1306. As in 1832, the infection appeared to die out in the late spring and

early summer; but in June it revived and increased in virulence until August, after which it subsided gradually until November, the whole mortality having been 3892, or ·98 per cent. of the population, nearly the same ratio as in 1848-9, (1·06) and a lower ratio than in 1832 (1·4). The first part of the epidemic fell chiefly on the north and east of the city, the second part, in summer and autumn, was all over the city, as in 1832, and among all classes, as in the winter of 1848-49, but perhaps less disastrously in the best quarters of the city than the last had been. The cholera hospital received a comparatively small part of all the cases--600 of cholera, 253 of diarrhoea, the deaths being 306, or less than a tenth part of the whole mortality[1573]. It is probable that the mortalities in Scotland on this occasion, besides those in Glasgow, Edinburgh and Dundee, were neither so general nor so great as in 1832. One remarkable outbreak happened at the village of Symington, in Ayrshire: in a population of 240 there were 110 attacks and 30 deaths; nearly all the cases were in houses on one side of the village street, which got their water from a public well; the houses on the other side, having private wells (and differing, doubtless, in other respects), were notably free from the infection[1574]. The cholera of 1854 was unimportant in Ireland. Cases appeared among emigrants on board ships in Belfast Lough and at Queenstown in the end of 1853, but no diffusion took place until 1854, and then only to a moderate extent. It is supposed that some 1706 persons died of it in Ireland in that year, according to the retrospective figures of the census of 1861; but a good many deaths from “cholera” were returned for every year of the decennium, so that it is improbable that the whole 1706 in 1854 were of the true Asiatic type. Ulster had 895 of these, Leinster 453, Munster 324, and the whole of Connaught only 34[1575]. The Cholera of 1865-66. Asiatic cholera reached Europe by a new route in 1865--by the way of Egypt with the pilgrims returning from the Hâj at Mecca. In the course of the autumn it appeared at Southampton and caused 35 deaths from 24 September to 4 November. A strange extension from Southampton (or from Weymouth) took place to the village of Theydon Bois in Epping Forest, where nine deaths were traced to one house from 28 September to 31 October, unhappily including the death of a most estimable medical gentleman who tasted the water of a well into which the evacuations of the sick had probably percolated. The cholera having become established on the continent of Europe in the end of 1865, was brought into England by emigrants passing from Hull and Grimsby to Liverpool on their way to America. On board one of the emigrant steamships, the ‘England,’ a very severe epidemic arose in mid-Atlantic in April. Liverpool had once more a severe epidemic (2122 deaths); but the only other important centres in England, besides London, were Swansea, Neath, Llanelly and Merthyr Tydvil, Chester and Northwich, a group of towns on the Exe in Devonshire, and Portsmouth with other places in Hampshire. Still, the deaths in all England made the large total of 14,378, no county excepting Rutland being absolutely free. That means that the infection, although widely diffused, now wanted the conditions favourable to its development and effectiveness; and that, again, seems to mean that a vast improvement had been made in the sewering of towns, in scavenging, and in all other matters of municipal police by which the soil of inhabited spots is preserved from saturation with excremental and other filth. The interest of the cholera of 1866 centres in London, and chiefly in the fact that three-fourths of the deaths, to the number of 3696, took place in the eastern parishes, Whitechapel, Bethnal Green, Poplar, Stepney, Mile End, St George’s in the East, and Greenwich. These had in former epidemics a fair share; but hitherto they had been surpassed by the Southwark parishes and others on the south of the Thames from Battersea to Rotherhithe, and nearly equalled by Shoreditch and the Liberties of the City. The comparative table of the four great choleras of London shows how remarkably the infection in 1866 had left its old principal seats, remaining, as if a residue, only in the East End, with death-rates comparable to those of 1849. _Comparative view of the Four Epidemics of Cholera in the several parishes of London_[1576]. 1832 1849 1854 1866 (17 wks. end. 4 Nov.) Rate Rate Rate Rate per Deaths per Deaths per Deaths per Deaths 10,000 10,000 10,000 10,000 Kensington 10 52 24 260 35 490 3·7 85 Chelsea 80 272 46 247 47 300 3·3 22 St George, Hanover Sq. 10 74 18 131 38 295 1·7 18 Westminster 50 450 68 437 60 423 6·2 43 St Martin in the Fields -- -- 37 91 24 58 4·2 10 St James, Westminster -- -- 16 57 152 485 3·5 13 Marylebone 30 355 17 261 16 347 3·0 54 Hampstead -- -- 8 9 11 14 ·8 2 Pancras 20 230 22 360 13 248 6·0 138 Islington 10 39 22 187 8 97 4·3 120 Hackney 2 8 25 139 11 73 10·6 103 St Giles 50 280 53 285 21 115 9·2 49 Strand 1 26 35 156 24 111 6·6 29 Holborn 10 46 35 161 5 25 5·2 22 Clerkenwell 10 65 19 121 9 59 7·0 45 St Luke 30 118 34 183 9 52 8·1 46 East City } 45 182 23 85 15·7 59 West City } 50 605 96 429 10 126 18·8 60 City } 38 207 14 71 5·0 20 Shoreditch 10 57 76 789 20 237 10·7 139 Bethnal Green 50 345 90 789 20 192 60·4 611 Whitechapel 110 736 64 506 40 330 84·2 909 St George in the East 30 123 42 199 30 154 87·9 385 Stepney 50 358 47 501 32 388 107·6 559 Mile End Old Town -- -- -- -- -- -- 67·7 501 Poplar 40 101 71 313 38 208 90·8 837 St Saviour } 120 1128 153 539 134 495 7·4 32 St Olave } 181 349 162 315 8·5 21 Bermondsey 70 210 161 734 158 845 5·3 35 St George, Southwark -- -- 164 836 101 546 6·6 38 Newington 40 200 144 907 101 696 2·8 26 Lambeth 40 337 120 1618 63 941 6·5 114 Wandsworth 10 46 100 484 77 422 4·8 40 Camberwell 30 107 97 504 91 553 5·6 46 Rotherhithe 10 19 205 352 147 285 8·7 25 Greenwich 20 149 75 718 53 576 19·5 284 Lewisham -- -- 30 96 20 81 6·1 56 Stratford -- -- -- -- -- -- 77·6 -- West Ham -- -- -- -- -- -- 49·3 -- Leyton -- -- -- -- -- -- 13·1 -- There was one significant thing associated with the peculiar incidence of the cholera of 1866 upon the East End. The main drainage of London, consisting of a high level and a low level sewer on each side of the Thames, was commenced in 1859, and was formally opened on 4 April, 1865. The two levels on each side of the river made together a length of eighty-two miles; the cost, with pumping station, was £4,200,000. When the cholera of 1866 broke out, only one part of the system was incomplete and not yet in working, namely, the low level main drainage on the northern side, which served the whole of the cholera-stricken parishes from Aldgate to Bow. However, the official mind in this country has somehow become prejudiced against the well-known and usually accepted generalities of von Pettenkofer, which make more of a foul soil in the causation of miasmatic infections, than of contaminated surface water or contaminated water from reservoirs. Accordingly, the somewhat remarkable fact that the East End of London alone retained its old proclivity for choleraic infection was not joined to the fact of its being the only great division of the capital still unsewered, but to the fact that it was supplied by water taken in from the river Lea in Hertfordshire and (it was alleged) insufficiently filtered or otherwise purified at the Old Ford waterworks[1577]. The extension to Scotland in 1866 was late in the season and insignificant compared with former epidemics. It was heard of about the end of summer in Fraserburgh and one or two other ports or fishing places on the East Coast, but it was not until October and November that it attracted notice in the eight principal towns, the whole mortality from it in Glasgow being 53, in Edinburgh 154, in Dundee 105, in Aberdeen 62, in Paisley 2, in Greenock 14, in Leith 95, and in Perth 15. Besides these deaths there were 435 more in smaller towns or villages. The year was a very healthy one, the death-rates of Glasgow, Greenock and Perth having been below the mean of the previous ten years. In Ireland the cholera of 1866 was even slighter than in Scotland, the only considerable epidemic having been at Belfast. Cholera has never obtained a footing in London since the epidemic of 1866. In 1873, while the disease was unusually active in some parts of Europe, a few cases occurred in Wapping among Scandinavian emigrants on their way to America, who had been landed for a few days. But the infection did not spread. In 1884, when cholera came from Cochin China to Toulon and Marseilles, two or three cases occurred on board steamships arriving at Cardiff and Liverpool. In 1893, when the disease raged in Hamburg, a number of choleraic cases occurred at Grimsby in August, which were considered certainly Asiatic owing to their high degree of fatality. In August-October, the deaths from cholera, whether cholera nostras or the Asiatic type, or both together, were about thirty in Grimsby, eighteen in Hull, and about fifty more in various other places, chiefly in the south of Yorkshire. The autumn of that year was favourable to bowel-complaints and to enteric fever. The Antecedents of Epidemic Cholera in India. The antecedents and circumstances that made the year 1817 so critical for cholera in India, and for its diffusiveness far beyond India, constitute one of the greatest problems in epidemiology. A full and minute examination of them cannot be attempted here; but the chapter would be incomplete without some statement on the subject, which, if summary, need not be dogmatic. Cholera with the same symptoms and a similar degree of fatality was certainly not new to India about the year 1817; it can be traced from the earliest records of the Portuguese and other Europeans in India, if not also in other countries in ancient times[1578]. The mortalities among troops during the military operations in the Northern Circars in 1781 and 1790, and the deaths of some 20,000 pilgrims in eight days during the Hurdwar festival of 1783, were undoubtedly from the same epidemic infective cholera that was seen fifty years after in Europe. But these were occasional great explosions, which arose suddenly and ceased abruptly; whereas from about 1817 onwards the infection became, as it were, a seasonal product of the soil of Lower Bengal year after year, and at the same time began to range widely beyond its “endemic area” to other provinces of India, beyond the North-Western frontier to Central Asia and to Europe, and across the ocean to America. It was not by any sudden change in the year 1817, we may be sure, that cholera began to be endemic at various places far apart in the valley of the Ganges. Things must have been tending towards that manifestation for some time before, and those things must have been of the same kind that made the great explosion at Hurdwar in 1783 and have made many other great explosions at the Indian religious festivals in later times. Briefly the opinion may be hazarded, that it was the permeation with excremental matters of the soil at large in and around Bengali villages that gave rise to the endemic miasmatic infection of cholera. The _odor stercoreus_ of those innumerable village communities is, or used to be, a familiar fact, just as it is well known to be the custom there to dispense with latrines or other systematic provision for the disposal of faecal matters. But it may seem improbable that personal habits of the peasantry, not unknown in other countries, and immemorial in Lower Bengal itself, should have led to a definite disease-effect in a certain year of the 19th century and perennially thereafter. As to the special risk of engendering such a soil-poison in the valley of the Ganges, it has to be said that the region is peculiar in its alternations from extreme saturation to extreme dryness, within a stratum of alluvial or other porous soil which has a bed of impervious blue clay beneath it at a depth seldom more than 10 feet. It is just where such extreme fluctuations of the ground-water within a limited range occur from season to season, that organic matters in the soil are most apt to develop a miasmatic infective property. But why should the year 1817 have been, by the general consent of Anglo-Indian observers, the beginning of a new era in the history of cholera? The guiding principle in all such cases is, that things must have been moving that way before, and that in the particular season there had been reached at length such a degree of aggravation as to make a specific result manifest or the cumulative causes effective. Two things may be indicated as relevant to this assumed aggravation, or integration of accumulating causes. One was a certain gradual change in the beds of rivers, especially in the province of Behar, which entirely altered the relative amount of water flowing above ground and under ground, and must have made a difference in kind and in degree to the decomposition-processes in the soil. (In Burdwan these changes in the ground-water have caused much miasmatic fever since about thirty years ago.) The other thing was the increase of the number of cultivators per square mile under British rule. The latter cannot be stated with even approximate exactness for periods before the census of 1872; but there can be no reasonable doubt that the increase was great and progressive from the end of last century, owing to the cessation of intertribal wars, and of famines which were chiefly caused by the overflow of rivers now no longer subject to floods, and of wilful and barbarous checks to population. Among the cholera localities of 1817 were some that have now the greatest pressure of inhabitants on the soil, not in cities, but in uniformly dispersed rural communities--such as the division of Patna with 637 inhabitants per square mile, the district of Jessore with 693, and of Dacca with 756. This is of course a very general account of the matter, which a minute study of localities and seasons might show to be highly inadequate; but in seeking for some circumstances of aggravation at the particular juncture, the two things that have been mentioned, both of them coincident historical matters of fact, will appear to be not irrelevant according to the received teaching on the favouring conditions of cholera. NOTE ON CEREBRO-SPINAL FEVER. British experience, or the records of it, afford so little material for the history of epidemic cerebro-spinal fever (very abundant for France, Germany and the United States of America, see Hirsch, III. 547) that it has not seemed desirable to interpolate the subject in the chapter on Typhus and other Continued Fevers. Although our experience of it has fallen perhaps wholly within the period of exact statistics of the causes of death (saving some doubtful identifications in the 18th century), yet the registration tables contain so few deaths from it that it hardly seems as if a new and remarkable type of fever of the typhus kind had really been in our midst. There are, however, two periods when a good many papers were written upon it in Ireland and England, the years 1865-67 and the year 1876. When the first cases were seen in London in 1865 Murchison pronounced the new fever to be closely allied to typhus (_Lancet_, 1865, p. 1417). At the same time in Ireland it was sometimes called “the black death,” from the dark or livid vibices of the skin, or purpura maligna, or purpuric fever (J. T. Banks, _Dubl. Quart. Journ. Med. Sc._ XLIII. 98; E. W. Collins, _ibid._ XLVI. 170; Cogan, _ibid._ XLIV. 172; Gordon, _ibid._ XLIV. 408; H. Wilson, _ibid._ XLIII.; Haverty, _ibid._; T. W. Belcher, _Med. Press_, N. S. III. 167; J. H. Benson, _ibid._ III. 387; editor, _ibid._ 506. For England, S. Wilks, _Lancet_, 1865, I. 388, _Brit. Med. Journ._ 1868, I. 427; F. J. Brown, _Trans. Epid. Soc._ II. (1865), 391; J. N. Radcliffe in Reynolds’ _System of Medicine_, 1st ed. II. 676; H. Day, _Lancet_, 1867, I. 731). In the second period, 1876, there were many cases in England, especially in the Midlands, but it is said that they were usually diagnosed as typhoid fever (Sir Walter Foster, _Brit. Med. Journ._ 1892, II. 278, and _Lancet_, 1876, I. 849; Neville Hart (for Birmingham), _St Barth. Hosp. Rep._ XII. (1876), 105; H. Thompson, _Lancet_, 1876, I.