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CHOLERA

the year it had not only spread extensively in Europe, but had reached the West Indies. In 1866 it invaded England and the United States, but during the following year it died down in the West. The subsequent history of cholera in Europe may be stated chronologically.

1860–1874.—This invasion was traced to the great gathering of pilgrims at Hardwar on the Upper Ganges in the month of April 1867. From there the returning pilgrims carried it to the Punjab, Kashmir and Afghanistan, whence it spread to Persia and the Caspian, but it did not reach Russia until 1869. During the next four years a number of outbreaks occurred in central Europe, and notably one at Munich in the winter of 1873. The irregular character of these epidemics suggests that they were rather survivals from the pandemic wave of 1867 than fresh importations, but there is no doubt that cholera was carried overland into Russia in the manner described.

1883–1887.—This visitation, again, came by the Mediterranean. In 1883 a severe outbreak occurred in Egypt, causing a mortality of above 25,000. Its origin remained unknown. During this epidemic Koch discovered the comma bacillus. The following year cholera appeared at Toulon. It was said to have been brought in a troopship from Saigon in Cochin-China, but it may have been connected with the Egyptian epidemic. A severe outbreak followed and reached Italy, nearly 8000 persons dying in Naples alone. In 1885 the south of France, Italy, Sicily and Spain all suffered, especially the last, where nearly 120,000 deaths occurred. Portugal escaped, and the authorities there attributed their good fortune to the institution of a military cordon, in which they have had implicit confidence ever since. In 1886 the same countries suffered again, and also Austria-Hungary. From Italy the disease was carried to South America, and even travelled as far as Chile, where it had previously been unknown. In 1887 it still lingered in the Mediterranean, causing great mortality in Messina especially. According to Dr A. J. Wall, this epidemic cost 250,000 lives in Europe and at least 50,000 in America. A particular interest attaches to it in the fact that a localized revival of the disease was caused in Spain in 1890 by the disturbance of the graves of some of the victims who had died of cholera four years previously.

1892–1895.—This great invasion reverted again to the old overland route, but the march of the disease was of unprecedented rapidity. Within less than five months it travelled from the North-West Provinces of India to St Petersburg, and probably to Hamburg, and thence in a few days to England and the United States. This speed, in such striking contrast to the slow advance of former occasions, was attributed, and no doubt rightly, to improved steam transit, and particularly the Transcaspian railway. The progress of the disease was traced from place to place, and almost from day to day, with great precision, showing how it moves along the chief highways and is obviously carried by man. The main facts are as follows:—Cholera was extensively and severely prevalent in India in 1891, causing 601,603 deaths, the highest mortality since 1877. In March 1892 it broke out at the Hardwar fair, a day or two before the pilgrims dispersed; on the 19th of April it was at Kabul, on the 1st of May at Herat, and on the 26th of May at Meshed. From Meshed it moved in three directions—due west to Teheran in Persia, north-east by the Transcaspian railway to Samarkand in Central Asia, and north-west by the same line in the opposite direction to Uzun-ada on the Caspian Sea. It reached Uzun-ada on the 6th of June; crossed to Baku, June 18th; Astrakhan, June 24th; then up the Volga to Nizhniy-Novgorod, arriving at Moscow and St Petersburg early in August. The part played by steam transit is clear from the fact that the disease took no longer to travel all the way from Meshed to St Petersburg by rail and steamboat than to traverse the short distance from Meshed to Teheran by road. On the 16th of August cases began to occur in Hamburg; on the 19th of August a fireman was taken ill at Grangemouth in Scotland, where he had arrived the day before from Hamburg; and on the 31st of August a vessel reached New York from the same port with cholera on board. On the 8th of September the disease appeared in Galicia, having moved somewhat slowly westwards across Russia into Poland, and on the 26th of September it was in Budapest. Holland and Servia were also attacked, while isolated cases were carried to Norway, Denmark and Italy. Meanwhile two entirely separate epidemics were in progress elsewhere. The first was confined to Arabia and the Somali coast of Africa, and was connected with the remains of an outbreak in Syria and Arabia in 1890–1891. The second arose mysteriously in France about the time when the overland invasion started from India. The first known case occurred in the prison at Nanterre, near Paris, on the 31st of March. Paris was affected in April, and Havre in July. The origin of this outbreak, which was of a much less violent character than that which came simultaneously by way of Russia, was never ascertained. Its activity was confined to France, particularly in the neighbourhood of Paris, together with Belgium and Holland, which was placed between two fires, but escaped with but little mortality. The number of persons killed by cholera in 1892, outside of India, was reckoned at 378,449, and the vast majority of those died within six months. The countries which suffered most severely were as follows:—European Russia, 151,626; Caucasus, 69,423; Central Asian Russia, 31,804; Siberia, 15,037—total for Russian empire, 267,890; Persia, 63,982; Somaliland, 10,000; Afghanistan, 7,000; Germany, 9563; France, 4550; Hungary, 1255; Belgium, 961. Curiously enough, the south of Europe, which had been the scene of the previous epidemic visitation, escaped. The disease was of the most virulent character. In European Russia the mortality was 45.8% of the cases, the highest rate ever known in that country; in Germany it was 51.3%; and in Austria-Hungary, 57.5%. Of all the localities attacked, the case of Hamburg was the most remarkable. The presence of cholera was first suspected on the 16th of August, when two cases occurred, but it was not officially declared until the 23rd of August. By that time the daily number of victims had already risen to some hundreds, while the experts and authorities were making up their minds whether they had cholera to deal with or not. Their decision eventually came too late and was superfluous, for by the 27th of August the people were being stricken down at the rate of 1000 a day. This rate was maintained for four days, after which the vehemence of the pestilence began to abate. It gradually declined, and ceased on the 14th of November. During those three months 16,956 persons were attacked and 8605 died, the majority within the space of a few weeks. The town, ordinarily one of the gayest places of business and pleasure on the continent, became a city of the dead. Thousands of persons fled, carrying the disease into all parts of Germany; the rest shut themselves indoors; the shops were closed, the trams ceased to run, the hotels and restaurants were deserted, and few vehicles or pedestrians were seen in the streets. At the cemetery, which lies about 10 m. from the town, some hundreds of men were engaged day and night digging long trenches to hold double rows of coffins, while the funerals formed an almost continuous procession along the roads; even so the victims could not be buried fast enough, and their bodies lay for days in sheds hastily run up as mortuaries. Hamburg had been attacked by cholera on fourteen previous occasions, beginning with 1831, but the mortality had never approached that of 1892; in the worst year, which was 1832, there were only 3687 cases and 1765 deaths. The disease was believed to have been introduced by Jewish emigrants passing through on their way from Russia, but the importation could not be traced. The Jews were segregated and kept under careful supervision from the middle of July onwards, and no recognized case occurred among them. The total number of places in Germany in which cholera appeared in 1892 was 269, but it took no serious hold anywhere save in Hamburg. The distribution was chiefly by the waterways, which seem to affect a larger number of places than the railways as carriers of cholera. In Paris 907 persons died, and in Havre 498. Between the 18th of August and the 21st of October 38 cases were imported into England and Scotland through eleven different ports, but the disease nowhere obtained a footing. Seven vessels brought 72 cases to the United States,