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266
CHOLERA

and 16 others occurred on shore, but there was no further dissemination.

During the winter of 1892–1893 cholera died down, but never wholly ceased in Russia, Germany, Austria-Hungary and France. With the return of warm weather it showed renewed activity, and prevailed extensively throughout Europe. The recorded mortality for the principal countries was as follows:—Russia (chiefly western provinces), 41,047; Austria-Hungary, 4669; France, 4000; Italy, 3036; Turkey, 1500; Germany, 298; Holland, 376; Belgium, 372; England, 139. Hardly any country escaped altogether; but Europe suffered less than Arabia, Mesopotamia and Persia. Cholera broke out at Mecca in June, and owing to the presence of an exceptionally large number of pilgrims caused an appalling mortality. The chief shereef estimated the mortality at 50,000. The pilgrims carried the disease to Asia Minor and Constantinople. In Persia also a recrudescence took place and proved enormously destructive. Dr Barry estimated the mortality at 70,000. At Hamburg, where new waterworks had been installed with sand filtration, only a few sporadic cases occurred until the autumn, when a sudden but limited rush took place, which was traced to a defect in the masonry permitting unfiltered Elbe water to pass into the mains. In England cholera obtained a footing on the Humber at Grimsby, and to a lesser extent at Hull, and isolated attacks occurred in some 50 different localities. Excluding a few ship-borne cases the registered number of attacks was 287, with 135 deaths, of which 9 took place in London. It is interesting to compare the mortality from cholera in England and Wales, and in London, for each year in which it has prevailed since registration began:—

Year. England and Wales. London.
Deaths. Deaths per 10,000
living.
Deaths. Deaths per 10,000
living.
1848 1,908  1.1 652  2.9
1849 53,293 30.3 14,137 61.8
1853 4,419  2.4 883  3.5
1854 20,097 10.9 10,738 42.8
1865 1,297  0.6 196  0.6
1866 14,378  6.8 5,596 18.4
1893 135   0.05 9 0.002
1894 nil nil nil nil

In 1894 no deaths from cholera were recorded in England, but on the continent it still prevailed over a wide area. In Russia over 30,000 persons died of it, in Germany about 500, but the most violent outbreak was in Galicia, where upwards of 8000 deaths were registered. In 1895 it still lingered, chiefly in Russia and Galicia, but with greatly diminished activity. In that year Egypt, Morocco and Japan were attacked, the last severely. The disease then remained in abeyance until the severe epidemic in India in 1900.

The great invasion just described was fruitful in lessons for the prevention of cholera. It proved that the one real and sufficient protection lies in a standing condition of good sanitation backed by an efficient and vigilant Preventionsanitary administration. The experience of Great Britain was a remarkable piece of evidence, but that of Berlin was perhaps even more striking, for Berlin lay in the centre of four fires, in direct and frequent communication with Hamburg, Russia, France and Austria, and without the advantage of a sea frontier. Cholera was repeatedly brought into Berlin, but never obtained a footing, and its successful repression was accomplished without any irksome interference with traffic or the ordinary business of life. The general success of Great Britain and Germany in keeping cholera in check by ordinary sanitary means completed the conversion of all enlightened nations to the policy laid down so far back as 1865 by Sir John Simon, and advocated by Great Britain at a series of international congresses—the policy of abandoning quarantine, which Great Britain did in 1873, and trusting to sanitary measures with medical inspection of persons arriving from infected places. This principle was formally adopted at the international conference ference held at Dresden in 1893, at which a convention was signed by the delegates of Germany, Austria, Belgium, France, Great Britain, Italy, Russia, Switzerland, Luxemburg, Montenegro and the Netherlands. Under this instrument the practice is broadly as follows, though the procedure varies a good deal in different countries:—Ships arriving from infected ports are inspected, and if healthy are not detained, but bilge-water and drinking-water are evacuated, and persons landing may be placed under medical supervision without detention; infected ships are detained only for purposes of disinfection; persons suffering from cholera are removed to hospital; other persons landing from an infected ship are placed under medical observation, which may mean detention for five days from the last case, or, as in Great Britain, supervision in their own homes, for which purpose they give their names and places of destination before landing. All goods are freed from restrictions, except rags and articles believed to be contaminated by cholera matters. By land, passengers from infected places are similarly inspected at the frontiers and their luggage “disinfected”—in all cases a pious ceremony of no practical value, involving a short but often a vexatious delay; only those found suffering from cholera can be detained. Each nation is pledged to notify the others of the existence within its own borders of a “foyer” of cholera, by which is meant a focus or centre of infection. The precise interpretation of the term is left to each government, and is treated in a rather elastic fashion by some, but it is generally understood to imply the occurrence of non-imported cases in such a manner as to point to the local presence of infection. The question of guarding Europe generally from the danger of diffusion by pilgrims through the Red Sea was settled at another conference held in Paris in 1894. The provisions agreed on included the inspection of pilgrims at ports of departure, detention of infected or suspected persons, and supervision of pilgrim ships and of pilgrims proceeding overland to Mecca.

The substitution of the procedure above described for the old measures of quarantine and other still more drastic interferences with traffic presupposes the existence of a sanitary service and fairly good sanitary conditions if cholera is to be effectually prevented. No doubt if sanitation were perfect in any place or country, cholera, along with many other diseases, might there be ignored, but sanitation is not perfect anywhere, and therefore it requires to be supplemented by a system of notification with prompt segregation of the sick and destruction of infective material. These things imply a regular organization, and it is to the public health service of Great Britain that the complete mastery of cholera has mainly been due in recent years, and particularly in 1893. Of sanitary conditions the most important is unquestionably the water-supply. So many irrefragable proofs of this fact were given during 1892–1893 that it is no longer necessary to refer to the time-honoured case of the Broad Street pump. At Samarkand three regiments were encamped side by side on a level plain close to a stream of water. The colonel of one regiment took extraordinary precautions, placing a guard over the river, and compelling his men to use boiled water even for washing. Not a single case of cholera occurred in that regiment, while the others, in which only ordinary precautions were taken, lost over 100 men. At Askabad the cholera had almost disappeared, when a banquet was given by the governor in honour of the tsar’s name-day. Of the guests one-half died within twenty-four hours; a military band, which was present, lost 40 men out of 50; and one regiment lost half its men and 9 officers. Within forty-eight hours 1300 persons died out of a total population of about 13,000. The water supply came from a small stream, and just before the banquet a heavy rain-storm had occurred, which swept into the stream all surface refuse from an infected village higher up and some distance from the banks. But the classical example was Hamburg. The water-supply is obtained from the Elbe, which became infected by some means not ascertained. The drainage from the town also runs into the river, and the movement of the tide was sufficient to carry the sewage matter up above the water-intake. The water itself, which is no cleaner than that of the Thames