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CHOLERA

three directions—due west to Tehran 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 6th June 5 crossed to Baku, 18th June; Astrakhan, 24th June; then up the Volga to Nijni 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 Tehran by road. On 16th August cases began to occur in Hamburg; on 19th August a fireman was taken ill at Grangemouth in Scotland, where he had arrived the day before from Hamburg; and on 31st August a vessel reached New York from the same port with cholera on board. On 8th September the disease appeared in Galicia, having moved somewhat slowly westwards across Russia into Poland, and on 26th 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 1890-91. 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 31st 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, 7000 ; 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 per cent, of the cases, the highest rate ever known in that country; in Germany it was 51'3 per cent.; and in Austria-Hungary, 57-5 per cent. Of all the localities attacked, the case of Hamburg was the most remarkable. The presence of cholera was first suspected on 16th August, when two cases occurred, but it was not officially declared until 23rd 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 27th 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 14th 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 miles 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 18th August and 21st 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, and 16 others occurred on shore, but there was no further dissemination. During the winter of 1892-93 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 tookplaceand proved enormously destructive. Dr Barry estimated the mortality at 10,000. 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 :— England and Wales. per 10,000 Deaths. Deathsperm.OOO Deaths. Deathsliving. f 1848 1849 (1853 1854 (1865 11866 ) 1893 1 1894

1,908 53,293 4,419 20,097 1,297 14,378 135 nil

1-1 30-3 2-4 10-9 0-6 6-8 0-05 nil

652 14,137 883 10,738 196 5,596 9 nil

261-8 342-8 0-6 18-4 0-002 nil