple remedies. The disease here never decimates cities, except when its poison is diffused through their potable waters. To the practical applications of these well-ascertained scientific facts, it is due that Asiatic C., which in 1849 destroyed 53,293 lives, in 1854 was only fatal to 20,097, in 1866 to 14,378 lives in E. and W. At the 8th International Statistical Congress, held at St. Petersburg, in Aug. 1872, the questions relating to sanitary statistics involved a discussion on the C. of great interest and animation. Mr. Samuel Brown, in his report on the Congress, read before the Statistical So. of Lond., 19th Nov. 1872, says thereon: The propositions in the programme, twelve in number, related to a variety of inquiries to be made as to the personal history, health, habits, etc., of the person attacked with the disease; and also as to the manner in which he first caught it, and the results of the medical treatment, and minute questions as to the locality invaded, its sanitary and atmospheric condition, and the mode in which the discase appeared and spread. The subject, together with the report on syphilis, was referred to a Sub-Section, under the presidency of M. Middendorf, and various alterations made in the questions proposed. On being brought before the General Assembly, by Drs. Benezet and Bredow, another lively debate ensued, some being of opinion that the questions were too long and complicated. M. Castiglione proposed that they should be referred to the Permanent Commission to revise; but an amendment was carried, to the effect that medical men and statisticians should take as a guide, as far as possible, the programme now proposed, carry it into effect in the mean time, and report to the next Congress how far it is capable of practical application to throw light on these two calamitous diseases. He (M. Castiglione) also proposed that at the next Congress a larger number of medical men from different countries should be called together, to constitute a separate Section for Medical Statistics. At the present time [Nov. 1872] epidemic C. is making considerable ravages in Austria. During the autumn it prevailed with some severity in Russia. CHOLERA, ASIATIC, DEATHS FROM (Order, ZYMOTIC; Class, Miasmatic).—The deaths from this cause in England present considerable, and very sudden, fluctuations. For the purposes of comparison and future reference, we give the following T. of the deaths regis. over a period of 33 years [a generation]. This T. includes under C. the deaths 35 VOL. I. |