In dealing with cholera, as with other difficulties, the maxim should be for each in his sphere" to grasp the nettle." Fortunately, it has already been deprived of much of its sting by the application of new scientific and sanitary knowledge, and for this country, at least, we have from the outset of its approach felt that there is a fair prospect of rendering it in the future almost innocuous. That time has not yet wholly come. But even now, and already, so great is the progress made that we have been able to set ourselves to face the impending danger with good heart, and with a sense of largely increased power to grapple with and neutralize it. The result thus far has justified these anticipations. In the terrible cholera epidemics of 1849 and of 1853 the nation felt itself almost helpless, and there was widespread panic NEW SERIES.-VOL. LVI., No. 6.

in the face of what was then a mysterious and almost invincible pestilence. All this is now changed; we know practically a very large part of what it is necessary to know as to the origin and causation of cholera, its mode of propagation and the means of arresting it; and it has rested only with our central sanitary organization, with our local sanitary authorities, and with ourselves, as citizens and householders, to take steps which shall in the near future make cholera a disease as rare, as little known, or as easily stamped out as typhus fever-once, and indeed not long since, so common and so fatal in this country. Typhus fever is now so rarely seen as frequently to fail to be recognized by medical men when scattered cases occur. Meantime cholera has been at our gates and a few cases have penetrated into

the country, so that we are still face to face with the enemy, and must take our measures accordingly.

TERMS OF MYSTERY NOW EXPLODED.

Until quite lately we heard a good deal of a pseudo-scientific terminology which is still occasionally used by eminent men, such as Sir Joseph Fayrer, and InspectorGeneral Lawson, but which really ought, in my opinion, to be brushed aside as obsolete (in this case at any rate), mystifying, and obstructive. Cholera used to be spoken of, and we may find it so spoken of now, from time to time, as subject to telluric influences, atmospheric miasms, pandemic waves, epidemic constitution, propagation by air-currents, and cholera clouds, and through "blue mists," with many other mysterious agencies, hard to comprehend and still harder to deal with. We are hearing still in Russia and Poland of the "cholera insect which flies across the frontier" (Hall Caine), and I have been gravely apprised from one or two quarters of blue mists" and plagues of flies, corresponding with what was observed in the last cholera epidemics. The plain truth is perhaps best expressed in one sentence, which tells us in homely words what Asiatic cholera is and points out at the same time what is our duty and what are our weapons with which to combat it. "CHOLERA IS A FILTH DISEASE,

CARRIED BY DIRTY PEOPLE ΤΟ DIRTY

PLACES. That is a hard saying in one sense, but it is simple and true, and goes to the root of the whole matter, as I shall proceed to show.

THE HOME OF CHOLERA.

The home of cholera is in India; it is there established endemically throughout a wide area, but not, as most Indian authorities once believed and many would even now apparently often have us believe, in virtue of any local, mysterious, unknown, or unpreventable causes. It is

so in virtue of conditions which may all of them be removed, and which, in time, I trust, will be removed. In 1878 there were 318,000 deaths from cholera in India; in 1881 there were 161,000 deaths from cholera; in 1887, 488,000; and in 1888, 270,000.

OUR IMPERIAL RESPONSIBILITY.
We have in this respect a great Imperial

responsibility, which we shall find it hard to fulfil. At the International Hygienic Congress in Vienna the remark was constantly made," You English have by your sanitary improvements prevented cholera from gaining a foothold in England; why do you not attack it in its birthplace and prevent it from springing into life in India?" We may well closely question ourselves, why we have not succeeded in carrying even further the great work which we have done for the sanitary improvement of Indian populations. It has not been, as Sir Douglas Galton has pointed out, for want of knowledge. In 1860 a Royal Commission, presided over by Lord Derby, made many observations and recommendations for this end. Physicians acting privately, or as sanitary commissioners, have collected in twenty-five years a vast mass of information all tending to teach the one lesson, that polluted water-supply, pollution of the soil, and water-logging, are the conditions which lead to the extension of cholera and other kindred diseases. Remove these sources, and the preventable diseases which are the effect of them are diminished or extinguished. THE ORGANIZATION NEEDED TO STAMP OUT CHOLERA IN INDIA.

The Royal Commission of 1862, on the basis of the medical evidence put before them, adopted important recommendations which, in proportion as they may be carried out, would stamp out cholera almost wholly, if not entirely, in India. I cannot here discuss these in detail; but obviously the first necessary step is that a central Local Government Board, efficiently constituted, be established in each province; with power to carry out sanitary regulations and to borrow money, when necessary, for the purpose. As matters stand, isolated district commissioners are appointed, but no central authority exists for enforcing their recommendations. The Board which the Commission of 1862 had in view was of members having real sanitary knowledge, and who would supersede the isolated commissioners. It would seem almost as if the Indian Government in general had come to regard the periodical outbreaks of cholera in India as irremediable, and to discuss only the means of preventing the infection from spreading to Europe. This is a quite mistaken, unjustifiable, and dangerous

view, and one against which other nations as well as our own are well entitled to protest, as they do protest.

CHOLERA AND WATER IN INDIA.

Dr. M. C. Furnell, in his recent excellent book on the subject, expresses himself as firmly of opinion that the general method of the propagation of cholera in India is by means of specifically polluted water. While in Europe, however, nearly every outbreak of cholera has been definitely traced to the contamination of the water supply, and much has been written about it, telluric and atmospheric conditions are distantly invoked by Indian authorities. These are terms of mystery and of indefinite meaning, which unfortunately have been adopted, however, by too many Government officials, who cannot explain what they mean, and frequently use them as a cloak for ignorance. Dr. Furnell has had no difficulty in finding masses of facts in support of his opinions. The habits of the natives, though in direct opposition to their own laws and sacred writings, are such as tend to the most filthy pollution of the water supplied for their use. Where pure water has been supplied to the natives, as in Madras and Calcutta, and care has been taken to guard such sources of supply from pollution, cholera epidemics have become of unfrequent occurrence and of greatly reduced fatality. In this opinion all the best authorities concur.

In brief illustration of these facts and conclusions I will only refer to the two great cities which are leading seats of government and most under our influence.

In the paper by Dr. W. J. Simpson, Medical Officer of Health, read at the British Medical Association in August, 1888, he gave a description of Calcutta, Howrah, and the suburbs, dwelling specially on the water-supply, the tanks, the drainage, the construction of the streets and houses, native and European; and the sanitary system generally. Calcutta, to the south of the native town, he stated, is well built, the streets are wide and straight, the houses are large and have gardens attached; there is a liberal supply of excellent water, the drainage and cleansing are good, and that portion of the city compares favorably with the better parts of London. With a few exceptions, northern and native Calcutta is

densely crowded, the streets are narrow and irregular, the drainage is bad, only the better and middle class have a fair supply of water; the poorer class have a very scanty water-supply, and depend upon the water in the tanks. The native town is studded with wells and tanks. Neither Howrah, with its 100,000 inhabitants, nor the suburbs of Calcutta with its 250,000, have any public water-supply, with the exception of the wells and tanks. The unsanitary condition of Howrah without a public water-supply, and without building regulations, is surpassed by the suburbs, which have no public water-supply, no drainage, no building regulations, nor any effective conservancy arrangements. As a general rule, European residents in Howrah get their water from Calcutta by carriers, and they avoid the well and tank water. The personal habits of the natives are cleanly. As a religious duty they bathe at least once a day, the women more frequently, and this is done, when convenient, in the river Hooghly, but generally in the tanks near their houses or huts. The tanks are thus defiled by the excretions of the body, by the washing of dirty clothes, frequently of clothes soiled by excretions of the sick, by human ordure due to the practice of children and others defæcating on the banks of the tanks, and by the drainage and soakage from the surrounding huts and houses. Thus the water in the tanks, except during the rainy season, varies in quality from moderately polluted up to concentrated sewage, and this is the only water-supply practically available for large numbers of the native population. Dr. Simpson traces out the connection between local outbreaks of cholera and a deficient and contaminated water-supply, showing that those who have an abundant and pure water-supply, namely, the Europeans and better class of natives, escape cholera epidemics, except in isolated instances, which can generally be accounted for; while the natives, who necessarily depend on the tank water, suffer severely when the tank becomes polluted by the excreta from a cholera patient. He says:

I would particularly direct attention to this scarcity of water in the parts affected. Go almost where one may, in the northern part of the town, and especially in the riparian wards, there is the same complaint of the want of water, and a very valid one it is. It is a common occurrence to see the people

grouped round one of the standposts, waiting their turn to fill their chatties, many of them to be disappointed, for the water from the standposts often comes in mere driblets, and the supply is exhausted or turned off before half the people are supplied. Scarcity of water brings in its train a great deal of sickness, apart from cholera. The districts which have suffered most from scarcity of water, have suffered also from a large amount of sickness of a dysenteric character.

The natives bathe, washe their utensils and clothes in the tanks, because it is the only available place for doing so; and they use the water of the tanks, contaminated in addition by soakage and sewage, for cooking and drinking, because it is the only available water-supply for domestic purposes. The remedies for the condition of affairs described are simple enough, but they need time, and must involve considerable expense. The first requisite is a liberal water-supply for Howrah and the suburbs, and a more liberal supply for Calcutta. Few will drink polluted water if they can obtain pure water. By specially constructed tanks even the habits of the people can be so directed as to permit them to enjoy the luxury of the bath, and to perform their ablutions without danger. The second requisite is well-planned streets with free ventilation, good building arrangements, a system of drainage to pass through these streets, systematic clearing, levelling, paving and filling up of ponds, draining, scavenging, removal of nuisance, and a well-organized sanitary department. The carrying out of these measures will ultimately convert Calcutta, Howrah, and the suburbs, containing nearly 800,000 inhabitants, into as healthy a locality as any in the world, in so far as the prevalence of diseases not due directly to a subtropical climate is concerned, and these measures of sanitation will change one of the most important centres in the endemic area of cholera into an area no longer marked by endemicity. Before any real progress in scientific medicine can be expected in India, the scientific branch of the medical service must be distinct from the administration, for when administrative functions preponderate, scientific research is relegated to such a subordinate position as to render it impossible to be carried out satisfactorily. A central institute is necessary, well-equipped, and having attached to it a body of men well trained in chemical, physiological, and

biological methods, whose whole time should be devoted to scientific research. I take my other example from Dr. Furnell, the Surgeon-General at Madras, writing in 1886 an address on cholera. For many years before the introduction of the Red Hill water-supply into Madras, the number of deaths from cholera annually amounted to hundreds, and too frequently to thousands; but from the year 1872, when the water-supply was first opened, there has been a very large reduction in the mortality, one year being absolutely free from the disease, and in three others the deaths being five, six, and two respectively. Of course, during the famine years there was a large increase in the fatal cases of cholera, caused by the migration into the town of many poor, half-starved creatures, who had no strength left to resist the disease. But, as soon as the famine was over, the rate of mortality again fell to below 100 per annum ; and, during the last four years, when there has been a severe epidemic of the disease throughout the greater part of the Madras Presidency, the average number of deaths had not exceeded 250 per annum. The greater part of these deaths, also, it is shown, took place in those parts of the town which had not had the benefit of the Red Hill's water-supply. Dr. Furnell, therefore, urges the necessity of extending the watersupply to these localities. Our duty then lies before us; it is a grave and difficult task, but must be looked steadily in the face.

SPECIAL METHODS OF PROPAGATION IN INDIA.

There are other modes of propagation of cholera in India, and special to it, which also admit of remedy; for in India the natives not only drink cholera as we do in Europe, but they also eat cholera ; but that is a question which I leave aside with this passing reference for the moment, since I have here to deal with things nearer home. Let me note only that the epidemic of 1830 passed into Europe from Astrakhan, mounting the Volga, and conveyed from the shores of the Baltic to Great Britain, Holland and France, making fearful ravages in all those countries, and spreading slowly (during more than a decade) throughout the world, leaving everywhere a devastating track, Switzer

land and Greece alone remaining untouched. The epidemic of 1849 passed out of India and the Burman empire, traversing the Caucasus and the Volga, entering Astrakhan, and ravaging in succession Russia, the German and Dutch countries, England and France. 1853 saw a fresh epidemic which again invaded Russia, England, and France, destroying victims in England, and 140,000 in France. This epidemic was believed, however, to be only the lighting up again of the smouldering ashes of that of 1847-50, of which a focus still remained in Poland and Galicia.

THE MECCA PILGRIMS.

The epidemic of 1866 which made 60,000 victims in Egypt in three months, and which caused 6000 deaths in the East of London, came to us from the Arabian shores of the Red Sea, falling so severely on Mecca that 30,000 pilgrims died of it. And here let me mention one of the customs of that pilgrimage which goes far to explain the intensity and the fearful mortality which attend any outbreak of cholera among the Meccan pilgrims. At a given period the pilgrims stand naked in turn by the holy well; a bucket of water is poured over each man, he drinks what he can of it, and the rest falls back into the well. The water of this well has been analyzed be an English chemist, Dr. Frankland; it is fearfully polluted with abominable contaminations. On this occasion, within a few days of the ceremony, the road for twelve miles to the foot of Mount Ararat was thickly strewn with dead bodies.

THE GREAT AND TRAGIC EXPERIMENT OF

THE EAST LONDON EPIDEMIC OF 1866;
DISTRIBUTION OF THE UNFILTERED
WATER OF THE RIVER LEE KILLS 6000
PEOPLE.

And now we reach England. Arriving on our shores from Alexandria, conveyed to England by a few persons in one ship -a family escaped prematurely from the detention of medical inspection at the port of Southampton, in the autumn of 1866. Very shortly afterward an intense outbreak in East London occurred. With the detection of the cause and inode of propagation of this outbreak I became immediately concerned. I have told the story before and need not dwell upon its details, but it is too instructive altogether to pass

over. Firmly convinced from a study of the researches and demonstrations of the immortal Dr. Snow (to whom, if to any man, a grateful country should erect a monument, instead of letting his name pass into oblivion), and further satisfied by the studies of Simon and Farr, that polluted drinking water had been a main factor in previous epidemics, and must be so in all probability in this, I dispatched Mr. James Netten Radcliffe to the headquarters of the East London Water Company. There, with much difficulty, and after several ineffectual efforts, we ascertained that one of the cholera-stricken family had traveled from the port of arrival to a house by the river Lee. The sewers of that house discharged into the river just above the intake of the water company; and, by a strange fatality, just at that time, the pumps and filter beds of the company being under repair, the water of the Lee was liberally distributed, practically unfiltered, to the inhabitants of East London. The whole story was subsequently laboriously worked out, and verified precisely as I discovered and told it, by Mr. Simon and Dr. Farr. It may be read in detail in the reports of the Registrar-General and of the medical department of the Local Government Board. Sixteen thousand residents of East London were attacked, and 6000 died. That was a great and tragic experiment on a scale of sadly vast proportions. But it has deeply engraved its lessons on the public mind, and has influenced our legislation and all our subsequent proceedings. The record. is one from which we have so much to learn that it cannot be too frequently held knowledge by proving that specifically pol up to view. It crowned the edifice of our luted drinking water was, is, and must now always be regarded, not only as an adjuvant cause of the spread of Asiatic cholera, but as the causa causans of this, and, as I have shown elsewhere, of all well-observed European cholera epidemics.

It is not altogether a pleasant reflection at this moment that a large part of the inbabitants of East London are still drinking the water of the river Lee, much less polluted, it is true, than heretofore, but still dangerously polluted, and much better filtered, it is also true. It is not entirely reassuring to know that only a filter bed and a pump, which are not necessarily always impeccable and infallibly reliable,