Columtim ^nibersiitp CoOege of ^fjpgictanss anb burgeons; 3aef erence Hifararp GEOGRAPHICAL PATHOLOGY. Digitized by tine Internet Arciiive in 2010 witin funding from Open Knowledge Commons http://www.archive.org/details/geographicalpath01davi r'lvr GEOGRAPHICAL PATHOLOGY: AN INQUIRY INTO THE GEOGRAPHICAL DISTRIBUTION OF INFECTIVE AND CLIMATIC DISEASES. BY ANDREW DAVIDSON, M.D., F.R.C.P. Ed., LATE VISITING AND SUPERINTENDING SURGEON, CIVIL HOSPITAL, AND PROFESSOR OF CHEMISTRY, ROYAL COLLEGE, MAURITIUS. EUROPE, NORTHERN AND WESTERN ASIA, INDIA, CEYLON, BURMA. EDINBURGH & LONDON: YOUNG J. PENTLAND. 1892. EDINBURGH : PRINTED BY MORRISON AND GIBB, FOR YOUNG J. PENTLAND, 11 TEVIOT PLACE, AND 38 WEST SJIITHFIELD, LONDON, E.G. CONTENTS. EUROPE. DIVISION I.— NORTHERN EUROPE. I. Iceland and the Faroe Islands, II. Norway, . III. Sweden, . lY. Denmark, V. Finland, . VI. Russia in Europe, (a) Baltic Provinces, (6) Northern Governments, (c) Central Governments, (d) Southern Governments, PAGE 3 14 27 42 46 49 52 55 57 61 DIVISION II.— CENTRAL AND WESTERN EUROPE. VII. Germany, VIII. AUSTRO-HUNGARY, IX. England and "Wales, X. Scotland, XI. Ireland, XII. The Netherlands, XIII. Belgium, . XIV. France, . XV. Switzerland, 67 91 103 136 141 145 157 160 182 DIVISION III.— SOUTHERN EUROPE. XVI. Spain and Portugal, . XVII. Italy, XVII I. Montenegro and Albania, XIX. Greece, ..... XX. ROUMANIA, SeRVIA, BULGARIA, ROUMELIA, 193 206 236 238 242 VI CONTENTS. ASIA. . DIVISION I.— NORTHERN AND WESTERN ASIA. CHAP. I. Siberia, Kikghiz-Land, ...... II. "Western and Eastern Turkestan, Mongolia, Manchooria, and COREA, III. Cyprus, .... IV. Anatolia (Asia Minor), Armenia, V. Syria, .... VI. Mesopotamia and Kurdistan, VII. Arabia, .... VIII. Persia, Baluchistan, Afghanistan, PAGE 249 253 257 271 275 278 282 291 DIVISION II.— INDIA, CEYLON, BURMA. I. India — Geography and Climatology, .... II. ,, Prevalence of Fever in, its Forms and Types, III. „ Epidemic and Endemic Malaria in the Punjab, . IV. ,, ,, ,, IN the North-West Provinces, V. ,, ,, ,, IN Bengal, VI. ,, ,, ,, IN Ra.jputana, etc.,* . VII. ,, ,, ,, IN the Lower Indus Valley, VIII. ,, ,, ,, IN Kutch and Gujarat, IX. ,, ,, ,, IN Bombay City, X, ,, ,, ,, IN the Western and Eastern Coast Regions, XI. ,, ,, ,, IN the Central Pro- vinces, XII. ,, „ ,, IN the Nizam's Do- minions, XIII. ,, ,, t, IN the Western Deccan, XIV. ,, ,, „ IN Mysore, XV. ,, Enteric, Typhus, and Relapsing Fevers, Influenza and Dengue, ....... XVI. ,, Plague, Dysentery, and Diarrhcea, XVII. ,, Cholera, ....... XVIII. ,, Diphtheria, Erysipelas, Cerebro - Spinal Meningitis, Whooping-Cough, Mumps, Smallpox, Scarlet Fever, Measles, ....... XIX. ,, Diseases of the Respiratory Organs, XX. ,, Diseases of Liver and Spleen, .... XXI. ,, Rheumatic and Venereal Diseases, Dropsy, Scrofula, Scurvy, Ulcers, Leprosy, etc., .... 303 311 327 349 360 367 372 377 380 383 386 389 391 393 397 413 418 442 446 455 459 CONTENTS. Vll CHAP. XXII. Cfa'lon, . . . . ■ . XXIII. The Andaman and Nicobar Islands, XXIV. Burma, ..... PAGE 467 478 480 DIVISION III.— SOUTH-EASTERN ASIA,i INDIAN ARCHIPELAGO, AUSTRALIA, AND POLYNESIA. I. Malayan Peninsula and Singapore, .... 485 II. Indo-China, Siam, Cambodia, Cochin-China, Tonkin, . . 490 III. China, ......... 501 IV. Hong-Kong, ........ 514 V. Japan, ......... 520 VI. Eastern Archipelago— Sumatra, Banca Billiton, The Riouw Archipelago, ....... 525 VII. „ Borneo, ..... 630 VIII. „ Java, ..... 536 IX. ,, Sumbawa Group, Celebes, Sulu Islands, Moluccas, Tenimber Islands, Philip pine Islands, New Guinea, . . 541 X. Australia, ........ 548 XI. Tasmania, ........ 566 XII. New Zealand, ........ 569 XI II. Polynesia, ........ 574 AFRICA. DIVISION I. Introductory, ...... I. Morocco, ....... II. Algeria, ....... III. Tunis and Tripoli, ...... IV. Egypt and the Western Coasts of Red Sea, V. The Sahara, ....... VI. Senegal, ........ VII. Sierra Leone, Sherboro, Los Islands, VIII. The Coasts of Guinea, Liberia, Grand Bassam, Gold Coast, etc, IX. Congo and the Congo Free State, .... X. South Africa — The Cape, Natal, Transvaal, etc., XL East Africa— The Coast Region, The South and East Centra Regions, ....... XII. Abyssinia, ....... 583 586 588 596 599 605 608 622 626 641 651 665 695 ^ This heading has been printed by mistake " South- Western " Asia in the text. vni CONTENTS. DIVISION II.— THE AFEICAN ISLANDS. CHAP. I. The AVest Afkican Islands, .... II. The Lesser East African Islands, III. ilADAGASCAE A^'D SEYCHELLES, lY. ilArPviTirs — Geography, Topography, and Clijlatology, "V. ,, PRE-ilALARIAL PERIOD, VI. ,, Fever Epidemy of 1866-68, VII. ,, Period of Endemic Fever, VIII. RODRIGUES A>"T) REtTSIOX, .... 701 709 712 724 732 741 758 783 AMERICA. DIVISION I.— XOETH AND CENTRAL AMERICA. I. The Northern Regions, . . ■ . . . . 787 II. Dominion of Canada and Neavtoundland, .... 791 III. The United States, ....... 799 IV. Mexico, ......... 876 V. Central America — British Honduras, Guatemala, Honduras, San Salvador, Nicaragua, Costa Rica, Panama, . . 883 DIVISION II.— AVEST INDIA ISLANDS AND SOUTH AMERICA. I. West India Islands — The Bermudas xsd Bahamas, II. ,, Cuba, ..... III. ,, Jamaica, ..... IV. ,, Hayti, Puerto Rico, Guadeloupe, Mar tinique, .... V. ,, The Leeward and "Windward Islands Trinidad, .... VI. South America — Colombia and Venezuela, ... VII. VIII. IX. X. XI. GENERAL INDEX, British Guiana, Dutch Guiana, French Guiana Brazil, ..... Ecuador and Peru, .... Bolivia and Chili, . Argentina, Paraguay, Uruguay, and the Falk land Islands, .... 893 896 902 911 921 926 929 940 966 972 977 989 INTRODUCTION. The object of this work is to sketch the geographical distribution of infective and climatic diseases, and to trace the influence of tempera- ture, rainfall, altitude, and soil - conditions on their prevalence, character, and epidemic spread. Under the term infective diseases, I include miasmatic diseases, such as malaria ; miasmatic- contagious maladies, such as cholera ; and the contagious diseases proper, such as scarlet fever.-^ Climatic diseases include, amongst others, croup, bronchitis, pneumonia, and rheumatism, which are either owing to, or are materially influenced by, meteorological conditions. Organic diseases of the heart, kidneys, and nervous system, which are not, as a rule, caused by infection, and are not materially ^ It seems to be necessary to define more precisely the sense in which I employ these tenns : — The terms miasm and malaria are not used in their etymological significance. By miasm is to be understood an infectious principle, whether organised or toxic in its nature, developing in, and derived from, the soil or other local surroundings of man, — even although the disease caused by such infectious principle may be communicable from man to man by inoculation. Recent experiments seem to show that malarial fever is capable of being thus communicated, but it is not the less a miasmatic disease in the sense which we have defined. By malaria, I mean the hitlierto undiscovered cause of intermittent fever and of the other forms of fever and constitutional disturbance due to the same infection. Malaria is a typical miasmatic disease ; but there are other miasms besides malaria, and mias- matic fevers other than those of malarious origin. A miasmatic-contagious disease is one due to an infectious principle which is derived from the body of a person or animal sufi"ering from it, but which is capable, not only of maintaining itself for a time, but also of developing or multiplying in the soil, water, food, or other substrata. This does not exclude the possibility of the more or less direct transference of the infective principle from the sick to the healthy. The infective agents of the class of true contagious diseases may adhere to clothes, walls, furniture, soil, or articles of food, but are not supposed to undergo any change, or even to multiply outside the body. It may, however, be ultimately proved that some of those diseases, which are at xjresent regarded as contagious, are really miasmatic- contagious maladies. X INTEODUCTIOK influenced by soil and climate, do not come within the scope of this work, and consequently are noticed only when their exceptional prevalence in a particular country or locality appears to be the result of infective processes, or of climate ; as, for example, in the instance of British Guiana, where the altogether unusual prevalence of chronic kidney disease is supposed to be the result of the malarial infection. Endemic malarial fever, in its various forms and types, and the extent to which its prevalence and type is affected by temperature, rainfall, inundations, marshes, subsoil humidity, disturbance of the soil, and other circumstances, has been treated in detail in connection with the pathology of Italy, Algeria, India, Africa, the United States, and other malarious countries. Charts illustrating the characters which malarial fevers assume in different countries have been introduced. Epidemic malaria has also received considerable attention. The history of particular epidemic outbreaks in Cyprus, India, Java, Madagascar, Mauritius, the United States, and Brazil, have been narrated somewhat fully. Eock fever, mountain fever, river fever, and other anomalous forms of pyrexia, have been described under the pathology of the countries in which they occur. Typhoid fever, in its miasmatic and miasmatic-contagious forms, as seen in Europe, India, the Cape, the United States, and Brazil, has received special attention. The principal facts relating to cholera are considered in connection with its occurrence in India, and those relating to yellow fever under Cuba. The forms assumed by syphilis in certain countries have been described in the con- cluding chapter. The distribution of pneumonia and phthisis has been investigated, with reference to their causation, in the chapter on the United States, and that of dysentery under East Africa. The various forms of influenza — their relation to one another, and the chief features of the epidemic disease, have been discussed in the chapter treating of the pathology of Brazil. A short account of the principal maladies of the aborigines of Australia, the Maories, the now extinct Tasmanians, and the American Indians, has been added to the chapters on the pathology of their respective countries. The primary point in the study of the geographical distribution of diseases is to ascertain their prevalence — actual or relative — in the different areas which come under review. To determine the actual prevalence of any given disease over an extensive area, with any approach to scientific accuracy, is obviously, under present conditions, impossible. The utmost that can be attained is an INTRODUCTION. xi approximate estimate of the relative prevalence of diseases in different countries. Fortunately such a knowledge as is attainable in regard to most countries is not only full of interest to the student, but of vast practical importance to the statesman, the army medical officer, and the sanitarian. The means of ascertaining the prevalence of diseases in a given country or district are direct or indirect. The direct method, which gives the number of cases of each of the more important maladies occurring monthly and yearly within a given area, is undoubtedly the best. In Sweden and Norway, the cases of disease which come under the cognisance of the district medical officers are regularly reported to the State authorities, who publish annual reports, from which the varying frequency of each disease in different localities and seasons can be readily ascertained. This method has the great advantage of enabling us to judge of the prevalence and distribution of those diseases which are seldom fatal. The indirect methods of arriving at a knowledge of the relative prevalence of diseases in different countries are — 1. The proportion of deaths from a given disease to a unit of the population. 2. The proportion of deaths from a given disease to the deaths from all causes within a certain area. 3. The ratio which each disease bears to the total treated in hospitals. 4. The reports of physicians who have resided in, or of travellers who have visited, the less civilised countries, as to the diseases they have observed to prevail amongst the natives. The first of these indirect methods appears to me to be the best, wherever the registration of the medically certified causes of death is efficiently carried out, and when the population is accurately known ; and it has been this basis for estimating the fatality, and, indirectly, the prevalence of disease, that I have adopted wherever it has been possible to do so. Many authorities, however, consider that the proportion which the deaths from a given disease bears to the total mortality furnishes the most reliable measure for estimating its frequency. In all cases it is desirable to replace vague expressions, such as " rare," " common," and " very common," by numerical ratios ; but it is no less true that a general statement by a physician who has resided for some years in a country, and who has had adequate opportunities for observing the prevailing diseases, will often give a more faithful idea of the pathology of a country than that which is derived from loosely-collected statistical data. As we are most familiar with the frequency and fatality of diseases in England, I have, in many instances, given the mortality of diseases in England XU INTEODUCTION. as a measure of comparison wliile treating of the pathology of other countries. All the methods which we have enumerated for determining the prevalence of diseases in different countries, impose upon us a politico-geographical treatment of the subject; for it is only for political divisions that we have the necessary basis of population and tables of mortality. Some writers on the geographical distribution of diseases have described the pathology of the various regions according to climates defined by isothermal lines, such as the polar, cold, temperate, warm, and torrid climatic zones. Although this arrange- ment looks well, it has the great practical disadvantage of cutting up States, such as Norway, into two divisions, which have to be considered separately, and without regard to the civil divisions for which alone all returns are made. I have preferred to accept the usual division of the world into continents, and the continents into the existing kingdoms and States ; and then by the grouping of the States into divisions, from north to south, the different climates come into consideration pretty much in their natural order. The sources from which I have drawn my information have been the official returns of the statistical departments wherever these have been attainable. These returns have formed the basis of the accounts given of the pathology of ISTorway, Sweden, Germany, Austria, Switzerland, Holland, the British Isles, France, Spain, Italy, India, the British Colonies generally, and the United States. For the Indian Archipelago, Senegal, and Tonkin, I have had to depend, to a large extent, on the admirable reports appearing from time to time in the pages of the Archives de vUdicine navale. For Borneo, Singapore, Ceylon, Cyprus, Persia, Gibraltar, the "West Coast of Africa, the Congo Free State, and some other places, I have been favoured with special reports by the medical authorities, or by medical men on the spot. The information obtained from these sources has been supplemented by that derived from medical periodicals and publications. The frequent references made to the works of Hirscli and Lombard show, although inadequately, to what extent I have availed myself of their labours. The Handhuch der historisch- geographischen Pailiologie is a monument of scholarly research, to which every student is indebted. From this the dates of outbreak, and the progress of the epidemics of cholera and influenza in Europe, and the distribution of goitre and leprosy generally, have been mainly derived. Lombard's great work, TraiU dc Climatologie INTRODUCTION. xiii M4dicale, has been specially consulted in reference to the pathology of Switzerland, France, and Eussia, No one can be more sensible than I am how incomplete are the accounts I have been able to furnish of the pathology of several important regions. In respect to some of these, the data for a fuller treatment of the subject are absolutely wanting ; in other instances, documents doubtless exist, to which I have not had access, which would have enabled me to fill up many of the existing gaps in the information I have been able to give. Errors, too, notwithstanding all the care I have taken to avoid them, must have crept into a work which presents such a mass of statistics ; but I am sanguine enough to hope that these are neither numerous nor important. London, January 1892. GEOGRAPHICAL PATHOLOGY. EUROPE. ♦ DIVISION I. NORTHERN EUROPE. GEOGRAPHICAL PATHOLOGY. CHAPTER I. ICELAND AND THE FAEOE ISLANDS. Geogeaphy. — Iceland is situated in the North Atlantic Ocean, between 63° 23' and 66° 33' N. lat, and between 13° 22' and 24° 15' W. long. Its area is estimated at 39,207 square miles, with a population, in 1888, of 69,224. The coasts are intersected by numerous firths or fiords. The interior consists of a table-land, having an average height of 2000 feet, sloping down towards the north and south. This table-land is covered with sand and lava, broken by high and extensive ice-hills, known as jokull, which attain their highest elevation in the south- east, where the great Vatna Jokull ice-field is estimated to cover an area of 4000 square miles. The highest peak in the island, the Oerafa Jokull, attains an elevation of 6466 feet. Numerous active volcanoes and hot springs or geysers are scattered over the central area. The largest lake, only recently discovered by Thoroddsen, named Langisjor, 30 to 40 miles in length, lies in the south-eastern part of the island. The most extensive plain is that which stretches westward from the Eyafjalla Jokull to the mountain chain terminating in the Cape of Eeykjanes, and backed on the north by several isolated moun- tains, amongst which stands out in bold relief the snow-clad peak of Hecla, which rises to a height of 5102 feet above the sea-level. This plain is covered with rich grass, and, like many of the smaller plains and valleys, it contains extensive marshes. The country is entirely pastoral. Only a few level tracts along the shore and in the more sheltered valleys are capable of cultiva- tion. The whole cultivated area does not, in fact, exceed 300 acres. 4 NOKTHEEN EUEOPE. The grass lands of the coasts and plains support some 30,000 horses, 20,000 head of oxen, and above half a million of sheep, upon which, and on their fisheries, the inhabitants entirely depend. The population live on isolated farms ; the villages are few, and the capital, Eeykjavik, has only a population of from 3000 to 4000 souls. Its site is low, surrounded by hills, with a lake to the south, which occasions unhealthy emanations. Climatology. — The climate of Iceland is less severe than might be expected from the high latitude of the island. The winters are long, but in the south they are comparatively mild. The summer heat, however, is insufficient to ripen cereals. The atmosphere is clear and pure, mountains being visible at a distance of 100 miles. The mean annual temperature of Eeykjavik is 39°"2 F. ; that of Akureyri, in the north, is 32° F. ; but the mean temperature of different years, and of individual months, varies considerably. The average rainfall of Eeykjavik (including snow) is about 29 inches, the heaviest rains falling in autumn and winter. The monthly distribution per cent, of the rainfall, and the mean monthly temperature at the capital, are as follows : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. "fSai?^°'}lO 10 9 6 6 5 7 7 9 11 9 11 Monthly m^eantem--t 29-8 28-4 30-0 36-5 45-0 51-S 56-2 51-0 46-6 36-8; 30-5 28-0' Small as Iceland is, an exceptional interest attaches to its pathology. From its position on the confines of the Arctic Circle,, it affords an illustration of the diseases prevailing in high latitudes. Its remoteness and limited intercourse with the outer world enable us to trace the introduction and progress of epidemic diseases more closely than is possible in the case of countries less isolated ; while the records of epidemic diseases in the past have been more care- fully preserved than in many countries in Western and Southern Europe. Vital Statistics. — The birth-rate of Iceland in recent years is given at 33 per 1000, and the death-rate at 24 per 1000. The proportion of deaths varies greatly in different years, according to the presence or absence of epidemic disorders. Thus, during the ten years 1854-03, the mean death-rate was 32-8 per 1000, the lowest being 23 per 1000 in 1856, and the highest 50 per 1000 in 1860. The deaths under one year were in the ratio of 27'3 per cent, of the births. - A remarkable feature in the pathology of Iceland, as pointed out by Lombard, is the peculiar seasonal distribution of the mortality ICELAND AND THE FAROE ISLANDS. 5 Unlike most cold countries, in whicli the greatest mortality occurs during the cold season, in Iceland it is the autumn season in which the deaths are in excess. The following is the distribution per cent, of the deaths for the four seasons (1845-54) : — Spring, Summer. Autumn. Winter. 20-24 19-38 33-31 27-07 Pathology. — Ilalaria. — Paroxysmal fevers are not endemic in Iceland. Torteinson never met with any, except in the case of foreign sailors or travellers. The numerous marshes which are met with throughout the inhabited districts are either naturally in- nocuous, or, as is more probable, they fail to develop fever on account of the low mean summer temperature, which at Eeykjavik does not, on an average, exceed 53° F. Although the marshes of Iceland do not give rise to paroxysmal fever, Hjaltelin is of opinion that they adversely affect the health of the population ; those dis- tricts, such as Pingvalla, where there are no bogs, being notably healthier than those where opposite conditions prevail.^ Enteric Fever, known as Landfarsot, is endemic in Iceland ; and it not unfrequently assumes an epidemic form. A mixed outbreak of typhoid and typhus fevers devastated the island from 1857 to 1860. An epidemy of typhoid fever occurred in 1871, causing a consider- able mortality. This outbreak began in the middle of July, during an unusually hot, dry, and calm summer ; the temperature of the summer having been about 8° F. above the average. " Carbuncle- like, black-crusted boils " were observed in some of the cases during this epidemy .2 Typhus Fever, as we have seen, occurs in an epidemic form. These epidemics are by no means of rare occurrence, but whether the disease is endemic in the island, or is introduced from without on each occasion, is unknown. Plague in former times was no stranger in Iceland. The date of the first outbreak was 1402. Pielapsing Fever has never been observed in Iceland, and Fpidemic Cerebro-sijinal Meningitis broke out only once, viz. in the winter of 1846. Dijphtheria appeared for the first time in Iceland in 1856, breaking out in Eeykjavik and the surrounding parishes, where the infection maintained itself during the succeeding year. In 1858, the disease began to spread to the northern and western parts of the country. It then appears to have died out ; but it was intro- ^ Hjaltelin, Edin. Med. Journcd, May 1866. 2 Hjaltelin, " Pythogeuic Fever," Edin. Med. Journcd, February 1872. 6 NORTHEKN EUEOPE. duced anew in 1860, and continued to maintain itself until 1864. If we consider that the disease appeared at Eeykjavik, which is practically the only spot in communication with Europe, and that it occurred at a time when the disease was not only widely diffused throughout Scandinavia, but when it was exhibiting a tendency to epidemic extension, it will appear probable that it was introduced from the continent of Europe. The second outbreak, in 1860, is supposed to have been caused by a reintroduction of the infection from the Faroe Islands. Croiqj, according to all accounts, is of common occurrence in Iceland. Acute affections of the throat, including croup, account for 3 2 per 1000 of the total mortality. Allowing that this figure includes deaths from diphtheria as well as croup, it is evident that anginal affections are of exceptional gravity in Iceland. In 1884, diphtheria, croup, laryngitis, and other diseases of the larynx and trachea, caused 21*9 per 1000 of the deaths from all causes in England. It will thus be seen that this class of diseases is much more fatal in Iceland than in England. Asiatic Cholera. — Hjaltelin, in treating of the epidemic fever of 1860, says: "Asiatic cholera made its appearance, but happily it was sporadic, and did not spread by contagion." ^ As cholera was at that time prevalent in the Baltic provinces of Eussia and in other parts of ISTorthern Europe, and had been epidemic during the previous year to a small extent at one point in Denmark (Aarhus), a country which is in constant communication with Iceland, and as a limited epidemy had broken out in 1859 as far north as Wick in Scotland, we cannot summarily reject as impossible the opinion of Hjaltelin, that the cases observed by him in Eeykjavik were really cases of Asiatic cholera. On the other hand, its occurrence in a sporadic form only, its limited spread, and the small mortality it occasioned, incline us to the opinion that the outbreak observed by this phy- sician was caused by cholera nostras, rather than to an importation of the Asiatic pestilence. Dysentery is occasionally met with in a sporadic form, but such cases are, upon the whole, rare, and of no great gravity. The ratio of deaths to the cases treated by Finsen was 6 '7 per cent. As an epidemic malady, dysentery plays a somewhat more important role in the pathology of Iceland. Epidemic outbreaks of this disease were more numerous, in past centuries than they are at the present day, and were in many instances to be ascribed to famine, or to the use of food of bad Quality. Malignant dysentery prevailed in an epidemic form in 1860 along with typhus. These two diseases ^ Edin. Med. Journal, September 1862. ICELAND AND THE FAROE ISLANDS. 7 have been frequently observed as associated epidemies, especially in times of famine, as, for example, in Ireland in 1817, and again in 1824—26. Scarcity, however, was not the underlying cause of their simultaneous outbreak in Iceland in 1860. In 1855 a limited outbreak was observed " in consequence of the use of bad food, but disappeared when a better quality was brought in '■' (Hirsch). Diarrkcea is comparatively rare in Iceland, a fact which may be explained by the low summer temperature of the island. Apart from the epidemic outbreaks of dysentery to which we have referred, abdominal diseases, as a class, are not prevalent in the island, form- ing, according to Schleisner, no more than 12 per 1000 of the total deaths. Infiuenza. — It is doubtful whether true influenza ever occurs in localised and independent epidemies, or whether each outbreak in any particular country or locality is not due to an extension to that locality of an epidemic influence affecting large tracts of the earth's surface. In Iceland, epidemic catarrhs are certainly not uncommon; and it is diffi- cult, in many instances, to distinguish between the local influenzoid outbreaks and the extension to Iceland of epidemic or pandemic influenzas prevailing in Europe or America. These local epidemic catarrhs, so frequent not only in Iceland, but in Greenland and other hyperborean regions, have been regarded by some as identical with infiuenza ; by others, as a specific affection closely allied to that disease, and distinguished as influenza ardica ; while others, again, look upon them as outbreaks of simple catarrh arising from the climatic conditions peculiar to cold regions, and owing their epidemic prevalence at certain seasons to meteorological causes. It would be foreign to my purpose to enter into any discussion of these questions, which, however, should be kept in view in con- sidering the facts relating to influenza and allied disorders as met with in Iceland and elsewhere. The earlier epidemies of influenza recorded by Hjaltelin^ as occur- ring in Iceland are those of 1627, 1669,1705, 1719, 1730, 1735, 1736, and 1776. Of these, the first and the four last were co- incident with epidemies of influenza in Europe or America, while those of 1669, 1705, and 1719 were, so far as can be ascertained, of local origin. As regards the outbreak of 1719, ic is stated to have been confined to the north of the island, and may thus be regarded as one of epidemic catarrh. During the present century, the epidemies up to 1866 occurred in the following years:— 1804, 1816, 1825, 1834, 1839, 1843, 1 Edin. Med. Journal, February 1863. O NORTHERN EUROPE. 1855, 1856, 1862, and 1866. Most of these coincided with, or followed closely in the wake of, extensive epidemies of influenza in Northern Europe or in North America. The epidemy of 1804 followed closely on an outbreak in Northern Europe ; those of 1816 and 1825 accompanied or followed the epidemic prevalence of influenza in North America; that of 1843 appeared in Iceland at the time it was prevalent both in Northern Europe and in North America; and that of 1855 coincided with a wide diffusion of the disease in Northern Europe. Some, if not all, of the other outbreaks may also have been extensions to Iceland of pandemies previously prevailing elsewhere, although their connection in point of time is not so close. The great pandemy of 1831-33 had run its course, and had pretty well died out in the north of Europe, by the middle of 1833, although it still lingered on to the end of the year in the south of Europe. In 1834, when Iceland was attacked, Europe and North America were alike free from the disease. In 1838 or 1839 — for the date is variously given, and perhaps both years suffered — the epidemy of 1836-37 had come to an end. The Earoe Islands had been invaded in 1837, without the extension of the disease to Iceland. In 1838, when the disease appears to have broken out in Iceland, influenza had been absent from Europe for about twelve months. In 1856, 1862, and 1866, influenza was not at all widely diffused either in Europe or in America ; and some of these out- breaks may have been of local origin. From what we have said, it would appear that Iceland may be invaded either during the prevalence of epidemic influenza in Europe, or at the close of such epidemy ; or, on the other hand, that quite a year or more may elapse after the disease has disappeared from the continent of Europe before Iceland is invaded. Some epidemies in Iceland cannot be connected with general outbreaks, while a con- siderable number of severe and widely diffused epidemies affecting Europe, such as those of 1846-48, never reacli Iceland. Epidemies of influenza proper have frequently been observed to start from Eeykjavik, as was the case in 1862, taking from six weeks to two months to overrun the whole island. The general rule is, that epidemies proceed from south to north ; but to this rule there are exceptions. In 1856 the epidemy took an opposite course, advancing from north to south ; but it is doubtful whether this was true influenza, or an outbreak of epidemic catarrh. Influenza has often been observed to make its appearance im- mediately after the arrival of a foreign vessel, altliough the passengers and crew of such vessel may not have been suffering from the ICELAND AND THE FAROE ISLANDS. 9 disease, and although influenza may not have been raging in the port or country from which it sailed. This remarkable coincidence, so often noticed and so well attested, between the arrival of foreign vessels free from the disease and outbreaks of influenza and influenzoid diseases, has also been observed in other countries, such as the Faroe Islands, St. Kilda, and in some of the South Sea Islands ; while in Brazil, a fatal disease allied to influenza has repeatedly caused destruction to Indian tribes, who ascribe its appearance amongst them to inter- course with strangers who are not themselves affected. The outbreak of influenza in Iceland on the arrival of foreign vessels can only be explained on the assumption that the specific cause of the disease is transportable ; but it does not follow that commercial intercourse is the only means by which the malady is diffused. Another remarkable circumstance in connection with the out- breaks of influenza in Iceland, is the immunity from the disease enjoyed by strangers and recent arrivals, while very few of the natives escape taking the disease. The mortality varies greatly in different epidemics. The out- break of 1855 was mild, while that of 1862 was one of the most malignant that had ever visited the island. It has been remarked that those outbreaks that coincide with epidemics on the Continent are more malignant than those that are of local origin. Highly characteristic of this disease is the suddenness with which it attacks large numbers of people at the same time. This was well seen in the case of the epidemy of 1862 in Iceland. On the 10th of May, which was a Saturday, an unusual mist settled down on the town of Eeykjavik, but there was then no sign of the disease. On the following day (Sunday), the disease had already affected many of the inhabitants. Hjaltelin quaintly remarks that the worshippers " made a very bad noise during the holy service." On Monday large numbers were confined to bed. Wliooping Cough is not endemic in Iceland, and, what is still more remarkable, it has never been observed to spread even when introduced into the country. Smallpox was introduced into Iceland from Denmark, for the first time, in 1306, and all the later outbreaks of the disease, which before the introduction of vaccination were both numerous and severe, were traced to fresh importations from the Continent. At the present day the disease is seldom seen. This immunity is partly owing to the efficiency with which vaccination is carried out, and partly to the prompt isolation of any case that occurs. 10 NOETHERN EUROPE. Measles have only appeared four times in the history of Iceland, viz. in 1664, 1694, 1846, and 1868, and on each occasion it has been traced to importation. Scarlet Fever only occurs at rare intervals, when introduced from without. It will thus be seen that none of the eruptive fevers are endemic in the island. Fneumonia, Pleurisy, and Bronchitis, as sporadic diseases, are not of more frequent occurrence in Iceland than in many countries in the south of Europe. Phthisis is seldom met with in those born in the island. E;pidemic Pneumonia, known in Iceland as Taksott, is by no means uncommon. It generally occurs during severe winters and cold springs. In the winter of 1862, pneumonia assumed an epidemic character in the north of the island ; and, following upon the outbreak of influenza which had prevailed in the summer, it caused a high mortality. In some parishes the deaths from this disease were in the proportion of 15 per 1000 of the population."^ Hepatitis is rarely seen in Iceland. Eydaticl disease of the liver, due to the introduction into the system of the eggs of the Taenia Echinococcus infesting the dog, is endemic in the island. The proportion of the population infested by this parasite has been variously reckoned as from one-seventh to one-thirtieth. Taking even the lowest estimate, it will be seen that the disease is excessively prevalent. As this parasite runs through its stages of development alternately in the sheep and dog, there is no difficulty in understanding the reason of its prevalence. Sheep, as we have seen, are reared to a large extent in the island, and dogs, according to Lombard, are in the proportion of one to three or five of the inhabitants ; while in France there is one dog to twenty-two, and in England one to fifty of the population. Females suffer from hydatids to a much greater degree than males. Diseases of the Spleen are not of frequent occurrence in Iceland. Trismus Neonatorum was excessively frequent during the earlier decades of this century, when it was estimated to cause from one- third to one-fourth of the total mortality. With improved hygiene, the prevalence of the disease has steadily diminished in Iceland, although it is still common on some of the smaller islands off the coast. Cancer, although not unknown, is much less frequent in Iceland than on the continent of Europe generally. The deaths caused by ^ Edin. Med. Journal, April 1864. THE FAROE GROUP. 11 cancer are estimated by Hirscli to be in the proportion of 0*07 per 10,000 living. Rheumatic affections are amongst the more common diseases of the island, and Rheumatic Fever is far from rare. Scrofula, so far as can be gathered from the conflicting reports of different authors, is of moderately frequent occurrence. Syi^hilis is excessively rare and of a mild type. This is to be ascribed to the orderly and moral lives of the Icelanders, rather than to any peculiarity of climate. Leprosy was formerly very widely diffused throughout the population, but it has been gradually and steadily diminishing in frequency since the middle of the last century. In 1768 the proportion of lepers was estimated at 73 per 10,000; in 1838 the ratio had fallen to 23"3 ; and in 1869 it stood at 15'7 per 10,000 of the inhabitants. THE FAROE GROUP. Geography. — The Faroe or "Sheep Islands," twenty- two in number, of which seventeen are inhabited, lie between 61° 25' and 62° 25' X. lat. Their population in 1880 was 11,220. They con- sist of volcanic rocks, mainly basalt, forming precipitous cliffs towards the sea, from 1000 to 2300 feet in height, rising inland into flat-topped mountains, which attain a maximum elevation of 2900 feet in Slattaretind in Ostero. The most important island of the group is Stromo, on which is situated the capital, Thorshaven, with a population of 984. The islands of Ostero, Yaago, and Sando are grouped closely round the main island, while the island of Sudero lies isolated at a distance of 12 or 13 miles to the south of the others. Climatology. — The mean annual temperature is 4 5 "'5 F. ; that of spring, 44°'2 F. ; of summer, 54° F. ; of autumn, 46°-8 F. ; and of winter, 40°"1 F. July, the warmest month, has a temperature of 57°*1 F. The temperature is thus mild and equable, but the cHmate is humid, misty, and rainy. The number of rainy days, on an average, is 160. Pathology. — Malaria. — Paroxysmal fevers are quite unknown in this group. Enteric Fever is endemic, and occasionally becomes epidemic, causing a considerable number of deaths. Typhus has never been met with in this group ; nor does it appear that Relaps- ing Fever or Epidemic Cerehro-spinal Meningitis has been observed. Erysipelas occurs not unfrequently in an epidemic form in the FarcJe Islands, as it does in many northern countries. 12 NORTHERN EUROPE. Diphtheria appeared in these islands for the first time, so far as is known, in 1860; but I have met with no later accounts of its presence in the group. Croup is said to be of rare occurrence. Asiatic Cholera has never reached the Faroe Islands. Dysentery is not endemic, but sporadic cases occasionally occur. Diarrhoea is of moderate frequency, and cases of Cholera Nostras are met with in the summer season. Sriiallpox has been only twice observed in these islands — first in 1651, and again in 1705. On both occasions it was introduced from Denmark, and in each case it proved very destructive. Measles are not endemic in the Faroe group, where, up to the present time, they have only been four times observed, viz. in 1781, 1846, 1862, and finally in 1875. On all of these occasions the disease was traced to importation. Searlet Fever has apparently never appeared in these islands. We may conclude, therefore, that none of the eruptive fevers are endemic in the Faroe Islands, which are thus free from a whole class of diseases that prove very destructive to infant life over wide regions of the globe. Influenza. — The Faroe Islands not only frequently suffer from influenza when it is raging on the Continent, but local influenzoid epidemics are of frequent occurrence in spring and summer. According to Panum,^ these outbreaks occur in the spring of the year, two or three days after the arrival of the first trading vessel from Denmark. The first to be affected are the men from the shore whose duty takes them on board ; the disease then spreads in the town of Thorshaven, and thence over the island of Stromo. The island of Sudero, which is situated at a distance from the rest of the group, often escapes the malady when the other islands close to Stromo are affected. The strangers themselves, who are supposed to bring the disease, are not attacked during these epidemics. That the outbreak does not simply coincide with the arrival of a vessel from abroad, is shown by the fact that the arrival of the first trading vessel happens at various times, sometimes as early as March, at other times as late as May ; but the disease breaks out with great uniformity just after its arrival, whatever may be the date. AVhether the cause of the disease attaches itself to the persons on board, or to the vessel itself and its cargo, it is impossible to say, but it seems clear that the cause of these epidemics is brought to the islands by the vessels. This would not be at all so remarkable, were it not for the fact that neither the men on board the ship nor the inhabitants of the port from which it sailed exhibit any signs of the disease. ^ BiUioth. fur Lcvgtr, 1847, v. i. 312, quoted by llirscli. THE FAROE GROUP. 13 Pneumonia is only moderately prevalent, and Bronchitis, as a sporadic disease, although of common occurrence, is not marked by any special severity. Phthisis is extremely rare. Hydatids, so prevalent in Iceland, are not met with in the Faroe Islands. The hosts (sheep and dogs) are there in ample numbers, but the guest, the Ttenia Echiuococcus, is wanting. Diseases of the livci' and spleen are rare. Trismus Neonatorum is not of frequent occurrence. Cancer seems to be quite unknown in the group. Panum saw no case of it during his residence in these islands, nor could he hear of any. Here, then, we have a country from which this terrible scourge of humanity is absent. Rheumatism and Rheumatic Fever are of frequent occurrence. Scrofula is scarcely ever seen among the natives, although it is occasionally observed amongst the children of Danish residents. Chlorosis is rather common. Syphilis is said by Panum to have been quite imknown in the Faroe Islands until the year 1844; but this is, at least, doubtful, as Manicus, in 1824,-^ appears to have met with the disease in its different forms. At the present day it is certainly very seldom seen. Leprosy died out in this group in the middle of the eighteenth century. Hysterical diseases and Insanity appear to be unusually common among the islanders. ^ Biblioth. filr Loeger, 1824, v. i. CHAPTEE II. NORWAY. Geography. — ISTorway, which forms the western division of the Scandinavian peninsula, stretches from 57° 58' to 71° 10' N. lat. It has an area of 120,079 square miles, with a population (in 1887) of 1,967,000 inhabitants. It is washed on the north by the Arctic Ocean ; on the west by the Atlantic ; on the south by the Skager- rack, and is divided from Sweden on the east by the lofty ranges of the Kiolen Mountains and their southern prolongations. The coast-line is fringed with islands, and is deeply indented with fiords. The Hardanger Fiord runs nearly a hundred miles inland, sending out numerous arms to the right and left. The interior is mountainous, the wider valleys and plains of the south being the only districts capable of cultivation. The country is watered by numerous rivers, the most important of which is the Glommen, which falls into Christiania Fiord, and has a length of 3 5 miles, draining a basin of 6657 square miles. The lakes are very numerous, but none of them are of any great size ; the largest being the Mjosen, situated to the north of Christiania. A very consider- able area is still covered with swamps and morasses ; but much has been done of late years for the reclaiming of marsh lands. The capital is Christiania, with a population (in 1887) of 133,300 inhabitants. Bergen, on the west coast, is the second city of the kingdom, with a population of 47,000 inhabitants. The only other towns of importance are Trondhjem (Drontheim), the ancient capital (pop. 23,753); Stavanger (pop. 22,634), and Dram- men (pop. 19,391). The people are chiefly engaged in agriculture and fishing. The bulk of the inhabitants are thus to be found in the rural districts. The population of the towns and villages numbered (in 1887) 435,700, while that of the country districts was 1,531,300. The open-air occupations of the inhabitants tell favourably upon the health of the country. The country is divided into six " stifts " or diocesal provinces, and these again into " anits " or counties, twenty in number. NORWAY. 15 The following are the "stifts" and their population in 188V :- Christiania, Hamar, . C'hristiansaud, 555.100 227,100 366,500 Bergen, . Trondhjem, Tromso, . 310,600 283,500 224,400 Climatology. — The temperature of Norway is materially affected by the extent to which the Gulf Stream makes its influence felt. This will be seen by the subjoined table, which gives the mean temperature of the seasons in five localities representing the west coast-line in three parallels, and the south-east region as represented by the capital : — Temperature of the Seasons in Different Eegions of Norway. Locality. Spring. Summer. Autumn. Winter. Mean of Year. Nortli Cape, lat. 71° 10', . . Drontheim, lat. 65° 26', . . Bergen, lat. 60° 24', . . . Christiania, lat. 59° 55', . . 29-5 35-2 44-7 38-5 43-5 61-0 59-0 60-5 31°5 40-22 46-4 42-0 23°-5 23-0 36-0 25-5 32-0 39-85 46-5 41-6 Christiania^ although situated so much to the south of Bergen,has a lower mean annual temperature, on account of the latter being more directly under the influence of the Gulf Stream. The winter season especially is much colder in Christiania than in districts situated considerably farther north. There are, indeed, only two degrees of difference between the winter temperature of Christiania and that of North Cape, lying within the Arctic Circle. The climate of the inland and elevated districts is much more extreme than that along the coasts. But other conditions, dependent on latitude, very materially influence the climate. The northern winter is character- ised by its long night, and the northern summer by its unsetting sun. The longest day in the south is about eighteen hours ; in the extreme north it is nearly three months ; the winter night within the Arctic Circle lasts about the same length of time. The annual rainfall along the west coast is heavy; at Bergen it averages from 80 to 90 inches, but this is one of the wettest districts of the country. The average precipitation along the west coast, between parallels 58° to 69°, maybe placed at 45 inches; on the east coast and inland it is less than half of this amount. The following, according to Hann,^ is the monthly distribution per cent, of the rainfall for the east and west coasts : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec West Coast, 5S°-69°, 9 8 7 6 5 6 7 8 12 12 10 10 East Coast and in-) ., land, 59°-63°, . j" ' 8 6 4 6 9 12 11 12 10 8 7 Hann, Handbuch der Klimatologie , Stuttgart 1883. lb IS^OETHEEN EUROPE. Vital Statistics. — N"o country can show a better record than Norway in respect to health. The death-rate for the sixteen years ending 1866 was only 16 "8. In 1887 the death-rate for the kingdom was 16*10 per 1000; in the town districts it was 19*27, and in the country it was as low as 15*20 per 1000. The mean annual death-rate of Christiania (1880—87) was 19*9 per 1000. The death-rate does not increase as we advance towards the north. On the contrary, we find that the most northerly province, Tromso, has a lower mortality than that of the two southern provinces of Christiania and Christiansand ; while the inland province of Hamar, with its rigorous climate, has the lowest death-rate of any part of the kingdom. The following table gives the average death-rate of the six "stifts" for the three years 1885-87 : — Cliristiania, . 18-0 Bergen, . 15-3 Hamar, . 14-58 Trondlijeni, . 15-45 Christiansand, . 16-6 Tromso, . 15*4 The quarterly distribution per cent, of the mortality is thus given by Lombard : ^ — Spring. Summer. Autumn. Winter. 28-79 21-88 22-33 27-0 The marriage-rate for the sixteen years ending 1886 was 14*01 ; the birth-rate for the same period, 30*8. It will thus be seen that the increase of the population in Norway is rapid, or would be so, were it not for the emigration which relieves the country of its surplus population. Pathology. — Malarial Fever is unknown in the northern part of Norway ; the cases occasionally observed in Bergen and to the north are probably imported. The number of cases reported in 1886 was 109, and in 1887 there were 93. In the latter year there were no deaths from ague. The number of cases reported from each province in 1887 was as follows : — . 3 3 1 It is only in a few marshy districts in the south of the country, such as Sarpsborg, in Smaalenes Amt ; Tonsberg, in Jarlsberg ; and East and West Nedenses, that the disease can be said to be endemic ; and in these localities the cases that occur are usually mild. Norway has not been exempt from epidemics of malaria. That of 1828-32 visited Christiania, and extended as far north as Bergen. This, so far as I know, is the farthest limit on the north to which the disease in its epidemic form has extended. Enteric Fever prevails all over the country. It was estimated 1 Tra'itide climat. m6d., Paris 1877. Cliristiania, . 37 Bergen, . Hamar, . . 6 Trondhjem, Christiansand, . 43 Tromso, . Christiania, . . 0-83 Bergen, Cliristiansand, . 0-57 Trondlijem Hamar (inland), . . 0-23 Tromso, NORWAY. 1 7 by Broch to affect o per 1000 of the iuhabitauts annually. This was some years ago, but during the three years 1885-87 the cases officially recorded averaged 0-83 per 1000 of the population, and formed 9 per cent, of the total deaths from all known causes. As the deaths from typhoid fever form 1*2 per cent, of the total mortality in England, we conclude that, at the present time, enteric fever is less fatal in Norway than in England. The following is the ratio of reported cases per 1000 of the population for the three years 1885-87 in the different " stifts" : — . 1-2 . 0-87 . 1-23 It will be remarked that, so far as these figures go, enteric fever is more common in the north than in the south, while the inland province of Hamar contrasts favourably with the other provinces. The monthly prevalence of enteric fever will be seen from the following table, which gives the monthly distribution per cent, of 3138 cases observed in 1886 and 1887: — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 11-3 7-3 S-9 S--1 5-S 6-1 VO S'l 9-5 10-5 S7 S'-t The quarterly distribution was as follows : — First Quarter. Second Quarter. Thii-d Quarter. Fourtli Quarter. 27-5 20-3 24-6 27-6 The first and fourth quarters are those during which enteric fever is most prevalent; the second quarter is that in which the fewest cases occur. The disease is more common in the country than in the town districts. Tyyhus Fever is not endemic in Norway. It would appear that it was introduced into the country, and prevailed epidemically more than once during the seventeenth century. As to the occurrence of the disease in recent times, Hirsch says there is no reliable information going farther back than 1845. Erom this date the country was quite free from the disease up to 1864, when it was introduced from Sweden and Einland. Erom that time it would appear never to have entirely died out, for a few cases continue to be reported annually, especially from the northern provinces of Trondhjem and Tromso. Scattered cases occur throughout the year, several months occasionally passing without a single case being seen ; but the most of the cases appear in December or January. Relapsing Fever is not met with at the present day in Norway, although it has more than once been epidemic at Vadsoe during this century. B 18 NORTHERN EUROPE. Epidemic Cerebrospinal Meningitis furnishes a certain number of cases every year. The northern provinces are those in which the disease is most prevalent, and the bulk of the cases occur from March to June. The disease is of most frequent occurrence in the country districts. Diphtheria takes the second or third place amoDg the fatal diseases in Norway, causing (1885-87) 80-8 per 1000, or about one-twelfth of the total mortality. It is slightly more fatal in the country than in the town districts, and attains its maximum preval- ence in the cold months (October to January). Croup is also extremely fatal. One death in 66 is ascribed to croup in Norway, while in England the proportion is one in 112 deaths. It is met with at all seasons; but the cold months of the fourth and first quarters are those in which the disease attains its maximum fatality, and the fewest deaths are recorded in the autumn quarter. Dysentery is of little account as a sporadic disease in Norway. The average mortality (1886-87) is in the ratio of 1-4 per 1000 of the total deaths ; but it is rather noteworthy that the cases are more numerous in the north than in the south, a result which we should not have anticipated. Here is the monthly distribution per cent, of 558 cases observed in 1886 and 1887:— Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. 5-4 9-0 11-2 8-2 3-6 4-8 8-4 10-0 10-13 10-3 11-3 Dysentery was epidemic in the southern districts of Norway from 1808 to 1810, and again from 1859 to 1862. On the latter occasion the disease was almost entirely limited to the districts south of Bergen. Epidemic dysentery, like epidemic malaria, thus appears to spare the northern provinces of Norway. Diarrhcea and Cholera Nostras are only moderately prevalent in Norway, as combined they form only about 4 per cent, of the total mortality, which is somewhat under the English proportion. It is about three times as fatal in the town as in the country districts ; but there is certainly no decrease in the fatality of the disease in the colder regions of the north, if we are to judge from the ratio which the deaths from diarrhoea bore to the total deaths from known causes during the years 1886-87, as exhibited in the following table: — . 2-5 . 2-4 . a-8 As in all countries, so in Norway, we find the disease to be most common during the summer months, and most fatal in very Christian ia, . . 6-3 15ergeii, . Hainar, . . 1-8 Troiidlijcm, Christiaiisand, . . 27 ! Ti'om.su, . NORWAY. 19 warm years. We shall give the monthly distribution of 45,830 cases of acute diarrhcca and cholera nostras observed in 1886—87 : — Jan. Feb. Mar. April. May. Juno. July. Aug. Sept. Oct. Nov. Dec. 6-0 5-9 6-S 7-0 O'o S-4 15-1 13-5 9-9 C-9 7-3 6-1 Asiatic Cholera. — During the first European epidemy, this disease appeared at Drammen, in the autumn of 1832; and in the following year, Christiania and a few localities on the south coast were attacked. In tlie autumn of 1834 the south coast suffered more extensively and severely, and in 1848 and 1850 a few districts on the west and south coasts suffered slightly. In 1853 the pestilence once more broke out at Christiania, and spread not only along the shores of Christiania Fiord, which had been invaded during the pre- vious epidemics, but extended inland for some distance, in the dis- tricts of Buskerud and Bratsberg, carrying off many victims. More limited and less destructive outbreaks occurred at one or two points on Christiania Fiord in 1855; and in 1857 it broke out at Bergen, which is the most northerly point attained by cholera in Norway. Infiuenza. — Norway enjoys no exemption from epidemic influenza, but we hear nothing of the frequent outbreaks of local influenzoid epidemics in spring and summer, which form so important a factor in the pathology of Iceland and the Faroe Islands. Wlwoping Cough is about as frequent and fatal in Norway as it is in England and the west of Europe generally. The south and the extrem.e north suffer alike and equally from the disease. Smaltjjox is only met with to a very limited extent, thanks to the efficiency with which vaccination is carried out. Scarlet Fever is one of the principal causes of death among children in Norway, forming from 3 to 5 per cent, of the total mortality. During the three years 1885—87, the cases officially reported were in the proportion of 5 per 1000 of the population; and the deaths were in the proportion of from 6 to 7 per cent, of the cases treated. The disease appears to be equally prevalent and severe in all the provinces. Measles. — This disease presents no special features as regards frequency, severity, or distribution calling for remark. Phthisis takes the first place among the causes of death in Norway. According to Hirsch, the death-rate of the whole king- dom, for the period 1871-75, was 2*5, and that of Christiania, for the ten years 1866-75, was 3*45 per 1000 living. As the deaths from consumption (1871-80) were in the ratio of 2"12 per 1000 for England and Wales, and of 2*51 for London, it will be seen that phthisis is more fatal in Norway than in England, and in Christiania than in London. Christiania, , . 14-3 Bergen, Hamar, . 13-4 Trondhjem, Cliristiansand, . 22-8 Ti'omso, 20 NORTHERN EUROPE. Tliis conclusion is confirmed by the proportion which deaths from phthisis bear to the total deaths in the two countries. The mean ratio of deaths from consumption to the total mortality for the period 1884-87, was 15'9 per cent, in Norway, while in England the ratio, in 1884, was only 9 '2. The ratio of deaths in the towns districts is 16"9 ; that in the country districts, 15"1. We shall now inquire into the relative prevalence of the disease in different parts of the country, and for this purpose we give the ratio of deaths to the total mortality in the six " stifts " for the four years ending 1887 : — . 13-4 . 16-9 . 13-2 Allowance being made for the influence of the higher death-rate of the capital upon the mortality in Christiania " stift," it appears that the phthisical mortality is pretty equally distributed over the south-east coast (Christiania), the south-east interior (Hamar), the middle Atlantic coast (Bergen), and on the north Atlantic and Arctic Ocean coasts (Tromso). Two provinces, one in the south (Christian- sand) and one on the north-west coast (Trondhjem), stand out as areas of excessive phthisis mortality. This general survey of the distribution of the disease does not appear to point to latitude as the main factor indetermining its prevalence. In order, however, to trace more minutely the areas where consumption attains its maximum and minimum prevalence, it will be necessary to give the percentage of deaths from phthisis to the total medically certified deaths in the Amtcr or smaller divisions of the provinces. We shall give the mean percentages for the four years 1884-87, the districts being arranged geographically: — Inland Districts, South-East. Hedemarken, . . . 15"3 | Christian, . . . . 11*2 South Coast DisTnicTS. Christiania (town), Smaalenenes, Jarlsberg, Nedenfes, ]4-l Akerhus, 13-3 Buskeruds, . 15-4 Bratslierg, . 23-6 Lister and Mandal, 13 -5 1.5-9 17-6 25-0 "West Coast, South of 62°. Stavanger, . . . . 25'4 I South Bergenhus, . . . 14'3 Bergen, . . . . 17"4 | North Bergenhus, . . . 77 West Coast, North of 62°, and Arctic Ocean Coast. Ronisdal, . . . .14-2 Nortli Trondlijeni, . . 14-9 Tromso, . -. . . 13-6 South Trondhjem, . . 18-3 Nordhmds, . . . .14*0 Finmarken, . . . . 11'5 The accompanying sketch map will serve to indicate the relative prevalence of phthisis in the different districts. NORWAY. 2 1 Map showing the Distributiox or Coxsumi'tion in Xuiiw.w. Pkoportiox of Deaths pee. cent, of Total Mortality. 20-25 p.c, ii| 18-20 p.c.,^ 15-18 p.c, <;>.f; 12-15 p. c, '^i^ under 12 p.c, ;';\^; It will be seen that there are two well-defined areas in which phthisis is in excess — one in the south and the other in the north- west. The southern area, comprising the districts of Stavanger, Lister and Mandal, and Xedentes, corresponds to the southern portion of the peninsula. The northern area is limited to the district of South Trondhjem. The areas of lowest mortality are North Bergenhus on the west coast (exclusive of the town), Christian amt, in the south interior, and Finmarken on the shores of the Arctic Ocean. In speaking of the distribution of phthisis in Norway, Homann, as quoted by Lombard, says : " The frequency of phthisis is so much greater as the latitude is southerly, and as the Continental and Baltic 22 NOETHERN EUROPE. climate predominates over the marine and Atlantic climate." This statement is not entirely in harmony with the figures we have given. First as regards latitude, is it the case that the disease increases in frequency in proportion as we advance from north to south ? If we compare the phthisis mortality of Smaalenenes in the south with that of Tromso in the north, we find that the slight difference between the two is in favour of the southern district. Finmarken, within the Arctic Circle, has, it is true, a low mortality, but that of North Bergenhus, situated 1 degrees farther south, is still lower. Nor does it appear that the districts with a Continental or Baltic climate suffer more than those with a marine or Continental climate. The worst phthisis centre is Stavanger, which has a marine and Atlantic climate ; while Smaalenenes with a Baltic climate, and Christian amt with a Continental climate, have a mortality from consumption below the mean. That climate and latitude are not the determining factors in the distribution of phthisis, will become still more evident if we compare the consumption mortality of North and South Bergenhus, or that of North and South Trondhjem. These districts lie contiguous to each other, with a similar climate, yet they differ considerably as regards the degree in which they suffer from phthisis. The facts point less to the influence of latitude and climate than to the influence of local conditions of the soil, and to the social habits and occupations of the population, in determining the relative prevalence of the disease in different districts. Other tubercular diseases, including tubercular meningitis, account for 4 per cent, of the deaths from all known causes. Combining the deaths from these various forms of tubercular disease with those from consumption, which, as we have seen, form 15-9 per cent, of all deaths, tubercular affections give rise to no less than 20 per cent, of the total mortality. Bronchitis. — Acute bronchitis caused 3 "6 per cent, of the deaths in the years 1886-87, and the chronic form of the disease 2"1 per cent. Combining the ratios for the two forms, bronchitis accounts for 5*7 per cent, of the medically certified deaths. In England the proportion of deaths from bronchitis to the total mortality in 1884 was 10 per cent. The question arises how far these figures may be accepted as representing the comparative fatality of the disease in the two countries ? Differences in nomenclature cannot be invoked in this case to account for the greater prevalence of bronchitis in England, as it is expressly stated that acute bronchitis in Norway includes not only catarrhal pneumonia, which is the disease most likely to occasion confusion, but also laryngitis, wliich is not included along with bronchitis in the English returns. Wo conclude, therefore, NORWAY. 23 Christiania, . . 4-1 Bergen, . Hamar, . . 3-2 Tiondhjem, Christiansand, . 3-3 Tromso, that notwithstanding the greater severity of the Norwegian climate, bronchitis is much less fatal in Norway than in England. Acute bronchitis is notably a town disease, and this goes far to account for the greater prevalence of the disease in England, where so large a proportion of the population is aggregated in towns. In Norway the ratio of deaths in the towns is 5"1 compared with 2-7 in the country districts. The mean percentage of deaths from acute bronchitis to the total deaths in eacli " stift," for the years 1886-87, was as follows: — 2-5 2-6 3-1 From this it will be seen that the disease is more fatal in the southern provinces — Christiania, Hamar, and Christiansand — than in the northern districts of Bergen, Trondhjem, and Tromso. The maximum mortality from acute bronchitis falls on the cold months, January, Eebruary, and March, and the minimum mortality in July, August, and September. The ratio of deaths in the individual "stifts," from the chronic form of the disease, is as follows : — 2-4 2-1 1-4 Nothing is more distinctly a matter of common observation and of individual experience than that bronchitis, in a vast majority of instances, is the result of a " chill ; " but a study of the distribution of the disease in Norway teaches us that the liability to chill is not in relation to the coldness of the climate. Within ordinary limits the human body is capable of accommodating itself, not only to low temperatures, but also to changes of temperature. Those who are habituated to low temperatures and to frequent changes of temperature get inured to these conditions. Thus it happens that those whose daily occupations subject them to constant exposure to cold are the least liable to experience the bad effects of such exposure. The overcrowding, the unhealthy occupations, and the overheated rooms of large, cities account for the greater prevalence of bronchitis in towns. The inhalation of a vitiated or irritating atmosphere, and the exposure of the body to cold after it has been relaxed by heat, are much more potent causes of bronchitis than simple exposure to cold. Pneumonia. — According to the statistics of Holmsen and Hallin, as given by Hirsch, the average death-rate from pneumonia in Bergen Christiania, . . 2-0 Bergen, . Hamar, . . 2-4 Trondhjem, Christiansand, . 2-6 Troms(3, 24 NORTHERN EUROPE. and Christiania for the ten years ending 1878 was 1'6 and 1"3 per 1000 living, respectively. From 1880 to 1887 the disease was to a certain extent epidemic, especially in the southern provinces. In the Introduction to the Medical and Sanitary Report for 1887, it is stated that, " although the known cases of pneumonia were fewer that year than in any year since 1879, it still prevailed as an epidemy in almost every part of the kingdom." We do not have the data for estimating the death- rate per 1000 living during the epidemic period, but we may he sure that it has been considerably in excess of that given above. The report to which we have referred gives the data for determining the ratio of deaths from pneumonia to the deaths from all causes for the whole kingdom and for the different provinces. Croupous pneumonia gave rise to a mean of 8*1 per cent, of the total deaths in ]N"orway during the three years 1885—87 ; the proportion in England being 4"9 per cent. This will show how prevalent pneu- monia has been of late years in Xorway. The relative prevalence of the disease in different parts of the kingdom is shown by the average number of cases reported in each " stift " per 1000 living, as under: — 4-5 4-5 3-0 Pneumonia was thus most fatal during these years in the inland province of Hamar, and the southern provinces generally suffered more severely than the northern parts of the country. The disease is more fatal in the country than in the towns, in the proportion of 9*5 : 6"3. The following is the monthly distribution per cent, of 18,708 cases of the disease : — Dec. Christiania, . . 5-7 Bergen, . Hamar, . . 7-0 Trondhjeni, Christiansand, . 4-7 Tromsb, Jan. Feb. Mar. April. 5Iay. June. July. Aug. Sept. Oct. Xov 11-1 10-3 13-1 12-4 13-6 7-4 4-8 3-2 2-9 5-0 7-3 Pleurisy is of frequent occurrence, at least it has been so during recent years, the proportion of deaths in 1886-87 being as high as 5 per 1000 of the total mortality. It is most fatal in the first, and is least fatal in the autumn quarter. Hcpaiiih and diseases of the S])lccn are of rare occurrence in Norway. Cancer and Sarcoma are excessively fatal in Norway, and appear to be increasing in prevalence. Founding upon the statistics of Dr. Kjier, Lombard estimates the deaths from cancerous affections at 32 per 1000 of the total mortality. These figures have reference to a period anterior to 1877. During the years 1886-87 the NORWAY. 25 proportion was GO per 1000, or G"0 per cent. The percentage of deaths to the total mortality in each " stift " in 1886, from cancer alone, was as follows: — Christiania, o'O; Hamar, 9'8; Christiansand, 4*3; Bergen, 5'4; Trondhjem, 6'Q; Tromsu, 6'0. The inland province, Hamar, where cancer is so prevalent, comprises two districts — Hedemarken to the east and Christian to the west. It is the eastern part of the province where cancer is most prevalent ; the deaths in Hedemarken being in the ratio of 10'6, while the ratio in Christian amt is 8"8 per cent. Such is the distribution of cancer in Norway, but I cannot offer any explanation of the facts, any more than I can explain why cancer should be so prevalent in Norway, while among the same race in the Faroe Islands the disease should be almost, if not altogether, unknown. We certainly have no reason to attribute the difference to climate or soil, and if it is due to any peculiarities in the food or the habits of the people, I cannot conjecture what these may be. Diabetes forms about 2 '5 per 1000 of the total deaths in Norway, and about 2 '7 in England. The disease is thus equally frequent in the two countries. Scrofula is far from rare in Norway. It appears to be most frequently met with in the southern districts, that is, in the districts where phthisis is most prevalent. Eheumaiic Fever. — The proportion of deaths from rheumatic fever to the total mortality is slightly under that which obtains in England. The months of January, February, and March are those when rheumatic fever is most frequent ; August, September, and October are those during which the fewest cases occur. Goitre is not met with in Norway. Leprosy finds one of its chief areas of prevalence, so far as Europe is concerned, in Norway, although the disease is evidently dying out here, as it has already done in so many European countries. The number of lepers known in 1885 was 1139, or 5'8 per 10,000 living. In 1856 the proportion was estimated at 19*1 per 10,000. We may thus anticipate the complete extinc- tion of the malady within the next fifty years. The disease is most common in North and South Bergenhus, but it occurs all along the west coast, and a few cases are met with in the other districts. The coastal distribution of the disease in Norway is one of the arguments of those who, like Hutchinson, ascribe leprosy to a fish diet. Syphilis is no doubt common enough in Norway at the present day; but so far as can be judged from the deaths ascribed to the disease, it is less prevalent in Norway than in England. During the last century and the first half of the present century, a disease 26 NORTHEEN EUROPE. known as Radesyge, or the " bad disorder," was endemic, especially in tlie provinces of Bergen and Christiansand. This disease is believed by Hebra, Baumler, Danielssen, and others to have been nothing else than forms of secondary, tertiary, or congenital syphilis. Historically the disease is interesting in relation to the doctrine of syphilis, and it deserves notice also on account of its affinities to similar endemic diseases met with elsewhere. A full account of it by Dr. Hjort will be found in the Brit, and For. Med. Bev. for 1842. From this I shall give a very condensed account of the principal features of this malady. The disease was in most cases preceded by catarrhal, rheumatic, or nervous symptoms, the most constant of these being flying pains in the limbs, head, skin, and ulna. They were followed by periostitis and thickening of the bones, followed by ulcerations of the skin, mucous membranes, and bones. The disease, as affecting the integument, might be limited to the skin proper, or, as was more common, it might involve the skin and subcutaneous cellular tissue, occasionally extending deeply, and laying bare the muscles and ligaments. The most common form of ulceration, we are told, began with round tubercles, elevated two or three lines above the surface of the skin, of a dirty-white colour, and varying in size from a hazel-nut to that of a walnut, which on softening displayed an ulcer two or three lines in depth, secreting a yellowish-green pus, which formed hard black scabs. The ulcers generally appeared in groups on the loins and extremities, par- ticularly over the anterior surface of the tibia ; but ulcers grouped in irregular forms, and not presenting the serpiginous circles of syphilitic eruptions, were also met with on the forehead, cheeks, back, and breast. The mucous membranes most liable to be attacked were those of the nose, mouth, and pharynx, leading to destruction of the soft parts, and sometimes of the bones. Necrosis of the long bones was also not uncommon during the progress of the disease. Faye affirms that " radesyge " appeared many years after birth in previously healthy children.^ In such instances, we cannot well suppose that the disease was congenital, and the age of the patients, in many instances, renders it impossible to believe that it was contracted by sexual intercourse. Assuming, as we are entitled to do, that the disease was chiefly propagated by ordinary inter- course, such as by eating out of the same dish, it is remarkable that we have no accounts of primary sores, or even of secondary affections, such as condylomata, which play such an important part in the descriptions of endemic syphilis in other countries. ^ Sclnnidt's Ja7(rft. vol. cxvii. p. 171. CHAPTER III. SWEDEN. Geography. — Sweden occupies the eastern and more extensive part of the Scandinavian peninsula. It extends from 55° 20' to 69 3' N. lat. Its area is 170,000 square miles, and the population, in 1887, was 4,734,901. Stockholm, the capital, in 1887, had 227,964 inhabitants. Physically, Sweden may be divided into three regions. The northern division is limited on the south by the 62nd degree north latitude. It slopes from the Kiolen range of mountains, which here separates Norway from Sweden, down to the Gulf of Bothnia. The middle region, which extends from lat. 57° to 62° N., may be called " the lake " region, and has a slope southwards to the Wetter, Venner, and Maelar lakes, which, with numerous smaller ones, almost inter- sect the country from the Baltic to the Skager Piack. The southern division comprises all the peninsula south of lat. 57 N. This division is, in general, level and fertile, and contains several lakes of considerable extent. Nearly one-fourtli of the entire surface is covered with forests, and the lakes are estimated to amount to nearly one-eighth of the area of the country. The rivers of Sweden are numerous, but short and rapid. The largest is the Angermann Elf, which falls into the Gulf of Bothnia. The country is divided into twenty-five provinces, with a population (in 1887) as under: — Stockholm (town), 227,964 Goteborgs ocli Bohus, 289,957 Stockholm (provinces), 152,160 Elfsborgs, 279,217 Upsala, . 120,084 Skaraborgs, 251,939 Siidermanlands, 152,296 Vermlands, 256,842 Ostergotlands, 266,084 Orebro, . 182,895 Jonkoping, 196,071 Vestmanlands, 134,625 Kronobergs, 165,009 Kopparbergs, . 195,667 Kalmar, . 236,333 Gfleborgs, 199,044 Gotlands, 52,065 Vesternorrlauds, 193,868 Blekinge, 141,677 Jemtlands, 97,474 Kristianstads, 226,070 Vesterbottens, 116,910 Malmohus, 364,543 Korrbottens, . 98,709 Hallands, 137,398 28 NOETHEEN EUEOPE. Climatology. — The mean temperature centigrade from south to north is as follows : — North Latitude. Jan. April. July. Oct. Year Kalmar, . , 56° 40' - 1-1 4-5 16-8 7-9 6-8 Jonkoping, . 57° 40' - 2-0 4-0 16-1 6-5 5-9 Stockholm, . . 59° 17' - 3-7 3-0 16-4 6-2 5-2 Falun, . . 60° 36' - 6-6 2-3 16-2 4-5 3-7 Haparanda, . . 65° 51' -13-1 -2-0 15-2 1-2 0-0 The following is the monthly distribution per cent, of the rain- fall in the north and south of Sweden : — North Latitude. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 56°-60° 7 5 5 6 7 10 11 13 10 10 9 7 60°-66° 6 5 5 5 7 9 12 14 11 10 9 7 The average annual amount of rain varies from 18 to 24 inches in different parts of Sweden. Vital Statistics. — The marriage, birth, and death rates per 1000 for the ten years ending 1886 were 12-8, 29-7, and 17*6 respectively. Sweden thus ranks among the healthiest countries of the world. The seasonal distribution of the mortality in the northern, central, and southern provinces of Sweden is thus given by Lombard : — Five Northern Four Central Thirteen Southern Provinces. Provinces. Provinces. Winter, 27-19 28-32 27-94 Spring, 26-69 27-59 29-62 Summer, 22-41 21-19 19-58 Autumn, 23-71 22-90 22-86 Summer in all the regions stands out as the healthiest season. In the north and centre of the country winter is the season when the highest mortality occurs. According to the same authority, the maximum mortality in Stockholm during the period 1851-61 fell on the autumn season, the month of September being that most charged with deaths. This Lombard ascribes to the predominating influence of malaria, owing to the situation of the city in prox- imity to the Maelar Lake. Pathology. — Malaria. — Intermittent fever is much less fatal at the present day in Sweden than it was during past centuries, or even during the earlier part of the present century. In Sweden, as in England and Holland, malaria is gradually falling into the back- ground as an endemic disease. This diminishing fatality, as regards Sweden, will be seen if we compare the deaths from malarial fever for the three decennial periods 1751-60, 1801-10, and 1861-70, as deduced from the statistics of malarial mortality given by SWEDEN. 29 Bergman.^ During the first of these periods the deatlis from inter- mittent fever numbered 12,964; during the second, 8165; while during the third the number of deaths had fallen to 1192. The following is the number of cases (not deaths) reported yearly from 1880 to 1887 by the Swedish Board of Health:— 1880, 1881, 1882, 1883, 4180 1884, 2776 1885, 2700 1886, 3602 1887, 3740 2538 2297 1591 The number of reported cases formed, in 1887, the small proportion of 3"36 per 10,000 of the population, and of these only 4, or 2-5 per 1000 treated, proved fatal. Although the number, both of cases treated and of deaths reported to the Board, must have been con- siderably under those that actually occurred throughout the country, these figures nevertheless show that malaria is comparatively rare and mild in Sweden at the present time. Malarial fever is endemic along the east coast, from the southern extremity of the peninsula as far north as Hudiksvall, which is close upon the 62nd degree, and it is met with at a few isolated points beyond this, near the mouths of some of the rivers, such as the Angermann Elf, where it is rather common. The shores of the Kattegat, on the west, are almost entirely free from the disease, except around Goteborg, and even there it is mild. That part of the east coast situated to the north of Gefle is little affected, as is also that south of Carlscrona on the south. The worst malarious areas on the east coast are found in Kalmar and Sodermanlands. The shores of Lake Maelar have a clayey subsoil, which maintains the subsoil water at a high level, and here malaria is specially prevalent. The northern shores of Lake Venner are also in a marked degree malarious, and the east, west, and south of the lake are affected, although to a much less extent. Lake Wetter and the whole of the inland country to the south are free from endemic malaria. Malaria is not endemic in the provinces north of 62°']Sr. lat., nor in the high lands of the interior. The remittent form has a much more restricted area of endemic prevalence. It is of somewhat frequent occurrence in Kalmar, on the coasts of Sodermanlands, and on the shores of Lake Maelar, but outside these districts it cannot be said to be endemic. Three factors determine the distribution of malaria in Sweden, viz. altitude, latitude, that is, temperature, and local conditions of the soil, the most evident of which is subsoil humidity. The influence of altitude is shown in the absence of the disease ^ Oiu SverifjdH folJcsjukdoniar, Upsala, 1875, p. 149. 30 NORTHEKN EUKOPE. from the whole of the Alpine districts, and even from the higher lands in the interior. ISTo less evident is the influence of latitude on the prevalence of malarial fevers. Taking the recorded cases in 1887, for each "Ian," the distribution of the disease for four different parallels was as follows : — p ,, , Ratio of Cases ■*^^^^^^^^'^- per 10,000 living. North of 62°, O'Sl 60°-62°, 1-80 58°-60% . 4-40 South of 58° 3-09 Malarial fever is seen to diminish in frequency as we advance north of latitude 60°; but to the south of this line the disturbing element of local conditions of soil comes into operation. The influence of the paludal conditions arising from the lakes is shown by the fact that whereas the ratio of cases of fever for the whole country is, as we have seen, 3*36 per 10,000 living, the proportion in the six lake departments is 7'49 per 10,000. This indicates the influence of the third factor, viz. paludal conditions of the soil in the genesis of malaria. The following are the six most malarious departments in Sweden, with the ratio of cases ]jer 10,000 of the population for the year 1887:— Sodermanlands, . . 14-7 Stockholm (city), . . 8-9 Kalmar, . 13 -5 Upsala, . 8-4 Stockholm (Ian), . . 12-4 Vermlands, . . 4-8 Having now traced the geographical distribution of malaria in Sweden, let us examine its seasonal prevalence. The subjoined table gives (1) the monthly distribution per cent, of 53,009 cases of malarial fever for the whole country from the reports of the Board of Health for the years 1870-73 ; (2) of 2835 cases occurring between 1864 and 1873 at Goteborg ; (3) of 6526 cases at Stockholm between 1860 and 1869. I shall add the monthly temperature of Stockholm to show the relation which the prevalence of malarial fever bears to temperature in Sweden : — Sweden, Goteborg, Stockholm, Jan. Feb. Mar. April. Slay. June. July. Aug. Sept. Oct. Nov. Dec. 5-94 6-47 10--24 15-35 IG'G 9-22 5-40 S'lS "-03 7-12 CMl 5-43 8-7 0-5 11-0 11-7 12-7 7-5 4-3 4-0 6-2 9-0 S'S 5-!l 8-8 7-8 9-3 11-3 12-5 lOl O'S 5-S 7*3 7-1 C-7 7-4 Mean monthly tein-) perature of Stock- >- -3-63 -3-33 -1-87 holm, . . ) 3-23 8-35 15-44 10-85 16-5(1 11-SS 5-45 -0-S3 -3-33 It will be seen from these figures that malarial fever has two maximal periods, the principal one in May, and the secondary one in September or October ; but that the monthly proportions vary in different localities and periods. SWEDEN. 3 1 The rule appears to be tliat the autumnal crop of fevers is large in proportion to the intensity of malaria either in its endemic or epidemic form. In the extreme north the autumn rise disappears, unless, perhaps, during epidemic years ; but it becomes more marked in the centre and south, especially in the years when the disease is prevalent. Thus, at Stromsholm, on the northern shores of the Maelar Lake, malarial fever was very prevalent in 185 9, and less so in the following year, 18G0. In 1859 the maximum occurred in October, while in 18G0 the usual May maximum was observed. As an endemic malady, malarial fever is thus mainly vernal in all parts of Sweden, and. most of all in those districts where the endemic influence is least felt, but it tends to become autumnal in those regions where malaria is more intense, especially during seasons when the disease is epidemic. It will be observed that cases of malarial fever are absolutely more prevalent at Stockholm in the month of March, when the mean temperature is below the freezing point, than in the mouth of July, when it stands at 16'85° C. We shall revert to this point when we come to deal with the seasonal distribution of malarial fevers in Eussia. The tertian type is that which is most common in Sweden. Taking as our basis a table given by Bergman, showing the number of cases of each type at various places and in different years between 1851 and 1868, the different types were represented in the follow- ing proportions : — Tertian, . . . 57'1 per cenl. Quotidian, . . . 26-4 ,, Quartan, . . . 16"4 ,, The following is the quarterly prevalence of each type : — First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Tertian, 11-9 76-2 10-6 1-2 Quotidian, 11-5 73-9 lO'S 37 Quartan, 32-1 19-6 26-8 2r4 These percentages are calculated upon 1401 cases of tertian, 406 of quotidian, and 56 of quartan, observed at Atvidabergs from 1856 to 1860, that is, during an epidemic period, and the proportions must be taken with some reservation as respects non-epidemic years. Further, the number of cases of the quartan type are too few to establish conclusively its seasonal prevalence. Children suffer in a larger proportion than adults from the quotidian type. Males are more liable to suffer from malarial fever than women ; the proportions being 58*1 per cent, of cases in males, and 41*9 per cent, in females. 32 NOETHEKN EUKOPE. The proportion per cent, in which the different age classes suffer is given by Bergman as follows : — Under 10 years. 10-20. 20-30. 30-40. 40-50. Over 50 years. 21-9 17-7 23-3 18-6 10-6 7*9 Malarial fever has repeatedly loroken out in Sweden in an epidemic form, the earliest outbreak of which there is any record dating as far back as 1575—76. Bergman enumerates fourteen such epidemies as occurring between the years 1691 and 1861, and most of these coincided with or followed the epidemic prevalence of the disease in other regions of Europe. It would appear from the dates assigned to these epidemies by Bergman, that Sweden has, as a rule, been visited by malarial outbreaks one or two years after the disease has been more or less general in other parts of Europe, which would point to an extension of the infective influence from south to north ; but it is always so difficult to fix the dates at which an epidemy begins and ends in any country, that the con- clusions based upon such dates, especially when these refer to past centuries, must be received with some reserve. The latest epidemic outbreaks occurred in 1852—56 and 1858—61. These may be regarded as one epidemy. It commenced in 1852, at three points on the east coast, viz. Christianstad, in the south ; at Kalmar, on the south coast ; and on the southern part of the Stockholm coast. During the succeeding years up to 1860 it invaded the whole south and east coasts to the northern extremity of the Gulf of Bothnia, and extended inland along the lakes, and over a large extent of the centre and south, where the disease is not endemic. The west coast also suffered during this outbreak, as well as the islands of Gotland and Oland. Speaking generally, the epidemy, starting from its three primary centres, spread circumferentially, in widening circles each successive year, yet in such a manner that the humid and marshy localities in which the disease is usually endemic were attacked in advance of the extending epidemic wave. As the manner in which malarial epidemies spread has seldom been so carefully noted as in Sweden, I shall reproduce the map constructed by Bergman to illustrate the progress of the epidemy year by year. Enteric Fever is extensively prevalent in Sweden. The average number of cases recorded during the eight years ending 1884 was 13,210; and as, the mean population for the same series of years was 4,570,047, this gives a ratio of nearly three cases per 1000 of the population annually. The average death-rate for the two years Map showing the Spkead of Epidemic Malaiua ix Sweden, 1852-61. SWEDEN. 33 1886-87, in ninety-one towns having a total pojoulation in 188G of 815,220, was 263 per million, or 0-26 per 1000. These towns are of all sizes, from Siiter, with a population of 57l, to that of Stockholm, with 219,370. In England, the average death-rate from enteric fever for the smaller towns may be stated at 0'24 per 1000, which is somewhat under the rate which obtains in Sweden. This disease is less fatal in the four northern provinces of Norrbottens, Vesterbottens, Vesternorrlands, and Jemtlands than in the middle and southern divisions. The region included between 58° and 60° N. lat. appears to suffer most from enteric fever. In Sweden, enteric fever is generally of a mild type. In 1886, out of 6045 recorded cases, there were 589 deaths — a proportion of 9 '7 per cent. Out of 383 admissions into hospital, 34 patients died — a ratio of 8 '9 per cent. Liebermeister estimates the mortality at Basle hospital at 1 6 or 17 per cent, of the cases treated ; while Murchison's tables give for England a mortality of 18'5 per cent, of the cases treated. The monthly distribution of 10,743 cases of enteric fever occurring in 1886-87 was as follows: — Jan. Feb. Jlar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 8-SS 6-51 6-81 5-SS 6-2r 5-71 8-09 10-33 11-53 9'99 11'24 8-69 The disease is thus most prevalent during the autumn months, when the rainfall is beginning to diminish ; but the increase com- mences during the months of July and August, when the rainfall is at its maximum. The disease varies considerably in prevalence in different years. I do not have the data for comparing the death-rates from typhoid fever for a series of years in England and in Sweden ; but it may be interesting to compare the annual prevalence of the disease in the two countries during a series of years, as indicated by the number of reported cases of typhoid and gastric fever reported annually in Sweden, and the death-rates per million from typhoid fever in England. The following are the numbers for the years 1877-84:— 1877. 1S7S. 1879. ISSO. ISSl. 1882. 1883. 1884. ''^^'*^andl!astric°Fevcr^°^*^}^-''^^'^ ^^'^^^ ^^'^^^ ^^'^^* ^^'^^'^ ^^'-^^^ ■^'^'^^^ ''■^'''^'^ England — Death-rate per) miUion from Typhoid >• 279 306 231 261 212 229 227 235 Fever, . . . .) Although no conclusions can be drawn from such imperfect data, it is interesting to observe that the deaths from typhoid fever in England rise and fall, in a rough way, with the number of cases of typhoid and gastric fever reported annually in Sweden, with the single exception of the year 1880, when an increase in the number c 34 NORTHERN EUROPE. of typhoid fever deaths occurred in England along with a decrease in the prevalence of the disease in Sweden. This suggests the question, whether the conditions which determine the prevalence of typhoid fever do not extend simultaneously over large areas of the earth's surface ? It is not improbable that the summer temperature has an important influence on typhoid mortality in Sweden, as will be proved to be the case in respect to other countries from which data are avail- able. The average annual number of cases of typhoid and gastric fever recorded during the ten years 1 878—8 7 was 1 2,474. The mean temperature of the third quarter at Upsala for the same period was 13°'8 C, The temperature of the third quarter in 1884 was exactly that of the mean of the ten years. Omitting, therefore, this year, we find that in six out of the remaining nine years when the temperature of the third quarter was above or below the mean, the number of cases of typhoid and gastric fevers was also correspondingly above or below the average. This seems to show that a high temperature during the third quarter tends to increase the number of cases of these diseases, while a low temperature has the opposite effect. Typhus Fever was epidemic in various parts of Sweden from 1873—75. In recent times isolated cases are annually observed. A few cases of relapsing fever were observed during the typhus epidemy. Gastric Fever is returned as the cause of much sickness. It appears to answer to the " simple and ill-defined fever " of the English reports. Whatever may be its nature, it is clearly not malarial, as it appears to be quite as prevalent in the non-malarious as in the malarious localities. Like simple continued fever, the gastric fever of Sweden is seldom fatal. Epidemic Cerelro-spinal Meningitis made its first appearance in Sweden at Goteborg, on the west coast, early in 1854, and towards the end of the same year in Kalmar and Blekinge ; and for the next ten years it raged throughout the country with great severity. Its progressive extensions from south to north could be traced in successive years. In 1855 it had reached the town of Kalmar; in 1856 it had extended north to Philipstad. In 1857 it attained to latitude 61° N. ; in 1858, a year in which it was widely diffused and severe, it penetrated as far north as latitude 63° IST., which was the farthest point to which it attained (Hirsch). During these years the epidemy died out after May or June, to recommence in the beginning of the following year. During the ten years ending 1886, the number of recorded cases averaged 85 per annum. A considerable recrudescence of the disease was witnessed in 1883, when the number of cases recorded rose to 400. Since that period SWEDEN. 35 the disease has occurred in single cases or in small groups of cases at various points in the south and centre. Cerebro-spinal menin- gitis is eminently a disease of the second quarter. Diphtheria. — We have accounts of the epidemic prevalence of diphtheria or Cynanchc maligna reaching as far back as 1755—62. In 1852—55 fatal throat affections were epidemic in various parts of the country. A wider extension of the disease began in 1860, and since that period it has taken its place among the more fatal epidemic diseases of Sweden. The cases observed between 1863-70 numbered, according to Hirsch, 18,156. This gives on an average 2269 cases annually. The cases reported to the Board of Health, during the ten years ending 1886, were on an average 5934. The disease has thus been more widely diffused during the latter than the former period. The mortality in proportion to cases reported from 1863-70 was 23 per cent, while in the latest years, 1886—87, it was 21 per cent. ; which shows that the malady has lost little in its virulence, while it has been gaining in frequency. The recorded cases in 1886 and 1887 were in the ratios of 9*7 and 12*2 per 10,000 living respectively. The average number of deaths from diphtheria in 1886-87 in ninety-one towns, with a mean population of 824,390, was 313*5 ; which gives a death-rate of 380 per million living. The ratio which the deaths from diphtheria bore to the deaths from all causes was for the same years 20'8 per 1000. As a measure of comparison, we may note that in England the death-rate from diphtheria (1881—84) was 154 per million, while the ratio of deaths from this disease to the total mortality was about 9*4 per 1000. Diphtheria is more prevalent in the northern and central than in the southern provinces. Stockholm often suffers severely from the malady. The fourth and the first quarters are those in which the maxi- mum of diphtheritic sickness is observed, but the exact period is very variable. Croup takes a somewhat important place among the fatal diseases of infancy. The average number of recorded cases during the ten years ending 1886 was 492-5. During the period 1863 to 1867 the proportion was considerably higher, viz. 611 cases annually. Whether this difference indicates a diminished prevalence of the disease during the later period is doubtful. I think it more probable that cases formerly returned as croup are now registered as diphtheria. Croup, like diphtheria, is less prevalent in the southern than in the northern and central divisions ; and if we leave out Stockholm from 36 NOETHEEN EUEOPE. the central division, croup is more fatal in the north than in the centre. The disease is specially fatal in the capital ; and, according to Hirsch, in Dahlsland and Wermland around the shores of Lake Venner, particularly in the districts of ISTasharad and Amal, where the By-Elf flows into the lake. The death-rate from croup in the towns (including Stockholm) in 1886—87 was 228 per million (0-22 per 1000); the ratio of deaths from croup to the total mortality was 12-50 per 1000. The corresponding ratios for Eng- land (1881—84) were 164 per million living, and 8 "9 per 1000 of the total deaths. The death-rate in Stockholm from croup during these years was as high as 290*4 per million. Croup is most fatal in the first quarter, and attains its minimum during the summer months. Diseases of the Digestive System. — Before considering the indi- vidual diseases of the intestinal canal, we may remark that diseases of the digestive system are slightly more prevalent in the south than in the centre and north of Sweden, and that this class of diseases is most fatal in the capital. The following is the mean percentage of deaths from this class of diseases to the total deaths in different parts of the kingdom for the years 1886-87 : — Stockholm. 14-69 The influence of increasing temperature, and of the agglomeration and misery of large towns, in raising the mortality from diseases of the digestive system, is here apparent, although not to a marked extent. Dysentery has of late years lost much of its importance in Sweden as an endemic disease, and its epidemic ravages are much less frequent and severe than during the last and the earlier part of the present century. Among the notable epidemies of dysentery by which Sweden has been visited, we may enumerate those of 1649-52, 1736-43, 1749-50, 1770-75, 1783-85, 1808-11, 1813, and 1838-39. The last extensive outbreak of dysentery occurred from 1853 to 1860, a period when, as we have seen, malaria was also epidemic. This outbreak began in the south-west in 1852 and 1853, invading during the latter year the provinces of Elfsborgs and Vermlands. In the following year, 1854, the epidemy extended to the east and south, attacking the provinces of Skaraborgs and Jonkoping, while it still continued its ravages in Vermlands. In 1 8 5 5 and 1856 it lingered on, but with diminished virulence, increasing again in 1857, during which and in the following years all excepting the two northern provinces of Vester- bottens and Norbottens, the two southern provinces Malmohus and Khristianstadts, and the central province of Sodermanlands, were The Skane Towns Maelar Provinces Northern Provinces (South). (Towns). (Towns). 13-57 12-41 13-05 SAVEDEN. 37 successively attacked. Its northern limit was 65° N. The severity of this epidemy may be judged by the fact that, during the eight years in which it raged, it carried off 19,999 victims, or nearly 2500 annually. The districts most affected will be seen from the following table from Hirsch, showing the deaths from dysentery in Sweden per 100,000 inhabitants during the period 1851-60 : — Joukoping, Skaraborg, . Elfsborg, . Vermlaml, . Goteborg and Bolius, Kalmar, Ostergiitlands, Gotlauds, . Blekinge, . Vexio, Falun (Dalarne), 395-8 255-1 197-2 121-7 92-7 82-7 50-4 48-7 38-9 37-1 34-5 JSTerika (Vermlands), Hallands, Stockholm (city), Stockliolm (lau), Norrluad, Upsala, Gefleborg, Vestmanlaiid, Sodennanland, Malmohus, . Kristianstadts, The following points deserve notice respecting epidemic dysentery in Sweden : — (1) Its greater malignancy during epidemic periods. During the outbreak of 1853-60, the deaths to the cases treated were in the ratio of 28 per cent., which is more than double that observed in non-epidemic periods. (2) Its mode of extension, — gradually and progressively invading large areas during successive years, which seems to point to its miasmatic character. (3) Its relation to locality. Dysentery in Sweden has frequently been most fatal in elevated districts, and in the last epidemy it will be observed that the malarious and low-lying province of Soderman- land was almost exempt from the disease. (4) Its relation to weather and season. It has been proved by Bergman that dysentery most frequently shows itself in an epidemic form during unusually hot weather, and it makes most victims during the warmest months. The disease in non-epidemic periods is marked by the great differences in its frequency in different years. This will be seen from the following figures of the cases recorded during the ten years ending 1887 : — Years. Cases. Years. Cases. 1878 587 1883 512 1879 245 1884 357 1880 1014 1885 179 1881 814 1886 694 1882 42111 1887 254 ' This high number of cases was owing to an epidemy of the disease limited to Malmohus, where there occurred 3150 cases and 602 deaths. 38 NORTHERN EUROPE. The northern provinces are little subject to endemic dysentery, but they are not entirely exempt from the disease. Thus, in 1886, no fewer than 11 out of 53 deaths ascribed to dysentery occurred in the province of Vesterbottens. In ordinary years the disease is more prevalent in the central than in the northern and southern divisions, the province of Vermlands being that in which the disease is most common. Dysentery is more common in the country than in the towns ; and the months of July, August, and September are those in which the disease attains its maximum. The mortality from the endemic form varies from 8 to 11 per cent. of the cases treated, Diarrhma. — The average number of cases of diarrhoea and Cholera infantum recorded between 1877 and 1886 was 24,883, or an average of 5*4 per 1000 on the mean population for that period ; the deaths being in the proportion of from 3 to 5 per cent. of the cases reported. Diarrhoea is more fatal in the towns than in the country. In Stockholm the deaths from diarrhoeal diseases for the four years ending 1888 were in the high proportion of 2-77 per 1000 living. The following was the regional distribution of cases of the disease reported in 1 8 8 6 and 1887 per 1 of the inhabitants : — 1886, 1887. Mean. North \ Vesterbottens, ) „.. „.„ . .„ iNortn, iNorbottens, ^ bU ^8 4 9 c!^„fi, S Kristianstadts, ) ^ - ^. r.n S°^^tli, JMalmolms, ' ( 65 5-4 5-9 Erom this it appears that diarrhoea increases slightly in frequency from north to south. Diarrhoea attains its maximum throughout the country in the months of August and September. Asiatic Cholera made its first appearance in Sweden in 1834, which has subsequently been visited by the disease in 1850, 1853, 1857, and 1866. On all of these occasions the chief centres of cholera prevalence have been "the basins of Lake Maelar, Lake Wetter, the valley of the Gota-Elf, and the southern belt of country extending from Malmo round to Karlshamm " (Hirsch). Influenza appears in Sweden with the same frequency and intensity as in the rest of Europe. Sm.all2Jox caused on an average only 158 deaths per million living from 1810 to 1850. From 1856-62 the disease was more prevalent, while from 1863 to 1867 smallpox assumed epidemic dimensions, carrying off during that period 7291 victims. lu SWEDEN. 39 1874 there were no fewer than 2774 deaths recorded, the highest number in any year since 1801. From 1877 to 1886 the average number of cases was 670 ; but the deaths have been comparatively few. The quarterly distribution per cent, of 5257 deaths occurring between 1856-62 was as follows: — First Quarter. Second Quarter. Third Quarter. Fourth Quarter. 38-6 33 -4 14-9 13-1 Scarlet Fever. — During the ten years 1877—86 the average number of cases of scarlet fever observed annually in Sweden w'as 11,845, or nearly 2*6 per 1000 living. The mortality to cases treated varies from 12 to 13 per cent. The year 1877 was the most fatal of the series. The cases that year numbered 16,682, and the deaths 7426, or nearly 1'7 per 1000 of the population. The disease is more fatal in the towns than in the country. The average mortality in the towns of late years has been 6 '00 per 10,000 living. The percentage of deaths in the different seasons is — spring, 22*1; summer, 23'9 ; autumn, 29'4; winter, 24"6. Measles. — The average number of cases observed during the ten years ending 1886 was 9727, or a ratio of 2*3 cases per 1000 living, with an average mortality in recent years of 2*40 per 10,000 living. The disease takes on an epidemic character at varying intervals. Thus it was excessively prevalent during the three years 1881, 1882, and 1883, especially in 1882, w^hen the cases rose from the mean of 9727 to 20,724. Measles were epidemic in Lapland in 1852. The disease is most prevalent during the cold months. Wliooping- Cough is quite as common in Sweden as in neigh- bouring countries. The cases reported during the ten years 1886 were in the ratio of 1*7 per 1000 of the population. The deaths are in the ratio of 5 per 100 of the reported cases. If the state- ment of Eosenstein, quoted by Hirsch, is correct, that upwards of 43,000 children died of whooping-cough in Sweden from 1749 to 1764, that is, during a period of sixteen years, it must have been very much more fatal during the last than during the present century. The percentage of cases in the several seasons, as given by Hirsch, is as follows: — spring, 21*8; summer, 28*2; autumn, 29-4; winter, 20-6. Diseases of the Resjpiratory Organs become more fatal as we advance from the north to the south. This, at least, is the case if we are to accept the ratio of mortality to the total deaths in 1886 and 1887 as evidence of the ordinary distribution of the deaths from The Skane Towns Maelar Towns (South). (Centre). 35-12 32-15 40 NOKTHEEN EUEOPE. these diseases. The following table gives the percentage of deaths from respiratory diseases for the towns in three regions, and separ- ately for the capital : — Northern Towns. Stockholm. 31-65 30-50 Phthisis is extremely fatal in Sweden. The average death-rate during the period 1861-76, as given by Hirsch on the authority of Devertie, was 3-5 per 1000 living. Since that time it has probably diminished in frequency, for the death-rate from phthisis and chronic pneumonia, which are included in the term " lungsot" in ninety-one towns, during the years 1886-87, was in the ratio of 2-72 per 1000 living, and formed 14*96 per cent, of the total deaths. The following table gives the death-rate from phthisis in twenty- nine towns situated in four parallels of latitude, the capital being excluded. It shows that, for the years 1886 and 1887, phthisis was more fatal in the centre and south than in the north. The region lying between 58° and 60° N. lat., which includes the lakes, and in which the malarial influence is most marked, is that where consumption is most prevalent : — Number p^rMiio+inn Deaths from Deaths from of ??ioQr Phthisis per Phthisis per Towns. inJ-sso- Jlilliou in 1SS6. JliUion in 1887. Mean. North of lat. 62°, . . 7 31,050 2930-7 2385-9 2658 Between lat. 62° and 60°, . 5 43,150 2688-3 2448-4 2568 Between lat. 60° and 58°, . 9 99,509 3336-4 3034-8 3185 South of lat. 58°, . , 8 214,798 2821-2 2860-2 2840 The provinces of Sodermanlands, Ivristianstadts, Jemtlands, Kopparbergs, and Vesternorrlands are those in which phthisis is most prevalent ; while Elfsborgs, Vestmanlands, and Norrbottens are those which are least affected. Pneumonia and Pleurisy are of frequent occurrence in Sweden, and the deaths occasioned by these diseases are more numerous in proportion to the population than in England. The death-rate in the towns for 1886-87 was 1-81 per 1000. The death-rate from pneumonia at Falun for 1860-66 was almost exactly the same as for the towns generally, viz. 1*8 per 1000. The death-rate from pneumonia is considerably higher in Stockholm than that of the country as a whole, being 2-18 per 1000 for the two years 1886—87. According to the investigations of Lombard into the geographical distribution of pneumonia, as deduced from the mortality of the five years 1863—67, the central provinces are those which are most affected, while the southern provinces furnish the lowest number SWEDEN. 4 1 both of patients and deaths. The mg-ximum of deaths occur in spring, and the minimum in autumn. Bronchitis is moderately common. The regions are affected in the same order as in pneumonia. At Fahm, in the interior, bronchitis forms rather more than one - fifth of the diseases treated. Diseases of the Liver and Spleen are of rare occurrence in Sweden. Cancer caused a death-rate in 1886-87 of 0'95 per 1000 living, a rate which is exceeded in few countries in Europe. Goitre is endemic only in a few localities in Kopparbergs and Vestmanlands. Chlorosis was a rare disease in Sweden even so late as the first quarter of the present century. During the last fifty years it has gradually been growing in prevalence, and is, at the present day, so common that in some districts very few young women are free from the disease. It is most common in the central and southern provinces. Leprosy is now rare in Sweden, and is rapidly dying out. It is chiefly confined to the province of Gefleborg. In 1887 the number of known lepers was 68, viz. 41 males and 27 females. Syphilis is widely diffused throughout the country. The death- rate from syphilis in the principal towns is 1*16 per 10,000 — a proportion only exceeded in Europe by Italy, where the deaths are in the ratio of 1"65 per 10,000. The "Eadesyge," described under Norway, was endemic in Sweden during the past and at the begin- ning of the present century, but it seems now to have entirely disappeared. Rheumatic Fever is frequently observed in all the provinces, but is most common in the northern districts,. CHAPTER IV. DENMARK. Geography and Climatology. — Denmark is situated between 54° and 57° 4:4/ N. lat., and includes the peninsula of Jutland and the islands of Seeland, Fiinen, Laaland, Falster, Moen, Langeland, etc. The area in square miles is 14,553, and the population in 1887 was 2,109,200. Copenhagen, the capital, in 1888 had 300,000 inhabitants. These islands are generally flat, fertile, and carefully cultivated. Jutland was formerly covered with forests ; since their destruction extensive districts have been converted into barren heaths and marshes. The climate is mild and humid. At Copenhagen the mean temperature of the seasons is — spring, 43°'5 F. ; summer, 63°"5 F. ; autumn, 4 9°' 3 F. ; and winter, 32°" 9 F. The prevailing winds are westerly; but in spring the cold, dry wind known as the sJcai, carrying clouds of sand, prevails. The marriage, birth, and death rates per 1000 for the ten years ending 1887 were 15-0, 32-2, and 18*7 respectively. The quarterly death-rate in Copenhagen for 1888 was as follows : — First Quarter. Second Quarter. Third Quarter. rourth Quarter. 24-2 23-4 20-2 19-4 Pathology. — Malaria. — Eey states that malarial fever is only endemic in the low and marshy parts of the islands of Laaland and Falster.^ At Copenhagen from 1843 to 1847, Hannover found intermittent fevers to form 30 per 1000 of the total admissions into the civil hospitals. The proportion of deaths at the present day from malarial fevers is small, and is gradually diminishing. Yet, during this century, Denmark has suffered from excessively fatal epidemies, described as malarious. Thus, according to Lombard, 50,000 died of inter- mittent fever in Denmark between the years 1828 and 1832; the ■ Nouv. Did. de mid. et de chlrurg., Paris 1872. DENMArvK. 43 islands of Seeland, Laaland, and Palster suffering most. In the island of Langeland, with 12,960 inhabitants, there were 2G4G cases of this disease, and 200 deaths. This was part of the great epidemy of 182G— 32 described by Haeser^ as having extended from Christiania and Bergen in Norway to the Morea in Greece, and from Liefland to the Atlantic Ocean. Holland, Holstein, Schleswig, Jutland, and England were all more or less affected. It was known along the shores of the Baltic as the Klisten epidemy. In the middle part of Germany it was called the summer fever, Haeser remarks that the most general effect of the epidemy was an increase of the mortality over a large part of Northern Europe. The year 1826, from which this epidemy dates, was one of the hottest within the memory of man. Erom contemporary references to this epidemy in Bust's Magazin, it appears that the fever usually assumed the tertian type ; the quotidian form was more rarely met with, and less frequently still the quartan. Dropsy and enlargements of the liver and spleen were frequent sequelae of the disease. An earlier epidemy is referred to by Sir John Pringle^ as having occurred at Copenhagen in 1652, marked by quotidian or tertian paroxysms, by bilious vomiting, and by the existence of spots which came out during the accessions and disappeared in the remissions. Erom 1835 to 1848 intermittent fever had almost entirely disappeared from Denmark. The epidemy reappeared in 1848, but was much less fatal than the former one. Erom 1849 there has been no epidemy of this nature. It is remarked as a proof that the fever of 1828-32 was due to some telluric influence, that it did not affect the sailors who visited the ports and fiords unless they landed. It was clear also that the disease was non-con- tagious. Typhoid Fever is met with in every part of Denmark in an endemic form, and as frequently recurring epidemics in particular localities. The mortality from typhoid and typhus fevers, the latter of extremely rare occurrence, attains an average of 385 per million living in the towns. In Copenhagen typhoid fever is rare, for from 1880-89 the deaths from typhus and typhoid fevers were in the ratio of 166 per million. The disease attains its maximum in the months of September, October, and November; .the month most charged with deaths in a series of years being September. Eelapsing Fever is unknown in Denmark. Cerelro-spinal Menin- gitis appeared in 1845-48 as a widespread and somewhat fatal 1 Haeser, Geschichte d. Med., Jena 1882. ^ Observations on the Diseases of the Army, Lond. 1775, p. 190. 44 NOETHEKN EUROPE. epidemy among the civil population. In 1873-74 it broke out again, but was limited to a few localities in Jutland. Since that time Denmark has remained free from the disease. Diphtheria and Growg cause an average death-rate (1881—84) of 628 per million. In Copenhagen the death-rate for the ten years ending 1889 was 5 4 7*0 per million. Smallpox presses lightly on Denmark. Finsen, writing in 1874, states that he had not seen a single case within the previous ten years. The smallpox death-rate from 1881—84 is given as 0"08 per 10,000 persons living. In Copenhagen (1880—89) it was in the ratio of 3-7 per million (0-037 per 10,000). The narrow limits within which smallpox has been restrained in Denmark is partly owing, no doubt, to efficient vaccination, and partly also to careful isolation of all cases of the disease. Measles and Scarlet Fever are endemic in the country, assuming an epidemic character from time to time. The death-rate from measles in Copenhagen for the ten years ending 1889 was 506"0, and that from scarlet fever during the same period, 303'0 per million. Wliooping -Cough is one of the most fatal diseases of childhood in Denmark. The average mortality for the period 1881-84 was 662 per million, and that of Copenhagen (1880-89), 506'0 per million; but it may readily be understood that the annual death-rates of a disease, so essentially epidemic in its character, varies widely, and that the averages drawn from a few years are not to be relied upon as indicating its prevalence. It would appear, however, that measles, scarlet fever, and whooping-cough are about equally fatal in Denmark and Great Britain. Dysentery, which was common enough last century, is now one of the rarest diseases in Denmark ; nor can diarrhcea be said to be specially frequent, although it causes a considerable mortality in the larger towns during the summer months. Copenhagen stands first in the order of mortality, the deaths averaging (1880-89) no less than 1660 per million from diarrhoeal diseases. Phthisis, including tubercular meningitis and tabes mesenterica, gives rise to an average mortality of 3042 per million, — a ratio very similar to that caused by phthisis in Sweden, less than that of the principal towns of Germany, but considerably in excess of that of England and Wales.^ Pneumonia is quite as common in Denmark as in the north of Europe generally. Hirsch gives the proportion of deaths in Copen- ^ In 1876-83 the deaths from phthisis per 1000 living were 3'0 at Copenhagen, 2 "63 for 5 of the largest towns, 2"27 for 24 medium towns, and 2"12 for 25 of the smallest towns. This shows the influence of density of population on the prevalence of phthisis. DENMARK. 45 hagen, founded on observations extending over seventeen years, as 1*7 per 1000 of the inhabitants. Of course the ratio will be less for the kingdom as a whole. Pneumonia attains its maximum in Denmark in the month of May. The cases are much more numerous in the spring (March-May) than in the winter season (December-February). The fewest cases occur in the month of August. Bronchitis is much less fatal in Denmark than in many countries in the south of Europe. Chlorosis, although less common than in Norway and Sweden, appears to have been increasing in frequency and gravity of late years. Scrofula must be regarded as one of the most common diseases in Denmark. The deaths from scrofula form 6 per 1000 of the total mortality. S-ypMlis gives rise to a death-rate of 0-94 per 10,000 of the inliabitants. Diabetes is comparatively seldom met with. Cancer is more fatal in Denmark than in any other European State, with the exception of Austria. The death-rate from cancer in the Danish towns reaches the high figure of 1098 per million living. Rheumatic Fever gave rise to 4 per cent, of the admissions into Erederikshospital during a period of twenty-four years. The deaths from this disease are in the proportion of 4 per 1000 of the total deaths in Copenhagen, and 4*6 per 1000 in the other towns. The proportion in England from rheumatic fever and rheumatism of the heart is about 5 per 1000 of the total deaths. We may conclude from these figures that rheumatic fever is about as frequent in Denmark as in England. CHAPTER V. FINLAND. Geography. — Finland extends between 60° and 70° N. lat., and between 20° and 32° E. long., its greatest length being 717 miles, with an average breadth of 185 miles. Its area is reckoned at 145,000 square miles, with a population of rather more than 2,000,000. Finland is called by the natives Suomcnmaa, i.e. the land of lakes and marshes; and it well deserves its name, for about 12 per cent, of the total area is occupied by lakes and 15 per cent, by marshes. Climatology. — At Helsingfors, the capital, the mean annual temperature is 39° F., and that of summer 59° F. The coldest month is February, with an average temperature of 17° F. ; while in July, the hottest month, the thermometer rises to 6 2° F. At Ulea- borg, in 65° l' IST. lat., the mean temperature of the year is 36°*5 F. ; in winter it sinks to 14° or 15° F., and rises in July to 61° F. The winters in the eastern part of the country are extremely severe. The rainfall at Helsingfors averages 20 inches. Vital Statistics. — The death-rate is 27*0 per 1000. The mortality according to season is as follows : — Spring, 28-01 ; summer, 23-39 ; autumn, 23-22 ; winter, 26-38. Pathology. — Hirsch states that " malarial fever is not endemic in Finland ; " while, according to Lombard, it is the most common disease of the country, causing IS per 1000 of the total mortality. This discrepancy is explained by the remarkable variation in the frequency and fatality of malarial fever in different series of years. Dr. Estlander, Professor of Surgery in the University of Finland, stated at tlie International Medical Congress at Philadelphia, that malarial fever was very common in Finland, particularl}^ on the southern coast, at certain periods. This is what he says : — "During the ten years 1850 to 1860 malarial fever raged there with great intensity ; but from 1862 to 1868 it disappeared FINLAND. 47 SO completely that not a single case was to be met with at the hospitals. From 1868 to the present time (1876) it has again attacked that part of the country very severely, but seems now to be fast decreasing." The causes affecting the prevalence of fever are stated as follows : " During the short summer the average stand of the barometer is high, the stand of the water is low, and the bottom of the sea is uncovered in the numberless small creeks and bays in the Gulf of Finland. ISTo tide is perceptible there, and the bottom lies exposed in the sunshine, forming a rich source of miasmatic exhalations. When, on the contrary, the average stand of the barometer is low, all is covered with water, and the summer is rainy and cold, but free from fever. Typhoid fever is endemic, and mixed forms — typho -malarial — are met with in spring and autumn" {Lancet, 25th November 1876). It will be noticed that the epidemic period in Finland mentioned above nearly corresponds with that in Sweden. In a return of diseases from thirty-three localities in Fin- land, I find 1003 cases of intermittent fever are recorded for the year 1889.^ Here is their monthly distribution : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. PS 87 95 139 138 91 99 46 68 67 40 35 It will be seen that the disease in Finland is vernal, a secondary rest taking place in autumn. The temperature in April, when the maximum is attained, is 32°-2 F. at Uleaborg; 33°*9 F. at Helsing- fors, and 33°'6 F. at Kuopio. In other words, intermittent fevers are most prevalent in Finland when the temperature is about the freezing point. Enteric Fever. — In the same year (1889) there were 639 cases of typhoid fever, which were distributed as follows : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 20 27 18 17 34 20 76 131 75 79 87 55 We note here the absence of the April rise, which is so marked in the case of intermittent fever. The maximum prevalence of enteric fever occurs in August, but a marked rise is observed to take place in July, when the temperature is at its height. It seems as if a continuance for some time of a comparatively high tempera- ture is necessary for the full development of the disease, which is thus more prevalent in August than in July. Under the heading of Gastric Fever, Pieniittent Fever, and Fehricula, 962 cases of disease are recorded. It is difficult to say if the fevers so classed are etiologically related to malarial or to typhoid 1 Finska Lakarescdhkapets Handlinrjar, Dr. Fagerliind, Helsingfors 1889. 48 NORTHEKN EUROPE. fever, or if they form a class by themselves, and are independent of both as regards causation. We shall give the monthly distribution of this class of fevers : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 100 104 94 107 77 74 64 43 62 73 96 78 Typhus is rarely met with. Dysentery is rather common in Finland during the summer season. In all, 379 cases were noticed in 1889 in the localities referred to, and of these no fewer than 335 occurred from June to September. This summer distribution of dysentery is also observed in Sweden, but not in Norway, when the maximum falls, on the three months — September to November. Diphtheria and Croup are frequent in Finland. Croup is endemic at lakobstadt, which occupies a low and damp site on the Gulf of Bothnia (Hirsch). Smallpox, Measles, and Scarlet Fever occur in Finland as elsewhere in epidemics of varying intensity. Pneumonia is common, and attains its maximum frequency in the months of February, March, April, and May. In 1889, Epidemic Influenza broke out in November, when there were 506 cases recorded. It attained its maximum in December, when the number of cases recorded rose to 9560, and fell in January 1890 to 1676 cases. Under this influence, a marked rise took place in the prevalence of pneumonia and bronchitis. Fhthisis is said to be common in the larger towns, but to be less frequent in the country districts. Scrofula, according to Lombard, is excessively common, especi- ally in the northern districts. CHAPTER VI. RUSSIA IN EUROPE, Geography. — Paissia occupies that immense region stretching from the Arctic Ocean on the north to the Black Sea on the south, and from the Baltic on the west to the Ural Mountains and the Caspian on the east. On the south-west it is bounded by Germany, Austro- Hungary, and Eoumania. It thus covers the larger part of the great plain of Europe. Excluding Finland and the Caucasus, Eussia has an estimated area of 1,923,503 square miles, and a population numbering about eighty millions. The chief rivers are the Petchora, the Mezen, the northern Dwina, and the Onega, flowing to the Arctic Ocean ; the Ural Eiver and the Volga, into the Caspian ; the Don, into the Sea of Azov ; the Dnieper, Bug, Dniester, and Pruth, into the Black Sea ; and the Neva, the western Dwina or Duna, and the Memen, into the Baltic. From the level nature of the regions through which these rivers flow, they are generally sluggish, sinuous, and liable to cause inunda- tions. Some account of local conditions as affecting the distribution of endemic diseases will be given in connection with the pathology of the several regions. Climatology. — A country so extensive as Eussia necessarily presents great variety of climate. The mean annual tempera- ture of Archangel on the White Sea is 0°*4 C, while that of Baku on the Caspian is 14°"3 C. But the temperature in Eussia is not determined by latitude only ; longitude also has a marked influence on the thermometric means. The climate becomes more extreme as we pass from west to east. The summers are warmer, the winters colder, and the mean temperature of the year lower in the interior than at corresponding latitudes along the Baltic coast. In order to simplify the study of the climate and pathology of a country which covers an area exceeding one-half of the continent of Europe, it will be convenient to divide Eussia into four regions. D 50 NOETHEEN EUEOPE. 1. The Baltic Eegion. 2. The Northern Eegion, extending between latitude 60° K and the Arctic Ocean. 3. The Central Eegion, lying between 50° and 60° N. latitude. 4. The Southern Eegion, between 40° and 50° N. latitude. 1. The Baltic Eegion. The climate of this region is marked by a low annual mean temperature, severe winters, cold springs, warm summers, and by a high degree of humidity. The following table gives the mean temperature of the year (centigrade), and of the months of January, April, July, and October, at St. Petersburg in the north, at Dorpat in the central part of the region, but inland, and at Mittau, on the coast, in the south : — Place. Latitude. Altitude (Metres). Jan. April. July. Oct. Year, St. Petersburg, . Dorpat, Mittan, 59° 56' 58° 23' 56° 39' 10 70 10 -9-4 -8-0 -5-0 2-0 2-3 4-9 17-7 17-4 17-6 4-5 5-4 6-9 3-6 4-3 6-1 The average amount of rainfall along the Baltic varies from 48 to 60 cm., according to locality, and its monthly distribution per cent, is as follows : — Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 5 5 6 6 s 9 12 12 11 11 9 6 2. The jSToetheen Eegion. That part of Eussia situated north of the 60tli parallel has an extremely rigorous climate. The winters are long, the country in the north being covered with snow from six to nine months. The summers are short, but moderately warm. We shall give the temperature at three stations, viz. Archangel, Petrosavodsk, and Ust- Sysolsk, as illustrating the climate of the north, south-west, and south-east of this region : — Jau. Ain-il. July. Oct. Year. -13-6 -1-1 15-8 1-4 0-4 -10-4 0-8 17-0 3-6 2-2 -15-2 0-3 16-5 0-5 O'S 3. The Centeal Eegion. The climate of the Central region is characterised by great extremes. Cold winters, especially towards the east; warm summers, Place. Latitude. Altitude, Archangel, . 64° 33' 10 Petrosavodsk, 61° 47' 50 Ust-SysoLsk, 61° 40' 100 RUSSIA IN EUROPE. 51 the mean summer temperature increasing as we advance south and east. We shall give the temperature of Kostroma, Moscow, and Ivursk for the central districts, from north to south ; that of Kazan and of Saratov for the eastern districts ; and of Kiev and Orenburg for the extreme west and east : — Place. Latitudi' Altitude. Jan. April. July. Oct. Year. Kostroma, . 57° 47' 110 -11 -s 1-8 19-0 3-8 3-1 Moscow, 55° 46' 160 -11-1 3-4 18-9 4-3 3-9 Kursk, 51° 45' 210 - 9-9 4-7 19-3 6-4 5-2 Kazan, 55° 47' 80 -13-8 3-2 19-6 3-7 2-9 Saratov, 51° 29' 90 -10-2 4-6 21-7 5-7 5-4 Kiev, . 50° 26' ISO - 6-0 6-7 19-1 7-6 6-8 Orenburg, . 51° 46' 110 -15-3 3-2 21-6 3-8 3-3 The annual amount of rainfall varies from 35 to 50 cm. 4. The Southern Eegion. The climate throughout this region is extreme, the winters are less severe than in the central governments, but the summers are excessively hot. The rainfall is scanty in many places in the east. At Astrakhan the average is about 12 or 13 cm. We shall give the temperature for Pultava and Sebastopol as representing the south- central districts, north and south ; for Astrakhan, Stavropol, and Baku for the east and south-east districts. Place. Latitude. Altitude. Jan. April. July. Oct. Yeai Pultava, 49° 35' 140 -8-2 6-8 21-1 8-2 7-1 Sebastopol, . 44° 37' 40 1-9 9-7 23-2 13-5 12-1 Astrakhan, . 46° 21' 20 -7-1 9-4 25-5 10-0 9-4 Stavropol, . 45° 3' 550 -4-1 7-8 20-9 9-7 8-6 Baku, . 40° 22' 3-4 11-1 25-8 16-6 14-3 Vital Statistics. — Lombard gives the birth-rate of Eussia at 50'7 ]3er 1000, which is higher than that of any country in Europe. The government of Saratov in the south-east has a birth-rate of 60 per 1000, while in many of the central governments the rate exceeds 50 per 1000. Wilna, Volhynia, and Archangel have the lowest proportion of births, the rate varying from 30 to 40 per 1000. The marriage-rate is also high in Eussia, especially in the provinces situated in the south-east and south-west. The death-rate for the whole of Eussia in Europe is estimated by Lombard at 3 5 '4 per 1000. The mortality in Eussia is thus nearly double that of Norway, and higher than that in any European country. The governments of Vologda, Perm, and Viatka show the highest mortality, and the next in order are Nijni-iSrovgorod, Moscow, Tula, Orel, and Voronez : in all of these the death-rate exceeds 40 per 1000. The death-rate is comparatively low in the 52 NOETHEEN" EUROPE. governments of Archangel, Lapland, Poclolia, Taurida, and Ekater- inoslav.i In the Baltic provinces winter and spring are the seasons of highest mortality; in the centre and south, summer is the most deadly season. The Baltic Peovinces — St. Peteesbueg, Esthonia, Livonia, coueland, kovno. Pathology. — Malaria. — The capital is built upon the delta of the Neva, occupying a site which was originally marshy, but which has now been drained, and either built over or laid out in gardens and meadows. The city of St. Petersburg is practically free from intermittent fever ; it is, however, far from healthy, the average death-rate being 30-2 per 1000. Esthonia, Livonia, Courland, and Kovno are low and marshy. Malarious diseases are common throughout these provinces, although they do not, as a rule, assume here a grave form. Dorpat, an inland town of Livonia, is situated on the Ptiver Embach, which falls into Lake Peipus. The Embach is subject to overflow, which adds to the humidity of a soil already damp. This explains the frequency of malarious diseases in the town and neighbourhood. Piga, again, the chief town of the province of Livonia, situated on the Dwina, five miles from where it enters the Gulf of Ptiga, is subject to the paludal conditions similar to those of Dorpat, and suffers in the same way from inter- mittent and remittent fevers. Tyijhoid Fever is endemic in St. Petersburg. It is, in fact, more fatal here than in any of the other great towns of Europe. The average death-rate from typhoid and typhus fevers for the five years ending 1889 was no less than 0-9 per 1000, the greater part of which mortality was undoubtedly due to typhoid fever. In 1885 the deaths from typhoid fever alone were 0"89, and in 1886 the ratio rose as high as 1'13 per 1000, The disease is most frequent in the first and second quarters, and least so during the third quarter. Typhoid fever is also met with, but to a less extent, in the other Baltic provinces. Typhoid fever is stated by Rey to have been epidemic in Dorpat in 1826 and in 1841 ; and in 1845-47 at St. Petersburg. Diphtheria caused a death-rate of 0-47 per 1000 in St, Peters- burg during the five years 1885-89. I have not met with any data for the other provinces ; but I find that in the Prussian town of 1 The death-rate of St, Petersburg (1885-89) Avas estimated at 30-2, that of Moscow (1888-9) at 38-2, and that of Warsaw (1886-87) at 27-G per 1000. KUSSIA IN EUEOPE. 53 Memel, which is on the frontiers of Russia, and geographically a part of Kovno, the average deaths from diphtheria and croup, in the two years 1887 and 1888, was 0*82 per 1000. It seems probable, therefore, that diphtheria is prevalent throughout these provinces. In the Baltic provinces of Eussia, diphtheria attains its maximum in the first quarter. Biavrhoia is an exceedingly prevalent and fatal disease in St. Petersburg; the mortality in the five years ending 1889 from diarrhoeal diseases reached the enormous ratio of 4'41 per 1000.^ There is this peculiarity about the disease in St. Petersburg, that it is by no means restricted to the warm months. In 1885 the maximum mortality took place in the third quarter ; but the number of deaths in the first quarter (January to March) was also very high. In 1886 and in 1888 the deaths in the first, second, and third quarters were all excessive. In short, the causes of this disease in St. Petersburg are, to a greater extent than elsew^here, independent of high temperature. Dysentery is by no means a fatal disease in the Baltic provinces generally, although it is somewhat prevalent at Dorpat and in a few of the more malarious localities. Dysentery was epidemic in these provinces, as well as in the west-central region, in the years 1845-46. ChohrcL — The Baltic provinces were visited by cholera in 1831, 1847, 1848, in 1852-53, in 1860, 1861, 1862,in 1866-67,1869, 1871, and 1873. In 1852—53 the epidemy raged in winter, notwithstanding the extreme cold of that season in these provinces. Typlius has been repeatedly epidemic in the Baltic provinces during this century. Although it is still endemic,^ I have no data for determining its prevalence at the present time. From 1864 to 1869 the admissions for typhus into the Obuchoff hospital in St. Petersburg numbered 6789, while in the same period the admissions for typhoid were 3664. At the present day typhus is certainly much less frequent. Edapsing Fever appeared in an epidemic form in the summer of 1864 at St. Petersburg, and in 1865 it broke out in Livonia. It was excessively common in St. Petersburg from 1864 to 1869, the cases being most frequent in the cold months, and not in the summer season, as in Glasgow and Edinburgh in 1843—44 and 1847. Measles and Scarlet Fever are prevalent and fatal diseases in St. ^ I take both tlie number of deaths and of tlie population from the Registrar- General's Annual Summary, but no gi-eat reliance can perhaps be placed upon the estimates of population. The figures are thus to be accepted as approximate only. " Pushkarey, Ejened, Mm. gazeta, 1884. 54 .NORTHERN EUROPE. Petersburg ; the average mortality from tLe former during the five years 1885-89 was 0-71, and from the latter 0*65 per 1000. Wliooinng -Cough in the same period gave rise to a death-rate of 0-23 per 1000. Influenza. — Eussia has been the starting-point of many of the epidemics of influenza that have spread over Europe ; and when it was raging in Eussia, the Baltic provinces have never escaped the disease. The mortality during the epidemy of 1889-90 was very considerable. Phthisis occupies a leading place among the fatal chronic diseases, and is perhaps as common as in Western Europe. Of the prevalence of Pneumonia, Hirsch states that it occurs to a moderate extent, but not more frequently than in many other countries more to the south. It is said to be common in spring. I have met with no more precise information respecting Pronchiiis than that it is common in the winter season in this region. Pleurisy is by no means rare in St. Petersburg and throughout the Baltic provinces. Leprosy exists along the coast from St. Petersburg to Eiga. Bergman published in 1869 notes of 104 cases observed from 1861. Of these, 77 were natives of Livonia, 17 of Esthonia, 3 of Courland, and 7 of St. Petersburg. The province of Livonia is thus the headquarters of the disease. Dr. Wellberg had 24 cases under his care in the hospital at Dorpat from 1878 to 1884. Syphilis, at the present day, is widely prevalent in the Baltic provinces both of Eussia and Prussia. Up to about the middle of this century it was so general as to be justly regarded as endemic in Lithuania, which includes Livonia, Courland, Kovno, and East Prussia. The Prussian Government had to establish special hospitals in the districts for the treatment of syphilitic patients. Of 665 cases of syphilis which came under the care of Dr. Schnuhr from the 1st November 1835 to 1st November 1837, no fewer than 218 were cases of broad condylomata, affecting the hips, arms, thighs, labia, and scrotum ; and in some cases the back, arm- pits, forehead, scalp, mammte, or angles of the mouth ; and 1 G were in boys and 12 in girls under the age of fifteen years. Primary ulcers of the throat and mouth occurred in 1 6 3 cases ; of these, 15 were boys and 8 were girls under 15 years. Secondary ulcers and broad condylomata of the mouth and throat occurred in 60 cases. Syphilitic diseases of the skin occurred in 30 men and 20 women; secondary ulcers of the extremities in 18 men and 20 women; affections of the bone in 24 cases. Primary RUSSIA IN EUROPE. 55 sores (chancres) on the organs of generation were met with in 48 cases, gonorrhoea and leucorrhcea in 28, and buboes in 6 instances. " Condylomata," Dr. Schniihr says, " were found in many cases, where, from minute medical examination, as well as medico-legal investigation, it appeared impossible to believe that any primary sore upon the organs of generation could have preceded their appearance. The tender age of many of the patients was in itself sufficient to rebut the idea of their being the result of sexual inter- course. Among the poorer classes whole families sometimes occupy the same bed, and in such cases it is by no means uncommon to find all the members of the family, from the grandfather to the infant, affected with condylomata in various parts of the body." The peculiar features of the syphilis of Lithuania, according to Dr. Schnuhr, are (1) the excessively large number of cases of condylomata and ulcerated sore throats ; (2) the occurrence of these two affections apparently as primary symptoms ; (3) the frequent propagation of the disease by other means than by coition ; (4) the comparatively rare occurrence of chancres ; (5) the almost complete immunity of the lymphatic system ; and (6) the rare occurrence of general lues, in spite of the frequent and great neglect of the primary affection. This account of the endemic syphilis of Lithuania is not without interest. It seems to be widely different from the radesyge of Norway, and bears the closest possible resemblance to the tety of Madagascar.^ Scrofida is frequently met with. Diabetes iQ exceedingly rare, at least in the capital. The Northern Governments — Archangel, Olonetz, Yologda. Pathology. — Malaria is little known in any part of this region. The few cases of intermittent fever occasionally met are restricted to the more marshy localities in Olonetz. Dr. Buchholz observed a considerable number of cases of tertian fever in 1856 in the district of Petrosavodsk on Lake Onega ; and the cases must have been of some gravity, inasmuch as the deaths were in the proportion of one to forty-six treated. This, it should be remarked, was the period when malaria was epidemic in Sweden, and we may suppose that the epidemic influence made itself felt on the shores of Lake Onega, where, we are told, the disease, as a rule, is seldom seen. Typhoid Fever is met with throughout the whole of these 1 Medkin. Zeituwj, 1837 ; Med. Review, July 1838. 56 NOETHERN EUEOPE. provinces, extending even to the Kola peninsula, in the extreme north, where it has prevailed in an epidemic form amongst the Lapps inhabiting that region. Typhus Fever is not a stranger in JSTorthern Eussia ; but, so far as can be gathered from the very imperfect data at our disposal, neither typhoid nor typhus fever is so frequent in the north as in the centre and south of the empire. Dysentery is not endemic in the northern provinces ; but sporadic cases are met with in all the governments. In certain years the cases become so numerous in some districts that the disease may be looked upon as epidemic. We have no accounts, however, from this region of those destructive epidemics which have been witnessed in Sweden ; but this may be owing to our ignorancfe of the medical history of ISTorthern Eussia. Di2jMheria. — To what extent diphtheria, which has been so prevalent in other parts of the empire, has established itself in the north, I have no means of knowing. Croup is of frequent occurrence in the northern governments. Asiatic Cholera visited Archangel in the summer of 1831, and again in 1871; but apart from these outbreaks, the territory north of latitude 64° has been spared. The eruptive fevers — Smallpox, Scarlet Fever, and Measles — are met with, the two latter in epidemics recurring at irregular intervals ; but none of them are specially prevalent in this region. Bronchitis is one of the commonest maladies in North Eussia, and pneumonia and pleurisy are also of frequent occurrence, especially in the governments of Olonetz and Archangel. Phthisis forms an important factor among the causes of death in every part of this region. During the three years 1857-59 this disease caused 204 per 1000 of the deaths occurring in the civil hospitals in Vologda, 190 in those of Archangel, and 65 in those of Olonetz ; while for the empire generally the proportion was 165 per 1000 (Lombard). It thus appears that phthisis is more fatal in the north of Eussia, as a whole, than in the central and southern governments ; and that, as respects the north, the western and, in parts, marshy government of Olonetz is that in which phthisis is least prevalent. Scorhutus is, in a certain sense, endemic in the governments of Archangel and Olonetz. Goitre occurs both on the eastern and western shores of Lake Ladoga. Leprosy is unknown in the northern governments. russia in europe. 57 The Central Governments, Central Eussia, lying between the 50tli and 60th parallels, comprises numerous governments, which may be arranged into three groups. (A.) The western subdivision includes the govern- ments of Pskov, Vitebsk, Vilna, Grodno, Minsk, Mohilev, the kingdom of Poland, and Volhynia. (B.) The central subdivision comprises Novgorod, Jaroslav, Tver, Kostroma, Vladimir, jSTijni- Novgorod, Moscow, Smolensk, Kaluga, Tula, Eiazan, Pensa, Tambov, Tchernigov, Kiev, Orel, Kursk, and Voronez. (C.) The eastern sub- division comprises Viatka, Perm, Kazan, Ufa, Simbirsk, Saratov, Samara, and Orenburg. Physical Features. — (A.) Pskov is not generally marshy, but contains numerous small lakes. Vitebsk, watered by the Dwina, is hilly, with extensive wooded plains, a considerable area being covered by marsh and lake. Vilna is generally flat ; the highest elevation does not exceed 1000 feet. It is watered by the ISTiemen, and is studded with some four hundred small lakes. The south of Grodno lies in the basin of the Vistula, the north in that of the Memen. Extensive morasses are met with in the southern districts. Poland generally is flat. The chief rivers are the Vistula and its affluents, which often overflow their banks and inundate large tracts of land. Minsk is to a great extent covered with woods and marshes. Amongst these are the Pinsk marshes, formed by the Pina and the extensive swamps in the course of the Beresina and the Pripet. Mohilev consists, for the most part, of a fertile plain, watered by the Dnieper and its tributaries. It has no great extent of marsh land. Volhynia, where it borders on Minsk, is marshy, but in the south it is hilly and well drained. {B.) The central division, corresponding in part to the low plateau stretching south from the Valdai Hills, between the head waters of the Volga and Dwina on the north and those of the Don and Dnieper on the south, is, upon the whole, less marshy than the western region. Still, numerous lakes and marshes are met with in Novgorod, Moscow, Tver, Kostroma, and in other localities, while Jaroslav and Nijni-Novgorod are subject to inundations, producing temporary marshes which are by no means innocuous. {C.) The plains of Kazan, Perm, Ufa, Simbirsk, and Samara are all subject to regular annual inundations of the Volga and the other large rivers, such as the Kama, Viatka, etc., which discharge into the A^olga. During the inundations, vessels may be seen sailing over pastures and cornfields to reach the tow^ns, which are here situated on heights. When the waters have withdrawn into their 58 .NOETHEEN EUEOPE. accustomed channels, pools are left behind, where water stagnates for several months. Pathology. — Malaria. — {A.) Intermittent fever prevails to a large extent in the western division of Central Eussia. In the govern- ment of Vitebsk malarial fevers are frequently seen ; in Pskov they are less common. In the inundated plains of Poland, fevers, sometimes of a pernicious character, are observed in summer and autumn. The vast marshes of Minsk render it one of the most malarious districts in the west. Prank, in noticing the prevalence of intermittent fever in Vilna, says that he has several times seen these fevers rage in the month of Pebruary, when the Eeaumur thermometer marked 20° of frost and more, and when the marshes formed a mass of stony hardness from which no exhalations could be given off.^ In Mobile V, Volhynia,^ and Grodno, intermittent fever counts among the commonest of maladies. {B.) Malaria is endemic in the marshy districts of Novgorod. Moscow and its neighbourhood suffer in a minor degree. Here intermittent fever forms about one-seventh of the total diseases treated. Some districts in the Moscow government, such as Podolsk, are decidedly malarious. The governments of Vladimir and ISTijni-lSrovgorod present numerous malarious foci. Jaroslav and Kostroma are more salubrious, but some of the inundated localities in the former are subject to fever. At Slouta, in the Gliickov district, and in other parts of the Tchernigov govern- ment, quotidian and tertian fevers are very prevalent. At Likhvin, in Kaluga, and in numerous localities in Tambov, Kursk, Kiev, and Voronez, malarial fevers are endemic. The other governments in this division suffer, but to a less extent. {C.) Malarial fever is endemic in many parts of Kazan, such as in Tchistopol,^ and in Perm and Ufa after the inundations dry up. According to a writer quoted by Graves,^ " Ufa is visited about that time by an intermittent fever, which attacks the patient every seventh day only, but is so violent that it generally proves fatal." In Samara intermittent and remittent fever formed almost the half of the cases treated by Dr. Ucke,^ and they also form a large proportion of the cases treated in the military hospital of Orenburg. Simbirsk is also subject to the malarious influence ; and in some places, as, for example, Sengilei, they are both frequent and grave. We observe a gradual increase in the intensity of the disease as we advance from north to south. The quotidian type becomes > Frank, TraiU path, intern., Paris 1838. - Vrach, 1884. " Shidlovski, VrcCch, 1883. * Graves, Clinical Medicine. ° Das Klima und die Kranhheiten der Stadt Samara, Pjerlin 1863, quoted by Lombard. RUSSIA IN EUROPE. 59 more frequent, and in the more malarious localities in the southern parts of the central division remittent fever is of more frequent occurrence. Typhoid Fever is endemic in all parts of Central liussia, but we have no means of ascertaining its relative prevalence in the several divisions and governments. At Warsaw the death-rate (188G— 87) from typhus and typhoid was 554 per million, while the death- rate for the same diseases at Moscow (1888-89) was 404 per million. Typhus Fever is both endemic and epidemic in this part of Eussia. Its endemic seats, according to Hirsch, are " Poland and the government of Viatka, and the adjoining districts on the Volga." Typhus has frequently assumed an epidemic form in these govern- ments durin£[ times of famine or of war. Bclaijsing Fever has often been observed in various parts of Central Eussia. It was epidemic at Moscow in 1840—41, in Novgorod and other districts in 1864, and in Poland in 1868. Cerebrospinal Meningitis has appeared from time to time in many of the central governments. In 1863 it was epidemic in the government of Kaluga; in 1865 and later, in Poland, Minsk, and Moscow. Dysentery is not endemic in any of the central governments, but sporadic cases are met with in them all. N'ovgorod, Minsk, Mohilev, Moscow, Jaroslav are the governments in which the disease is of most frequent occurrence. It is interesting to note, as bearing on the etiology of the disease, that it appeared in 1857 in all localities where troops from the Crimea, amongst whom it was common, were stationed. Dysentery occasionally becomes epidemic in limited localities, but we do not read of extensive and fatal outbreaks of the disease in Central Eussia such as those which have been witnessed in other countries. We have already noticed its extension to the western governments in 1845-46, when it was epidemic in the Baltic provinces. Diarrhoea is more or less prevalent throughout this region during the summer season, especially in Moscow, Tula, and other large towns. The death-rate from diarrhoeal diseases at Moscow in 1888-89 was no less than 9-12 per 1000 living, which is the highest rate of any town in Europe. Warsaw had also a very high death-rate from this class of diseases, the ratio in 1886—87 having been as high as 4*46 per 1000. Asiatic Cholera has overrun every government in Central Eussia during one or other of its numerous epidemic visitations. This region of Eussia with which we are dealing has probably suffered 60 NOETHEEX EUEOPE. to a greater degree from cholera than any other part of Europe. In 1830—31 cholera rasred from the eastern governments of Perm and A^iatka to those of Minsk, Grodno, A^ilna, and Volhynia on the west. No less widely diffused was the epidemy of 1847-48. In 1852, 1853, 1855, and 1859, many districts were visited once or oftener by the disease. Still more general was the diffusion of this pestilence from 1865-68. From 1869 to 1874 a series of most destructive outbreaks occurred, which proved excessively fatal in the central group of provinces in this region, especially in Tambov, Jaroslav, and Moscow. In these three governments the cholera mortality in 1871 averaged 6 per 1000 of the population. The later outbreaks, such as that of 1874, have been of small extent and less malignant. Plague. — The central parts of Eussia have not escaped the inroads of plague during past centuries. No later than 1770 it appeared at Moscow, and the close of the eighteenth century (1798) witnessed an outbreak of the disease in Volhynia. From that time Central Eussia has been free from this pestilence, although, as we shall presently see, it has several times, during the present century, broken out in the southern governments. Bvplitlieria appeared at Moscow in 1853, and since that date it has been frequently seen throughout this region. In 1888—89 diphtheria caused a mortality of 812 per million in Moscow, and of 864 in Warsaw. These figures no doubt include croup. Croup is prevalent to a greater or less degree in all the central governments, especially in those of the western division. The Eruptive Fevers appear to be moderately prevalent in Central Eussia, but we have no means of comparing their frequency here with that in other countries. Scarlet Fever is stated to be exceed- ingly rare in Samara. As to Whooping-Covgli, all we know is that it appears in epidemics in all parts of the empire. Fiespiratory diseases are met with as frequently as in "Western Europe generally. Pneumonia is stated by Boulgakoff to be frequent at Tchernigov. At Moscow respiratory affections are signalised as common, and at Samara pleurisy and pneumonia were found by Dr. Ucke to form nearly one-twentieth, and bronchitis and tonsillitis one-twenty-third, of all the cases treated. Phthisis is less prevalent in Central Eussia than in the north, but is considerably more common than in the south. The authorities quoted by Hirsch testify to its prevalence in Novgorod, Yiatka, Kazan, and Kursk. It is also of frequent occurrence in Tchernigov and Orenburg ; while in Samara, on the other hand, it is exceedingly rare. Hepatic diseases are rare in the more northern governments, but they are of more frequent occurrence in the south. At Samara IIUSSIA IN EUROPE. 61 diseases of the liver and spleen form 13 per 1000 of the diseases treated. Scrofula prevails to a great extent throughout the centre of Eussia, from the Baltic to the Urals. Goitre is endemic in the hilly districts of Perm and Orenburg, and at one or two localities in other governments. Leprosy is unknown. Rheumatism and Rheumatic Fever are reported to be of frequent occurrence throughout this region. Scorhutus is of not unfrequent occurrence, especially in prisons. Plica Polonica, an affection of the scalp, in which the hair is matted together in tufts, sometimes forming an irregular cap-like mass, is endemic in the western division of Central Eussia. The governments of Vitebsk, Grodno, Kovno, Minsk, and Volhynia are those in which the disease is most prevalent. The Southern Governments. That part of Eussia in Europe lying to the south of the 50th parallel may be divided into four governmental groups. {A.) The south-western governments of Podolia, Bessarabia, Poltava, Kherson. {B.) The south-central governments of Kharkov, Ekaterinoslav, Taurida (Crimea). (C.) The south-eastern governments of Astrakhan, the Don Cossack country, and jSTovo Tcherkask. {JD.) The Caucasian governments of Kuban, Stavropol, and Circassia. Physical Features. — With the exception of the country bordering on the Caucasus, the whole of the governments within this region consist of low plains, through which the Volga, Don, Dnieper, Dniester, and other rivers flow on their way to the Caspian, the Sea of Azov, or the Black Sea. Some of the southern parts of Astrakhan are actually below the sea-level. The Volga, for 300 miles from its mouth, flows through a level, treeless plain, the soil of which is sand or light clay strongly impregnated with salt and nitre. The left bank of the river is low, permitting it to break up into collateral streams connected by cross- channels, and intersected with shallow watercourses. The river begins to rise in the end of April, and continues rising until the beginning of June, flooding a belt of land ten miles broad. It then begins to subside, and regains its old level by the beginning of July. The Don, in the same way, overflows its banks for miles when the ice melts, so that in many places the houses have to be raised on piles to prevent them from being submerged. The Dnieper, the Dniester, the Bug, and their tributaries are also liable to overflow 62 NORTHERN EUROPEr their banks ; ancV extensive tracts of swamp and water-logged soil are formed along their course, especially in their lower stretches, where they flow through flat plains. Similar conditions are met with near the mouth of the Kuban, the Kouma, and the Tereck in the Caucasian provinces. . Pathology. — Malaria is endemic to a large extent throughout the whole of this region, exhibiting a higher degree of intensity than in the central governments. The remittent type here assumes greater prominence, although the intermittent, often of the quotidian type, is still that which is most frequently met with. The greater part of the mortality, however, is caused by autumnal remittents. The period of maximum fever prevalence differs from that of the northern and central regions. In the centre and north of Eussia, as in Sweden, malarial fever is chiefly vernal ; in the southern provinces it is autumnal, the fever season extending from August to jSTovember. This change in the period of the fever maximum is the result of the greater intensity of the malarial infection. The Inch summer temperature, combined with local conditions of soil found in this region, give rise to an infection sufSciently powerful to manifest itself at once in fever paroxysms of the remittent or quotidian type. Whereas in the north the temperature is low, the infection is less intense, and it is only after months of latency that it manifests its presence in the system by febrile phenomena during the cold and changeable spring months. It is difficult to believe that the malarial infection is contracted at the period when the fever manifests itself, when that period coincides with tempera- tures below the freezing point. It appears much more probable, for reasons which shall be given in the concluding chapter of this work, that the vernal fevers of cold countries are the manifestation of an infection dating from the previous summer or autumn. When, therefore, Meyersohn states that he has observed inter- mittent fevers to prevail in the province of Astrakhan during winter, when the thermometer registered 20° of frost,^ we are to look upon these paroxysms as the expression of an infection of the system contracted during the previous summer or autumn. jMalaria is general and intense in the government of Astrakhan, where the climatic and telluric conditions are highly favourable to its development. We need not wonder, then, that a German colony that attempted to settle in this province was decimated by fever.^ Accounts are numerous of the prevalence of malarial fevers in Kharkov, Poltava, Ekaterinoslav, Kherson, and in many parts of ^ i\Ieycrsohii, Med. ZUj. liuss. 1859, quoted by Hirsch. - Report of Plague Inquiry Commission, Privy Council. RUSSIA IN EUROPE. 6S the Crimea (as, for example, in the valley of Inkermann), and along the swampy shores of the Sea of Azov. Bessarabia, as a whole,^ but more particularly some districts, such as Bendery,- are extremely malarious. In few parts of the world is malaria more widely diffused than in the country north of the Caucasus. In Daghestan and Stavropol, both along the shores of the Caspian and inland, even at considerable elevations, fevers of a remittent type, and accompanied by cachexia, are of constant occurrence during the autumn, while the intermittent type is observed to prevail during the other seasons. Derbend and Temir-Khan-Shura in Daghestan, and the delta and banks of the Tereck, are noted haunts of fever. Typhoid Fever is endemic in Southern Eussia, and often assumes an epidemic form. As it is included with typhus in returns of disease, it is impossible to ascertain its relative prevalence in the several governments. Typhus is frequently epidemic along the Eussian shore of the Black Sea and in the Caucasus. Witness the extensive outbreaks of the disease among the troops during the Crimean war in 1854-56, by whom it was disseminated over a great part of Eussia, and even to some extent in England. During the Eusso-Turkish war of 1877—78, " the army of the Caucasus was decimated by typhus " (Hirsch). At Astrakhan, in 1862, typhus and typhoid fevers constituted 87 per 1000 of the diseases occurring among the marines. At iSTikolaiev they formed 172 per 1000 of the total diseases and a large pro- portion of the deaths.^ Relapsing Fever has so frequently made its appearance at Odessa that we may regard it as endemic on the shores of the Black Sea. Cerebrospinal Meningitis was epidemic in the Caucasus in 1864, and in 1867—68 it spread over the whole of the Crimea. These epidemics are recorded by Hirsch, but I have not met with any reference to later outbreaks in this region. Plague has found the conditions favourable to its outbreak and spread in this region, as is shown by the fact that it has repeatedly made its appearance in these governments after it had become an historic disease in most parts of Europe. A severe epidemy of plague, introduced from Turkey, and extending from Odessa to the Crimea and inland to Podolia, occurred in 1811. In 1828—29, and again in 1837, the disease was epidemic in Odessa. Its last appearance on European soil, and then only to a limited extent, was in the government of Astrakhan, in the winter of 1878—79, where, ■^ Voyenno-sanit. dielo, 'No. 14, 1885. ^ RussTcaja Meditsina, 1884. ■'' Lombard, Traite de dimaiologie mid. 64 XOETHEEN EUROPE. after an absence of 70 years, it appeared in the valley of Yetlianka on the Volga, and a few other localities, causing about 600 deaths.i Asiatic Cholera. — Astrakhan was the first point on European soil visited by cholera. This was in September 1823, during its first pandemic outbreak ; and it was again through Astrakhan that this pestilence penetrated into Paissia in 1830, and from Piussia spread to the rest of Europe and America. The third pandemic invaded Europe in 1847 through Astrakhan and Odessa ; and during these or the succeeding outbreaks, to which we have already referred, the whole of this region has paid its tribute to this pestilence. Diphtheria appeared in Podolia in 1869, having been introduced from Eoumania. Erom Podolia it spread over a great part of this region, causing a terrible mortality. It still prevails widely through- out this part of the empire. Dysentery and Diarrhcea are endemic in Southern Eussia, especi- ally in the Caucasus. Smallpox is more prevalent in the southern governments than in any other part of the empire. The other eruptive fevers are also met wuth, but we have no data for estimating their prevalence. Bronchitis, Pneumonia, and Pleurisy are far from rare. In Astra- khan and iSI'ikolaiev they formed, along with croup and diphtheria, 9 1 and 8 7 per 1000 respectively of the total treated. Phthisis is decidedly less frequent in the south than in the centre of Eussia. The statistics of the military hospitals of the Caucasus, published by Lombard, seem to prove that the disease is comparatively rare in this part of the empire. Diseases of the liver and spleen are of frequent occurrence in the provinces bordering on the Black Sea and in the Caucasus. Scrofula is met with in all parts of the south, and is said to be very common in Odessa and Astrakhan ; but it is upon the whole less prevalent in the southern than in the central and Baltic provinces. Goitre is endemic in various localities in the Caucasus. Leprosy is still met with in the Crimea, along the shores of the Sea of Azov, at Astrakhan and Jaik, and amongst the Ural Cossacks (Lombard), and in the Caucasian provinces. Syphilis is excessively common in some of the southern govern- ments, such as Astrakhan, Kiev, Poltava, and Podolia. 1 ISTetten Radcliffe, Practitioner, vol. xxvii. p. 67. EUROPE. ♦ DIVISION II. CENTEAL AND WESTERN EUROPE. CHAPTEE VII. GEE-MANY. Geography. — Germany comprises an aggregate of twenty- six States, occupying the north-west of Central Europe. It stretches from the North Sea and Baltic on the north to the borders of Switzer- land and Austro-Hungary on the south, and is bounded by Holland, Belgium, and France on the west, and by Eussia on the east. The area of the whole empire is 211,168 square miles, with an estimated population, in 1887, of 47,580,000. Prussia has an area of 136,073 square miles, with a population, in 1887, of 28,700,000. Bavaria has an area of 29,632 square miles, with a population, in 1885, of 5,420,199. Saxony, with an area of 5856 square miles, had 3,249,000 inhabitants in 1887. Wurtemberg has an area of 7619 square miles, and a population, in 1885, of 1,995,185 souls. The Grand Duchies, Duchies, Principalities, Free Towns, and the Pteichsland of Alsace-Lorraine have a combined area of 31,988 square miles, with an aggregate population of 8,210,801. Berlin, the capital of Prussia and of the empire, had a population of 1,438,000 in 1888; Hamburg, 550,694; Dresden, 259,142; Breslau, 313,451 ; and Munich, 275,000 inhabitants. The northern part of Germany is a continuation of the vast plain of Eussia and Poland, which extends along the Baltic and North Sea to Holland. The central and southern regions consist of a table-land, ranging from 500 to 2000 feet above the sea-level, broken by ranges and groups of mountains rising in the ISToric Alps of Bavaria to a height of 9665 feet. The soil of the plains is, for the most part, light and sandy, with tracts of peat interspersed. Moors and heath occupy a con- siderable area in Hanover and Llineburg. The higher lands are generally fertile, and the country, as a whole, is w^ell cultivated. The chief rivers are the Vistula and Oder, flowing into the Baltic ; the Elbe, the Weser, the Ems, and the Ehine, running into the North Sea ; and the Danube, which, rising in the Black Forest in Baden, runs through Wurtemberg and Bavaria in German territory on its •course to the Black Sea. The country on the Baltic lying between 68 CENTRAL AND WESTERN EUROPE. the Memen and the Vistula, as well as Pomerania and Mecklenburg, are dotted over with numerous small lakes. The littoral of the Baltic and North Sea, as well as the banks of the rivers in the lower part of their course, and the margins of the lakes, are in many places swampy. The interior is generally well drained, and presents only very limited areas of marshy soil in the river valleys. Climatology. — The temperature over Germany does not pre- sent the diversity that the extent of the country might lead us to expect. The vicinity of the ocean on the north mitigates the cold, while the higher altitude of the interior modifies the heat which its more southern latitude would otherwise possess. The following table, after Hann, gives the mean temperature centigrade of various localities in the north from east to west, and in the eastern, the central, and the western districts from north to south : — Northern Stations, East to West. -^,^ T 4.-4. 1 Altitude Temperature. Place. Latitude, ^^^^^^^y j^n. April. July. Oct. Year. Danzig, . . .54° 21' 22 -1-5 6-4 17-9 8 '8 7-6 Stettin, . ■. . 53° 26' 42 -1-5 7-4 ISl Q'2 8-3 Hamburg, . . . 53° 33' 20 -0-4 7-6 17-3 8-9 8-5 Eastern Stations, North to South. Bromberg, . . . 53° 7' 52 -2-8 7-0 18-1 8*2 7-5 Posen, .... 52° 25' 82 -2-6 7-4 18-4 S'S 7-9 Breslau, . . . 51° 7' 147 -2-2 7-9 18-5 9-4 8-3 Central Stations, North to South. Berlin, . . .52° 30' 48 -0-8 8-4 18-8 9*7 9-0 Leipzig, . . . 51° 20' 119 -1-2 8-3 IS'O 9-0 8-5 Nuremberg, . , 49° 27' 316 -2-8 8-1 17-8 8-6 7*9 Munich, . . .48° 9' 528 -3-0 7-6 17-3 8 '3 7*5 Western Stations, North to South. Crefeld, . . . 51° 20' 45 O'S 8-7 18-2 9-8 9-3 Trier (Treves), . . 49° 46' 150 I'l 9-5 18-5 lO'l 97 Strassburg, . . . 48° 34' 144 -0-3 9-8 19-2 10-1 10-2 The mean rainfall of the whole country is estimated at 71 cm., or 2 8 inches. The coast line and the mountains have the heaviest, while Silesia and Ehenish Bavaria have the scantiest rainfall. The months of June, July, and August are, throughout the whole country, those in which the rainfall is heaviest. Vital Statistics. — The marriage, birth, and death rates for the whole empire for the ten years ending 1887 were 15-3, 37-4, and 25-7 respectively. In Prussia the average death-rate (1881-87) was 25-2 ; in Saxony (1885-87) it was 28-6 ; in Bavaria (1885) it was 29-5 ; and in Wurtemberg (1885-88) it averaged 26-2 per lOOQ, GERMANY. 09 The maximum mortality in Germany falls on winter and spring, — the prolonged cold giving rise to a higher mortality than the heats of summer. This rule does not apply to the large towns, in many of which the mortality is estival, as will be seen by the follow- ing table, giving the mean quarterly death-rates per 1000 for five of the most important cities: — City. Period. First Second Third Fourth Quarter. Quartcr- Quarter. Quarter. Hambur£f, . 1885-88 28-1 26-6 25-9 27-8 Berlin, 1881-88 23-1 25-6 30-4 22-3 Breslau, 1885-88 28-7 30-7 32-5 26-5 Dresden, 1881-88 24-7 24-6 26-4 22-1 Munich, 1881-88 30-7 33-7 32-1 27-3 Pathology. — Malaria at the present day occupies a very subordinate position in the pathology of Germany compared to what it held in the last century. In many localities in which it was formerly common and severe, it is now either unknown or rare. Griesinger, for example, says that intermittent fever was wont to rage with great intensity at Mannheim, where it is now almost unknown ; and Hirsch informs us that pernicious malarial fever was prevalent, as late as the eighteenth century, in the Hartz, in Augsburg, Saxony, Silesia, and Wurtemberg, where it now occurs only in occasional epidemics, and in its mildest forms. This great decrease in the prevalence of malaria throughout the empire is chiefly to be ascribed to the draining, and to the more extended and careful cultivation of the soil whicli has been in progress during the present century. It would be interesting, however, to know whether a similar, or at least a certain, diminution in the prevalence and intensity of malarial fever has not, at the same time, taken place in localities where such improvements have not been carried out. That the decrease in the prevalence of malaria is still going on, will be seen from the yearly diminishing proportion which the cases of malarial fever in the hospitals bear to the total treated, as exhibited in the following table : ^ — Ratio of Cases of Ratio of Cases of Year. Malarial Fever per Year. Malarial Fever per 1000 of total treated. 1000 of total treated 1877, . 12-3 1882, 7-2 1878, . 10-7 1883, 5-8 1879, 9-6 1884, . 4-7 1880, . 9-7 1885, 4-1 1881, . 9-2 Arhdten cms darn KaUerlichen Gesundheitsamte, Berlin 1888. 70 CENTEAL AND WESTEEN EUEOPE. Prussia, 6-7 Oldenburg, . Bavaria, 3-2 Brunswick, . Saxony, 0-8 Saxe- Weimar, Wurtemberg, 0-5 Anhalt, Baden, .... 0-9 Lubeck, Hessen, 1-2 Bremen, Mecklenburg-Schwerin, 5-1 Hamburg, Mecklenburg-Strelitz, , 7-8 Alsace-Lorraine, . The relative prevalence of malaria in the principal divisions of the empire is shown in the following table, giving, for three recent years, the ratio of cases of intermittent fever per 1000 of the total cases treated in the public hospitals : — Meajt PeopopvTION of Cases of Intermittent Fever per 1000 of all Diseases treated, 1883-85. 14-5 2-7 0-6 1-6 5-9 6-5 5-1 3-7 It will be seen from this statement that malaria can only be said to be at all extensively endemic on the plains, the higher lands in the interior being very slightly affected. Oldenburg, with its marshes, fens, moors, and lakes, is the most malarious State in Germany ; while "Wurtemberg, with its upland terraces, — the lowest of which is 400 feet above the sea-level, — is the State in which malaria is at its minimum. Having shown the distribution of malaria as regards the States composing the German Empire, we shall now trace its incidence on the different provinces of Prussia. Mean Pkoportion of Cases of Intermittent Fever per 1000 Cases of all Diseases treated, 1883-85, in the several Provinces of Prussia. East Prussia, 12-7 Prussian Saxony, . . 3-4 West Prussia, 21-4 Schleswig-Holstein, . 7-0 Berlin, . 2-7 Hanover, . 5-9 Brandenburg, 14-0 Westphalia, . . 3-6 Pomerania, . 8-0 Hessen-Nassau, . 0-8 Posen, . 27-7 Ehine Province and Holic n- Silesia, . mi • ■ 1 1 8-0 zoUern, f T • • -r> • . 1-1 J- The principal endemic seats of malaria in Prussia are thus seen to be Posen, West Prussia, Brandenburg, and East Prussia. Speaking generally, malaria in the plains of North Germany is found to be endemic in the basins of the Vistula, the Warta (Werthe), the Oder, the Elbe, the Weser, and the Ems, and in the low-lying marshy tracts, such as the Ditmarsh, which stretches along the German Ocean from the Eider to the Elbe. In the interior, intermittent fever is only met with, and, as a rule, in a mild form, in some water-logged valleys, along the marshy banks of rivers, in tracts subject to inundations, and in the basin- like depressions among the mountains of the Lower Ehine. The nature of the local conditions of soil which are associated with malaria in the interior of Germany is well illustrated in the GEKMANY. 71 case of Saxony. The kingdom is divided into four circles : Bautzeu, Dresden, Leipzig, and Zwickau. Saxony, as we have seen, is little subject to malarious influences. Bautzen, however, to some extent forms an excej^tion to this rule. Pteinhard thus describes the medical topograpliy of the malarious locality : " Immediately to the north of the town of Bautzen stretches a marshy tract traversed by tributaries of the Spree, which give rise to inundations twice a year, after the melting of the snow in the mountains, and, again, in the middle of summer. There are, besides, numerous ponds for carp, the rearing of which forms an important industry. The land, in some places, is covered with water for several years for the purpose of fish-breeding ; then it is allowed to dry up for a series of years for the purposes of agriculture." This district, Eeinhard says, has been subject to malaria from time immemorial. Comparing the mortality of this district with that of the adjoining mountainous country, this observer found the annual mortality on the hills to be 21-8, and that on the plains to reach 29-8 per 1000.^ Outside this district ague is almost entirely confined to a few localities on the banks of the Spree, Lobau, and Parthe. In Bavaria, malaria is almost entirely restricted to the damp valleys of some of the tributaries of the Danube. A certain number of cases is also met with at Bamberg (Lombard), situated on the banks of the Eegnitz near its confluence with the Maine. The environs of Tubingen in Wurtemberg must be to some extent malarious, as they furnished Griesinger with 409 cases of intermittent fever between the years 1854 and 1860. The altitudinal limit of malaria in Germany, according to Hirsch, may be placed between 400 and 500 metres above the sea-level. Malarial fever in Germany is a disease of the country rather than of the towns. Thus, while the cases of fever in Berlin formed only 2*7 per 1000 of the total treated, the proportion in Branden- burg, the province in which Berlin is situated, reached 14"0 per 1000. The existence of paludal conditions in or near a town, such as ditches or moats, may, however, render a town unhealthy. The towns of Julich, Bartscheid, and Aix-la-Chapelle were said to owe their insalubrity in past times to this cause. Endemic malaria is observed to assume epidemic proportions under two sets of conditions, viz. disturbance of the soil, and the inundation of level tracts of land. The influence of excavations in causing outbreaks of fever was shown in the sickness which affected the neighbourhood of Jahde (1859—69) while the harbour was under construction. At the height of the local epidemy consequent on the excavations, about 1 Year Booh, Sydenham Soc, Lond. 1852, p. 500. 72 CENTEAL AND WESTERN EUROPE. two-thirds of the population were attacked within a month. As the newly upturned ground settled down, the fever gradually diminished in prevalence. When the disease was at its height, Wenzel found the quotidian type, and the fevers approaching the continued form, to become relatively more frequent. In the year 1854 malarial fevers became epidemic in some parts of Silesia after an overflow of the Oder ; and this outbreak must have been of a severe character, inasmuch as it furnished Frerichs with the 45 cases illustrative of pigment liver which he details in his classical work on the diseases of that organ. Such local exacerbations of endemic malaria must be distinguished from true epidemic malaria, which is not localised in endemic areas, and cannot be traced to local conditions. Let us now briefly examine the seasonal distribution of malarial fever in Germany. The following table gives the monthly percentage of cases of malarial fever occurring in different regions of the empire. It will be seen that in the Ditmarsh and at Jahde, where the malarious influence is more intense than in Germany generally, there are two maxima, the principal one occurring in autumn ; while in Leipzig and Tubingen, where the infection is less severe, the fever is vernal or estival : — Monthly Percentage of Cases of Malarial Fever in Germany. Ditmarsli.i Jalide.^ Leipzig. 2 Tubingen.'* January, 2-87 4-42 1-26 0-98 February, . 3-07 4-51 2-20 1-47 March, . . 7-10 4-77 6-35 5-65 April, . . 10-84 5-28 14-74 18-43 May, . . 11-45 5-28 24-00 31-20 June, . . 7-10 4-94 21-20 22-35 July, . . 4-72 4-94 12-60 10-82 August, . . 17-14 14-39 8-20 3-68 September, . 19-11 18-30 5-38 3-19 October, . 8-64 16-65 1-85 0-98 November, . 4-84 10-66 1-17 1-23 December, . 3-07 5-90 0-85 0-00 It has been stated that malarial fever is more severe in warm than in cold seasons, and particular instances are not wanting of warm summers having been specially malarious. The summer of ' Dose, from obaervation of 6896 cases, 1842-63 (Hirsch). - Wenzel, cases occui'ring among harbour labourers, 1860-69. ' Thomas, tweuty-tliree years' observations. "* Griesinger, 407 cases observed between 1854-60. GERMANY. 73 1868, for example, was an exceptionally warm one, and intermittent fever prevailed to an unusual degree, not only in the marshy districts of the Elbe, but all along the Dutch and German coasts of the North Sea. To what extent, however, the prevalence of autumnal fevers in Germany is regulated by the summer temperature is uncertain.^ Dry years are, as a rule, more unhealthy than wet ones in fenny localities. This, at least, has been observed to be the case in the Ditmarsh region. It is probable that rainy years are the most malarious in non-marshy districts. The character of malarial fever, as met with in Germany, is generally benign. I find only 15 cases of death recorded in Prussia in 1882 out of 2984 patients under treatment in general hospitals. The pernicious forms are chiefly met with in level districts subject to inundation. Dr. Burdon Sanderson, who visited the region comprising the basin of the Vistula in 1865, states that to be exposed for a few hours on the banks of one of the canals in the Mederung, at the fall of the year, is sufficient to insure an attack of fever, the cases occasionally assuming a pernicious character.- The tertian type is that which is most frequently met with in Germany. The proportions per cent, of the different types observed in the Holstein marshes are : ^ — Tertian, Quartan, Quotidian, 51-0 26-1 20-5 Duplicated Quartan, Pernicious Fever, 2-4 0-3 Apart from local outbreaks due to the special causes to which we have referred, Germany has repeatedly suffered from the wider epidemics of malaria that have at intervals spread over extensive regions in Europe. During these visitations the disease has ex- tended to districts where ague is not endemic. Thus it broke out in 1826 at Stuttgart, and again in 1834, both there and at other high and dry places in Wurtemberg which are not subject to the endemic form. Malarial fever has also exhibited periods of activity and latency in particular localities which deserve notice. Hirsch informs us that at Konigsberg " malarial diseases were scarcely at all observed from 1811 to 1825; but that after that an epidemy developed which lasted until 1833. Erom 1833 to 1841 the disease occurred in isolated cases only. From 1841 to 1852 it appeared every year in the spring to a moderate extent; but from 1852 to ^ Vircliow's Archiv, 1869. ^ Dose, quoted by Hirscli. - Privu Council Reports, 1865, p. 267. 74 CENTEAL AND WESTERN EUROPE. 1855 it was prevalent to an extent and witli a severity but rarely seen in so high a latitude." It is recorded that intermittent fever disappeared entirely from Marienwerder (where it is generally rife) on the cessation of cholera in 1831, and only reappeared with the return of cholera in 1849. This time, however, it did not disappear with the cholera as in 1831, but remained the predominating sickness in that locality up to 1856, when malarial fever again diminished in frequency. No satisfactory explanation can at present be given of these epidemic extensions of malaria, of the remarkable fluctuations in the prevalence of the infection in particular localities, or of the relation of malaria to cholera such as was observed at Marienwerder. Unieric Fever occupies by no means an insignificant place among the causes of death in Germany. The average death-rate for the period 1881—87 was 406 per million living, in Prussia; and in Saxony, from 1876-85, the ratio was 280 per million. I do not have the figures of mortality for Bavaria, Wurtemberg, and Baden, but, as we shall presently see, the ratio of typhoid sickness for these States does not exceed that of Saxony. The typhoid death-rate of the principal towns of Germany (1881—84) was 356 per million, which is considerably in excess of that of London, where, from 1871 to 1880, it averaged 240 per million. The typhoid death-rate of Germany, however, has been under- going a marked decrease during recent years. In Prussia this decrease will be seen by the following figures, showing the death- rate from typhoid fever per million living from 1881 to 1887: ^ — Years, , . 1881 1882 1883 1884 1885 1886 1887 Death- ■rate, . 544 488 453 443 340 314 204 In Saxony the death-rate from enteric fever from 1876 to 1880 was 301; while from 1881 to 1885 it had fallen to 260 per million. In 1886 it was 209 ; and in 1887 it sank to 162 per million. No doubt much of this diminished prevalence is to be ascribed to the measures of sanitation which are being actively carried out, especially in the more important towns ; but enteric fever, like other infectious diseases, has its cyclical periods of increase and decrease, and it would seem that the last decade has been one of diminished typhoid intensity. The relative prevalence of enteric fever in the several divisions of the empire no doubt varies considerably in different series of years ; but the following table, giving the average number of cases of typhoid and gastric fevers treated in the public hospitals per 1000 1 Preussische Statktih for 1886 and 1887, Berlin. GERMANY. 75 treated for all diseases, will indicate approximately the distribution of the disease in Germany during the three years 1883-85 : — Pnissia, Saxony, Bavaria, Wurteinberg, Baden, . Hesse, . Mecklenburg-Scliwerin, Mecklenburg- Strelitz, 37-7 25-9 25-5 16-0 23-4 17-1 36-9 4 9 "2 Oldenburg, Brunswick, Saxe-AVeiniar, Anlialt, Lubeek, Bremen, Hamburg, Alsace-Lorraine, 49-2 32-8 29-8 531 18-4 16-6 31-9 35 •« Typhoid fever during these three years was evidently more prevalent in Prussia, Mecklenburg, Anhalt, and Oldenburg than in the middle and southern States, such as Saxony, Bavaria, Wurtemberg, Baden, and Hesse, and it will be observed that districts such as Oldenburg, in which malaria is prevalent, enjoy no immunity from enteric fever. Lombard refers to the researches of Dr. Zuelzer, which show that the mortality from typhoid fever was higher in the towns of the south than in the north of Germany. At the present day the north of Germany appears to pay a much heavier tribute to typhoid fever than the south. ISTor, if we restrict our attention to the mortality in the towns, will the result be different. I take from Dr. Billings' Eeport on the Census of the United States the following figures, giving the typhoid death-rate per 10,000 living of some of the more important towns in Germany for the five years 1878-82, which I have arranged into four geogTaphical groups, from north to south and from west to east, for the sake of comparison : — Northern Coast Towns. North Inland Towns. Interior Towns. Southern Towns. Bremen, 1.1. Hanover, 2 "6. Cologne, 2 "9. Strassburg, 3 "6. Hamburg, 2-7. Magdeburg, 2-8. Elberfekl, 5-0. Stuttgart, 1-8. Kbnigsberg, 6'7. Diisseldorf, 3'1. Xuremberg, 2'4. Danzig, 2'2. Barmen, 3"7. Munich, 5"0.^ Frankfort O.M., 1-8. Leipzig, 2 '5. Chemnitz, 2*9. Dresden, 1-8. Breslau, 3 '5. These figures certainly do not show any progressive intensity of enteric fever from north to south ; the highest death-rate occurs in the northern town of Konigsberg. If latitude has any influence at all upon the distribution of enteric fever in Germany, it is entirely obscured by the preponderating influence of local conditions. Having glanced at the general distribution of typhoid fever in ■^ Munich is built on a sandy soil, and is jirovided with cessjiools, from which more than 90 per cent, of the contents soaked into the giound. This may help to explain the prevalence there of typhoid fever and also of diarrhojal diseases. 76 CENTRAL AND WESTERN EUROPE. Germany, we shall now examine its relative prevalence in the different provinces of Prussia. The following table gives the pro- portion of cases of typhoid and gastric fevers per 1000 hospital cases for the three years 1883-85 ; and for the two succeeding years (1886-87) the ratio of deaths from enteric fever in the same provinces per 1000 deaths from all causes. This gives a comparable statement of the morbidity and mortality of typhoid fever in the various provinces of Prussia for five consecutive years. "We add the ratio of typhoid deaths per 1000 of the total mortality of the principal towns for 1886-87 : — Ratio of Cases Ratio of Ratio of Typhoid and Typhoid Deaths Typhoid Deaths Province. Gastric Fever to per lOOO Towis. per 1000 Total treated, Total Mortality, Total Mortality, lSS3-Sy. 1 1886-87. 18S6-S7. East Prussia, . ' 40-7 14-3 Berlin, . . . . 7-1 West Prussia, . 1 47-6 15-7 Breslau, . . 5-0 Berlin, . . . ; 21-9 7-1 Cologne, . . 5-4 Brandenburg, 32-4 10-7 Frankfort O.M. 5-0 Pomerania, , . i 60-2 12-5 Konigsberg, 12-7 Posen, . . . i 47-2 15-9 Magdeburg, 12-3 Silesia, . . . j 44-1 8-9 Hanover, 5-1 Prussian Saxon J, . \ 48-5 12-0 Dusseldorf, . 6-7 Sclileswig-Hols :ein, 35-1 11-2 Danzig, . . 8-8 Hanover, 25-8 12-6 Elberfeld, . 9-6 Westphalia, 49-8 12-2 Altona, . . 21-8 Hessen-Nassau, 28-0 9-2 Barmen, . . 7-1 ^"69 Towns with a ) Rhine Province 1 > ( 10-7 -< population between } 11-9 i 33-1 (20,000andl00,000, ] ( S-0 ( 1199 Towns with ) HohenzoUern, . ) •< a population of } 12-9 (20,000 and under. ) It will be seen from the above table that, during the five years 1883-87, typhoid and gastric fevers were most prevalent in East and West Prussia, in Pomerania and Posen, and least prevalent in Hesse n-Nassau, the Pthine Province, and in the southern detached province of HohenzoUern. The mortality from typhoid fever was greatest in East and West Prussia, in Posen, and in Pomerania. The towns of Konigsberg, Magdeburg, and Elberfeld, which appeared at the earlier period, viz. 1878-82, to be particularly subject to typhoid fever, are seen to maintain their former character. The typhoid death-rate of the provinces is affected b}^ the occasional outbreak of local epidemics, such as that which evidently occurred in the town of Altona in 1886-87; but, apart from these local outbursts, the normal prevalence of typhoid fever is probably pretty uniform in certain areas. Local insanitary conditions may be assumed to go a good way in keeping up the persistently high mortality from typlioid fever in Konigsberg ; but, apart from the GERMANY. 77 presence of such exceptional local typhoid haunts, we observe a fairly uniform incidence of the disease all along the low, humid coasts of the Baltic, in East and AVest Prussia, Pomerauia, Mecklen- burg, and Oldenburg, and also inland, in the marshy plains of Posen. In all these districts the normal typhoid tension, if we may so speak, is high, and it readily breaks out into destructive epidemics. The better drained regions of Hessen-Nassau, Saxe-Weimar, the Pihine Provinces, and Alsace-Lorraine, although liable to epidemic out- breaks in special localities from time to time, do not appear to have the high normal typhoid prevalence which characterises the coast region. Enteric fever is somewhat more fatal in the country than in the town districts of Prussia. In 1886-87 the ratio of deaths from enteric fever to the deaths from all diseases was 11-3 per 1000 in the towns, and 11"6 in the country. Typhoid fever is least fatal in the largest towns with a popula- tion over 100,000. By referring to the table given above, it will be seen that in the four largest cities, Berlin, Breslau, Cologne, and Erankfort, the typhoid deaths form from 5 to 7 per 1000 of the total mortality ; whereas in the towns with a poj^ulation of from 20,000 to 100,000 they form 11 "9 per 1000 ; and in the small towns, having 20,000 and less inhabitants, the proportion is 12*9 per 1000. The same rule holds as regards Saxony, where, in the years 1886 and 1887, the deaths from enteric fever in the great towns were in the proportion of 167, and in the rest of the country of 193, per million living. Typhoid fever attains its maximum prevalence and fatality in autumn in most parts of Germany, and generally either in the month of September or October. Here is the seasonal distribution per cent. of typhoid deaths in Berlin, Breslau, and Stuttgart, according to the figures published by Hirsch : — Spring. Summer. Autumn. Winter. Berlin, . . 18-1 24-5 36-5 20-9 Breslau, . 20-2 25-6 30-7 23-5 Stuttgart, 21-8 217 26-9 29-6 In Berlin and Breslau the months of September and October are those most charged with typhoid deaths ; in Stuttgart the maximum typhoid mortality occurs in November and December. The months of May and June are those in which enteric fever is at its minimum. One notable exception to this autumnal prevalence of typhoid fever in Germany has to be noticed. At Munich the season is not only different from, but, as regards the period of the minimum. 78 CENTEAL AND WESTERN EUROPE. just the reverse of, that obtaining in Germany as a whole. At Munich the maximum of deaths (1852-68 and 1873-79) falls on February, and the minimum in September or October. The reason of this departure from the usual period of typhoid prevalence has given rise to much discussion. Typhoid fever is seen, in most places, to follow at a certain interval the heats of summer : and Liebermeister suggests that at ^ CO Munich the same rule holds good, only that the retardation is greater there than elsewhere in Germany, on account of the breed- ing-places of typhoid fever in Munich lying deeper than at Berlin and other places. The maximum temperature of the earth at a depth of 4 metres is reached, according to the researches of Forbes, two or three months later than the maximum surface temperature. If, therefore, the localities where the fever poison is developed are situated deeper in the earth at Munich, this, it is held, would explain the retardation of the typhoid' maximum there. It must be remembered, however, that we have to account for a similar retardation at Prague, Vienna, and other places ; and it will be observed when we come to deal with Prague, that in this city other diseases besides typhoid exhibit a peculiar seasonal distri- bution. In Munich, Berlin, Breslau, and other parts of Germany, it has been observed that the number of cases of typhoid fever falls with the rise of the subsoil water (as measured by the depth of water in the surface wells), and rises with its fall, the amount of typhoid sickness being in relation to the range of fluctuation of the water. We may just point out that this rule is by no means universal. The Terling epidemy, to which we have referred under England, broke out when the water in the wells was high. Foder says that at Buda-Pesth the rise in the enteric fever mortality accompanies the rising ground-water, and that the two fall together (Parkes). Inquiring into the relation of temperature and rainfall to typhoid fever prevalence in Berlin from 1871 to 1878, Hirsch concludes that, " as regards Berlin, there is no definite relation whatsoever to be made out between the height of the death-rate from typhoid and the states of the weather." If we compare the mean temperature of the year with the proportion of typhoid deaths, these are as often above the average in years when the mean temperature is below as in those years when the temperature is above the average. Taking, however, Hirsch's figures simply as they stand, it would appear that the temperature of summer, or of the third quarter, does, to some extent, determine the greater or lesser frequency of typhoid fever in the autumn quarter, and in the second half of the year generally. This will be seen from the following table : — GERMANY. 79 Relation between' Typhoid ^Ioktality in Berlin and Temperatuke (Reaumur). Avei-age An- Temperature of Year above or below Average of Eight Years : above -|-, below - . Deatlis in Temperature Deatlis iQ Temperature nual number Second Half of Third Autumn in .Summer of Deaths of Year above Quarter above (Sept. to Nov.) (.June to Aug.) 12 above or be- or below or below above or below above or below S low Average of Average of Average of Average of Average of !^ EiRht Yeai-s : Eight Years : Eight Years : Eight Years : Eight Years : above +, above -f, above +, above -J-, above +, below - . below - . below - . below - . below - . 1871 + — 1872 + + + + + + 1873 -j- + — ■ — — 1874 — + — + — — 1875 + + + 1 + + 1876 — — 1 -(- 1877 — -j- — — -|- 1878 — + "■ ~ It will be seen from this table that when the temperature of the third quarter is above or below the mean, the deaths in the second half of the year are correspondingly above or below the average in six out of the eight years ; and the same relation is observed between the temperature of summer and the enteric deaths in autumn. So in Munich it was found that typhoid fever frequently appears after very hot and dry summers (Liebermeister). Typhus caused an average death-rate in Prussia of 8 per million for the seven years 1881—87. In Saxony typhus is scarcely known at the present day ; nor does it appear to be met with at all frequently in Bavaria or Wurtemberg. The eastern provinces of Prussia, both maritime and inland, are those most affected, and are also those most liable to suffer from typhus epidemies, which have generally invaded Germany from Poland and Galicia. Typhus has a special tendency to spread during periods of war and famine. Thus typhus was extensively prevalent in 1813-14 during the w^ar, and in 1847—48 in a time of scarcity. Whether the outbreak in the Palatinate and in Silesia in 1853—56 was connected with want, I am unable to say ; but bad crops and famine were the causes of the epidemy in East Prussia in 1867. East and West Prussia and Breslau again suffered in 1876-77. A considerable number of cases were observed in East and West Prussia and Brunswick in 1883—84, in Mecklenburg- Schwerin in 1884, and in the Pthine Province in 1885, — which seems to show that the infection tends to make its way from the east to the west. Relapsing Fever was first noticed in Upper Silesia and Konigs- berg in 1847-48 in isolated cases. The disease broke out in an 80 CENTEAL AND WESTERN EUROPE. epidemic form in 1868, having been introduced from Poland and Eussia, and it spread over a wide area. It made its appearance again in 1871-72, but not to any extent ; and a third outbreak occurred in 1878—79. I find it mentioned in the returns as occurring in Posen, Silesia, East and West Prussia, and in Mecklen- burg-Schwerin and Strelitz, in connection with typhus in 1884. Epidemic Cerebro-sinnal Meningitis was widely diffused over the eastern and western departments in 1863-70, attacking isolated localities, and not affecting extensive districts uniformly. It was fre- quently confined to barracks, workhouses, or prisons, while the towns in which these were situated escaped entirely or suffered only slightly. Diplitheria and Croup together caused a mean death-rate in Prussia of 1750 per million living from 1881—87, a rate in excess of that of any country in Europe except Austria. In Saxony the death-rate for the period 1876—80 was 1056 per million, while in 1881-85 it had risen to 1763. The death-rate of Berlin, 1880— 8 9, for diphtheria alone, was 1307 ; of Dresden, for the same period, for croup and diphtheria, lo75"3 ; and for Munich, 1089*7, per million. The deaths in Wurzburg (1878-82) were 860 per million. We observe that a marked increase took place in Saxony during the last five-yearly period given above, and it is these irregularly recurring epidemic extensions that render it difficult to say in what part of the empire the disease is most fatal. In Prussia the admissions from diphtheria per 1000 of all diseases averaged 21'0 for the years 1883—85 ; in Bavaria for the same period they were 12*2 ; in Wurtemberg, 9'9 ; in Baden, 10*8 ; and in Saxony, 36'3. Hirsch gives it as the result of his study of the distribution of diphtheria, that elevation and configuration of the ground have no influence on the occurrence of the disease. Even the influence of overcrowding, bad drainage, and general neglect of hygiene in favouring the prevalence of the disease has been called in question by many authorities. Diphtheria has been of late years particularly prevalent in the plains of North Germany, along the shores of the Baltic, in the eastern districts of Marienwerder and Bromberg, and in Brandenburg, Hanover, Prussian Saxony, and the kingdom of Saxony, and is, upon the whole, notwithstanding epidemic exacerbations, less prevalent in the higher hilly regions of Prussia and in the southern States of the empire.^ Diphtheria is, other things being equal, least fatal in the largest towns with a population of over 100,000 ; although some of these, such as Danzig and Konigsberg, have suffered very severely, the former having had a 1 Living ill damp dwellings and in rooms on a level with the earth seems to exercise an evil iniiueuce in respect to the spread of diphtheria. Ziemssen's Cyclop, vol. i. GERMAN'. 81 death-rate of 2050 and the latter of 1820 per million for the five years 1878-82. It is more fatal in the towns of 20,000 to 100,000 inhabitants, and most prevalent in the small towns with a population under 20,000. Thus in 1886-87 the deaths from croup and diphtheria formed 61"7 per 1000 of the total deaths in the 1199 towns having 20,000 inhabitants and under; while they amounted to 50 '2 per 1000 only in the 69 towns having a population between 20,000 and 100,000. In Saxony the deaths per 10,000 living were 16*31 in the large towns and 21-79 in the country. In Berlin, Dresden, and Munich, the distribution of the deaths from diphtheria and croup occurring between 1881—88, by quarter, were : — First Quarter. Second Quarter. Tliird Quarter. Fourth Quarter. Berlin, . 27-03 21-40 19-77 31-80 Dresden, . 28-10 20-14 17-86 33-89 Munich, . 29-17 23-17 16-97 30-69 These diseases are thus most fatal during the cold season, particularly in the fourth quarter. Diarrhcecd diseases are classified in the Prussian official returns as Ruhr (dysentery), Einheimischer Breclidurclifall (cholera nostras), and diarrlioe der Kinder (infantile diarrhcea). In Prussia an average of 419 deaths per million living was ascribed to infantile diarrhcea, of 473 to cholera nostras, and of 104 to dysentery, in the seven years ending 1887 — or a total average for the three diseases of 9 9 6 per million living. According to the figures given in the Eegistrar-General's Quarterly Pieturns, the death-rate from the whole class of diarrhceal diseases per 1000 living, for the ten years 1880-89, was, for the Hamburg State, 2-57 ; for Berlin, 4*0; for Breslau, 3-73; for Dresden, 1881-89, 2-34; and for Munich, 5*37. The exceptionally high mortality from this class of diseases at Munich points to local sanitary defects in that city ; but the diarrhceal death-rate is inordinately high in all the large German towns. The prevalence of the diarrhcea of children and cholera nostras is largely dependent on the density of population, or, to speak more precisely, on overcrowding, with its accompaniments and results, as will be seen from the following table : — 82 CENTEAL AND WESTEEN ETJEOPK Diarrlicea of Children (1886-87). Average Deaths per 1000 Deaths from all Causes. Berlin, Breslau, Cologne, Sixty-nine toAvns with ) 20,000 to 100,000 in- > haijitants, . . ) One thousand one hun- \ dred and ninety-nine f towns with 20,000 in- i habitants and under, ) 68-3 91-55 63-25 37-05 15-6 Cholera Nostras (1886-87). Average Deaths per 1000 Deaths from all Causes. 93-6 32-35 57-8 50-8 22-8 Diarrhcea of children and cholera nostras and cholera infantum are most fatal during the third quarter. Both of them are, no douht, more prevalent in warm seasons. This relation has been proved as respects the latter, as will be seen by the following table from Hirsch, showing the deaths from cholera infantum and the summer temperature at Berlin for the years 1877-82 : — Year. Mean Summer Tenipe (Reaumur), rature Deaths for the Year 1882, 16-1 2510 1881, 16-2 2684 1877, 16-3 2947 1879, 16-7 3124 1878, 16-8 2886 1880, 17-5 3477 Diarrhoea, cholera, and dysentery were all very much more fatal in 1886 than in 1887. The death-rates per 10,000 in these two years were : — Dysentery. 1886. 1887. 0-59 0-35 Cholera. 1886. 1887. 6-55 4-90 Infantile Diarrhcea. 1886. 1887. 5-23 4-23 The explanation of the excess of mortality in 1886 was the high temperature in August and September of that year. In Berlin the temperature of August was 0-9, and that of September 3 '2, above the normal; whereas in 1887 August had a mean temperature of 1-6, and September 0'9, below the normal. Lombard states that, from 1835-38, the deaths in Berlin caused by diarrhoea and cholerine formed 18-6 per 1000 of the total deaths ; in 1868-69 they amounted to 109 per 1000 of the deaths; in 1872 they constituted 134 per 1000, and in 1873 they had risen to 173 per 1000 ; and be inquires: " Ou s'arretera cette augmentation ? " It appears that only a slight improvement in this respect has taken place, as in 1886 the proportion was 178'4, and in 1887 it was 145--1. This remarkable increase in the fatality of diarrhoeal diseases during the fifty years covered by these figures is, as Lombard remarks, a fact of the highest importance ; but GERMANY. 8 3 it can scarcely be said to be "unique dans les annales de la statistique niddicale," for it will be seen that a similar augmentation in the fatality of this class of maladies has been observed in England. Dysentery, \\\ 1882, furnished 3*47 per 1000 hospital admissions in Prussia ; 0-27 in Bavaria ; 0'28 in Saxony; 0*18 in Wurtem- berg; and 0*12 in Baden. It thus appears to be more common on the plains than on the higher lands of the interior. Hirsch, however, notices that dysentery is rarely seen in the Dittmarschen, where ague is common. He also remarks that in the Wurtemberg epidemy of 1838 it was almost exclusively the highest districts that were attacked, which proves that the epidemic disease does not confine itself to localities where it is endemic. Dysentery is most prevalent in the Prussian districts of Bromberg, Oppeln, Gumbinneu, Danzig, and Liineburg. Asiatic Cholera. — Germany was visited by cholera in 1831, the disease having been introduced from Poland, Eussia, and Galicia. From Poland it spread through the eastern governments of Prussia and Bohemia ; from Eussia it was carried to Danzig and the neighbouring departments on the Baltic, and from Galicia it invaded Austria and Moravia. In 1832-33 it entered the Ehine provinces from Holland. In 1837, Bavaria was attacked through the Tyrol. In this latter year cholera was again introduced into Silesia and East Prussia from Poland. In the summer and autumn of 1848, Germany was anew invaded by cholera, which, advancing from Eussia, attacked the Baltic and eastern provinces. The south and south-west districts suffered only slightly during this epidemy. In 1852, 1853, 1855, and 1859, cholera was again introduced into the plains of the north and east of Germany from Eussia. Bavaria was attacked in 1854, at a time when North Germany was almost entirely free from cholera. In 1865, cholera was imported by a family from Odessa into Altenburg in Saxony, whence it spread to a few other places in the kingdom. In 1 8 6 6, cholera spread from Luxemburg into the Ehine provinces and Westphalia, and, surviving the winter, it caused a considerable mortality in this region in 1867. It made its appearance in May 1866 at several of the Baltic ports, and, extending inland over a great part of the country, it carried off no fewer than 114,683 victims. The spread of the disease was favoured on this occasion by the operations of war. Bavaria suffered from the pestilence in the same year. Cholera was once more introduced from Eussia into the northern and eastern districts of Prussia in July 1871, 84 CENTEAL AND WESTEEN EUEOPE. dying out in November, and reappearing in isolated cases in 1872. The following year (1873) witnessed a wide extension of this pestilence both in the north and in the south, it having been re- introduced at once from Eussia and Austria. It proved specially fatal in the districts of Bromberg, Marienwerder, Konigsberg, Magde- burg, and Danzig. It is thus evident that cholera, when it has appeared in Germany, has always been introduced from without ; that it has raged with greatest severity in the plains of the north, Baden and Wurtemberg having almost escaped its ravages ; and that the season of its greatest violence has been the summer and autumn. Sinallijox. — The death-rate from smallpox in Prussia, from 1881-87, averaged 43 per million ; and in Saxony, from 1876-85, only 12 per million. In the other States the deaths range between the means of Prussia and Saxony. The influence of vaccination and re-vaccination in reducing the smallpox mortality in Grermany has been clearly proved. Between 1781 and 1805 the death-rate from smallpox at Berlin averaged 3142 per million; while, during the forty years 1810-50, the ratio was 176 per million. At Berlin (1863-67) the greatest number of deaths occur in the three months April, May, and June, the maximum falling on. May. The months of August and September are those when the deaths in that city are least numerous. Scarlet Femr caused an average death-rate of 509 deaths per million in the principal towns of Germany from 1881-84 ; in Prussia (1881-87) the ratio was 518 per million, and in Saxony (1876-85) it was 503. At Berlin the deaths from scarlet fever (1880-89) numbered 392 per million; at Dresden, for the same period, 324 per million; and at Munich, 357"4. The English death-rate from scarlet fever (1881-84) was 485 per million.^ Measles appears in epidemics at irregular intervals. The death- rate in Prussia, for the period 1881-87, was 451 ; and in Saxony (1876—85), 249 per million. We cannot say with any confidence whether, or to what extent, humidity of the soil, the physical con- figuration of the country, the geological formation of the crust, or even sanitary conditions, affect the prevalence of measles. Scarlet fever and measles break out after a certain number of susceptible persons of tender years have accumulated in a locality ; but it would be rash to conclude that the increase in the number of the suscep- tibles is a full explanation of the outbreaks of epidemics, and that ^ Fliigge makes the interesting observation that "Miiuster has been free from scarla- tina for fifty years, Tuttlingen for thirty-five years, and Ulm for seventeen years." Tliis he seems to ascribe to the result of accident, which appears to be a very doubtful explanation. — Micro-Organisms, Syden. Soc. Translation, p. 764. GERMANY. 85 increase in the amount and virulence of the poison as determined by temperature, locality, or other causes, counts for nothing in the epidemiology of these affections. The seasonal prevalence of measles in Berlin will be given under England. Erysiiodas, judging from the three years 1883-85, is rather pre- valent in Wurtemberg, Hessen, the Khine provinces, Baden, West- phalia, and Bavaria, but it is much less frequent in the northern plains. Influenza has been frequently epidemic in Germany during this century. Thus, omitting slight visitations, it was epidemic from October 1800 to June 1801; in January and February 1803 ; and in November 1805. It was again epidemic from April to July 1831,^ also during the same months of 1833, and in December 1836 ; from January to March 1837 ; from January to April 1841 ; in March 1843; in January 1844; and in November, December, and January 1847-48. Then it appeared in 1851, and again in 1855 from January to March, and in 1857 in December; in the winter of 1874, in the later months of 1889, and in the beginning of 1890. In most instances influenza has reached Germany directly or indirectly from Eussia, and has passed westwards to France, the Netherlands, Britain, and, as in 1890, has then crossed the Atlantic to America. Its mode of spread is as yet imper- fectly known, but there is little doubt that it may be introduced into a place where it has not been known by persons arriving from an infected locality. The frequency with which it made its first appearance in the post-offices during the recent epidemy, makes it probable that the infection can be transmitted by letters. It tends to recur in the year following its first appearance. Wliooping - Cough is one of the most dangerous diseases of children in Germany, as elsewhere. The death-rate from this disease in Prussia, from 1881-87, was 519 ; and in Saxony, from 1876—85, it was 309 per million. At Berlin, for the ten years 1880-89, the deaths were 319-4; at Munich, 298-3 per million; and at Wiirzburg (1878-82), 290 per million living. In England, the ratio for 1881—84 was 452 per million. In the large towns of Prussia, with a population between 20,000 and 100,000, the deaths in 1886 numbered 11-8 per 1000 deaths; and in the towns with 20,000 inhabitants and under, the ratio was 16"5. In the town districts the proportion was 14*1, and in the country districts 24*3, per 1000. This relation is not met with ' The epidemy of 1831 appears to have originated in China in 18-30, and to liave spread in two directions — through the Eastern Archipelago to Singapore and India, and through Eussia to Germany, England, and other countries in Europe, reaching Xorth America in January 1832. 86 CENTRAL AND WESTERN EUROPE, constantly, for in Saxony whooping-cough is more fatal in the town than in the country. Phthisis is a very widely-diffused malady in Germany, where it causes a higher mortaUty than in most countries of Europe. In Prussia (1881-87) the death-rate from tuherculosis was 3082, and in Saxony, for the ten years ending 1885, the deaths from consumption averaged 2477 per million. Judging from the admissions into the public hospitals for the three years 1883—85, phthisis and tuber- culosis M'ere somewhat less prevalent in Bavaria and Baden than in Prussia, and considerably less so in Wurtemberg. This view of the distribution of phthisis in Germany is supported by the following figures, taken from Hirsch, showing the incidence of the disease on the different regions of Germany. It must be remarked that the returns for Bavaria include not only pulmonary consumption, but other tubercular diseases : — Deaths from Phthisis per 1000 Inhabitants. 1-61 to 3-22 2-20 to 3-07 2-29 to 2-79 3-02 to 5-14 3-55 to 5-29 3-17 to 3-9S 0-90 to 2-81 2-24 to 3-87 2-42 to 2-83 3-141 Other things being equal, phthisis is more fatal in the large than in the small towns. In 1886-87 the ratio of deaths from tuberculosis to the deaths from all causes, in the towns with a population of between 20,000 and 100,000, was 141-8; while in the smaller towns, with a population of 20,000 and under, the. deaths, to 1000 deaths from all causes, were only 124'9. Dr. Schlockow of Breslau gives, for 1876-79, the urban mortality from phthisis at 3710, and the rural at 2840, per million. As regards sex, he says that the mortality is in the ratio of 3470 males and 2810 females per million. The disease does not appear to be influenced by latitude. It is true, as Hirsch points out, that the disease is less frequent in the territory of the Vistula, Oder, and Elbe, than in the territory of the Weser and PJiine ; but it cannot be said that the plains of the north suffer less than the southern districts in the same meridian. Schlockow has shown that tuberculosis is much more fatal in the western than in the eastern provinces, tlie high mortality in the Lower PJiine towns being specially remarkable. This has been 1 For phthisis, general tuherculosis, and wastinj^, in persons over 15 years. Baltic Departments, Warthe and Oder, 1875-79, Prussian Saxony, The Mark, etc. North Sea, .... Lower Rhine, . . . Upper Ehine, Saxony, .... Baden, 1873-80, 1874-81, Hesse, ..... 1877-81, Bavaria 1867-75, GERMA.NY. 87 expLained by the extent to which hurtful industries are here carried on in badly-ventihated rooms. Yet this explanation is not altogether satisfactory, inasmuch as in the smaller rural districts, where one would suppose that overcrowding and unhealthy industries were less common, the mortality from phthisis is vory high. Whatever may be the explanation, the distribution-area of phthisis in Germany is in a marked degree determined by longi- tude. The following figures from Schlockow are quite conclusive upon this point. They give the mortality per 100,000 living: — Eastern Provinces ]\Iarieinverder, l^UVl rojoii? 161 Koiiigsberg, 174 Dauzig, 174 Posen, 230 Stettin, 239 Potsdam, . 253 Frankfort, 254 Erfurt, 270 Magdeburg, 279 Breslau, . 307 Western Provinces. Sclileswig, , Triers (Treves), Wiesbaden, Hanover, . Aachen (Aix-la-Cliapelle), Coblenz, . Minden, . Koln (Cologne), Miinster, . Diisseldorf, 322 355 398 399 402 433 471 511 517 529 In the smaller eastern rural districts the mortality was often as low as 102, 112, etc., while in some of the western Kreise it was as high as 600 per 100,000. Phthisis is thus less frequent in those districts where typhus and gastric fevers, ague and diphtheria, are most fatal ; but it would not be difficult to point out localities, such as Oldenburg, where typhoid fever, ague, and tuberculosis all flourish side by side. On the contrary, the districts in which consumption is most prevalent are also those where pneumonia is most fatal. The months of winter and spring are those charged with the greatest mortality. Phthisis diminishes in frequency, other things being equal, according as we rise above the sea-level, as will be seen by Mer- bach's table for Saxony, and Corval's table for Baden : — Saxony. Altitudes in Metres. Deaths per 1000 Erom 14 to 60. 100-200, . 4-9 200-300, . 3-3 300-400, . 3-2 400-500, . 3-5 550-650, . 3-3 Baden. Altitudes in Feet. 330-1000, . 1000-1500, . 1500-2000, . 2000-2500, . 2500-3000, . Above 3000, . Deaths per 1000. 3-36 2-75 2-60 2-75 2-33 2-17 Pneumonia and Ple^irisy together occasion a mortality of 1422 per million in Prussia, the rate varying slightly in different years ; thus : — Deaths per Million, 1881. 1426 1882. 1348 1883. 1449 1884. 1336 1885. 1417 1886. 1496 1887. 1481 88 CENTKAL AND WESTEEN EUEOPE. The following are the death-rates from pneumonia of several towns of Germany, as given by Hirsch, arranged from north to south: — Town. Ko. of Years observed. Death-rate per 1000 Hamburg, 9 2-1 Bremen, . 7 1-2 Berlin, 13 1-5 Halle, , 10 2-3 Frankfort-on -Maine, 21 1-4 Wurzburg, 4 1-5 Stuttgart, 10 1-9 If, instead of the death-rate, we take the admission-rate into public hospitals for acute inflammation of the lungs and pleura, we have the following results as respects the principal States of the empire : — Admissions for Pneumonia and Pleueisy pek 1000 of all Cases. 1882. 1883-85. 1882. 1883-5 German Empire, 38-4 Wurtemberg, . 30-8 30-8 Prussia, '. 43 '-7 Baden, . . 25-8 29-5 Bavaria, . 39-9 39 '7 Hessen, . 31-1 35-9 Saxony, . 24-9 31-3 It appears from these figures that pneumonia and pleurisy are most prevalent in Bavaria and Prussia, and least frequent in Baden and Saxony ; while, although somewhat more common in Wurtemberg and Hesse than in the last-mentioned States, pneumonia and pleurisy are still in these countries under the average of Germany as a whole. In Prussia the mean death-rate from pneumonia and pleurisy for the whole country, in 1886, was 1-49. In the same year the ratio was 2-64 per 1000 in Miinster ; 2-02 in Osnabruck ; 2-00 in Cassel; 1-97 in Minden ; 1*88 in Diisseldorf; and 1*87 in Hildes- heim. It will be observed that all these districts are in the west, and correspond, at least in a general way, with the area of excessive phthisis prevalence. In the eastern departments the deaths from pneumonia were under the mean of the whole country. Thus the death-rate in Bromberg was 0-82; in Posen, 0-96; in Liegnitz, 1-06 ; and in Breslau, 1*17. This distribution is not peculiar to the year for which we have given the figures, but appears to be the normal distribution of pneumonia in Prussia. Pneumonia is more fatal in the large than in the small towns ; and it may be safely said that density of population, and the nature of the industries carried on in different regions, are more potent factors in determining the distribution of pneumonia than climate. The months of March, April, and May are those in which pneumonia is most fatal. Lombard is of opinion that altitude plays an important part in respect to the prevalence of pneumonia. According to him, the mortality from this disease increases with altitude. This may be Acute Articular Rheuuiatisni Heart Disease. aud Gout. 10-8 8-8 20-3 30-2 12-2 29-6 13-9 23-4 16-4 23-9 16-3 24-4 24-9 32-1 GERMANY. 89 the case ; but the data is not sufficient, as respects Germany, to establish this relation with certainty. Bronchitis is much less fatal in Germany than in England. It is most fatal in Potsdam, Arnsberg, Schleswig, Stralsund, Magdeburg, and Diisseldorf; and is least prevalent in Posen, Bromberg, Gumbinnen, and Miinster. Bronchitis gives rise to a greater mortality in the larger towns than in the country generall}'. Heart Disease and Acute Articuleer Rheumatism and Go^tt vary greatly in frequency in different parts of the empire, as will be seen from the proportion of hospital admissions from these affections •per 1000. I give the average for the three years 1883-85 : — State. Prussia, Bavaria, Saxony, Wurteuilierg, Baden, . Hessen, Alsace-Lorraine, The excessive prevalence of acute rheumatism and of heart disease in Bavaria and Alsace-Lorraine must find its explanation in the habits of the population of these countries as regards diet. Excess in beer-drinking is possibly a cause of increased rheumatic affection and of heart disease in some parts of the empire. Acute articular rheumatism gives rise to 54 deaths per million, and heart disease to 231 per million in Prussia. Cancer is one of the fatal diseases of Germany ; and although less common in the north of Germany than in England or Sweden, it is yearly increasing in frequency, as will be seen from the follow- ing figures, which give the annual mortality per million from 1881 to 1887 in Prussia : — 1881. 1882. 1883. 1884. 1885. 1886. 1887. Deaths from Cancer per Million, 312 318 335 349 353 385 383 The average death-rate in Prussia for this period was 348, and in Saxony (1876-85) it was 697, per million. In the large towns of Prussia the disease is much more common than in the smaller towns. Cancer is excessively fatal in Schleswig, Stralsund, and Llineburg; least so in the eastern districts of Marienwerder, Bromberg, Posen, and Oppeln. Goitre is endemic in some parts of Wurtemberg, especially in the districts of Jaxt, Neckar, and the Black Forest, where, according to Hirsch, the cretins number 3-8 per 1000. The disease is also met with in some parts of Upper Bavaria, Baden, Alsace-Lorraine, and other districts. 90 CENTEAL AND WESTERN EtJEOPE. Ancemia is a common affection, especially in Bavaria, Baden, Saxon}^, and Alsace-Lorraine ; it is less general in Prussia, Hessen, and the Thuringian States. Scorhutus is seldom met with save in the seaports, such as Hamburg and Bremen, and also to some extent in Bavaria. Scrofula and Pdckets gave rise in Prussia to a mean death-rate of 0-94 per 10,000 living in the period 1881-87, and to 0-37 per cent, of the total mortality. As scrofula and rickets are combined under the same heading, the returns do not permit us to compare the frequency of scrofulous diseases in Germany and in England, where rickets is returned separately, and scrofula is combined with other tubercular diseases. Still we may infer from these figures that scrofulous diseases are widely diffused in Germany. Scrofula is of specially frequent occurrence in Schleswig and Liineburg, and to a smaller, but still to a considerable, extent in Stettin and Stralsund. In the east I find only one district, viz. Breslau, in which the death-rate from scrofula is above the mean of the whole country. In Mlinster in the west, and Marienwerder and Bromberg in the east, scrofula is less common. Hirsch states that besides the large towns, such as Munich, Stuttgart, Leipzig, Berlin, Stettin, Hamburg, Danzig, and Breslau, there are many other foci of it of greater or less extent, such as the Dittmarschen, the Hartz country, the Saxon Erz Mountains, Upper Silesia, Westphalia, Thuringia, etc. He believes that altitude and the wetness or dryness of the soil are of much less significance in relation to the prevalence of scrofula than dietetic and hygienic errors, especially the want of out-door exercise in children. JJiuhctcs appears to be neither more nor less common in Germany than in Europe generally. The average deaths in five localities, given by Hirsch, formed one per 1000 of the total mortality. SyioMlis, judging by the statistical returns of the disease among the soldiers, is less prevalent in Prussia than in any European country. But this is a fallacious test, inasmuch as the prevalence of the disease in the army depends to a large extent upon the proportion of celibates in the different armies. AVhere the soldiers are mostly married men the cases of syphilis v/ill be correspondingly rare, even if the disease is prevalent in the country or locality in which the troops may be stationed. The average number of admissions into the public hospitals in Germany for venereal diseases, 1883-85, was 5 7*2 per 1000. In Hamburg the pro- portion was 110-8; in East Prussia, lOT'l ; in Berlin, 98*0; in West Prussia, 87-2; in Bavaria, 36-5; in Wurtemberg, 34-5, per 1000 of cases treated. CHAPTEE VII I. AUSTEO-HUNGARY. Geogeaphy. — The Austro- Hungarian Empire occupies the south- east of Central Europe, lying between 42° and 51° N". lat., and between 10° and 27° E. long. Austria proper is divided into fourteen administrative depart- ments, with an area of 115,903 square miles, and an estimated population in 1888 of 23,484,995 inhabitants. Hungary, includ- ing Transylvania, with Croatia, Slavonia, and the town of Eiume, has an area of 125,039. square miles, and a population in 1888 of 16,979,813 inhabitants. The total area of the empire is thus 240,942 square miles, with a population of 40,464,808 in- habitants. Austro-Hungary is traversed by three great mountain chains — the Alps, the Carpathians, and the Sudetes. The Ehaetian Alps, intersecting the Tyrol on the west, are continued, under the name of the jS'oric Alps, through Carinthia and Styria, terminating in the Leithan mountains south of Vienna. On the eastern side of the Danube the same system is continued from near Presburg as a semi-circular range, which, although bearing different names in its course, forms in its entirety the Carpathian range, dividing Hungary from Moravia on the north-west, from Galicia and Bukowina on the north and north-east, and then, running to the south and west, separates Transylvania from Moldavia and Walla.chia. The Sudetes divide Silesia from Bohemia and Moravia, and, under the names of Piiesen Gebirge, Erz Gebirge, and Bohmerwald, encircle Bohemia. The plains are the Greater Hungarian Plain in the east, traversed by the Danube, the Theiss, the Maros, and other streams of smaller size ; and the Lesser Hungarian Plain on the west. In Galicia there are the deep plains traversed by the Vistula and Dniester and their tributaries ; and in Bohemia the elevated central plain traversed by the Moldau and its feeders. . The greater part of the country — perhaps three-fourths— is mountainous or hilly. 92 CENTEAL AND WESTERN EUEOPE. The principal lakes are the Flatten See (Balaton Tava), with an area of 400 square miles, and the Neusiedler See, 117 square miles in extent. The Elbe and its tributaries, the Moldau and the Eger, rise in and traverse Bohemia. The Vistula, the Bug, as well as the Dniester and several of its tributaries, rise in Galicia. The Danube and its tributaries, the March, the Waag, the Gran, the Theiss, the Koros, the Maros, the Bega, and the Temes, which join it on the left, and the Inn, the Traun, the Leitha, the Eaab, the Drave, and the Save, which enter it on the right, traverse Upper and Lower Austria, Moravia, Styria, Garniola {Krain), Slavonia, Hungary, and Transylvania. The soil of the Hungarian plains consists chiefly of humus and clay. Swamps abound along the course of the Theiss and other rivers. A morass, covering some eighty square miles, is connected with the ISTeusiedler See. In Galicia, marshes of considerable extent are found in the department of Cracow, and in the circles of Wadowice, Zolkiewo, and Zloczow (Hirsch). Humid, water-logged, and marshy tracts are also met with in some parts of Bohemia, near the banks of the streams. Climatology. — The following tables give the temperature and rainfall of various regions in Austro-Hungary : — Temperature of Various Localities in Austro-Hungary. Locality. Altitude in Metres above Sea-level. Jan. April. July. Oct. Year. Prague, Bohemia, . 202 -1-4 9-1 19-6 9-8 9-2 Brunn, Moravia, . 225 -2-5 9-3 19-8 10-0 8-9 Lemberg, Galicia, . 298 -4-1 7-7 19-5 9-3 8-1 Ltnz, Upper Austria, 377 -2-7 9-0 19-1 8-8 8-5 Vienna, Lower Austria, . 197 -1-7 9-9 20-5 10-0 9-7 Klagenfurt, Carintliia, . 440 -6-3 8-8 19-0 8-7 7-3 Laibach, Carniola, 287 -2-6 9-8 19-7 10-8 9-4 Agram, Slavonia, . 163 -0-5 11-9 22-3 12-3 11-3 Buda-Pesth, Hungary, . 153 -1-4 10-8 22-3 11-3 10-7 Szegedin, ,, 89 -1-1 n-8 22-8 12-6 11-3 Panscova, , , 65 -0-8 12-2 23-0 13-3 11-7 Debreczin, , , 124 -2-4 10-7 22-4 11-4 10-5 The average annual rainfall is about 64 centimetres in Bohemia, Moravia, and Silesia ; 73 cm. in Galicia and Bukowina; 83 cm. in Upper and Lower Austria ; 115 cm. in Vorarlberg, the Tyrol, and Salzburg; 94 cm. in Styria, Croatia, and Slavonia; 107 cm. in Carintliia; 137 cm. in Gorz, Carniola, and Istria ; 92 cm. in Dalmatia ; 59 cm. in Hungary; and 77 cm. in Transylvania. AUSTRO-IIUNGAKY. Monthly DisriinsunoN i>er cent, ok tjie Rainfall in Austro-Huni;auy Month. Alpine Bohemia, Austria, — Moravia, Salzliurg, Silesia, and E. Galicia, Hukowina,and Transylvania. Hungarian Plains. S. -W.Hungary, Croatia, and S.-W. Carintliia, andStyria. ,W. Galicia. Slavonia. Carniola. Jan. .5 5 4 6 6 G Feb. .0 6 5 5 5 5 Mar. 7 7 7 7 7 7 April, 7 7 7 7 8 7 May, 10 10 12 11 9 9 Jnne, 12 1 13 15 12 11 9 July, 13 12 14 11 9 9 Aug. 13 12 11 10 9 9 Sept. 9 , S 7 6 9 10 Oct. () 6 6 8 10 11 Nov. 7 7 6 9 9 10 Dec. (J 7 6 8 8 8 Vital Statistics. — The marriage-rate in Austria for the ten years ending 1887 was 15 '6; the birth-rate, 36*8 ; and the death-rate, oO'O, per 1000. In Hungary the marriage-rate for the ten years ending 1884 was 19*7 ; the birth-rate, 44-4 ; and the death-rate as high as 35-7, I3er 1000. The heaviest mortality falls on winter or spring throughout Austro - Hungary, except in Dalmatia, the Banat, and Temesvar, where it is estival or autumnal. Pathology. — Malaria. — In Bohemia, malaria is chiefly confined to the banks of the Moldau and its tributaries, and to some of the marshy localities of the south and east. In Prague the disease is not endemic. Malarious foci are met with in the marshy districts of Cracow, Wadowice, Zolkiewo, and Zloczow in Galicia. According to Duchek, intermittent fever is by no means rare in the neighbourhood of Lemberg. Hirsch states that the southern part of the country, risino- in terraces towards the Carpathians, is little affected by malaria, and that a like exemption is enjoyed by the southern slopes of that range. The Duchy of Bukowina enjoys a certain immunity as regards malaria. Czernowicz, the capital, situated in the centre of a marshy region, suffers considerably in summer, as does also the environs of Smyatin and Zalcaspki, on the banks of the Dniester (Lombard). In Silesia and Moravia, malaria is endemic in a few places along the course of the Oppa, the Oder, and the March. The Tyrol, Styria, Carinthia, and Salzburg are, as a whole, healthy, malarious foci of limited extent being met with only in some of the marshy valleys. At Klagenfurt, the capital of Carinthia, situated on 94 CENTEAL AND WESTEEN EUEOPE, the river Glan, two miles east of the Worthsee, with its marshy surroundings, intermittent fever is rather common. Tlie upper course of the Danube is but little affected with endemic malaria ; but below Vienna ague is rife on the banks of the Danube, and still more so in the basin of the March. In Vienna itself malarial sickness is by no means prevalent or severe. As we descend into the plains of Hungary, we come upon a region where malaria is widely endemic, and manifests itself in its more intense forms. In the basins of the Waag and the Gran to the north, and alons; the lower course of the Eaab to the south of the Danube, and in the country lying to the east of the Eaab, through the Bakonyer Wald and stretching south-east to Stuhlweissenburg, and to the districts between the Flatten See on the west, the Danube on the east, and the Drave on the south, malaria occupies a leading place, not only in respect to frequency, but also in regard to its deteriorating effect on the constitution of the inhabit- ants. The lower courses of the Drave and Save are also more or less malarious, but Croatia and the higher lands of Slavonia are com- paratively healthy. Buda-Pesth is comparatively free from ague, as is the country along the left bank of the Danube from Buda-Pesth to Pelegyhaza. The marshy region traversed by the Theiss and its tributaries, notably the Szamos, the Bodrog, the Koros, and the Maros, is in a high degree malarious ; and the fever here often assumes a grave type after the inundations to which these rivers are subject. The inhabitants in many localities suffer from cachexia. The Banat, in the south-east corner of Hungary, situated between the Maros and the Danube, is another district noted for its extreme unhealthiness. Paget in his work on Hungary and Transylvania says, "that from the flatness of a large portion of the surface, and from the number of the rivers by which it is watered, immense morasses are formed, which taint the air, and make it really what the French writers call it, ' le tombeau des etrangers.'" The soil is a rich loam. After the hottest day, the sun no sooner sets than a cool breeze arises, refresh- ing at first, but which becomes dangerous to those unprepared for it. The province of Transylvania is a moderably-elevated plateau, surrounded by mountains on the north, east, and south. It is a country of hills and valleys, drained by tributaries of the Theiss. Here malarial diseases are much less generally met with, being only prevalent in a few humid valleys, along the banks of some of the AUSTIIO-HUNGARY. 9 5 streams, and in the marshy district between the Maros and the Szamos. The Istrian Peninsula is, upon the whole, much less malarious than Hungary. Trieste, formerly subject to fevers, is, according to my inquiries made on the spot, now almost exempt from this class of diseases. Ague is, however, met with, although in a comparatively mild form, at numerous spots along the coast, such as Citta ISTuova, Parenzo, Eovigno, Pirano, and Capo d'Istria. Pola is perhaps the most unhealthy spot in the peninsula. It is situated near the south point of Istria. " The soil has for basis a compact calcareous forma- tion of metallic hardness, presenting numerous crevices filled up by the clay, which forms also at the bottom of the valleys a subsoil covered over by a more or less thick layer of vegetable matter. In these valleys the rainfall accumulates, on account of the clayey bed, and hence arises permanent foci of marsh emanations." ^ In Dalmatia, fever is met with at numerous points along the coast — at Zara, at the mouth and for some distance up the course of the Narenta, and at Eagusa. The high lands of the interior are healthy, as are also most of the islands lying along the coast. As in Germany, so in Austro-Hungary, local epidemics of malaria are often observed to arise from excavations of the soil and from inundations. In 1856-57, numerous cases of ague, complicated with the worst forms of malarial cachexia and dropsy, were admitted into the General Hospital, Vienna, occurring in labourers employed on the railroads in Hungary. As illustrating the baneful influence of inundations in developing and intensifying the malarial infection, we may quote two instances cited by Lombard. After the inundations of 1853, at Gross Wardein on the Koros, 18,000 persons were attacked with fever out of a population of 22,000. Such is the effect of inundations in a malarious country. Galicia, on the other hand, as we have said, is little subject to malaria ; but, after the inundations of 1845 and 1846, fevers of a refractory character spread wherever sheets of stagnant water were left to form marshy pools. We are indebted to Hirsch for statistics of the monthly incidence of malaria on four localities in Austro-Hungary, which we shall give along with the mean monthly temperature (centigrade) and rainfall of Vienna in the north and of Pola in the south. ^ Rey, Nonveau Diet, de mdd. et chir., Paris 1872. 96 CENTEAL AND AVESTEEN EUROPE. V'lESNA POLA. Klagenfurt. Monthly SzENT-MlKLOS. S" ? § ^1 ^ Monthly "rt C3 ^_ =-gg-i S 5 g F^.^ TsTi J-^ Percentage pf Percentage of II >=2 3 "« ^^1 1 m Fever Admissions. 6 Fever Admissions. 7 Jan. -1-7 35 3-47 5-7 47-0 2-4 7-10 3-95 Feb. 0-1 36 3-13 7-0 41-2 1-9 5-08 2-71 Mar. 4-3 43 5-71 8-0 82-3 2-0 5-60 3-44 April, 9-9 42 10-50 12-6 77-4 2-4 7-20 9-08 May, 15-1 64 15-01 16-2 62-4 2-8 11-95 12-06 June, IS -8 66 11-70 22-1 81-3 2-9 10-08 8-65 Julv, 20-5 65 8-90 , 23-6 37-8 8-7 9-72 9-56 Aug. 19-7 72 9-44 i 24-7 73-0 14-2 9-00 16-26 Sept. 1.5-9 45 11-44 i 20-1 105-4 12-6 7-61 13-43 Oct. 10-0 44 9-49 1 14-1 117-0 11-3 9-90 9-47 !N"ov. 3-9 43 6-90 9-8 119-7 5-8 9-90 6-72 Dec. -0-3 40 4-22 4-6 109-9 3-1 6-83 4-63 In Vienna there are two maxima, one in spring (April, May, and June) and the other in autumn (September). The spring rise is the principal one. Klagenfurt shows only one period of fever prevalence, which attains its acme in May and June. At Szent- Miklos there is a vernal exacerbation in April and May ; but the principal rise takes place in August and September, In Pola, on the other hand, the vernal rise disappears, and more than half the cases occur in the three months, August, September, and October. The difficulty of explaining the seasonal distribution of malarious fevers by reference merely to temperature and rainfall will be ap- parent by examining this table. In Szent-Miklos the greatest rain- fall is from May to July ; in Pola, from September to December ; in both localities fever attains its maximum in August and September. Perhaps it is still more difficult to account for the disappearance of the vernal rise in Pola. Were spring fevers relapses of autumn attacks, such relapses ought to be frequent in such a place as Pola. It may be, however, that among the civil resident population vernal fevers are more common than among the troops. We have no data bearing upon the question as to whether the intensity or prevalence of these fevers is in proportion to the warmth of the season. Hirsch quotes from Jilek a table giving the relation between the amount ^ Ilandhuch dar Klimatuloi/ie, vuu Julius Haini, Stuttgart. - Hussa, ten years' admissions into General Hospital. •' Average temperature of three years, 1877, 1878, 1879. •* Average rainfall for the nine years, 1877-79 and 1882-87. •' Jilek, sickness on total force of troops, 1863-67. •' Hussa, twenty-five years' observations. " Lach, for three years (1854-56). AUSTRO-HUNGARY. 97 of malarial sickness at Pola, and total annual rainfall, which we here reproduce : — 1864. 1863. 1866. 1865. 1867. 1868. Rainfall in Paris, inches,' 18-44 14-2.5 12-10 3-44 5-49 1-5 Cases of fever, jjer 100 men. 51-4 48-6 3G-3 3i>-4 22-9 14-2 From this it will be seen that rainy years are the most feverish in Pola. At Vienna the tertian type is the most common. Of 3126 cases, 1495 were of the tertian, 1293 of the quotidian, 243 of the quartan, and 95 irregular. Here we remark the large proportion of the quotidian type compared with that observed in Holstein. In the Banat and in Istria the quotidian type appears to be the most common. The pernicious and remittent forms are by no means rare in Hungary, Istria, and Dalmatia. In all these regions, where malaria is intense, it is remarked that strangers suffer much more than the native population. Austro-Hungary has frequently suffered from general malarial epidemics, and here, as in the rest of Europe, the disease has been observed to extend to localities where it is not endemic. Enteric Fever is widely prevalent as an endemic and epidemic disease in Austria. In the four years 1876-79 the deaths ascribed to typhoid fever (probably including typhus) were in the ratio of 76 5 per million living, and in 1881—84 the proportion is given by Easeri at 731 per million. In 1885-87 it stood at 683 per million. In the fifteen principal towns of Austria, for the period 1881-84, the typhoid death-rate was 449 per million. The disease is thus less prevalent in the largest towns than in the country generally. In Vienna the death-rate from typhoid and typhus fevers (1880-89) was 160*4 per million, while in Prague the ratio 1881-89) was 441 per million. As a point of comparison we may note that the typhoid death-rate of London in 1884 was 230 per million, — a proportion considerably in excess of Vienna, but little more than one half of that of Prague. In Austria the ratio of the deaths from enteric fever to 1000 deaths from all causes, from 1882-86, fluctuated between 22-4 and 2'5-7, with a mean of 23'7. Enteric fever appears to be of most frequent occurrence in Galicia, Bukowina, and Dalmatia, and to be least common in Lower Austria and Styria. Enteric fever is still more prevalent in Hungary than in Austria. Of 316,166 deaths occurring in Hungary (1878-80),^ the causes of which were known, 11,497, or ^ Ba2')portH annuel de I'hdpital rjineral de Vienne, pour les mmicn 1855-62. Colin, Fi&vrefi Intermittentes, p. 138. 2 Statistik der Bevolkerunj Ungarns, Buda-Pesth 1885. G 98 CENTEAL AND WESTEEN" EUROPE. 3"64 per cent., were caused by typhus and typhoid fevers. Enteric fever is thus excessively fatal in Hungary, side by side with malarial fever, — a fact which shows that there is no antagonism between typhoid fever and malaria. Buda-Pesth suffers somewhat severely, for the deaths from typhus and typhoid in that city in the ten years ending 1889 were in the ratio of 533"1 per million living. The quarterly distribution of typhus and typhoid deaths is given in the following table. The proportions are certainly deter- mined by the typhoid element : — First Quarter. Second Quarter. Third Quarter. Fourth Quarter. Vienna (1881-88), 27-12 22-51 2-5-55 24-82 Prague (1882-88), 30-39 31-05 19-46 18-94 At Prague, as at Munich, the usual autumnal maximum dis- appears, and the second quarter is that during which the typhoid deaths are most numerous. Typhus Fever is said by Hirsch to have been epidemic in Galicia and Austrian Silesia in 1846—47, in Bohemia in 1847-50, and in Vienna in 1853, 1855-56, 1858-59, 1862-63, 1870-71, and in 1875. In the official statistics of recent years to which I have had access, this disease is not distinguished from typhoid fever, so that its frequency at the present time cannot be determined. Hungary has been ravaged at different epochs, especially during war, by epidemics which some believe to have been typhus, but which more probably included various forms of fever, continued and malarial, and differing in different periods. Belapdng Fever was epidemic in Galicia in 1847, in 1865—67, in 1875, and in 1877-78. In Prague it broke out in 1865-67. I have not met with any reference to it in recent years. Biplitlicria. — The earliest account of the epidemic prevalence of diphtheria in Austro-Hungary, at least during this century, dates, according to Hirsch, from 1870, when it was introduced from Eoumania into Transylvania. It appeared in Bukowina in 1874, and only reached A^ienna in 1875. Since then it has become one of the most fatal diseases in Austro-Hungary. In Austria the average percentage of deaths from diphtheria and croup to the total mortality, from 1882—86, was 4-73. In 1886 the disease was most fatal in Silesia, Galicia, and Bukowina. Kaseri gives the death-rate per million from diphtheria and croup (1881—84) at 1036 in the fifteen principal towns, and at 1663 per million for the country as a whole. During the three years 1885-87 the ratio for the country as a whole was 1397 per million. To show how excessively fatal diphtheria and croup are in Austria, it may be AUSTltO-IIUNGARY. 99 stated that the death-rate from these diseases in England in 1884 was only 360 per million. In Hungary (1878-80), diphtheria caused 5'15 per cent, of the total deaths, which is a proportion somewhat higher than that of Austria. Here are the quarterly percentages of deaths from diphtheria in Prague, Vienna, and Buda- Pesth : — First Quarter. Secoiiil (,)uarter. Third' Quarter. Fourtli Quarter. Prague (1SS2-SS), 23-3 17-8 19-2 397 Vienna (lS63-S3),i 31-3 23-5 157 29-5 Vienna (1881-88), 307 247 16-1 28-4 Buda-Pesth (1884-86), 20 "3 217 24-6 33-3 It will be observed that the first and last quarters are most charged with diphtheria deaths. In Prague it is the second, in Buda-Pesth it is the first quarter, and in Vienna it is the third quarter that has the fewest deaths. It will be remarked from the two periods given for Vienna, that the same seasonal relation seems to be pretty constant for a given locality. Diarrhcea (Darmkatarrh) caused 4"89 per cent, of the general mortality, and Dysentery (Piuhr) I'OS, in Austria in the year 188G. The mean death-rate from the former (1885-87) was 1370, and for the latter as high as 440 per million. The average percentage of deaths from these diseases to the total mortality from 1878-80 in Hungary (excluding Croatia and Slavonia) was 6 '03 and 1*84 respectively. If we remember that dysentery and diarrhoea together caused 4'9 per cent, of the deaths in England, we may judge of the frequency of these diseases in Austro-Hungary. Dysentery appears to be most fatal in Galicia, Bukowina, and Dalmatia, and least so in Upper and Lower Austria and Salzburg — the provinces in which diarrhoea makes most victims. The death-rate per million living from diarrhceal diseases as a class in Vienna (1881—88) was 1912'2, — a much smaller propor- tion than that of Berlin, but double that of London. In Prague the mortality from diarrhceal diseases (1882-88) was lOlO'G per million. In Buda-Pesth (1885-88) diarrhoea! diseases gave rise to a death-rate of 3440 per million. In all these localities it is the third quarter in which diarrhoea is most fatal, and the excess in the third over the other quarters is in proportion to the prevalence of the disease, Asiatic Cholera visited Austro-Hungary in 1831-32, in 1837, in 1849-50, in 1854 and 1855, in 1865— 66, when it proved very fatal, and again in 1871—74. The mortality was at its height in •^ Hirsch, op. r.it. If it le the case that diphtheria only appeared in Vienna in 1870, the cases before that date must have lieen of the nature of croup, or at most, sporadic cases of diphtheria. 100 CENTRAL AND WESTERN EUROPE. the year 1873, the deaths from cholera in that year being 107,007. In 1886 there were 354 cases of Asiatic cholera in Buda-Pesth. Smallpox makes considerable ravages in Austro-Hungary. In Austria (1881-84) the deaths per million living were 705, and in 1885-87, 460 in the country as a whole, and in the former period 843 in the principal towns.^ Galicia has always been noted as one of the principal haunts of smallpox. In the five years, 1882-86, smallpox caused 2'01 per cent, of the deaths in Austria, and in 1878-80 it gave rise to 2*62 per cent, of the deaths in Hungary. Scarlet Fever and Measles caused 586 and 460 deaths respectively per million living in 1881-84. In 1885-87 the ratios were 573 and 583 in Austria, — proportions in excess of those in England and "Wales during recent years. The quarterly distribution of these two diseases in Prague and Vienna is as follows : — JIeasles. Scarlet Fever. First Second Third Fourth First Second Third Fourth Quarter. Quarter. Quarter. Quarter. Quarter. Quarter. Quarter. Quarter Prague (1SS2-SS), . 21-1 45-1 20-6 13'2 20-7 19-9 26-5 32 -S Vienna (1881-88), . 29-5 41-1 13-7 15-6 29-4 2S-9 18-2 23-4 If we refer back to the seasonal distribution of diphtheria, it will be observed that that disease is at its minimum in A^ienna in the third quarter and in Prague in the second quarter ; the same seasonal peculiarities are here observed in res23ect to scarlet fever. Measles attains its maximum in the second quarter both in A^ienna and Prague. Influenza has never failed to visit Austro-Hungary when it has been epidemic in Germany ; and what we have said respecting the periods of its prevalence in the latter country will apply generally to Austro-Hungary. During the late epidemy there occurred, between the 11th November 1889 and the end of January 1890, no fewer than 930,478 certified cases of influenza, and 2823 certified deaths. Phthisis is more fatal in Austro-Hungary than in any other European country. The official reports give the phthisis death-rate in Austria from 1876-79 at 3910 per million; from 1881-84 phthisis (including tabes mesenterica and tubercular meningitis) caused a death-rate of 3839 per million; and from 1885-87 of 3890 per million living. In the fifteen principal towns the mor- tality for 1881-84 is given as 7220 per million. This excessive urban mortality is so far confirmed by the figures given by Hirsch, ^ In Austria, wEere neither vaccination nor revaccination are compulsory, the mortality (1874-84) was twenty-seven times higher than in Germany, where both are compulsory. Proust at Acad, de M^d., Jan. 1891. AUSTKO-IIUNGAltV. 101 OH the authority of Kiirosi, for Vienna, which give the average phthisis death-rate of that city from 186 5- 7-4 as 7*7 per 1000. In 188G the highest death-rates were observed in Lower Austria and Carniola, and the lowest in Upper Austria, Salzburg, the Tyrol, and Galicia. Dalraatia, as a rule, stands favourably as regards its low phthisis death-rate. The percentage of the total deaths ascribed to phthisis in Austria for the hve years 1882—86 was 13'26, and in Hungary (1878-80) it was 1212 per cent.i In Buda-Pestli the mortality from phthisis (1872-75) reached 0000 per million (Hirsch). The death-rate from phthisis in Hungary, although excessive, is somewhat under that of Austria ; but there is here at least no antagonism between malaria and phthisis. Pneiimonia, Pleurisy, and Bronchitis (in 1881-84) occasioned a death-rate of 2809 per million, and in 1885-87 of 3020, in Austria as a whole, and of 3795 per million in the principal towns (1881-84). From 1882 to 1886 inflammatory diseases of the respiratory organs occasioned on an average 10*24 per cent, of the total deaths ; while in England, bronchitis, pneumonia, and pleurisy formed 15'2 per cent, of the deaths from all causes in 1884. In Hungary, inflammation of the lungs, by which pneumonia and pleurisy are probably understood, accounted for 7 "4 6 of the total mortality. In Vienna, pneumonia caused 7 "3 per cent, of the deaths from 1869 to 1873 (Lombard). In London, pneumonia and pleurisy caused only 5*2 per cent, of the deaths in 1884; from which we conclude, although with some reserve, that in Austro - Hungary bronchitis is considerably less fatal than in England, and that pneumonia is more so. The monthly distribution of pneumonic cases in Vienna (1847- 5 7) is thus given by Hirsch : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 9-T 9-2 11-6 13-1 13-0 8-1 .-.•0 3-9 4 -(J 5-1 7-2 8-0 Whooping-Cough causes a considerable mortality both in Austria and Hungary. The death-rate from whooping-cough in Austria (1885-87) was 9 76 per million, — a ratio nearly double that of Prussia and England during the same period. The average per- centage of the total deaths due to this disease in Austria (1882- 86) was 3-61; and in Hungary (1878-80), 2-24. It is much more fatal in the towns than in the country. Diseases of the iSjyIeen are said to prevail in the Hungarian levels of the Danube and in the plains of the Moldau. Dropsy. — The prevalence of malaria may account for the pro- ^ StatMlk der Bevolkerinui Unrjarns, Buda-Pesth 3 885. See also CEsterreichisclies Statist. HandUich, Wien. 1889. 102 CENTRAL AXD WESTERN EUROPE. fuinent place taken by dropsy among the death-causes in Hungary, when it gives rise to I'SO per cent, of the total mortality, — a pro- portion rather more than ten times as great as in England. Cancerous diseases are far from rare in Austria. During the period 1885-87 the death-rate from cancer was 480 per million. These diseases are most common in the towns. I have no data as to their prevalence in Hungary. Goitre and Cretinism have their headquarters in the Central Alpine regions of the Tyrol, Salzburg, Carinthia, and Styria, — there being in the last-mentioned province 1'5 cretins per 1000 of the population. The greatest proportion of the disease is found on gneiss and granite formations.^ It is also met with in the valleys of the Bohemian mountains, in Galicia, on the northern slopes of the Carpathians. In Hungary, goitre is endemic in the valleys of the Carpathians, in the mountainous districts of the east, and also in the valleys of the Koros and Temes, in the Bakonier Wald, and in some other parts of the Hungarian plains. It is not endemic in Croatia, Dalmatia, Caruiola, or in the valley of the Drave. Leprosy is not endemic in any part of the empire. Scrofula is frequent in the mountainous parts of Bohemia, in some parts of Upper Austria, Salzburg, Styria, and on the military frontier (Hirsch). Syphilis does not appear to be more common in Austria than in the neighbouring States of Europe. It was endemic in a few localities in the circle of Bidschow (Bohemia) during the second quarter of this century .^ Whether it has now been eradicated, 1 know not. According to Lombard, syphilis shows itself in Hungary with an intensity and gravity unknown elsewhere. He remarks that secondary and tertiary forms are very common in Croatia and Slavonia. In the year 1800 a contagious disease, of a kind previously un- known, appeared in the government of Fiume. It broke out in the village of Scherlievo, which is situated about eight miles to the east of Fiume, and about three miles from the Adriatic coast. Cambieri, who was delegated by the Government to inquire into its nature, concluded that it was similar to the epidemic syphilis of 1493, and, like it, was propagated by ordinary social intercourse. It soon spread through Istria to Trieste in the north, to Dalmatia in the south, and inland to Carniola. This endemy lingered on in various localities in Croatia until the year 1855, perhaps later. 1 Kratter, Dcr alpine Cretini>>mn>i, Graz 1884. - Hirscli, op. cit. CHAPTEE IX. ENGLAND AND AVALES. Geography. — England and Wales, which together form the southern and larger division of Great Britain, lie between lat. 49° 57' and 55° 48' N., having an area of 58,186 square miles, with a popula- tion estimated in 188 7 at 28,247,151. The greater part of England is level or undulating, the moun- tainous districts being chiefly confined to the north and west. In the north, along the Scottish border, are the Cheviots, which are continued southward for above 200 miles as the Pennine range through Northumberland and York to the centre of Derbyshire. Connected with this range is the Cumbrian system in Cumberland, Westmoreland, and the north of Lancashire. The Cambrian or Welsh mountains consist of several ranges, occupying a large part of the Principality, and penetrating into the neighbouring border counties of England. The south-western highlands of Devon and Cornwall, with which may be included the Cotswold Hills in Gloucestershire, the Mendips, the Quantock Hills, and the Blackdowns in Somerset, form a third system. In addition, there have to be noticed the minor chalk ranges : the Wolds in York ; the South Downs in Hampshire and Sussex ; the North Downs in the north of Hampshire, Surrey, and Kent ; and the Chiltern Hills, running through Oxford, Buckingham, and Hertford. T]ie principal plains are the Salisbury Plain in the south-west ; the eastern plains, stretching along the coast from the Thames to the Wash ; the plain of York, between the Wolds and the Pennines, which is continuous wdth the north-eastern coast plain ; and, finally, the Central and Cheshire plain, which latter is continuous with the north-western coast plains. Considerable tracts of level land also skirt the northern shores of the Bristol Channel. The fireatest stretch of low flat la.nd extends alona" the shores 104 CENTRAL AND WESTERN EUROPE. of the Wash, runnino- inland throuo-h Cambridge, Huntino;don, and Northampton. This district, known as the " Pens," covers about 700,000 acres, of which considerable areas are below the high- water level of the "Wash, and are protected from overflow by embankments. The rivers along the south coast are small. On the west we have the Severn, the basin of which has an area of 8580 square miles ; the Mersey, draining an area of 1748 square miles ; the Dee and the Eden, draining areas of 862 and 990 square miles respect- ively. As the highlands are situated along the western side of the island, the slope of the country is mainly from west to east, and as a result the chief rivers fall into the ISTorth Sea. Of the rivers on the east coast we may mention the Thames, with a basin of 6160 square miles ; the Southern Ouse, the Nen, the Trent, and the Northern Ouse, terminating in the Humber, with a basin area of 9550 square miles. To the north of the Humber are the Tees, Tyne, and Tweed ; the two former of which run through densely- populated regions. The southern districts of England are chiefly agricultural ; the central, south-western, and northern districts are the main seats of the mining and manufacturing industries. The great density of the population in these districts, and the nature of the industries carried on in them, tell more or less upon the health of the inhabitants, and determine the prevailing diseases. Climatology. — The climate of England is mild, humid, and changeable. The difference between the temperature of the north, where it borders on Scotland, and that of the south coast, is about 3° to 3 '5° E. The west has a higher temperature and a heavier rainfall than the east coast. Average Mean Tempeuatuke axd Average Eaixfai.l in the Sovth, Centre, West, and East of England. SOUTH. CENTRE. GUERXSEV. Bourne- mouth. Plymouth. Oxford. BiRMIXOHAM Li ED.S. Mean Rain- llean Rainfall (Lyming ton). Jlean Hainfall Mean Ti-niTi liain- Jfean Rainfall Temp. fall. Temp. Temp. 1881-88. Tenip. (Thames) Oseutt. fall. Temp. (1881-85). Januarj', . 42-S 4-58 40-3 3-38 42-2 2-98 3s-(; 2-4(> 36-3 2-80 37-8 2-44 February, 43-9 .S-01 42-1 2 -.58 43-(; 2'.02 41-1 2-17 40-4 2-S5 40-2 2-26 March, " . 44-.5 2-01 43-3 1-88 44-8 2-81 42-3 1-55 40-9 2-13 41-6 1-79 April, . . 48-9 2 -.03 48-7 1-96 50-0 2-10 48-.-> 1-85 45-3 2-21 47 -S 2-10 May, . . 52-4 2-15 62-6 1-65 .53-9 1-93 52-8 1-79 49-5 2-52 52-6 1-34 June, . . 56-9 1-78 58-4 1-98 59-3 2-07 .09-2 2-08 57-2 2-72 58-8 2-39 July, . . 60-8 2-40 61 -S 2-31 ()2-5 2-82 62-3 2-34 68-1 3-01 62-0 2-79 August, . Gl-3 2-4.5 . 61-3 2-.')4 (52-1 1-97 61-6 2-61 60-3 3-23 60-9 1-78 September, 59-0 •6-o7 57 -S 3-53 58-4 3-33 57-0 2-85 54-9 3-60 66-6 2-39 October, . . 54-4 4-'.i0 r)l-9 3-20 52-.5 S-()'J 50-3 2 -51) 48-5 3-40 49-3 2-91 November, . 47-0 4-r,7 44-1 2-87 45-6 4-29 42-4 2-09 40-7 2-36 41-9 2-32 December, . 44-.") 4-S2 '41-3 2-98 42-8 3-59 39-7 2-04 37-0 2-76 39-2 1-88 Means and) TotaLs. )" 01-4 30-:!- 50-3 30-80 .-Jl-j 34-10 49-7 26-99 47-6 33-09 49-1 26-39 ENGLAND AND WALES. 105 WEST. EAST Barnstaple. Liverpool. Carhslk. Greenwich. Norwich. North Shields. Mean Rain- Moan RainfaU Mean Rain- Mean Temp. OO yeai-s. Rainfall Mean Rain- Mean Rain- Tt-nip. (18t«5-88t. lall. Temp. (1885-88) Temp. fall. 15 yeara. Temi". fall. Tuinp. fall. January, . 41-S .S-94 30-4 1-97 37-8 2-80 37-1 2-43 37-8 1-83 37-8 1-88 February, 42-0 i-so 41-3 1-43 39-8 2-04 39-0 1-70 40-1 1-90 39-5 1-71 March, . 41-6 2-02 42-3 1-72 41-1 rc.i; 41-5 1-39 41-5 1-70 40-2 1-51 April, May, . . June, . . 4V0 2-02 48-3 1-44 47-0 1-72 46-6 1-95 47-9 l-)-3 45-1 1-99 5S-9 2-54 52-3 2-03 50-7 1-73 52-9 1-84 52-5 1-Sl 49-2 1-79 59-7 2-04 58-2 1-67 50-9 2-15 .59-1 2-14 59-0 2-14 55-3 1-76 July, . . August, . 63-1 2-35 61-2 3-02 59-5 3-l(i 62-1 2-49 62-4 2-55 58-2 2-5i; 01-0 2-00 60-9 2-07 58-7 3-52 61-3 2-52 61-8 2-43 57-6 2-74 September, October, . 57-2 3-89 57-0 3-08 54-8 3-1(3 56-8 2-49 57-6 2-90 54-0 2-63 50-0 4-81 50-6 3-73 48-0 3-07 50-1 2-76 50-6 2-49 48-0 2-43 November, 4S-ti 4-28 43-4 2-97 40-5 2-60 43-0 2-03 42-6 2-95 41-6 3-01 December, 43-8 4-19 40-8 2-12 38-4 2-46 39-9 2-39 38-9 2-67 39-1 3-03 Means and ) Totals. ; 51-29 3t)-o4 49-0 27-25 47-5 3007 49-1 26-13 49-4 27-20 47-1 27 '04 The mean daily range of Greenwich, on an average of ten years, is as follows : — Jan. Feb. Mar. April. JIay. June. July. Aug. Sept. Oct. Nov. Dec. 8-S 10-3 14-7 17-6 ■20-0 20-2 20-2 19-8 17-3 13-7 10-4 9-1 The humidity attains its maximum from October to February, Vital Statistics. — The mean marriage-rate for the ten years (1878-87) was 14-8 per 1000. The average birth-rate for the same period was 33'5 ; during the first five years it stood at 34-4, but has lately been decreasing, for during the last five it had fallen to 32-6. The average death-rate in England during the seven years (1881-87) was 19-2, while in the ten years preceding (1871-80) it was 21*4. The death-rate is thus diminishing, and is lower than that of any European countiy, except Ireland, ISTorway, Sweden, and Denmark. The lower death-rate in these countries being due to the relatively smaller proportion of the population aggregated in large towns and employed in unhealthy occupations. The average death- rate of the town districts (1881-87) was 20-21 ; that of the country districts, 17 '5 4. In some of the agricultural counties, such as Surrey, Sussex, and Westmoreland, the average mortality for some years back has been under 17 per 1000. The average death-rate per quarter in England and Wales is as follows : — First Quarter. 21-40 Second Quarter. 18-86 Third Quarter. 17 -.57 Fourth Quarter. 19-1 The first quarter is decidedly the most unhealthy, and the third quarter the healthiest. The higher mortality of the first quarter is chiefly owing to deaths from diseases of the respiratory organs, and from whooping-cough. Let us now compare the quarterly death-rates of the town and country districts for the same series of years : — lOG CENTKAL AND WESTEEN EUEOPE, Jan.-Maixli, April-June, . July-Sept., . Oct. -Dec, . Town Districts. Country Districts. Difference. 22-17 20-17 2-00 19-49 17-84 1-65 18-97 15-17 3-80 20-26 17-06 3-20 The order in whicli the seasons stand as regards mortality is the same both in town and country ; but the proportions in which the town and country stand to each other vary considerably in the different quarters, as will be seen from the third column. The excess of the death-rate of the town districts, as compared with that of the country, in the third quarter, is chiefly due to the fact that infantile diarrhoea, which is so common at this season, is specially prevalent and fatal in the large towns. The same disease also contributes to raise the town death-rate during the fourth quarter, as will be seen when we treat of diarrhoea ; but the relatively high mortality of the town districts in the fourth quarter is mainly due to the fact that scarlet fever, diphtheria, erysipelas, and enteric fever attain their greatest prevalence during these three months ; and as they are all, with the exception of diphtheria, more fatal in the large towns than in the rural districts, this helps to raise the town mortality proportionately higher than that of the country. Pathology. — Malarial Fever. — In the time of Sydenham, and indeed much later, malarial fever was one of the most common, and by no means the least fatal, of the diseases met with in England. It is now comparatively seldom seen, and is still more rarely fatal. In 1841 and 1842 the mortality from ague was in the proportion of 8*2 to a million of persons living ; in 1885 and 1886 the proportion had fallen to 3 "2 per million. But the number of deaths from ague does not give an adequate idea of the amount of sickness it occa- sions. In Ceylon about one only in two hundred hospital cases proves fatal, and we may assume that only the worst cases are sent to hospital. In England, where the disease is incomparably milder, we cannot suppose that there are less than a thousand cases of illness for one case of death. Now, in 1887 there were four 2oersons per million who died of ague, and the population numbered 28 millions; the total deaths from ague in that year were 112, which would give 112,000 cases of intermittent fever during that year, and this estimate is doubtless mucli under the mark. Simon justly remarks that " the amount of injury done to the health of the community by malarial disease is not to be reckoned by the number of deaths which malaria occasions. In a country where the disease is comparatively mild, death frequently results from ENGLAXD AND WALES. 107 the secondary consequences — an;emia, dropsy, and debility — rather than from the disease itself." ^ The deaths from ague in the several registration districts are too few to indicate, except in a very general way, the areas of its endemic prevalence. Although remittent fever is returned as malarial, and is, in fact, often so, yet there can be no doubt that under this head- ing many deaths caused by fevers of a non-malarious character are included. It is therefore the ague deaths alone that can with certainty be regarded as malarious. We shall give separate tables of the average death-rates from ague and remittent fever for the five years 188.3-87: — Average Death-rate per 1000 living from Ague ix the Reglsthatiox Counties of En -;la> D FOR THE Five Years 1883-87. Eutlandsliire, 000 Lincolnshire, 0-003 Westmoreland, . 000 Xottinghamshire, 003 Oxt'ordsliire, 001 Derbyshire, 003 Shropshire, 001 Lancashire, 003 "Warwickshire, 001 West Riding, 003 Cheshire, 001 Xorth Riding, . 003 Monmouthshire, 001 North Wales, 003 South Wales, 001 Surrey (extra j\Iet.), . 004 London, 002 Somersetshire, 004 Middlesex (extra Met), 002 Durham, 004 Kortliamptonshire, 002 Northumberland, 004 Sufiblk, 002 Sussex, 005 jSTorfolk, 002 Hampshire, 005 Devonshire, 002 Essex, 005 Gloucestershire, . 002 Wiltshire, . 005 Herefordshire, 002 Cumberland, 005 Staftbrdshire, 002 Buckinghamshire, 006 "Worcestershire, . 002 Cambridgeshire, . 006 Leicestershire, 002 Cornwall, . 006 East Riding, 002 Huntingdonshire, 008 Berkshire, . 003 Kent (extra Met.), Oil Hertfordshire, 003 Bedfordshire, 0-011 Dorsetshire, 0-003 Average Death-rate pe R 1000 LIV ING FROM Remittent Fever IN THE Eegistratiox Co UNTIES FO] \ THE Five Years 1883-87. Oxfordshire, Leicestershire, 0-002 Huntingdonshire, ^ IS one. \ North Riding, 002 Dorsetshire, Surrey (extra Met.), . 003 Rutlandshire, ) Berkshire, . 003 Middlesex f extra Met.), 001 Northamptonshire, 003 Norfolk, '. 001 Devonshire, 003 Wiltshire, . 001 Cornwall, . 003 Somersetshire, 001 Herefordshire, 003 Shropshire, 001 London, 004 Warwickshire, . 001 Sussex, 004 Monmouthshire, . 001 Suffolk, 004 Herefordshire, 002 Staffordshire, 004 Cambridgeshire, . 002 Worcestershire, . 004 Gloucestershire, . 0-002 Nottinghamshire, 0-004 Privy Council Report's, vol. i. 108 CENTRAL AND WESTERN EUROPE. Average Death-rate from Remittent 'E'evtlv.— continued. Cheshire, . . . .0-005 West Riding, . . . 0-005 Westmoreland, . . . 0-005 South Wales, . . . 0-005 Buckinghamshire, . . 0-006 Lincolnshire, . . . 0-006 East Riding (with York), . 006 North Wales, . . . O'OOa Lancashire, . . .0 007 Cumberland, Hampshire, Essex, Derbyshire, Durham, Northumberland, Kent (extra Met.), Bedfordshire, 0-008 0-009 0-009 0-009 0-010 0-010 0-01.=? 0-ou The position occupied by Bedfordshire and Kent in both tables points them out as specially malarious ; and this is accounted for by marshy conditions prevalent in these counties. Huntingdon, with a death-rate of 8 per million from ague, as against an average for the whole of England of 3-2, must also be looked upon as an endemic seat of the disease in its more typical form ; but it is rather remarkable that the remittent form was entirely absent from this county during these five years. It seems as if the great drainage works of 1851, by which the Whittlesea-Mere was con- verted into pasture aud corn land, had completely banished the sraver forms of malarial fever from Huntingdon. The small amount of malarious disease in Lincolnshire, with its low level plains, formerly noted for their insalubrity, is specially remarkable. That Cambridgeshire should occupy a high place in the list of aguish localities is easily understood ; but one could scarcely have antici- pated that Cornwall should have ranked along with Cambridge as respects the number of deaths from ague. Is this accounted for by the clayey nature of the soil — in many parts derived from dis- integrated granite — and the heavy rainfall ? Dr. Peacock signalised ISTorth Aylesford in Kent, Huntingdon and Wisbeach in Cambridgeshire, as specially malarious.^ The upturning of the soil is not so frequently followed by local extensions of the disease in England as in many other countries ; yet ague was observed to increase in a marked way, and hypertrophy of the spleen in children to become common, at the time when the Metropolitan Eailway was being constructed.- So far as we can judge, endemic malaria in England is related to marshy and moist clayey soils, or, more rarely, to the upturning of ground formerly malarious. We have seen that malarious diseases have been steadily decreasing in England, and the question rises. To what is this due ? There can ho. no doubt whatever that this result is chiefly to be ascribed to the extended reclamation, drainage, and cultivation that 1 Year Book, New Sydenham Soc. 1859. - Med. Times and Gaz., July 29, 1876, [>. 1:>1. ENGLAND AND WALES. 109 have been going on during this and the preceding century. I>ut it is not so certain that other conditions of which we know nothing have not also been working in the same direction, for it would appear that malarial fevers have become rare in recent years in localities where no drainage works have been carried out. Dr. Thorne describes the village of Terling in Essex as placed on a bed of London clay which here comes to the surface at the bottom of a small valley through which a stream flows. " This country for many miles around is generally fiat ; land springs are most plentiful ; water is found in great abundance in ponds and in ditches by the road-side, and the atmosphere is unusually moist." " Ague," he adds, " was very prevalent throughout the neighbourhood until about the year 1840, but it is now seen on rare occasions." We read of no drainage, no improvements in cultivation, no alterations in the conditions of life, to account for the almost entire disappearance of a disease prevalent so recently as 1840, and the soil conditions exist- ing when he wrote in 1866 appear to have been highly favourable to the persistence of the disease, which, however, has given place to typhoid fever. Other examples of the same kind could be quoted. England, although at the present day it does not suffer from destructive epidemies of malaria, responds in a feeble way to epidemic influences. Thus we find that the deaths from ague increase in certain series of years, and some at least of these cycles correspond to wider epidemies affecting Europe generally. Thus intermittents were extremely prevalent in London between 1781 and 1785, — a period when it was extensively diffused over many parts of the Continent. Ague underwent a marked recrudescence in England in the years 1825—27, and I am not sure that this epidemy entirely disappeared before 1832. At the same time it was common all over Europe. Brown ^ says: "Since 1825 inter- mittent and remittent fevers have begun to show themselves with considerable frequency in districts on the east coast where they had formerly been little known, such as Sunderland, Shields, Newcastle, Hull, and in the northern parts of Lincolnshire." Macculloch - mentions that in 1826 the disease was common outside its usual haunts. In 1827 we are told that ague prevailed in every county of England, and in almost every street of London. The character- istic note of epidemic malaria is clearly noticed here, namely, its extension to districts where no marshy conditions prevail, and where it is, at other times, unknown. It is during such epidemies that the high lands, usually exempt, are often even more subject to the ^ Med. Essays on Fever, etc., London 1828. - Macculloch, On Malaria, London 1827. 110 CENTRAL AXD WESTEKX EUEOPE. disease than low and fenny localities. Thus, in 1780, Sir George Baker found malarial fevers to be prevalent in the elevated parts of Lincolnshire, while the inhabitants of the fens escaped. I have not ascertained whether 1825 and 1827 were unusual in any way as respects the weather, but it is stated that the year 1826 was very warm. The epidemy, however, had begun before then.^ The years 185 7, 1858, 185 9, and 1860 witnessed another, although less marked, period of malarial prevalence in England, which appears to have been part of what Hirsch calls " the great pandemic of 1855—60." During these years the deaths from remittent fever, as well as from ague, showed a marked increase ; but, as we have already said, the deaths registered as caused by remittent fever are far from being all due to malaria. The following are the deaths from ague and remittent fever, and the relation of the rainfall and temperature to the average, for the years 185 3-62 : — 1S53. Ague, . . . 183 Remittent Fever, . 707 Departure of rainfall) Irom average of - +4-6 -5-7 -3-3 -2-2 -3-3 -6-6 +1-5 thirt -nine years, . ) Departure of mean temperature from I _, , IS54. 1S55. 1S56. 1857. 1S5S. 1S59. 1S60. 1S61. 1862. 192 149 124 195 207 233 203 149 150 64(5 575 162 270 5159 400 314 254 2S4 average of thirty- . nine years, . . ) -0-3 -fl-7 -0-1 -M-4 -2-3 +0-1 -1-0-2 In 1852, the earliest period of which I have the record, the deaths from ague numbered 151 ; they increased up to 1854. A very decided decrease takes place in 1855, and a still more marked one in 1856. There was nothing, so far as we can see, in the meteorology of that year to account for this decrease. The tem- perature at Greenwich in 185 6 was 0"3 under the average; while in the previous year, when the decrease in ague was much less marked, it was no less than 2 '2 degrees under the average. There is surely some cause for the extraordinarily low mortality at once from ague and remittent fever in 1856. Are we to suppose that the very cold season of 1855 only attained its maximum effect in reducing the amount of ague in the succeeding year ? Or are we to consider that ague and remittent fever were held in check by some anti- epidemic influence preceding and premonitory of the coming epidemy ? This question can only be answered by studying the evolution of malarial epidemies elsewhere. In 1857, a year when the temperature was bejow and the rainfall above the average, the rise commences, and, as regards ague, attains its maximum in 1 Good's StiulT/ of Me-f., vol. i. p. 604, London 1834. ENGLAND AND WALES. Ill 1859, when the number of deaths was nearly double that of 1S5G. By 1861 the deaths from ague had already fallen to about the normal. It is impossible to connect tliis recrudescence with any peculiarities of temperature or rainfall, — these meteorological elements varied during the different years. During this epidemy the disease appears in many cases to have assumed graver forms than those which it usually exhibits. Peacock says that there were " numerous cases of rapidly increasing anajmia, sometimes combined with purpura and jaundice" — symptoms often met with in epidemic malaria else- where. Enteric Fever. — Tlie death-rate per million living from enteric fever during the three successive quinquennial periods between 1871 and 1885 was: — Five years Five years Five years 1871-75. 1876-80. 1881-8.5. 373-8 277-2 215-0 In 1887 the deaths from enteric fever formed nearly 1 per cent. (9-71 per 1000) of the total mortality. Considerable as the mortality is from typhoid in England, it is smaller than in many European States. Taking the three years 1885-87, the average mortality in sixteen of the great towns of France was in the ratio of 640 per million, or -64 per 1000 persons living. Easeri gives for the period 1881—84 the enteric fever death-rate of Italy at 937, of Austria at 731, and of Spain at 563 per million. In Switzerland, during the same period, the deaths from typhoid fever were 230 per million, — a ratio very similar to that of England; while in the ISTetherlands the ratio was 140 per million in 1886-87. The sickness-rate per 1000 of the population for the five years 1883-87, in 41 notification towns (Tatham), was 1"36. It is most fatal between the ages fifteen to twenty-five. In the quarterly returns of the Eegistrar-General, typhoid, typhus, and ill-defined fevers are classed together ; but as typhoid fever causes about ten deaths for one caused by typhus, it is reasonable to suppose that the greater or lesser prevalence of fever in each quarter will be a pretty fair measure of the greater or lesser prevalence of typhoid. The fever deaths in England for the ten years 1878—87 were thus distributed as regards seasons : — First Quarter. Second Quarter. Third Quarter. Fourth Quarter 0-26 0-24 0-27 0-34 112 CENTRAL AND WESTERN EUROPE. This shows that the fourth quarter (October, ISToveraher, and December) is that in which typhoid fever is most fatal. The monthly percentage of admissions of 2657 cases of typhoid fever, according to Murchison and Tweedie,^ and the weekly mortality, according to the Eegistrar-General, are distributed as follows : ^ — ExTEEic Fever.— (12 years, 1869-80.) Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. 30 40 50 per cent. The mean line represents an average weekly number of 17 deaths. The months when the admissions are at their minimum are April and May. The number begins to rise in June, and attains its maximum in September and October. In London, the admis- sions are thus most frequent in those months when the rainfall is above the mean of the year, and when we may infer that the soil attains its maximum of humidity, but when the subsoil water in most localities is below the mean. As regards temperature, the rise in admissions commences in June, increases in July and August, when the temperature is at its highest, to attain its maxi- mum in the months when the temperature is falling. The rise begins under one set of temperature conditions, and attains its maximum under another set of conditions ; but the enteric curve follows closely, although at an interval of about two months, the temperature curve. The curve of the monthly enteric death-rate is somewhat different, as will be seen from the diagram, representing the deaths for the period 1869-80. Does the annual variation in the death-rate from typhoid fever bear any relation to the annual or quarterly temperature ? If we examine the annual death-rate from this disease, we shall find that it fluctuates considerably. Before 1869, typhoid fever was ^ Murchison on Fever, Tweedie, Lavret, February 1860. ■•' Annual Sumviari/, 1880. ENGLAND AND WALES. 113 classed along with typhus and simple or ill-defined fevers ; but as typhoid is always by far the most fatal of the three, a great excess of fever in any individual year must be taken to indicate excessive prevalence of typhoid fever. Now, on looking over the period 18G3 to 18 (ST, we observe certain years in which there was a marked excess of enteric fever deaths, and other years when their number was much under the average. AVe shall arrange these years in two tables, giving the difference of annual temperature above and below the mean, the difference from the mean of the temperature of the individual quarters, and the annual rainfall for the two series. It must be remembered that the disease is becoming less prevalent yearly : — Years in which Enteuic Feveu was unusually fatal. Year. 1865 1878 1880 1884 Temperature of Year above or below Average. Temperature of First Quarter above or below Average. Temperature of Second Quarter above or below Average. Temperature of Third Quarter above or below Average. Temperature of Fourth Quarter above or below Average. Annual Kainfall above or below Average. +1-0 +0-3 +0-1 +1-4 -3-4 +1-6 -0-1 +3-5 4-3-6 +2-0 -0-2 -0-1 +2-1 +0-4 +1-0 -(-2-3 +1-9 -2-5 -0-1 0-0 +4-6 --4-8 —5-4 -6-3 Years in which Enteric Fever avas less than usually fatal. Year. Temperature of Year above or below Average. Temperature of First Quarter above or below Average. Temperature of Second Quarter above or below Average. Temperature of Third Quarter above or below Average. Temperature of Fourth Quarter above or below Average. Annual Rainfall above or below Average. 1867 1877 1879 1881 1885 -0-7 +0-1 -3-1 -0-6 -0-7 -1-0 +2-4 -2-8 -2-6 +0-4 +0-9 -0-7 -3-1 +0-3 -0-2 -0-7 -1-9 -2-3 -0-4 -1-3 -1-6 +0-9 -4-2 -t-0-5 -1-3 -f4-0 ■ +2-5 4-6-9 -fO-8 -0-4 It appears from these figures that those years in which enteric fever in England is unusually fatal, are years in which the mean annual temperature is above the average, and in which the temperature of the third quarter is considerably above the average. The annual temperature is generally below the mean, and the temperature of the third quarter uniformly so (as far as the above table goes), in those years when enteric fever makes few victims. We observe here, apparently, something more than a simple coincidence. Although it is not to be assumed that the temperature of the third quarter necessarily regulates the prevalence of fever in the H 114 CENTRAL AND WESTERN EUJtOPE. succeeding quarter, it has a distinct influence in tliis direction. ISTo rule is to be observed in respect to the influence of rainfall upon the amount of enteric fever. Typhoid fever is more prevalent in the smaller town districts than in the twenty-eight great towns ; and it is more prevalent in the great towns than in the country districts.^ Average Death-rates from Enteric Fever in Large Towns, Smaller Towns, and Country Districts (1885-88). Large Towns. Other Towns. Country Districts. 0-21 0-24 0-18 The mortality from enteric fever in the different counties will be seen, from the following table, to vary greatly ; the extremes being (1883-87) 0-05 per 1000 in Eutlandshire, and 0-34 per 1000 in South Wales: — Average Death-rate per 1000 living in the Counties of England, from Enteric Fever, for the Five Years 1883-87, and for the Ten Years 1871-80. 1883-87. 187 1-80. 1883-87. 1871-80 Rutlandshire, 0-05 31 Kent (extra Met.), 0-17 0-25 Herefordshire, 0-07 19 Middlesex (extra Met. ) 0-17 0-24 Bedfordshire, 0-09 22 Northamptonshire, 0-17 0-33 Dorsetshire, 0-09 19 London, 0-18 0-24 Somersetshire, 0-10 26 Devonshire, 0-18 0-31 Surrey (extra Met.), 0-11 22 Leicestershire, 0-18 0-34 Suffolk, 0-11 21 Derbyshire, . 0-lS 0-34 North Wales, 0-11 24 Essex, 0-19 0-24 Berkshire, . 0-12 22 Cheshire, 0-19 0-29 Oxfordshire, 0-12 26 Stafibrdshire, 0-20 0-36 Wiltshire, . 0-12 24 Norfolk, . 0-22 0-25 Gloucestershire, . 0-12 26 Worcestershire, . 0-23 0-26 Huntingdonshire, 0-13 26 West Riding, 0-23 0-45 Cumherland, 0-13 29 North Riding, 0-23 0-44 Sussex, 0-14 19 Hampshire, . 0-24 0-30 Hertfordshire, 0-14 24 Nottinghamshire, 0-25 0-43 Warwickshire, 0-14 30 Lancashire, . 0-25 0-39 Shropshire, . 0-1.5 25 Monmouthshire, . 0-25 0-33 Buckinghanisl lire, 0-16 24 East Riding, 0-26 0-40 Cambridgeshiix', . 0-16 24 Durham, 0-26 0-56 Cornwall, . 0-16 34 Northuml>erland, 0-27 0'37 Lincolnshire, 0-16 27 South Wales, 0-34 0-45 Westmoreland, 0-16 30 Let us now observe the geographical distribution of enteric fever in England, or rather the regions in which the mortality is in excess or in defect of the mean, which, for the period 1871-80, was 0-32 per 1000. An examination of the figures for the ten-yearly period will show that the enteric fever death-rate is in excess of the mean in the northern and north- central districts, in South Wales, in Monmouthshire, and in Cornwall; while it is below 1 In the London Fever Hospital there have been far more admissions during the dry and hot summers 18'i5, 1866, 1868, 1870, than in the wet and cold summers of 1860 and 1872. Fagge, V incip. and Pract. of Med., Lond. 1888. ENGLAND AND WALES. 115 the mean in the central and southern counties, in London, and in North Wales. To be more precise, the death-rate is in excess in Northumberland, Durham, York, Lancashire, Derby, Leicester- shire, Nottingham, Stafford, Northampton, South Wales with Monmouth, and in Cornwall. It is evident that this distribution is not determined by climate ; for in the same county, districts in close proximity to each other suffer very unequally from enteric fever. Nor does its prevalence bear any definite relation to density of population ; for, to take a single example, in the district of St. Giles in London, with only •005 of an acre to each person, the death-rate from enteric fever was 0-19 ; \vhile in that of Thorne, in the West Eiding of York, with 4-28 acres to a person, it was 0-57 per 1000. The disease is evidently more prevalent in the mining and manufacturing than in the agricultural counties, and, although truly ubiquitous, its excess appears to depend chiefly on those sanitary defects which are not peculiar to, but are more generally to be met with in, the smaller towns and villages of manufacturing and mining districts. The death-rate of the two sexes for the whole of England for the period 1871-80 was exactly equal, which seems to prove that the liability to the disease is the same in both. If, then, we find that one sex suffers more than the other in any particular locality, we may assume that this is owing to that sex being more exposed to the cause of the disease. Now, it will be found that in the agricultural counties the female death-rate, as a rule, is in excess, while the reverse is the case in the mining and manufacturing counties. This seems to show that in the agri- cultural counties the cause of the fever is generally to be sought for in the homestead; while in the mining and manufacturing counties the cause is not so exclusively restricted to the home, but exists in connection with the mine, factory, and workshop. Enteric fever, as we have seen, is most prevalent in the later months of summer and autumn ; and, as a rule, it is most fatal in those autumns which follow upon warm summers. Why is this so ? Let us at once accept the view which modern pathology regards as the only admissible one, that enteric fever is a specific disease, notwithstanding the variety of symptoms it exhibits, and the widely differing degrees of intensity it manifests. The disease is not, as a general rule, communicated directly from the patient to his attendant. When, therefore, we find the arrival in a village, previously free from the disease, of a typhoid patient being followed by an outbreak of fever, — and this often enough among those who have not been 116 CENTEAL AND WESTERX EUROPE. in personal contact with the patient, — we are forced to conclude that something must have been given off from the sick person that has in some roundabout way entered the bodies of those who have subsequently contracted the disease. Now, observations of the most varied and convincing character point to a contagium present in the excrements of the sick as the so7netMng causing the infection, and to drinking-water, milk, and other articles of food, as well as the breathing air of dwelling- houses contaminated by these discharges, or polluted by the specific infection derived from them, as the media by which the infection is carried from the sick to the healthy. Such is, no doubt, the usual way in which infection is conveyed. But the pollution of drinking-water, food, or air by the infective matter directly derived from typhoid excreta is in every case of the nature of an accident, and we see no reason why such accidents should occur more frequently in certain months than in others. There must be something more, then, for the spread of typhoid fever than the accidental pollution of a well by percolation from a cesspool, or the diffusion of sewer gas into a dwelling by some defect in a trap or drain. To account for the relative frequency of enteric fever in certain months, and for its greater prevalence after warm summers, we have to suppose that the infective matter is more generally diffused in these months and seasons ; and this again presupposes the multi- plication of the virus of the disease outside the human body ; and, further, that this multiplication is favoured or hindered by certain conditions of soil, or of weather, or of both. In what way does this multiplication take place ? Let us assume, for the moment, and for the sake of illustration only, that the infective agent of typhoid fever is Eberth's bacillus. It was formerly pretty generally held that the spore derived from the typhoid bacillus is incapable of further development and growth in the soil, — that it is only after it has found its way anew into the body of a fitting host that it could accomplish the second stage of its development into a spore-producing bacillus. It was held, in fact, that the tw^o stages of development take place alternately in the soil and the body.^ Now, if this were so, it is evident that no multiplication of the infective matter outside the body is possible if the spores only are evacuated in the typhoid dejecta, for the multi- plication of the bacillus by fission could, under ordinary circum- stances, be only of limited duration. But it has been shown by Gaffky, as regards Eberth's bacillus, that these organisms are chiefly ^ Lieljermeister, Ziemssen's Cyclopadia, ait. on Infectious Diseases. ENGLAND AND WALES. 117 evacuated along witli the dejections " as resting spores." If these spores cannot multiply themselves until they once more enter the body, we have no adequate explanation of the greater prevalence of typhoid fever in the autunni months. Nor can we explain the numerous instances in which typhoid fever has been observed to break out in a locality where no cases had been observed for years, and where no fresh case has been known to have been introduced, unless we allow that the typhoid germ is capable of multiplication outside the body. The view that the spores must enter the body before undergoing further development, is necessarily associated with the doctrine of continuous transmission, — every case being assumed to be dircctlij derived from a previous case, which is just the weakest point of the theory, inasmuch as, in perhaps a majority of instances, the previous case cannot be discovered. A more probable explanation of the seasonal character of the disease is, that the typhoid spores evacuated in the stools can sprout into bacilli, and these again produce spores outside the body, in a suitable soil, and under certain conditions of temperature, such conditions being those found in warm autumns succeeding warm summers. Gaffky's observations have proved that, as regards Eberth's bacillus, such sprouting and multiplication actually take place, and he justly concludes that " even outside the animal economy they may increase enormously in numbers, and in the warmer part of the year may form spores afresh." ^ If this view is correct, we should have the disease communicated in a certain number of instances by spores directly derived from a recent case ; in other and more numerous instances, by spores originally derived from a typhoid patient, but which have been running through their development in the soil or other nutrient substrata, for an indefinite period. This variety in the mode of cultivation may yet be found to account for the great variety of type and intensity met with in different epidemies and in different countries. If we accept the view that the enteric microbe is a facultative parasite, capable of living and growing during comparatively long periods outside the body, we shall find it easy to understand those outbreaks of the disease occurring in localities from which it has been absent for considerable periods. This view also accounts for the great diminution of fever which Buchanan has shown to follow the purification of soil and air by hygienic measures. It is in impure soils charged with organic matters that, under the influence of warm weather, we should expect to find the typhoid germ ' Microparasites in Disease, New Sydenliain Soc. 1886, p. 252. 118 CENTRAL AND WESTEEN EUROPE, multiply itself with greatest rapidity. The greater frequency of typhoid fever in the small than in the large towns is probably owing, in part, to the fact of the soil in the former being more impure. The scattered dwellings so common in the smaller towns present special difficulties in the way of effecting the speedy and thorough removal of refuse. All these considerations favour the view that typhoid fever in England is both a miasmatic-contagious and also quasi-miasmatic disease. Melapsing Fever was epidemic in 1851, but it has been less frequently noticed in England than in Scotland or Ireland. A small number of deaths ascribed to this fever are registered every year. In the five years ending 1887, they averaged only 2 1 per million of deaths from all causes ; so that it can be said that in recent years the disease has been scarcely known in England. Diphtheria has acquired a general extension in England since the year 1857. During the live years 1881—85, the average death-rate from this disease was 155'6 per million, or '15 per 1000 persons living; while in the decennium ending 1880, the mortality was 121'3 per million. Its quarterly prevalence during the ten years ending 1887 was as follows : — First Quartei-. Second Quarter. Third Quarter. Fourtli Quarter. 0-14 0-11 0-12 0-17 According to the Eegistrar-General,^ " there are two tolerably definite areas in which this disease apparently finds its most suitable home. The one has its base in the south-eastern counties, Sussex, Hampshire, Surrey, and Kent, and stretches upwards along the eastern side of England, through Middlesex, Hertfordshire, Essex, Cambridgeshire, and Bedfordshire, occasionally reaching Norfolk, Nottinghamshire, and Lincolnshire ; while the other area has its nucleus in North Wales and Shropshire, and tends to spread through Herefordshire and other bordering counties, as also in some years into South Wales, Monmouthshire, and even across the Bristol Channel into Somersetshire," The disease is more common on retentive than on porous soils ; and is more fatal in the sparsely- peopled country districts than in the large cities ; and a larger pro- portion of women than of men die of the disease. The mortality from diphtheria varies greatly in different years, but it does not appear to have any relation to temperature or rain- fall. Its annual prevalence does not bear any close relation to that of scarlet fever. ^ Rei.ort, 1884. ENGLAND AND WALES. 119 Enjsipcla^ causes an average mortality of about 95 per niillion. The deaths from this disease rise and fall, along with those from puerperal fever, in such a way as to show that tliere is a close affinity between them. It attains its maximum prevalence in the last quarter. Diarrhcea, with which is included dysentery, occasioned an average annual death-rate of 653"'4 per million persons living in the five years 1881-85. During the twenty years 1861-80, the average death-rate was 942 per million. It is notably a disease of infancy. The average quarterly mortality for the ten years 1878—87 was as follows : — First Quarter. Second Quarter. Third Quarter. Fourth Quarter. 0-24 0-28 1-90 0-45 Diarrhcea is the only zymotic disease which attains its maximum in the third quarter. Nearly one half of the deaths occur from July to September. The proportion of deaths from diarrhcea bears a constant relation to the temperature of the third quarter : — Death-rate from Diarrhoea Mean Temperature in the Third Quarter. of the Third Quarter. 1876, . . 3-22 61-8 1877, . . 1-97 58-5 1878, . . 3-22 60-8 1879, . . 1-28 58-1 1880, . . 3-25 61-4 From this it appears that for every degree Fahrenheit above 5 8° there is an increase in the diarrhceal death-rate of about 0"6 per 1000 of the population. Wet seasons, perhaps because they are cold, show a small diarrhceal mortality. Its relation to density of population is also well marked, as will be seen from the average of four years 1885-88 : — Twenty-eight gi-eat Towns. Other Towns. Eural Districts. 0-85 0-67 0-45 Diarrhcea is specially fatal in infancy; no less than 6 2 '5 per cent, of the mortality occurs in children under one year of age. The dysentery deaths, as distinguished from diarrhcea, averaged, from 1871 to 1880, 28 per million living. Sporadic Cholera gave rise to an average death-rate of 18 per million in the ten years ending 1887. Like diarrhoea, it is especially prevalent in warm summers, and in the large towns. It is limited, as Sydenham says, to the month of August or to the first week or two of September. Asiatic Cholera made its first appearance in England in 1831 breaking out in Sunderland on the 26th of October, having been 120 CENTEAL AND WESTERN EUEOPE. introduced from Hamburg, where it had been raging. It soon showed itself in Newcastle, North and South Shields, and G-ates- head ; and in January of 1832 it broke out in different parts of the south of Scotland, invading Edinburgh and Glasgow in February and March. It appeared in London about the 13th February, and spread over large districts of England, Wales, and Ireland. It reappeared in London and some other parts of the country in the summers of 1833 and 1834. The second epidemy occurred in 1848-49, lasting seven months, from October 1848 to the following April. The third epidemy broke out in 1853-54 ; and the fourth and last outbreak occurred in 1865-66. The visitations of 1832, 1848, and 1854 were coincident with great atmospheric pressure, high temperature (except in 1832), small diurnal range, owing mostly to high night temperature, deficiency of rain, very little wind, few electric disturbances, and in 1854, and again in 1866, with the presence of a remarkable blue mist. In 1866 the temperature was low, the daily range small, owing to low day temperature ; there was abundance of rain, and the air was in constant movement. The meteorological conditions in the last epidemy were widely different from those prevailing during the first three outbreaks, and this was thought by some to be the cause of its diminished virulence. Mr. Eadcliffe remarks that " since the great outbreak of epidemic cholera in this country in 1832—33, an enormous development of diarrhoea has taken place in the metropolis as in the rest of the country generally." The tables he gives go back only to the year 1838, and there is nothing to show what the mortality was before 1832. His figures prove that, for the quinquennial periods between 1841-65, the annual average deaths from diarrhoea per 10,000 of the population of London were as follows : — 1841-1845. 1846-1850.1 1851-1855.1 1856-1860. 1861-1865. 3-4 10-1 10-6 9-1 9-1 These figures certainly show an extraordinary increase of diarrlicea in the later quinquennial periods. The increase began by a sudden bound from 841 deaths in 1845 to 2152 deaths in 1846, that is, two years before the outbreak of the second epidemy. I confess I can see no reason to connect this rise in the diarrhoea death-rate in 1846 with the preceding cholera outbreak of 1832 or with 1 Years of ei)idomic cholera. The deiitlis from cholera in 1865 were so few that they need not be taken into account. ENGLAND AND WALES. 121 the succeeding one of 1848 ; but the subject deserves further iuvestigation. The following points respecting cholera, as observed in London, deserve notice : — (a) The disease has always been introduced into England from abroad. (h) A subsidence of diarrhoea has been observed two or three weeks prior to the development of the epidemy (18-18-49, 1853-54, and 1866). (c) There has been an increase of diarrhcea during the epidemy. (d) As a rule (in London), the mortality from cholera has been inversely as the elevation of the district assailed above the sea-level. Typhus. — The deaths from typhus fever for the five years 1881-85 averaged 2 2 "8 per million. It is most general in the northern counties, notably in Lancashire and Durham, in both of which counties the death-rate from this disease is above three times that of England and Wales. The mortality in typhus falls more heavily upon the ages between twenty and forty years. Scarlet Fever, in the ten years ending 1880, caused a death- rate of 720 per million living. It attains its greatest frequency in the mining and manufacturing counties — Durham, Yorkshire, Northumberland, Stafibrdshire, Warwickshire, Cheshire, Lancashire, Monmouthshire, and South Wales ; but this is partly to be accounted for by the large proportion of young children in the population of the industrial counties, the mortality from scarlet fever being highest in children under five years. In London the mortality from scarlet fever has, in late years, been under the average of England and Wales.^ The following diagram from the Eegistrar-General's Annual Summary, 1880, shows the weekly prevalence of scarlet fever: — Jail. 7-4 +60 per cent. 50 40 30 20 10 Meak Linr 10 20 30 40 - 50 per ceut. Feb. 4-6 Mar. 5-1 April. 3-4 May. 3-S June. 6-1 July. 8-3 Aug. 12-5 Sept. 13-6 Oct. 14-3 Nov. 12-5 Dec. 8-4 Scarlet Fever.— (40 years, 1840-79.) Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct . Nov. Dec. /^/^-' L /n 1 -^v ^ 1 1 1 ' ' ' 1 X j 1 1 1 \ I ) I 1 ■ ^-^ '/I 111 ! i_in ' t /j j 1 ' i ! 1 / i 1 ' 1 1 1 1 1 1 j ' ,/ ' 1 / -\' _H_ _-^ , 1 I \ ^ ± y^ x , 1 - /."" z ^-is_ r'' " - Zj If: 'S. ! >v"".- ^^ ^— f^ X- 1 i 1 1:1 ! 1 ' ! ! tj~ - The mean line represents an average weekly number of 47 deaths. +60 per cent. 50 40 30 20 10 Mean Line. 10 20 30 40 —50 per cent. Annual Report of Registrar-General, 1884. 122 CENTEAL AND WESTERN EUROPE. Measles. — In the ten years 1871-80, measles caused a death- rate of 379'4 per million, and was most prevalent in Lancashire, Devonshire, Monmouthshire, London, Cumberland, Leicestershire, and "West Elding. We may judge that density of population has some influence in determining the prevalence of measles ; but it is not the only cause, otherwise Devonshire and Cumberland would not occupy the places they do in the list. The following interesting table is from the Eegistrar-General's Eeport of 1884, and shows the monthly distribution of deaths from measles in London, Paris, Berlin, in Scotch towns, and in certain groups of English towns : — Monthly Disteibution of Deaths feom Measles per 1200 in the Ybak. Months. London, 1840-84. Paris, 1865-69, 1872-83. Berlin, 1875-83. Scotch Towns, 1862-82. Lancashire Towns, 1871-84. Hull, Sheffield, Newcastle, 1871-84. Bradford, Birmingham, Bristol, Brighton, Wolverhampton, 1871-84. January, . February, . March, . April, . May, . . June, . . July, . . August, September, October, November, . December, . Ill 80 88 102 110 118 105 89 66 79 112 140 79 96 87 91 123 117 165 119 96 73 66 88 51 56 65 92 185 240 202 78 44 36 69 82 89 97 114 133 145 146 132 80 53 49 73 89 116 91 107 135 120 123 101 74 49 73 90 121 94 67 100 135 130 134 121 90 62 92 92 83 92 73 105 134 136 136 94 87 47 74 90 182 1200 1200 1200 1200 1200 1200 1200 In Berlin, in the Scotch towns, and also in Hull, Sheffield, and Newcastle, the maximum mortality occurs from March to July. In Paris it is from May to August; in Scotland the rise begins in March. In London there is a winter rise from November to January — the maximum of the year being attained in December. In the Lancashire and the Bradford groups of towns there is a winter rise in December and January. Where there are two maxima, the mortality is naturally high; but why in certain localities and not in others there should occur two maxima, is quite unknown. " It is everywhere," says Hirsch, " the cold season in which epidemics of measles most commonly begin and in which they are apt to spread farthest." The universality of this rule is doubtful. The greatest mortality in Berlin and in Scotland falls in June ; in Paris it occurs in July. ENGLAND AND WALES. 123 111 a purely contcagious disease, such as measles, it might naturally have been supposed that only three factors would have been required for its extension, — a source of contagion, a supply of susceptible persons, and the agglomeration of the suscei:)tibles, — so that the contagion may be more directly carried from the sick to the healthy. Ihit the problem is not quite so simple, otherwise there is no reason why the disease should not occur with equal frequency at all seasons. Mtiyr remarks "that the weather, tlie season of the year, as well as the nature of the other diseases which happen to be prevalent at the time, or have recently been epidemic, deter- mine the character of the disease." ^ It is evident that season not only affects the type, but in some way also determines the pre- valence of measles. If we take the twenty-five years 1863—87, we find that the mean death-rates from measles per million living for the successive five-yearly periods were as under : — 861-65. 1866-70. 1871-75. 1876-80. 1881-85, 456 428 373 384 410. Now, if we take the mean of the last quinquennial for the two succeeding years 1886 and 1887, and arrange the individual years in two series according as they are above or below the mean of the respective cpiinquennials in which they occur, we find that in thirteen of these years the average of deaths was over, and in twelve years the average of deaths was under, the mean of their respective five-yearly periods. The years when the deaths were in excess of the average of the five-yearly period were the following: — 1863, 1866, 1868, 1869, 1871, 1874, 1876, 1880, 1882, 1884, 1885, 1886, and 1887. In the intervening years the deaths were less than the average. The following table represents in how many of the years of the two series the temperature of the years and of the quarters were above or below the average : — [Table HeLra, Diseases of the Skin, New Sydenham Soc. vol. i. p. 185. 124 CENTKAL AND WESTEEN EUROPE. Thikteen Years, between 1863 and 1887, in which the Death-eate feom Measles was above the Average. Table showing the number of these years in which the mean temperature of the year and of the several quarters was above or below the average temperature of thirty-nine years. The sign -|- shows the temperature to have been above, and the sign - indicates that it was below the average. Number of Years. Above or below Annual Mean Tempera- ture. Number of Tears. Above or below Average Tempera- ture of First Quarter. Number of Years. Above or below Average Tempera- ture of Second Quarter. Number of Y''ears. Above or below Average Tempera- ture of Third Quarter. Number of Years. Above or below Average Tempera- ture of Fourth Quarter 8 4 1 + average 9 4 + 5 8 4- 9 4 + 6 6 1 + average Twelve Years, between 1863 and 1887, in which the Death-rate from Measles was below the average. Table showing the number of these years in which the mean temperature of the year and of the several quarters w as above or below the average temperature of thirty-nine years. The sign -|- shows the temperature to have been above, and the siu;n - indicates that it was below the average. Number of Years. Above or below Annual Mean Tempera- ture. Number of Years. Above or below Average Tempera- ture of First Quarter. Number of Years. Above or below Average Tempera- ture of Second Quarter. Number of Years. Above or below Average Tempera- ture of Third Quarter. Number of Years. Above or below Average Tempera- ture of Fourth Quarter. 7 5 + 8 4 + ! 3 9 + 7 5 + 6 6 + From this table we see that measles are twice as often in excess of the mean when the temperature of the year is above the average ; that in nine years out of thirteen, in which measles was in excess of the average, the temperature of the first and third quarters was also above the normal, while in only five out of the thirteen years was the temperature of the second quarter above the normal, and in eight years it was below the average. All this is reversed in the second series of years in such a way that one can scarcely look upon it as a coincidence. The inference is that a high temperature in the first and third quarters in some way increases the fatality of measles, and that a lov/ temperature in these quarters reduces it. That a low temperature in the second quarter tends to increase, and a high temperature to diminish, the deaths from measles. That the temperature of the fourth quarter has no influence on the ENGLAND AND WALES. 125 mortality from this disease. The whole subject of the seasonal dis- tribution of the eruptive fevers demands fuller examination. Wliooping-Cough, in tlie ten years 1871 — 80, occasioned a death- rate of 513*3 per million. It is most fatal in London ; somewhat less so in the twenty-eight great towns ; still less fatal in fifty other smaller towns, and least fatal in the rural districts. It is more fatal among females than males. It is most fatal from December to May. Smallpox, for the ten years 1876—85, caused a death-rate of 78'2 per million, as against an average in the previous twenty years of 238'4. It is most fatal from January to June ; attaining its maximum in May, and its minimum in September. Infiuenza. — Although a certain number of deaths are registered yearly as occurring from this disease, a number varying from 3 to 39 per million, it is probable that these are really cases of bronchial catarrh. In the year 1866 the deaths from influenza were 31 per million, and Hirsch states that in that year there was an epidemy of the disease in London in the month of May. The following are the principal epidemics of influenza which have been recorded in England: — 1510—81, by Thomas Short; 1658, by Willis; 1675, by Sydenham; 1693, by Molyneux ; 1729, 1737, and 1743, by Huxham ; 1732-33, by Arbuthnot ; 1758, by Whytt; 1762, by Baker and Paitty; 1767, by Heberden ; 1776, by Fothergill ; 1782, by Gray and others; 1789-90, by Warren; 1803, by Pearson and Falconer; 1831, by Burne and others; 1833, by Hingeston and others; 1837, by Streeten, Graves, and others; 1847, by Peacock, Laycock, and others ; ^ and finally, the epidemy of 1889—90, with a recrudescence in April and May, 1891.- In the epidemics of 1658, 1762, and 1776, influenza assumed a remittent or intermittent character — usually tertian — either in its course or towards its decline. This has not been observed in recent epi- demies since malaria has become so much less prevalent in England. Phthisis. — The deaths registered from phthisis in the successive quinquennial periods from 1861 show a constant decrease: — Deaths from Phthisis, 1861-1885, per Million living. 1861-65. 1866-70. 1871-75. 1876-80. 1881-85. 2526-6 2447-8 2218-0 2040-0 1820-6 ^ Thompson, Influenza, London 1890. - The influence of the epidemy in augmenting the deaths from respiratory diseases, as •well as the duration and march of the disease, will be seen from the following table from the Registrar-General's Report, showing the deaths in London from December 1889 to 8th February 1890 : — December. January. February. 7. 14. 21. 2S. ' '' " " Respiratory Diseases, . 432 552 518 4tj7 Influenza 4. 11. 18. 25. 1. 8. 843 1069 1010 736 550 485 4 67 127 105 75 38 126 CENTRAL AND WESTERN EUROPE. It has been proved that sanitary improvements, especially the drainage of towns, have had a marked influence in reducing the death-rate from phthisis. Females are more liable to phthisis than males up to the age of 25, after that the sex liability is reversed. Phthisis is most fatal at the ages from 15 to 55. The following table gives the distribution of the disease in the several counties, taking the average of the ten years 1871—89: — Average Deaths from Phthisis in the Counties or England for the Ten Years 1871-80. Dorsetshire, . Worcestershire, Rutlandshire, Herefordshire, Leicestershire, Staffordshire, Buckinghamshire, Hertfordshire, Northamptonshire Somersetshire, Shropshire, . Derbyshire, . Westmoreland, Lincolnshire, North Riding, Berkshire, Middlesex (extra Oxfordshire, . Kent (extra Met. ) Gloucestershire, Monmouthshire, Bedfordshire, Wiltshhe, . ]\Iet. 1-72 1-48 1-42 1-52 1-77 1-60 1-69 1-75 1-86 1-65 1-64 1-90 2-03 1-69 Nottinghamshire, . 1-96 Norfolk, 1-94 Essex, .... 1-83 Cheshire, 2-01 Surrey (extra Met. ), 1-91 Warwickshire, 1-95 Huntingdonshire, 1-93 Cumberland, 2-20 East Riding, 1-97 Durham, 1-93 Sussex, ... 2-0.5 Suffolk, 2-02 Cambridgeshire, . 1-99 Devonshire, . 2-07 West Riding, 2-26 Cornwall, 2-20 Lancashire, . 2-47 Hampshire, . 2-20 London, 2-51 North Wales, 2-57 South Wales, 2-54 Northumberland, . 2-27 The mean death-rate from phthisis in England, for the ten years ending 1880, was 212 : that of the male population being 2*21, and that of the female, 2-03 per 1000. It will be seen from the above table that the phthisis mortality was in excess of the mean in North and South Wales (excluding the counties of Eadnor and Brecknock), in Lancashire, the West Eiding of York, Cumberland, Northumberland, London, Hampshire, and Cornwall. In all the other counties the phthisis mortality was below the mean. As regards Hampshire, it has to be noticed that the deaths are abnormally increased by the location there. of the naval and military hospitals, receiving patients from all parts of the world. The region of maximum prevalence will thus be seen to stretch along the western side of England, from Cumberland to Cornwall, extending into Northumberland. The disease is at its minimum in the central counties — Rutland, Wor- cester, Herefordshire, Staffordshire, and Shropshire. The explanation of the comparatively low mortality from phthisis in these counties, is not to be found either in the sparseness of the population, or in the agricultural occupations of the inhabitants. ENGLAND AND WALES. 127 Overcrowding in badly ventilated houses, with the resulting pollution of air and soil, is undoubtedly favourable to the development of consumption ; but the density of the population of a given county, as estimated by the number of acres or fractions of an acre to each inhabitant, affects in no appreciable degree the general distribution of the disease, although its influence may be evident enough in particular localities, especially in London and Liverpool. In liutlandshire, where the mortality from phthisis is at its minimum, the acreage to each person is 4*63, — a proportion identical with that of Xortli Wales, where the disease attains its maximum prevalence. Nor can it be said that the entirely agricultural counties suffer least, for in Bedfordshire, which is purely agricultural, and three- fourths of which has a clayey soil, the consumption death-rate is higher than in the mining county of Durham, or in Staffordshire with its potteries ; although the earthenware manufacture, next to tin mining, is the occupation of all others most conducive to the de- velopment of phthisis. The great differences observed in the death- rates of agricultural counties largely depend upon the character of the soil. Buchanan, in his inquiry into the relation of dampness of the soil to phthisis in Surrey, Kent, and Sussex, has shown that there is less phthisis on pervious, high-lying, and sloping soils than on impervious, low-lying, and level soils.^ The excess of phthisis in certain localities is obviously owing to the unhealthy industries carried on in the district. Thus, in Cornwall, consumption is found to be highly prevalent in the tin- mining districts, and in these the males, who work in the mines, suffer in a much higher proportion to the females than that which obtains in the country as a whole. So in Lancashire and the West Eiding of York, the prevalence of consumption may reasonably be attributed, in part at least, to the cotton and woollen manufactures, which furnish employment to so large a part of the population, and which is known, by statistical evidence, to favour the development of the disease. In Xorth and South Wales, where phthisis reaches its maximum, the case is different. Here the principal industries are coal, copper, and lead mining, and slate quarrying. The consumption death-rate of slate and stone cj^uarriers is high ; and the same is probably true of copper and lead miners. Coal miners, on the other hand, enjoy a comparative immunity from phthisis ; so much so, that some writers have claimed for coal dust the property of hindering the development and arresting the progress of consumption. That the slate, copper, and lead mining industries increase the death-rate from phthisis in North Wales is certain, but 1 Privy Council Reports 128 CENTEAL AND ^YESTERN EUROPE. tlie excess due to these industries does not explain its excessive prevalence there. The deaths from consumption are nearly as uumerons in districts in which these occupations are not carried on as in those in which they are. If mining were the sole or principal cause of the high death-rate from phthisis in iSTorth Wales, we should expect the proportion of male deaths to be in excess of the female deaths, as in Cornwall and Lancashire. Such, however, is not the case. On the contrary, the male mortality from consumption in Xorth "Wales is 2-44, and the female rate 2-71 per 1000. In South Wales, again, where coal mining is the principal industry, phthisis is almost as fatal as in Xorth Wales ; and in the island of Anglesey, where only a small proportion of the population is engaged in mining, the male death-rate from phthisis is 3'28, and the female death-rate 3 ••13 per 1000. It thus appears that no complete explanation can be given of the geographical distribution of phthisis in England. We have here to recognise the existence of a zone similar to that which is observed in the Ehine provinces of Germany, and at certain altitudes in Switzerland, in which phthisis, for reasons not yet understood, attains a high degree of prevalence. The monthly distribution of deaths from phthisis in London, taking the weekly average for the thirty years 1845-74, was as follows : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 154 153-25 160-2 162 157-25 150 144-75 136-50 132-4 135-75 146 147 It will be seen that the difference between the months, as regards the number of deaths, is far less marked than in the case of bronchitis. Piuii/riionia caused, during the ten years ending 1880, an average death-rate of 1012 per million living. The proportion of deaths from pneumonia to deaths from all causes is about 52*8 per 1000. The proportion of males to females who die of pneumonia is 1289 to 966. As more females attacked by pneumonia die of the disease than males, it follows that tlie liability of males to the disease is much higher than the difference in the proportion of deaths in the two sexes indicates. The ages most liable are early childhood, and again the period of life after thirty-five. The sub joined table gives the distribution of pneumonia in England (average of three years) 1885-87; but as it is calculated on the basis of population for 1881, the figures will be somewhat in excess of the true ratios, especially in Loudon and other rapidly-growing localities. It serves, however, to show, in a general way, the relative prevalence of the disease in different parts of England. ENGLAND AND WALES. 129 Average Distribution of Pneumonia in the several Counties of England (]885, 1886, 1887).! Rutlandslure, 0-45 Herefordshire, 0-85 Wiltsliire, . 0-69 Shropshire, . 0-85 Buckiiiglianishire, 0-70 East Riding (with York), 0-85 Westmoreland, 0-70 ]\[iddlesex (extra Met. ), 0-86 Sussex, 0-71 Cumberland, 0-87 Hampshire, . 0-72 North Wales, 0-87 Bedfordshii-e, 0-72 Northamptonshire 0-90 Norfolk, 0-72 AVorcestershire, 0-92 Dorsetshire, . 0-72 War\\'iekshire, 0-95 Somersetshire, 0-73 Cornwall, 0-97 Lincolnshire, 0-74 Northumberland, 0-97 Nottinghamshire, 0-74 Devonshii'e, . 0-99 Huntingdonshire, 0-74 Leicestershire, 1-00 Essex, . 0-74 Cheshire, 1-01 Hertfordshire, 0-75 North Riding, 1-06 Oxfordshire, . 0-76 Staffordshire, 1-07 Kent (extra Met. ) 0-77 Durham, 1-08 Siu-rey (extra Met ), 0-78 London, 1-11 Berkshire, . 0-80 West Riding, 1-19 Suffolk, 0-81 South Wales, 1-32 Derbyshire, . 0-81 Monmouthshire, 1-52 Gloucestershire, 0-82 Lancashire, .- 1-59 Cambridgeshire, 0-84 The disease is evidently more fatal in the densely peopled manufacturing and mining districts than in the agricultural counties. Those living out of doors in the same county are less liable to the disease than those whose occupations confine them to the house. In keeping with this, we find that prisoners are specially liable to suffer from pneumonia. The annual fluctuation in the death-rate does not exhibit a constant relation to temperature ; yet it is to be observed that the two out of the last twenty years when the mortality from pneumonia was lowest, viz. 1868 and 1872, were years in which the annual mean temperature was 2°-2 and l°-4 in excess of the average. The winters of 1856, 1872, and 1877, again, were mild, and these were also years when the deaths from pneumonia were few. The cold year, 1879, was not marked, however, by a corresponding increase in the fatality of the disease, but still there was an increase over that of the preceding years. Then, again, the winter quarter of 1858 was characterised by great severity, and the deaths from pneumonia were much above the average. It cannot, I think, be doubted that pneumonia is, as a rule, most fatal in cold seasons. The following is the average monthly temperature for the years ^ Longstaff gives the following registration counties as those in which pneumonia is more fatal than bronchitis : S.W. Gloucester, Rutland, Surrey (exti-a Met.), Bedford, Cornwall, Monmouth, and Cambridge. — Trans. Epid. Soc. 1875-80. 130 CENTRAL AND WESTERN EUROPE. 1845-74, and the average number of deaths weekly, in London, for each month for the same period : — Jan. Feb. Mar. Apr. May. June. July. Aug. Sept, Oct. Nov. Dec. Average Mean Temperature, . 38-6 40-1 42-2 48-6 52-7 60-0 64-2 63-5 59-1 52-2 41-2 40-5 Average Deaths from Pneumouia, 98 86 91 82 67 53 42 37 43 66 98 108 So closely does the pneumonic death-rate rise and fall with the temperature, that, if we were to confine our attention to England alone, we should be justified in concluding that the greater or lesser prevalence of pneumonia in any month was deter- mined solely by the lower or higher mean temperature of that month. But when we observe the seasonal distribution of the disease in other countries, the case assumes a somewhat different aspect. In Berlin, for example, during the ten years 1873-82, the maximum number of deaths from the disease occurred six times in April or May, twice in March, once in January, and once in June. In Stockholm, Copenhagen, and numerous other places. May is the month when pneumonia is most prevalent. In short, as a rule, it is in the comparatively warmer months of spring that the disease is most generally fatal. Many suppose that it is the rapid changes of temperature, rather than the degree of cold or heat in any season, that determines the prevalence of pneumonia, and it is stated that such changes are more common in spring in those places when the maximum is attained in April and May. But it must be observed that in England the deaths are most numerous in those months in which the daily range of temperature is lowest. Without going so far as to deny the influence of chill, arising from sudden changes of weather, as an exciting cause of pneumonia, we will hesitate to attach extreme importance to this cause, if we observe that in some countries, where the temperature is the most equable, as, for example, in the Bahamas and Cayenne, pneumonia is more than usually fatal among the coloured population. That the deaths from pneumonia in Eutlandshire should number 450, in Leghorn 1700, in Turin 2400 per million, cannot be adequately explained by any known peculiarities of weather. There is much in the clinical history, as well as in the distribution of pneumonia, that suggests i*"i affinity to the miasmatic class of diseases. It is not at all improbable that more than one disease is included under the name of pneumonia. Pneumonia, as we have already seen, becomes unusually pre- valent in certain years, and this is sometimes clearly owing to the severity of the season ; but a disease known as pneumonia has repeatedly been observed to become so general as justly to be ENGLAND AND WALES. 131 regarded as epidemic, and under such circumstances it has often exhibited typhoid symptoms, — great nervous prostration, stupor, and delirium, — and has been thought by many to have a contagious character.^ These epidemies may be arranged under three categories — (1) Those limited to public institutions, and generally connected with overcrowding. (2) Those confined to a particular locality. (3) Those coinciding with, or preceding or following similar outbreaks in other localities, or invading larger areas, and extending sometimes over several successive years. Whether these classes are all of the same nature, and whether one or all of them are simple varieties of ordinary pneumonia, it is at present impossible to decide. Pneumonia becomes exceedingly fatal during epidemies of in- fluenza. Pleurisij does not give rise to a great proportion of deaths, the average death-rate in the ten years ending 1880 being only 49 per million. The geographical distribution of pleurisy is widely different from that of pneumonia. Taking the average of the three years 1885-87, the counties where the death-rate reached 70 per million were London, Cornwall, Eutlandshire, Lancashire, and Northumber- land. Herefordshire headed the list with an average of 80 per million. Bronchitis takes the first place among the causes of death in England ; and whether from greater exactness in diagnosis, or from some other cause, the registered mortality from bronchitis has been increasing instead of diminishing. In the five years 1850-54 the average death-rate was 1016*4 per million; in the five years 1875-79 it had risen to 2464-6 per million; and during all the intervening five - yearly periods there was a steady rise. It is at the ages under five, and again at those above fifty-five years, that the mortality is greatest. From five to fifteen, females suffer more than males ; at all other age periods, bronchitis is more fatal to males. Its regional distribution will be gathered from the following table : — 1 In 1888 there was an epidemy of pneumonia at Middlesbrough, which was investigated by Dr. Ballard for the Local Government Board. The population is under 70,000 ; but there were 369 fatal cases, and probably not fewer than 1000 persons were attacked. Dr. Klein found that he could reproduce the pneumonia in rodents by inoculating them with the morbid material taken from the lungs of patients, and from this matter could cultivate a bacillus which had the power of inducing the disease. 132 CENTEAL AKD WESTERN EUROPE. Average Death-eate ix the Coixs'ties of England from Beoxchitis, 1885-87. Kutlandsliire, Surrey (extra ilet "Westmoreland, Kent (extra Met.) North Kiding, Bedfordshire, Cambridgeshire, Suffolk, Lincolnshire, Northumberland, Herefordshire, Berkshire, . Sussex, Middlesex (extra Worcestershire, Hertfordshire, South Wales, Shropshire, . North AVales, Leicestershire, Northamptonshire Cornwall, Norfolk, Met. Huntingdonshire, 1-94 Oxfordshire, 1-95 East Riding (with York), Durham, 1-95 1-95 Hampshire, . Buckinghamshire, 1-98 1-98 Cumberland, 1-98 Derbyshire, . Dorsetshire, . 1-99 2-02 Essex, .... 2-04 Somersetshire, 2-07 Nottinghamshire, 2-09 Devonshire, . 2-09 Cheshire, 2-12 Wiltshire, 2-14 Gloucestershire, . 2-15 West Riding, 2-30 Warwickshire, 2-34 Staffordshire, 2-39 London, 2-53 Lancashire, . 2-72 ilonmouthshire, . 2-82 The annual prevalence of the disease is to a considerable extent determined by the weather. Thns we find that in the unusually warm seasons 1865, 1868, and 1872, the death-rates from bronchitis were exceptionally low; while the years 1871, 1875, and 1879, when bronchitis was unusually fatal, were years when the mean annual temperature was below the average. The following shows the average weekly deaths in each month in London from bronchitis for a period of thirty years, 1845- 74:— Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 193-5 172-5 165-0 127-5 90-0 63-2 4S-2 41-0 4S-2 76-5 141-2 190-2 The mortality from bronchitis in London is thus seen to stand in an inverse relation to the temperature ; and although the data on the subject are inadequate, it would appear that generally all over the world the months v.dien the weather is cold and changeable are those in which bronchitis is most prevalent. The prevalence of bronchitis is determined much more by the quality of the inspired air than by its temperature. It is thus we find bronchitis to be specially fatal in cities where large numbers are employed in badly ventilated and over-heated rooms, and especially where the work- men have to breathe a dust-laden atmosphere. Those engaged in earthenware, cotton, linen, and woollen manufacture are particularly liable to suffer from bronchitis ; while fishermen, farmers, graziers, and agricultural labourers, although continually exposed to the inclemencies of the weather, are the classes that pay the smallest tribute to bronchial affections. ENGLAND AND WALES. 133 Croiqj. — The only other disease of the respiratory organs which we shall notice is croup, which, in the ten years ending 1880, furnished an average death-rate of 170 per million. As the distinction between croup and diphtheria is not universally acknow- ledged, what to one is a case of croup is to another a case of diphtheria. The statistics, therefore, relating to the disease are of comparatively little value. The mortality is higher on the western than on the eastern side of the country. The first and last quarters are those in which most deaths occur ; the third quarter has the fewest deaths from croup. In London the greatest mortality falls on the fourth quarter. Diseases of the Liver and Spleen. — The deaths from disease of the liver, other than cirrhosis, in 1887 were 194 per million living. The deaths from disease of the spleen gave a ten years' average (1871-80) of 4-5 per million. Diabetes causes an average of 50*8 deaths per million. Rheumatism. — The death-rate from rheumatic fever, rheumatism of the heart, and rheumatism combined, for the four years 1881-84, was 130"2 per million; that from rheumatism alone was 35'5. In Ireland the death-rate from rheumatic fever and rheumatism of the heart is 20*2, while rheumatism is credited with 124*6 per million. In New South Wales the mortality from rheumatic fever and rheumatism of the heart is about 35 per million, while in Switzer- land rheumatic fever gives rise to 26 deaths per million living. The Collective Investigation Committee of the British Medical Association found that acute and sub-acute rheumatism was uni- versally prevalent all over the British Islands and Ireland in such a way that there is no district where the disease is not common.^ Eheiimatic fever is most fatal between 10-20 years of age, and attains its maximum in the fourth quarter. Cancer caused an average death-rate of 544-6 per million for the period 1881—85. Like rheumatism, it is generally diffused over the three kingdoms. In Scotland it appears that the disease is somewhat less prevalent in the south than in the north ; but in England, Wales, and Ireland the disease is distributed in a tolerably uniform manner, occurring alike along the coast and inland, in mountainous districts and on plains. The disease is not observed to follow the course of rivers, or to be affected by geological formation ; it affects indifferently the poor and rich, and occurs with equal frequency in agricultural and industrial districts.- ' Brit. Med. Journal, Jau. 19, 1889. ^ It deserves to be noticed, however, that the Eegistrar-General has pointed out that cancer, during the thirty years 1857-80, has been most fatal in London, the south- 134 CENTEAL AND WESTEEN EUROPE. A gradual increase of cancer mortality lias been observed in the successive decennia since 1851, common to both sexes, but con- siderably greater in the case of males than of females, and at all age periods. The Eegistrar-General points out that the liability to death from cancer increases much more rapidly than the liability to death generally up to the 45-55 years period; but that in the later age periods the general mortality increases more rapidly than the cancer mortality ; " the characteristic feature of cancer mortality is not its increase with advance of age, — for this it shares with other fatal affections, — but its disproportionate increase in the middle periods of life." Tahes Mesenterica. — The death-rate from tabes mesenterica, which may be taken to include all wasting diseases of infancy, was 0*32 per 1000 for the ten years 1871—80. Amongst the severely affected counties, Durham heads the list with a death-rate of 0"75 ; Northumberland follows with 0"62 ; Nottingham, with 0"41 ; Loudon, with 0-40; the West Eiding, with 0-38; Staffordshire and the East Eiding, with 0'35 ; and Lancashire, with a rate of 0"34 per 1000. The counties with the lowest death-rates from this disease were Eutland, Hereford, and Berkshire. North and South Wales, which suffer so severely from phthisis, show a low death-rate from tabes mesenterica. The view that tabes mesenterica is mainly caused by the improper feeding of infants, is not incon- sistent with what we know of its incidence in the different districts of England. HydroceiJhalus is another fatal disease of infancy, causing an average death-rate of 0*32 per 1000 ; the male mortality being 0*38, and the female, 0'26 per 1000. The maximum mortality, 0-45, occurs in Durham, as is the case in tabes mesenterica. The deaths are also in excess in Cumberland, London, Northumberland, the West Eiding of York, and Lancashire ; and they are below the mean in Eutland, Shropshire, and Norfolk. Whatever may be the cause or causes of this disease, they are general tliroughout the county of Durham, where, out of fourteen districts, the disease is below the average in one only, Scrofula. — The mean mortality in England from scrofula, from 1871-80, was 0-13 per 1000, — a proportion about double that of Switzerland, and somewhat above that of Germany. Oxford, which registers tlie greatest number of deaths from scrofula, has a ratio of eastern and south-midland divisions, and least fatal in Wales, the north-midland and the north-western divisions. The high mortality of London is partly explained by it being a place to which persons resort when surgical operations are required. — Annual Eeport, 1884. ENGLAND AND WALES. 135 0"19 per 1000; Moumoiitli stands next witli 0*17; London and Norfolk follow with rates of 0*1 G; while in Buckingham, Here- ford, Worcester, and Eutland the death-rate is as low as 0*08 per 1000. It will be seen that the geographical distribution of scrofula differs considerably from that of phthisis. In Norfolk, Monmouth, and Oxford, where scrofula is prevalent, the mortality from phthisis is below the mean. In North Wales, on the other hand, where consumption is so fatal, scrofula is rather rare. In Anglesey the phthisis death-rate stands at 3 "3 6 per 1000, while that of scrofula is as low as 0'06. It would appear that the prevalence of scrofula is mainly determined by purely local conditions, and not by climate. Thus the Headington district of Oxford has perhaps the highest scrofula death-rate in England, viz. 0'48 ; while in the immediately adjoin- ing district of Oxford proper the rate is 0'12, which is below the average of England. In Monmouthshire, again, we find the excess of scrofula to be limited to one or two districts, and notably to the densely peopled mining district of Bedwelty, including Tredegar, where it reaches the figure of 0*34 per 1000. In London the disease makes most victims in the overcrowded slums of the Strand, St. George's in the East, and Whitechapel. In Norfolk the districts most affected are Blofield, Downham, and Thetford. BicJcets give rise to 22 deaths per million. This disease is comparatively rare in the rural districts, being mainly a disease of towns and industrial regions ; but it is exceptionally prevalent in Cornwall, Kent, and North Essex. Venereal Diseases gave rise to a mortality of 6 2 '7 per million in the three years 1858—60, to 77"-i per million in the five years 1861-65, and reached 95'6 per million in 1876-80. This class of diseases has thus been steadily increasing in fatality of late years. Hydrophobia causes an average death-rate of about 1 per million. It has two centres of prevalence, — the one in Lancashire, radiating into the neighbouring counties of Cheshire and the West Pdding, gradually diminishing as the distance from the centre increases. The second centre consists of London, from which the disease extends into the extra metropolitan portions of Middlesex, Surrey, and Kent, and then shades off in the wider belt surrounding this area. CHAPTEE X. SCOTLAND. Geography. — Scotland occupies the northern part of Great Britain, ex- tending from 54'' 39' to 58^ -40' X. lat. To the north of the main- land lie the Orkney and Shetland Islands, reaching as high as lat. 60° 50' X. The Hebrides, divided into an inner and outer group, stretch along the west coast, which is extensively indented by deep firths. As we do not propose to enter in detail into the pathology of Scotland, but rather to point out those particulars in wliich it differs from the southern part of the island, it will be unnecessary to do more than note in a few words the chief physical features of the country which distinguish it from England. The country may be described as mountainous. Even the low- lands are more boldly undulating than the southern part of the island. The extensive low and level plains, which occupy so large a part in the topography of the south, are here replaced by hill and dale. In the south are the Cheviot Hills ; in the middle are the Grampians, running obliquely across the country from Argyleshire to Aberdeen, having an average elevation of from 2000 to 3000 feet, and rising in Ben Xevis to a height of 440 6 feet. Beyond the narrow and deep depression of Glenmore, which here intersects the island, and through which passes the Caledonian Canal, there extends northward a rugged mountainous region, terminating in the plain of Caithness. The country abounds in inland lakes, which together are estimated to cover an area of 500 square miles. The principal rivers are the Tay, Tweed, Clyde, Spey, Dee, Forth, and Don ; and it is in the basins of these rivers and in the Forth and Clyde plain that we find the greatest extent of level land. Many of the straths (valleys), now drained and highly cultivated, were formerly marshes and quagmires. Climatology. — The mean annual temperature of Scotland is about 4 6 '2. Tlie West coast is, generally speaking, about a degree warmer than the east. SCOTLAND. 137 The Mean Annual Temperature and Rainfall of East, "West, AND Centre of Scotland. Localities Temperature ^ Means » 1 and and e ^ ■~ >• ^ to -^ 4J i~ and a Altitudes. KainfalL IS ■-5 ^ S ■< S •^ •^ < w 25 Q Totals. >> Dalkeith, 190 ft.. . Temperature, 37-1 39-0 41-1 45-7 49-9 56-2 58-9 58-2 .53-8 47-0 40-1 38-1 47-1 ■^0 Edinburgh, 230 ft., Rainfall, . .! 2-5j 2-lti i-e4 2-00 1-92 2-13 2-88 3-11 2-88 2-17 2-52 2-36 28-32 CuUoden, 104 ft., . -j Teniiierature, 37'2 3S-9 40-2 4o-4 49-1 55-1 57-8 57 1 53-1 46-9 40-1 38 j 46-6 19 Rainfall, . .i 2-30 i-53 i-eo 1-4S 1-63 1-94 2-69 2-88 2-82 2-39 2 -.53 2-08 25-87 Greenock, 233 ft., . Temperature, 3S'S 39-5 40-6 46-0 50-2 oC-1 58 -.i .57-9 5H-9 47 -S 41-,T 39-6 47-5 "0 Glasgow Rainfall, . .i 4-SO 3-83 2-57 2-41 2-18 3-09 3-40 3-99 4-32 4-31 S-fi,! 4-47 43-08 15 Perth, 48 ft., . . -| Temperature, 37-2 39-1 40-6 46-0 50-4 56-3 59-7 58-4 54-0 47-3 40-3 38-1 1 47-3 :?0 Rainfall, . . 3-69 2-24 1-99 2-19 2-12 2-22 2-74 3-52 2-98 .'i-OO 2-67 2-74! 32-10 Fettercaim, 247 ft., -| Temperature, 35-2 36-8 38-7 44-1 48-8 .54-7 57-4 oO-o 51-9 45-5 38-9 35-9 45-4 20 Rainfall, . . 3-44 3-iS 1-92 2-4(5 2-01 2-34 2-94 3-33 3-43 3-97 3-42 3-90' 36-34 — Sand wick(Orkney), "> 100 ft., )' Temperature, 38-9 39-1 39-2 43-2 46-6 52-3 54-7 .54-8 52-0 47-0 41-7 40-0 45-8 20 The average annual rainfall of Sandwick in Orkney is 37*79; of Carsphairn in Kirkcudbright, 61-48 ; of Loch Dhu in Perthshire, 82-73 inches. The rainfall on the east coast averages from 25 to 28 inches, and on the west coast from 27 to 60 inches ; the heaviest rainfall is in summer and autumn. Vital Statlstics. — The average marriage-rate for the ten years ending 1887 was 13*2 per 1000; the birth-rate, 33-1 per 1000; and the death-rate, 19 "6 per 1000. In 1886 the death-rate of the entire country was 18'6, — that of the principal towns being 21 per 1000, that of the large towns 19*2, that of the smaller towns 18"1, that of the mainland rural districts 15'7, and that of the insular- rural districts 15*4 per 1000. The mean monthly distribution of deaths during the ten years 1871-80 was as follows : — Jan. Feb. March. ApriL May. June. July. Aug. Sept. Oct. Xov. Dec. 1154 1061 1138 1064 1040 939 921 893 834 885 949 1122 December, January, and March are the months which are most charged with deaths ; while August, September, and October are the healthiest. Pathology. — Malaria. — Up to the beginning of the present century, malaria was endemic in some of the more marshy localities. The " How of the Mearns," a broad and shallow valley lying between the Grampians and the Garvock Hills, with a clayey subsoil, and so level as to render drainage difficult, was an endemic haunt of malaria even so late as 1815 or thereabouts. Labourers who went from the coast districts to work in the " How " during harvest generally returned home with ague. I doubt if a single case has been observed in this locality for the past fifty years — so completely has drainage and cultivation banished the disease. This is only an example of what has taken place all over the country. 138 CENTEAL AND WESTERN EUEOPE. I know of no locality in Scotland where ague can be said to be endemic at the present time. In 1885 ague caused 9 deaths in Scotland, of which 7 were males and 2 were females. This gives a death-rate of 2'3 per million. In the succeeding year the deaths from ague were much more numerous — no fewer than 17 deaths having been recorded from this disease in 1886, of which 13 were males and 4 were females, being a death-rate of 4*3 per million. This great excess of males makes it probable that some of the cases had occurred in sailors or others who had contracted the disease abroad. In 1885, 4 out of the 9 male deaths occurred in sea- port towns, in which no females died of ague. In 1886 only 2, or at most 3, of the deaths occurred in large seaport towns ; although it is not improbable that some of the deaths that occurred in the inland towns or rural districts may have been imported ones. This is a point, however, on which we have nothing to guide us. Clackmannan, a comparatively small county on the Forth, takes the first position as regards ague, and Inverness ranks second. In the other counties the cases are solitary. Remittent Fever caused 30 deaths in 1885 and 17 in 1886, equal to ratios of 7 '6 and 4*3 per million respectively. Enteric Fever gave rise in 1885 to a death-rate of 230, and in 1886 to one of 190 per million. The moderately large towns and the smaller towns suffer very considerably more than the great towns, and these again suffer more than the mainland and insular- rural districts. Typhoid fever appears to be about equally common in Scotland and in England. The monthly distribution per cent, of 3548 fatal cases in the principal towns of Scotland, for the ten years 1876-85, was as follows: — Jan. Feb. Marcli. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 8-51 7-69 7-41 7-38 8-85 7-41 5-92 7-41 9-64 11-70 8-71 9-36 The highest mortality occurs in September and October, just as in England and in most parts of Germany, Switzerland, in Paris, and in Norway. Relapsing Fever has been frequently epidemic in Scotland. Omitting the outbreaks during the eighteenth century, it was epidemic in 1799-1800, 1817-19, 1826-27, 1841-44, 1847- 48, and in 1868-73. Most of these outbreaks were coincident with epidemics of the disease in Ireland. In 1885 and 1886 only 3 deaths were registered from this fever. Diphtheria caused an average death-rate of 230 per million in Edinburgh and Glasgow in the years 1885-88, In the great English towns, for the same period, the death-rate from this disease was 180. For the whole kingdom the death-rate in 1885 was SCOTLAND. 139 180, and in 1886 it was 150 per million. It thus appears to be somewhat more fatal in Scotland than in England. The largest towns suffer most, the insular-rural and rural districts least. The distribution of diphtheria in Scotland will be seen to differ from that which is observed in England, where the sparsely peopled localities present the highest diphtheritic death-rates. The death-rate from Erysipelas was 90 per million in 1885, and 70 in 1886. Its distribution is not materially influenced by density of population. Diarrhcea is less fatal in Scotland than in England. In Edin- burgh and Glasgow the death-rate averaged 0-59 per 1000 for the four' years ending 1888 ; while in the great towns in England, for the same period, it was 0-85. The deaths from diarrhcea and dysentery for the whole of Scotland in 1885 gave a ratio of 0*42, and in 1886 of 0-47, per 1000. The fatality of the disease is in proportion to the density of the population. Enteritis gives rise to 0*22 deaths per 1000, or 225 per mUlion living, — a proportion considerably in excess of that observed in England, where, in 1884, the ratio was 119 per million living. Scotland has not escaped when Cholera has been epidemic in the southern part of the island. Ty pints gives rise to a death-rate of about 0*025 per 1000. It is chiefly met with in Glasgow, Greenock, and Leith. The following is the monthly distribution per cent, of 1277 cases occurring during ten years ending 1885 : — Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 10-26 9-63 10-26 8-93 10-65 7-75 6-97 6-81 6-57 5-63 7-67 8-8o Smallpox, from 1855 to 1874, caused a high mortality com- pared with the period 1875 to 1887. The average death-rate from this disease, during the ten years ending 1887, was 34 per million living, as against 53 per million in England. Measles and Scarlatina affect Scotland in about the same degree as England. Whooping-Gougli is quite as common in Scotland as in England. It is more fatal in the towns than in the rural districts. Phthisis causes an average death-rate of 2045 per million (1885-86), which is a considerably higher rate than that of England. The disease is most fatal in the large towns, less so in the° small towns, and least of all in the rural districts. The death-rate from Pneumonia in 1885 was 1150 per million, and in 1886 it fell to 1030 per million. Its fatality is greatest in the lar^e towns, and is at its minimum in the country districts. 140 CEXTKAL AXD "WESTERN EUROPE. Indeed, it is three times as prevalent in the principal towns as in the insular-rural districts, which are chiefly situated in the north. Thus in 1886 the ratio per million was 1440 in the principal towns, and 480 in the insular-rural districts. Pleurisy causes a death-rate of 84 per million, which is more than a third higher than that of England. Broncliitis caused, in 1885, 2050 deaths per million; in 1886 the ratio was 2030. Thus, like most chest diseases, it is less fatal in the rural than in the urban districts. The proportions per 100,000, in 1886, were as follows: — In the principal towns, 257; in the large towns, 209 ; in the small towns, 180 ; in the mainland -rural districts, 145 ; and in the insular-rural districts, 116. This is conclusive evidence of the influence of occupation, habits, and social condition on the fatality of bronchitis. Croup gives rise to the same death-rate in Scotland as in England — 170 per million living. Diseases of tlie Liver, other than cirrhosis, occasioned, in 1885, 196 deaths per million, which is practically the same as in England. Diseases of the Spleen causes 4' 7 deaths; Cancer, 575 deaths; DiaheUsl 16*2 deaths; Q.nd.R]ieuriiatisrii, 115 deaths, per million. The death-rate from diabetes is less than a third of the EngHsh death- rate from this disease, — a fact which at present does not admit of explanation. In 1886 the deaths from cancer in Scotland were in the ratio of 59 per 100,000 living. The ratio in the principal towns was 58 ; in the large towns, 61; in the small towns, 58 ; in the mainland-rural districts, 61; and in the insular-rural districts, 59. The disease is for some reason very unequally distributed over the principal towns. Thus, in 1866, the ratio of deaths from cancer per 100,000 living was in Edinburgh, 94; in Glasgow, 52 ; in Dundee, 59; in Aberdeen, 64 ; in Leith, 56 ; in Paisley, 52 ; in Perth, 25 ; and in Kilmarnock, 82. It would thus appear that the east of Scotland is more affected with cancer than the west or centre. The remote island of St. Ivilda, with a population, in 1881, of 77 souls, is subject to three diseases, — trismus neonatorum, pro- bably due to the vitiated atmosphere of their huts ; a species of dysentery, attributed to their use of sea-fowl as food; and the peculiar influenzoid disease called by them "boat cough," which is intimately associated with the arrival of strangers on the island.^ This is precisely wliat is observed in Iceland and the Faroe Islands. ^ Mean of 1885-86. Nev/sliolme, however, gives the mean annual mortality in England as only 26 per cfent. above that of Scotland, — a ratio which is probably based on the returns for a larger number of years. - Morgan, Brit, and For. ^fed. Chir. Ber., .Jan. 1SG2. CHAPTER XL IRELAND. Geogeappiy. — Ireland lies between lat. 51° 26' and 55° 23' K, and long. 5° 20' and 10° 26' W. Its area is 32,524 square miles, with an estimated population, in 1887, of 4,837,313 inhabitants. The hills are arranged in irregular, interrupted clusters round the coast. The highest peaks, rising from 3000 to 3400 feet above the sea, are met with in Kerry. The central plain extends between the bay of Galway on the west and the bay of Dublin on the east, and from Lough ISTeagh on the north to AYaterford on the south. Excepting where broken in upon by hills towards the south, the general level of the plain is less than 300 feet above sea-level. The soil is, in part, of clay and gravel, resting upon limestone ; but a greab extent of the plain consists of peat bog. These peat- bogs, which are not confined to the plain, but are also met with in the uplands, are estimated to cover an area of 1,772,450 acres. The lakes are numerous ; the principal being Lough ISI'eagh, Lough Erne, and Lough Corrib. Some of the loughs are rather arms or inlets of the sea, than lakes properly so called. The principal rivers are the Shannon, Barrow, Blackwater, Bann, Boyne, and Liffey. Climatology. — The mean temperature in the south of the island is 51°'5; in the north it falls to 48°"5. The mean temperature of winter is about 41°*5 ; of spring, 47°'0 ; of summer, 60°; and of autumn, 51°. The average mean temperature and rainfall of Dublin for the eleven years ending 1880 was as follows: — January, Tebruaiy, March, April, j\lay, June, July, August, September, October, November, December, Temperature. Eainfall 40-4 2-109 41-6 2-196 43-0 1-856 46-6 2-087 50-8 1-636 56-4 2-193 59-6 2-752 58-6 3-018 54-4 2-376 49-3 3-783 43-7 2-364 39-5 2-447 48-7 29-017 142 CENTEAL AND WESTERN EUEOPE, Vital Statistics. — The average marriage-rate for the ten years ending 1887 was 8-6 per 1000, as against a marriage-rate in England of 14-8 ; the birth-rate for the same period was 24"4 ; and the death-rate, 18 •4. Pathology. — Malaria. — Malarial fever is still rarer in Ireland than in England or in Scotland. In each of the years 1878 and 1879, we find four deaths from ague recorded, and in 1880 and 1881, two and three deaths respectively. This immunity from malaria is all the more remarkable, from the fact that so large a portion of the surface is covered with bog. This seems to show that peat bog is innocuous, but we must not assume that other marshes are equally harmless. Graves says : " Formerly agae was of rather common occurrence in some marshy districts in the immediate vicinity of Dublin, and consequently, when I was a pupil, cases of intermittent fever were constantly to be met with in the hospitals ; now the low ground has been drained, and thus the production of malaria has been entirely arrested." ^ Fevers. — The fever death-rate of Ireland for the years 1871-80 was 567"8 per million living. This includes typhus, enteric, and simple continued fevers. These fevers during the same period caused a death-rate of 490 per million in England. Wliile the total number of deaths ascribed to fever is probably correct, the proportions in which the individual forms prevail is less certain, as it may reasonably be assumed that the term "simple continued fever " includes many cases of enteric fever, and it is not improbable that a certain number of typhoid cases are returned as typhus. Takincr, however, the returns as we find them, we observe that in 1881, out of 2446 fever deaths, there were 859 ascribed to typhus, 813 to typhoid, and 774 to simple continued fever; which gives for that year of 166*7 for typhus, 158-0 for typhoid, and 150'0 per million from simple continued fevers. Even allowing for inaccuracies in the returns, it is evident that typhus occupies a very important position in the pathology of Ireland compared with that which it holds in England, or, we may say, with any country in Europe. Typhoid fever, on the other hand, is probably less frequent in Ireland than in England or in Scotland. Eela'psing Fever, as we have already seen when treating of Scotland, has been frequently epidemic in Ireland, but at the present day it is seldom met with. Diphtheria gave rise to a mortality of 64 per million in the ten years ending 1880, as against a ratio in England during the same period of 120 per million living. During the decennium ending 1 Graves, Clinical Led., Syden. Soc. Ed., London 1885. IRELAND. 143 1880, scarlet fever, measles, erysipelas, and, we may add, whooping- cough, were considerably less fatal than in England. Diarrhcea and Dysentery combined are by no means frequent in Ireland. From 1871-80 the average number of deaths ascribed to these diseases was 2064. Taking the mean population of the country during that period at 5,299,100, the death-rate would be 389'5, as against that in England for the same period of 910 per million living. Dysentery, on the other hand, taken by itself, appears to be considerably more fatal in Ireland than in England ; the average dysenteric death-rate for the three years 1878—80 having been about 36 per million, as against the English average (1871-80) of 28 per million. Sjporadic Cholera caused an average mortality in Ireland of 13"8, while in England the rate was 30 per million. The tubercular class of diseases, including phthisis, tabes mesenterica, and hydrocephalus, is somewhat less fatal in Ireland than in England, and Scrofula is about equally frequent in the two countries. The death-rate from consumption (1871—80) was 1954 per million. Pneumonia. — The average number of deaths from pneumonia during the four years 1878—81 was 2291. If we assume that the average population during this period was 5,223,875, which if not exact is not wide of the mark, we get a death-rate of 438'5 per million, as against an average in England of 1012. To what are we to ascribe this remarkably low death-rate from pneumonia in Ireland ? We have seen that pneumonia is, as a rule, more common in overcrowded manufacturing and mining localities than in agricul- tural districts ; and the proportionally larger number of the popula- tion following agricultural pursuits in Ireland doubtless tells in a diminished pneumonic death-rate. The mild and equable character of the climate may also be supposed to contribute to the same result ; but, as bearing upon the question of the influence of climate on pneumonia, it must be borne in mind that pleurisy, which gives rise to a death-rate of 49 per million in England, is credited with a mortality of 59*7 per million in Ireland. Why, it may be asked, should the mild climate have the effect of reducing the pneumonic and at the same time increasing the pleuritic mortality ? If climate has any influence upon the death-rate from pneumonia, one would expect that it would tell still more in reducing the death-rate from hronchitis ; but this is by no means the case, for bronchitis causes only a slightly smaller death-rate in Ireland than in England. Thus in the four years 1878—81, the average annual number of deaths from bronchitis was 12,190, which, taking the average population 144 CENTEAL AND WESTERN EUROPE. at 5,223,875, would give a ratio per million of 2315'3. That this is approximately correct, is evident from the fact that in 1881, when the population was accurately known, the mortality from bronchitis was 2270"5. In England the death-rate from bronchitis was 2464"6 per million during the period 1875-79. Such a difference as exists between the death-rates in the two countries scarcely requires us to resort to a climatic explanation, while we bear in mind the influence of occupation on the prevalence of this disease. Rheumatism. — Eheumatism of the heart and rheumatic fever caused a mortality in 1881 of 20*7, and rheumatism of 124*6, or a combined ratio of 144'8, compared to the English average of 131-8, per million. Is it that the greater exposure to weather, incident to agricultural life, tends to develop rheumatic and pleuritic, and perhaps bronchitic affections, while they do not have this effect on pneumonia ; or is there something in the habits of the people as regards food which favours this prevalence of rheumatic diseases ? Diabetes is much less prevalent in Ireland than in England. The mean mortality in England from this disease exceeds that of Ireland by 40 per cent.^ ^ NewslioLme, Vital Statistics, Lond. 1889. CHAPTER XII. THE NETHERLANDS. Geography. — The kingdom of the Netherlands is situated between 50° 43' and 53° 36' K lat., and between 3° 22' and T 16' E. long. It is bounded on the east by Germany, on the north and west by the North Sea, and on the south by Belgium. It is to a great extent formed by the Ehine ; so that Holland may be said to be " the gift of the Ehine," as Egypt is of the Mle. It is a level, or rather, as the name implies, a hollow country, many parts being below the level of the sea, and protected from its inroads either by sand-hills or embankments. Canals and rivers intersect it in all directions. The country presents numerous drained lakes called "polders," and there still exist not a few undrained morasses. The Zuyder Zee, fringed by islands, penetrates deeply into the north-western part of the country. The only portions that are at all elevated are the provinces of Drenthe, Overyssel, and parts of Gelderland and Utrecht. This tract of country has in many places a light sandy soil, is well watered, and carefidly cultivated. The soil of Holland generally is clay, superimposed on banks of sand, marine shells, and beds of peat and clay. The soil of Walcheren is described as consisting of a fine white sand and a third part of clay. Eosendaal and Oosterhout, in ISTorth Brabant, where the British troops suffered so severely from malaria in 1794, are described as level plains of sand, perfectly dry on the surface, but permeated with water a few inches underneath, and covered only with a few stunted heath plants. The soil of Holland generally is charged with humidity at all seasons, and surcharged during heavy rains, or after inundations. The rivers are the Ehine, the Maas, and the Scheldt, with the Yssel, the Leek, and the "Waal, forming numerous intercommunications, either directly or by means of canals. The kingdom of the Netherlands is divided into eleven provinces, having an area of 12,597 square miles, and a population on 31st December 1886 of 4,390,857. K 146 CENTEAL AND WESTEEN EUEOPE. The subjoined table gives the population of each province at that date, and the death-rate per 1000 for 1887 : — ISTorth Brabant, Geldeiiand, South Holland, Xorth Holland, Zeeland, Utrecht, Friesland, . Overyssel, . Groningen. Drentlie, . Liraburg, . Population. Death-rate per 1000 500,315 23-34 502,049 20-39 911,534 23-36 786,116 22-05 198,567 19-51 212,454 21-97 335,597 18-78 291,462 22-60 270,608 18-18 127,309 20-09 254,846 21-14 4,300,857 21-60 Climatology. — The mean temperature of Utrecht and Gron- ingen is as follows : — -r , Altitude in Metres. Jan. April. July. Oct. Yeai Utrecht, . 52° 05' 13 1-5 9-4 18-4 10-4 9-9 Groningen, . . 53° 15' 15 0-8 8-3 18-1 10-0 9-4 The average monthly rainfall at Utrecht, for a period of forty years ending 1888, in millimetres is as follows: — Jan. ¥eb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec 48-9 44-4 44-5 37-9 49-4 54-8 75-4 81-1 66-0 73-0 59-4 61-2 The climate is variable, high temperatures often being closely succeeded by cold weather. The rainfall in the third quarter is considerable ; the first and second quarters are the driest. Vital Statistics. — The marriage-rate in the Netherlands, for the ten years ending 1887, was 14-3 ; the birth-rate, 35-0 ; and the death-rate, 21-7 per 1000. The death-rate has been steadily falling during the past thirty years. In the period from 1853-58 — years free from epidemic sickness — the average death-rate was 25*8, while it is now about 21 per 1000. Pathology. — Malaria. — Holland is still the most malarious- region of Northern Europe ; although, from the progress of drainage and cultivation, improvements in the water-supply and in the dwellings of the middle and lower classes, and the general advance in social wellbeing, the health of the population has improved immensely during the present century. The deaths from intermittent and pernicious fevers per 10,000 inhabitants, in the ten years 1879-88, were as follows: — 1S79. 1880. 1881. 1882. 1883. 1884. 1885. 1886. 1887. 1888 Intermittent Fever, . 0-7 0-7 0-6 0-5 0-4 0-4 0-4 0-4 0-3 0-2 Pernicious Fever, . 0-7 0-6 0-6 0-5 0-5 0-3 0-3 0-3 0-3 0-2 Total, . 1-4 1-3 1-2 1-0 0-9 0-7 0-7 0-7 0-6 0-4 In addition to these distinctly paroxysmal fevers, we meet in THE NETHERLANDS. 147 the returns of deaths with a continued fever, distinct from typhus and typhoid, which is probably mainly of malarial origin. This view of the character of this continued fever is based upon two facts — (1) that it is most prevalent, as a rule, in malarious localities; (2) that it has been diminishing in frequency yari ixtssu with the decrease of intermittent fever, which seems to show that the same causes underlie both, — the sanitary measures which have effected a decrease in the one having produced a corresponding decrease in the other. The following is the death-rate per 10,000 of the population from this form of continued fever for the ten years 1879—88 : — 1879. ISSO. 1881. 1882. 1883. 1884. 1885. 1886. 1887. 1888 2-6 2-7 2-7 2-1 2-1 2-1 1-8 1-7 1-4 1-2 Combining these various forms of malarial fever, the deaths in 1 888 gave a ratio of 1'6 per 10,000, or 160 per million of the population. The subjoined tables give the death-rate per 10,000 living from intermittent and pernicious fevers in the several provinces, arranged in a descending scale as regards frequency, and also the death-rate from continued fever. The ratios are for the year 1887 : — Provinces, ntei-mittent and Pernicious Fevers. Continued Fevers. Deaths per 10,000 Inhabitants. Deaths per 10,000 Inhabitants Zeeland, 2-06 2-82 Friesland, 0-98 1-50 Groningen, . 0-92 1-18 I^orth Holland, 0-83 1-60 South Holland, 0-57 1-71 Uti-echt, 0-38 1-31 Overyssel, 0-27 1-09 Gelderland, . 0-20 1-15 Drentlie, 0-15 1-02 North Brabant, 0-12 0-98 Limburg, 0-00 0-28 Zeeland is the province which takes the first place as regards the prevalence of paroxysmal and continued fevers. This province, aptly named " Sea-land," consists of the low-lying islands of "VVal- cheren, jSTorth Beveland, South Beveland, and Shouwen, at the mouth of the Scheldt, and of the contiguous districts on the mainland. Much of the land has been reclaimed from the sea, and, being in many places below the sea-level, it is protected from its inroads by sand dunes and artificial dykes. The country is studded with polders, and intersected with ditches and canals. The soil is clayey, or an admixture of clay and sand. The coast districts of Friesland and Groningen, which, next to Zeeland, are the most malarious parts of Holland, abound in lakes and ponds, and are covered with a network of canals. The same conditions prevail in those districts of North and South Holland where malaria is intense. 148 CENTEAL AND WESTERK EUEOPE. Limburg and ISTorth Brabant, where malarial fevers are rare, are by no means destitute of marshy and water-logged localities ; but, taking these provinces as a whole, they are much less marshy than the malarious provinces mentioned above. Drenthe, Overyssel, Gelderland, and Utrecht, all of which are com- paratively free from malaria, are more elevated and undulating, with a lighter and more porous soil, and they are generally non-marshy. In what way the marshy soils favour the development of malaria is by no means clear ; but that they do so in Holland cannot admit of doubt. A correspondent, writing from the Hague, says, " The common cause of malarial fevers is the summer drought drying up places commonly covered with water, and the ditches that are seen everywhere for the drainage of our agricultural land, and which in the neighbourhood of houses become the receptacles of all kinds of impurities." The nature of the causes of the disease may be inferred from the measures that have been found to improve the health of the country. Let us take as an example the town of Middleburg, the capital of Zeeland, situated in Walcheren, Here a steady diminu- tion in the fever mortality has been going on throughout this century. Dr. de Man has constructed a table from the death registers of the municipality, showing the number of deaths from various diseases for the ninety years 1792-1881. I extract the figures relating to intermittent fevers during that period : — - Decennial Periods. Deaths from Intermittent Fevers 1792-1801, 305 1802-1811, 534 1812-1821, 404 1822-1831, 304 1832-1841, 230 1842-1851, 211 1852-1861, 168 1862-1871, 88 1872-1881, 62 In this table the population (at present actually 16,000) has been reduced to a constant mean of 10,000. There were only 7 deaths from endemic fevers in each of the years 1879 and 1881. This great improvement is ascribed by de Man to the means taken to prevent the admixture of sea water with the fresh water of the canals, and the alternate submersion and uncovering of the soil by the flux and reflux of the tide, and to the better drainage of the soil, the prevention of the impurities of the latrines passing into the canals, the better construction of liouses, the paving of streets, and, finally, to the improved method of treating these fevers.^ ^ Annahs (V hygiene imh.. May 1883. THE NETHERLANDS. 140 Coming now to the seasonal distribution of malarial disease in the Netherlands, we remark that the malarious influence is suffi- ciently pronounced in Zeeland to afi'ect the monthly distribution of the total mortality in that province. This will be seen by com- paring the monthly percentage of the total deaths occurring in the non-malarious province of Overyssel with that of Zeeland during the years IS 75-80 :— .Monthly rEUCENTAGE of. Deaths fkom all Causes ix O^tjiiyssel AND Zeeland. Jan. Feb. March. ApriL May. June. .July. Aug. Sept. Oct. Nov. Dec. Overyssel, 9-51 S'TtJ 0-71 8-05 S-7S 8-27 7-49 7-78 6-67 7-29 7-03 O-l' Zeeland, 8-41 8-28 0"27 8-50 iJ-30 7-47 7-44 9-98 9-12 7-01 7-11 8'27 Hence the quarterly distribution of the deaths in the two provinces is as follows : — First Quarter. Second Quarter. Third Quarter. Fourth Quarter Overyssel, . 27-98 26-00 21-94 24-07 Zeeland, , 25-96 24-86 26-54 22-99 Whereas in Overyssel, as in the kingdom taken as a whole, the first is the most unhealthy quarter, in Zeeland the months of August, September, and October are those in which the maximum mortality occurs. This disturbance of the seasonal death-rate in Zeeland is evidence of the dominating influence of malaria in the pathology of this province. It is rather remarkable that the deaths from intermittent and pernicious fevers also show a different distribution in Zeeland from that in the non-malarious provinces. This will be seen by compar- ing the monthly percentage of the deaths from these diseases in Zeeland and ISTorth Brabant for the years 1875-80. The total number of deaths from intermittent and pernicious fevers in Xorth Brabant during that period was 198, and in Zeeland 327. The monthly percentage in the two provinces was as under : — Monthly Percentage of Deaths from Intermittent and Pernicious Fevers DURING the Period 1875-80 in- North Brabant and Zeeland. Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Xov. Deo. North Brabant, 11-11 10-10 7-57 7-57 9-09 7-07 10-60 S-59 5-05 7-57 4-04 11-62 Zeeland, . . 6-72 5-81 7-64 10-09 8-87 9-78 4-80 8-56 11-01 11-02 S'lO 9-78 The months of September and October, which are among the healthiest in North Brabant, are those in which malaria is most fatal in Zeeland. Perhaps the explanation is that in Xorth Brabant malarial fever comparatively seldom cuts off the patient at once, the sufferer succumbing during the succeeding winter ; while in Zeeland the infection has sufficient intensity to induce a fatal issue during the first attacks. 150 CENTEAL AI^D WESTERN EUEOPE. The months of March and April, and again of August, September, and October, are those during which pernicious attacks are most frequently fatal. In Overyssel and ISTorth Brabant these cases are particularly common in the cold months, and also in May. Females, in all the provinces, are more liable to malaria than males ; and this holds good for continued fevers. The special liability of the female sex is particularly marked in the healthy province of Overyssel, where, out of 9 1 deaths from intermittent and pernicious fevers, 57 were of females and 34 of males. Holland has suffered frequently from malarial epidemies. Sylvius de le Boe describes a severe epidemy which raged in Leyden and the surrounding country in 1669. He ascribed the disease to the great heat and stillness of the atmosphere, and to the impure exhalations from the soil and marshy grounds caused by the intense solar heat. This epidemy was marked by bilious vomiting, petechial spots, epistaxis, and discharge of blood from the rectal veins. The fever was of a quotidian or tertian type. Some doubts, however, may be entertained as to the precise nature of this fever. Several epidemies occurred during the eighteenth century, but I have no precise information as to the character or the con- ditions in which they arose. Pringle, who has narrated the sufferings of the troops in Holland in 1748, states his opinion that the heat and moisture of the air were the chief external causes of these fevers.'^ He notices that, towards the end of July, when the days were sultry and the nights cool and foggy, several of the men (of those regiments which lay nearest the inundation) were seized suddenly with fever. Mr. Jough describes the village of Dintha as lying low, and as being surrounded by ditches and thick plantations. He says that the district was covered by a fog from sunset to sunrise, which had the offensive smell of a foul ditch newly drained. This offensive fog was evidently suspected to be a cause of fever among the troops. In 1794, as already stated, the troops suffered greatly in the moist sandy plains of Eozendaal and Oosterhaut. To what extent the disease was prevalent in the general community in these years I know not. Haeser states that in 1807 to 1809 the Paissian, Prussian, and Polish armies in Holland were decimated by pernicious fevers. The Walcheren Expedition of 1809 is one which exhibited in a manner, and to a degree seldom met with, at least in temperate regions, the dire iniiuence of malaria under certain conditions. The leading points connected with this expedition, as narrated by Sir ^ Observations on the Diseases of the Army, 7tli ed., I.ond. 1775, p. 184 ct seq. THE NETHERLANDS. 151 Gilbert Blane, are these : — The troops sailed from the Downs on the 28th July 1809, lauded in Walchercn and North and South Beveland on the 31st July and the 1st August. Flushing was invested on the 1st August, and capitulated on the 15th of the same month. In the beginning of September the islands of North and South Beveland were evacuated, and that portion of the army which occupied them returned to England, leaving about 18,000 men to garrison Walcheren. More than one half of these died, or were sent back to England on account of sickness, in the course of the three following months, and the island was finally evacuted on the 23rd of December 1809. The admissions into hospital between tlie 21st August and the 18th of November amounted to 26,846, including relapses, and the whole number of sick, including a small number of wounded, conveyed from thence to England between the 21st August and the 16th December, amounted to 12,863; and many instances occurred, in the case of those who returned to England apparently in health, in whom the endemic disease of Zeeland appeared after the slight fatigue of a march. The disease did not show itself among the soldiers during the first month of their residence in Holland. This year, so fatal to the British army, was not an unusually unhealthy one for the natives, but rather the reverse. They accounted for the comparative healthiness of the year by the uncommon quantity of rain that had fallen, the result of their observations being that sickly years were those in which there had been great droughts and heat in the latter end of summer and in the early part of autumn. The following table, given by Blane, shows the progress of the epidemy from week to week. I have added the proportion per 1000 of sickness and deaths to the average weekly strength: — Weekly Number Weekly Ratio Number Weekly Ratio Date of Return. Strength. of of of of Sick. Sick per 1000. Deaths. Deaths per 1000, lOtli September, 17,870 6,931 387-86 221 12-37 17th 17,410 8,141 467-60 227 15-95 24tli 16,409 8,754 533-43 287 17-49 1st October, 16,156 9,127 564-93 254 15-72 8th 15,276 8,969 587-13 217 14-20 16th wanting wanting — — — •23rd 13,017 7,145 548-13 128 9-83 31st 11,747 6,228 531-04 1-21 10-31 7th November, wanting — — — — 14th 8,868 .3,799 428-38 40 4-51 21st 7,926 1,226 154-66 36 4-66 29th 6,261 1,158 185-95 30 4-79 From this it would appear that the disease was most prevalent in the last fortnight of September and during the month of October, 152 CENTRAL ANrr WESTERN EUROPE. but still continuing, probably as relapses, in November. The fever, judging by the death-rate, attained its highest intensity in September, diminishing rapidly in virulence in October, and losing its fatal character in ISTovember. In 1826 the malarial pandemy already referred to, which in Holland followed an overflow of the German Ocean, and occurred in a very warm season, was more or less general over the kingdom, but visited some localities, such as Groningen, with special severity. Here 8000 out of a population of 30,000 were attacked, and 3000 died. It was observed to be more severe in places where the soil was an impermeable clay than where it was sandy. Indeed, it is said that from sandy localities, even when they had been subject to inundation, the disease was, so to speak, cut off, while surrounding clayey soils suffered. Dr. Nieuwenhuys gives the fever deaths in Amsterdam during this year at 2390, out of a population of 200,784, being 1 in every 84 inhabitants.^ Another epidemy of malaria occurred in 1834. That year was remarkable for its uncommonly mild winter, cool spring, and hot summer. In Amsterdam, Hoorn, Eukhuizen, and Alkmaar, which are or were marshy, the excess of deaths over births varied from one-fifth to one-tenth. In Eotterdam, Utrecht, 'SGravenhage, and Dordrecht, where the soil is solid or sandy, the births preponderated over the deaths. It was in August that the intermittent fever began to assume a formidable aspect, and in October it reached its height. The disease was generally of an intermittent character at the commence- ment, often assuming during its progress a remittent or sub-con- tinued type. There was a frequent tendency to bilious disorder ; delirium in adults and convulsions in children were common. Intermittent fever was again prevalent in the Netherlands in 1846, after a hot summer. I am not aware to what extent the pandemies of 1855-60 and of 1866-72 affected the Nether- lands. Typhoid Fever is less prevalent in the Netherlands than in England. The mean annual number of deaths from typhoid and typhus, for the five years 1883-87, was 60 7*6, and the mean population 4,308,425, which gives an average death-rate of 155 per million ; while the death-rate in England for the same years for typhoid alone was 199 per million, or for typhus and typhoid together 214 per million living. The death-rate from typhoid fever is, as in England, a diminishing one, and varies considerably ^ Trans. Pror. Mad. and Surg, yl.ssoc, vol. iv. , T.oiulon 1836; and Med. Chir. FriK, July 183t>. THE NETHEllLANDS. 153 in different years. It will be seen from the subjoined table that in 1885 the disease was considerably less frequent than in the preceding and following years, — which was also notably the case in England. Indeed, the enteric mortality in Holland and in England during these years rises and falls simultaneously. This shows that the prevalence of typhoid fever is determined by some general cause or causes, climatic or other, affecting extensive regions,— a point of considerable importance as bearing upon its etiology. Local conditions also afiect its prevalence, as is proved by tlie fact that the different provinces suffer very unequally : — Dkaths vkom Typhus and Febiu.s Tyi'Hoidea.i 1 1883. ' 1884. 1885. 1886. 1 1887. On 1000 deaths (except still-bom and unknown causes), and on 1000 inhabitants. 1887. N. Brabant, Gelderland, S. Holland, N. Holland, Zeeland, . Utrecht, . Friesland, Overyssel, Groningen, Drenthe, Limburg, 44 1 78 117 224 11 48 69 64 50 37 23 57 75 147 157 19 35 74 80 44 46 30 34 59 70 77 99 122 129 137 14 20 38 30 61 57 53 70 40 67 15 22 18 , 9 49 55 109 104 25 24 55 64 49 21 13 4-98 6-37 5-71 6-73 7-46 5-88 10-02 11-14 11-22 10-64 2-73 0-098 0-110 0-120 0-132 0-126 0-113 0-164 0-220 0-181 0-165 0-051 The Xetherl anc Is, 765 764 571 670 568 6-86 0-129 We cannot observe here any law of mutual exclusion or otherwise between the prevalence of malaria and typhoid. Zeeland, the most malarious province, has a typhoid death-rate close upon the average. Friesland, which takes the second place in respect to malaria, has a typhoid death-rate considerably above the mean. Overyssel, wliich is non-malarious, pays, it is true, the heaviest tribute to typhoid ; but, on the other hand, Limburg, which did not return a single death from malaria in 1887, also suffers least from typhoid fever. The total deaths from typhus and typhoid in the three great towns of Amsterdam, Eotterdam, and the Hague in the four years 1885-88 were 352, which were thus distributed by quarters : — First Quarter. 91 Second Quarter. 66 Third Quarter. Fourth Quarter. 120 Reijorl of the Medical Commissioners for 1887, p. 246 154 CENTEAL AND WESTERN EUROPE. Bijjhtlieria, in the five years ending 1887/ caused 161 deaths per million living in the Netherlands, and for the same period the ratio was 162 in England, so that we may say that the disease is equally prevalent in • the two countries, — a proof, if proof were required, that diphtheria is in no way related to malaria. In 1887 the provinces of North Holland and Utrecht were most affected, and Drenthe and Limburg least so ; but the variation in the mortality in the same province in different years is very marked. Thus, North Brabant had only 11 deaths from diphtheria in 1883, while in 1886 the deaths numbered 147. The epidemic causes of diphtheria are local; this is proved by the fact that in 1883 North Brabant was almost free from diphtheria, while North Holland suffered with unusual severity ; and the case was again reversed in 1886, when North Holland suffered little and North Brabant much. Out of 590 cases occurring during the four years 1885—88 in Amsterdam and the Hague, the distribution by quarter was as follows : — First Quarter. Second Quarter. Third Quarter. Fourth Quarter. 171 137 102 180 Croup caused, for the five years ending 1887, a death-rate of 0-303 per 1000 living, and 16-06 per 1000 of the total mortality. The disease is most prevalent in the provinces of Overyssel and Friesland, and is rare in Limburg and Groningen. Diarrhcea. — The mean death-rate from diarrhoea, exclusive of dysentery, in the ten years 1879-88, was 461*0 per million for the whole kingdom; for the five years 1881-85, the ratio in England was 652'4 per million; diarrhoea is thus less common in the Netherlands than in England. The distribution of diarrhoea! deaths per 1000 in the several provinces in 1887 was as follows : — North Brabant, Gelderland, . South Holland, North Holland, Zealand, Utrecht, 0-32 : Friesland, 0"16 Overyssel, 0"79 Groningen, 0-19 Drenthe, 1 '24 Limbura;, 0-53 0-14 0'24 O'OS 0-20 0-02 It will be seen that diarrhoea is specially fatal in Zeeland. Dysentery. — The death-rate from dysentery from 1879 to 1888 averaged O*! per 10,000 inhabitants, or 10 per million. Eor 1887 the ratio was as low as 0-06 per 10,000, or 6 per million. In England, during the ten years ending 1880, the ratio was 28 per million. It would thus appear that dysentery is actually more fatal ^ Verdag aim den Koning van de Beviiidiiif/en en Ilanddingen ran het Gtneeslcundi'j Staatstoezicht in hetjaar 1887, Hague 1888. THE XETIIERLANDS. * 155 in England than in malarious Holland. It may be noted that in 1887 none of the 26 fatal cases of dysentery occurred in Zeeland. Last century dysentery was epidemic in the Netherlands in 1719 and 1779 (Hirsch). During this century the disease, in a severe epidemic form, has seldom been noticed. Cholera Nostras gave rise to 0-034 and 0-019 deaths per 1000 in 1886 and 1887 respectively. The Netherlands suffered from all the cholera epidemies which visited the neighbouring regions. TyiJlius. — We have no data for estimating the prevalence of typhus in the Netherlands, as the cases are returned along with typhoid. So far as one can judge, it is extremely rare. Smallpox, during the five years ending 1887, gave rise to an average of 39*7 deaths per million; in England, during the .same period, the mortality was 49*8 per million. Scarlatina gave an average death-rate of 177 per million, and measles of 346 per million, for the five years ending 1887, which ratios are lower than in England. Whooping-Cough, in the four years 1885-88, caused a death- rate of 0-32 per 1000 in Amsterdam, Rotterdam, and the Hague; and the mortality for the whole country for the ten years 1879-88 was 0*34. The mortality in England for whooping-cough averages about 0-46 per 1000. Acute Diseases of the Respiratory Organs, during the ten years ending 1888, gave rise to a death-rate of 2470 per million. Chronic Respiratory Diseases caused a mortality of 1272 per million.^ Phthisis. — The death-rate per 1000 from phthisis, for the period 1869-74, in the Netherlands was 2-46 per 1000, or 2460 per million, and during the ten years 1879-88 to a ratio of 1977 per million. The ratio for the several provinces during the earlier period was as follows : — North Brabant, . . 2-46 Friesland, . 2-51 Gelderland, . . 2-49 Overyssel, . 3-27 South Holland, . . 2-28 Groningen, . . 2-38 Xorth Holland, . . 2-38 Drenthe, . 3-09 Zeeland, . 1-87 Limburg, . 2-33 Utrecht, . 2-62 It is to be remarked, in connection with the theory that malaria is antagonistic to phthisis, that Zeeland, the most malarious province, is that where phthisis is least fatal, while Overyssel and Drenthe, which are little influenced by malaria, have a high phthisical mortality. Yet, on the other hand, it will be noted that as a whole 1 Jaarcijfers over 1888 en vorige jaren. 156 • CENTEAL AND WESTERN EUROPE. phthisis is more fatal in Holland than in England, notwithstanding the freedom of the latter from malaria.^ Malaria may have some antagonistic influence ; but if so, it is not a dominating one. Scrofidosis (Klierziekte) and Racliilis are combined in the returns. Together they gave rise to a death-rate of 340 per million for the ten years 1879-88. Syphilis gives a ten years' average death-rate of 12 per million, which contrasts favourably with that of England, where, in 1884, it stood at 84 per million. Eheumatism. — Eheumatism is combined with heart disease in such a way that it is impossible from the returns to ascertain the fatality of rheumatic affections. The death-rate from Cancer (1884—88) was in the ratio of 656 per million. ^ Droeze, De Sterfte van jihthisis in Nederland, Leid. 1879, quoted by Hirsch. CHAPTER XIII. BELGIUM. Geography. — Belginm is bounded ou the north by Holland and the Xorth Sea, on the east by Germany, and on the south and west by France. It has an area of 11,373 square miles, and its popula- tion in 1887 was 5,974,743. The sea-coast of West Flanders is continuous with Holland, and presents the same physical features as the latter, requiring in parts to be protected by dykes. The Campine, in the north-east of the province of Antwerp and the adjoining districts of Limburg, is a tract of marsh and heath. Luxemburg, j^amur, part of Hainault, and Liege are more or less elevated and diversified, rising in the Ardennes to 2000 feet above the sea-level. The principal rivers are the Scheldt and Maas, and the tributaries of the former, which, along with the numerous canals, intersect the country in all directions. Climatology and Vital Statistics. — The mean temperature C. of Brussels is as follows : — maiy. ApriL July. October. Year 2-0 9-0 18-0 10-4 9-9 The annual rainfall of Brussels is 727 mm.; along the sea- coast it amounts to 900 mm., and to 1000 on the Ardennes. The coast country is cool, humid, and equable ; in the high lands the summers are hot and the winters warm. The marriage-rate in Belgium, for the ten years ending 1887, was 13-7 ; the birth-rate, 30-6 ; and the death-rate, 20-9 per 1000. The seasonal distribution of deaths per cent, is as follows : — Winter. Spring. Summer. Autumn. 28-34 27-85 21-76 22-05 Pathology. — Malaria is at the present time almost confined to the provinces of West Flanders, East Flanders, Limburg, and Antwerp, — the cases in the last-mentioned province being few. The other ]3rovinces are healthy. In 1888 three deaths from ague are 158 CENTKAL AKD WESTEEN ETJEOPE. recorded as having occurred in Brussels, but it by no means follows that they were contracted there. Ghent suffers very considerably from intermittent fevers. In Liege, malaria is unknown. Meynne observes that in Belgium malarial fever is found to prevail most, and with greatest intensity, in warm summers.^ Lombard mentions some local epidemies of malaria in Belgium. One of these occurred between 1839 and 1841, in the Commune of Lonze in Xamur, as the result of cleaning out the mud from the hassin cTArlon ; twenty-five persons died. The epidemy subsided when the works were finished. Another epidemy developed from a similar cause in the Commune of Soye in 1836 and 1837. The moats of Ypres have also given rise to occasional epidemies of fever. Typhoid fever is most fatal in the non-malarious districts of Belgium, Enteric Fever. — Easeri gives the typhus and typhoid death-rate of the principal towns (1881-84) at 469 per million ; and of Belgium, as a whole, at 617 per million. In Brussels the death-rate from typhoid fever from 1855 to 1888 was only 211 per million. The maximum mortality from this disease falls on the three months of September, October, and ISTovember. Typhus was epidemic in Belgium in 1840-44, and again, and still more severely, in 1846-48 ; and in both instances, according to Hirsch, it coincided with interruption of commerce and failure of the crops. A few cases of Relapsing Fever were observed in Belgium in 1867. Diphtheria and Crouy are prevalent in Belgium, especially in the country districts. Brussels, however, is not so much affected, the mortality from 1885 to 1888 having been at the rate of 164 per million. Diarrheal Diseases, including diarrhoea, dysentery, and enteritis, according to the figures given by Lombard, are less fatal in Belgium than in England — the death-rate being 8'2 per 10,000 inhabitants. In Brussels the mortality from these diseases, from 1885 to 1888, averaged 25*42 per 10,000. The three months, July, August, and September, are those in which the disease is most fatal. Asiatic Cholera. — It was observed that the low humid lands did not suffer from the epidemies of this disease. Lombard remarks that many localities where polders exist, and which are low and humid, escaped, as did also that part of Flanders where one meets much water. Miliary Fever. — Belgium is one of the countries in which the sweating sickness has been observed, but here only to a small ^ ilcj'iiue, Toporj. m6d. de la Bthfiqne, Bnix. 1865. BELGIUM. 159 extent. A mild epidemy occurred in 1838 ; it then appeared along with cholera in 18 49, and again in the neighbourhood of Mons in 1850. It was last observed in the province of Luxemburg in 1866. The eruptive fevers, Smallpox, Measles, and Scarlet Fever, differ little in frequency or character from those observed in neighbouring countries. Fhthisis is more fatal in Belgium tlian in most parts of Europe, The death-rate from this disease (1851—55) was given by Meynne at 3500 per million, and (1856-59) by Bertillon at 4100 per million. In Brussels, from 1864 to 1878, the mortality was 5600 per million. It is least prevalent in Luxemburg, oSTamur, Liuge, and Hainault, where malaria is least felt ; and it is most common in Limburg, East and West Flanders, and Antwerp, — provinces which are in varying degrees subject to the malarious influence. Brabant and Hainault occupy an intermediate position on the list, while Namur, Liege, and Luxemburg suffer least. JBronchitis is less frequent in Belgium than in England ; Pneumonia is about equally common in the two countries. During the ten years 1871-80, the deaths from pneumonia in Brussels were in the ratio of 2 '2 per 1000 living. In Brussels, bronchitis attains its maximum in December, January, and February, and pneumonia in January, February, and March.^ Whooping -Cough appears in outbreaks of varying severity at irregular intervals ; but the average mortality from the disease does not appear to differ in Belgium from that in neighbouring countries. Cancer gave rise to a death-rate in Brussels of 390 per million from 1864 to 1873, and of 420 per million from 1874 to 1878, — a proportion considerably under that of many large towns in Europe, It is most fatal in Brabant and East Flanders, and much less so in Luxemburg and Limburg. Acide liheumatism caused, from 1862 to 1875, a proportion of 3 per 1000 deaths. In England, rheumatic fever and rheumatism of the heart caused 5*1 per 1000 deaths from all causes. Chronic rheumatic affections are said to be very common, especially in the country districts. Diabetes caused a proportion of 0'60 per 1000 of the total deaths in Brussels from 1864 to 1880. Scrofula is widely diffused in West Flanders, Limburg, Antwerp, and Brabant. It is less frequent in Hainault, Liege, Luxemburg, and Namur. Goitre is met with only in a few localities in Belgium, and the cases are not numerous. Cretinism is very rare. ^ Janssen, Annuai7'e Demor/raph. Ville de Bruxelles, Brux. 1888. CHAPTER XIY FEANCE. GEOGEA.PHY. — rrance stretches across- the \yest of Europe from Belsfium on the north to the Pyrenees and the Mediterranean on the south. It is divided by the Alps from Italy on the south-east and by the lines of the Jura and Yosges mountains from Switzerland and Germany. On tlie north-west and west it is bounded by the English Channel and the Atlantic. Prance has an area of about 201,600 sc^uare miles, and is divided into thirty- si.x; depart- ments, with a population of 38,218,903. The chief rivers running into the English Channel are the Somme and the Seine ; and into the Atlantic flow the Loire and Garonne. The only river of importance running into the Mediter- ranean is the Ehone. These and their tributaries form the great river systems of Prance. Besides these, the Moselle, Meuse (Maas), and the Scheldt rise in the north and north-west of Prance. Considerable tracts of marshy land are still met with in some departments of Prance. Lombard gives the area, in hectares, of marsh as follows: — Charente-Inferieure, 30,531; Loire-Inferieure, 19,498 ; Bouches - du - Ehune, 15,270 ; Landes, 13,742 ; .Gard, 11,325; Gironde, 10,584; Somme, 8930; Manche, 7645; Oise, 6152; Pas -de - Calai.s, 6071; Aisne, 5800; Aude, 5751; Isere, 5281; Herault, 4251; Vendee, 4151: Marne, 3834; Morbihan, 3591; Deux-Sevres, 2 691. Smaller areas are met with in other departments. The greater part of the country is fertile, well cultivated, and free from malaria ; but in some of the districts, as we shall presently see, endemic fevers are frequent and severe. The mean annual temperature C. from the north to the south is as follows : — Xortli Coast and Interior. Middle Zone. .South Coast and Interior. Lille, . . .9-08 La Rochelle, 11-8 Bayonne, . 14-2 Havre, . . 10-2 Bordeaux, . 12-6 Toulouse, . 12-65 Brest, . . 11-3 Moulius, 10-05 Moutiiellier, . 13-6 1 Xantes, . 11-5 Limoges, 10-5 ^Marseilles, . . 14-0 Meziere.s, . 8-5 Dijon, . 9-15 Xice, . . 14-0 Paris, . . 9-9 Lyons, . 9-6 Xancy, . .S-7 Besan^on, 9-:l Orl^ns, . 10-1 Valence, 11-7 1 Arnould, Diet, encij. scim. m6iL, art, "Climat.," Paris. FRANCE. 161 It Mill be seen that the iiieau annual temperature of Xice iu the south is o'o degrees higher than that of Mezieres in the north. Martins divides the climates of France into the following : — («) The " Vosgien," on the north-east, from Mezieres south to Auxerre, and stretching to the east frontier. The mean temperature is 9° to 10°; the difference between summer and winter is 18°; the rainfall is 670 mm. The summer is the rainy season in this region. (b) Tlie "Sequanien," or north-west region, extends from Mezieres and Auxerre w^est to the Channel and Atlantic, and south to the river Loire. The mean temperature of this region is 10°'9 ; the difference between summer and winter is 13°'6 ; the rainfall is 548 mm. (c) The "Girondin," or south-west climate, is that of the country lying between the Loire and the Pyrenees. It has a mean annual temperature of 12°*7 ; the difference between winter and summer being 15°'7 ; the rainfall is 586 mm. The autumn and winter are the most rainy seasons. (d) The " Pihodanien," or south-east climate, comprises the valley of the Saone and Pthone. The mean annual temperature is 11°'0 ; with a difference between winter and summer of 18 '8. The spring and autumn are rainy, the summer and winter drier; the rainfall is 946 mm. (e) The "Mediterranean" climate is that of the region included in the triangle formed by the towns of Montpellier, Marseilles, and Viviers. The mean temperature of this region is 14°'8 ; the difference between summer and winter beins 16°*1; the rainfall is 654 mm. The summer here is very dry; this region is exposed to the destructive north- west wind called the Mistral. We shall add the monthly temperature C. and rainfall in mm. of a few representative localities : — Bordeaux, Perpignan, \l ^i^ Toulon, Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Xov. Dec. (T. 7-1 8-S 8-5 14-4 17-9 20-6 22-"t> 20-0 IQ'O 14-3 10-4 6-S (R. 93-4 63-1 58-2 53-0 68-8 66-9 58-4 50-6 53-6 101-0 72-S 63-0 T. 7-6 9-7 9-9 14-3 18-0 22-3 23-1 23-0 20-4 14-7 11-2 6-8 45-6 65-6 35-6 20-5 31-7 51-8 50-7 54-3 47 Montpellier, -j^' Paris, Lyons, 8-S 8-5 63-1 58-2 9-7 9-9 40-5 40-7 9-8 9-5 78-2 60-1 8-4 9-0 90-6 71-14 4-5 6-5 23-3 41-9 (T. 7-3 9-8 9-5 13-0 17-0 20-6 22-9 21-9 19-9 15-0 10-4 8-1 iR. 62-7 78-2 60-1 51-5 49-2 16-5 5-S 21-6 87-5 187-5 110-5 70-7 4-8 8-4 9-0 13-2 18-0 21-0 23-4 21-4 18-6 13-2 7-9 5-7 78-8 90-6 71-14 39-4 89-0 44-3 21-9 40-3 93-3 142-4 93-0 62-5 p„,i JT. 2-0 4-5 6-5 10-1 14-2 17-2 18-9 18-5 15-7 11-3 6-5 3-7 "' ■ (R. 35-8 23-3 41-9 32-5 51-2 42-3 48-9 38-9 52-5 51-5 40-7 32-4 (T. 3-6 6-4 6-7 12-7 15-4 20-0 21-3 19-7 18-2 11-7 6-5 2-1 ■(R. 34-0 29-4 52-0 43-8 76-0 79-7 50-6 04-3 66-2 99-2 52-7 3S-4 Vital Statistics. — The marriage-rate in France for the ten years ending 1887 was 14-9 ; the birth-rate, 24-5 ; and the death- L 162 CENTEAL AND WESTERN EUROPE. rate, 22*2, or 1 per 1000 higher than that of England and Wales. The extraordinarily low birth-rate may well give rise to reflection. The following was the monthly mortality in Trance for the period 1855-61:— Jan. Feb. jMaroIi. April. May. June. July. Aug. Sept. Oct. 1090 1141 1094 1026 936 855 876 1016 1073 983 Nov. Dec. 950 = 12,000 The winter is thus the season of the highest mortality in France ; but along the coast of the Mediterranean and in the marshy districts the mortality is autumnal. Pathology. — The distribution of malaria in France is chiefly maritime or fluviatile, and has an evident relation either to salt or fresh water marshes, properly so called, or to simple water-logging of the soil. Where it appears in the interior, and not along the course or the banks of any great river, it is always in marshy plains or damp valleys. Its presence is thus associated with stagnant water in the soil rather tlian with climate ; but its intensity, as measured by its fatality, increases as the temperature rises. It is thus more severe, other things being equal, in the south than in the north — along the Mediterranean than along the Channel. The deaths from intermittent fever for the whole of France formed, according to Lombard, 6 "30 per 1000 of the total deaths in the years 1855-57. The following table will serve to indicate in a rough way the incidence of malaria in France generally : — Dlstribution of Admissions from Malarial Fevers in each Corps d'Armee FOR THE Quinquennial Period 1875-79. ^ Algeria, Marseilles, Montpellier, Government of Paris, Bordeaux, Nantes, . Clermont, Eennes, Limoges, Tours, . 165 22 17 14 12 10 9 8 Amiens, Le Mans, Bourges, Orleans, Lyons, . Eouen, ) Chalons, ) Lille, . Besan^on, 6-8 6-4 5-4 4-9 4-0 If we examine the distribution of malaria in detail, beginning with the river basins, we find that the basin of the Somme itself, and the country to the north and south of that river, are generally healthy. Dr. Arnould, of Lille, in a private letter which I have seen, says that malarial fever and dysentery are almost unknown in Lille, but that fever exists in Dunkirk and St. Oiner in the districts of AVaterinques and AVatergands — veritable polders, but they are neither very common nor very grave. ^ Mnrvand, Annates (Vhygiine puh., Nov. 1883. FKANCE. 163 The basin of the Seine is more distinctly malarious. Tlie mouth of the river, on its right bank, says ]\I. Gilbert, has been ravaged at different epochs by marsh fever. During the past twenty years important drainage works have considerably reduced the number of cases of paludism. The comparative prevalence of malaria in Paris, as compared to other parts of France, is shown by the table given above. The figures represent the Government of Paris as being as severely affected as Bordeaux, which is a decidedly malarious locality. This is scarcely what we might have expected from the latitude and surround- ings of the capital. According to this table, Paris occupies the third place in the list of malarious stations, following Marseilles and Mont- pellier, and standing before Nantes and Clermont. The comparative prevalence of malarious affections in Paris may arise from temporary conditions connected with the building of the new fortifications. We know that disturbance of the soil in Paris is by no means free from danger. An epidemy of intermittent fever broke out here in the quarters of the Temple. La Villette, and Pantin, in 1811, while the canal of St. Martin was being dug. In 1840 an epidemy of the same nature occurred while the excavations for the former forts were being made.-^ The following table, for which I am indebted to a correspondent, gives the deaths from malarial fever and malarial cachexia in Paris from 1880 to 1888: — Deaths from Malarious Diseases, and Ratio per Million of Population. Years. Number of Deaths. Intermittent Fever. Ratio per Million. Number of Deaths, Malarial Cachexia. Eatio per Million. Total. 1880, 1881, 1882, 1883, 1884, 1885, 1886, 1887, 1888, 15 14 10 8 9 11 5 11 5 5-57 5-20 3-71 2-97 3-34 4-08 1-86 4-08 1-86 8 4 6 6 11 1 5 3 2-97 1-49 2-22 2-22 4-08 0-37 1-11 1-86 1-11 8-54 6-68 5-94 5-20 7-42 4-45 2-97 5-94 2-97 Mean of Nine Years, 88 3-63 47 1-91 5-56 It will be seen that the proportion of deaths per million of the population for the nine years included in the table is, on the average, ^ Colin, Fiivres intermittentes, Paris 1870, p. 16. 164 CENTEAL AND WESTERN EUEOPE. 3 "6 3 per million for malarial fever, and 1"91 for malarial cachexia, or a mean average death-rate for malarious diseases of 5 "5 6 per million. Under what conditions of soil are these fevers developed in Paris and its neighbourhood ? This question is partly at least answered by Dr. Eives in the instance of the quarter of Maison- Blanche. He informs us that the insalubrity of this quarter arises essentially from its situation on the banks of the Bievre, and is manifested by the frequency of paludal affections. The soil is a permeable calcareous alluvium resting on clay. The fever is mostly confined to the bottom of the valley, but reaches altitudes of 25 metres in those houses which are not shut off from the valley. Dr. Eives observed 131 cases of malarial fever in this quarter from 1878 to 1886, of which 96 were of the normal intermittent type, 32 abnormal, and 3 pernicious, of which last-mentioned form 1 died.^ Intermittent fever was epidemic in the department of Aisne, with its 5800 hectares of marsh, in 1866, and again in 1868 (Eey). Proceeding southwards, we come to the valley of the Loire, which forms an extensive habitat of endemic fevers. They are met with in varying degrees of frequency and severity from the mouth of the river up to Tours. Prom the table of deaths in the French army, intermittent fever would appear to be more common at Nantes near the mouth of this river than at Tours in the interior. This can readily be understood, from the fact that the department of Loire-Inferieure ranks second in respect to the area of marsh land. Beyond Tours, in the department of Loiret, there is the Sologne, a district of evil repute for malarious diseases. According to Armand, the marshes of La Sologne, covering a fourth of the soil, are artificially formed by barriers, and stocked with fish. At the end of three years they are emptied by raising the sluice, and the fish are collected. The following year they sow the soil, aud when the harvest is gathered they recommence as before. In 1793 the Convention decreed the suppression of these artificial marshes (£tangs). The measure was carried into effect ; but the Convention soon discovered that, under the pretext of ameliorating the hygienic condition of the inhabitants, they had simply condemned them to starvation. The decree was recalled.^ Of late years much has been done to improve the health of this district. In the department of Indre, between Chateauroux and Leblanc, is the feverish and swampy plain of La Brenne, situated in the valley of the Indre, a tributary of the Loire. The department of ^ Rives, ijtude des Causes d'insalubriti speckdes an Quartier de la Maison-Blanche, Paris 1887. - Annaiid, Med. et Hyg. des Pays Chauds, p. 453, Paris. FEANCE. 165 the Indre, where this focus of malaria exists, is not given by Lombard as one containing marsh. Bertrand gives the following account of this region : — " Brenne," he says, " comprises the three cantons of Blanc, Tournon-Saint-Martin, and Mezieres, and a part of that of Saint Gaultier. The soil is clayey and destitute of vegetable mould. The water, not being able to penetrate the tuff, settles in large pools. Everywhere there are large uncultivated plains, named BrancUs, covered by pools and marshes. Intermittent fevers ravage the country, and often exhibit the gravest forms." Angers and La Fleche, to the north of the Loire, the latter occupying the valley of the river Loire, are also feverish. In the eastern part of the Loire basin, between the Upper Loire and the Cher, is the department of Cher, a calcareous plateau liable to inundation from the numerous streams. It is subject to malarial fevers, but of a mild type, generally quotidian, which are met with chiefly in the autumn and spring. The valley of the Garonne, from its mouth through the depart- ments of Gironde and of Lot et Garonne, is under the malarious influence, which, however, does not reach, or only in a mild degree, the upper course of the river. As an example of the causal con- nection between a wet soil and the production of malaria, Hirsch quotes the following from Gentrac : — " The department of the Gironde is divided by the Garonne into two almost equal parts, a north-eastern, with higher elevation and a thoroughly dry soil, and a damp south-western division, the southern extension of which is the plain rising somewhat towards Landes, with the highly malarious Bordeaux at the northern apex of the triangle. Of 484 patients admitted for malarial fever into the Bordeaux hospital during four years, 105 came from the arrondissements on the eastern bank of the Gironde, and 379 from those on the western; but inasmuch as the population of the first division was 254,150, and that of the second only 179,429, the ratio of sickness in the whole population was in the former case 1 in 2420, and in the latter 1 in 473. We come now to the Ehone valley, where there exist many foci of malaria. The delta of the Ehone, comprised in the department Bouches-du-Pthone, contains, according to the estimate given above, 15,270 hectares of marsh lands. This region is extremely un- healthy, especially at Aigues-Mortes, Martigues, Marignane, and the Etang de Berre. The Camargue is, in fact, probably the most unhealthy region of France. In the department of Vaucluse the Palus de Monteux is also noted as specially malarious. From this point up to Lyons, although less intense than in the delta, malaria is still met with along the whole basin of the river. Lyons itself. 166 CENTKAL AND WESTEEN EUEOPE. situated at the junction of the Saone and the Ehone, is certainly not free from the disease. We have the authority of Marmy and Quesnoy for stating that malarial diseases are common in the more humid suburbs of the town, where, towards the end of summer and in autumn, they sometimes assume a pernicious character. The army returns do not, however, give an unfavourable view of the salubrity of Lyons. In 1872, 2 '4 per cent, of the admissions into the civil hospitals were for malarial fever, and of these only four died. To the north of Lyons are the marshy plains of Dombes and Bresse, between the Saone and the Ain, which are highly in- salubrious. Nepple has given an admirable description of the physical character of this region, its inhabitants, and diseases, which has lost none of its value by the changes which may have taken place in later times. We interrupt for a little our general survey in order to take a glance in passing at the picture of Dombes as drawn by ISTepple.^ He divides La Dombes into three zones : {a) the country of ponds (Etangs) ; (b) the region of slopes ; (c) the plains. The region of Etangs covered, when he wrote (1835), two-thirds of the plateau of the Dombes, which occupies the centre of the depart- ment of Ain. The plateau is level, the soil an impermeable clay, which would have converted the whole region into a vast un- inhabitable marsh, were it not that the inhabitants have drained off the water into the depressions, thus forming small lakes or ponds. These are stocked with fish, and after about two years the ponds are drained, the fish secured, and the bed of the lake ploughed and sown. Besides these ponds, there is to be met with an infinite number of small marshes, formed and maintained by the rains or by the overflow of the ponds. The banks of the shallower ponds, and the pits dug in preparing these reservoirs, also form marshes, in which myriads of insects, worms, toads, and frogs multiply. The smell from these marshes is extremely heavy and sickening in summer. The atmosphere of the Dombes is hot and humid during the day. The north-east wind from the mountains begins to blow at night, causing, after sunset, a sensation of cold, and condensing the vapours into an abundant dew. During autumn and winter, unless when there is frost, thick fogs envelope the country. The Dombiste {i.e. the inhabitant of the Dombes) is recognised at the first glance by his pale complexion, his drawn-out, emaciated, or puffy features, his flabby muscles, his slow step, a certain in- dolence in all his movements, and his swollen belly. His intellectual ^ Nepple, Traite sur Uxfitwes remittentes el intermiUenies, Paris 1835. FIIANCE. 167 faculties are limited. He is indifferent as to his condition, and wants moral energy. The strangers that come to assist in reaping the harv^est often carry back with them the germ of interminable fever. The cattle also degenerate in the zone of Etaugs ; horses thrive better. The region of the Etangs terminates abruptly towards the south by a steep slope. This region is comparatively healthy, except in some narrow humid valleys. The village of Montluel had already attained a moderate degree of salubrity when Nepple wrote. The plains towards the Ehone are divided into two portions : 1. an arid, stony district of a reddish soil, destitute of trees or shrubs ; 2. a smaller district, fertile, well-wooded, and populous. The scanty population of the first district is not subject to fever except in those places where the overflow of the Ehone has given rise to pools and marsh. In such localities the disease is endemic and the natives cachectic. In the second or fertile district, comprising Nievres and Thil, surrounded by marshes, some are always covered with water, while others are constantly dried during the heat of summer. These villages furnish a great number of fever cases, especially of a remittent type, during the months of August, September, and October. The inhabitants do not suffer to the same extent from the malarial cachexia as do the inhabitants of the first zone. This is accounted for by N'epple, partly because they live in more comfortable circumstances, and partly because the marshes do not arise from the clayey nature of the ground, as in the zone of pools, but from the overflow of the river. As regards the influence of the weather upon the prevalence of fever in the Dombes district, the following are the conclusions of Xepple: — 1st. In very warm years fevers are very violent, and often begin by the remittent or even the continued type. 2nd. When the temperature of summer is very variable or humidity is dominant, these diseases, although less severe, are more frankly intermittent, and very much more prevalent. In the hospitals of Chatillon-les-Dombes and of Chalomont, in the centre of the zone of ]£tangs, malarial fevers formed two-thirds of the admissions. At Montluel, on the slopes, they form about three-sevenths. Of 678 cases of fever treated during 54 months in the hospital at Montluel, the forms and types were as follows : — f Quotidian, . . 198 Intermittent, . . 386-!^;;*!^"^"^^; ; ; ^H L Pernicious, . . 14 Remittent, . .195 Continued, . . 97 168 CENTRAL AND WESTERN EUROPE. The endemy becomes less severe as we follow the Saone upwards. BesanQon, although not free from fever, is as regards malarial fevers the healthiest station occupied by the French army. Outside these river basins, we may note that the department of Puy-de-Dome, which, according to Hertz, " abounds in swamps," is far from salubrious. The number of deaths from malarial fevers among the troops stationed at Clermont in this department, is abundant evidence of this fact. The moist plain, again, between the Cantal and Forez ranges in Auvergne, is also notably malarious. Let us now cast a glance at the distribution of the disease in the maritime provinces. Malaria is little known in the departments of Pas-de-Calais, Calvados, Manche, and Cotes-du-Nord, although the first and third of these districts contain extensive tracts of marsh. Calvados, so far as we can learn, is the only one of them that can be called malarious. Nor does the disease become at all common until we reach the mouth of the Loire. Finistk^e and Morbihan during last century were very unhealthy, but drainage and other sanitary works have led to a great improvement in the public health. We are informed that malarial fevers and dysentery are rare in Finistere. At Brest, it is true, the admissions into hospital for these diseases are rather numerous, as will be seen by the following table, but the most of the patients come from the Colonies : — Malarial Fever. Dysentery and Diarrhoja. Admissions. Deaths. Admissions. Deaths. 1885, . . 257 7 463 11 1886, . . 333 44 8 1887, . . 136 86 7 1888, . 86 160 7 Vendee is moderately malarious. The Charente - Inferieure, which is the most marshy department in France, is highly malarious. Lombard gives the deaths from pernicious fever at Eochefort, in comparatively recent years, as 12-1 per 1000 of total deaths. Eochelle, in the same neighbourhood, also suffers to a considerable extent from malaria. The departments of Gironde and Landes are, like Charente- Infdrieure, low, level, and sandy, with numerous lakes, pools, and marshes. The whole coast line of this region is a hotbed of fe\'er. Bordeaux, as we have already said, is decidedly malarious, but the coast country generally is much more so ; although, of late years, drainage and planting have here as elsewhere effected a considerable improvement in the health of this unpromising locality. FRANCE. 169 In some districts where these works have resulted in almost banishing fever, special circumstances have led to its reappearance. The study of such cases has such importance in relation to the etiology and prophylaxis of malaria, tliat I may cite the following instance : — " In the report of the Council d'Hygiene de la Garonne, reviewed in the Annalcs cVhygicnc iniblique for 1879, it is stated that intermittent fever, which had almost disappeared from the Commune d'Ares, had again begun to rage there with great severity. A commission, appointed to investigate the causes of this recrud- escence, ascribe it to a number of causes, which have all this in common, that they led to excess and stagnation of water in the soil. The danger, on the other hand, from the drying-up of lakes or ponds, is illustrated by what occurred at Bordeaux in 1805, when the ponds at the west end of the town were drained. The result was, that an epidemy of ague broke out, and seized 12,000 of the in- habitants, of whom 3000 died in the space of five months.^ The Mediterranean coasts of Aude, Herault, Gard, Bouches-du- Ehone, and Yar, with their numerous lagoons, present many active foci of malaria, which are rendered more intense on account of the high summer temperature, and the dryness of the summer season. AVe have already noticed the extreme insalubrity of the department of the Bouches-du-Ehone, which, according to Colin, was during the Eoman period covered by flourishing cities and rich and well-cultivated fields. In 1866 malarial fever was epidemic in this department. The coasts of Aude are flat, the soil mostly calcareous and fertile. It contains a considerable area of marsh, and several lagoons. Herault, watered by the river of the same name, and by the Orb and Lez, presents, along the shore from Agde to Vidourle, a number of marshy lakes united by the Canal-des-I^tangs, and communicating with the sea. The department of Gard to the east presents the same features, the coast line being fringed with extensive marshes. Var differs considerably from the other depart- ments along the coast. It is well watered by numerous streams, but contains little marshy land. Malarious diseases are endemic along the coast of all these departments and for varying distances inland. At Narbonne, which is the centre of the marshy regions of Aude and Herault, pernicious fevers were credited by Lombard with 22*4 per 1000 of the deaths from all causes. At the present time the mortality is less. Toulon furnishes 13 per 1000 ; but whether they are contracted on the spot is perhaps doubtful. ^ Trans. Epidem. Soc. 1856. 170 OENTEAL Ind'WESTEEN EUROPE. A few particulars respecting Narbonne will serve at once to illustrate the conditions under which malaria is met with alonej the Mediterranean coasts of France, and also to exhibit tlie steps by which a healthy and populous country became infested by malaria, as well as the means by which it has been enabled again to make headway against the infection.^ The town of ISTarbonne, with a population of 13,000, is situated on La BoMne branch of the Canal clu Midi. The soil is alluvial, with underlying clay. The annual mean temperature is 16°. Spring has a mean temperature of 15°, summer of 25°, autumn of 17°, and winter of 7°. In summer the thermometer rises to 33° or 34°, and sometimes even several degrees higher. The summer season is generally very dry. Nearly half the rain falls in autumn, the other half in winter and spring. The rains tend to come in torrents, with considerable intervening periods of dry weather. Under the Eoman Empire ISTarbonne was a prosperous town, situated in a fertile and healthy country. The cutting down of the forests in the thirteenth century, resulting in the conversion of some of the salt lakes into marshes, others into plains, by the alluvial deposits washed down from the denuded hills, alterations in the course of the river Aude, and other circumstances leading to more frequent inundations of the plains, were successive steps on the downward path. Towards the end of the fourteenth century (1398), we are told that the inhabitants suffered greatly from want of water during the dry weather of summer, the river having lost itself in the mud before reaching ISTarbonne. In spring, when the snow melted, and again in autumn, during the heavy rains, the country became inundated to such an extent that the inhabitants were confined within the walls of the town, and could not even communicate with the neighbouring villages. The sand collecting towards the mouth of the river formed barriers along the shore, separating the greater part of the ancient lake of Kubrensis from the sea, converting it into a marsh, which was alternately filled during the rains, and left, in parts, exposed during the dry summer weather. As these changes in the physical condition of the country progressed, its ancient salubrity disappeared, the fever - stricken population diminished in numbers, and the prosperity of the town departed. The surrounding country became in many parts a desert. The efforts that have been made for more than a century, at first somewhat spasmodically, to retrieve the errors of the past, have ^ Martin, Ei^miaurla Topo(jraphie Phydque et Medicate de la Ville de Narhonne, Montpellier 1859. FEANCE. 171 not been without success. Marshes have been dried, the admixture of fresh and salt water has been prevented, the inundations have been limited, deforestation has been arrested, the clearing of the beds of the streams has been carried out, and agriculture has been encouraged. Gradually, as these measures have been proceeding, the public health has improved, and if fever has not been banished, it has diminished in prevalence and above all in virulence. In 1782 we read of an epidemic of la fievre iiudignc pourpr6c. The purple spots covered the whole body. The fever was high, and there was sometimes considerable sweating. The disease was marked by subsultus tendinum, convulsive movements, and by a dry tongue covered with a black or yellow crust. The colour of the skin became livid and the respiration embarrassed. The treatment, by emetics at the commencement, followed by a decoction of chinchona and tamarinds, was so successful wlien the case was seen early, as to make it doubtful whether this was really an epidemic of typhus or of a special form of malarial fever. Some years later there was another epidemic of fievre ijeUcMaU remittente pe7-nicieuse. The remissions were well marked at the outset of the disease. After the seventh day typhoid symptoms appeared. The disease generally ended by a crisis on the eleventh or thirteenth day. Sweat- ing, or an abundant discharge of urine, led to a favourable termina- tion. When a critical diarrhoea came on the patient was not free from danger. A similar fever was noticed several times towards the close of last century, but not, so far as I know, during this century. Intermittent and remittent fevers of the ordinary kind have been frequently epidemic, notably in 1810 and in 1825. We shall mention a few of the circumstances which have in recent years been found to give rise to outbreaks of fever. Inundations of the plains are often followed by an increase of malarial fever. Eice culture was attempted some years ago at Mandirac, near the city. The greater part of the labourers were attacked with grave intermittents. The manager of the estate lost several members of his family, and the culture had to be abandoned. The commune of Ouveilhan, in the environs of Narbonne, has been ravaged with murderous epidemics of fever each time that its salt lake has received fresh water, whether from extraordinary rainfalls or other causes. Conversely, the salt marshes of Bages and Sigean, near the town, have become less unhealthy since the fresh water from La Eobine has been prevented from flowing into them. As a consequence of the works on the railway du Midi, many of the labourers entered the Narbonne hospital suffering from per- nicious fevers and typhoid, neither of which prevailed in the town 172 CENTKAL AND WESTEKN EUEOPE. at that time. This observation has an important bearing upon the nature of the typhoid fever of warm climates. At the present day malarial fever at ISTarbonne is by no means severe. The spleen is seldom affected. Pernicious cases, however, of the algid and choleraic forms occur. Masked ague is by no means uncommon. The following table, which gives some of the principal death- causes from 1854 to 1857, illustrates the pathology of ISTarbonne and its neighbourhood. The total deaths during these four years numbered 1775 : — Diseases. Typhoid Fever, Intermittent Fevei Cerebral Fever, Continued Fever Enteritis, Diarrhcea, Dysentery, . Plitliisis, General Dropsy, Liver Disease, Spleen Disease, Number of Ratio per 1000 Deaths. of Total Mortality. 185 104-2 26 14-6 33 18-6 9 5-0 103 58-0 78 43-9 27 15-2 100 56-3 14 8-0 14 8-0 2 1-1 We shall only add the distribution of 67 cases of malarial fever admitted into hospital from 1886 to 1888, as transmitted by Dr. Martin to Dr. Monty : — Jan. Feb. jVIarcli. April. May. June. July. Aug. 2 2 1 3 3 2 6 10 Sept. 13 Oct. 8 Nov. Dec. 4 3 It will be observed, as bearing upon the health of this region, that the greatest number of deaths from malarial fever among the French troops occurred in those stationed at Marseilles and Mont- pellier, and these are certainly by no means the most malarious localities in this region. Maurin states that malarial fever has been more frequent in Marseilles since the opening of the canal convey- ing water from the Durance. This result he ascribes to the infiltra- tion from the canal soaking into the subsoil. Typlioid Fever is a widely spread and fatal disease in France. The average death-rate in 195 towns, with a total population of 8,575,576, in the three years 1886-88, was 593 per million.^ The official statistics '^ do not include towns with a population under 10,000, nor do they include the rural districts, in which a very large part of the French population are located. We are thus without data for estimating the average typhoid death-rate of France ' Statistique Scmitaire : Mortal'de par Maladies Epidimique-f, Mclun 1880. - Statisiiqvr Hanitairc dex Villes de France et d'Alfjdrie. from 1887, Paris 1889. Statistique Sanitaire dans /es Villes de France, from 188G, Paris 1887. FRANCE. 173 as a whole ; but, so far as the ground is covered by the returns, it would appear that the mortality from typhoid fever is about three times as high as in England. The higher mortality from typhoid fever in France is confirmed by the military returns. The average mortality among the French troops from 1862 to 1875 was 2-23 per 1000,1 or ^bout twenty times as high as that of the troops in England. The following table gives the death-rates in the towns arranged in six groups, according to population, for the three years 188 G, 1887, and 1888:— Eatio r Deaths to 10,000 living. Groups of To-svns. Total Population. 1886. 1887. ! 1888. Average. 38 Towns, with 2,260,945 to ) 5,768,888 5-3 6-7 5-0 5-67 41,007 Inhabitants, . . ) 30 Towns, with 39,600 to 23,491 | 868,590 6-8 7-1 7-0 6-97 Inliabitants, . . • i 41 Towns, with 22,781 to 17,024 ( 810,688 5-3 6-4 5 "5 5-73 Inhabitants, . . • ) 34 ToM-ns, with 16,857 to 14,014 ( 516,559 4-6 6-3 6-5 5-83 Inhabitants, . . ■ \ 31 Towns, with 13, 992 to 11, 620 } 386,566 5-S 9-1 7-1 7-33 Inhabitants, . . • \ 21 To^^-ns, with 11,542 to 10,030 | 224,285 5-4 6-6 5-0 5-67 Inhabitants, . . ■ \ Totals and Means of 192 Towns, 8,575,576 5-4 6-8 5-5 5-93 It will be seen from these figures that the minimum typhoid mortality falls on the two extremes of the scale, that is, on towns with a population above 41,000, and on those with from 11,542 to 10,000 inhabitants. The highest typhoid mortality is met with in the group of towns with a population between 13,992 and 11,620 ; and the next highest in the second group, with a popula- tion of 23,000 to 40,000. The relation of typhoid fever to the size of the towns is not uniform. The mortality in the great towns varies considerably from year to year, and in different cycles of years, according to the absence or presence of epidemic outbreaks. The following table gives the average typhoid mortality in some of the principal towns in the north, centre, and south of France for 1886-88 : — 1 Colin, De la fievre typhoide dans Varmee, Paris 1878, and Archiv. rh med. iiavale, vol. xxxii 174 CENTRAL AND WESTERN EUROPE. Average Death-rate from Enteric Fever in certain Towns in the North, South, and Centre of France, 1886-88. North of Latitude 48°. 1 ! Between Latitudes 48°-45°. South of Latitude 45°. Towns. Death-rate per 1000. Towns. Death-rate ' per 1000. Towns. Death-rate per 1000. Lille, . . Havre, Paris, . . Nancy, . Brest, . . Troyes, . 0-17 2-33 0-45 0-52 0-97 0-88 Nantes, . Dijon, . . Besan9on, Rochefort, Ijiinoges, . Lyons, . . 0-49 0-38 0-99 0-76 0-31 0-29 Bordeaux, Toulouse, . Pau, . . Cette, . . Marseilles, Toulon, . 0-71 1-02 0-41 1-17 1-10 0-56 The disease was unusually prevalent in Havre during these three years. In Brest enteric fever is endemic in a severe form, causing, according to Borius, 1 per cent, of tlie total mortality.^ Bourges, in the centre of France, the lower parts of which are exposed to marsh miasm, is said to have an average typhoid mortality of 1-8 per 1000. It will be observed that most of the towns situated in the south of France suffer very severely from typhoid fever. Lombard con- cludes, from his analysis of the returns of 1855, 1856, and 1857, that the number of deaths from typhoid increases as we advance from north to south, or from west to east. His statement will be seen to be supported by the distribution of the disease in 1886 : — Average Death - rate per Million Living in the 222 Towns of France, HAVING a Population of 10,000 Inhabitants and over, in the different Geographical Regions of France in 1886. Region. Population. Enteric Death-rate. Region. Population. Enteric Death-rate. North, . . East, . . . North-East, South- East, South, . . 4,091,053 1,034,358 471,472 916,736 370,756 400-4 438-9 612-9 823-5 1070-8 West, . . North-West, South-West, Centre, . . 593,886 446,966 642,349 330,567 442-S 724-9 663-2 529-4 The decreasing frequency of the disease as we attain higher latitudes, even under what may be assumed to be similar conditions of age, mode of life, and social condition, is perhaps better illustrated by the typhoid mortality among the troops, as given in the follow- ing table compiled by Marvand," who remarks that the frequency ^ Archiv. di mid, nav. vol. xxxi. p. 310. ^ Annates d^Jij/fjicne ]wh., Nov. 1883. FRANCE. 175 and gravity of typhoid fever in the French army depends in the main on two conditions, viz. tlie latitude and climate, and the greater or lesser agglomeration in the great centres of population. It will, howevei', be observed that, as among the civil population, the mortality from typhoid among the troops is not determined entirely by the size of the garrison town : — PuoroRTiON OF Deaths from Typhoid Fkveu teu 1000 ix the diffekent Coiirs d'Aumee, 1875-79. 1. XVtli Corps (Marseilles), . 5-1 2. XlXth „ (Algeria), 5-0 3. XVIth ,, (I\Iontpellier), 4-8 4. Government of Paris, . . . . 4-7 5. Xlth Corp - (Nantes), 4-4 6. IVth ,, (Le Mans), 3-9 7. Ilird „ (Rouen), 3-8 S. Xth ,, (Rennes), 3-0 9. Xlllth ,, (Clermont), . 3-1 10. XlVth ,, (Lyons), 2-7 11. Ylth ,, (Chalons), 2-6 12. I Xth ,, (Tours), 1 2-5 13. XVIIth „ (Toulouse), ) 14. Ilnd ,, (Amiens), 2-4 15. Xllth ,, (Limoges), 2-3 16. Vth „ (Orleans), } 1-7 17. Vllth ,, (Besan^on), \ 18. XVIIIth „ (Bordeaux), 1-6 19. Vlllth ,, (Bourges), 1-3 20. 1st „ (Lille), 1-0 Having noticed the distribution of the typhoid mortality as regards latitude, longitude, and density of population, we shall nov/ give the monthly distribution of the deaths from the disease in Paris (1868-78) and in Marseilles (1886-87). Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Nov. Dec Paris,^ . 6-2 5-7 4-6 4-9 4-2 4-9 6-9 12-3 13-5 12-5 13-6 10-3 Marseilles,2 . 6-7 4-2 4-4 4-5 6-5 7-0 10-4 14-6 14-6 H'O 8-2 V'S Here, again, we find evidence of the distinctl}'' seasonal character of the fever. The rise appears to begin earlier, and the curve to be marked by a greater amplitude, in Marseilles than in Paris. It would appear that the regions most exposed to typhoid epidemics are not those where the disease is most prevalent as an endemic malady, but rather the reverse. The following is the order as regards liability to epidemics, beginning Avith those where they are most frequent: — 1. The north-east. 2. The south-east. 3. The north-west. 4. The south-west. 5. The Mediterranean coasts.^ Diphtheria and Croup caused an average death-rate, in 1 9 5 towns of France, of 637 per million living, for the three years 1886—88. Taking the same groups of towns, arranged according to size, as ^ Besnier, Union mid., Paris 18G7-79, quoted by Hirscli. - Statistique Sanitaire, Paris 1886 and 18S7. ^ Rey, Giographie rtiM., Paris 1872, 176 CENTEAL AND WESTEEN EUEOPE. have been already defined when dealing with typhoid fever, we find the mortality per 10,000 inhabitants on each group to be as follows : — Peoportion pee. 10,000 Inhabitants. 1886. 1887. 1888. Average. Group i., 6-1 6-7 6-9 6-60 Group ii., 5-7 5-1 6-7 5-86 Group iii.. 4-7 6-9 5-6 5-76 Group iv.. 4-1 7-0 6-8 6-00 Group v., 5-2 8-8 6-8 6-93 Group vi., 4-3 4-2 5-5 4-70 Means, . . 5-7 6-6 6-8 6-37 From this table we judge that in Erauce there is no fixed relation between the size of towns and the prevalence of diphtheria. During the three years with which we are dealing, the lowest death- rate was in the group of smallest towns, while the group standing next in order with only a slightly larger population had the highest death-rate. The largest towns also appear to have a heavy death-rate from diphtheria and croup. The following was the distribution of the disease in 1886 in 222 towns of France arranged according to geographical regions : — Regions. Deaths per Million. 1 Regions. Deaths per Million. North, East, . North-East, South-East, South, 579-1 458-2 339-3 . 963-2 604-2 West North-West, South-West, Centre, 447-9 872-3 242-8 435-6 Diphtheria, in the year to which the table refers, had two centres of intensity, — the north-west along the shores of the Channel, and in the south-east on the Lower Ehone, stretching east to Nice, and including the island of Corsica. Although diphtheria was some- what more prevalent in the south than in the north during that particular year, the small mortality in the south-west bordering on the Pyrenees forbids us to attach much importance to latitude as influencing the prevalence of the disease. Equally ambiguous is the influence of longitude. In the north it is the west that suffers more ; in the south it is the east. FRANCE. 17' We shcall add a table giving the death-rates from diphtheria in some of the principal towns of France arranged according to latitude : — Average Death-kate fhoji Diphtheria in certain Towns in the North, South, and Centre of France, 188G-88. North of Latitude 48°. Between Lat. 48° and 45°. South of Latitude 45°. Towns. Death-rate per 1000. To\vns. Death-rate per 1000. Towns. Deatli-rate per 1000. Lille, . . Havre, Paris, . . Nancy, Brest, . . Troyes, . 0-397 0-587 0-710 0-227 0-607 0-453 Nantes, . Dijon, . Besangon, Rocheibrt, Limoges, . Lyons, . . 0-600 0-31 0-247 0-553 0-407 0-400 Bordeaux, Toulouse, . Pau, . . Cette, . . Marseilles, Toulon, . 0-487 0-407 0-350 0-983 1 -390 1-130 The following was the monthly percentage of 3505 cases occurring in thirty-five of the largest towns in 1886 : — Jan. Feb. JIarch. April. 11-0 10-3 11-2 10-0 May. 9-4 June. July. Aug. Sept. Oct. Kov. Dec. C-3 7-0 5-4 3-9 6-9 7-0 10-4 Diphtheria is most fatal during the four months December to April, and becomes very rare in August and September. TVJioojnng-Cotigh is by no means fatal in France ; the average death-rate in the 195 towns from which we have returns during the years 1886—88 having been 180 per million. During these years the disease was most fatal in towns of the second and last groups. Diarrhceal Diseases. — Under the heading " diarrliee, gastro- enterite," are included infantile diarrhoea, cholerine, and dysentery. Omitting twelve towns for which the returns are incomplete, the death-rate from this class of diseases in 216 towns, having a total population of 8,998,514, was 2068-1 per million in 1887. The deaths from cholera, diarrhoea, and dysentery in England in 188-i were in the ratio of 1003 per million living, and including enteritis, 1122 per million; and it may be remarked that diarrhceal diseases were more than usually fatal in England that year. In estimating, however, the comparative frecj[uency of diarrhoeal diseases in the two countries, it must be remembered that the figures for England represent the death-rate of the whole country, while those for France refer only to towns with a population of above 10,000 inhabitants. In England the diarrhoeal death-rate of the towns is about twice as high as that of the country.^ If the same rule obtains in France, ■^ In 1884, for example, the death-rate per 1000 from diarrhr.eal diseases was for the twenty-eight great towns 1-21, and for the rural districts 0-72. M 178 CENTEAL AND WESTERN EUROPE. we should be warranted in concluding that diarrhoea is about equally- fatal in the two countries. Yet, on comparing the death-rate in Paris from this class of diseases with those in London, it will be found that the French capital has a mortality nearly twice as great, — the average death-rate in Paris (1886—87) being 1908 per million; that of London (1871-80) being 980 only. In 1887 the mortality from diarrhoeal diseases in five groups of towns with a gradually diminishing population was as follows : — 49 towns with a total population of 6,232,341 45 „ ,, „ 1,088,008 40 ,, ,, ,, 683,321 40 ,, „ „ 544,928 42 ,. ,, ,, 449,916 death-rate, 2-15 per 1000. ,, 2-12 ,, 1'62 1-72 1-89 The death-rate in the largest towns is very considerably higher than in the smaller ones ; but the disease, from some disturbing cause, does not decrease in regular proportion as the towns diminish in population. The following table gives the regional death-rate per million from diarrhoea in France for 1886 :^ — Regions. Deaths per Million. Eegions. Deaths per MUIion. North, East, . North-East, South-East, South, 1906 979 2619 532 812 West, North-West, South-West, Centre, 426 602 805 426 Diarrhceal diseases are excessively frequent in the north-east, although there are only three towns of any size included in this region, viz. Ptheims, Nancy, and Troyes. The position held by the north in this list, as compared with the south, is explicable by the number of large manufacturing towns it contains. Com- paring the figures for some of the towns in the south-east with those for other years, I am inclined to think that the figures given above rather understate than otherwise the diarrhceal mortality of this region. Dysentery. — Judging from the statistics of individual towns, dysentery is more fatal in the south than in the north. Thus we find the ratio of deaths from dysentery to 1000 deaths from all causes to be, in Nancy, 2-4 ; in Paris, 6-0 ; in Bordeaux, lO'l ; in Lyons, 18'2 ; in Narbonne, 15"2. In Lille, in the extreme north, dysentery is said to be almost unknown. Several of the localities where dysentery may be said to be endemic, such as Brenne, Sologne, and Medoc, are dis- ^ For the diffei-ent regions, population, etc., see Siatistique, Sanitaire des Villes de France tt d'Alydrie, Paris 1887. FRANCE. 179 tinctly marshy. The disease, however, is also prevalent in the southern towns of Alarseilles and Toulon, apart from marshy conditions. Epidemic dysentery, on the other hand, is comparatively rare in the south, Provence is seldom visited by these outbreaks. It is in the north-east and north-west of the country that these epidemics have chiefly occurred. It will thus be seen that the regions of endemic and epidemic dysentery do not correspond. Asiatic Cliolcra has been eight times epidemic in France, viz. in 1832, 183-i, 1837, 1848, 1850, 1853, 1867, and 1884-86. The following towns have enjoyed an absolute or relative exemption : Eouen, Versailles, Lyons, and Sedan. The Vosges in the north-east, and some of the mountainous districts of the south- east, have almost escaped during these epidemies. Typhus Fever can scarcely be said to be endemic in France, but it has broken out in an epidemic form several times during this century. Miliary Fever. — This mild form of " sweating sickness " has been frequently epidemic within limited areas in France during the past and present centuries. Hirsch states that no fewer than 194 epidemies of this strange malady have been recorded between the years 1718 and 1874. Many of these have been limited to a single village, or to a few localities. The north-east and extreme north have been the regions which have suffered most severely. Fjndemic Cerebro- spinal Meningitis. — France has formed the principal European centre of this deadly disease, which has been observed in numerous localities from 1839 to 1842, especially in the garrisons and garrison towns. A second epidemic period began in 1846 and continued until 1850. A third, but quite limited outbreak, occurred in 1867-68. Most of the epidemies have occurred in winter and spring. Smallpox is never entirely absent from the great centres of popu- lation. The average mortality in 195 towns (1886-88) was 0"34 per 1000. The disease is specially fatal in the large towns. Measles. — The average death-rate for the three years 1886-88 in the towns was 0'47 per 1000. The monthly distribution of the disease in Paris we have already given when treating of its seasonal prevalence in England. It is, upon the wdiole, most fatal in the large towns. Scarlatina gave an average annual death-rate of 0"97 per 10,000, or 97 per million, in 195 of the great towns for the years 1886—88, and which is rather less than one-seventh the average death-rate in England from this disease for the ten years ending 1880, which stood at 720 per million. Lombard remarks the low mortality from scarlatina in France during the three years 1855-57, 180 CENTRAL AND WESTERN EUROPE. and states that no severe epidemy of the disease was observed in France from 1830-70. Pneumonia is returned along with broncho-pneumonia in the official statistics of the French towns. In 1887 the deaths in thirty of the great towns, with a total population of 5,137,453, from these two diseases, were in a ratio of 2097'7 per million living.^ In ten towns north of the 48th parallel, with an aggregate population of 3,104,369, the ratio was 1919*9 ; in ten towns between the 48th and 45th parallels, with an aggregate population of 935,168, it was at the rate of 2033*8 ; in ten towns south of the 45th parallel, with a total population of 1,097,916, the ratio was 2655 per million ; from which we conclude that, in the great towns at least, pneumonia and broncho-pneumonia are more fatal in the south than in the north. In London the death-rate from pneumonia in 1884 was 1058 per million. Bronchitis, acute and chronic, was the cause of 171 1'7 deaths per million in 1887 in the thirty great towns already referred to, as against the London ratio (188 4) of 2291 per million. In the ten towns north of parallel 48 the proportion was 1660'8 ; in the ten towns between parallels 48 and 45 it was 1877*7 ; and in the ten towns to the south of parallel 45 it was 1 714*1. If, again, we compare the five towns in the north, Paris, Lille, Havre, Eouen, and Eoubaix, with Lyons, Marseilles, Toulouse, Bordeaux, and Nice in the south, we find that the deaths from bronchitis were 1535*9 in the northern, and 1864*1 per million in the southern towns. This points to the greater prevalence of bronchial affections in the south. Acute bronchitis, which is principally a disease of infancy and childhood, caused 669 deaths per million living in the ten northern towns, 719*6 in the towns in the middle zone, and 819 per million in the southern towns. There is thus a steady increase in the acute form as we advance from north to south. The ratio in the mortality from the chronic disease affecting adults is different. In the north it is 991 ; in the middle region, 1158*17 ; and in the south, 895*3 per million. The chronic form of bronchitis is tlius seen to be most prevalent in the centre, and least prevalent in the south of France. Combining the acute and chronic forms of bronchitis and pneumonia, the death-rate from these diseases, which include the ^ The following are the thirty towns upon whicli the calculations resiiecting pneumonia and broncliitis have been made : — (1) North : Paris, Amiens, Rouen, Havre, Rheims, Lille, Troyes, Nancy, Rennes, Brest. (2) Middle zone : Rochefort, Nantes, Angers, Bourges, Dijon, Besan9on, Lyons, Grenoble, Limoges, Rochelle. (3) Soutli : Bordeaux, I'ayonne, Pan, Toulouse, Nimes, Marseilles, Toulon, Aix, Nice, Avignon. FRANCE. 181 larger number of diseases of the respiratory organs, we find the death-rate for the tliirty towns with which we are deahiig to have been in the proportion of 3809 per milhou. The death-rate from bronchitis and pneumonia in London in 1884: was 3349 per million. Lombard found the deaths from bronchitis to form 4 9 '5 per 1000 of the total mortality in the north, and 32*2 only in the south, — a result different from that which I have arrived at from the returns of 1887. It is due to liis intimate knowledge of the subject to give his conclusions, although they do not agree with mine. Phthisis caused a mean death-rate of 4393 per million in 1887 in the three northern towns of Paris, Lille, and Havre ; in the four southern towns of Marseilles, Bordeaux, iSTice, and Ximes, the ratio was 3307 per million. Comparing ten towns along the coasts of the Bay of Biscay, from Brest to Bayonne, with ten along the eastern frontier, from Eheims to Grenoble, the mortality from phthisis is in the ratio of 2848"7 per million in the west, and 2818*6 in the east. These figures show a greater prevalence of phthisis in the north as compared with the south ; while, as regards the eastern and western regions, the proportions indicate no decided difference between the two regions.""" Goitre is endemic in the Alpine departments. Hirsch estimates the proportion of the goitrous at 1 "4 per 1000 of the total popula- tion of France, and that of cretins and idiots at 3'3. Leprosy. — A few isolated cases of leprosy are still met with on the coasts of the Mediterranean. Pellagra is endemic to some extent in the Gironde, Landes, Hautes-Pyrenees, Basses-Pyrenees, and Aude, where maize forms an important part of the food of the poorer classes. Scrofula is very common in many parts of France. According to the recruiting lists (1831-53), 1 per cent, of those examined suffered from this malady. It prevails most in the south-eastern departments of the Hautes-Alpes, Is^re, Pthone, Loire, Haute-Loire, Lozere, Cantal, and Aveyron ; to a less, but still to a considerable extent, it prevails in the departments of Saone-Loire, Allier, Puy-de-Dome, Creuze, Xievre, and Loiret, extending from Auvergne through Bourbonnais and Mvernais. Another focus of the disease exists in Franche Comte ; another in Haut-Ehin, Bas-Pthin, and Vosges ; while stiU another is met with in the coal districts of the Department du Xord. (Hirsch.) ^ Here are Lombard's conclusions respecting the distribution of phthisis in France : " La phthisic pulmonaire est a son maximum de frequence dans le nord compart au midi ; dans I'occident compart a I'orient, tandis qu'elle est plus rare au centre de la France qu'a I'occident ou sur les bords de I'oc^an ; elle est ^galernent moins frequente au midi et sur les bords de la Mediterran^e, sur les montagnes que dans la plaine, dans les petites que dans les grandes villes." — Op. cit. vol. ii. p. 519. CHAPTEE XV. SWITZEELAND. Geography. — Switzerland is situated between 45° 48' and 47° 49' N. lat. ; and between 5° 55' and 10° 30' E. long. It has an area of 15,721 square miles, with a population in 1886 of 2,940,602. The Jura range on the north-west forms its western boundary. The Alps run from east to west along its southern frontier, spreading their ramifications over more than half the area of the country. In the angle formed by the ranges of the Jura and the Alps lies the table-land of Switzerland, which has a mean elevation of about 1400 feet above the sea-level. The inhabited country consists of this table-land, and of the numerous mountain valleys drained by the Ehone, the Ehine, the Ticino, and their tributaries. The principal lakes are, — Lake Geneva (1218 feet), Lake Neuchatel (1437 feet), Lake Bienne (1427 feet), Lake Constance (1299 feet), Lake Zurich (1332 feet). Lake Lucerne (1430 feet). Lake Thun (1923 feet), and Lake Brienz (1946 feet). The altitudes of these lakes indicate generally the height above the sea-level of most of the more densely inhabited localities. The valleys of the Engadiue have an elevation of from 6000 to 6700 feet. The country is divided politically into twenty-five cantons, to which we shall have frequently to refer, but which we need not enumerate here. Some of these are industrial, others agricultural, while in many both manufactures and agriculture are carried on. Climatology. — The mean annual temperature is here deter- mined by altitude, and by the physical features of special localities. The following table gives the temperature of five stations according to altitude : — Locality. Latitude. Altitude. Metres. Jan. Temperature. April. July. Oct. Year Geneva, 46° 12' 408 0-1 9-4 19-3 9 '8 9-5 Gersaii (Lake Lucerne), 46° 59' 440 0-8 9-8 19-0 9-7 9-6 Zurich, . 47° 23' 470 -1-2 9-1 18-7 8-5 8-6 Berne, . 46° 57' 574 -1-8 8-6 18-2 8-1 8-1 St. Bernard, . 45° 52' 2478 -9-0 -3-3 6-2 -0-5 -1-8 SWITZERLAND. 183 In the Ehine basin the heavy rains fall in summer. In the Ehone valley the rains are pretty equally distributed over the spring, summer, and autumn seasons, winter being the period of minimum rainfall. In the Ticino the winters are dry and the autumns rainy. Vital Statistics. — The marriage-rate for the ten years ending 1886 was 13'9 ; the birth-rate, 29"3 ; and the death-rate, 21'7 per 1000. Switzerland thus ranks amongst the healthier countries of Europe. It may be remarked that the average death-rate of Switzerland is precisely the same as that of the Netherlands for the same period. So that the lowest-lying country in Europe is, as regards health, no worse off than the most elevated country. The seasonal distribution of the deaths in 1876 are thus given by Lombard: winter, 27'54; spring, 27"07 ; summer, 23'83 ; autumn, 21 '5 6. The effect of increasing altitudes upon the distri- bution of the mortality is to augment the proportions in the winter and the spring, and to diminish those of summer and autumn. Pathology. — In sketching the pathology of Switzerland, I shall rely mainly on late official returns ; but in respect to the distribu- tion of malaria, and many points connected with the influence of altitude, I shall follow the guidance of Lombard, who is the greatest living authority upon the diseases of Switzerland. Malaria. — From the elevated and mountainous character of the country, malaria is found to play a very insignificant role in the pathology of Switzerland, and this notwithstanding the existence of numerous marshy districts. The more extensive marshes on the plains have, however, been drained during this century, and the land so reclaimed placed under cultivation, with the result that ague has disappeared from many localities where it was formerly endemic. In 1885 only nine deaths are registered from malarial fever, which shows that the disease is of a mild nature. In the same year two deaths are recorded from "■ splenite." Basel, which is fertile and well cultivated, is free from malaria. The same may be said of Berne, although a few cases of fever occur in the Oberland, on the borders of Lakes Thun and Brienz, and along the banks of the Aar to Meyringen. The marshy valley of Travers in Neuchatel, at an altitude of about 2440 feet, furnishes a few cases of ague. Freiburg is almost entirely free from fever. At Villeneuve, in Canton Vaud, which is low, and liable to inundations, malarial fever is, to some extent, endemic. The cases reported from some localities, at altitudes of 4000 to 6260 feet, are supposed by Lombard to be imported. In Canton Valais the Ehone is enclosed, as it were, between two walls of rock, which raises the summer temperature of the valley, which is also liable to be 184 CENTEAL AND WESTEEN EUEOPE. submerged by inundations of the river. Here malaria is endemic in the plains, especially from St. Maurice downwards to Lake Geneva. Above St. Maurice fever occurs with varying degrees of frequency as high as Sierre ; but Haut-Valais is practically free from malaria. In Geneva the cases of fever now and again met with are mostly imported. In Ticino, on the Italian frontier, malarious diseases are much more common. Thus they are met with in the districts of Mendrisio and Lugano, and still more frequently in Bellinzona and Locarno. In the latter districts numerous malarious foci exist. It is stated that the great inundations of 1868, which covered all the marshes, put an end to the fevers, but they reappeared when the cuttings for the St. Gothard railway commenced. In the Levantine valley there are many malarious localities, and also at and near Malvaglia, in the district of Blenio, especially along the marshy banks of the Brenno. Enteric Fever. — The death-rate from enteric fever throughout the country (1881-85) was 291'0 per million, and 510 in the fifteen towns having a population over 10,000. During the previous quin- quennial period (1876-80) the death-rate in the towns was still higher, viz. 530 per million. These figures, which refer only to duly attested cases, show that enteric fever is far from rare in Switzerland. In considering the distribution of disease in Switzerland, the point of greatest interest is to trace in what way a given disease is affected by altitude. The problem, however, is not so simple as it seems to be, inasmuch as other factors, which affect health in a still greater degree, such as the sanitary condition of the towns and villages, the density of the population, and the occupations of the inhabitants, come in to complicate the problem. The purity of the air, which is associated in our minds with high altitudes, is the result of the absence of vegetable and animal con- tamination. The air in a densely-populated locality is not necessarily purer because the locality is so many thousand feet above the sea- level. Two elements alone seem peculiar to high altitudes, viz. diminished density of the air, and a decrease in the temperature. The free circulation of the air, which is characteristic of the mountain slope or elevated plain, is wanting in the confined mountain valley. In the same way, although the mountain slope is usually well drained, the mountain valley is often damp and marshy. When we inquire into the effects of altitude on the prevalence of a disease, it is only by comparing localities as much as possible under the same conditions that the influence of elevation upon health can be deter- mined. In a few places, as in Berne, it would seem as if typhoid fever is less prevalent in the higher districts. SWITZERLAND. 185 Thus Lombard points out that in the years 1864, 1865, and again in 1876, enteric fever was less fatal in the Oberland and in the Alpine regions than in the lower districts and in the valleys of the Jura ; but these differences, even if constant, may find their explanation in social conditions rather than in altitude. This view is rendered the more probable by the fact that in some cantons the reverse relation has been observed. Thus, in the Canton Valais, it is stated that "typhoid fever is met with as well in the low as in the high regions, where epidemics often develop with great intensity, as was observed some years ago in the most elevated permanently inhabited spot in Europe, the Monastery of St. Bernard, where several of the monks were successively attacked." The average enteric fever death-rate in the mountainous and agricultural canton of Uri (1885-88) was 222*0, and that of the Unterwalden, 250'0 ; while for the same period the ratio was 225*6 for Geneva, with its comparatively dense population and manufactur- ing industries. In Berne it was 185*8; in Basel (town), 254*5; and in Zurich, 86*8 per million. There is thus no evidence that altitude, apart from other conditions, exercises any influence on the prevalence of enteric fever ; and it is farther to be noticed that the agricultural suffered from this disease more severely than the industrial cantons during these three years. The following table gives the monthly percentage of 5080 cases observed during twenty-four years at Basel, from which it will be seen that enteric fever attains its maximum prevalence in the months of August, September, and October, and its minimum in March, April, and May : — Monthly Percentage of Hospital Cases of Enteric Fever at Basel. Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 6-5 4-7 5-1 3-0 5-6 10-4 9-8 11-8 12-2 12-3 9-2 8-3 As respects the influence of local conditions, Socin found that at Basel the low and elevated districts suffered equally, whether they were near to or at a distance from the Pthine. Di;phtheria and Croup. — Diphtheria did not occur as an epidemic disease in Switzerland until the second half of the eighteenth century. Hirsch notices a severe outbreak of the disease in the Simmenthal in 1752. In 1826 it was again prevalent in Geneva and Canton Vaud ; but we have no more accounts of its epidemic prevalence until 1854, when it broke out in Canton Zurich. Since the year 1881 it has taken a wider extension in Switzerland, giving rise to a mean mortality of 639*2 per million in the years 1881-85. During the same period the mortality in the principal towns from diphtheria 186 CENTRAL AND WESTERN EUROPE. and croup was in the ratio of 750 per million — falling in 1886-88 to 403 per million. Altitude has no appreciable influence on the prevalence of diphtheria. Thus, in Canton Grisons, the average death-rate from diphtheria and croup (1885-88) was 486-3; in Uri, 270-2; in Schwyz, 360-4 per million. These are hilly and agricultural cantons. In the industrial cantons of G-eneva the mortality was much less, viz. 173-8 per million; in Basel (town) the ratio was 341-6 ; and in Basel (country), 490-8 per million. These figures show that in Switzerland some of the elevated, sparsely-peopled districts suffer more than the lower -lying and densely -peopled industrial centres. Typhus is not endemic in Switzerland, although it has been several times epidemic in some localities during this century. In 1885 four deaths were ascribed to typhus. Relapsing Fever has never been observed in Switzerland. Miliary, or Sweating Fever, which has prevailed at different times in France, has never extended into Switzerland. Small'pox, Measles, and Scarlet Fever present nothing peculiar, either as respects their frequency, fatality, distribution, or seasonal incidence. During the five years 1881-85 measles and scarlet fever were considerably less fatal than in England ; and they press with greater severity on the town than on the country districts. WJiooping-Cough is moderately fatal, causing (1881-85) 240-2 deaths per million living, and in the principal towns 270 per million. Erysip)elas, which is specially common in the months of February, March, April, and May, caused an average death-rate of 53-0 per million from 1881-85. In 1885, Cerchro-spinal Meningitis is reported to have caused 26 deaths. There is room to doubt if the deaths were really caused by the epidemic disease, inasmuch as Switzerland has almost entirely escaped when the malady has been epidemic in France and Germany. Influenza has frequently been epidemic in Switzerland, and has proved as severe here as in other countries. Phthisis takes a leading place among the diseases of Switzerland, and it appears, taking the country as a whole, to be rather increasing than diminishing in frequency. In the five-yearly period 1876-80, the mortality from pulmonary phthisis was in the ratio of 1988 per million; in 1881-85 it appears to have risen to 2080 per million living. In the principal towns the rate for the former period was 3288-4, in the latter period (1881-85) it stood at 3230-3 per SWITZERLAND. 187 million, and in 1886-88 it fell to 3097 per million. If the phthisis mortality in the country generally has slightly increased, that of the principal towns has been diminishing, although it is still much in excess of that of the country. The following table by Hirsch, founded upon Milller's researches/ exhibits the influence of altitude and occupation on the prevalence of phthisis in Switzerland: — Table showing the Death-rate from Phthisis in Swiss Towns and Villages, ition in Metres. Industi-ial Cantons. Mixed Cantons. Agi'iciiltural Cantons. Averac 200-500 2-7 1-85 1-4 2-15 500-700 3-0 1-55 1-2 1-9 700-900 1-35 1-7 0-7 1-0 900-1100 1-5 1-9 1-9 1-2 1100-1300 2-3 2-3 0-7 1-9 1300-1500 1-4 0-6 0-8 1500-1800 1-3 0-7 1-1 2-55 1-7 1-1 1-86 The preponderating influence of occupation and agglomeration on the prevalence of phthisis, is evident from the fact that the average mortality in the industrial cantons at corresponding elevations is twice as high as in the agricultural cantons. It will be observed that, although there is a decrease in the death-rate from phthisis as we ascend to higher elevations, this decrease is neither regular nor continuous. There is, in fact, a zone situated somewhere between 900 and 1300 metres in which the mortality is higher than at greater or lesser elevations. The existence of this zone is confirmed by Lombard's researches, which, however, point to a steady decrease from 200 up to 899 metres, then a go-adual increase from 900 to 1499 metres, and finally a second fall in the phthisis mortality in the zone lying between 1500 and 1800 metres. This peculiar distribution cannot be accepted as an ultimate fact, although its explanation has yet to be given. Lombard remarks on the frequency of phthisis in the cantons consisting of elevated plains, such as the Grisons and Yalais, compared to wdiat is observed in the mountainous regions of Uri and the Unterwalden, and in the low districts of the Ticino. The Valais, however, has by no means a high mortality, even among the agricultural cantons, if we are to judge by the average death-rate during the four years 1885, 1886, 1887, 1888, when it reached only 938*5 ; Uri having a ratio of 1025*0 ; Unterwalden (high and low), of 1495*6 ; Grisons, of 2206*5 ; Schwyz, of 2390*0 ; and Freiburg, of 1654*0 per million. Of the mixed cantons, Ticino had a ratio of 1690*3; Zurich, of 2213*5; Aargau, of 2110*5; and Berne, of ^ Die Verhreitung der Lungeiischwindsucht in der Schiceiz, 1876. lo« CENTEAL AND WESTEEN EUEOPE. 2308-0. The death-rates in the industrial cantons also varied considerably; Basel (town), for example, had a ratio during the four years mentioned above of 3161-5; Geneva, of 3123*2; Basel (country), of 2120-0, and Neuchatel, of 2136-7 per million living. Perhaps the death-rate in the Grisons is augmented by the deaths of phthisical visitors to the Engadine ; but it is difficult to account for the high mortality of Schwyz, which is hilly and agricultural, with a sparse population. Pneumonia and Pleurisy. — The deaths from pneumonia in Switzerland in 1885 numbered 1669-'±, and those from pleurisy 186-4 per million living, — proportions very considerably in excess of those in England. Hirsch gives the proportion of deaths from pneumonia in the Upper Engadine (1861-70) at 1*8 per 1000, and in Geneva (1843-45) at. 1*3 per 1000. As regards Neuchatel, Dr. Cornaz found pleurisy to augment in frequency with the altitude, and pneumonia to be most common at medium altitudes ; but it is very doubtful whether these generalisations will stand the test of wider and longer investigation. It is remarkable that in 1885 the hilly cantons of the Unterwalden had the highest death-rates from pneumonia and pleurisy, — the proportions having reached 2471-8 and 429-8 respectively, — while Aargau, the least hilly of the cantons, followed next as regards the pneumonic death-rate with a ratio of 2387-4. Valais had the smallest death-rate from both diseases, viz. 776-4 for pneumonia and 88-4 for pleurisy. Geneva and Basel (town), situated at comparatively low elevations, and industrial, had death-rates from pneumonia of 1508 and 1587 per million respectively, — rates under the average of the country generally. In Switzerland, unlike England, the greatest mortality from pneumonia does not appear to take place in the great industrial centres. Acute Bronchitis furnished, in 1885, a death-rate of 486-4, and Chronic Bronchitis, of 999-4, or a combined rate of 1485-8 per million. There can be no doubt that both forms of the disease are less prevalent in the agricultural tlian in the industrial and mixed cantons. Taking acute bronchitis alone, the mortality per million in 1885 in six industrial cantons,^ with an aggregate population of 434,441, was 483*4; while in eight agricultural cantons,'-^ witli an aggregate population of 798,249, the ratio was 367-1. It is impossible to say how far the lesser prevalence of acute bronchitis in the agricultural cantons is owing to the greater purity of the air as compared to that of the industrial and mixed cantons, and how far ^ Outer Apponzell, Glaris, Neuchatel, Basel (town and country), Geneva. - Lucei'ue, IScliwyz, Unterwalden, Vaud, Freiburg, Grisons, Uri, Valais. SWITZERLAND. 189 it is to be ascribed to the out-door life of the agricultural classes, by which they become seasoned, as it were, to changes of weather. Acute affections of the respiratory organs attain their maximum in the montlis of February, ]\Iarch, and April, — the actual maximum, and a well-marked one too> occurring in March. The following is the distribution of 6633 cases, being the average for the five years 1881-85 : — Jan. Feb. March. April. May. June. July. Aug. Sept. Oct. Xov. Dec. 824 860 1000 857 057 406 266 213 220 305 409 610 A special form of disease, called " alpenstich," has been repeatedly observed as an epidemic in Switzerland. It is a pleurisy or pleuro- pneumonia accompanied with typhoid symptoms, and running a rapid course, often to a fatal termination. It has been most frequently observed in the higher valleys of the Alps.^ Umpliysema and Asthma are very common in the high regions — the asthma montanum is the name given to the disease. The prior of St. Bernard informed Lombard that all the inmates of the monastery become emphysematous and asthmatic after a certain number of years. Dysentery is practically unknown in Switzerland at the present day. I do not find a single case of death from this disease recorded for 1885 or 1888. Lombard states that epidemies of dysentery, which have been observed at long intervals, have been limited to the zone lying between 700 and 800 metres. The Enteritis of Infants caused a mortality in 1 8 8 6-8 8 of 1 1 2 9 "3 per million. The disease is considerably more fatal to males than to females. It is much less prevalent in the Grisons, in Uri, in Valais, and in the Unterwalden, than in Basel, Geneva, or ISTeuchatel. We may here safely acknowledge the favourable influence of altitude and its associated conditions in reducing the frequency of the disease ; but it is not very clear why Valais should have the low death-rate from infantile enteritis of 287'0, while the ratio for Unterwalden reaches 812*0 ; or, again, why Freiburg should have a higher enteritis death-rate than Geneva, and Schwyz one almost as high. Rheumatic Fever occasioned a mortality in 1888 of about 26 per million. This does not appear to be a high rate ; but, as the English returns combine rheumatic fever and rheumatism of the heart, no exact comparison is possible. In Geneva the deaths from acute rheumatism are much in excess of the average. Organic Heart Diseases caused, from 1881-85, an average mortality of 878*9 per million in the country generally. In the principal towns the rate was 1126 per million. Heart diseases are ^ Guggenbuhl, Der Alpenstich endemisch im Hochgebirge der Schweiz, Zuricli 1838. 190 CENTEAL AND WESTEEN EUEOPE. thus considerably more common in the towns than in the country; and amongst the towns, Zurich, Berne, Lausanne, and, above all, Geneva, show the highest death-rates from this class of affections. Cancer appears to be considerably more fatal in Switzerland than in England. Syphilis is reported to have caused 81 deaths in 1885, which gives a ratio of about 27 per million living. Scrofula gave rise in 1885 to 178 deaths, — a proportion of 60*8 per million living. It is stated by Lombard to be particularly prevalent in the low or moderately elevated regions, and on the slopes of the Jura and of the Alps, especially in connection with badly built and imperfectly ventilated dwellings and insufficient nourishment. Bickets caused 55 deaths, and Dictbetes 19*8 deaths per million living in 1885. Ancemia is not uncommon, causing about 95 deaths per million. Goitre and Cretinism. — Switzerland forms one of the great endemic centres of goitre in Europe. In 1868 the cretins were estimated to form 1"7 per 1000 of the population. The cantons of Uri, Valais, and Berne contain the largest number ; while Lucerne, IsTeuchatel, and Ticino are those that suffer least. Wherever cretin- ism exists, goitre is also endemic ; but the reverse does not hold good, for goitre is not uncommon in Geneva, while cretinism is rare. It is in the valleys of the Alps that both diseases are most common ; while those of the Jura enjoy almost a complete immunity. In the Upper Engadine, goitre and cretinism are little seen. The low plain country on the one hand, and the opener plains of the most elevated districts on the other, although not exempt, suffer less than do the narrow valleys of the middle zone. EUROPE. ♦ DIVISION III SOUTHERN EUROPE. CHAPTER XVL SPAIN AND PORTUGAL. Geography. — The Iberian Peninsula, comprising the kingdoms of Spain and Portugal, is bounded by the Pyrenees and the Bay of Biscay on the north, by the Mediterranean on the south and east, and by the Atlantic on the west. The combined area of the two kingdoms is 225,611 square miles. The central part is an immense plateau rising to the height of from 2000 to 3000 feet above the sea-level, and occupying nearly half the area of the country. This plateau is bounded and intersected by different ranges of mountains, which give rise to the numerous rivers which flow into the Atlantic and Mediterranean. As the watershed between the Mediterranean and the Atlantic is placed to the east, the most important rivers, those haviug the longest course and the largest volume of water, flow into the Atlantic. Of these we may mention the Minho, the Douro, the Tagus, the Guadiana, and the Guadalquivir. The streams running into the Bay of Biscay, arising in the Cantabrian Mountains, have a short course. Of those that flow into the Mediterranean the most important are the Ebro, the Guadalaviar, the Xucar, and the Seguja. The northern region, comprising Galicia, Asturias, the Basque Provinces, Navarre, Catalonia, and the northern parts of Old Castile and Aragon, is diversified with hill and valley, and is well watered. Here the winter is cold, the spring and autumn rainy, and the summer hot. To the south of this stretch the southern districts of Old Castile and Aragon, which, with New Castile, Leon, and Estremadura, form the greater part of the central plateau. The winter in this region is cold and the summer intensely hot. Spring and autumn are pleasant. The Mediterranean provinces of Valencia, Murcia, and Andalusia have a milder winter and a pleasant spring and autumn, but during the summer this region is exposed to the hot simoon N 194 SOUTHEEX EUEOPE. " levanta " blowing from Africa. In Valencia lagoons are met with along the coast. The valleys and coast lands of Portugal are fertile, but in some places, as in Setubal, in Estremadura and Aveiro, in Beira, there are salt marshes along the coast. In Portugal the rains between October and March are abundant, and the climate is tempered by the breezes from the Atlantic. Cldiatology. — Having already noticed briefly the general char- acters of the climate in different regions, we shall now give the mean average temperature and the average rainfall of Alicante on the south-east coast, of Madrid in the interior, and the mean temperature of Lisbon on the west, and of Cadiz on the south-west coast : — Alicaxte. ■^rAT>EID. LiSBOX. Cadiz. Mean Temperature. Rainfall. 3Iean Temperature. EainfaU. Temperature. Temperature. January, 10-76 28-4 4-90 26-1 11-4 10-78 February, . 12-38 34-0 6-84 27-9 12-0 12-70 March, 13-18 41-9 9-06 33-6 13-5 12-89 April. . 17-06 29-4 11-08 29-5 15-0 15-36 May,' . . 18-40 45-9 15-04 40-1 17-6 17-64 June. . 22-02 16-9 20-74 29-2 20-8 20-90 July, . 25-28 12-3 24-61 6-0 22-3 21-26 August, 26-06 12-8 24-72 12-5 21-8 22-70 September, . 23-88 58-4 19-84 25-9 20-8 21-21 October, 19-62 76-6 13-92 47-5 17-0 19-50 Xovember, . 14-68 34-4 8-30 44-1 13-0 14-89 December, . 11-46 86-6 6-28 41-8 10-8 11-99 16-33 16-82 17-90 427-6 13-78 364-2 The coast of Portugal has a larger rainfall than most parts of the Peninsula. At Coimbra it is said to reach 89-4 mm. ; at Bilbao it is still higher, 1192 mm. ; and at Santiago, 175 9 mm. At Lisbon the annual rainfall is 610 mm. The greatest rain- fall on the Atlantic coast is from October to March. The summer season is dry. YiTAL Statistics. — The average marriage-rate in Spain for the seven years ending 1884 was 12-9; the birth-rate, 36-6; and the death-rate, 31-0, per 1000. In Portugal the marriage-rate was 14-6 iu 1886 and 1887; the birth-rate, 35'0 ; and the death-rate,23-4, per 1000. On the eastern coasts, and iu the south and east of the central region of the Pen- insula, the maximum mortality occurs in summer and autumn ; on the western coast, winter and autumn are the most fatal seasons. In the north and west of the central region, the mortality is some- times hivernal and sometimes autumnal. Spring and winter are the most healthy seasons along the Mediterranean. In the central region, spring is the healthy season. Pathology. — Mcdaria is widely diffused over the Peninsula. It is known to occur on what have been called " the bare rocky or SPAIN AND PORTUGAL. 195 dry coasts " of Asturias and Galicia (Hirsch, Lombard, and liey). Asturias, however, contains many rich and fertile valleys, with a humid climate and a high summer temperature, Galicia, again, has a heavy rainfall, possesses numerous rivers, forming estuaries at their mouths, with rich meadow-land and dense forests. Altogether these two provinces must furnish many not unlikely spots for the pro- duction of these fevers. The description of bare, rocky, and dry applied to them is misleading. The province of Minho is generally remarkably healthy. To the south the salt marshes of Aveiro and Setubal and the banks of the Mondego are seats of endemic malaria. Fever prevails extensively in the basin of the Tagus north of Lisbon up to Santarem, the population along its banks frequently showing signs of the malarial cachexia, although the city itself is not malarious. Ferguson states that the Tagus here separates a healthy from a very unhealthy region. On the one side of the river is a bare hilly country with free open watercourses among the hills. This is the healthy side. But the Alemtejo land on the other side, though dry superficially, contains water at small depths, and being perfectly flat and sandy, is pestiferous. To sleep a night in this locality would be to run the risk of being seized with remittent fever.^ Salvaterra, on the left bank of the Tagus, about a mile from the river, becomes so unhealthy in autumn that " every person who has the means of making his escape flies the place." The south-west of Alemtejo is a dry country covered with heath broken by marshy wastes, but to the east the country is fertile and wooded. The marshy districts of the province are said to be affected with fever of a grave form. The banks of the Sado are also un- healthy. Algarve is said not to be exempt from malaria, which attains considerable intensity along the banks of the Guadiana. It was on the banks of this river, after the battle of Talavera in 1809, and when the Guadiana itself presented the appearance of lines of detached pools rather than a river, that the British troops, during their retreat along its course, suffered so severely from remittent fevers of a malignant character. The lower course of the Guadalquivir flows through a flat alluvial swampy region almost uninhabitable from malaria ; Seville, situated at a considerable distance from its mouth, on low ground subject to inundations, suffers from summer and autumnal fevers (Francis). Gibraltar consists of a grey limestone rock with many cavities filled with reddish clay. An absorbent red earth forms the subsoil. ^ Ferguson, "On the Nature and History of the Marsh Poison," Edinh. Royal Society's Trans, vol. ix. p. 277. 196 SOUTHEEN EDEOPE. The mean annual temperature is 64°-l F., hottest month (August) 76°-6 r., the coldest month (Jan. or Feb.) 53°-77 F. Eainfall, 32-8 inches (Parkes). Paroxysmal fevers contracted on the Eock are certainly rare, and it has even been doubted if such cases occur ; although it is right to add that Dr. Maclean's observations do not support this view. He states that invalids from Gibraltar are often admitted at Netley with malarial fevers who have never served in any other station.^ Such cases cannot, however, be numerous, as during the eight years 1859-66 the admissions per 1000 for paroxysmal fevers were only 5-3, and the deaths -09. In 1880 the admissions were 2-5 per 1000, and no deaths; but in 1879, owing to the presence of troops from Cyprus, paroxysmal fevers gave 292-3 admissions, and 3-32 deaths per 1000. In 1888 there were no admissions or deaths from malarial fevers in Gibraltar, and the ratios for 1886-87 were 2'8 admissions and no deaths. It is probable that cases of that special form of fever now spoken of as Gibraltar Fever, Piock Fever, Malta Fever, or febris complicata, were formerly returned as paroxysmal. This is a fever of long duration, often begins with rigors, is remittent in form, the temperature rising at night and falling in the morning, attended with copious and exhausting night-sweats, and accompanied with digestive, locomotor, genito-urinary, hsemorrhagic, and other com- plications — rheumatism being one of the most common of these. This fever will be noticed afterwards. The Mediterranean coast of Spain is in some places severely affected with fever. Valencia, with its vast evaporating surface of rice grounds, and with the lake of Albufera to the south, suffers much from ague, remittent and pernicious fevers. The population is miserably cachectic. Families in the unhealthy localities die out, and the dead are replaced by strangers." Entire villages have disappeared from this swamp. At Malaga, malarious affections form about a third or a fourth of the admissions into hospital, but they are of a milder character. Granada in Andalusia, though situated at an altitude of about 2000 feet, is also subject to fevers. When we ascend to the central parts of the plateau, we still find ague endemic in every province. In this region it does not so often take on the remittent form, nor assume so grave a character as along the coast ; yet this plateau has on more than one occasion proved very fatal to the British troops during the Peninsula War. Malarial fevers are met with at Ciudad Eodrigo and Badajoz. ^ Pract. January 1885. - Cazenave, Anno clinico tie C'trurtjla, 1848, (quoted by Loiubanl. SPAIN AND rORTUGAL. 107 In the t'ornier locality the British troops suffered severe losses from fever ; at the latter, the Spanish garrisons have been decimated by pernicious fevers. Merida, to the east of Badajoz, is also malarious. Coria, on the banks of the Alagon, has suffered severely from fever from ancient times. Ferguson states that the canons and ecclesi- astics had a dispensation for five months' leave during the summer and autumn on account of fever. During autumn all are affected, and few old men are to be met with. In Madrid, ague is far from rare ; thirty-eight deaths were registered from it from February to December 1888. It is most fatal in June and July, and again in September. Daring the construction of the railway from Madi-id to the Escurial in 1863, an epidemic of intermittent fever broke out on that part of the line from Torrelodones to the Escurial in the midst of arid mountains ; but it would appear that the epidemic began after or during the rainy season.^ In Pamplona, again, in the extreme north, fever appears to be endemic- In the absence of sufficient information, it is impossible to say what, if any, parts of the interior are free from the disease, and what districts suffer least or most. ISTor have we the means of pointing out the conditions, nor even the months in which the disease is most prevalent in different districts. As a rule, it appears to be most common in the end of summer and autumn. This, as we have seen, is the case in Madrid and Coria; but whether this holds good for all the central provinces I am unable to say. Hirsch points to the presence of malaria on what he calls "the bald, arid, and sterile table-land of New Castile, one of the most rainless steppes in Europe, whose scanty cultivation is kept up by artificial irrigation," as an instance of malaria occurring in dry places ; yet, on the other hand, it must be remembered that plateaux are very favourable to the stagnation of water in the soil. There being little outflow, the rainfall does not run off so readily as in other regions, and this may help to account for the frequency with which malaria is observed on table-lands. The very existence of irrigation on level ground, rendered necessary by the scanty rainfall, is itself favourable to the development of fever. So that while the great plateau of Spain is truly a dry and bare steppe, we must not assume that malarial fever arises here on dry, well-drained soils. It may be that here, as in many other localities which may justly be called dry, malaria is in direct relation to the amount of stagnant water in the subsoil. Upon this, as upon many other points relating to Spain, the infor- mation is utterly inadequate to justify any definite conclusion. ^ Meunier, Compte-rtiida d'une mission medicale, Paris 1863. ^ Briant, f[uoted liy Lombard. 198 SOUTHERN EUROPE. Local conditions often explain the endemicity of malaria in some elevated regions, the general characters of which seem little favour- able to the prevalence of the disease. Dr. Vieta, referring to the town of Azagra in Navarre, says : " The situation of the town is damp and low, being surrounded by the rivers Ebro and Ega, and was formerly liable to periodic submersion from their overflow. Intermittent fever in its worst forms was prevalent, but it has almost disappeared since the embanking of the river and the paving of the streets. He adds, that since the fever has abated, phthisis has become more prevalent." ^ Malarial fever was epidemic in Portugal from 1849 to 1853, and from 1858 to 1860. In 1852 the epidemy extended to all the provinces. Fehris Com.'pUcata {Boch Fever, Malta Fever, Neapolitan Fever, the Country Fever of Constantinople, the Nev: Fever of Crete). — This fever is not peculiar to Gibraltar, but, as the names given above imply, is met with at various points along the Mediterranean. Its precise area of diffusion cannot be stated ; and, up to the present time, its nature is a matter of dispute. Some observers regard it as malarial, and others as a form of typhoid.^ Without entering into any lengthened discussion of this question, I think it will be admitted that the symptoms, course, complications, and pathological lesions met with in this disease are different to a large extent from those proper to malarial or enteric fever, as we at present know them ; and there thus seem to be good reasons for provisionally admitting its specific character, until bacteriological research finally pronounces on its nature. The fever is generally ushered in by rigors, and is often preceded by malaise, loss of appetite, headache, and pains in the back. The fever varies greatly in severity, in different cases and even in the same case, at different periods ; for one of the peculiar- ities of this disease is that it is exceedingly liable to relapse. The most constant complication is rheumatism. Eheumatic symptoms — pain and slight inflammation of the joints — appear at various periods during its course ; and, like the fever, they may pass away and recur. Eheumatism generally occurs for the first time about a fortnight or three weeks after the commencement of the fever. Bronchitis is also a common complication of this disease. The ^ El Genio Medico-Qidrurgico, January 15, 1883. - Turner, Pract. vol. xxxiii. Cliartris liad already do.scrilied this fever under the name of Mediten-anean Gastric Remittent, in the Army Medical lieport for 1865 ; and mentions dozing, or delirium, as a common symptom, and pneumonia, neuralgia, nervo- rheumatism, stiffness of the joints (knee especially), orchitis, and (I'dcma of the feet, as complications. Brace says that it prevails at Cagliari, Catania, Smyrna, and in Tunis. SPAIN AND PORTUGAL. 199 toDgiie is covered with a slight white fur ; the bowels are con- stipated ; the stools light-coloured ; the liver torpid, and the spleen much congested and enlarged. The urine is dark-coloured, and, in severe cases, may be albuminous. The perspirations are often profuse. In the worst cases death is the result of the continuous high tem- perature, causing failure of the heart and congestion of the lungs. The 2^ost mortem appearances are, thinning of the intestines ; congestion of the large intestine, especially near the ilio-CcCcal valve ; enlarged spleen, which may exceed four times the normal size ; congestion of lungs and kidneys ; liver slightly congested ; brain and membranes much congested ; no ulceration of the intestine. Bruce, who has described the disease as seen in ]\Ialta, states that the average stay in liospital is eighty-five days. It is thus a very protracted fever. The fever, which often runs high, is continued, remittent, or intermittent ; one case being almost purely intermittent, another almost purely remittent. The relapses, he says, are almost invariably accompanied or followed by pains of a rheumatic or neuralgic character, sometimes with swelling of the joints or orchitis. Its gravity varies greatly in different years. Out of 91 cases treated in 1886, not a single death occurred; whereas, in 1887, up to the middle of July, it had caused 9 deaths amongst the soldiers. Bruce found a micrococcus in the blood of the spleen, which he has succeeded in cultivating, and which he considers to be peculiar to the disease. It shows no signs of growth below 22° C, or above 45° C. Cases of this disease are met with throughout the year. In May a sudden rise in the number of the cases occurs ; the maximum is attained in July ; the disease then slowly declines in frequency till December, when it reaches its minimum. The cases are so protracted that we cannot find space to insert even a single case from beginning to end. The following chart represents very fairly the course of a severe and protracted case. The patient, a soldier, stationed at Gibraltar, was admitted to hospital on the 20th of August 1888, and was discharged on the 29th of January 1889 — a period of 162 days. During this time there were four distinct relapses, separated by four periods of normal or subnormal temperature, and these were followed by a period of fever, of an irregular remittent type, lasting for another month. The last period, during which the patient had another attack of rheumatism in both knees and in the left ankle, is not represented in the chart. The first febrile attack, it will be observed, lasted about eleven days, and was followed by a period of decline lasting three days, during which the thermometric fluctuations were very marked. The first relapse lasted eight days, and was 200 SOUTHERN EUKOPE. followed by two days of marked rise and fall in temperature. The third relapse lasted about ten days, and was followed by three days of intermittent fever. The fourth lasted about eight or nine days, and terminated as usual in a few days of intermittent fever. While the course of the fever and its relapses are uniform, the periods of intermission are very variable. No doubt there are genuine cases of the disease in which no relapses occur; but these are with difficulty distinguished from other forms of fever, unless they happen to be accompanied by some of the complications peculiar to, or, at least, unusually common in this complaint. P3 1 1 flit ■ 5 ? - So' 1 i|^.> .... 5 . . ;?stt ,. M ,:»!•■■ rj I 'v. i-1 ^^: t^: S S? 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Si s^ _ ■ ■ ' SPAIN AND rOKTUGAL. 201 Typhoid and Tyjplius Fevers, according to Raseii, cause an aver- age mortality of 8'35 per 10,000 in the principal towns of Spain, and of 5*63 in the country. At Madrid, on a pojndation of 397,816, the deaths from typhus and typhoid fever in 1888 numbered 235, which gives a proportion of 5 '9 per 10,000 ; and this was the lowest mortality from the disease registered for a considerable number of years. The average number of deaths ascribed to typhoid fever in the capital during the six years 1880-85 was 448, which gives the excessive death-rate of 11 or 12 per 10,000.^ I have met with no general statistics respecting the prevalence of these diseases in Portugal, but the average typhoid death-rate in the Portuguese army, for the eight years ending 1881, was I'l per 1000, and in Lisbon, in 1884, it was 4-02 per 10,000 living. Typhoid fever is far from rare in Gibraltar ; the admission and death-rates among the troops, for the seven years 1882-88, having been 9-1 and 1-84 per 1000 respectively. For 1871-76, Kerr Innes gives the admissions at 4*04, and the deaths at 0*89 ; while for the same period the admissions and death-rates for the troops stationed in the United Kingdom were 0'99 and 0'24 per 1000.^ Mackinnon is of opinion that most of the fevers which prevail in Gibraltar are due to blood-poisoning from the respiration of an atmosphere charged with exhalations of organic matter in a state of fermentation or decomposition ; for he has observed that in houses and barracks in which the drains are in a proper condition and their connection with the main sewers formed on sound principles, these diseases do not occur.^ Enteric fever is most frequent in the hot and dry months from May to September. Typlms Fever does not appear to be frequently met with in the Peninsula. It is included in the returns with typhoid fever. Yelloiv Fever. — The Iberian Peninsula is the only region in Europe to which yellow fever has extended its epidemic range. Hirsch notices six epidemic outbreaks of this pestilence in Spain during the eighteenth century, five of which were confined to the town of Cadiz, During the present century it has extended not only over the Mediterranean coast provinces and Gibraltar, but has penetrated to Cordova, and " thereafter deep into the interior, and from Andalusia to the sea-board of Murcia, Valencia, and Catalonia," attaining elevations of 1000 feet. The Atlantic coast of Portugal has not entirely escaped these visitations, but here the outbreaks have been more limited as well as less frequent. In 1878, yellow fever was carried by the troops from Cuba to Madrid, 1 Boletin de Sanidad, Madrid 1888. - Army Mtdkal Report, 1878. •' H>., 1888. 202 SOUTHERN EUROPE. at an altitude of 2000 feet, where "50 cases occurred, of which 30 were fatal " (Hirsch). Croup and Diphtheria are excessively prevalent and fatal — the average death-rate being 11'83 in the towns of Spain per 10,000. Madrid has a high death-rate from croup and diphtheria. The deaths averaged 844 during the eight years ending 1887. Assum- ing the mean population, included in the returns, to have been 397,816, we shall have the enormous death-rate from this cause of 21 per 10,000. Without claiming any great accuracy for these figures, we may safely conclude that diphtheria is at the present day excessively fatal in Madrid, and widely prevalent throughout the Peninsula. Hirsch shows that Spain suffered severely from epidemics of diphtheria in the sixteenth, seventeenth, and eighteenth centuries. In the year 1887, the months of October, November, and December were those in which the disease proved most fatal in Madrid. Dy^ientery and Diarrhcea, including cholera nostras and the cholera of children, are common complaints throughout the Peninsula, becoming more fatal as we advance southwards."^ The deaths registered in Madrid from dysentery in 1888 are given as 11, and these were chiefly confined to the summer months, during which diarrhceal diseases are also most prevalent. Smallpox causes an average death-rate of 13*07 per 10,000 in the principal towns. A very severe epidemy raged in Madrid from August to December 1890, carrying off, according to official returns, no fewer than 2590 victims. As an explanation of this high mortality, it is stated that the lower classes are much opposed to vaccination. ■Measles gives rise to a death-rate of 11 "44 per 10,000 in the large towns ; while Scarlatina, on the other hand, gives rise to the low death-rate of 1*46 per 10,000 in the towns. Asiatic Cholera made its first appearance in the Peninsula in 1833, breaking out at Oporto, into which it is supposed to have been introduced in January of that year by an English vessel. From this point it spread to Coinibra, Aveiro, and Lisbon. In the middle of the same month it appeared at Vigo, the principal seaport of Galicia, from whence it spread southwards, extending through the whole of Spain, during this and the following year. Spain and Portugal escaped in 1848, when the disease overran the greater part of Europe ; but they suffered severely during tlie period ^ Diarrliccal diseases (1880, 1881, 1884) gave rise to a death-rate of 2917 per million at Madrid, and of 2104, in 1881, at Barcelona. SPAIN AND rORTUGAL. 203 1853-60, when cholera was once more introduced through the port of Vigo, as in 1833. In 1865 the disease was introduced from Marseilles into Valencia, and into Gibraltar from Malta, spreading to most parts of Spain and to a few spots in Portugal. Another severe epidemy broke out in the years 1884-86 ; the deaths in 1885 were officially stated to number 119,620. In Valencia alone, the deaths from cholera numbered 21,613. Cholera dis- appeared from Spain in tlie beginning of 1886, and the country remained free from the disease until the 13th of May 1890, when it appeared at the village of Puebla de liugat in the province of Valencia, coincidently with the excavation of a considerable amount of drain-sodden earth in the village.^ From this, point it spread gradually into the interior, causing a considerable mortality. In this instance there is no evidence whatever of the disease having been introduced from without, as on all previous occasions. We must therefore conclude that it either originated de novo at this village, a very unlikely assumption, or that its cause had remained latent for the space of five years, which would be a fact of special importance in relation to the etiology of the disease. Influenza has generally extended to the Peninsula when it has been epidemic in neighbouring countries, but its outbreaks there have exhibited no peculiarities that require notice. Whooping-Courjli is only moderately prevalent, the death-rate from this disease being 2-68 per 10,000 in the towns, and 3"14: in the country, — ratios about half of those which obtain in England. Bronchitis and Pneitmonia are amongst the common and fatal diseases in Spain, together giving rise to a death-rate of 53 per 10,000 in the principal towns. The deaths in Madrid from these two diseases in 1888 numbered about 3100, which is equivalent to a ratio of 77'0 per 10,000 living — the ratio from bronchitis being 48 per 10,000, and that from pneumonia 29 per 10,000. The table-land suffers more than the coast line, the north than the south, and the towns than the country districts, from acute respiratory affections. At Gibraltar these complaints are by no means frequent, giving for 1879-84 an average admission-rate of 34-9, and a death- rate of 0-69, per 1000. Pleurisy is a fatal disease on the high lands of the interior. The death-rate from this cause in Madrid, in the year 1888, reached 120 per million. Bronchitis and pneumonia are at the minimum from June to September ; the former attains its maximum in December and January ; the latter, in February and March. 1 Lancet, 21st June 1890. 204 SOUTHEEN EUROPE. Phthisis is very common in the large centres of population, but less so in the country districts. The higher altitudes of the table- land enjoy no immunity from the disease. The disease is less frequent at Malaga and Valencia. The ratio of admissions and, deaths per 1000 in the force stationed at Gibraltar for the period 1879-84, was 4-9 and 0-98 resjDectively, while 2'48 per 1000 were invalided home. These figures show that Gibraltar suffers only moderately from consumption. Acute Rheumatism is reported to be common throughout the Peninsula ; but I have no data from which to deduce its actual prevalence or fatality in the country generally, or its relative prevalence in different regions. Lombard states that the mortality from rheumatism at Lisbon is higher than at Copenhagen, Brussels, Glasgow, or Edinburgh, but less than at Bordeaux or at London. He further states that rheumatism is endemic on the plateau of Castile and in Asturias, and that it is also frequently met with in Seville, Granada, Valencia, and Malaga. The rate of admissions from rheumatism in Gibraltar averages about 397 per 1000, which is somewhat less than that of the troops stationed in the United Kingdom. The proportion of cases of rheumatic fever to the total of rheumatic affections appears to be less than in England. At Gibraltar rheumatism is a frequent complication of Eock Fever. Heijcititis is frequently met with in the south of Spain, and abscess of the liver is by no means rare. Scrofula is prevalent both in Spain and Portugal, especially in the larger towns, both on the coasts or on the table-land. Anccmio,, whether due to malaria, insufficient nourishment, or to other causes, is common in Spain. In Madrid, in 1888, the deaths ascribed to anaemia were in the ratio of 4*1 per 10,000 living. Syphilis. — We have no exact data as to the prevalence of syphilis in the Peninsula as a whole. The British troops during the Napoleonic wars suffered from a malignant form of the disease, popularly known as the " black lion ; " but at the present day, according to Jullien, Portugal is less severely affected.^ In Spain, on the other hand, venereal complaints must be common and severe. In 1850, according to Mollindeo, out of 11,527 soldiers attacked with these complaints who entered the Spanish hospitals, 79 died. The disease is said by Cazenave to be excessively common in Malaga. At Gibraltar primary and secondary syphilis cause fewer admissions than at liome. ^ Julliei), " Etudo .sur la distrib. gcograpli. du sy[)liili.s," Archiv de mid. nav. vol. xxx. SPAIN AND rOKTUGAL. 205 Lcprofiy is met with in Galicia, Asturias, Catalonia, Granada, and Andalusia, although the exact number in the various provinces is uncertain. The latest accounts give the number of lepers in Seville as 30 to 35. Cazenave found ()1 patients in the leper hospital of Granada about thirty years ago. In 1S77 the number of lepers officially reported in Valencia was IIG, Ijut numbers escaped notice. Leper centres also exist in other places bordering upon the Mediterranean, such as Malaga and Alicante. In Portugal leprosy still survives in the district of Lafoiis, in Beira, and in the province of Algarve. Goitre and Cretinism are endemic in the valleys of the I'yrenees and of the Cantabrian mountains, as well as in the mountainous districts of Estremadura and New Castile. Pellctgra, known as the Mai de la Eosa, prevails in the neigh- bourhood of Oviedo in Asturias, where it is attributed to the use of maize of bad quality ; but it is also met with to a small extent in many other districts of Spain. The Balearic Islands — IviQa, Tormentera, Majorca, Minorca, and Cabrera — lie off the east coast of Spain. Majorca, the largest of the group, is 64 miles long by 48 broad, with an area of 1386 square miles. The north-east is mountainous ; the other parts consist of plains and valleys. The inhabitants number about 200,000. The capital is Palma. Minorca is 31 miles long by 13 broad, with a population of 37,000. The capital is Port Mahon. The country is undulating, and indented by deep bays. A very complete and interesting account of the diseases of Minorca was written about the middle of last century by Cleghorn.^ He mentions that " tertian fevers of various forms becfin in June, and increase daily in frequency till the autumnal equinox, when they rage with the utmost fury ; then they gradually decline, and die out as winter approaches." He notes, that "in 1741 there were heavy rains towards the end of May and the beginning of June. Scarcely had June ended when tertian fevers began, and increased daily until September, when they attained their greatest degree of frequency, and then gradually declined." He observes also that " cholera morbus " sometimes has its regular periods like a tertian ague ; that tertians are frequently associated with a cholera morbus, and that a dysentery may be converted into a tertian or vice versa. Majorca is also severely affected by malaria. Typhoid fever is common. Yellow fever was introduced into Palma from Barcelona in 1804, and again in 1821. ^ Observations on the Ex>idem.ical -Diseases of Minorca, Loudon 1768. CHAPTER XVIL ITALY. Geogeaphy. — Italy consists of a peninsular and an insular portion. Along with the latter I shall include the islands of Corsica and Malta, although they do not politically form parts of the kingdom. The peninsular part of Italy is bounded on the north by the Alps, and extends south-eastward, in the form of a boot, for 700 miles to the Strait of Otranto. It is washed by the Adriatic on the east, and by the Tyrrhenian Sea on the west. The heel of the boot is turned towards Greece, and the toe points to Sicily and Africa. The Italian kingdom, with an area of 110,657 square miles, is divided into sixteen departments, — the population being, in 1887, 30,101,103. Eome, the capital, in 1887 had a popula- tion of 382,973. Turin had 294,826, l^aiiles about 481,000, and A^enice 150,502 inhabitants in that year. The physical configuration of Italy is to a great extent determined by the Apennine range. The Apennines are a con- tinuation of the Alpine system, which forms the northern boundary of Italy. This range, under the names of the Graian, Cottian, and Maritime Alps, separates Piedmont from France on the north-west ; and then, as the Ligurian Alps, it skirts the Gulf of Genoa. Under the name of Apennines the range now strikes obliquely across the peninsula from north-west to south-east, forming tbe southern boundary of the Po valley ; then, turning southwards, it follows the axis of the peninsula, giving off numerous spurs and secondary ranges towards either coast. Arriving at the southern extremity of the peninsula, it projects a spur into the Apulian heel, while the main ridge, changing its direction to south-west, traverses CalaVjria through its entire extent. Its continuation can be dis- tinctly traced through Sicily from the neighbourhood of IMessina in a more or less westerly direction across the entire island, but keeping much nearer to the northern than to the south-western coast. ITALY. 207 The Apennines thus cut off the great valley of the Po from the rest of the peninsula. Their longitudinal ridges and spurs form a central region of various elevations and possessing a varying climate, which is, upon the whole, a healthy one, leaving a coast margin, in some places narrow, in others widening out into great plains and fertile valleys — the salubrity of which, as we shall see, varies very much in different parts. Hivcrs. — The most important river in Italy is the Po. Pasing in the Cottian Alps, it flows eastward into the Gulf of Venice. It receives the Tanaro from the Ligurian Alps. The Ticino, the Adda, the Oglio, the Mincio, and numerous smaller streams from the Helvetian and Ehtetian Alps, join it from the north. The Trebbia, Taro, Parma, and Secchia, from the Apennines, fall into it on the right. It begins to form its delta about fifty miles from its mouth, — the principal branches of which are the Fo ddla Maestra, on the north, and the Fo di Frimaro, on the south. The Tagliamento, the Piave, the Brenta, and the Adige flow into the Gulf of Venice. The rivers of the southern part of the peninsula, running transversely from the central ranges of the Apennines towards either coast, are comparatively short and liable to overflow. The more important of these are the Tiber, in the Roman territory ; the Arno and the Ombrone, in Tuscany ; and the Garigliano and the Volturno, in Campania (Naples). Numerous small rivers and streams, of w^hich we may mention the Pescara, the Sangra, and the Ofanto, fall into the Adriatic. The lakes of any considerable size are the Maggiore, Lugano, Como, Iseo, and Garda, in the north ; and Perugia, Bolseno, Bracciano, and Celano, now drained, in the south. Of the great ijlains the most important is the valley of the Po. This valley has a length of 250 miles from west to east, and a breadth of about 50 miles, with an irrigated area of 5000 square miles. On the Mediterranean coast a series of low-lying districts stretch through Tuscany down to the Neapolitan frontier, comprising the Maremma, the Roman Campagna, and the Pontine marshes. The plain of Naples, which, but for Vesuvius, is " free from in- equalities that would serve to conceal a sheep, runs in upon the Apennines like a sea upon a rocky coast." On the south, along the Gulf of Tarento, we have the plains of Basilicata, 100 miles long by about 24 miles broad. The plain of Apulia stretches down towards Otranto, while narrower tracts of level land, watered by numerous streams, extend along the eastern coast. Hitherto we have chiefly met with malarious diseases in con- nection with marshy lands, moist banks, and deltas of rivers, or 208 SOUTHEEN EUEOPE. with artificial marshes, such as the etangs of Sologne and Bresse. Along the west coast of Italy malaria of an intense kind is met with on soils which have none of the nsual characters of a marsh. As the Eoman Campagna is a typical instance of a malaria- producing plain, it may be well to interrupt for a moment our description of the physical features of the country in order to give a short account of a region respecting which so much has been written, and which counts for so much in all controversies about the nature of malaria. I shall follow the description of Colin, who, as he informs us, went carefully over the Campagna in order to satisfy himself respecting its physical characters. This plain is furrowed over throughout its entire extent with undulations so slight that one can seize all the details of this great basin and its periphery from the smallest elevation, either in Eome itself or its environs, or from Tivoli, Frascati, or Albano. This appearance of flatness is increased by the absence of habitations or high vegetation in the Campagna. The few oases, and the few miserable houses that do exist, scarcely attract notice. Nothing whatever of the nature of marshy grounds or even of stagnant pools is met with. From the month of June, when the rains cease, the soil is characterised by its extreme dry- ness. It cracks and opens under the high temperature of the summer. Nor is the Campagna subject to inundations (except in isolated spots), which might help to explain its insalubrity. The soil is constituted superficially of a porous volcanic tuff, which rests upon an impermeable layer of sub-apennine marl, extending from one extremity of the Eoman plain to the other. The numerous slight undulations or hollows in a flat expanse on the one hand, and a porous soil with an impermeable subsoil on the other, are conditions favouring at once the rapid disappearance of the rainfall from the surface and its accumulation and retention in the subsoil. In the same way the water percolating from the Apennines finds no ready exit to the sea, and much of it, instead of draining off, lodges in the hollows of the plain, and is gradually dissipated by evaporation. In spring and autumn the Campagna is covered with rich verdure ; but during the mouths of June, July, and August the natural vegetation disappears under the combined influence of drought and heat. That the soil of the Campagna is naturally fertile, may be inferred from the fact that in olden times it was the seat of a dense population, and was regarded as the granary of liome. The Maremma of Tuscany may be regarded as the continuation ITALY. 200 northwards, of the Campagna. The whole of this tract is eminently malarious, especially the commune of Grosseto. The accounts given by authors of the physical features of tlie Maremma are so entirely contradictory, that I have obtained a full description of Grosseto from a competent authority on the spot, which I shall here give in full. The Commune of Grosseto. " 1. The town is situated on an open plain, about 10 kilometres from the sea, and about 12 '4 (metres ?) above its level. " 2. During the summer, especially, it has great and trying variations of temperature. The average annual temperature during 1875-84 was 14°-o C. ; the highest, 37°-4; and the lowest, 6^ Fogs sometimes exist during the morning hours in summer ; snow falls rarely — every six or seven years ; rain is comparatively rare. During 1875—84 it reached a medium of 6 54*10 mm. durincr ninety-eight rainy days. Strong winds are frequent from the N. and S.S.W. ; during the summer they generally blow from the S.W. ; in winter from the S.E. and N.E. Every year hail falls, but does not do much harm to the country. " 3. The river Ombrone, and the streams Salica, Eispecia, and Grillese, pass through the commune. The first is about a kilometre distant from the town, varies very much in its level, and is often the cause of inundations. The streams often become dry in summer. They drive mills for grinding corn, and, along with two large canals from the Ombrone, help to raise the level of the marsh Castiglion della Pescaia. " 4. The marshes which merit special notice are Castiglion della Pescaia, 4000 elt. in extent; Alberese, 300 elt. ; Trappola, 500 elt. ; Paludine, 600 elt. They are almost all of fresh water, and at some distance from habitations. They become dry in summer, and exhale very dangerous vapours. Some are being dried by means of filling them up, and other methods are now under con- sideration. " 5. Water is of good quality, but scarce during the summer. It is in part procured from cisterns (six public, and sixty-four private), and in part from the stream Marano, and is brought to the city from a distance of 15 kiL in terra cotta tubes, the interiors of which are varnished. The fountains are in the piazza and streets, the cisterns in the courtyards of the houses. " 6. There are hot springs at Ptoselle, where there is a bathing establishment that dates from the time of the Piomans. The water 210 SOUTHERN EUEOPE. contains sulphate, carbonate, and mnriate of lime, magnesia, and soda (grammes "169 per litre). " 7. The woods are almost entirely destroyed. Near the sea, to the S.W. of the town, there is a pine wood about 15 kil. in length and 1 kil. in breadth. There are no fenced fields. jN'either rice nor flax is cultivated, and the cultivation of the silkworm is very limited. " 8. Agriculture and the raising of sheep and cattle are the principal employments. There are two important foundries for the manufacture of agricultural implements, and an oil mill for the extraction of oil from olive husks by means of sulphurate of carbon. Here 123 men and 6 boys are employed. " 9. The town is surrounded by walls. The streets are wide, straight, even, and paved with sandstone. The principal ones have sewers, into which water from the Ombrone is almost continually poured. The cleaning of the streets is let out by contract. The refuse is generally carried to a sufficient distance from human dwellings. There is only one house which has more than three floors. The number and size of the houses are sufficient for the inhabitants. "10. The labouring classes and those engaged in tilling the ground live chiefly on bread made of wheat or Indian corn. A considerable quantity of beef, pork, and mutton is also consumed, but very little salted meat or fish. There is one public slaughter- house, which is visited by an inspector ; the people, however, prefer to kill their animals in the country, where there is no examination. "11. There are two cemeteries for the city, the one 1 kil. and the other 800 m. distant. There are other two for the frazioni of Bastignano and Istia, distant respectively 150 and 300 m. from these villages. Each grave is separate, but all the corpses are not enclosed in coffins. At all the cemeteries there are mortuary chapels. The communal doctors make the j^ost mortem examina- tions. " 12. There are three druggists' shops, six doctors, five dentists, three niidwives, four veterinary surgeons — three of whom are in Government service. The commune pays one doctor and one veterinary surgeon. "13. The number of children vaccinated from 1880-84 was 481. Ee- vaccination is not practised. " 14. Cases of malarial fever are very frequent; those of scurf, scab, and diseases of the eyes are but rare. Pleuro-pneumonia and rheumatism are common ; but consumption, heart disease, and inflammation of the bowels seldom occur ; tape-worm is very rare. ITALY. 211 and pellagra is unknown. Cholera has never visited tlie commune. For twenty years there has been no plague amongst the cattle. " 15. There is a private infant asylum, which, up to the end of 1884, had received 133 inmates. The place is large and well ventilated. " 16. There is a private hospital for both sexes, supported by the congregation of Charity. It has 160 beds, and in January 1884 there were 50 patients (average number during five years, 57)." The Maremma thus appears to differ from the Campagna in being traversed by a greater number of streams, several of which are liable to overflow, by the existence of numerous true marshes of considerable extent, and, so far as one can judge, by a wider exten- sion of cultivation ; but malaria in the Maremma is by no means confined to the marshy localities. Eeturning to our survey of the physical features of the country, we shall now notice the marshes of the peninsula. Leaving out of view the extensive rice fields of the Po valley, we meet with large tracts of marsh and lagoon along the shores of the Gulf of Venice, in the delta of the Po, stretching through Comacchio and Ptavenna to Eimini. In the Grosseto commune of the Maremma are the marshy tracts already mentioned in detail. An area of about 1500 hectares of marsh is to be found at Macarese, Porto, and Ostia, near the mouth of the Tiber. In the south of the Campagna are the Pontine Marshes, occupying an area of about 25 miles long by 14 broad. On IsTeapolitan territory (Campania), marshy spots exist near Salerno, with its rice fields, and at Caserta and Capua. Marshes of greater or lesser extent are met with in some parts of Calabria, in Basilicata, and in Apulia, especially along the Gulf of Manfredonia. Indeed, from Manfredonia to the mouth of the Ofanto, the coast is fringed with marshes, lagoons, and salt lakes. To the north are the lakes of Lesina and the inundated plains of Abruzzo. Sicily is separated from the mainland by the Strait of Messina. It has an area of 10,000 square miles, and a population of about two and a half millions. One of the spurs or secondary ranges given off from the central mountain range, which we have already mentioned, encloses the valley of Catania in the east, through which the Simeto flows. Another spur from the central range, running southwards, marks off the valleys of the Salso and Platani. The only lake of any importance in Sicily is the Lentini, at some distance from the coast, between Catania and Syracuse. The plains, which are of great fertility, are those of Catania, Palermo, Castellamare, Licata, and Terranova. Lombard gives the area of marsh and submerged lands in Sicily as 62,833 hectares. 212 SOUTHERN EUROPE. out of a total of 2,924,124 hectares. If this estimate is correct, marshy grounds abound in the island. The southern coast is the most swampy. Irvine mentions that the beds of rivers and streams in Sicily often become dry in summer, but that a certain amount of water continues to pursue its way underneath the surface. These river beds are called fiumari, and are somewhat of the nature of marshes.^ Sardinia, situated in the Mediterranean, to the south of Corsica, is 166 miles long by 90 miles broad. Its area is about 9000 square miles, with a population of 700,000. The capital is Cagliari. The island is divided into two provinces — Cagliari and Sassari. The country is mountainous, but between the ranges there are many fertile valleys. Along the southern and western coasts are some plains of great fertility, but in many localities the low lands are marshy. Lombard gives the area of marsh and submerged lands in the province of Cagliari as 22,000 hectares. From Oristani north to Cape Mannu there are numerous lagoons. A large salt lagoon lies to the west of the city of Cagliari. In the province of Sassari the area of marshy land is given at 8000 hectares only. Corsica forms a department of France. It extends 100 miles from north to south, and has a breadth of about 5 miles. Its area is 3340 square miles, with a population of 260,000. The island is traversed in the direction of its length by mountains, the highest of which reach an altitude of 9068 feet, covered with perpetual snow. On the west side of the island the mountains reach the sea ; on the east side alluvial plains stretch between the mountains and the coast. These are edged with lagoons, and present numerous swampy tracts. The plains are in many parts covered with bush or brushwood, called makis or macchie ; others are of great fertility. The chief rivers, and these of no great importance, are the Tavignano and the Golo on the east coast. Numerous mountain torrents and streams run down the ravines, but these dry up in summer. Many of them form lagoons at their mouths. Malta. — The island of Malta is of limestone formation. It is not mountainous, rising at no part above 590 feet. It is diversified with hill and valley, well cultivated, and free from marsh. Climatology. — The temperature, and rainfall of four localities, represeiiting the north-west of the Po valley, and the south-west coast, the north-west coast of Sicily, and the temperature of Venice, as given in the following table, will give a general idea of the climate of Italy : — 1 Obsrrvationx on T^i.wrtw.s, chiefly in Sicily, London 1810. ITALY. 213 >c w .-r W w P< r^ Pi w S!i Cd p^ ^ ei t3 [4 Ph '-' ^ s _g 00 a-. 05 CO '^i CO 05 CM O 1^ o -^ ^ 2; CO l^ Ol ^ CO CO cr. r- 1^ -i* CO u A (N tN S ^ CO O CO o Ol m CO *^ -.^ C4 o (N >» 1- x> CO -* lO ^ CJi CO .— CO o (N '^t" l^ I-- d K a h4 Ch CO CO J^ CO o ,_, •ff CM l^ CI CM CI 2 •* (N CO >n c» Oi CO -^ o CI O ft ,_, CM CO CO a-. CO »n CO •^ o CO CO oo i-i 'M ca (M CM CI 1— t r-i 1—1 H _-■ o OJ i^ iO ^ CO .^ O CM -* t--. CO CO =^ O CO (M ,_, ,_, CO CO O CM \Ci CO UO .™ o CO l^ kO ■^ CM C>1 CO CM CM r-H T « l-l IT rt U b <: £ ^ ^ Ci tH (>] c-^ ^ lO CO lO o J^ Oi t^ 2 VO CJ t^ lO CO (N lO o> Oi o Oi CO S CO o o -* t-^ (M -*l -# f^ CO CI Ci CD i-l !N (M CM 01 T-l 1—1 H ■^ 00 t^ t^ m CO CO CO I-H •^ CM OO p CO CO OJ o CO CO CO CD CO T— I Oi (30 CO .^ CO o CO CD o CO CM CO CI o Oi K H z O CS p^ C5 05 CI (N 05 -^ t— 01 o o CI a t^ CO iO •^ 1^ ^ CO CM oo CO CO ^ «o CO o -* i^ Ol '^ lO ,—1 CD rH CO lO s 1—1 CI CM CM CM '"' H J^ o in o o 1—1 P< 1 i-i C-5 CM oq r-l 1-1 '"' H • • • S J^ cj " a Ol s a o o o Cj •XI Q 3 s s <1 ^ s ►^ ►^ SD o > o 214 SOUTHERN EUEOPE. The climate of Turin and the north of Italy is temperate ; that of the south is almost tropical in summer. The prevailing north- east winds render the climate on the Adriatic coast colder than corresponding latitudes on the Mediterranean. The hot sirocco blows over Sicily and the south of Italy, caus- ing great depression and parching of the vegetation. This wind is most felt in summer and autumn. The temperature at Valetta, in Malta (average of 11 years), was 66°'8 F., and the average rainfall is about 22 inches. The rainfall at Citta-Yecchia, in the centre of the island, at an elevation of nearly 600 feet above the sea-level, is considerably greater than that of Valetta. The rainy season is from November to January. The south-east wind, or sirocco, blows for about seventy days a year, and is the prevailing autumn wind. Vital Statistics. — The marriage, birth, and death rates of the kingdom of Italy, for the ten years ending 1887, were on an average 15*4, 37"0, and 28'1 respectively. The death-rate is thus much higher than in the countries of Northern Europe. In the north of Italy, with the exception of Liguria and Tuscany, winter and spring are the seasons of the greatest mortality. In the south, and in the two provinces just mentioned, the mortality is highest in summer, and this is also the case in Sicily. The provinces of Calabria and Basilicata forming exceptions, for in these, as in Sardinia and Malta, autumn is the most unhealthy season. The death-rate of Malta in 1886 was 27-0 per 1000. Pathology. — Malaria. — Malarious diseases are more frequent in Italy than in any other part of Europe, with the exception, perhaps, of Hungary. The average malarial death-rate (1881—86) in 284 communes, all over the kingdom, comprising a popula- tion of nearly seven and a half millions, was 4*8 per 10,000 inhabitants, or 480 per million.^ In England, which is one of the least malarious countries in Europe, the proportion is about 3 per million ; in the Netherlands it is about 160 per million. These figures will show how important is the role of malaria in Italy. The deaths from malaria are in the ratio of 1G7'3 to 10,000 deaths from all causes. The following table gives a general view of the intensity of malaria in the several departments of Italy : — ^ The number of deaths ascribed to malarial fever in 18S7 tlirougliout the kinfjdom Avas 21,033, which would give a ratio of about 700 per million. ITALY. 21! Deaths from Malarial Fever in the Chief Placks ok the Provinces and Districts, distributed according to "Compartimenti." (Population in 1886, 7,440,287.) Average of the Six Years 1881-86. ^ Proportion of roMPvRTrMFVTi Dpatlis from COMlARriMENTi. Malavious Diseases per 10,000 Inhabitants. Proportion of Deaths from Malarious Diseases per 10,000 of the Total Deatlig. Piedmont, | 1*9 69 Liguria, . 0-2 7-2 LoMibardy, Venice, . 1-2 2-1 38-3 73-4 Emilia, . 1-6 53-3 Tuscany, JIarclies, 1-4 0-8 52-9 29-3 Umbria, . 1-5 56-3 Latium, . 13-2 490-6 Abruzzo and Molise, 8-4 297-6 Campania, Apulia, . Basilicata, 2-5 14-6 27-5 82-3 413-8 822-2 Calabria, 20-4 663 '0 Sicily, . Sardinia, 8-4 20-0 326-1 777-2 The incidence of tlie disease on more limited areas is shown in the following table, which also shows the annual variation of the death-rate for the four years 1883—86 : — Table of Deaths from Malarial Fever in Nineteen Communes of above 60,000 Inhabitants, per 10,000 of the Population. 1883. 1884. 1885. 1886. Naples, 0-9 0-9 1-0 0-7 Milan, . 1-2 0-9 0-6 1-0 Rome, . 16-2 12-3 12-3 10-3 Palermo, 1-9 1-9 2-6 1-8 Turin, . 0-8 1-1 0-3 0-1 Genoa, . 0-1 0-3 0-1 0-2 Florence, 0-2 0-1 0-2 0-2 Venice, . 0-9 0-9 1-1 1-0 Messina, 1-7 2-3 1-4 0-8 Bologna, 0-2 0-2 0-2 0-2 Catania, 5-0 3-8 5-1 3-3 Leghorn, 0-6 0-3 0-1 0-2 Ferrara, . 7-3 5-2 6-1 8-8 Padua, . 0-6 0-7 0-4 1-7 Lucca, . 0-1 1-0 0-4 0-3 Verona, . 0-9 0-4 1-2 0-7 Alessandria, 0-3 0-2 0-2 0-2 Bari delle Puglie, 2-1 3-0 4-2 3-2 Brescia, . 1-5 0-5 1-5 0-8 ^ These averages are obtained by adding together the average for the four years 1881-84, and the death-rates per 10,000 for 1885 and 1886, and dividing the sum by three. This gives a close approximation to the ti-ue average of the six years. 216 SOUTHERN EUROPE. We shall see how far the greater or lesser malarial mortality is regulated by latitude and by local conditions. A glance at the former of these tables will show that malaria is, upon the whole, much more fatal in the south than in the north of Italy. The influence of the increasing temperature in augmenting the intensity of the malarious influence can scarcely be doubted. But if we compare the mortality from malarial fever in Naples and Eome, we shall be satisfied that local conditions are of still greater importance than the higher or lower temperatures of the different latitudes in determining malarial prevalence. We shall examine a little more in detail the prevalence of malarious diseases in different parts of Italy, and their relation to local conditions of the soil, and the types they assume. Turin is comparatively healthy, its annual death-rate from malarial fever and cachexia being 0*6 per 10,000 inhabitants. Bertini found the types of fever in 550 cases observed in the hospital of St. Maurice and Lazzare to be in the following proportion per cent. : quotidians, 28 p.c. ; tertians, 59 p.c. ; quartans, 11 p.c. ; and abnormal forms, 2 p.c.^ The southern slopes of the Alps in Piedmont, Lombardy, and Venice are either entirely healthy or suffer only slightly from malaria, which, however, is more common in the low, damp lands of the south. Milan has a mortality from malaria about one-third above that of Turin; but the fact that the troops stationed here furnish a smaller mortalit}'- from fever than those in any other part of the kingdom, forbids us to regard the city as unhealthy. The facts indicate that some districts, such as those in which the troops are located, are nearly free from malaria, while others relatively suffer more, so as to raise the malarial death-rate above that of some of the healthier towns of Italy. The neighbourhood of Milan to the south and west is said to be unhealthy. Although Lombardy, as a whole, like Milan, does not appear to suffer much from malaria, the mischief is rather latent than non- existent. Witness the sufferings of the French army in Lombardy during the campaign of 1859. It was in this region that epidemic remittent fever raged to such a degree, that, according to Cazalas, it constituted almost the entire pathology of the army.- This is an example of an epidemo-endemy affecting the un- acclimatised. The enormous population, which is aggregated chiefly ' Bertini, Seconda Statisiica nosologica del F" Spedale Magr/iore del SS. Maurizio e Lazzaro, Torino 1839 (quoted by Lombard). 2 Cazalas, "Maladies de I'arniue d'ltalic," ISfiP-GO, in the Mimoiresde mid. milit., t. ii., 1864. ITALY. 217 in towns or large villages, and the careful cultivation of the soil, help to explain tlie comparative salubrity of this region. Venice has only a slightly higher fever death-rate than Milan. The salubrity of this city, built as it is in a lagoon, is remarkable. Is this not owing to the fact that Venice is very much in the position of a vessel anchored out at sea ? Being surrounded by water and intersected by canals, there is little soil in which malaria can grow or be evolved. The marshes and lagoons to tlie north and soutli of the city have an evil repute. All writers concur in insisting upon their un- healthiness, but I can quote no statistics bearing upon the point. In support of the malariousness of these localities, we observe that while the city of Venice is remarkably free from malaria, as is also Verona, the fever mortality of the department of Venice is nearly double that of Lombardy, and also considerably higher than that of Piedmont. This points to the existence of malarious foci in certain parts of the province. The greater intensity of the disease in Venice, as compared with Piedmont and Lombardy, will be seen not only in the greater number of deaths from malaria to the unit of population, but also in the higher proportion which deaths from malarious disease bears to the total mortality in Venice. Ferrara, situated on a low marshy plain in the delta of the Po, and in the neighbourhood of lagoons and lands alternately dried and submerged, is highly malarious. After Pome, it is the most malarious commune of Italy included in our tables. Emilia, according to Lombard, is the most marshy province of Italy. He calculates that one-eighth of the land is marsh. Yet we are met by the fact that the fever mortality of this province is only 1'6 per 10,000. It ranks sixth, in the scale of salubrity, amongst the sixteen departments of the kingdom. Equally favour- able is the view of its position supported by the military returns, the deaths from malarial diseases being 0'28 per 1000. The location of the chief seats of population in districts remote from paludal conditions may explain to some extent this anomaly. Tuscany, at the present day, occupies a position, as regards salubrity, when compared with the past, which renders much that has been written concerning this department obsolete and mis- leading. There is, in fact, only one highly malarious district in Tuscany, viz. Grosseto in the Maremma. The following table gives the deaths per 10,000 inhabitants in the various divisions of Tuscany, for the years 1882—84, from typhoid and malarial fevers respectively : — 218 SOUTHERN EUEOPE. Typhoid. Malarial Fever. Arezzo, 17-4 1-8 Florence, 7 "8 0"1 Grosseto (Maremma), .... 27 "1 65 "1 Leghorn, 12-2 0-5 Lucca, 10-6 0*6 Massa, 24-1 2*2 Pisa, 8-6 0-9 Sienna, 9-1 1-1 Florence, the capital, lias one of the lowest malarial death-rates of any of the Italian towns. Leghorn, in the same province, occupies by no means an un- favourable position in respect of health. The northern part of Tuscany has been rendered comparatively healthy by the application of two measures, the one having for its object the removal of water stagnating in the soil, the other the prevention of the admixture of fresh and salt water in the marshes and lagoons of the littoral. The plains of Fuceechio, Pisa, Lucca, Leghorn, and Viareggio were formerly each occupied by its lake. These lakes have now been drained. Viareggio, up to 1740, was a miserable village, avoided on account of its unhealthiness. It is now a favourite health resort. A notable instance of the benefit to be derived from drainage and cultivation, is furnished by the change that has been effected in the Val di Chiana. In this locality, the spurs from the Apennines, instead of descending directly towards the sea, change their direction, and become parallel ranges. So completely are the ridges in Tuscany thus separated from the main chain, that the head waters of the Arno, which passes Florence, have been connected by a navigable passage with those of the Chiana, a tributary of the Tiber, along a valley formed by these parallel ranges. Formerly the watershed between the basins of the Arno and Tiber was close to the Arno, and the greater part of the valley of the Chiana was occupied by stagnant pools extending for 20 miles to the south-east. The whole of this valley was excessively malarious. Dante spoke of it as " an accursed place." After having been drained, it has now become one of the most healthy and populous districts of Italy. About the middle of last century, an engineer named Zendriui proposed to construct sluices to hinder the mixture of the sea and fresh water in the lagoons. This was carried out, with the result that the fever disappeared from localities previously uninhabitable. In 1768 and 1769 the sluices fell out of repair. This was at Viareggio. The result was that the malarial infection immediately ITALY. . 219 reappeared with great virulence, carrying off 170 out of a popula- tion of 1350 in the course of those two years. The disease subsided when the sluices were put in order. Twice since that date have similar results followed neglect to keep the works iu proper repair. The northern part of Tuscany has thus experienced a great amelioration in resjDect to health in recent times by means of the measures indicated. The Marennna lies to the south of the district to which we have been referring. It may be said to extend from Piombino to Orbitello along the coast, and to a distance of 15 to 25 miles inland. This region is still highly malarious — perhaps the most malarious spot in Europe — 'notwithstanding the measures that have been taken to improve it. The inhabitants, we are told, never reach a great age ; and although they descend to the plains only when they are compelled to do so for the purpose of cultivating the soil or of reaping the harvest, they often contract fevers that impair their health or prove fatal. During the winter the Maremma is habitable, but in the other seasons it is very unhealthy. The malarial death-rate, as we have seen, averages 65*1 per 10,000 of the population. The principal towns in the province of Grosseto are Arcidosso, Campagnatico, Castel de Piano, Castiglione della Pescaia, Cinigiano, Gavarroano, Grosseto, Isola del Giglio, Magliano, Manciano, Massa, Marittima, Monte Argentario, Montieri. In Arcidosso it is remarked that malaria is rare, also in Monte Argentario. In the Isola del Giglio there is none. In the other districts it is very frequent, as may he seen from the above statistics. This province has suffered from malarial epidemics at various times. That of 1842—44 was very fatal. It is estimated that about 60 per cent, of the population was attacked, and a large number died. During the epidemy, out of 25,968 cases of intermittent fever, the various types were represented as follows : — Quotidian, ........ 18,445 Tertian, 3,821 Quartan, ......... 807 Abnormal, ........ 145 Pernicious, ........ 750 It is worthy of remark that the towns of Orbitello and Piombino, although situated in the neighbourhood of swamps, are not malarious. This is ascribed to their position, which permits them to enjoy freely the sea breezes. Perhaps other circumstances connected with their sites may contribute to their immunity. 220 SOUTHEEN EUROPE. Eome, and the whole plain on which it stands, is extremely malarious. One or two regions of Italy vie with Latium as haunts of malaria ; but no great town in the kingdom, or in Europe, can compare with Eome in respect to the proportion of deaths ascribed to malarial fevers, which here (1883-86) reaches the high figure of 12-8 per 10,000 of the inhabitants. The whole of the city is not equally affected by the scourge, for it has been observed that the more densely-peopled and central districts are the healthiest. Even those localities which are inhabited by the poorer classes, such as the Ghetto or Jewish quarter (no longer existing), noted for want of ventilation, the great overcrowding of the population, and the filthy condition of the streets, are less malarious than many other dis- tricts, the general condition of which appears in every way superior. " The less densely-peopled suburbs, where the houses are few, well built, surrounded by gardens, and apparently answering the conditions required for perfect salubrity, are extremely unhealthy" (Colin). The tertian type of fever is that which is most common amongst the civil population. The Erench soldiers on their arrival were attacked, during the first years of their sojourn, with the continued or remittent forms, or with the quotidian type of intermittent ; while those who had been stationed for a long time in the city or its vicinity, suffered from the tertian or quartan types of inter- mittent fever. Gastric and bilious complications are exceedingly prevalent in all forms and types of the disease, but more particularly so in the continued and remittent forms. In the Eoman Campagna fever exists independently of any visible marsh. A striking proof of the extreme insalubrity of this plain is the danger which attends even a short sojourn within its inhospitable confines. In this plain, says Colin, " we see only a few cultivated spots. The danger of encountering the exhalations is such, that the harvesting has to be done rapidly, stealthily, and with precipitation, in order that the sojourn in the plain may be as brief as possible. It seems as if each harvest were a sort of larceny committed upon this murderous soil." But if the superficially dry plain is unhealthy, still more so are the marshy districts, such as Ostia and Porto Macarese. Ostia is now comparatively deserted on account of its unhealthiness. Nor is it doubtful that the vicinity of the Pontine Marshes is more malarious than the Campagna generally. At Terracina the inhabitants suffer greatly from malarial fever and its results. Strangers contract the remittent, which may also affect the acclimatised in summer ; but the tertian and quartan forms are the most prevalent among the natives in this and other towns and villages situated near the marshes. The ITALY. 221 malarial cachexia is also prevalent amongst those who have been long subjected to the endemic influence. Few parts of Italy appear to suffer more from malaria than Calabria. The country is mountainous. Although destitute of large rivers, it is watered by numerous mountain streams, which often overflow the low plains, leaving black and stinking swamps, which poison the surrounding districts. How far these conditions are to be accepted as explaining the feverishness of this province, I cannot say. I have not met with any precise information respecting the conditions under which malaria is generally met with in this part of Italy. Cozenza, one of the most important towns in this depart- ment, is situated in a narrow valley at the confluence of the Crati and Busento, which pass through the town. This part of the town is marshy and malarious ; but the upper part is drier and healthier, showing the influence of stagnant moisture in determining the prevalence of malaria. It is probably to the existence of similar conditions in other parts of this department that Calabria owes its notorious liability to malarious diseases. The towns along the southern shores of this department are notably malarious. In 1886, Catanzaro had a death-rate from malaria of 30-6, Cotrone of 30-4, and Gerace of 30-0 per 10,000 inhabitants, as against a mean of 5 per 10,000 for the 284 " Comuni " in the official returns. The plains of Basilicata are very severely affected. Taken as a province, without reference to special districts, Basilicata is the most malarious region of Italy. The average death-rate from malarious diseases in this department for the six years ending 1886 was no less than 2V*5 per 10,000 of the inhabitants, and these fevers gave rise to 822*2 per 10,000 of the deaths from all causes. In other words, about one in twelve of the deaths are due to malaria. Matera, in the province of Potenza, had a death-rate of 55*8 in 1885, and in 1886 of 85"0 per 10,000 from malarious diseases. This enormous malarial mortality is no doubt owing in part to the humidity of the soil ; but much of it, we may suppose, is to be ascribed to the social habits of the natives, who dwell for the most part in caverns excavated in the side of the deep valley surrounding the town. Apulia suffers in a less degree ; but the shores of the Gulf of Taranto,. and of the Gulf of Manfredonia, with its numerous brackish marshes, are far from salubrious. The average death-rate from malarial diseases is 14"6 per 10,000, which is a slightly higher rate than that of the Eoman territory. Taranto, Brindisi,^ and ^ Dr. Patterson, of the British Seaman's Hospital at Constantinople, remarks on tlie specially malignant character of the malarial fevers contracted at Brindisi. 222 SOUTHERN EUEOPE. Foggia record death-rates from malaria in 1886 of 34-6, 45-9, and 25*1 per 10,000 respectively. The plains of Abruzzo are subject to inundations. Large tracts of land lie waste and uncultivated, which amply accounts for the rather high incidence of fever in a province which is in many parts salubrious. The proportion of deaths per 10,000 inhabitants from malarious disease averages 8-4. The commune of Vasto, in this department, had a rate of 35-9 in 1886. In Sicily the swamps are most numerous along the southern shores of the island, and it is here also that malaria is most intense. At Sciacca the deaths from this cause vary from 30*0 to 40-0 per 10,000, Terranova, the country around Syracuse, especially the district of Noto, the borders of the Lentini Lake, and the commune of Catania, are all more or less severely affected. Catania, next to Eome and Ferrara, is the most malarious town of Italy. In the neighbour- hood of the town there are marshy tracts of considerable extent, which are productive of fever. In 1881 three officers belonging to the British navy went on a shooting expedition to these marshes. One of the three escaped the fever altogether, and this was ascribed to his having taken quinine as a prophylactic ; the two others, who took no quinine, were attacked with fever, and one of them died.i Palermo, situated on a fertile and well-cultivated plain, is fairly healthy. Trapani, in the north-west, appears to be much less favourably situated. Sardinia must be regarded as decidedly malarious. Next to Basilicata and Calabria, it is indeed the most malarious department of Italy, and, judged by the military returns, it takes the first rank among the malarious regions of Italy — the deaths among the troops stationed in the island reaching 1-45 per 1000. Malaria has estab- lished itself in the Campagna since the decay of Eome, but it has made no new conquest in Sardinia, the insalubrity of whicli was well known from the earliest times.^ Igiesias and Oristano on the west coast, both swampy districts, return year after year an enormous nialarial death-rate. Oristano, for example, had a malarial fever death-rate of 76-5 in 1885, and of 63-8 in 1886, per 10,000. Igiesias is little better in this respect. Lanusei, on the east coast, is another focus of malaria. Although the marshy localities in Sardinia are 1 Navy Report, 1881. - "Actum et de sacris iEgyi)tiis Judaicisyue pelkaidis facUiiiiciuc iiutnun con- sultum, ut quattuor nulla llbertlni generis ea snper.stitione inl'ecta, (juls Idoiiea setas, in insnlam Saidiulani vuherentur ca-rcendis 1111c latrocinlls et, si ob gravltatem coeli Interissent, vile dannuini."— 7'ac^ Annul, lib. 2, cap. 85. ITALY. 223 the most deadly, the plains, apart from visible marsh, are, like the Roman Campagna, decidedly unhealthy. The plains of Corsica, especially along the east coast, are highly malarious. Carlotti ^ considers the Makis, that is, the tracts covered with bushes and undergrowth, as productive of malaria. Other causes of the disease, according to this author, are the overflow of torrents and rivers, leaving behind deposits of mud ; fish ponds, where fresh and salt water mix, and the rotting of seaweed along the shore. He states that fever sometimes reigns epidemically in localities placed in the best possible conditions as regards salubrity. In these instances he believes that the miasm is carried from a distant malarious focus by the agency of the winds ; and he affirms that when such epidemics do occur in healthy localities, it is always observed that the winds at the time have been blowing from some centre of miasmatic infection. In another work, the same author says that 90 per cent, of those who sojourn on the plains are affected with malarious diseases. Scipion Gras, quoted by Colin, gives an equally unfavourable account of the climate of the Corsican plains. He remarks that, when the wheat is ripe, the farmer hastens to reap it and get back to his mountain village. If the harvest is retarded, he is under the necessity of abandoning it, or of com- promising his health. The fertile plain of Aleria is like a trap laid for the neighbouring population. The fruits which are gathered there are mixed with the seeds of disease and death."^ In Malta paroxysmal fevers are unknown. Dr. Mufsid, in a private letter, says that " no malarial fever at the present day is to be met with in Malta, except as occurring in old emigrants returned from Cyprus and Alexandria." This is, upon the whole, borne out by the health of the troops stationed there. Since the occupation of Cyprus, and the arrival in Malta of troops from that island, paroxysmal fevers are not unfrequent ; but they are not contracted in the island. During the period 1859-66 the admissions per 1000 of strength were 4*6, and the deaths 0'2, and there is no reason for supposing that even this small proportion was contracted on the spot. While paroxysmal fevers are unknown among the natives and among the troops who have not contracted the germs of the disease in other places, a species of ephemeral fever is very common. This is described by Boileau ^ " as a sudden accession ^ Assalnissement des rigions chaudes imalubres, Ajaccio 1875. - Hirscli mentions that in recruiting for the army in Corsica, no fewer than 774"7S out of 1000 were found unfit for service, and these had been rendered unfit mostly by severe malarial illness. ^ "Eemarks on Fever in Malta," Army Medical Report, 1866. 224 SOUTHERN EUROPE. of febrile phenomena of the continued type, gradually disappearing in about seven days by lysis, unaccompanied by any eruption, and characterised by debility, anorexia, thirst, white tongue, quick pulse, and frontal headache.'' There is often an aggravation of the symptoms about the third day ; on the fourth day there is generally a decided amendment ; exceptional cases may last for ten or eleven days. Jaundice, commencing about the fifth day, occurs occasionally. Severe muscular pains in the calves, insomnia, epistaxis, and vomit- ing are pretty common accompaniments ; but bronchitis, diarrhoea, nocturnal sweating, and suppression of urine are seldom observed. The febris complicata, of long duration, to which we have alluded in speaking of Gibraltar, is also frequently met with ; and there is good reason for believing that this fever is not uncommon in other Mediterranean countries.^ Occasionally a remittent fever of a dangerous character prevails. In the year 1881 there were 69 admissions and 5 deaths among the troops from remittent fever. " Most of these cases had a yellow countenance, with heavy, dull expression ; thickly-coated, yellow, waxen-like tongue ; and a high temperature, almost resembling the bilious remittent of the West Indies."^ It is not very clear what relation, if any, exists between this and the other forms of Maltese fever already mentioned. The influence of altitiuh on the prevalence of malaria in Italy can best be illustrated by citing a few facts. The city of Sovana, in the Maremma, at an elevation of 325 feet, is notoriously unhealthy. In the Campagna, the town of Isola Farnese, at an altitude of about 660 feet, is malarious. Albano, at 1250, and Frascati, at 1100 feet, are not entirely exempt ; for Colin informs us that the lower streets of these towns, being enveloped in the fever-bearing fogs, suffer, while the higher placed streets of the same are healthy. According to the same authority, the small villages of Rocco Priora and Eocco di Papa, at elevations of 2366 and 2663 feet respectively, are entirely free from malaria. In the more unhealthy parts of Italy, as we have already seen, the inhabitants take refuge in the mountains during the summer and autumn months, which is the testimony of experience to the comparative salubrity of the higher grounds. The limits of safety vary in different localities, and even in a particular locality it is difficult to fix the lowest point beyond which safety from malaria is attained. The distribution of malaria according to season has now to be considered. We shall first give the average monthly per- 1 Marston on " Mediterranean Kcinittent," Arviy Medical Hcjjort, 1861. Bmce, Practitioner, 1888. ^ Army Medical Report, 1881. ITALY. 225 centage of deatlis from malarial fever for the kingdom of Italy, calculated upon the four years 1881, 1883, 1885, 1886:^ — Januaiy, February, March, April, . May, . June, . 6-15 5-55 5-28 5-17 5-36 5-35 July, . . 9-24 August, . 14-50 September, . . 14-03 October, . 12-48 November, . . 9-46 December, . . 7-37 It will be seen that the deaths from malarial fever begin to rise in July, and attain their maximum in August or September, — some- times in the one month and sometimes in the other. For Turin the monthly repartition of 201 deaths from inter- mittent fever occurring during the ten years 1828—37, as quoted by Lombard from an official work,^ is given here, as we have no later statistics respecting the seasonal distribution of malaria in the north of Italy. We shall repeat the figures of the average mean temperature and rainfall, so that their relation to the evolution of fever may be the more readily understood : — Percentage of Deaths from Malarial Fever. Average Mean Temperature. Average Rainfall. January, February, March, . 2-5 2-5 4-0 -0-6 2-4 7-0 36-7 29-6 63-5 ^: : 6-4 6-4 11-5 16-8 103-2 106-5 June, 2-5 20-3 92-8 July, . August, . 4-0 12-9 22-7 22-9 56-5 82-5 September, October, . 22-8 16-9 18-0 12-5 64-5 73-4 November, 9-5 5-9 67-9 December, 9-5 0-7 Total, 49-8 826-9 Here, as elsewhere throughout Italy, the death - rate from malarial fever attains its maximum in August, September, and October, the rise manifesting itself in July. The highest mean temperature occurs in August, coincidently with a very decided increase in the fever mortality. The distribution of the rainfall in Turin differs very consider- ably from that of many other parts of Italy — April, May, and June being here the wettest months, and not August, September, and ^ Statistica delle Caiise di Morte, Roma 1881, etc. 2 Informazioni Statistiche raccoUe dalla Reah Commissione per gli Stati di Ttrra ferma, t. iii., Torino 1840. 226 SOUTHEEN EUROPE. October, as in Eome, Naples, and elsewhere. Yet the monthly distribution of malaria, so far as this is indicated by the number of deaths, is much the same in Turin as in Eome, — a proof that the season of malaria is not determined solely by the periods of rain and drought. For Eome our statistics deal with admissions, not with deaths ; and, as in the case of Turin, we shall place in juxtaposition the average mean temperature and rainfall : — Table of Admissions into the French Army and Hospitals at Rome fob Malapjal Fever. Monthly Admissions per Cent. Fever Admis- sions, French Army (Armand). ^ Admissions into St. Esprit Hospital.- Malignant Fevers (Baccelli).^ Average Mean Temperature. Average Rainfall." January, . 3-1 8-5 3-34 6-79 83-4 February, 3-7 7-5 0-67 8-89 63-8 March, 4-7 7-2 0-93 10-51 69-7 April, . 5-3 5-9 1-07 14-49 60-7 May, . 5-2 5-1 1-70 17-72 53-5 June, . 5-4 8-9 2-67 22-49 36-3 July, . 10-1 6-9 14-30 24-84 16-8 August, 24-7 12-9 30-62 25-27 26-3 September, . 17-6 11-6 20-59 21-82 63-1 October, . . 9-4 10-4 14-45 16-80 121-4 November, . 6-6 10-6 5-61 11-80 109-2 December, 3-9 9-0 3-74 8-49 98-8 All these figures point to August as the month when malaria in Eome is at its height.^ This is the month also of maximum temperature. But the fact that in June, with the high temperature of 22-49, and in May when the mean is 17-72, malarial fever is at its minimum, must also be borne in mind in estimating the influence of temperature upon the evolution of malaria. In September and October, with a temperature less than that of May and June, fever is also very prevalent. Of course it may be urged that the period of maximum prevalence of fever occurs after the high temperature has been persistent for some time. 1 Armand's Observations for 1851-52 (Lombard). " Admissions into St. Esprit Hospital, 1850-60 (Lombard). 3 Two Years' Observations (Hirsch). * Average from 1782 to 1885. 6 Hirsch gives the monthly fever admissions from Bailey into the Military Hos- pital of St. Andre at Eome for 1858-60. Bailey's ligures represent the maximum of admissions as occurring in October ; but a reference to the numbers admitted for all diseases into the ndlitary hospitals for these years, as given by Colin, makes it clear that the strength of the troops was subject during this period to fluctuations which seem to deprive the results of any real value. ITALY. 227 A sudden rise in the number of fever admissions takes place in July, when the rainfall is at its minimum ; and the greatest number of admissions is reached in August, when the rainfall is still very scanty. In October, when the heavy rains fall, the fever prevalence begins to diminish. Colin informs us that cases of remittent fever were observed to begin amongst the French troops, with great regularity, about the 5th or 6th of July ; and he states, as a matter of observation, " that each of the first rains at the end of summer is followed by a recrud- escence of fever." The number of admissions from intermittent fever attains its maximum, he says, about the 20th of July, and maintains this level until about the 20th of August, when their frequency declines very rapidly ; so that by the end of that month remittent fevers have become relatively rare, and by the month of September only a few isolated cases, lost, as it were, in the general mass of intermittents, are met with. Thus, on the 21st of July 1864, there were fifteen cases of remittent under treatment to one case of intermittent ; on the 5th of August there were eighteen of remittent and four of intermittent ; while on the 5th of September the proportions were completely reversed, there being then only one case of remittent, and fifteen of intermittent fever in hospital. The only other place in Italy for which I have obtained the monthly fever admissions for malarial fever is Terracina, near the Pontine Marshes. The following table, founded on the figures given by Colin, gives the monthly percentage of 6972 patients received into the Central Hospital during eleven years. As the patients are mostly furnished by the population in the neighbourhood of the marshes, there can be little doubt that the greater part of them suffered from fever or its consequences. The table may therefore be taken to indicate the monthly prevalence of fever in this region : — Peecentage of Patients admitted Monthly into the Central Hospital, Terracina. January, . 7-21 July, . 11-90 February, . . 5-85 August, . 13-16 March, . 5-98 September, . 10-71 April, . 7-21 October, . . 8-99 May, . . 5-39 November, . 8-76 June, . . 5-6o December, . 9-16 The monthly distribution of fever is here the same as in Eome. The autumn months are also the most unhealthly in Sardinia — the first notable increase in deaths from malaria occurring in July The month of maximum prevalence varies somewhat in different 228 SOUTHERN EUEOPE. years. In the deltas and near the mouths of rivers, the country is uninhabitable from July to October. Malaria is said to disappear with the first autumnal rains ; but this is not uniformly the case. The seasons are practically the same in Corsica as in Sardinia. Years of heavy rainfall, especially if heavy rains precede the fever season, are at Eome years of the highest fever prevalence and mortality. The reverse is the case at Terracina, where dry years are the most unhealthy. Years of high temperature, such as 1865, at Eome are healthy, provided they are dry. Years in which the mean annual temperature is below the mean may be highly feverish, if the rains are even moderately abundant. In Turin, as we , have seen, 5 9 per cent, of the intermittent fevers are of the tertian type ; 2 8 quotidian ; 1 1 quartan ; and 2 per cent, abnormal. The natives of Eome also suffer chiefly from the tertian type — the quotidian variety forming only about 1 per cent, of the admissions into St. Esprit Hospital in July and August. Quartans are by no means rare. The French troops in Eome appear to have suffered from a continued form of malarial fever, and such forms are also met with among the civil population ; but the malarial nature of the continued fevers is in many cases open to doubt. The remittent type of fever is by no means rare, and, as we have seen, it is most common in the earlier part of the fever season. At Terracina, near the Pontine Marshes, strangers suffer most from the continued and remittent forms, while the intermittent — especially the tertian and quartan — affect those who have been long subjected to the miasmatic influence. Pernicious forms are frequent in Eome as well as in all the worst foci of malaria. The comatose is the form most frequently seen. The apoplectic (often without much, sometimes without any fever) is also met with. The delirious, the convulsive, the algid, and the choleraic are all far from rare. August is par excellence the month when the pernicious fevers abound; in September they are much less common, and become more and more rare until the succeeding June, when they begin to increase again in frequency. Enteric Fever causes an average death-rate of 9'G3 per 10,000 inhabitants, or 963 per million in the towns, — a proportion about four times that of England. In the Netherlands, a country which is to some considerable extent under the malarious influence, we observed that typhoid fever is rarer than in England ; but that this demands some other explanation than the assumed antagonism between malaria and typhoid, is evident from the extreme prevalence of the disease in Italy; and the same thing will be further shown by comparing the distribution of the two diseases in Italy. ITALY. 229 TABLE I. Average Death-rate from Typhoid Fever per 10,000 Living. 1881- -1886, Piedmout, 8-6 Latium, . 5-2 Liguria, . 5-8 Abruzzo, 9-6 Lombardy, 9-4 Campania, 7-2 Venice. . 8-5 Apulia, . 18-7 Emilia, . 8-1 Basilicata, 9-4 Tuscany, 11-2 Calabria, 10-7 Marches, 6-2 Sicily, . 14-3 Uinbria, . 6-6 Sardinia, 12-6 TABLE II. AxNTJAL Prevalence of Typhoid 1883-86 in Nineteen of the Commtjnes HAVING A Population over 60,000. 1883. 1884. 1885. 1886. Average. Naples, .... 6-4 6 4 6 5 4-9 6-05 Milan, . 9 3 7 3 8 3 8-4 8-32 Rome, . 4 6 4 6 5 4-9 4-78 Turin, . 6 5 9 3 7 4 5-7 7-22 Palermo, 13 4 11 2 19 2 14-9 14-67 Genoa, . 5 8 4 5 6 2 5-1 5-40 Florence, 8 5 6 9 10 5 11-1 9-25 Venice, . r. 6 4 2 8 1 4-5 5-60 Messina, 7 9 10 1 12 3 8-6 9-72 Bologna, 7 2 4 5 5 4 6-6 5-09 Catania, 18 2 17 4 17 8 11-0 16-10 Leghorn, 12 7 12 1 6 1 8-6 9-87 Ferrara, 14 9 7 8 12 3 9-8 11-20 Padua, . 6 9 7 11 2 10-6 8-92 Verona, . 12 5 9 g 11 9 12-3 11-50 Lucca, . 12 2 8 7 17 7 23-3 15-50 Alessandria, 3 2 3 7 4 3 4-9 4-02 Brescia, . 26 1 17 3 9 8 6-0 14-80 Bari delle Puglie, 24-4 22-2 32-1 33-9 28-15 It will be seen, from the first of these tables, that typhoid fever bears with special severity on the southern departments. Apulia, Sicily, Sardinia, Calabria, are those most affected ; but Tuscany in the north also stands out very prominently in the list of typhoid- stricken localities. If we compare these two tables with the corresponding ones showing the distribution of malaria, and with that giving the prevalence of the two diseases in the various districts of Tuscany, it will be seen that there is no law of mutual exclusion or antagonism between malarial and typhoid fevers, so far 230 SOUTHEEN EUROPE. as Italy is concerned. The department of Apulia, where typhoid fever is most prevalent, is one where malaria abounds. Basilicata, Calabria, Sicily, and Sardinia are all highly malari- ous, and they all suffer severely from typhoid. Of the several districts of Tuscany, Grosseto is at once the most malarious and the one which is most devastated by typhoid fever. "When we come to the communes, it will be seen that, as respects the relation between the frequency of these two diseases, the greatest diversity is manifest. Some communes, where the deaths from malarial fever are com- paratively few, such as Palermo and Lucca, are haunts of typhoid. Others, such as Catania, suffer severely from both diseases ; while Eome, which of the larger towns of Italy has the heaviest death-rate from malaria, has the lowest death-rate from typhoid. In regard to towns, the extent to which typhoid prevails depends, no doubt, to a large extent upon the local sanitary conditions and on the water supply. In Eome the water supply is remarkably pure. At Bari delle Puglie, typhoid reaches the extraordinary proportion of 28"15 per 10,000 of the inhabitants, but we have no explanation of this excessive typhoid mortality. The geographical distribution of typhoid fever in relation to soil and climate is better shown by its prevalence in the departments as given in the first table ; and it would seem, upon the whole, that the malarious districts in which the population is not massed in large cities have the highest typhoid death-rates. We have already noticed that a considerable decrease in typhoid mortality was observed both in England and the Netherlands in 1885. This decrease did not extend to Italy. In England, as in Italy, typhoid was moderately prevalent in 1884 ; but a correspond- ence between the typhoid death-rate of the two countries is far from a constant one; in the year 1881, for example, the deaths from typhoid fever in England were comparatively few, but in Italy they were unusually numerous. The average monthly percentage for three years of deaths from typhoid fever in Italy is as follows : — Jan. Feb. March. April. May. June. Jnly. Aug. Sept. Oct. Nov. Doc, 6 -GO 6-48 6-82 7-24 7 -20 7-22 9'3G 11-25 11-08 10-(jl 8-58 7-37 The months in which typhoid fever is most fatal in Italy are August, September, and October, and these are precisely the months when it is most prevalent in England ; they are also the months when malarial fever is at its height. Tliis surely points to its miasmatic (we do not say malarious) origin. 1881. 1882. 1883. 1884. 1885. Typlioid Fever, . . 9-6 9-4 9-3 8-8 10-3 Malarial Fever, . . 6-2 4-9 4-G 4-2 4-5 ITALY. 231 The following are the annual death-rates per 10,000 for typhoid and malarial fevers from 1881 to 1886 for Italy: — 1886. 9-4 5-0 It will be seen that, as a rule, a rise or fall in the death-rate of one of these fevers is followed by a rise or fall in that of the other. The only exception to this was observed in 1886, when there was a decrease of typhoid and an increase of malarial fever. In Malta (1871-76) the admission-rate from enteric fever amongst the troops was 4*72, and the death-rate 1*57, per 1000, against the English ratios of 0-99 and 0-24. {Armij Medical Report, 1878.) Belapsing Fever is not mentioned in the death returns of Italy, and I do not find any notice of its epidemic occurrence in Italy in Hirsch's work. This is all the more remarkable, that relapsing fever is often associated with typhus, which is by no means rare in Italy. Miliary Fever, or sweating sickness, has been repeatedly epi- demic in Italy during the past and present centuries. In 1885 and 1886, Fehhre Migliare is returned as the cause of 142 and 175 deaths respectively. Diphtheria and Diphtheritic Croup give rise to an average death- rate of 7*73 per 10,000, or 773 per million. As the average death- rate in England from croup and diphtheria is 318 per million, these diseases are more than twice as prevalent in Italy. In the Eoman territory (Latium) its prevalence is about the average of the whole country. In Sardinia, a decidedly malarious region, it is below the average. Apulia and Basilicata are affected in a high degree, the mean death-rate in the latter for 1881-86 being 28-0 per 10,000. The months in which diphtheria is most prevalent are November, December, January, and February, its maximum being attained in December. The first and fourth quarters are about equally charged with diphtheric deaths. Enteritis and Diarrhcea together give rise, on an average of six years, to 29-4 deaths per 10,000, or 2940 per million. In England we found that diarrhoea and enteritis occasioned, in 1884, 1094 deaths per million. We judge, then, that the death-rate of diarrhoeal diseases in Italy is nearly thrice that of England. The high temperature of Italy is doubtless one of the causes of this excess, for few diseases are more influenced by temperature than diarrhoea. The death-rate from Dysentery for the whole kingdom averages (1881-86) 2-2 per 10,000, or 220 per million, against an average of 28 per million in England. 232 SOUTHERN EUEOPE. The several departments give the following ratios of deaths from diarrhoea and enteritis, and from dysentery: — Diarrhoea i Diarrhoea and Dysentery. and Dysentery, Enteritis. Enteritis. Piedmont, . 31-3 0-87 Latium, . 22-0 0-60 Liguria, 31-5 0-50 Abruzzo, . 38-5 4-13 Lombardy, 27-0 0-57 j Campania, 28-6 2-63 Venice, 23-0 0-97 1 Apulia, 44-6 2-40 Emilia, 23-2 1-23 Basilicata, 56-3 8-03 Tuscany, . 19-2 1-93 ' Calabria, . 35-9 5-03 Marches, . 28-9 0-96 ' Sicily, 40-5 6-03 Umbria, . 22-0 4-00 Sardinia, . 31-4 1-23 Both diarrhoea and dysentery are more common in the southern than in the northern departments of Italy. It will be noticed that Umbria, which is only slightly malarious, has a higher dysenteric death-rate than Piome, Sardinia, or Apulia, all of which sulfer severely from malaria. Both diseases attain their maximum in the summer season. Asiatic Cholera was epidemic in Italy in 1835-37, in 1854-55, and again in 1884-85. It has been less fatal in Italy than in most European countries. In 1884 the record of deaths from cholera was 10,940. Asiatic cholera has on five occasions pre- vailed in an epidemic form in Malta. 1. In 1837, when the out- break lasted for 117 days, from June to October, causing 3792 deaths. 2. In 1850, when it was imported from Barbary. On this occasion the epidemy raged from 9th June to 13th October. The deaths in Malta and Gozo numbered 1736. 3. In 1865 the epidemy lasted for 155 days (9th June to 11th Xovember). The deaths were 1479. 4. Cholera appeared for the fourth time on the 5th of July 1867, and lasted until 2oth Xovember, giving rise to 259 deaths. 5. In 1887 the disease broke out about the end of July, and lasted till 11th Xovember, causing 462 death, — the villages suffering more than the towns. {Pract. vol. xlii.) We have already noticed the interesting fact that the commune of Grosseto has hitherto escaped cholera. Typhus during recent years has occasioned a mortality of 0'27 per 10,000, or 27 per million, a ratio very similar to that observed in England. It is most frequent in Abruzzo, Campania, Calabria, and Sardinia, and attains its maximum from July to October. It has, how- ever, been frequently epidemic in Italy during this century, no fewer than forty-five such outbreaks having been recorded by Corradi from 1816 to 1850, and Hirsch reckons six more between 1851 to 1873. Scarlet Fever causes an average of 2-8 deaths per 10,000 (280 ITALY. 233 per million). It is thus only about half as common in Italy as in England. Apulia and Basilicata, where malaria, typhoid fever, and diphtheria reign, suffer most from scarlet fever. It is most fatal from August to December. Measles account for a mortality of 5"7 per 10,000. This disease is least fatal in the malarious months July to November. Small'pox caused an average mortality of 3 '9 per 10,000 in the six years ending 1886. In England (1876-80) it was O'TB per 10,000. It is most prevalent from October to January. Erysipelas causes about 1'5 deaths per 10,000 living. JVhoojnnr/- Cough, which is most prevalent from j\Iarch to July or August, gives rise to an average of 2 "8 deaths per 10,000. It is thus comparatively rare in Italy. Flithisis. — This disease is very fatal in Italy. The average deaths per 10,000, for the six years ending 1886, were 23*9 (2390 per million), as against an average in England (1881-85) of about 2080 per million.^ We do not find in this any evidence of the alleged antagonism of malaria and phthisis. Let us see how the disease is distributed geographically in the several regions of Italy. The specially malarious departments of Basilicata, Calabria, Sicily, Sardinia, and Apulia all show death-rates from phthisis con- siderably below the mean ; while, on the other hand, the non- malarious departments of Lombardy, Liguria, and Piedmont exhibit high death-rates from phthisis. It is also to be noticed that the most malarious department of Italy (Basilicata) is that in which the death-rate from consumption is lowest. But two kinds of exceptions to the rule are to be noted. 1. In Eome we have an instance of a highly malarious region with a death-rate from phthisis very con- siderably over the mean. 2. In the Marches and Umbria we have two departments comparatively free from both diseases. There is clearly no dominating antagonism between consumption and malaria, otherwise Eome should be among the districts where phthisis is less frequent ; nevertheless the excessively malarious regions in Italy, as a rule, suffer in a less degree from pulmonary phthisis. The minor degrees of malarial prevalence have certainly no tendency to reduce the fatality from phthisis. Bronchitis and Pneumonia., which are classed together in the returns, cause in Italy an average death-rate of 46'1 per 10,000. Although pleurisy is not specially mentioned, it is doubtless included under the same heading. These three diseases gave rise, in 1884, to 2 9 '9 deaths per 10,000 living in England ; from which it appears ^ This includes general tuberculosis, tubercular meningitis, and consumption. As regards England, we include tubercular meningitis. 234 SOUTHERN EUEOPE. that acute diseases of the respiratory organs are considerably more fatal in Italy than in England. They are most fatal in the departments of Campania, Calabria, and Piedmont, and least so in Sicily, Sardinia, Venetia, and Tuscany. Their prevalence is clearly not regulated by latitude. Among the cities, Lucca, Palermo, and Bari delle Puglie are particularly favoured as respects exemption from this class of disease ; while Xaples and Turin show very high death-rates. Bronchitis, pleurisy, and acute pneumonia are distinctly cold weather diseases in Italy ; the death-rate from both affections show a decided rise in ISTovember, and a still more marked one in December. They are at their height in January, February, and March, and decline in frequency in April and May. Their minimum is attained in September. Hepatitis causes an average death-rate of 2*53 per 10,000. It is remarkable that it is in the northern and least malarial departments- — viz. Piedmont, Liguria, and Lombardy — that the deaths from inflamma- tion of the liver are most frequent. It is rarely seen in the Maremma. Cancer, including all malignant tumours, causes an average mortality of 647 per million, as against 544*6 in England. This disease is much more fatal in the north than in the south of Italy. Pellagra is a disease which makes its appearance as an erythematous eruption on the back of the hands, face, or other parts of the body most exposed to the sun. The affected parts, or the extremities generally, are the seat of a burning or smarting sensation. The disease generally makes its first attack in spring. The eruption disappears or declines in the autumn and winter, leaving the skin dark, rough, and dry ; the eruption returning in the following spring with greater intensity, implicating a larger surface, and accompanied by an aggravation of the constitutional symptoms. The affected skin becomes thickened, dry, fissured, and scaly. Gastro-intestinal symptoms, such as dyspepsia, diarrhoea, or constipation, supervene. Inflammation of the mouth and bleeding from the gums are also common. The nervous system is affected, as is evinced by giddiness, pains in the head, back, and extremities, and by tonic or clonic spasms, or paralysis, especially in the extensor muscles. The patients may have hallucinations or delirium ; they often exhibit symptoms of melancholia, with a tendency to suicide. The disease runs a chronic course, lasting from three to nine or ten years. This disease was observed for the first time in Italy about the year 1730, which is the time when maize came into general use in Italy as an article of diet. Its area of prevalence coincides with that in which maize forms an important part of the food of the ITALY. 235 people, and the disease principally attacks the agricultural labourers. The most probable view of the etiology of pellagra is that which ascribes it to the use of damaged maize ; but whether this disease is owing directly to a fungus, or to a chemical poison developed in the corn, is not quite clear. Perhaps the latter theory has most to be said in its favour, although it may well be that the chemical poison is itself the result of fungoid diseases. The departments south of Eome did not return a single death from pellagra for the six years 1881-86. In the departments to the north of Eome it caused a death-rate in 1881-84 of 3'5 ; in 1885, of 2-4 ; and in 1886, of 2-3, per 10,000. The disease is thus decreasing very considerably at the present time. Yenetia is the department most affected, the deaths numbering on an average 10 per 10,000. Lombardy takes the second place, with a death-rate of 6 •7. Emilia, the Marches, Tuscany, and Piedmont sufi"er in a much lesser degree. The greatest number of deaths from this disease occur from March to August. We have already noticed the spring and summer exacerbations of the symptoms of the disease, which so far explain the greater mortality of the spring and summer seasons ; but I know of no explanation, upon the maize theory of the disease, why it should break out and become aggravated during these months. Goitre and Cretinism are endemic " in the district of Aosta, at the foot of Mont Blanc, and in the valleys of the Alpine chain which traverses Piedmont and Lombardy. . . . And in Venetian territory, in the valleys of the provinces of Belluno and Udine. It is also met with on the northern slopes of the Apennine range, in Piedmont, Liguria, and Emilia, and in a few localities in Umbria, Abruzzo, and Terra di Lavorno." (Hirsch.) Scrofula causes a mortality of 1'6 per 10,000, or 160 per million. It is most prevalent in Tuscany, Sardinia, and Yenetia, and least so in Basilicata. Tales Mcsenterica is credited with a death- rate of 6'1 per 10,000, which shows that it is prevalent in Italy. Acicte Articular Rhcurnatisrn, gives rise to a death-rate of 50 per million. Leprosy is fast dying out on the Gulf of Genoa. In Comacchio, in Yenetia, this disease is endemic, but not to any great extent, and it is met with at numerous points along the coast of Sicily. Syphilis causes a death-rate of 1'4 per 10,000 ; the two depart- ments that suffer most being Umbria and Latium. Of the large cities, Xaples, Milan, Florence, Messina, and Ferrara are most affected. It is less fatal in Yerona, Alexandria, Yenice, and Leghorn. CHAPTER XVIII. MONTENEGEO AND ALBANIA. Montenegro lies to the south of Dalmatia, having Herzegovina on the north, Bosnia on the east, and the province of Skutari on the south. In the low country or zeta, the winters are mild but the summers are very hot. In the high lands the winters are long, cold, and humid (Rey). , Dr. Ferriere, who stayed for several weeks at Bjelopawlitsch, treated sixty cases of fever, all coming from Danilograd in the valley of the Jetla (Lombard). In the low country malarious fevers are met with towards the end of summer and autumn, and result in great enlargement of the spleen and in cachexia. Cattaro and its vicinity, and Budua on the coast, are specially mentioned as malarious. The mountainous region is free from malaria. Dysentery is rarely seen in Montenegro. Albania, a province of European Turkey, stretches along the eastern shores of the Adriatic from Montenegro on the north to Greece on the south. The northern part corresponds to the Illyria of the ancients, and the southern part to Epirus. On the eastern boundary are the ranges of the Bora-Dagh and the Pindus ; the coast line is low, and in many places covered with swamps and lagoons, especially about Valona and to the north of Samana Point, and along Saiada Bay. Numerous rivers, but of no great magnitude, descend from the mountain range continuous with the Pindus chain, which forms the eastern boundary. The largest lakes are the Skutari, the Ochrida, and the Janina. The mean temperature of the year at Janina is 58° F. That of winter 40° F., and that of summer 73° F. The mean thermometric range is 40°-l F., and the extreme range as high as 92° F.-^ The ^ Stuart, Journal E. Geo. Soc, 1869. MONTENEGRO AND ALBANIA. 237 rainfall averages about 50 inches. From April to September the rains are scanty, but from October to March they are heavy. Malaria. — The coasts and valleys of Albania are malarious. Stuart says of Butrinto (opposite Corfu), " that the pastures are almost deserted, and fever and ague await the sportsman who would visit the place." Schltefli received 1600 cases of malarial fever into the military hospital of Janina, on a mean effective of 19,000. Of 1591 cases of which the type is mentioned, 679 were tertian, 751 quotidian, 31 quartan, 127 remittent, 2 were masked ague, and 1 a pernicious attack.^ TyiDlioid Fever is not unknown in this province. Dr. Schlsefli having treated 114 cases in Janina. TypliiLs does not appear to be endemic in the country. Smallijox and Measles appear as epidemies from time to time, but Scarlatina is seldom seen. Dysentery does not appear to be a common disease at the higher elevations, but it is doubtful if the coasts enjoy a similar immunity. Pneumonia, Bronchitis, Pleurisy , and Phthisis are frequently met with, both on the coast and in the interior. Rheumatism is common, but we have no means of comparing its relative frequency on the coasts and in the interior. ' Versuch, einer CMmatologie des Thales von Janina, Zurich 1865. CHAPTER XIX. GrREECE. Geogeaphy. — Greece, bounded on the north by Turkey, occupies the southern part of the eastern peninsula of Europe. The out- line of the country is very irregular, being in many places indented, and at one part almost intersected, by gulfs, and surrounded by clusters of islands. Its area is 25,041 square miles, with a population, in 1889, of 2,187,208. The Pindus range of mountains, which is the eastern boundary of Albania, forms the western limits of Thessaly (Trikale), which is separated from Macedonia by the Olympus range. This range, branching off from the Pindus chain, runs down towards the Gulf of Salonika. Another cross range from the same chain, running to the Gulf of Volo, forms the southern boundary of Thessaly. The Pindus range is then continued to the south-east, spurs being given off to the south-west towards the Gulf of Corinth. The Morea or Peloponnesus is traversed by a range running from east to west more or less parallel with the Gulf of Corinth. From this a range is given off which runs down the centre of the Morea, ending in Cape Matapan. The three great plains of Greece are those of Thessaly, Bcetia, and Messenia ; but numerous smaller plains exist along the Gulf of Corinth, the Gulf of Arta, and elsewhere. The rivers are numerous but small. The principal lakes are Lake Karla in Thessaly and Lake Topolias in Boetia ; but small lakes are numerous among the mountains, some of which dry up in summer, or become converted into swamj^s. Of the Greek islands the largest is Negropont (Eubcea). The principal islands of the Cyclades Group are Andros, Naxos, Paros, Syra, Tinos, Santorin, Milo, and with these we may include ^gina. Crete, although under Turkish rule, is a Greek island, and shall be considered as such. The Ionian Islands skirt tlie western coast. Climatology. — Greece has many varieties of climate, according GREECE. 239 to altitude. The higher mountains are covered witli snow durina: the winter months ; the lower ranges enjoy a more temperate climate ; while the plains and lower valleys are subjected during summer to extreme heat. The mean annual temperature of Athens is 17°'6. In summer it is 27°'3 ; in winter, 7°"9. The rainfall only reaches 385 mm. In the Ionian Islands the mean temperature of the year is somewhat higher than at Athens ; the summer is cooler, but the winter temperature is nearly 7 degrees higher. The rainy seasons are summer and winter. Pathology. — Malaria. — The elevated lands in continental Greece are generally healthy ; the littoral, the plains, and lower lying valleys are in many places malarious. Malaria is endemic in the Thessalian plain, especially along the borders of lakes, the banks of rivers, and on the shores of the Gulf of Volo and of the ^gean Sea. The swampy shores of Lake Topolias and those of the smaller lakes of Bcetia are also notoriously unhealthy, as, in a lesser degree, is the Theban plain in general. The town of Athens and its neighbourhood is not free from the disease. Pernicious fevers and the malarial cachexia cause 14'2 per 1000 of the total deaths (Lom- bard). Foci of malaria exist on both shores of the Gulf of Corinth. The plains of the Morea are in many places rather severely affected. Boudin,^ who accompanied the Prench expedition to the Morea in 1820, witnessed, as he states, the sad drama which was enacted among the marshes of ISTavarino, in which an army was cruelly decimated by malaria without having to fight a battle. But other conditions of soil in Greece are almost equally favourable to the production of malaria. Thus at Modon, not far from Navarino, there are, according to Paure, no marshes ; but, as he tells us, a part of the plain is covered with water during the rains, and this water does not run off, but evaporates with the first heats. He adds that it is not necessary to dig far to find water. Here also the Prench troops suffered greatly from fevers. At Patras, on the Gulf of Corinth, fever was very common among the Prench troops during that war, the greatest number of admissions taking place in October, November, and December. The two large islands, Negropont and Crete, differ, as regards the prevalence of malaria, in no respect from the mainland. The island of ^gina is upon the whole healthy, although its eastern shores are said to be feverish. Syra, arid and rocky, is visited in summer by pernicious fevers. Tinos is also to some extent malarious during the hot season. Eespecting the pathology ^ Train dejievres inter mittentes, Paris 1842. 240 SOUTHEEN EUROPE. of the other islands of the Cyclades G-ronp, I have come across no trustworthy information. The English found the Ionian Islands, although the soil is naked and dry, not to be entirely exempt from paroxysmal fevers. Continued fevers, however, of uncertain character were those that predominated and proved most fatal, as will be seen by the following figures : — 1837-46. 1859-61. Per 1000 of Strength. Per 1000 of Strength. Admitted. Died. Admitted. Died. Paroxysmal Fevers, . . . 79-6 2-33 32-0 0-42 Continued Fever, . . . 190-6 3-47 149-0 4-40 Dysentery, Diarrhoea, and Cholera, 114-7 1'03 ... ... This table shows that during the later years of the English occupation a considerable reduction in the number of paroxysmal fevers had taken place. It must further be remarked that the highest figures of the most unhealthy period do not indicate that these islands are subject, except in a moderate degree, to malarious influences. These fevers are most common from October to December. Typhoid Fever was, no doubt, included in the English returns under the term " continued fever," which appears to have been so fatal to the troops stationed in the Ionian Islands. This disease occupies an important place among the causes of death at Athens, and is doubtless general throughout the country. Typhus is not endemic in Greece. Uelapnng Fever and Bilious Tyi^hoid are believed to be endemic in Greece, but I have not met with any exact accounts as to their occurrence either on the continent or the islands. Diphtheria made its first appearance in Greece in 1865 at Phthiotis (Hellas), where it has continued to be endemic (Hirsch). Croup appears to be seldom met with. Cerebrospinal Meningitis was epidemic at Phthiotis in 1863—64, and in 1868 it appeared in ISTauplia and Milos, extending in the succeeding years to every province of the kingdom, with the exception of the Ionian Islands. Smallpox and Measles do not appear to be more common in Greece than in the rest of Europe. Scarlet Fever appears in an epidemic form, but it is perhaps less fatal than in iSTorthern Europe. Diarrhcea, Cholera Infantum, and Enteritis are common and fatal affections during summer and the early weeks of autumn. Dysentery is endemic in many parts of Greece, continental and insular, especially in localities where paludal conditions prevail ; but it is also met with in dry regions, such as the Ionian Islands, where no marshes exist. GREECE. 241 Phthisis is frequent and fatal in Athens, where, in 1877, it caused 183'4 of the total deaths; and it is met with but to a very moderate extent throughout the country. Pneumonia, Bronchitis, and Pleurisy are diseases of common occurrence in Greece, but they do not give rise to so great a mortality as in England. Bronchitis especially is of a milder type than in the north of Europe. HejKititis and Ahsecss of the Liver are of somewhat frequent occurrence in Greece, especially in malarious localities. Rheumatism is somewhat prevalent, judging by the returns of the English troops stationed in the Ionian Islands. PJicumatic Fever, on the other hand, is seldom seen in Sparta, Nauplia, and Livadia. Syphilis. — A form of syphilis known as spirolwlon broke out during the war of 1820-25, and was supposed to have been intro- duced by Egyptian troops. It was characterised by mucous patches around the anus, followed by ulcerations, as in the case of radesyge. It was believed to be communicable by ordinary intercourse. Leprosy still exists in Greece, but, excepting on the high lands in the interior of Crete, lepers are nowhere numerous. Here Hirsch, on the authority of Smart,^ estimates them to form 3"6 per 1000 of the population. Ponos is a peculiar disease of early childhood, characterised by wasting, enlargement of the sj^leen, hsemorrhage from the gums, and petechiee or ecchymoses of the skin. Its cause and nature are unknown. It is only met with in the islands of Spezza and Hydra. Aleppo Boil is endemic in Crete. 1 Med. Times and Gazette, Oct. 1853. CHAPTEE XX. EOUMAXIA, SEEYIA, BULGAEIA, EOUMELIA. Geography. — Servia, Bulgaria, and Eoumelia occupy the eastern and larger part of the Balkan peninsula, having the Save and the Lower Danube on the north, the ^gean Sea and Greece on the south, the Black Sea and the Sea of Marmora on the east, and Bosnia and Albania on the west. Eoumania is also partly a Balkan State, as the province of Wallachia, although situated be}'ond the Danube, belongs geographically to the peninsula, while Moldavia, stretching northwards between the Carpathians and the Pruth, is outside its limits. The following table gives the area and population of the several States : — State. Area in Square Miles. Population. Eoumania, 48,307 6,000,000 Servia, 18,757 2,013,691 Bulgaria and Eastern Roumelia, . . 38,560 2,984,000 Turkish Roumelia, 63,875 4,500,000 The capital of Eoumania is Bucltarcst, population 221,805 ; that of Servia is Belgrade, population 38,313 ; of Bulgaria, Sofia, population 30,428 ; of Turkish Eoumelia, Constantinople, population 875,000. As our acquaintance with the pathology of these countries is so limited, it would serve no good purpose to enter into any minute geo- graphical details. Suffice it to say that this region is hilly, being intersected by the Balkans, the Dinaric Alps, the Pindus ^lountains, the Despoto Dagh range, and their numerous offshoots. On the north is the Wallachian plain, traversed by numerous tributaries of the Danube descending from the Carpathian Mountains. The country on the left bank of the Danube from Galatz downwards is excessively marshy, as is also the Dobrudja, which stretches between the shores of the Black Sea and the Danube in that part of its course, where, turning north, it runs paraUel to the Black Sea, The valleys of the Drin and Morava, and the banks of the Save ROUMANIA, SERVIA, BULGARIA, ItOUMELIA. 243 in Servia ; of the j\Iaritza, the Ivara-Su, the Struma, the Vardar, and other rivers in Eoumelia, present many marshy localities. Climatology. — The climate of the whole of this region is extreme. The winters are excessively cold, especially in the mountain regions, and the summer heat is very great. The mean temperature of the year at Constantinople is given by Hann as 16°'3; that of January as 5°-8, and of July as 23°"5. Bucharest has a mean annual temperature of 9°-3. In winter the thermometer falls to -20°, or even to -25°. The mean of summer is 19°-5. The rainfall varies greatly in amount in different parts of this region. Autumn is the rainy season. Vital Statistics. — The marriage, birth, and death rates of Roumania in 1887 were 28-4, 38-1, and 27-86 respectively. Those for Servia in 1885 were stated to be 16-8, 45-0, and 25-9 per 1000. The marriages that year appear to have been fewer than in the preceding or following years. These figures, although official, must be received with reserve. At Constantinople, winter is the most unhealthy season, then spring and summer, while autumn is the season when the mortality is at its minimum. Pathology. — Malaria is intense throughout those districts in Eoumania which stretch along the left bank of the Danube. At Galatz and its neighbourhood, malarious diseases prevail to a large extent, as is shown by the frequent occurrence of the disease among the men belonging to the British ships of war stationed at this place.i The banks of the Lower Danube are throughout very severely affected. Here fevers prevail in spring after the subsidence of the waters, and again in autumn after the first rains. In summer they assume a bilious remittent form. The inhabitants of the swampy districts suffer from malarial cachexia and enlarged spleen. That part of Eoumania which is known as the Dobrudja, extending along the shores of the Black Sea, is intensely malarious. The fevers here commence in June, and last until the end of autumn. Eemittent and quotidian forms are the earliest to show themselves, while tertians prevail in August and September, and quartans towards the end of autumn. Here also the malarial cachexia sets its mark on the inhabitants. The northern slopes of the Balkans are healthy. The hilly districts of Servia are healthy, but malaria prevails along the banks of the Save and its tributaries. In Eoumelia, fever is most generally met with along the shores of the ^gean Sea, the Sea of Marmora, and the Black Sea. The 1 Navy Health Reports, 1881, and others. 244 SOUTHEEN EUEOPE. sailors visiting Gallipoli and its environs frequently suffer severely from fever, but I have no information respecting other parts of the coast between Gallipoli and Salonika. The southern slopes of the Balkans are free from fever. Adrianople, built on the slope of a hill at the base of which flow the Toundja and Maritza, suffers from malaria. Half of the admissions among the French troops stationed here in 1854 were from malarial fevers. They were generally of the quotidian type (Eey). Malarial fever, frequently with great enlargement of the spleen, is also prevalent in those parts of Constantinople close to the shores of the Bosphorus. Typlioid Fever is met with more or less throughout the whole of this region. Lecomte -^ bears witness to its frequency in the region of the Lower Danube. At Bucharest the deaths from typhoid fever were 0"53 per 1000 in 1885, and 0"57 in 1886. Its severity in Adrianople was experienced by the French army in 1854, while numerous authorities attest its prevalence in Constantinople. So far as we know, no part of Turkey in Europe is exempt from this disease. Typlms has frequently been epidemic in Bulgaria, Servia, Eoumania, and Eoumelia, especially during and after wars, the disease being disseminated by the soldiers ; but it is doubtful whether typhus is endemic at the present day in any of these countries. Relapsing Fever and Bilious Typhoid will probably be found to be endemic in Turkey. Hirsch suggests that the " bilious typhoid " observed by Eigler at Constantinople in 1843 was of this nature. As yet, however, no positive evidence of its presence has been obtained. Cereho-spincd Fever has not been observed in any of these countries, with the exception of a slight epidemy at Jassy in Moldavia in 1869. The Eruptive Fevers present nothing special, either as regards prevalence or type, requiring notice, except that smallpox is more prevalent than in Western Europe. Asiatic Cholera has extended to every country between the Adriatic and the Black Sea, during one or other of its epidemic outbreaks in Europe ; while Eoumania, Bulgaria, and Eoumelia have repeatedly suffered from destructive epidemies of this pestilence. The Plague. — During the Middle Ages, when the plague was so frequently appearing in an epidemic form over a great part of Europe, Turkey and the adjoining countries were special endemic centres of the infection. After the disease had ceased its inroads into Western Europe, it maintained its footing in Turkey, from whence it extended, from time to time, to the south and east of Europe. During the present century, plague was epidemic in 1 Considirations aur la patliologic des ijrovinces du Bas-Danuhe, Slontpell. 1867. ROUMANIA, SERVIA, BULGARIA, ROUMELIA. 245 Turkey in 1811-13, in 1828-29, in 1834, in 1836-39, and finally, in Constantinople, in 1841, when its long centuries of pre- valence in this country came to an end. Since that time down to the present day Turkey has been free from plague. Diphtheria made its first appearance in Eou mania in the year 1868, from whence it spread to Transylvania and Bessarabia and to many parts of Turkey. To what extent Croup prevails in these regions is somewhat uncertain. According to Lombard, it makes many victims at Constantinople, especially in the months of December, under the influence of the cold north-west winds ; but Marroin's observations cast some doubt on the accuracy of this statement.^ Diarrhcea is excessively common throughout Turkey and the dependent kingdoms. In the large towns, diarrhoeal complaints give rise to a great mortality among the young during the summer season, when the temperature is high. Dysentery, comparatively rare in the hilly districts of Servia, Eoumania, and Bulgaria, is one of the most fatal diseases of the low lands of Eoumania and Bulgaria, and is also generally diffused throughout Eastern Eoumelia and Macedonia. The French troops suffered severely from dysentery at Adrianople in 1854. It is also frequently met with at Constantinople. Phthisis, according to Lecomte, is a common malady in Eoumania and Bulgaria. All observers agree in regarding it as one of the most frequent and fatal diseases at Constantinople and the other large towns in Turkey. Pneumonia, Bronchitis, and Pleurisy. — Although numerous accounts attest the greater or lesser frequency of these affections in Turkey and the adjoining countries, we have no means of estimating their comparative prevalence in different regions or localities. In Constantinople, chest affections are said to be quite as common as in the large towns of Western Europe. Rheumatic Diseases. — Turkey enjoys no immunity from these ubiquitous affections. In Constantinople, rheumatic fever, with heart complications, is said by Eigler to be of frequent occurrence. Hepatitis is far from rare in Turkey, and abscess of the liver is occasionally met with. Scrofula is widely diffused throughout these countries. Syphilis is believed to be more prevalent in these regions than in Europe generally, but in the absence of statistical evidence there can be no certainty upon the point. In Eoumania, in particular, it is stated that almost all the inhabitants suffer from venereal diseases ^ Archiv. de mid. nav., December 1869. 246 SOUTHEEN EUKOPE. — young and old, infants and adults, both in town and country (Lombard). Let us hope that there is some exaggeration in this statement. Leprosy is unknown in Eoumania, is rare in Macedonia, and is still more rare in Constantinople. Pellagra is prevalent in Moldavia and Wallachia, especially in the former, where it is said to have been observed for the first time in 1846. It is ascribed to the use of a maize diet. Goitre is endemic in a few mountain districts in Moldavia and Wallachia, where Cretinis77i is, however, for the most part, merely sporadic. ASIA. — ♦ — DIVISION I NOETHERN AND WESTERN ASIA. CHAPTER I. SIBERIA, KIRGHIZ-LAND. Geography. — Siberia is bounded on the north by the Arctic Ocean, on the west by the Ural Mountains, on the east by the Kamchatka Sea, the Sea of Okhotsk, and the Sea of Japan. It is bounded on the south by the Kirghiz country, by Mongolia, and Manchooria. The area of Siberia is reckoned to be about 4,660,415 square miles. Its population is estimated at three and a half millions only. Much of the country bordering upon the Arctic Sea is composed of swamp and moor, thawing for a few inches only during summer. To this succeeds a semi-barren zone, which again, as we proceed to the south, merges into forest, and in lat. 64° in the west and 61° in the east the cultivation of the hardy cereals can be carried on. "Western Siberia is a great plain sloping northward to the Arctic Ocean. Four-fifths of the country is drained by three great rivers — the Obi, the Yenisei, and the Lena, all of which fall into the Arctic Ocean. Numerous lakes, many of them brackish, are scattered over this immense country ; of these, Lake Balkash and Lake Baikal are the largest. Kirghiz-land has the Ural Eiver and the Caspian Sea on the west, Mongolia on the east, Turkestan on the south, and is continuous with Siberia in the north. It is a vast sterile steppe or plain, with few rivers, — those which do exist terminating in marshes or brackish lakes. It is covered in some parts with rank herbage, in others it is bare sand. The Aral Sea occupies the south of this region, into which flow the Syr Daria, the ancient Jaxartes, and the Amu Daria or Oxus, which is called the Jihun by the Turks and Persians. Climatology. — The climate of ISTorthern Siberia is excessively rigorous. In winter, spring, and autumn, the thermometer is always considerably below the freezing point, while in summer the tem- perature, according to the latitude, varies between 7° C. and 10° C. At Tobolsk (lat. 58° 12') the summer temperature reaches 17°'6 C. ; 250 NOETHEEN AXD "^TISTERN ASIA. while in winter the thermometer falls to -IS^'-Q. Orenburg, in lat. 51° K, at the western border of the Kirghiz steppes, has a mean annual temperature of 3°-2, that of July is 26^-6, and that of January -15°. ISTertchinsk, about the same latitude in the east, has a summer temperature of 16^^-2, that of winter being — 26°'5 (Lombard). At Irkutsk, 1536 feet above sea-level, the mean temperature ranges from 18°-8 in July to -20°-5 in January. At Petropavlovski the temperature of July is 14°-8, that of January -10°-0. Pathology. — Malarial Fever is scarcely known in the extreme north of Siberia, although isolated cases apparently do occur in the provinces of Yeniseisk and Yakutsk. Malaria is met with more frequently, but still in a mild form, in the government of Tobolsk, around Omsk, and in Irkutsk around the shores of Lake Baikal. Hirsch states that malarious diseases occur at the mines of Smeinogorsk (51°"9 N.), at Barnaul, and in the Barabinsky steppe, which is a marshy country, traversed by the Irtish, the Om, and the head- waters of the Obi, and covered with numerous lakes, the largest being Lake Chuni. The Kirghiz steppes are upon the whole healthy. The eastern shores of Siberia are nou-malarious. Typlioid Fever is not unknown, but its distribution is uncertain. Typhus also appears to be common in the prisons, as at Tobolsk, and among the civil population of Irkutsk. Pi,elapsing Fever was epidemic in some parts of Siberia in 1866, and accounts seem to point to its not unfrequent occurrence in this region ; but the confusion between typhoid, typhus, and bilious typhoid is so great, that it is difficult to decide in many instances what disease is referred to. Influenza has not spared these northern regions during its pandemic extensions. Apart from these general extensions, epidemic influenza, or catarrh, similar to that observed in Iceland and the Faroe Islands, is of frequent occurrence in the northern districts. Cholera, spread in 1828 from Khiva to the hordes of the Kirghiz stej)pes, by whom it was carried to Orenburg on the west frontier in the succeeding year. In 1847 the pestilence spread from Orenburg to Tobolsk, extending over a great part of Western Siberia. This retiion was acain overrun with the disease in 1871, the governments of Tobolsk and Tomsk being those chiefly affected. Lombard says that, after having ravaged China and Mongolia, cholera penetrated into Eastern Siberia ; but I have met with no particulars as to this eastern extension. Kamchatka and the northern regions of Siberia have hitherto been unvisited by this disease. SIBERIA, KIRGHIZ-LAND. 251 I am not aware whether Diphtlicria has hitherto been observed in Siberia. Croup is said by Lombard not to be of frequent occurreuce. Dysentery is not nnknown in the southern districts of Siberia. At Vladivostock it is never seen ; and the same is true of Northern Siberia generally, although epidemies of the disease at Tobolsk and other localities have been observed, for the most part, in connection with scarcity. Smallpox is said by Hirscli to iiave reached Siberia by way of Paissia for the first time in 1630, spreading over the whole country, and causing great havoc. Kamchatka was only infected as late as 1767. Since that period down to quite recent years, this disease has frequently spread in destructive epidemies all over the country. Measles and Scarlet Fever break out from time to time in an epidemic form in certain localities, but neither disease seems to be unusually prevalent or severe. Whooping-Oough occurs, but it is rare and benign. Bronchial Affections and Pneumonia are prevalent throughout Siberia ; but whether they are more prevalent in the regions bordering on the Arctic Ocean than in the southern governments, is doubtful. Phthisis is said to be quite unknown on the Kirghiz steppe, which is a low tract in some parts below the sea-level ; and the disease is known to be rare in Tobolsk. At Nijni Kolimsk, on the borders of the Arctic Ocean, phthisis was not observed by Admiral "VYrangel during his visit in the early part of the century. In no district of the country has it hitherto been reported as common ; so that we are entitled to conclude that phthisis is of comparatively rare occurrence in Siberia. Scrofula, on the other hand, is a common disease in many parts of the country. Its prevalence has been remarked at Tomsk ; the region near Lake Baikal, and at Vladivostock, in the extreme east. On the Kirghiz steppe it is rare. Eheumatic Fever is stated to be of frequent occurrence in Kamchatka and at Tomsk. Eespecting other parts of the .country we have no accounts. Syphilis is seldom seen among the Samojeds in the north-west, and the cases that do occur are mild ; but in other parts of the country it is very prevalent. This is the case as regards the Kirghiz steppe, where the disease is widespread and severe, as well as in the southern and central parts of the country. In Kamchatka syphilis is very prevalent, especially in Petropavlovski, where 252 NORTHERN AND WESTERN ASIA. Maurin found thirty severe cases of the disease in a population of 300 persons/ Goitre is endemic in the valleys of the Lena and its tributaries, in the government of Irkutsk, where the number of goitrous persons is given for 1870 as 34,000 in a population of 366,000. It is also met with on the slopes of the Altai range in Tomsk, and in the circle of Nertchinsk. (Hirsch.) ^ Archiv. de m4d. nav., 1877. CHAPTEE IL AVESTEEISr AND EASTERN TURKESTAN, MONGOLIA, MANCHOORIA, AND COREA. Western Turkestan has the Kirghiz steppes on the north, Afghan- istan and Persia on the south ; on the east it is bounded by Eastern Turkestan, and on the west by the Caspian and the Aral Sea. Eastern Turkestan is bounded on the north by the Thian Shan ]\Iountains, on the west by Western Turkestan, on the east by Mongolia, and on the south by Thibet and the Karakorani range, Mongolia, which occupies the centre of Asia, includes the greater part of the great desert of Gobi. It is bounded on the north by Siberia, on the south by China, and on the east by Manchooria, which latter extends to the Eiver Usuri and Corea on the east. Corea extends from Manchooria to the Sea of Japan on the north-east, and the Yellow Sea in the south-west. Eespecting the climatology and pathology of this great region,, which may be said to extend across Asia from the Caspian Sea to the Sea of Japan, comparatively little is known. We shall there- fore content ourselves with a few notes concerning individual localities respecting which we have come across particulars. Khiva is in great part a desert ; the only fertile parts are those that are irrigated. The town of Khiva itself is situated on an oasis stretching from the mouth of the Oxus for 200 miles along its banks, and is irrigated by canals from that river; the soil is very fertile. In this irrigated district intermittent fevers prevail. iSText to ague, smallpox and oplithalmia are the most common diseases. Phthisis is rare in Khiva. The Merve Oasis, supplied by the Murgab Piiver and the canals leading off from it, is, to a certain extent, malarious ; but the country through which the lower waters of the Tejend flow is much more so. Malaria is also prevalent among the Yamuds.^ Bokhara. — The land can only be cultivated in the vicinity of 1 O'Donovan, The Merv Oasis, vol. ii. p. 388. London 1882. 254 NOETHERN AND WESTERN ASIA. the rivers, where irrigation can be carried on ; the rest of the soil is a stiff and arid clay. The rivers are, — the Amu Daria (Oxus), the Zer-Afshan, and the Kurshi or Shehri Sebz. The temperature at the capital is — 4°'25 in January. In summer the heat is insup- portable. The country is almost rainless. The town of Bokhara, according to Vambery, is one of the dirtiest and unhealthiest places in all Asia. Goitre is here unknown. O'plitlialmia is very general among the inhabitants. Samarcand, in the Khanate of Bokhara, situated four miles to the south of the Zer-Afshan, in the very fertile plain of Sogd, is also visited by malaria, but dysentery is rare. Goitre is unknown. Leprosy is here endemic to some extent. Balkh is a desert, except in those localities where it is irrigated. In the irrigated districts, and in those inundated by the Oxus, intermittent fevers are common. Balkh and Bokhara and Turkestan generally were visited by cliolcra in 1827, 1845—46, 1859-61, 1865, and 1872. Khokan", or Kokand, in the upper basin of the Jaxartes, or Syr Daria, is extremely fertile and well populated. The town of Kokand, at an altitude of 1400 feet, is situated on the banks of the river. The rains here are very scanty. As in the other districts of which we have been treating, the summers are excess- ively hot and the winters cold. The district is largely irrigated. Intermittent fevers are very common in many districts of the Khanate. In this, as in all the other regions of Western Turkestan, malaria is most prevalent in July, August, and September. Goitre is very common in the capital, and in the hilly parts of the country. Yarkand, in Eastern Turkestan, at the height of 3958 feet above the sea-level, is situated on a marshy plain. The temperature here undergoes considerable fluctuations ; this at least was the case in August and September while Dr. Henderson and his party were there.^ Thus the thermometer stood at 92° F. at 3 p.m. on 29th August, in a lofty verandah with a northern exposure, and this was the highest temperature recorded ; the lowest temperature reached during the night was 47° F. on the 3rd September. The whole country of Eastern Turkestan traversed by this traveller and his party was free from malaria. " I doubt," he says, " if intermittent fever exists here." Goitre is frequent at Yarkand. Mongolia. — The climate of Mongolia is marked by great extremes. At Ourga, in 47° 55' N". lat., at an altitude of 1150 metres, the temperature C. is as follows: — January, -26°"7; April, l°-0; July, 17°- 7; October, -l°-9; and of the year, -2-5°. ^ Lahore, to Yarkand. By George Henderson, M.D. London 1873. WESTERN AND EASTERN TURKESTAN, ETC. 255 According to Gilmoiir,^ ague is very rare, although it is not altogether unknown in Mongolia. Indeed, it apparently occurs here at times in an epidemic form. Eheumatism, for the cure of which the natives resort to kneading, is the most prevalent disease. Oph- thalmia, itch, and other skin diseases are prevalent. Syphilis is said by Morache to be very prevalent among the nomads of Mongolia (Annal. cVhyg., 1870). Epidemies of influenza, or what is looked upon by the natives as catching colds, are of frequent occurrence. Hirsch refers to the existence of Goitre in the Mongolian districts of Thian Shan, and it is probable that the disease has a much wider distribution in Mongolia than is at present known. Manchooria. — The southern part of Manchooria is comparatively well known. On the south-west the country is a vast fertile alluvial plain. " The soil generally tends to be swampy." Numerous lagoons, covered with reeds, and swarming with water-fowl of every descrip- tion, render it somewhat interesting, even at the bleakest season of the year. On the north-east the country is mountainous. The climate experiences marked extremes of heat and cold. In summer the temperature varies from 70° to 90° F., and in winter from 45° to 1 0° F. below zero. The rivers are generally frozen over by about the 20th November, and are not navigable till the middle of March. In the hills the extremes are not so great. I add the temperature of Mu-chwang for 1865, reproduced by Williamson from the Trade Eeports of T. J. Meadows, Esq., H.M. Consul there for that year : — Table of Temperature. Month. Coldest. Warmest. Morning, Afternoon, from Morning, Afternoon, from at Daybreak. 2 to 4 o'clock. at Daybreak. 2 to 4 o'clock. January, . . -10 3 3°9 4°4 Febraary, -10 7 35 50 March, . . 14 43 60 April, . . 27 41 53 68 May, . . . 41 52 65 74 June, . . . 57 70 76 84 July, . . . 62 74 79 87 August, . . 63 73 77 85 September, . 41 52 73 80 October, . . 28 42 66 71 JTovember, . 7 17 52 61 December, . -6 2 37 44 ^ Among the Mongols. By the Rev. James Gilmour, M.A. London 1888. 256 NORTHERN AND WESTERN ASIA. Manchooria generally appears to be free, or nearly free, from malarious diseases, except in some localities in the south, such as Fungkiaug. Williamson mentions that Dr. Watson assured him that serious sickness is very rare among the foreign residents.^ Smallpox and Syphilis are, however, very prevalent among the natives. CoREA. — The peninsula of Corea, extending between 34° 40' and 42° 30' K, and longitude 125° and 129° E., is separated from Manchooria by the rivers Ya-lu and Tu-men. The northern provinces are believed to be generally healthy, but the interior of the country is not much known. In the south, intermittent fevers are endemic, and the remittent type also occurs. At Seoul, the capital, the quartan and tertian types occur with almost equal frequency ; but in the southern province the quartan type predominates, and the double quartan and the bi-quotidian types are also met with.^ Typhoid Fever, notwithstanding the existence of all the conditions supposed to favour its prevalence, appears to be rare in the capital. Cholera has extended into Corea from China when it has been epidemic in that empire. Diarrhma is a common disease at Seoul. Smallpox is frequently epidemic in the country. Bro7Lchitis and Asthma are stated to be of frequent occurrence ; but Allen met with no case of Pneumonia during the six months April to September 1885. Phthisis appears to be of frequent occurrence amongst the natives. Beriberi is well known, but most of the cases seen by Allen came from the province of Chula-do, situated to the south-east of Corea. Abscess of the Lixcr is rare, but Jaundice is a common malady. Gonorrhcea is said to be " as common as intermittent fever," but is looked upon as of no moment. Sirphilis, known as the Chinese Disease, is widespread, and often grave. Leprosy is frequently seen in all its forms. 1 Williamson's "Notes on Manchuria," Royal Gcorjraphkal Society's Eeport, 1869. 2 Allen, Arcldv. de nnid. nav., 1886, CHAPTER III. CYPRUS AND THE ISLANDS OF THE LEVANT, ASIA MINOE, AEMENIA, SYKTA, AND MESOPOTAMIA. Geography. — Cyprus, situated in the Mediterranean, in the angle formed between the south-eastern coast of Asia Minor and Syria, lies between 34° 30' and 35° 41' N. latitude, and between 32° 15' and 34° 35' E. longitude. Its greatest length is about 140 miles, and its greatest breadth about 60 miles. Its area is 3584 square miles, with a population (in 1881) of 186,173. A range of mountains skirts its northern shore, from Cape Kormakiti to Cape Andreas. Another lofty range runs across the island, to the south of its centre, from west to east, terminating in a peak called Saint Croce, 12 miles west of Larnaca. This range sends numerous spurs southwards, forming valleys, through wdiich streams find their way to the coast. The highest summits of this range are Mount Troodas (Olympus), 6590 feet, which is occupied during the summer season by the British troops, their cantonment standing at the height of 5720 feet above the sea ; Mount Paputsa (Adelphi), 5380 feet; and Mount Makhseres, 4730 feet. The great plain of Messaria extends across the island between these ranges, from the Bay of Morphou to that of Famagusta (Ammochustus). The principal river of Cyprus is the Pedfeus, which rises in the southern range, and runs through the central and eastern parts of the Messaria plain, to fall into the sea at the distance of about four miles north of Pamagusta. It can scarcely be said, however, to fall into the sea, for it has no defined mouth, and forms extensive marshes at its termination. The Idalia is a tributary of the Pedeeus, rising from the same range. The Morphou Ptiver, rising between Mounts Paputsa and Makhferes, traverses the western part of the Messaria plain, to fall into the Bay of Morphou. The Diorizos, the Kuris, the Garilis, and the Helenes are a few of the smaller streams or rivulets that flow through the parallel valleys formed by the spurs running south from the central range. These dry up entirely, or nearly so, in summer. We have already noticed the B 258 NOETHEEN AND WESTEEN ASIA. marshes formed at the mouth of the Pedasus. Salt lakes stretch for some miles along the shore south of Larnaca, but the island generally is not marshy. It is well, however, to note that local conditions here and there exist of a paludal character. Thus Lang, in his work on Cyprus, states that the town of Famagusta is encumbered with debris, and the covered pits, from which the Turks assaulted the castle in the sixteenth century, are stagnant marshes to-day. Heidenstam's remarks on this point deserve attention, as they are the result of long experience and personal observation. He says, " Cyprus, generally speaking, is not a marshy country, at least if we adopt the hygienic acceptation of the word marsh. There exist, however, low situated localities in the plains, which, during winters of heavy rain, are submerged with the water, which finds its way from the surrounding heights and becomes stagnant; or under other circumstances, where the soil is dry and porous, large accumulations of subsoil water are met with ; and lastly, in many of the principal towns and villages, owing to the overflow of defective watercourses or to the want of proper drainage, water is allowed to locate in low sites and there forms stagnant ponds. The above-mentioned accumulations, on a soil rich with organic matter of vegetable oricjin, form the malarial foci to which the fevers of this island must be attributed, and which would account for the prevalence of fever in what could be termed an epidemic form only after very rainy winters." The town of Lefkosia, or ISTikosia, on the Messaria plain, about 35 miles inland from Famagusta Bay, is the capital. It has a population of about 16,000. Climatology. — The rains, which average about 1 4 inches, begin in October and continue until February, and are more abundant on the south coast than in the central plain. The following is the average monthly rainfall and mean tempera- ture at Nikosia and Larnaca for the years 1887—88 : — iSriKosiA— 35° 11' 6" N. ; 33° 22' 20" E. Alt. 509 Feet. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Xov. Dec. Temperature- |_ _ ^-.g ^^.g ^^.^ gj-T V2-0 79-7 S5-0 S3-1 7S-1 74-9 GO": 52-8 ]n6mi, loo/— ooj ) ^^'"''^^iTcor . 1-59 1-36 0-70 1-27 0-78 S'Ol O'OO 0-00 0-31 0-39 0-94 3-14 average, iobi-bo, ) Lae]s-aca-34° 54' 30" N. ; 33° 37' 0" E. Alt. 35 Feet. Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Temperature-) . ^g-i 54-1 58-0 G3-9 70-2 76-7 83-7 84-3 79-9 77-7 65-1 57-7 mean, iSoi-bb, j ^'^■'^^f^.^T CO !- 0-73 1-12 0-22 1-24 0-14 0-68 0-00 0-00 0-18 O'OO 1-4S 3-4S average, 188i-SS,j Pathology. — Malaria. — The fact that malaria prevails in Cyprus has long been known. Tlie troops of St. Ludovic, when CYPEUS AND THE ISLANDS OF THE LEVANT. 259 passing througli the island in 1259, suffered severely from fever. Lusignan, in his Geography and Hidory of the Island of Cyiirus, written in 1572, remarks that, though the climate of Cyprus is very iine, fevers often occur on the low plains. Castiglione, in 1663, notices the pernicious atmosphere emanating from stagnant waters. P. N. Mariono Marone da Maleo, in his Terra Santa (1669), mentions that in the plains and near the sea much water accumulates during the winter months, forming marshes, which are most unhealthy during the summer. Finally, Giovanni Mariti, in his Viaygi jJcr I'isola di Cipro, notices the prevalence of tertians and quartans, and mentions Famagusta as being worse than any other part of the island.^ Our knowledge of the pathology of Cyprus may, however, be said to date from the period of the British occupation in 1878. This year is stated to have been an unusually warm one, but I have not come across any record of the temperature. The British troops landed in the beginning of July, and an epidemic fever soon began to manifest itself amongst them. The first notice of the sickness I have met with occurs in the Lancet of the 20th of July 1878. The epidemy had then declared itself. On 24th August, Colonel Stanley stated in Parliament that the proportion of sick did not exceed 6 per cent. In the first week of September the number actually in hospital amounted to 11-5 per cent., but about 25 per cent, of the strength were then sick. By the 28 th of September the reports were more satisfactory, and the improvement continued, and became more marked in October and November. In July, August, and September the disease was of a remittent form, marked, in many instances, by relapses, and was compara- tively fatal ; but from the middle of September the fever assumed a distinctly intermittent type, and was less grave. Although it is stated that the year 1878 was an unhealthy one in the Levant, we have no proof that the same fever which was epidemic in Cyprus was observed elsewhere. The troops at Larnaca, JSTikosia, Limasol, and in every other locality occupied by them, were affected. It is further certain that the natives all over the island suffered from this epidemy to a greater or lesser extent; and in this respect it differs from the Walcheren expedition, in which the natives escaped from the fever that was so fatal to the British army. The Syrians, Maltese, Italians, and Greeks who accompanied or followed the expedition suffered as much as the British troops, and it was as fatal among them. {Lancet, 7th December 1878.) The ^ Cyprus Fevers, Heidenstam, Colonial Office, Lend. 1886. 260 XOETHEEX AXD WESTERN ASIA. 42ncl Eegiment, which had been in the Ashantee war, and the 101st, which had been long in India, enjoyed no immunity on account of their previous residence in malarious countries. The Indian native troops appear to have suffered equally with the British soldiers. {Medical Times and Gazette, 1878.) The marines, employed on duty on the beach or inland, were visited with the same disease. Out of a party of seamen and marines that had been detached for duty at Xikosia, 73 per cent, were attacked with the fever before the end of August ; while among the beach party up to the same date only a few cases had occurred, and those were of a mild type. Later on, however, among the latter the attacks became more numerous and severe, and some of them, like the Kikosia cases, were attended with relapses. About the 12th of August fever first appeared among those of the men who had never quitted the ship Minotaur. {Navy Report, 1878.) If the epidemy attacked every class, it is no less certain that all did not suffer equally. It was observed that in September the Eoyal Engineers were attacked in great numbers, and the disease amongst them assumed the form of a bilious remittent of a severe type. It is deserving of remark, in passing, that in 1881, when there was no epidemy in question, the Eoyal Engineers suffered much more from paroxysmal fevers than the troops generally, the admissions among the latter being in that year 140 per 1000, while among the Engineers the admissions were 842-4 per 1000. Is this to be explained by the nature of their duties, involving, in their case, more exposure in the sun and to the exhalations from the soil upturned in connection with the constructing of barracks and other public works ? "We thus see that an epidemy raged in the summer of 1878 all over the Island of Cyprus, attaining its acme in August and September ; that it affected natives and strangers ; that even the sailors in the ships anchored off the coast, who had never landed, were not spared ; and that it was at first, and during its height, of a remittent type, which, as the colder weather set in and the epidemy became less severe, was replaced by the intermittent form. The number of admissions into hospital in 1878 for all febrile diseases was 3713-6 per 1000, of which 24-61 per 1000 died, and 78-30 were invalided. The fevers returned as remittent numbered 2203, and those returned as ague 89 5. We thus see that the epidemy, whatever may have been its nature, gave rise to great sickness and to subsequent loss of health, as is proved by the numbers rendered unfit for service by it. The mortality it occa- sioned, too, was by no means inconsiderable. CYPEUS AND THE ISLANDS OF THE LEVANT. 261 Such are the general facts regarding the epidemy upon which all are agreed. Let us try to see what were the forms of fever actually observed in Cyprus during this epidemic period ; and for this purpose we shall reproduce the original descriptions of the disease by the medical men who saw and treated it. Having done this, we shall be in a better position to consider the character of the epidemy. Home says that the fevers " were only certain of the phenomena in the course of a disease due to the infection of the marsh miasm, which attacked many organs of the body, and might be fatal in a short time, through the changes produced in them, or in a longer time by the slower effect of the dyscrasia, which was set up as a consequence of its long continuance. . . . The illness rarely ended after one attack of fever, in a way that, in a favourable case, illness ends in the recovery of the patient, after an attack of typhus or rheumatic fever. . . . The access of fever might be followed after a few hours by an interval of comparative health — an intermission ; or there might be an abatement of the fever for a few hours — a remission — followed by another access, and perhaps another, before the interval of comparative health sets in, or the remission might be so short and indistinct as to be undistinguishable. But it was characteristic of the fever in this illness that the access very often returned after a period of seven days from the last fall in the temperature. As in marsh fever in other places, the fever access might return every day, or every second, or every third or other day. In this fever the type was that of a seven-day access ; but it rarely remained so long, as the access became irregular, was advanced or retarded, and the severer forms of a fever with remission tended normally to end in one with intermissions. The continuity of the illness was not broken, however, nor in every instance was the change for the better. The coma which came on in the cold stage of the fever was very dangerous." He adds that dysentery occurring with the fever as a secondary affection was dangerous, that hsemorrhages from the bowels, lungs, and stomach often accom- panied the severer forms of the disease, and that it was frequently followed by anaemia and cachexia. {Army Medical Report, 1878.) The surgeon of the Black Prince says that this form of remittent, while resembling the common type of this disease usually met with in these regions, presented in many respects peculiarities, among which were the following : — 1. The greater mildness of the febrile symptoms.^ ^ This is the only writer who describes the fever as even comparatively mild ; but in the Black Prince the mortality was only one out of 147 sick,— of these 21 were 262 NOETHERN AND WESTERN ASIA. 2. The unaccountable tendency to syncope, and the great prostration with which the seizure usually commenced in men, however previously robust. 3. Its liability to relapse, especially during the height of the epidemy in Cyprus in July and August. These relapses were of two kinds : either a definite high temperature attended with malaise, slight headache, and other febrile symptoms occurring from the tenth to the fourteenth day ; or more frequently a return of vertigo, headache, bilious vomiting, or diarrhoea, with a temperature a little or not at all above the normal. 4. Greeks, Turks, and Indian troops seemed as liable to contract this disease as Englishmen. 5. The usual sequelae of Mediterranean fever were infrequent. 6. The prevalence and persistence of fever in the ship, and its probable short period of incubation. In half of the relapsing cases the fever lasted about five days ; a complete intermission then occurred, followed by a marked return of the fever in ten to fourteen days from the original seizure. The others had irregular relapses, in which a marked return of high temperature either did not occur or escaped observation. In rare cases two or more relapses were noticed, and no man thus affected was fit for active service for many months subsequently. (Navij Report, 1878, p. 13.) The following is an account of the disease as seen in hospital : " On September 3, three or four men were admitted with relapses of fever, which were severe. Temperature, 103° to 105°. They were in hospital the first time from five to eight days, and had been out of hospital about seven days when the relapse occurred. In the course of a few days I had the opportunity of seeing primary attacks with the following general symptoms : sudden invasion, no shivering, intense frontal headache, great heat of skin, thirst, bilious vomiting, bowels generally confined, tenderness of liver and some- times of spleen, tongue yellow or white fur. Temperature about 104° to 106°, occasionally with profuse perspiration. This lasted without any distinct remission for periods varying from two to seven days. The high temperature and other symptoms usually disappeared suddenly during the night, often with perspiration, sometimes with diarrhoea. Sometimes the temperature lingered a degree or two higher than normal for a day or two. Spongy and ulcerated gums were common in and out of the hospital." This writer adds that quinine had no effect upon the disease. This is probably the description to which Hirsch refers in his " Handbook," invalided. In the remittents of the Mediterranean the fatality is often more con- siderable. CYPRUS AND THE ISLANDS OF THE LEVANT. 263 and which, he says, " leaves no doubt that we have to do here with a form of relapsing fever running its course with bilious symptoms." (Hirsch, Op. cit. vol. i. p. 600.) A medical correspondent of the Lancet, writing from Larnaca, describes the fever in very much the same terms as the above, noticing epistaxis as a symptom, but saying nothing of relapses. The surgeon of the Raleiijli notices its sudden accession, generally with a rigor, rapid rise of temperature to 104° and 105°, intense headache, pains in back, nausea, and diarrhoea. He adds that " in some cases delirium occurred, and hairaorrhage took place from the mucous membrane. In favourable cases a crisis was developed in from twenty -four to forty -eight hours, characterised by copious perspiration and a subsidence, more or less complete, of the acute symptoms ; then, followed some days of languor and anorexia, with a regular exacerbation of the fever every evening, while in the morning the pulse and temperature might be about normal. This condition lasted between one and four weeks. Here we find a fever with hsemorrhage from the mucous membrane beginning as in remittent, and ending as in distinct intermittent, apparently without any intervals and relapses. {Navy Eeport, 1878.) Are we to look upon this as only a modification of the relapsing type described above, or as a separate disease ? One case is recorded in the Lancet of November 30, 1878, in which the fever began on September 12, and lasted till the l7th, then relapsed on October 1, — that is, fourteen days from the date of the termination of the first access. In another case, the first seizure, without rigors, lasted seven days, and the patient had a similar attack three weeks later, which lasted four days. At the beginning of October he had an attack of ague. In a third case the patient was attacked with the usual symptoms, — giddiness, vomiting, heat of skin, and pains. The fever in this instance lasted for eighteen days, and after being out of hospital for about a fortnight, the patient had another attack of fever, which differed from the first by beginning with shivering. In a fourth case the fever is said to have lasted about ten days, then after an interval of a week it was followed by a second seizure. Such are some of the recorded cases. A writer in the Lancet (December 7, 1878) remarks that remittent fever in Cyprus " always recurs on the seventh, fourteenth, or twenty-first day, and so on, resembling in this respect relapsing fever ; but the temperature charts usually show a remission in thirty hours of the access, then a second remission." 264 XOETHEEX AXD WESTERN ASIA. "We shall now see in what condition the invalids were found when they reached Iletlej. This is what Dr. Yeale says upon the point : " Xine-tenths of those who came direct from Cyprus were suffering from malarial fever or its effects, as was evidenced by their sallow, worn, and cachectic aspect, but still more certainly by the fact that many of them were actually in the cold stage when they arrived." Some suffered from intermittent fever, others had relapses of the remittent tj-pe of a very severe nature, — the fever sometimes even assuming a pernicious character. In most cases the liver was enlarged — the spleen was also often enlarged, sometimes tender or painful. Many suffered from bronchitis, but it must be noted that the season was then very inclement. He observed in several cases purpura — blotches on the lower extremities, epistaxis with a certain degree of sponginess of the gums — but without any ulceration, effusions, or dyspnoea. Dysentery, as a complication, was very rare, but extremely intractable. Dr. Yeale found the history of the disease given by the men to be tolerably uniform. " They said that shortly after their arrival in camp, they suffered from a fever of sudden access and without rigors, which was attended with pains in the back and limbs, vomiting, thirst, constipation, and great prostration. After a period varying from three or four days to as many weeks, they would return to duty, but were soon seized again with an attack of a similar kind, and after two or three such attacks they began to have fever and ague." What then was the nature of this epidemy ? If we are content to shut our eyes to one half of the e\idence, there would be little difficulty in deciding either in favour of the view that Hirsch takes, namely, that we have to do with an epidemy of relapsing fever, or, on the other hand, to accept the opinion of Home, that the epidemy was simply one of malarial fever of a severe character. The opinion of most of those who saw and treated the disease was certainly in favour of its malarial nature. But here we have to examine and weigh facts rather than opinions. The more carefully and imparti- ally we consider this epidemy, the more the difficulties in coming to a positive decision become apparent. As regards the existence of malarial fever as a factor and as an important factor in this epidemy, there can, I think, be no doubt. The condition of the invalids when they reached Netley is conclusive upon this point. The disease, as seen on the Raleigh, if it is correctly described, was certainly not ordinary relapsing fever. It was marked by sudden access, high and apparently continuous fever lasting for one or two days, followed by copious perspiration ; CYPRUS AND THE ISLANDS OF THE LEVANT. 265 all of which symptoms were sucli as might occur either in malarial or relapsing fever ; but then the disease assumed an intermittent character lasting from one to four weeks. There is no mention of relapses. The histories of the individual cases quoted above show relapses, but can we be at all sure that a relapse occurring, certainly in the first and second of the cases, twenty-one days after the date of the original seizure, is that of relapsing fever ? It is extremely rare that the relapses in this fever should be protracted till the twenty-first day. Griesinger and Begbie do not seem to have observed relapses at so late a period of the disease. Lebert states that " the interval of freedom from fever lasts on an average for one week, sometimes only four or five days, rarely two wrecks or so." In the third case quoted, the primary access appears to have presented the usual symptoms of the epidemy, but after the patient had been eighteen days in hospital the second attack began a fortnight after his discharge ; this makes thirty-two days from the date of the first access. I conclude that these cases were in all probability malarial. Then again there can be no doubt of the existence during the epidemy of cases of remittent fever without relapses, such as the earlier cases that occurred in the beach party of the Minotaur. These were also in all probability malarious. Another remarkable feature of the disease as seen in the Black Prince was, that only half of the patients had regular relapses of fever, the others had what are called irregular relapses, characterised by vertigo, headache, bilious vomiting, or diarrhoea. If we assume that those cases in which true febrile phenomena recurred in ten, twelve, or fourteen days were cases of true relapsing fever, what are W'C to say of the cases in which the relapse was non-febrile ? I think I am right in saying that these dumb or non-febrile relapses have never before been described as occurring in relapsing fever. Home says that the initial fever might either be of a remittent or intermittent form. It is certainly rare for the initial fever of genuine relapsing fever to be intermittent. All these facts tend to show that numerous cases occurred which were malarious in their nature. But we have, on the other hand, the fact that large numbers suffered from a primary access without distinct remission, often accompanied by hsemorrhages and ending by perspiration ; and relapsing from the twelfth to the fourteenth day. Nothing could be more characteristic of relapsing fever than these symptoms ; and if they had occurred in a non-malarious country, and not as part of an epidemy in which malaria played at least an important role, they would be perfectly decisive as to the nature of the affec- tion. I do not place great weight upon the statement, that it is 266 NOETHEKlSr A\D WESTERN ASIA- " common for remittent fever in Cyprus to recur on the seventh, fourteenth, and twenty-first day, and so on/' because, for anything we know to the contrary, relapsing fever may be endemic in Cyprus, and may have been mistaken for remittent. In estimating the diagnostic value of relapses occurring about the fourteenth day, the fact must not be lost sight of that malarial fevers often recur on the fourteenth day from the date of the original seizure. G-ranting that malarial fever existed at that time in Cyprus, the fact of the relapse occurring frequently from the twelfth to the fourteenth day does not conclusively establish the non-malarious character of the affection in the relapsing cases. Griesinger points out that the " relapses of malarial fever develop in the greater number of persons with a great regularity after fourteen days or after three weeks." Out of 182 cases of intermittent fever observed by him, the relapses occurred in fifty-three instances between the eleventh and fourteenth day. In the case of remittent fever the same period of relapse has been observed in Tonkin ^ and elsewhere. Xo more does the occurrence of epistaxis and other hsemorrhages decide the nature of the epidemy. Hemorrhages have often been observed in malarial fever, and more commonly in some seasons and epidemies than in others. A point of great importance with regard to these haemorr- hages is the occurrence of epistaxis as well as purpura and sponginess of the gums amongst the invalids at Xetley who were undoubtedly suffering from malarial poisoning. Hsemorrhages are certainly very common in the course of relapsing fever ; indeed more so than in ordinary cases of marsh fever. If we admit that the haemorrhages and the sponginess of the gums during this epidemy were symptoms develojDing in the course of relapsing fever, to what, it may be asked, were due the epistaxis, sponginess of the gums, and purpura observed at Xetley ? Are w^e to suppose that they were the sequelae of the relapsing fever from which the patients may or may not have suffered during the previous summer ? This view cannot be rejected as impossible, but we know of nothing in the history of relapsing fever to support it. Sponginess of the gums has been observed in some epidemies of a genuine relapsing fever. It was a prominent symptom in the Yusufzie fever in India, described by Dr. Lyell in 1852. I do not think that there is the slightest reason for believing that the spongy gums observed in the Cyprus epidemy were the result of true scorbutus due to the want of green food. Veale states that the soldiers were supplied with plenty of grapes, and we know that soldiers are generally well fed and not liable to scurvy. This symptom was part of the epidemy itself, and * Grail, Ardiir. de mid. nav., Tomes xlv., xlvi. CYPRUS AND THE ISLANDS OF THE LEVANT. 267 was no doubt one of the conditions favouring btemorriiage. In the absence of any records of the pathological appearances in those who died, and in our ignorance as to the presence or absence in the blood of spirochiytio, no very positive opinion can be given as to the nature of this epidemy. I am satisfied that much of the fever of that year was malarial. From the character of the initial attack in many instances, its crisis, the relapses, the haemorrhages, the spongi- ness of the gums, and, above all, the fact of the disease spreading in some instances on board ship in a way that suggests contagion, and from the extent to which the natives suffered, I think it probable that numerous cases of relapsing fever did occur along with malarious remittent.-^ I cannot say whether it is more probable that these cases in which dumb relapses occurred were malarial or relapsing. I am equally at a loss to pronounce upon the question, whether the general condition of the system, which was manifested by the sponginess of the gums, haemorrhages, and purpura, was due to the malarious or to the relapsing fever, or whether it was not an independent cachexia. As it persisted after the relapsing fever had disappeared, and while only malarious poisoning appeared to remain, it might be argued that it owed its origin to the disease with which it ultim- ately remained associated. In this view the malarial epidemy would be conceived as having manifested or developed a scorbuto-heemorr- hagic cachexia. I use the term scorbuto-heemorrhagic, not as desig- nating a disease allied etiologically to scorbutus, but as a convenient name for a condition such as we have described — marked by spongy gums, purpura, and haemorrhages from the mucous membranes. This scorbuto-hsemorrhagic cachexia has been noticed in more than one epidemy of malarial fever. It would be going too far to assume that it was necessarily due either to the poison of malarial or relapsing fever. Another theory, and one for which much could be urged, is that it was a cachexia developed under unknown influences, and which aggravated the character of the fever or fevers with which it became associated. The climate of Cyprus has proved much healthier than the experience of 1878 gave us reason to expect, the ratio per 1000 of 1 Dr. Heidenstam, the cMef medical officer of Cyprus, in a private communicatiou to me says, "As to tlie fact that men suffered from those fevers who never left the ship, that is easily explained. Those ships were lying in roadsteads not far off from malarial foci, and consec|uently surrounded by a malarious atmosphere, and, further, used water from localities eminently infected with malaria. As regards hseniorrhages, although not always, it very often happens in cases of severe intermittent fever caused by hypersemia, effusion of blood, or perhaps pigmentary obstructions of the circulation in different organs." Altogether, he is of opinion that the epidemy was purely one of malarial fever. 268 NOETHEEN AND WESTEEN ASIA. fever admissions, fever deaths, and invaliding from fevers, for the succeeding three years was as follows : — Fever Admissions Fever Death-rate Invaliding from Fevers per 1000. per 1000. per 1000. 1879, 578-8 10-61 16-97 1880, 219-0 0-00 0-00 1881, 140-0 0-00 0-00 It will be seen from the above that while fever was frequent, pretty fatal, and severe during 1879, it was far less frequent in the two following years, and perfectly mild and harmless, the type being quotidian and tertian with little tendency to recur. The year 1884 was more unhealthy; this was ascribed by the medical officers to " the excessive rainfall of that year in a subsoil without drainage and in parts thoroughly water-logged" (Ar7ny Medical Report, 1884). The return for 1886 gives the ratio of admis- sions for malarial fever at 160-4 per 1000. No deaths were recorded for that year, and the invaliding from this cause was 1-57 per 1000. The higher lands in Cyprus may be regarded as healthy, but what elevation is necessary to ensure immunity is unknown. The cantonment at Troodas, at a little over 5000 feet, is non- malarious. Larnaca, situated near salt lakes, is stated by Lefevre (quoted by Lombard) to be particularly unhealthy, the fever in this locality often assuming a pernicious form. The appearance of the inhabitants is also said to be cachectic. ISTikosia and Limasol are less affected. Heidenstam indicates the Potamia quarries, situated on the coast between Larnaca and Famagusta, as a specially feverish area. The two cases of the algid form met with by him during seven years both came from this locality. The choleraic form is also met with, but is not common. The comatose form is apparently more common.'^ Continued or Remittent Fever. — The following is Heidenstam's description of the remittent or continued fever of Cyprus : — " This type is due to intense malarial infection, and is often met with in this island during epidemies of intermittent fever, especially towards the autumnal season ; they greatly resemble in symptomatology inter- mittent fever, with the exception that instead of clear, there are simply slight and very often almost imperceptible remissions, and a sensation of chilliness and rigor generally precedes the paroxysm. The ana- ' The coma which terminates the febrile paroxysm is very similar to natural slecji, but of prolonged duration '; and as the first attack is rarely fatal, this plienomenon is constantly considered by the friends of the patient as a salutary sleep, but in the second attack the patient sleejis never to awaken. CYPRUS AND THE ISLANDS OF THE LEVANT. 2G9 tomical appearances also do not differ from those met with in intermittent fever as far as the spleen and liver are concerned, but we, however, meet congestion in the brain, catarrhal and diphtheritic inflammation of the intestines, and sometimes even signs of hfcmorr- hage into the stomach and hemorrhagic infractions in the lungs. " The disease may be divided into three classes — mild, severe, and intense. " The first or mild class sets in with a sudden feeling of oppression about the epigastrium, mental depression, headache, and a cold feeling down the back. These symptoms are soon followed by high fever, flushing of the face, the skin being very hot and dry, the temperature rises to 103° or 105° F., the pulse is small and full, from 120 to 130, the tongue is furred and dry, the spleen is enlarged and mild jaundice is observed, the bowels are irregular, the faeces discoloured, and bilious matter is often vomited. A most particular symptom, which I have never failed to meet in cases of remittent fever, is a buzzing noise in the ears. At the commence- ment of this form of fever there exist irregular exacerbations, which become more and more regular, and are subsequently followed by clear remissions generally occurring in the morning ; the symptoms gradually decrease, perspiration sets in, and the patient recovers. This course lasts from a few days to three weeks. " In the second, severe class, the remissions are only slightly marked at the invasion, all the symptoms of the previous form are aggravated, the patient becomes delirious and stupid, the disease lasts from eight to twenty-one days, and sometimes more, and if it ends in recovery it usually assumes an intermittent type. If death results, it is generally sudden, with symptoms very analogous to typhus fever. " The third, intense class, has a striking similarity to typhus fever of a very adynamic character. . . , The spleen and liver are con- siderably enlarged, epistaxis and hasmaturia are often noticed, and sometimes suppression of urine or albuminuria. Inflammatory exudations not unfrequently form in the serous membranes or lungs ; towards the second week, petechise are met with on the skin, the patient soon falls into a deep apathy, which is followed by collapse." Enteric Fever is prevalent among the civil population, and a certain number of cases occur among the troops. Ty^phus Fever was stated by Fracastori, in the earliest description extant of the disease,^ to be a malady indigenous in Cyprus and the neighbourinfT islands, but I have met with no recent accounts of its existence in the island. ^ De morhis contajiosis, Venet, 1584, 87. 270 NOETHERN AND WESTERN ASIA. Dysentery prevails to a considerable extent in the plains, but the disease is usually of a mild type. Biarrhcea is one of the commonest diseases in the towns during the warm season, and causes a considerable infantile mortality. Acute diseases of the Resinratory organs are exceedingly rare, and Phthisis is only moderately common. Bheumatic Diseases do not prevail to any large extent ; and although Bheumatic Fever is met with, it is of less frequent occurrence that in Western Europe. Syphilis is widely diffused among the population of the towns, but is generally of a mild type. Zcjjrosy. — At the time when the British occupation began, it was calculated that 33 out of 667 villages were infected with leprosy; the number of lepers at that period being estimated at 150. The greater number of cases come from the low-lying villages in the district of Famagusta. It is rarely met with amongst the Mussulman population. The sore known as the Aleppo Boil is frequently seen on the island. CHAPTER IV. AXATOLIA (ASIA MINOE), ARMENIA. Geography. — Anatolia and Armenia extend from the ^gean Sea to the borders of Persia, and from the Black Sea on the north to the Mediterranean Sea, Syria, and Mesopotamia on the south. Together they constitute a vast plateau, rising to a height of from 2400 to 7000 feet above the sea, surrounded along the coasts by a belt of low land of varying breadth. In some places the mountains abut on the sea ; in others, wide and fertile plains stretch between the sea and the high lands. Even where the coast line is narrow, the river valleys extend for some considerable distance inland. The table-land is bounded on the north by a more or less continuous range of hills running parallel to the Black Sea. These are in many places covered with forest. On the south, along the Mediterranean, is the Taurus range, which attains altitudes of from 8000 to 12,000 feet. On the west, along the ^gean and the Sea of Marmora, the mountains are more detached, and run perpendi- cularly to the coast line. The table-land thus bounded is generally bare and treeless, presents extensive grassy plains, and naked tracts covered with an incrustation of salt, with numerous salt and fresh water lakes and marshes. The principal lakes in Anatolia are the Tuzla Gol, the Bei-sher, and the Egerdir in the interior. Lakes Maniyas, Abullonia, and Isnik are found at some little distance inland from the Sea of Marmora. The largest sheet of water in Armenia is Lake Van, which has a length of 80 miles, and is 50 miles broad. It is a salt lake. The rivers running into the Black Sea are the Yeshil-Irmak, the Kizil-Irmak, and the Sakaria. Into the ^gean flow the Sarabat (Hermus) and the Mendereh (Mseander). No river of any note falls into the Mediterranean. 272 NORTHEEN AND WESTERN ASIA. The population of Anatolia is estimated at about 5,000,000, and that of Armenia at about 2,000,000. Climatology. — The climate of the higher parts of the plateau extreme. The sum.mers are excessively hot, the winters very IS cold and prolonged. Snow lies on the table-land of Armenia up to June. The climate of the coasts of the Black Sea is milder than that of the high lands, but here, too, the summer temperature is high. Winter is the rainy season, the summers are dry. The annual mean temperature of Trebizond on the Black Sea is 18°-5 C. ; that of January, 6°-8 ; of April, 12°-2 ; of July, 24°-3 ; and of October, 15°-o C. Smyrna, on the ^gean coast, has a mean annual temperature of 18°-7 C. ; that of January, 8°-2 ; of April, 14°-6; of July, 26°-7 ; and of October, 16°-9 C. At Erzeroum, in Armenia, at an altitude of 1591 metres, the monthly mean temperature, according to Lombard, is as follows : — January, February, Marcli, . April, . May, . June, -778 -3-5B 1-39 9-28 11-06 18-78 July, . . . . 22-28 August, . 22-78 September, . . 16-89 October, . 10-89 November, . . 3-17 December, . -4-94 Pathology. — Malaria. — Malarial fever is endemic all along the Mediterranean. Ague and remittent fever prevail at Besika Bay {Navy Beport, 1878). Inland from this bay, on the plains of Troy, malaria is common, and is sometimes epidemic after heavy rains, as was the case in 1870 (Lombard). Dr. Schliemann's excavations had to be suspended for a part of the year on account of malarial fever, which appears to have been rendered more intense by the dis- turbance of the soil. During the Crimean War, Parkes witnessed its frequency here, and observes, that " on making some inquiries of the inhabitants of the highly malarious plains of Troy, I found the villagers universally stated that those who drank marsh water had fever at all times of the year, while those %vho drank pure water o-ot af^ue during the later summer and autumnal months." The shores of the Sea of Marmora and the coasts of the Black Sea are severely affected with malaria. At Trebizond and Sinope, fever is extremely frequent. According to Hell, those parts of the country near the Black Sea suffer most wliere the forests descend to the sea, but no part is entirely exempt from fever. The high plateaux of the interior enjoy only a relative immunity. Fever is met with at altitudes of 4000 feet, or perhaps even higher. Ague exists along the shores of Lake Van, and in the upper course of the Tigris and its tributaries. At Bitlis, a short distance south of Lake Van, after passing tlirough a rugged country with numerous ANATOLIA (ASIA MINOR), ARMENIA. 273 rivers and streams, Layard's party was for the first time during the journey visited with that curse of Eastern travel, " fever and ague." At the higher elevations, the fevers are of the intermittent type, and mild in character ; but remittents as well as intermittents of a more severe form are met with at the lower levels, especially along the borders of the lakes which become partially desiccated in summer. According to Tchiatcheff, the fever attains its maximum in Asia Minor in the month of September, a minor rise taking place in spring (Eey). Typhoid Fever. — Although our accounts of this disease are scanty and confused, they leave us in no doubt as to its endemic existence in Asia Minor ; we are unable, however, to estimate its comparative prevalence in different parts of the country. Tyxjhus Fever was introduced into Trebizond, Samsoon, and other parts of Asia Minor in 1863 and 1864 by Circassian immigrants from the Caucasus, but the disease is not endemic in the country. Hirsch is of opinion that Bilioiis Typhoid is the disease referred to as " Levant fever " and " Smyrna fever." The typhus complicated with jaundice, which has been observed at various times at Smyrna, is probably of this nature. Cerehro-spincd Meniwjitis was observed at Magnesia in 1869, and at Smyrna in 1870. Diphtheria, which appeared at Smyrna for the first time in 1865, has since that date raged disastrously in many places in Asia Minor (Hirsch). Cholera reached the northern and southern confines of Asia Minor in the years 1822-23, but did not then invade the country. The disease was introduced into Smyrna in 1831, and on this occasion, again, it does not appear to have made its way into the interior; but in 1848 and in 1853-56, cholera became widely diffused all over the country. Trebizond, Samsoon, Sinope, and some parts of Armenia were visited during the epidemy of 1865, but the country generally escaped during this outbreak. Dysentery may be regarded as endemic in Asia Minor. It is met with along the coasts, especially in Adana; and it is also prevalent in the valleys of the Anti-Taurus and on the table-land. Diarrheal diseases are common in all parts of the country. BroTwhitis and catarrhal affections are signalised as specially prevalent on the high table-land of Armenia, and Pneumonia as of frequent occurrence on the plains of Troy. Phthisis is common in the large cities, but is seldom seem on the Armenian jjlateau, where, according to AYagner, it is seen only in persons who have migrated from other countries.^ 1 Wagner, Relse nach dem Arrarat, Stuttg. 1848, quoted by Hirscli. S 274 NORTHERN AND WESTERN ASIA. Syi:)liilis is by no means rare in the seaport towns of Asia Minor ; but we have no accounts respecting the extent to which it prevails in the interior, with the exception of Armenia, where it is reported to be unusually frequent. Scrofula is a common disease throughout Asia Minor. Leprosy is only met with in isolated cases in Smyrna, and at some points on the coast of the Black Sea. Goitre and Cretinism occur endemically, according to Hirsch, only in one or two localities. These are " at Bolat, in the valley of the Kulschuk-Mender, in the neighbourhood of Aidin, in Marsovan, in the upper valley of the Euphrates (north-east of Arabkir), and in Esin." CHAPTEE V. SYRIA. Geography. — Syria is bounded by the Taurus range on the north, on the south by Arabia, on the east by ]Mesopotamia, and on the west by the Mediterranean. The northern provinces of Adana (politically a part of Anatolia) and Aleppo are traversed by mountains running from north to south, which are offsets from the Taurus range, and are continuous in the south with the Lebanon and Anti-Lebanon chains, which enclose Ccele-Syria and bound the valley of the Jordan. The Dead Sea, the Sea of Galilee, the Lakes of Damascus, into which flow the Abana and Pharpar, and the Sabaka to the south-east of Aleppo, are the only lakes of importance in this province. The Dead Sea is especially remarkable. It is 40 miles long, by an average breadth of 9 miles, and is 1312 feet below the level of the Mediterranean. Its southern shores are low, level, and marshy. The soil of Syria is generally rich wherever water is abundant, but towards the east the country is a dry and parched desert. Climatology. — The mean annual temperature of Beyrouth, on the coast, is 20°"6 C; that of January, 12°-9 ; of April, 18°'7; of July, 27°-8; and of October, 24°"2 C. Eains are rare between the 15th of June and the 15th of September. Jerusalem, at an altitude of 2670 feet, has a mean temperature of 17°"2; that of January, 8°-5 ; of April, 14°-5 ; of July, 24°-5 ; and of October, 20°-8 C. At Aleppo, on the border of the desert, the mean temperature of the year is 17°"6 ; the winter temperature is 6°'3 ; and that of summer, 27°'2. The climate of Aleppo is very dry. Pathology. — Adana, on the great Cilician plain in the northern part of Syria, is highly malarious, especially along the course of the Tersus Chai, of the Sihun, and of the Jihun. The evil is augmented in respect to the country traversed by the first of these rivers, by the fact that it is liable to overflow. The coast line here is marked 276 NOKTHEEN AND WESTEEN ASIA. by sand hills about ten feet higb, and by lagoons and marshes fringed with reeds and cane-brakes. There are also two large marshes, one south-west of Tarsus, the other five miles south-west of Adana. On the banks of the Jihun there is a Noghai settlement. After the Crimean War about 20,000 Noghai families left Eussia and took up their abode on this plain. 'Now, barely 2000 families remain. This shows how powerfully malaria dominates this once healthy region.^ The inhabitants of Tarsus and Alexandretta take refuge during the summer months in the neighbouring hills to escape fever. The plain of Antioch is unhealthy ; the coast towns, Tyre, Acre, and Jaffa, all suffer more or less. At Tripoli fevers are very frequent, and this is ascribed to the fact that a stream from Lebanon runs through the town, causing humidity of the soil.^ The hilly regions are healthy ; but the inland districts, although at an elevation of from 500 to 2000 feet, are not free from fever. At Jerusalem, from a quarter to one half of the admissions into hospital are for fever. The intermittent and bilious, or gastric remittent forms, are all met with. Damascus, at an elevation of about 2260 feet, suffers from intermittent fever from August until the cold season sets in. Aleppo is healthy ; and, according to Barret, Beyrouth is free from malarial fevers. Typhoid Fever is of frequent occurrence at Jerusalem and Damascus, and also, although less frequently, at Beyrouth. March, April, and May are the months when it is most prevalent. TypJius has occasionally been observed in an epidemic form, but it is not endemic in the country, so far as is known. A few cases of epidemic Cerehv-spinal Meningitis were observed in Jerusalem in 1872. Plague was formerly a frequent visitor in Syria. Hirsch reckons that thirteen outbreaks occurred between 1773 and 1843. Since the latter date the disease has not been observed in Syria. Diphtheria and Croup are met with, but we do not know to what extent they prevail. Asiatic Cholera has repeatedly invaded Syria. Dysentery, DiarrhceCc, and Gastro-Enteritis are prevalent diseases, constitutino- from one-fourth to one-sixth the admissions into the 1 Wilson, Proc. Roy. Geog. Soc, June 1884. 2 Rey makes this statement in his article ' ' Geo. Med. " {Nouv. diet, de mdd, et chir., tome xvi. p. 221) ; but it should be remarked that Barret [Archiv. de mdd. nav. 1878) says that intermittent fever is very rare at Tripoli, is more fre(][uent at St. John d'Acre, and rages with force on the north part of the coast, notably at Mersina and Alexandretta, where pernicious cases occur in autumn. SYRIA. 277 hospitals at Jerusalem ; they are also of frequent occurrence in Damascus, Beyrouth, and Aleppo (Lombard). Smallpox. — From the general neglect of vaccination, smallpox is frequently epidemic in Syria, and causes a high mortality. Measles often makes its appearance, but Scarlet Fever is seldom seen. Fhthisis is rare at Beyrouth, where it follows a slow course ; nor is it at all a common disease at Jerusalem. It is more frequent in the Lebanon, and is said to be endemic at Baalbec and Aleppo.^ Bronchitis and Pneumonia are frequently met with in Jerusalem. Pneumonia is rare at Beyrouth, but is much more common in the mountainous parts of Syria. Sepatic diseases are by no means rare ; but Abscess of the Liver is only occasionally seen. Bheumatism is one of the common diseases of the country, and Rheumatic Fever is not unfrequently met with. Yates treated 429 cases of rheumatism at the British dispensary at Beyrouth (1842-43) out of 4298 patients. Leprosy prevails to a considerable extent in the valleys of the Lebanon and Anti-Lebanon. Considerable numbers of these sufferers, from all parts of the country, congregate at Jerusalem. The sea-coasts are but little affected. The Aleppo Boil is met with not only in Aleppo, but also at Alexandretta, and in many other localities in the north-west of the province of Aleppo.^ Syphilis is moderately diffused throughout Syria. Scrofula is seen in all parts of the country among the poorer classes, but is decidedly rare in the mountainous districts. Rickets are also by no means rare. Amongst the prevailing diseases of Syria have to be named Conjunctivitis, simple and purulent, and eye affections generally. Anmmia, according to Barret, is a frequent disease at Beyrouth. 1 Guys, Statist, du PaschaliJc d'Ale]}., Marseille 1853, quoted by Hirscli. - Fox and Farquhar, On certain Endemic Skin Diseases, London 1876. CHAPTEK VI. MESOPOTAMIA AND KUEDISTAN. Geogeaphy AND CLIMATE. — Mesopotamia comprehends not only the valley of the Tigris and Euphrates, but the whole region bounded by the Zagros Mountains and Kurdistan on the east, and by the Syrian desert and Arabia on the west. On the north is Armenia, on the south the Persian Gulf. The northern districts of Diarbekir and Kurdistan, bordering on Armenia and Persia, are mountainous ; the rest is a plain, which, except near the banks of the rivers, is covered with verdure only during the rains. This region, the seat of ancient empires, and once one of the richest and most populous parts of the world, is to-day in many parts barren and desolate. Layard tells us that " the greater part of the country below the site of ancient Babylon has been for centuries a great swamp. Another extensive swamp is formed by the Euphrates above its confluence with the Tigris at Korna, and these swamps are ;^early increasing in extent,^ so as to threaten to cover the whole of southern Mesopotamia." The province of Bagdad, comprising the greater portion of the basin of the Lower Euphrates and Tigris, has an estimated population of 4,000,000; that of Diarbekir has about 700,000 inhabitants. The population of the city of Bagdad is variously estimated at from 60,000 to 180,000 ; that of the town of Diarbekir numbers about 40,000. The former is liable to inundations; the latter presents numerous stagnant pools, which are supposed to render it unhealthy. The climate of the mountainous districts differ little from that of Armenia. As we descend to the plains the temperature increases; the winters especially become shorter and more temperate. The following, according to Hann, are the temperatures at Mosul and Bacjdad : — Mosul, Bagdad, 1 Layard'.s Discoveries in the Ruins of Nineveh and Bcil»jlon, London 1853. Jan. ApriL .July. Oct. Year. 7-0 15-4 34-1 22'4 20-1 9-7 23-1 34-9 24-8 23-3 MESOPOTAMIA AND KURDISTAN. 279 At Bassorah, on the Shat-el-Arab, nearer to the Persian Gulf, the temperature is still more oppressive. The rainfall throughout this region is scanty. For the Mesopotamian plain, Colville gives it at 18-25 inches. The rainy season being the months of December, January, and February.^ Sclih-efli, calculating upon 10,509 deaths occurring at Bagdad between 1853-62, found that the four seasons range themselves, as regards mortality, in the following order : — Summer. Spring. Autumn. "Winter. 23-8 24-76 25-26 26-18 Pathology. — Malaria. — No part of Mesopotamia is free from malaria, which may be regarded as the dominating element in the pathology of this region. At Diarbekir fever is prevalent. Mosul, situated on an elevated position on the right bank of the Tigris, is the prey of remittent fever in summer, and of intermittents in winter. Bagdad is highly malarious. Hyslop informs us that " in the hot season of 18 34, the town suffered very much from inter- mittent fever ; a circumstance," he says, " never known before, but easily accounted for by the vast number of marshes left all around the city by the late overflow of the Tigris. In 1 8 3 6, the mortality, in a population of 75,000, exceeded sixty a day from bilious-remittent fever, the weather then being hot and oppressive. From that time to 1840 intermittents were prevalent every autumn. The overflow of the river in March and April 1849 was followed in the middle of June by a great mortality from fever, dysentery, and diarrhoea. In 1850, fever again prevailed to as great an extent as in the former year. The fever of 1849 is stated to have been accompanied by bilious vomiting and intensive headache. When it proved fatal, it generally did so by ending in coma. In the beginning of the epidemy no cold stage was observed, but as it progressed this stage became more marked, and at last the ague was the worst part of the fever." - Hillah and Samareh are comparatively healthy. After the junction of the Tigris and Euphrates, the united stream takes the name of the Shat-el-Arab. The entire course of this river, the country through which it flows, and its delta, form one of the most malarious regions anywhere to be found, especially those districts liable to inundation. Mr. Ives, who visited this district in 1758, says that he "was informed that the Arabs had broken down the banks of the river near Bassorah with design to cover with water the deserts in the neighbourhood — an act of 1 Trans. Epiclem. Soc. 1875-80. - Hyslop, Trans. Bomhay Med. and Pliys. Soc. 1849-50, and 1853-5-4. 280 NORTHEEN AND WESTERN ASIA. barbarity causing general sickness."^ Evatt, writing in 1875, states that " Bassorah is decimated by malarious diseases, — every man in Bassorah has ague." The fever is often of the pseudo- continued form, with liver and spleen complications. As proving the intimate relation between soil-conditions and malaria, it is to be noticed that the heights round Bassorah are healthy. The years of heavy rainfall are specially feverish. The saying is, and it is certainly true for miasmatic fevers, " the hotter the season the healthier it is." A great fall of snow on the hills is accompanied by a great fall of rain on the plains ; and to an unusual fall of rain, more than to inundation, is increased sickness due (Colville). Enteric Fever has been observed at Bagdad. It was epidemic among the Kurdish prisoners in 1855 and 1857. It has also been noticed at Suleimanyeh in Kurdistan, to the east of Mosul (Lombard). Evatt signalises the frequency of fevers of a low type in Bagdad, which may probably be taken to include Typlioid Fever. {Army Medical Report, 1874). Typhus was observed at Mosul in 1854, and at Suleimanyeh in 1855. Typhus is probably endemic in Turkestan and in the basin of the Euphrates and Tigris. Dr. Schlsefli signalises the frequency of simple and membranous sore throats, from which we may conclude that Diphtheria is not unknown. Cholera is a frequent visitor in Mesopotamia. Evatt reckons that Bagdad had suffered from thirteen outbreaks during the preceding forty years. Dysentery and Dlarrhcea, as we have seen, are occasionally epidemic in Bagdad. Eloyd's observations ^ seem to point to the prevalence of dysentery in Bagdad, but Hyslop says that it is not common. Our information respecting other districts is vague, but we gather from general references that dysentery, both as an inde- pendent disease and as a complication of malarial fever, is wddely diffused over the Mesopotamian plain, and that it is most fatal in the warm season. Cholera Infantum is also signalised as of frequent occurrence during the summer months. Smallpox was observed by Dr. Schkefli in Mesopotamia in 1854, 1856, 1857, 1858, 1859, and 1860. Evatt, in 1875, states that it is of frequent occurrence in Bagdad. Smallpox thus appears to be, to a certain extent, endemic in this region. Measles and Scarlet Fever prevail from time to time, but do not appear to exhibit any special malignancy. Whoopiivj-Coiujh is met with from time to time in an epidemic form. 1 Lind's Essay, London 1768. - Floyd, Lcuicet, July 1843. MESOPOTAMIA AND KURDISTAN. 281 Plarjuc is endemic iu Mesopotamia, and has been so for ages. A terrible visitation of plague is said to have occurred at Bagdad in 1715, another severe epidemy occurred in 1772, and other severe outbreaks were witnessed in 1800-2 and 1831-34, on which latter occasion the disease is said to have caused great havoc in the city. From 1856 down to 1885 (which is the latest date for which we have trustworthy data) plague has never been absent from the country, shifting from one place to another. Irak Arabi, the ancient Babylon, Hillah, and Bagdad have all suffered, but not more than the smaller towns. During these out- bursts some villages have lost more than a third of their inhabitants.^ Pneumonia and Bronchitis are by no means rare in Mesopotamia during the winter season. Phthisis is seldom seen at the higher altitudes, but Dr. Schlffifli ^ states that Ttcberculosis is by no means rare among the natives of the plain, and that strangers also contract the disease. Scrofula, PJieumatisni, and Oijhthalruia are mentioned by Floyd as diseases affectinfr the natives of all classes in the delta of the Euphrates. The Aleppo Sore is endemic throughout the country. Lep'osy is said to exist in Mesopotamia, but I have met with no data to enable me to form any estimate of its prevalence. ^ Mahe, Archiv. de m6d. nav. tome xliv. ColviUe, Trans. Epidem. Soc. 1875-80. 2 ScHtefii, Zur physikalischen Oeographie von Unter - Me-sopotamien, Bagdad 1862, quoted, by Lombard. CHAPTER VII ARABIA. Geography. — The peninsula of Arabia is situated between 12° 40' to 34° K lat., and between 32° 30' to 60° E. long. Its greatest length, from north-west to south-east, is about 1800 miles; its mean breadth, about 600 miles. Its area is 1,230,000 square miles, with an estimated population of about 5,000,000, The interior of Arabia consists of a vast plateau, from 2000 to 7000 feet above the sea-level. An Alpine chain (serat), whose peaks form a crest from 8500 to 9800 feet in altitude, extends all along its west side from the extreme south to Syria. The southern edge of the peninsula is likewise formed by a mountain mass, which sends out its spurs as far as Muscat on the east. The interior is in its central part furrowed by numerous streams or torrents which contribute their scanty waters to the Wady-el- Dawasir. The IsTejid plateau to the north contains a scattered population living in the valleys and oases where water is obtain- able. To the south extend the elevated Dahna deserts. But whilst the interior is arid, and but sparsely populated by nomadic tribes, the costal fringes are rich, productive, and well culti- vated. Aubert Eoche ^ describes three terraces on the western side of the peninsula, rising one above the other. The lowest of these is subject to inundations, and is alternately submerged and left dry by the sea, or as a result of the rains ; the second occupies the middle zone, and is consequently free from this source of danger ; whilst the third is situated at the higlier elevations. Climatology. — All along the coast the temperature is very high. At Hodeida the thermometer frequently rises to 104° F. Its minimum record in the coldest month is 57° F. At higher elevations the heat is less oppressive ; but even at Sana (7284 feet) 93° F. are often registered in the hottest season ; and in ^ Ann. d'lnjij, publ. voL xxxi. 1844, p. 26. ARABIA. 283 winter, although ice is formed during the night, yet the ther- mometer registers 68° F. after noon. In the mountainous districts there are two periodic rainy seasons — a minor one in March, and a major one in July, August, and September. Pathology. — Malaria. — The western, southern, and eastern coasts of Arabia, with the exception of isolated localities, are malarious, and the infection, which extends for some distance inland, reaches considerable elevations. The lowest of the three terraces mentioned above is the most unhealthy ; the second less so ; but it is only when we reach the third or highest terrace that the climate becomes entirely healthy. Yembo, Jeddah, Konfodeh, Lohei, Hodeida, and Mocha, along the west coast, are all affected in different degrees. Malarial fevers prevail with great intensity, and sometimes in an epidemic form, at Medina. This is ascribed to the marshes which exist in the environs of the city. Mecca is more healthy ; but even here fevers, supposed to be of malarious origin, occur. The whole central plateau, " com- prising the space occupied by Djebel-Toweyk on the east, Wadi Dawasir on the south, the desert margin of Hajj or pilgrim route to the west, and the Nefood above Djebel Shomer to the north, with whatever lies within these four limits, is one of the healthiest of conntries." Palgrave says, " Of intermittent fever, though I heard of it, and witnessed one or two cases, I should say that it is extremely rare." ^ Typhoid Fever is not unknown along the coast line. Courbon says that it is met with at Jeddah, although it is rare. Perhaps it will be . found to be more frequent than is at present supposed. Typhus and typhoid fevers, according to Palgrave, are wholly unknown through- out the Nejid, taking that term in its widest geographical acceptance. This writer, however, states that a remittent fever of a simple type, milder than the remittent of India, which soon yields to tartarised antimony in small but repeated doses, exists here and there throughout the Nejid. If improperly treated, it may drag on for two or three weeks. This seems to be similar to the fever observed by Peters at Muscat. Plague was destructively epidemic along the west coast in 1815 and 1832. On the former of these occasions it was estimated to have carried off about a sixth of the population of Jeddah and Mecca. It again showed itself in the mountainous district of Assir in 1853, 1874, and 1879. From this centre, on all of these occa- sions, it invaded considerable, but imperfectly defined tracts. 1 Palgrave, Journey through Central and Eastern Arabia, Lond. 1S65. 284 NORTHERN AND WESTERN ASIA. Cholera. — Zaciitus Lusitanus, writing in 1629, notices the existence in Arabia of the disease known in India as Mordeshi, which was undoubtedly epidemic cholera/ In recent times Arabia has suffered from frequent outbreaks of this disease. Cholera ap- peared at Muscat in 1821. The coasts were invaded in 1831, 1835, 1846-48, 1859, 1864-65, and 1871-72. The pestilence was introduced from India in 1864. In May 1865 it broke out among the pilgrims in Mecca, by whom it was diffused through Egypt, from which it extended to Europe and America. The disease has penetrated into the central districts. El Hail, the capital of the district of Djebel Shomer in the inland provinces of Nejid, was attacked in 1871, although in former epidemies this district appears to have been spared, even when the low isolated valley of the Djowf suffered severely (Palgrave). Dysentenj is widely prevalent along the coasts, but is of less frequent occurrence in the interior. Smallpox has been endemic in Arabia from time immemorial, and is propagated by the practice of inoculation, which is still in use in the Nejid. The prejudices of some of the tribes prevent the adoption of vaccination. Measles is known, but is neither frequent nor severe. Scarlet Fever also exists, but it does not appear to be a common disease. PneuTtwnia and Bronchitis, rare on the coasts, are common enough on the plateau. Phthisis, according to Palgrave, is rare on the Arabian plateau. On the shores of the Eed Sea the settled Arabs suffer to a con- siderable extent from the disease. What Palgrave calls abdominal phthisis is common in the interior. From the fact that this malady does not appear to have been peculiar to infancy and childhood, other diseases than tabes mesenterica are perhaps indicated or included. Scrofula, affecting the glands of the neck, and rachitis pro- ducing distortions, are often seen in the southern Nejid, but are rare in Shomer, Kaseem, and Sedeyr. Bheumatism, of all possible forms, is common among the Bedouins and the poorer villagers, and cardiac affections are not at all rare. Cancer seems to be practically unknown. Syphilis, called Belegh, is " frightfully common." Palgrave says that the disease is supposed to be communicable from one to another in no less comprehensive a way than smallpox and scarlet fever; and he adds that he saw cases that hardly admitted any other explanation. ' Trans. Epklem. Soc. vol. iii. ARABIA. 285 Ophthalmia is one of the commonest maladies of Arabia. Two points on the peninsula demand more detailed considera- tion, viz. Aden and Muscat. ADEN. ToPOGEAPHY AND Climate. — The peninsula of Aden is 1 5 miles in circumference, and is joined to the mainland by a narrow isthmus about 3 miles in length. It consists of a mass of volcanic rocks destitute of vegetation, except where the furrows made by the occa- sional rains show a faint trace of green. The population is confined to two localities — Steamer Point, and the Crater or Camp where the native town is situated. The shores of Aden Bay are left exposed at low tides. Swampy ground exists at the further extremity of the isthmus, and large salt marshes near the shores of the bay. At Steamer Point the soil along the shore is sandy; but this sandy fringe is quite narrow, terminating in bare rocks upon which are built the barracks and houses of the officials and wealthier merchants. The greater number of the houses, however, are built along the sandy shores. The Crater is a sandy hollow, encircled by a high wall of bare volcanic rocks. The water supply is derived from four sources : 1. An aqueduct from the mainland ; 2. Con- densed water: 3. Prom the enormous tanks that form one of the sights of Aden ; 4. Prom wells which have a considerable depth and yield a brackish water. Water from the aqueduct is sold at two pies per gallon ; that from the tanks at one and a half pie. The humidity of the air is at times excessive, rendering the outside stairs of the buildings as wet as if they had been watered. Carts pass round and remove the night-soil, which is burned. The town within the Crater is protected by its perpendicular wall of rock from infection which might be carried by the winds from without. The very rare, scanty, and irregular rainfalls must be rapidly absorbed by the sandy soil, and nothing in the nature of a marsh, temporary or permanent, exists within the Crater. A popula- tion of twenty to thirty thousand must always, however, require a considerable daily water supply for domestic purposes ; and in Aden the waste water is thrown out into the sandy paths that serve for streets. This soakage of liquid impurities is, so far as I can see, the only source of moisture to give rise to malaria, if, indeed, this infection is really endemic in the Crater, which I doubt. At Steamer Point we cannot, it is true, exclude the possibility of miasm arismg 286 NOKTHEEN AND WESTERN ASIA. from the foreshores and from the swampy lands and salt marshes in the neighbourhood. So much for the physical conditions of the soil at Aden, which certainly appear little favourable to the development of malarial fever. The following table gives the temperature, rainfall, and humidity at Aden, along with the monthly fever admissions per 1000 of the European troops, 1839-45 (Webb).i It must be remembered that the troops which garrison Aden have previously served in the malarious Presidency of Bombay. Mean Tempera- ture. Average Rainfall. Hii midity. Fever Admissions per 1000 of strength. Fever Deaths per 1000 of strength. January, February, Mareli, April, ]\ray, June, July, August, September, October, November, December, 74-9 75-9 78-6 81-5 84-9 86-7 84-7 84-7 86-3 81-8 77-2 75-6 0-53 0-48 0-15 0-39 0-28 0-00 0-02 0-11 0-00 0-00 0-16 0-24 70 70 70 67 69 65 67 66 64 63 66 70 26-902 22-148 30'475 43-198 61-388 74-796 51-371 19-446 26-878 82-407 33-881 26-953 0-284 0-568 1-147 1-746 0-875 0-273 2-439 0-505 0-272 Totals and ) Means, \ 81-1 2-36 67-3 499-843 8-109 Pathology. — An examination of this table will show that the fever curve at Aden exhibits two maxima and two minima. The maxima occur in June and October, the minima in February and August. The fever admission-rate rises steadily from March to June along with the increasing temperature and the decreasing humidity of the atmosphere ; it begins to fall again, however, in July, and in August and September the admission-rate is low, and this notwithstanding the persistence of nearly the same conditions of temperature and humidity ; the fever admission-rate rises rapidly in October, — a month during which there is a decided fall in the temperature with the minimum of humidity. This rise is a sudden and temporary one, for in November the fever admissions diminish greatly, and during the cool season — ISTovember to March — the fever admission-rate remains low. The first rise in the fever rate, from IMarch to June, being constant and steady, is probably connected with the steady increase in temperature during these months. But that the high tempera- ^ Trans. Bombay Med. and Fhys. Soc. 1851-52. For the month of January the average is for three years only, viz., 1840, 1841, and 1842. AEABIA. 287 ture is not the sole cause of the evolution of fever, is evident from the great fall in the admission-rate in August, when the temperature is still high, and by the second rise in October, when the tempera- ture has considerably fallen. Do these two rises depend on two fevers, or on two forms of one and the same fever ? In October malarial fever is most prevalent in these latitudes, and we may conjecture that the second maximum is owing to relapses of malarial fever, brought on by the falling temperature. We shall see, as we proceed, that in Muscat, as in Aden, these two maxima appear, and about the same time, which points to the conclusion, that whatever may be its true explanation, this curve corresponds to something real in the pathological evolution of the seasons. We shall now try to ascertain the general features of the pathology of this remarkable spot, and the nature of the fever met with in this domain of burning rock and sand. Mr. Steinhauser, Civil Surgeon, in his report on amative and General Hospitals, Civil and Military, for 1853 and 1854,'- says : " The chief diseases, taking them numerically, treated during the past year at both hospitals have been fevers, ulcers, rheumatism, diarrhoea, dysentery, and scurvy, all of which affections may be considered as prevalent at Aden. Fevers are of daily occurrence during the entire year, and cannot be said to prevail at any given season. During the months of June and September the admissions were, in the past year, most numerous. The total number of fevers treated have been 505. The casualties under this head are five in number — about 1 per cent, of the treated. Fever as it presents itself at Aden is not a very formidable disease. Among the Europeans it mostly assumes the bilious-remittent type — inter- mittents being uncommon. . . . The moist, hot climate of this part of Arabia appears ill adapted for convalescents from any disease. Among the native population fever presents itself as a quotidian intermittent, or in the common continued form, accompanied by much derangement of the chylopoietic organs." It must be observed that in the civil hospital sailors and others, who may have con- tracted the disease elsewhere, are treated. We do not know what proportion of these treated belong to this class. It is a question, too, whether the natives who suffer from intermittents contracted them in Aden or in the environs, which, as we have seen, contain marshy localities. It may, however, be regarded as possible that some of the cases of intermittent fever occurring among the native population were contracted on the peninsula. But, considering the large population, permanent and floating, it must be conceded that 1 Tranfi. Bonibay Med. and Phy. Soc. 1853-54. 288 NOETHEEN AND WESTEEN ASIA. Aden is by no means a feverish locality. This is confirmed by the following statement by Dr. Edkins : ^ ' The most important disease that occurs at Aden among Europeans is shown to be continued fever. It appears to be caused by the ardent heat of summer ; and those who arrive at the beginning or during the course of the hot season are more predisposed to these attacks than others. There was only one admission from intermittent fever in the year 1862 in the wing of the 4th Eegiment, while in 1860 there were 237, and in 1861 there were 54.' This shows, as Dr. Edkins remarks, how completely the miasmatic poison, which affected the troops when in Gnjerat, their previous station, had disappeared, and how free Aden is from such malaria. It may thus be concluded that Aden is only slightly affected with malaria, but that a continued fever of some sort is rather common. Some additional light is thrown upon the nature of fever in Aden by the following extract from the Navy Beport of 1878. In the Undaunted, 125 cases of simple continued fever occurred in the end of May. This, it will be observed, is the period when the first rise, culminating in the June maximum, takes place. The symptoms of this fever are thus described : " Headache, vertigo, heat of skin, thirst, loss of appetite, watchfulness, and constipation. The patients appeared languid ; the conjunctivse were injected ; skin hot and dry; the tongue furred. Pulse, 90 to 110 ; tempera- ture, 101° to 103° r. A difference was observed in the symptoms exhibited by the deck hands and those employed below. In the first, the temperature was highest at the commencement, the fur on the tongue was thin, defervescence was rapid and convalescence short. In the second, the temperature on admission was only a degree or two above the normal standard ; it gradually rose, however, and remained at 102° to 103° for several days. The fur on the tono-ue was thick and brown. The convalescent stage was pro- longed ; greater exhaustion ensuing. The average term spent on the sick list by each patient was between seven and eight days. Eor three months prior to this outbreak the ship had been moored in the Aden harbour, and during the latter part of this time the men had generally complained of an indisposition to eat. They cared for nothing but fluids, and suffered from sleeplessness. There was also a general indisposition to go ashore." This is no singular instance of fever of this kind contracted here. Simple continued fever, in fact, is of frequent occurrence amongst the men of the ships of war that visit Aden. The average time during' which cases of this form of fever remain under '^ Army Medical Eeport, 1862. ARABIA. 289 treatment is four or five days {Navy Report, 1887). As we do not read of this fever having been followed by attacks of the intermittent type, or of the patients developing other signs of malarious infection, it may be concluded that the fever was of climatic origin. For just as exposure to cold, in certain conditions of the body, is capable of inducing catarrh of the air passages with the catarrhal fever proper to the same ; so exposure to a continuous high temperature is, in certain circumstances, capable of inducing catarrh of the. alimentary canal and congestion of abdominal viscera, accompanied by a catarrhal fever proper to the same. There is a fever a frigorc, and a fever a adore,. Both are symptomatic, and depend on catarrhal or congestive processes induced by temperature. Heat probably never induces fever except by causing congestion in some organ. I am inclined to regard the fever in the Undaunted as a climatic fever in the sense here defined. But I am not prepared to subscribe to the view that the bulk of the fever cases met with in the spring and autumn at Aden amongst the resident population are of this nature. The fact that the continued fever observed at Aden is specially prevalent at definite seasons — May and June, and again in October, and that, as we shall presently see, fever prevails at the same time in Muscat, and further, that these are the periods when malarial fever attains its first maximum in many parts of the northern hemisphere — appears to me to point to its miasmatic character.^ The town of Shaikh-Othman on the adjoining mainland, as well as the whole of this part of the peninsula, is excessively malarious. The remittent or continued fevers contracted at the former place are of a severe and often dangerous type, as the experience of the Medical Mission established there has sadly attested. We conclude, therefore, that if Aden itself is free, or almost free, from malaria, malarious foci of great intensity are to be met with in its immediate neighbourhood, and that the whole of the coast country near Aden is unhealthy, — a point which it may be well to bear in mind in the event of military expeditions being required in this region."^ MUSCAT. Mr. Peters, the Civil Surgeon at Muscat, has given us some interesting details relating to the topography, climate, and diseases of this part of Arabia, which I shall condense. The country here 1 Steinhauser notices the prevalence at Aden of tlie ulcer known as the "Yemen sore," which he defines to be a sloughing ulcer, showing a strong tendency to mortifica- tion. In 1853-54 above 3 per cent, of the persons admitted with ulcers died. 2 Steven's " Keport on the Country round Aden," Journal Roy. Oeog. Soc. 1873. T 290 NORTHEKN AND WESTEEN ASIA. is intersected by numerous water-courses forming some very fertile valleys lying between the various mountain chains. In one of these Muscat is situated. Just outside the fort is a large circular ditch about sixty feet in diameter. It is a salt marsh, in parts dry, in parts boggy, and covered with an incrustation of salt — except during the rainy months, when it is covered by the rain water from the surrounding hills. The huts of the poor people encroach upon the borders of this marshy ditch. The mixture of salt and fresh water, along with excreta and the putrid flesh of quadrupeds and fish, gives rise to a pestiferous atmosphere, and deaths from a severe form of remittent fever are frequent among the inhabitants and the poor pilgrims who crowd together in its vicinity. To the west of this lies another valley, called Meabin, where a deep but dry wady runs along the foot of the hills, part of its damp bed being enclosed as a garden for growing vegetables. Further to the west, across a mountain, is the valley of Tuian, noted for its sweet water wells, which supply Muscat with its drinking water. Both of these valleys are very populous. Ague is endemic along the sea-coast and in the valleys. The spleen and liver become enlarged. Eemittent fever, complicated with jaundice, prevails only at certain seasons when there is abundant malaria in the air. This is noticed chiefly when the north-westerly gales set in, the disease abating with a change in the direction of the wind. A shower of rain is observed to act beneficially rather than otherwise on the prevalence of malarial fever. Peters notices also the existence of a continued fever, probably similar to that observed by Palgrave on the table-land of Arabia, attended with severe headache and thirst, aggravated by quinine, but yielding to purgatives and emetics. The following table gives the monthly distribution of 1273 cases of malarious fever observed by Peters in 1873, 1874, and parts of 1872 and 1875, with the mean tempera- ture, and the rainfall for 1873 : — Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. Mean tfimperature, 68-02 71-33 74-70 8r73 89-32 92-64 02-&7 89-47 86-15 85-64 77-83 72-28 Rainfall on873, . 3-25 4-13 0-36 0-00 0-00 O-QO O'OO 0-50 O-OO 0-00 0-47 1-Oii Percentage of Fever) ^.g ^.g g.^ g.g jq.o, g.o 4.3 ,-,.(; 9-1 10-7 9-9 10-3 Cases, . . ) Here we observe two maxima, one in March, April, and May, the other in September, October, November, and December, corres- ponding generally with those observed at Aden. The most feverish months are May and October, the least feverish are February and July. CHAPTEE VIIL PEESIA, BALUCHISTAN, AFGHANISTAN. Geography. — Persia. — The Elburz range of mountains runs along the southern coast of the Caspian Sea, forming the watershed in this direction. The strip of land between this range and the Caspian varies from five to thirty miles in breadth. On the west it opens out into the plains watered by the Kur and the Araxes — the plain of Mogan ; on the east, again, it merges into the plains of the Gurgan and Atrek. The Elburz range thus shuts off the central plateau of Persia from the Caspian. On the west the watershed between Persia and the Tigris valley is a more or less continuous double chain, running from the north-west to the south-east, parallel with the shores of the Persian Gulf, at the southern extremity of which it changes its direction to the east, running parallel with the Gulf of Oman. Elevated plains occupy the space between the ranges of this double chain. These ranges shut off the central plateau of Iran on the west and south. The Turcoman, Afghan, and Baluchistan ranges form the water- shed on the east. The great central plateau, thus almost closed in on all sides by high mountain ranges, is traversed by two parallel chains running from north-west to south-east. The rivers may be divided into three systems — 1st, the Oceanic — running into the Caspian, the Persian Gulf, or into the Arabian Sea ; 2nd, those running into the great lakes ; 3rd, the inland river system — the rivers belonging to which lose themselves in the sands or salt marshes. Of the 610,000 square miles included in Persia proper, 230,000 are estimated to drain into the seas, 60,000 into lakes, and 32,000 into the interior. This is an important fact in relation to the pathology of this region. The Elburz chain on the Caspian shore intercepts the moisture from the north, rendering the Caspian coast-line excessively humid, and at the same time rendering the central plateau dry. The southern chain along the Arabian Sea in the same way abstracts the greater part of the moisture coming 292 NORTHEEN AND WESTERN ASIA. from the south, the result being that the great central plateau has a very scanty rainfall. Over a great part of Central and South- Eastern Persia and Baluchistan the annual rainfall is estimated at about five inches. A little rain falls in November. In December, and again in February, there are usually considerable falls of snow, followed by showers in March and April. From May to jSTovember little or no rain falls. The rainfall along the Caspian is heavy, that along the Persian Gulf is scanty. The only plain near the sea-level is Khuzistan at the upper part of the Persian Gulf, through which flow the Diz, the Karun, and the Jerrahi. The flat lands along the shores of the Caspian and the Persian Gulf are generally narrow. Tbe plains of Ispahan and Shiraz are about 5000 feet above the sea-level, that of Karman somewhat higher. The principal lakes are the Urmia, the Bakhtegan, and the Shiraz. One remarkable feature of the Persian table-land, which has to be noticed, is the salt marsh called kavir. A kavir is an impassable bog covered with a saline incrustation that prevents evaporation, formed by a river or a mountain torrent at a place where there is not sufficient slope to allow it to run off. The principal kavir is the great salt desert. It has no great elevation. It receives the Shurab Karsio from the west, and some streams from the east. Among the innumerable smaller salt marshes may be mentioned that on the Saidabad plain west of Karman, that in the valley of Kutru, that on the banks of the Zaindarud in the valley of the Kuh-Banan. Ordinary marshes are met with in numerous places, but, excepting those on the coasts and the marshes along the Seistan Lake on the frontier of Afghanistan, they are not of any great extent. In a great part of Persia cultivation can only be carried on by irrigation, by means of streams, canals, or wells, or of the underground channels called hcindt. It will readily be understood, then, that the population in the plateau is gathered into centres where water is to be had, sufficient not only for domestic purposes, but for irrigation. The dry, barren, sandy, rainless desert tracts, as well as the districts covered by salt marshes, are uninhabited. Hirsch refers to the existence of malaria on the table-land of Iran, " which lies always under a cloudless sky and bright sun, and has no water from natural sources," as one of the remarkable instances of malaria occurring in dry i)laces. Such, no doubt, it is. Yet we should not forget that the driest districts often become the most humid and water-logged under the influence of irrigation, and that it is just such localities that are the centres of population. As the PERSIA, BALUCHISTAN, AFGHANISTAN. 293 dry sandy deserts are uninhabited, we have no means of ascertain- ing whether or not they are malarious. Climatology. — As we have ah-eady noticed the distribution of rainfall in various regions of Persia, it will suffice to add a few particulars respecting the climate of Teheran. Teheran, the capital, is situated at an altitude of 3840 feet above the sea-level. During four months of the year the heat is intolerable, the thermometer standing at 86^ to 94° F. in the shade. In winter the thermometer has been seen to fall to 20° below freezing point. The coldest month is January, the hottest July. The highest temperature in the centre of the town, where the natives live, is about 110° F. In the European quarter it does not exceed 102° F. The great char- acteristic of the climate is the extreme dryness of the atmosphere, especially in summer. The annual rainfall was formerly only ten or twelve inches at Teheran ; of late years it has been somewhat heavier. This may be taken generally as a type of the climate in the central parts of Persia. Pathology. — Malaria. — The western and southern shores of the Caspian, from the Araxes, through the marshy provinces of Ghilan and Mazanderan, are highly malarious. Piesht and its neighbour- hood is particularly feverish.^ The plain of Mogan on the west, and the plains of the Atrek and the Hiirgen on the Turcoman frontier, are alike noted for the amount and intensity of the endemic fever by which they are infested. Stebnitzky informs us that the Turco- mans of the Atrek and Hiirgen, in order to escape the fever, are often compelled to migrate in summer to the steppe.^ The fever met with in these provinces, and which is most prevalent from August to October, frequently assumes the remittent type, and is often complicated with enlargement of the liver and spleen, and with lymphyngitis. Although our information respecting the high lands of Kurdistan and the Zagros mountains is very scanty, they are known to be comparatively, if not entirely, exempt from the disease. The plains of Khuzistan share with the delta of the Euphrates, already described, the claim to be reckoned amongst the most malarious regions of the world. Mohammara, the chief port of the Karun Pdver, is described as a regular plague-spot. The sur- veyors of the Turco-Persian Boundary Commission suffered greatly in this locality, as did also the English expedition in 1857. Two of the officers belonging to this expedition committed suicide, and one died of fever. The eastern shores of the Persian Gulf are almost throughout visited by malaria, as are also the coasts bordering on ^ Bonvalot, Thronrjh the Heart of Asia, Loudon 18S8. ^ Journal Roy. Geog. Soc. 1874. 294 NORTHERN AND WESTERN ASIA. the Grulf of Oman. Bander Abbas, or the Gombroon, was found by Ives in the last century almost deserted — the inhabitants suffering from 'putrid intermittent fevers,' which raged from May to Sep- tember, and up to the present day the inhabitants, who can afford to do so, leave the place during the summer and autumn months, and take refuge either in the shady gardens at the top of Ganao, or go to Minab. Pernicious attacks, succeeding to the tertians, are common from August to October. Coming to the central plateau, we find that malaria, although in a less intense form, prevails even here to a considerable extent. The province of Azerbijan, at a height of about 4000 feet, is generally salubrious.^ Malarial fevers and their sequelae are, on the other hand, very common at Teheran.^ This city, which is situated on a dry plain, is to a large extent supplied with water from subterranean streams. The country, especially towards the north, is extensively irrigated. " It is supposed that a marshy tract of country close to Teheran has to answer for much of the fever met with here." These fevers prevail in the months of iTovember, December, and January, when the cold is very intense. Malarious diseases are also met with at Kum, Kashan, Ispahan, and Yezd. Shiraz, in Coele-Persia, situated in a hollow formed by two parallel chains of mountains, with a moist subsoil, is, notwithstanding its elevation, to a marked degree malarious. Karman, at an elevation of 5700 feet, in the centre of an irrigated area, where the summer heats are intense and sudden vicis- situdes common, is not spared. Of Bampur, in the east, the Boundary Commissioners, from whose report I have gathered a number of the details given in this chapter, state that " the highly irrigated land to the south and the burning desert to the north cause sudden changes of temperature and alterations from intense dryness to com- plete saturation, which make Bampur a by-word for unhealthiness." Malaria, in a less severe form, prevails along the Afghan border around the Zirreh Swamp and the Seistan Lake. Bell's account of the disease called Tab-i-ghash, or fainting fever, as seen at Teheran and the surrounding country, is so often referred to and so little known, that it may be well to reproduce it here. "Its usual form is an ague in which — 1st, the cold fit is accompanied by extreme oppression at the heart and pain when pressure is made on the pit of the stomach. This goes on for some days. When at the commencement of each ague fit the patient becomes insensible, the pulse is not to be felt ; he neither shivers nor ^ Eastwick's Three Years' Residence in Persia, London 1864. 2 Private letter, dated 24th February 1890, from a medical man Avho has practised for nine years in Teheran. PERSIA, BALUCHISTAN, AFGHANISTAN. 295 sweats properly, and his skin is cold and clammy ; if you bleed him, no blood comes ; he has a few spasms, and dies mottled, like a man in cholera. 2nd, Sometimes there is pain and hardness of the belly and no aoue ; this the Tersians fancy to be colic, but it is the same complaint ; the pulse gets weaker, the skin colder, oppression at the lieart greater, and the patient dies as in cholera. 3rd, Sometimes, with scarce any previous symptoms, the skin is puffed up in an hour or two, and the man nearly suffocated with oppression of the chest and dropsy. This is a sort of inward sweating, where the perspiration does not come out. I hear this is very prevalent at Burajird. This requires bleeding freely, and calomel and jalap- tartar in strong doses. 4th, But the commonest form is a daily ague, with pain and swelling under the ribs of the left side, viz. in the spleen. 5th, More rarely, there is the regular purging and vomiting of the blue cholera, with strangury, but spasms only come on before death. 6th, Often after eating water-melon people are found dying or dead in their beds without previous complaint ; in children and infants it is very prevalent ; without shivering they become cold and insensible, only recovering during the fever to fall again into a state of insensibility, and dying in the same manner after two or three such alternations. Now this is all the same complaint, and is to be treated in the same way." Ty;plioid Fever, according to the information I have received from Teheran, is of frequent occurrence there. Cases that are called typho-malarial are also met with. The extent to which the disease occurs in the different provinces is unknown. Typhus may be regarded as endemic in Persia. It is met with, although apparently not frequently, at the capital, and to a greater or lesser extent at numerous points in Persia. Polak observed an epidemy of the disease in 1857, which was chiefly confined to the troops. It was also epidemic in the years 1864-66, and I have received accounts of a severe outbreak in the town of Kasvin in the summer of 1879. It is uncertain whether Belapsing Fever exists in Persia. Diphtheria (1890) is common in Teheran, but appears to have been rare before 1858. I have no accounts of Croup from Teheran. Plague. Twelve epidemies of the plague are known to have occurred from 1571 to 1863. From 1864 up to 1885 numerous local outbreaks have been witnessed in different localities along the western frontier. In 1876-78 a severe epidemy occurred at Eesht, in the province of Ghilan. In 1885 it broke out at Hamadan. Azerbijan has been the province which has suffered most during recent years. The plague has generally been introduced 296 NORTHERN" AND WESTERN ASIA. into Persia from Mesopotamia, and has been chiefly confined to the provinces of Azerbijan and Kurdistan. Teheran and Ispahan have hitherto escaped. Cerehv-S2nnal Meningitis was observed in Persia in 1874—75. Dysentery and Diarrhcea prevail in summer, and Cholera nostras makes many victims in the beginning of autumn. Eindemic Cholera made its first inroad into Persia in the year 1821. Appearing at Bander Abbas, it penetrated into the north- eastern part of the interior by the Yezd caravan route. The north- western part of the country was infected by the troops from Bagdad, where, as well as at Bushire, the disease was then raging. In the following year the provinces of Ghilan and Mazenderan were attacked, but Teheran escaped until the second visitation of the disease in 1829. Subsequent outbreaks, some of which have been very destructive and others very persistent, have occurred in the years 1844-46, 1853, 1856, 1857, 1859-61, and irregularly at various points and intervals from 1865-72. (Hirsch.) Measles and Scarlet Fever are common diseases in Teheran. The same is the case as regards Smallpox, which however, at the present time, is expressly said to be milder than in Europe. Pneumojiia and Bronchitis are very prevalent in Teheran in winter and spring. Phthisis, according to all authorities, is decidedly rare in Persia, and is even said to be unknown in the mountainous regions. This does not, however, apply to the capital, where my correspondent says that he has seen many well marked cases of the disease during his nine years' residence. Leprosy, according to Hirsch, is confined, as in endemic, to a few districts of the hill country of Irak Ajemi, and in the provinces of Azerbijan and Khuzistan ; but does not occur at all on the shores of the Caspian. This distribution is not apparently in favour of the theory that leprosy is caused by a fish diet. Scrofula is rare among the Persians. Cancer is seldom met with. The Aleijpo Boil is a common disease of childhood in the interior, but is unknown along the shores of the Caspian. Syphilis, contrary to what is generally stated, is very common in the capital. Acute Eheumatism does not appear to be common. Rickets are said to be almost unknown. PERSIA, BALUCHISTAN, AFGHANISTAN. 297 BALUCHISTAN. Malaria is endemic along the Mekran coast. At Gwadur, in 1873, fifty of the men of the Rijlcman, who landed during the latter part of July and the beginning of August, contracted remittent fever. It is stated that heavy rains had fallen at the time after a prolonged drought. The disease is described by Surgeon Hill {Navy Ilcport, 1873) as beginning suddenly, generally without rigor, with great prostration, constrictive pain of forehead, heat of skin, nausea or vomiting, pains all over the body, — especially in the back, loins, and prascordial region, — thirst, loss of appetite, constipation, tongue coated in centre, clean at edges ; urine scanty, high coloured, not albuminous ; with giddiness, ending sometimes in delirium. There were morning remissions, and evening exacerbations in a more serious form, unless checked by treatment. The period of remission was sometimes that of the greatest danger in consequence of the sinking of the vital forces, coldness of the extremities, and profuse perspiration. The intermittent type occurred later in those who had suffered from this remittent form. It will be observed that this fever differs widely from that which occurred on tlie Unckmntcd at Aden. As respects other diseases, the pathology of Baluchistan differs little from that of Afghanistan, which we shall presently consider. AFGHANISTAN. Geogeaphy. — Afghanistan is separated from Bokhara on the north by the Amu-Daria or Oxus from its source in the Sir-i-Kul Lake to Khoja Saleh. To the west of this point the new boundary line crosses the Turkoman desert south of Panjdeh to strike the Hari-Piud near to Zulfikar. On the south it is bounded by Baluchistan ; on the east by the Suliman range of mountains, by which it is separated from India ; and on the west it is divided from Persia by the Hari-Ptud on the north, and by a line extending from this river to the Seistan Lake. The area of the country is estimated at 240,000 square miles, with a population of about 5,000,000. Climatology. — The climate of Afghanistan is extreme, especially in the mountainous regions of the east and north-east. At Ghazni (7279 feet), and even at Kabul (5600 feet), the winters are ex- tremely cold. At Herat and along the west frontier generally the climate is milder. At Quetta, situated in the south-east, close on the borders of Baluchistan and India, the mean temperature, and daily range (1883), and the average rainfall for six years was as follows: — 298 NORTHEKN AND WESTEEN ASIA. Mean Temperature. Daily Range. Rainfall Average January, 37-6 17-5 0-94 February, 39-8 22-4 1-67 March, . 48-4 22-5 1-90 April, 59-9 25-3 0-94 May, 67-2 29-1 0-31 June, 76-1 32-3 0-17 July, 76-3 25-9 1-00 August, . 75-0 32-3 0-57 September, 68-4 35-4 0-21 October, . 54-8 34-9 0-00 November, 43-9 29-9 0-00 December, 40-9 26-2 0-53 Means and Total, 57-8 27-8 8-24 Pathology. — Malaria. — Malarial fevers, both remittent and intermittent, but especially the latter, have been among the most prevalent diseases affecting the Indian troops during the various Afghan campaigns. No part of the country, so far as we know, is exempt from fever. During the last war malarial fevers formed one of the principal causes of sickness among the troops stationed in Kabul, Jellalabad, and Kandahar. Perhaps the high lands stretch- ing between Jellalabad and Kabul are as free from fever as any part of the country. The passes between India and Afghanistan — the Khyber, the Kuram, and the Bolam passes, in their lower and narrower defiles — are notably malarious ; ^ the higher elevations, especially when open, are comparatively salubrious. Malaria pre- vails aloEg the Persian frontier in the neighbourhood of the Seistan swamps. Typhoid Fever is a widely diffused disease in Afghanistan. Crawford {Army Medical Report, 1880) states that "at all the posts occupied by the European troops co-operating with the various columns in Afghanistan, extending from the British territory up to Kabul and Kandahar, cases of enteric fever appeared, some of which posts and camps must in all human probability have been occupied for the first time in the late campaign." We shall revert to this important observation in connection with the etiology of typhoid fever in India. It is probable that Bilious Typhoid is also epidemic in the country from time to time. Cholera is not endemic in Afghanistan, but it has on several occasions invaded the country from India, notably in 1827, 1842, 1859-61, and 1879-80. Dysentery has proved to be one of the most fatal diseases among ^ Crawford says: "As regards fever, some of the places in the Khyber were dis- proportionately malarious and unhealthy ; as, for instance, Lundi Kotal, Ali Musjid, Dakka, and Jellalabad, but especially the foimer" {Army Medical Report, 1880). PERSIA, BALUCHISTAN, AFGHANISTAN. 299 the troops in Afghanistan, and it doubtless prevails to a considerable extent among the natives, although we have no reason to suppose that it is severely endemic in the country generally. Dysentery and diarrhoea have made numerous victims among the troops stationed at Quetta. Lundi Kotal (3500 feet) is noted for the prevalence of dysentery. Phthisis is not unknown in Afghanistan, but I have no data for estimating its prevalence. Pneumonia and Pleurisi/ are common affections throughout Afghanistan. The British troops suffered considerably from respira- tory diseases in winter. Hepatitis, although not widely prevalent, is met with in the more malarious localities. I have not met with any accounts of the existence of Leprosy in Afghanistan ; nor am I able to state to what extent Goitre, Syphilis, and Scrofula prevail. Rheumatism is one of the most common affections among the natives. ASIA. ♦ DIVISION II INDIA, CEYLON, BURMA. CHAPTER I. INDIA. GEOGKAPHY AND CLIMATOLOGY. Geogkaphy. — The great natural divisions of India are — 1st, The sub-Himalayan region. 2nd, The Punjab, or plains of the Upper Indus. 3rd, The plains of the Upper Ganges. 4th, The table-lands of Malwa, Meywar, and Eajputana. 5th, The Lower Indus and its delta. 6th, Lower Bengal and the delta of the Ganges. 7th, The Peninsula proper south of the Vindhyan Mountains. These natural divisions correspond more or less to the political divisions, which we shall have to follow in this work, as the statistics apply only to the political divisions. 1. The sub -Himalayan region includes Cashmere, Gurhwal, Kumaon, Xepal, Sikkim, and Bohtan. A shallow depression, 5 to 30 miles in width, extending along the base of the Himalayas from Hurdwar to the Brahmaputra, is known as the Terai. The want of fall prevents the rainfall and the water from the hills from being rapidly carried off. The accumulation of moisture in this shallow trough is further favoured by the clayey nature of the subsoil, which hinders percolation. The Terai is thus a swampy region, covered with forest, jungle, or grass, the haunt of wild beasts. The sub- Himalayan region has a heavy rainfall ; the temperature at the higher elevations is temperate. 2. The plains of the Punjab, or Upper Indus, stretch from the frontier mountains of Afghanistan, on the west, to the Jumna. The northern districts are divided into numerous vaUeys by offshoots from the Himalayas, but the south forms a comparatively level expanse, sloping gently towards the plains of Sind, where it narrows to a point, and is unbroken by any elevations, except the Salt Piange between the Indus and the Jhelum, from 2000 to 5000 feet high. It is watered by the Indus and its five affluents, viz. the Jhelum, the Chenab, the Eavi, the Beas, and the Sutlej. These rivers divide the country into four interfluvial plains or docdts : — the Sind Sagar Doab ; the Jetch Doab ; the Pteechna, or Eichna, Doab ; and the Bari Doab. 304 INDIA, CEYLON, BUEMA. The principal canals are the Bari Doab, the West Jumna, the Sirhind, the Sutlej (upper and lower), the Muzaffargarh, and the Swat. The districts where irrigation is most extended are those around Amritsar, Lahore, Mooltan, Muzaffargarh, Lodhran, and Mailsi, the country to the east of Montgomery, and the district of Dera Ghazi Khan. The soil varies from a sand to a stiff clay. The country is bare, and cultivation in many parts is chiefly carried on by means of irrigation. The Punjab has two seasons of rainfall — the monsoon, from the middle of June to the end of September, which brings the greater part of the annual supply, upon which the autumn crops and spring sowings depend, and the winter rains, which fall early in January, and which, though insignificant in amount, affect very materially the prospects of the spring harvest. The Eabi, or spring crop, is the most important, the Kharif, or autumn crop, less so. The average annual rainfall of the Punjab is about 21 inches. 3. The plains of the Upper Ganges, comprising the North-West Provinces and Oudh, extend from the Jumna on the west to the western boundary of Patna on the east, and from Gurhwal on the north to the Central Provinces on the south. This country, which comprises the Doab, Eohilkund, Oudh, and Benares, has a gradual slope from the north-west to the south-east. This extensive region is watered by the Ganges and its tributaries, including the Jumna, Goomtee, and Gogra, and is irrigated by the Ganges Canal and its numerous branches. 4. The table -lands of Malwa, Meywar, and Piajputana have elevations of from 800 to 2000 feet above the sea-level. Exclud- ing the fertile portions along the Loni Ptiver, the greater part of Eajputana is a sandy tract, destitute of streams, with a scanty rain- fall. Water is only found at great depths. The extensive plains of the Meywar plateau are fertile, when irrigated, and almost every village has its artificial lake. The States of Bikanir and Jaisalmir depend entirely upon the scanty supply of rain which sinks into the soil and does not run off, so that a very light rainfall suffices for the crops. (Hunter.) The Malwa table-land is better watered and more fertile. 5. The Lower Indus and its delta. The delta, which extends for 125 miles along the coast, is perfectly level and destitute of trees. The soil generally consists of sand, clay, and vegetable mould, and is fertile where irrigation is possible. In some places it is marshy. Higher up, in the province of Hyderabad, Thar and Parkar, Shikarpur, and Upper Sinde frontier, the soil is in some parts sandy, in others clayey. Shikarpur has a rich alluvial clay. INDIA. GEOGRAPHY AND CLIMATOLOGY. 305 which only requires rain to render it fertile. Along the banks of the Indus the soil is a rich alluvium, irrigated and fertile, but in many parts it contains much salt and nitre. The irrigated area in Karachi extended in 1883-84 to 248,371 acres, in Haiderabad to 517,403 acres, in Shikarpur to 563,897 acres, in Upper Sind frontier to 209,867 acres, and in Thar and Parkar to 88,362 acres. The Indus begins to rise in March, attains its maximum in August, and subsides in September. At Haiderabad the rise is about 15 feet, and often causes extensive flooding. The climate of the Lower Indus valley is extremely hot in the summer months, and although it has only a very scanty rainfall the air is often very moist. Fogs occur in the mornings and evenings, with night dews in September and October. The extensive irrigation, the frequent inundations, and the humidity of the air, are facts which are believed to have special importance in regard to the pathology of this region. 6. Lower Bengal and the delta of the Ganges. This region may be described as a vast aUuvial and nearly level plain, watered by the Ganges and the Brahmapootra and their numerous affiuents, forming a complete network of streams, which tend to change their channels from time to time. The country is naturally jungly and swampy, and in some places, such as the Sunderbunds, the jungle is impervious — the haunt of tigers, jackals, and leopards. It is subject in many parts to inundations. This province is densely peopled, and as a whole well cultivated. The rice crops, which form the principal culture, necessitate the putting of large tracts annually under water. The delta may be said to extend about 200 miles along the coast, and inland for 180 miles. By the end of July large portions of this region are covered with water — villages on slight elevations forming islands, as it were, in a gTeat lake. 7. The peninsula proper extends from the Vindhyan chain south to Cape Comorin. It consists, 1st, of an elevated table- land, 1500 to 3000 feet above the sea, bounded on the north-west by the Vindhyan range, and on the north-east by the high lands forming the southern watershed of the Ganges; on the east and west it is bounded by the Eastern and Western Ghauts, which run along both sides of the peninsula, shutting the table-land off from the sea ; 2nd, of a littoral region extending between the sea and the Ghauts. The low country between the sea and the AVestern Ghauts varies from 5 to 5 miles in breadth ; on the eastern side the plains are from 25 to 100 miles in width. The northern parts of the table-land comprise what are termed the Central Provinces ; the districts of Saugor and Damoah in the north drain into the Ganges valley. To the south, in the valley of u 306 INDIA, CEYLOX, BUEMA. the Nerbudda, are Mandla, Jubbulpore, Xarsinghpur, Hoshangabad, aud part of Ximar. Still farther south we have Betul, Chhindwara, Seoni on the high lands of the Satpura table-land, and Balaghat. These districts attain a height of 2000 feet. To the south, again, is the great Xagpur plain, comprising the districts of Xagpur, Wardha, Bhandara, and Chanda. This region has a considerable elevation. The general surface slopes towards the south-east coast of Orissa and the Xorthern Circars. The central and eastern parts of this region are drained by the Mahanuddy and Godavery rivers, which fall into the Bay of Bengal. On the north and west the streams join the Xer- budda, which empties itself into the Gulf of Cambay, and the Tapti, which also runs to the western coast, to fall into the sea at Surat. The north-eastern part of the Central Provinces is to a consider- able extent covered with jungle, and in many places it is marshy. The town of Xagpur is situated in a hollow, at an elevation of about 1000 feet above the sea-level. The soil of this part is the black cotton soil. The temperature throughout this region is high in summer, and comparatively low in winter. The annual range is high, and so is the daily range. At Kamptee, for example, in June 1878, the thermometer reached 120° in the shade ; while in December of the same year it fell to 25°. The average rainfall varies much in different districts. The average at Kamptee is about 22 inches; in 1887 it reached 52 inches. The Deccan proper, or the Xizam's Dominions, is a part of the same plateau, but situated to the south of the Central Provinces. Excluding the province of Berar, it covers an area of 71,771 square miles. It is from 1500 to 2000 feet above the sea-level. Annesley thus describes the country: "It is hilly but not mountainous. The hills are chiefly composed of granite, which has the appearance of having been dislocated by some powerful force. The masses are of all sizes, and almost always quite bare and weather-worn, thrown into the most fantastic and irregular forms. The face of the country is rough, rocky, and sterile, consisting of a succession of heights and hollows ; . . . the hollows or valleys are generally formed into lakes or tanks, by blocking them across with strong mounds (bunds) of stone or earth, for the purpose of irrigating the land." ^ Secunder- abad, the chief military station, is situated at a height of 1800 feet above the sea. The rainfall in 1860 was 18 '50 inches; in 1876 it was a little over 15 inches; in 1877, 30-90 inches; in 1878 it was 46 '15 inches. The province is drained by the Godavery and Kistna. Its cultivated, and consequently more densely-inhabited districts, are studded with enormous tanks, some of which attain the * Annesley, Diseases of India, Lonil. 1841, p. 116. ixui.\. — GEO(;i;\riiY and CLLMATOLOGV. 307 proportions of lakes, being many miles in circumference, by means of which rice cultivation is carried on. Annesley notices that fogs collect, morning and evening, along the whole tract of the low, swampy rice districts. To the south of the Deccan is Mysore, with an average elevation of 2000 feet, reaching in some places to 4000 or 5000 feet, and sloping towards the north and north-east. In the nortliern part of the country the rivers run northwards to join the branches of the Kistna. The Cauvery, rising in the high lauds in the south, runs south-east ; while the Pennar drains the lower eastern slopes. Bangalore, the most important military station, is 3000 feet above the sea. The soil of Mysore is in many places formed of decomposed gneiss, the rock disintegrating readily under exposure to the air. In the valleys the soil is generally a dark fertile loam. The average temperature of Bangalore is 72°-9, rising to 85° or 90° in the hot season, and falling to 60° in cool nights. The rainfall averages 35*87 inches per annum; but, like at most of the stations in the Deccan, it varies much from year to year. Vital Statistics. — The following table gives the civil divisions of India, the area of each, the number of towns and villages, the population, the number of persons per square mile, and the number of towns and villages per 100 square miles : — Province or State. Area in Square Miles. So. of Towns and Villages. Population. No. of Towns and Villages per 100 Miles. Males. Females. Total. Ajmere, .... 2,711 739 248,844 211,878 460,722 170 27 Assam, .... 46,341 22,408 2,503,703 2,377,723 4,881,426 105 48 Bengal, .... 193,198 264,765 34,625,591 34,911,270 69,536,861 360 137 Berar, .... 17,711 5,585 1,380,492 1,292,181 2,672,673 151 32 Bombay : — British territory, 124,122 24,598 8,497,718 7,956,696 16,454,414 133 20 Feudatory States, 73,753 13,191 3,572,355 .3,368,894 6,941,249 94 18 Burma, .... 87,720 15,857 1,991,005 1,745,766 3,736,771 43 18 Central Provinces : — British territory. 84,455 34,612 4,959,435 4,819,356 9,838,791 117 41 Feudatory States, 28,834 11,242 867,687 842,033 1,709,720 59 39 Coorg, .... 1,583 503 100,439 77,863 178,302 113 32 Madras, .... 141,001 52,648 15,421,043 15,749,588 31,170,631 221 37 N.-W. Provinces : — British territory, 106,111 105,421 22,912,556 21,195,313 44,107,869 416 99 Feudatory States, 5,125 3,322 384,699 357,051 741,750 145 05 Punjab : — British territory. 106,632 34,324 10,210,053 8,640,384 18,850,437 177 32 Feudatory States, 35,817 18,546 2,112,303 1,749,380 3,861,683 108 52 Baroda, .... 8,570 3,012 1,139,512 1,045,493 2,185,005 255 35 Central India, . 75,079 31,506 4,882,823 4,379,084 9,261,907 123 42 Coehin, .... 1,361 655 301,815 298,463 600,278 441 48 Hyderabad, 71,771 20,398 5,002,137 4,843,475 9,845,594 137 28 Mysore 24,723 17,655 2,085,842 2,100,346 4,186,188 169 71 Kajputana, 129,750 30,001 5,544,665 4,723,727 10,268,392 79 23 Travancore, Total, . 6,730 3,719 1,197,134 1,204,024 2,401,158 257 55 1,372,588 714,707 129,941,851 123,949,970 253,.syl,S2l 185 52 The registration system of India is still in its infancy, and is far from perfect. The returns for Bengal, Assam, Madras, Coorg, and 308 INDIA, CEYLON, BUEMA. the Feudatory States are specially defective and unreliable, and for most purposes useless ; those for the Punjab, the North-West Pro- vinces, the Central Provinces, the Hyderabad Assigned Districts, and Bombay and Bengal, although not accurate, are more trust- worthy, and, judiciously used, enable us to draw important infer- ences as to the health of the population in these parts of the empire. We shall here give in a tabular form the birth and death rates of the principal provinces. Those for Bengal and Madras are esti- mated from official returns ; for the other provinces the figures are from the Administration Eeports for recent years, and are all some- what below the true ratios, the defects being greater in the birth than in the death rates : — Bengal. North-West Provinces. Punjab. Bombay. Birth-rate Deatli-rate Birtli-rate Death-rate Birth-rate Death-rate Birtli-rate Death-rate (estimated), (estimated). 1882-86. 1SS2-S6. 1881-85. 1882-86. 1882-86. 1874^85. 5-0 32-0 40-2 32-3 38-8 28-0 32-6 26*16 Central Provinces. Hyderabad Assigned Districts. Madras. Birth-rate Death-rate Birth-rate Deatli-rate Birtli-rate Death-rate 1881-87. 1881-87. 1883-87. 1888-87. (estimated), (estimated 41-2 31-3 40-5 38-4 SO'O 25-0> More dependence may be placed on the accuracy of the death- rates for the three Presidency cities than of those of the Provinces ; but the birth-rates, even of these, are not reliable. The population of Calcutta is abnormal in respect to the proportion of the sexes, the males being nearly two to one female. A similar, although less marked, disproportion obtains in Bombay. Calcutta. Madras. Bombay. Birth-rate Death-rate Birth-rate Deatli-rate Birth-rate Death-rate (estimated). 1881-84. 1880-84. 1880-84. 1881^4. 1881-84. 24-0 29-4 40-9 41-1 19-3 29-9 The death-rates of children under one year of age are every- where excessively high. In 1884 the deaths of children under one year formed 2 8 '3 6 per cent, of the total deaths at all ages in the city of Bombay; 21 per cent, in Calcutta; and 22 per cent, in the Madras Presidency. The proportions are still higher in the Punjab, the North-West Provinces, and the Central Provinces, where they vary from 28 to 31 per cent. But all these proportions are probably under the truth. The seasonal mortality varies considerably in the different provinces, and in the individual districts in each province. The months of greatest mortality are, for Assam, May, June, and July ; for Bombay, July, August, and September; for the Central Provinces and Assigned Districts, August, September, and October ; for the ^ The death-rate of this Presidency for the six years 1884-89 is given at 21 "5 per 1000. This is certainly much below the true figure. INDIA. GEOGRAniY AND CLIMATOLOGY. 309 North- West Provinces, September, October, and November; for Bengal, November, December, and January ; and for Madras, December, January, and February. Climatology. — India, extending over nearly 27° of latitude, and lying partly within and partly without the tropics, necessarily possesses a very varied climate. The diversities of altitude occa- sioned by great mountain ranges, as well as the physical configura- tion of the country, with its extensive low plains, and elevated plateaux, give rise to extensive varieties of temperature ; the same circumstances determine great differences in the annual rainfall of particular regions. For our purpose it will be sufficient to give here a table of the mean temperature and rainfall of certain represent- ative stations for future reference : — Average Air Temperature and Eainfall of certain Statioss in India, Punjab. Noeth-West Provinces. Peshawar Jlooltan Lahore Meerut Agra Lucknow 1110 feet). (420 feet). (732 feet). (737 feet). (555 feet). (369 feet). Temp. Eain- faU. Temp. Eain- faU. Temp. Eain- fall. Temp. Eain- faU Temp. Kain- fall. Temp. Rain- fall. January, 40-5 1-58 53-8 0-25 53-6 0-52 56-9 0-84 59-8 0-53 60-3 0-76 February, 51-7 1 .52 58-2 0-30 59-0 1 30 62 1 0-84 65-1 0-32 65 8 0-3.5 March, . 63-2 1 .50 70-7 0-46 69-6 99 73 4 0-63 76-9 0-22 76 4 0-25 April, 71-3 1 91 79-6 0-38 81-1 67 83 5 0-44 87-3 0-17 86 5 0-15 May, 80-2 72 88-8 0-45 88-5 78 88 3 0-78 93-2 0-71 91 7 0-79 June, 88-4 20 94-4 0-37 93-2 1 67 92 4 3-69 94-1 2-85 92 3 4-41 July, 89-0 1 7.T 92-0 2-08 89-0 6 87 86 4 9-47 87-1 9-13 86 4 10-85 August, . 86-4 2 48 89-0 1-36 87-9 4 73 85 1 6-50 85-2 6-32 85 6 10-37 September, 80-6 68 86-4 1-12 84-8 2 09 83 1 3-91 84-0 4-56 84 2 7-99 October, . 70-7 26 76-7 0-13 77-0 63 74 6 0-46 79-5 0-36 78 6 1-55 November, 58-0 94 66-5 0-OS 64-9 17 66 0-05 70-2 0-03 68 5 0-02 December, Year, 50-1 1 0-75 56-0 0-31 55-2 0-58 58-1 0-37 61-8 0-26 60-7 0-42 69-9 14-29 76-0 7-29 75-3 21-00 75-8 27-98 7S-7 25-46 78-1 37-91 Bengal. Central Provinces. Patna (183 feet). Dacca (22 feet). Calcutta. Saugor (1709 feet). Hoshangabad. Nagpur (1025 feet). Temp. Rain- fall. Temp. Rain- fall. Temp. Rain- fall. Temp. Riiin- falL Temp. Rain- fall. Temp. «t.T- Januarj', February, March, . April, May, June, July, . . AugTist, . September, October, November, December, Year, 61 65 86 88 88 84 84 83 79 70 62 9 6 6 6 6 7 1 9 6 3 3 0-73 0-59 0-28 0-30 1-46 6-55 10-19 9-50 8-29 2-80 0-22 0-13 66-5 71-7 79-4 82-9 83-4 83-8 83-4 83-6 83-6 81-6 75-2 68-4 0-81 1-02 2-44 5-96 9-18 13-11 13-17 12-46 10-42 5-53 0-72 0-20 64-7 69-9 77-4 82-0 83-1 82-3 81-7 81-6 81-6 78-8 72-0 65 1 0-02 1-22 0-44 1-92 6-56 7-66 12-96 13-36 9-74 2-61 0-31 0-86 63-3 67-8 78-0 85-2 88-4 85-5 77-5 76-4 77-2 75-5 70-2 64-1 6 17 11 7 1 62 59 16 20 64 12 00 33 95 19 38 31 66-0 70-5 79-4 87-9 92-7 88-2 79-4 78-4 79-4 77-3 70-8 66-7 0-36 0-17 0-21 0-04 0-57 5-34 14-19 13-04 10 00 0-79 0-40 0-29 68 73 82 88 92 86 79 79 79 74 70 67 6 7 6 9 5 1 1 1 1 9 4 8 12 8 7 2 64 46 61 49 86 61 52 84 57 14 29 37 77-8 41-04 78-6 74-52 76-7 57-66 75-7 46-49 78-0 45-40 78-5 43-40 310 INDIA, CF.YLOX, BURMA. Ateeage Aie Temperature axd Eaixfall or certain Stations xn Ixdia. EAJPrTAXA. Bombay. Eikanlr an feet.) Aimeer (16il feet). Indore (1823 feet). Haiderabad (9i feet). Karachi (49 feet). Bombay. Temp. Eaiu- faU. Temp. Eain- faU. Temp. Eain- falL 0-40 0-34 0-02 0-17 0-42 6-20 10-30 8-93 9-04 0-95 0-16 0-14 ~ Kaiu- Temp. fajL Temp. Eain- faU. Temp. Rain- faU. ■ January, February March, AprU, May, June, July, August, Septembe October, Novembe Decembe r, r, 60 63 78 88 93 94 91 86 88 83 70 60 1 7 7 1 5 7 4 5 7 9 8 6 0-01 0-35 0-09 0-35 145 3-30 3-15 4-84 1-20 0-08 02 0-04 58-9 64-8 75-4 8-5 3 91-0 90-6 84-0 81-6 82-6 78-3 68-9 61-5 0-15 0-37 0-48 0-09 0-66 2 -.57 6-33 7-85 3-36 0-31 0-16 0-32 64-6 08-5 77-2 83-3 87-5 84-4 77-8 76-5 76-9 76-2 67-8 62-8 62-8 66 3 79-4 S6-0 90-9 90-8 88-3 85-8 86-5 83-3 72-0 62-3 0-16 0-17 0-09 0-07 0-03 0-49 2 -.58 3-34 0-63 0-01 0-07 0-01 64-9 67 -S 76-9 so-s 85-6 86-7 83-9 82-0 82-2 79-6 72-4 67-0 0-62 0-25 0-15 0-01 0-06 0-20 2-73 1-97 0-90 0-08 0-08 0-21 72-7 74-2 78-2 81-7 84-2 82-7 80-8 79-7 79-5 80-3 77-9 74-8 0-12 0-02 0-00 0-04 0-59 20-89 24-17 15-15 10-81 1-62 0-49 0-04 Tear, SO-1 14-88 76-9 22-65 75-3 37-07 79-5 7-65 77-5 7-26 78-9 73-94 HTDERABAD ANT) MtSOEE. I Coasts or Pexixscla i (.JiAST AND west;. Seciinderabad Bella ry Bangalore Sladras (1787 feet). (1455 feet). (2981 feet). (22 feet). Temp. Eain- fall. Temp. Kain- falL Temp. Rain- | falL Temp 1 Rain- fall. Temp. Eain- faU. Janiiarv, 70-4 0-31 73-4 0-10 67-8 0-22 ' 75-9 0-98 79-6 0-00 Februarv, 75-6 0-26 78 7 0-05 72-2 0-16 77-6 31 80-7 0-00 March, . 82-0 0-77 85 4 0-60 76-8 0-63 81-0 44 83-4 0-01 April, 87-0 0-66 88 9 0-82 80-1 1-39 85-2 67 85-2 0-05 Mav, SS-3 1-49 87 7 1-90 78-4 5-07 87-4 33 86-1 2-64 June, 82-2 3-61 82 9 1-86 74-0 3-31 87-7 , 1 98 82-4 29-05 July, . 77-1 5-75 SO 6 1-45 72-2 4-06 85-6 ' 3 to so-o 28-99 August, . 77-1 5-63 80 6 2-32 72-0 6-02 84-7 4 53 79-7 21-73 September, 76-4 5-08 79 6 3-69 71-9 6-56 84-2 4 SO 79-6 13-73 October, . 76-0 1 3-47 78 8 3-93 71-9 6-26 1 81-5 10 SI 81-1 4-28 November, 72-2 0-65 75 5 0-73 70-2 1-54 ' 78-5 13 12 S2-S 1-63 December, Tear, 69-4 0-23 73-1 0-28 67-8 0-65 ! 76-3 4-99 81 -9 0-16 77-S 27-91 80-4 17-73 72-9 35-87 82-1 48-76 81-9 102 "27 CHAPTER 11. THE PEEVALENCE OF FEVER IN' INDIA, ITS FORMS AND TYPES. The sources of our information respecting the pathology of India are — 1st, The Annual Eeports of the Sanitary Commissioners for the different Governments, which deal with the health of the civil population only; these we shall refer to as S. C. E. 2nd, The Eeports of Sanitary IMeasures in India, which contain a resume of the statis- tics bearing on the health of the civil and military populations, and the progress of sanitation throughout the country ; these, when quoted, will be distinguished by the letters S. M. I. 3rd, The Annual Army Medical Eeports, which deal with the health of the European and native troops. 4th, Indian medical journals, special reports, and standard works on Indian diseases. The Eeports of the Sanitary Commissioners furnish us with the deaths from fever, and other diseases, occurring among the civil popu- lation in each of the districts and registration circles into which the Governments are divided. Nothing could be more satisfactory, if the system of registration were at all perfect. Unfortunately, as I have already stated, this cannot be said to be tlie case, although great advances in this respect have been made of late years, and I shall confine myself chiefly to the statistics of recent years, and of those Governments for which the returns are most reliable. The total deaths registered represent with sufficient accuracy the total mor- tality. It may be assumed, also, that the census returns of the population furnish for these provinces a reasonably sound basis for calculating the proportion of deaths to the population. The chief defect of the vital statistics of the civil population undoubtedly lies in the uncertainty respecting the assigned causes of death. Dr. Browne, of Hoshangabad, having inquired into the history of 77 deaths ascribed to fever, came to the conclusion that only 32 of them were so caused. Of 150 deaths registered from fever, investi- gated by the civil surgeon of Chanda, only 41 appeared to him really to have been fever deaths.^ A considerable number of the 1 W ^ i=^ Ph 2 « ?5 E-i od •^ O c. 0-. CO ,_ "" _ -r 00 00 •"• 'T 1—1 CI *7* CO o CO o -^ -t< C) CI -T o -f" ■^ «o Ci lO ^ CO Oi o o o CO ^w' OS ■T a< ■T< eo 6 t< •^ o CI CO o CO ■* cr. o c cr. ,- CO CO CO CO CI o o -o o CO -T- o -^ -r ift o >.•:! ,, cv CI CO c ^ ^ CO -o CO o I-H o -^ -ri o CI ct ^ CI -^ ■T) ^ i~- 1^ 1^ -f lO Ol CO CO CO o o CO CO ■-< •-' CI Ol -f CO -t* Ol ■o OD CO CO 1- as CO lO C". CJ CO »r; o c^ CI o cq CO o --^ CI oi 1^ o 1^ ,^ Oi CO J_^ o ^_l oo CO CI o CO CO Ci 1^ r— 1 o (M CO o CI CI o --^ CI ". ^ (N CO Oi M ,^ ^ CO _^ <» ra -p u": I^ c. CO I^ CO o o\ CO o o o o CI CO „ ,_, ._, 1^ CO Ol »o CO CO Ci CO CO CO l^ CI 1^ C3i CO CI CO lb o r-l '-' CO o CO ^ ._, ^ CO CO Oi ~r< CO -+I 1^ CO CO •V 1^ -n CO Ci lO C/D CI CO o o '-' CI •^ '-' CO C-. Oi CO ^ o ^ CI J- l^ lO (M I — 1 CI CO 1 — ' I* CO '-' -^ <:o "-^ "^ Ci ^ CI CO •o i.O ^ I^ o 1^ o C3 c. -Xi o 01 C) o CI li* CO CO' CO o ■-^ Ol o CI CI o •-^ '-' ^_, kC CO CO en .c. c CO ll: i^ I^ l^ -tf ^ Ci -^ 1—1 CO o T-( CI o '-' CI o '-' CI CO Oi l^ CO CO CI CO I-- ,^ i^ o l^ CO CO c. CI l^ o CO I— 1 '-' Ol o o o '-' '-' CO o ^_, ^ ,^ ^ J_^ CO 00 Ci o I — 1 r-H o l^ CO CO '-^ 01 CO o ■-^ '-' o '-' CI CO Gi CO CI o CO oo CO ^ l^ CO o Ci I— l^ ^ \a, CO GO CO ■-^ 1—1 CI o o >-( o r-\ I-f c-i (Xl (M o Ci -t< CO -V CI CO l^ 'O CO CO o CI Ci CZJ I-H I-l CO o CI CO o CI CI m CO CO ,^ o ,_, CO Ci Ol I-- Ci CO -* CO CZj CI ^ CO o '-' CI '-' '-' CI ^-— ^^^ .'— ^— s ^— '■— ^ K 5 •^ 5 „ J -t-T 'tJ -m" rr ■^"^ 't; S n 'rt S ^-T S "t: a > 15 a =3 ^ •- o •g ^ •^" H P.^"? ■g" H -w ^ - ^ -;2 ^ - —' -y ^ a >- la *-' w 1 n J- < >r (ii 3 y. p S s m 316 INDIA, CEYLON, BURMA. The average death-rate from intermittent, remittent, and con- tinued fevers on the one hand, and from enteric fever on the other, for the ten years 1870-79, in the European army of India and in each of the three Presidencies, stands thus : — Mortality from Enteric Fever and other Fevers. During 1870-79. Enteric Fever. Malarial Fevers. Total of both. Aiiny of India, . ,, Bengal, ,, Madras, ,, Bombay, 2-03 2-28 1-42 1-75 1-42 1-74 0-62 1-14 3-45 4-02 2-04 2-89 The proportion of fever deaths among the civil population, whatever allowance may be made for registration errors, is enor- mously larger than that of the military, European or native. In the year 1884 no less than 16*70 per 1000 of the population is stated to have died of fever. In the same year only 0'64 of the European troops died of intermittent, remittent, and continued fevers. If we include enteric fever along with the malarious affections, the total fever death-rate of the English army amounted to 3-38. The total fever death-rate of the native troops, who are little liable to enteric fever, was, for the same year, 1-80 per 1000. The explanation of this difference between the civil and military populations as respects the mortality from fever is not difficult to find. A large proportion of fever deaths in India, as in all malari- ous countries, occurs among infants and children. In Bombay, for example, out of 5186 deaths from remittent fever in 1885, 1193 occurred among children under three years of age. The troops consist of men who have attained a period of life when they are better able to withstand the attacks of malaria. The troops, — native and English, — except when on active ser- vice, are less exposed to some of the conditions which increase the fatality of malarious fevers. And when engaged on active service, with its fatigues and exposure, the death-rate of the troops — especially that of the native army — rises at once. To begin with, the native soldiers are picked men ; they are better clothed, fed, and housed, are placed under better sanitary conditions, and, when sick, are better treated, than the natives generally. The English soldier enjoys the same advantages, and lias the additional one of being able, in nmny cases, to escape death by being invalided home. INDIA. PREVALENCE OF FEVEE, ITS FORMS AND TYPES. 317 The native population suffers from poverty, hardship, and scanty clothing ; being often insufficiently fed, and compelled to dwell in malarious localities, in badly constructed, overcrowded houses, and beino- destitute, in many localities, of skilled advice when sick, it is no wonder that they succumb to fever in a much larger propor- tion than the troops. The forms of malarial fever prevailing in India are the inter- mittent, remittent, and the continued. Among the natives the intermittent is by far the most common, but the remittent is by far the most fatal. Among the European troops the continued form, according to Waring,^ is the most common. He gives the proportion of admissions to strength in the two armies in Madras for the ten years ending 1838, from which I deduce the following ratios per cent, of the different types of fever treated : — Euroioean Troops. l^ative Troops. Ephemeral Fever, .... 6 '0 21 "4 Continued, 45-9 3-5 Intermittent, 36-2 69*3 Eemittent, 11'9 5-8 100-0 100-0 For the twenty years ending 1850, the same authority states that of 160,128 cases of fever occurring amongst the European troops of Bengal, the proportions were : — Eemittent, . . • .22-3 Intermittent, . . . .33-7 Continued, . . • .44-0 100-0 Waring points out that the continued form of fever is that most commonly met with among the European troops in India. The figures show, as regards Madras, that the continued forms are in excess of the paroxysmal ; but the contrary is the case as respects BengaL Of late years paroxysmal fevers show a preponderance in all the Presidencies. Thus in the Madras Presidency, during the period 1871-80, out of an average of 2952 fever admissions, 831 were for simple continued fever, 491 for febricula, 176*8 for remittent fever, 1413 for ague, and 39-3 for enteric fever. It would appear that in the warm and equable regions the con- tinued forms predominate ; in the elevated regions, with a high range of temperature, the intermittent form is out of all proportion the'most common. Thus, along the coasts of Madras, comprising the Eastern and Western Districts, the continued form is usually more common than the intermittent ; while at Nagpur, on the table-land, 1 Indian Annals of Medical Science, April 1856. 318 INDIA, CEYLON", BUEMA. at a high elevation and with a great range of temperature, paroxysmal forms are in great excess. The proportion in which the various types of intermittent fever occur, varies somewhat in the different regions of India, but every- where the quotidian is the most common. In Sind, out of 537 cases observed by Inglis, 531 were quotidian and 6 tertian — in other words, 98*9 per cent, of all cases met with in this pro- vince are of the quotidian type. Of 53,753 cases observed in Bengal amongst European troops, the types and ratio of deaths were :— Ratio of Types. Deaths per cent, to Treated. Quotidian, Tertian, . Quartan, . 95 "5 per cent. - 3-9 • 0-6 1-259 0-573 0-542 At Secunderabad, out of 902 cases observed, 774 were of the quotidian type, 124 tertian, and only 4 were quartan. At Mhow, according to Impey, there were only 55 quotidians to 49 tertians and to 4 quartans. At Bombay the proportions in 73 cases reported by Leith were 43 quotidian, 29 tertian, and 1 quartan. That form of bilious remittent known as jungle fever requires a short description, from its analogy to the same disease observed in the United States and other malarious countries. When a pre- monitory stage exists, the symptoms observed are nausea, headache, pains in loins and limbs, oppression at the prsecordia, and mental dejection. In some cases, without any previous indisposition, the patient is attacked with delirium and with vomiting. In other cases, and these are the most numerous, the scene opens with rigors, followed by fever. In whatever way it commences, the paroxysm is marked by rapid pulse, burning skin, thirst, pain at the stomach, and bilious vomiting. The countenance is flushed, the eyes red and suffused ; there is intense headache, and often delirium. After twelve hours or more, profuse sweating breaks out, and an ameliora- tion of all the symptoms occurs ; but the patient remains in a state of great debility. After an interval of varying duration, an exacerbation occurs, usually without rigors, during which the symptoms of the first paroxysm are repeated, either in a mitigated or aggravated form, according to the intensity of the disease and the influence of treatment. If the disease progresses, the remis- sions become shorter and less marked, and the disease tends to become continuous. The vomiting often persists, the tongue becomes dry, black, and crusted, the debility more extreme, and the mind wanders. If the disease is tending to recovery, the paroxysms become less severe, the remissions more distinct, and it IXDIA. riiEYALENCE OF FEVEK, ITS FOHMS AND TYPES. 319 may either pass off from tlie fourth to tlie seventh day, or terminate in intermittent. The various forms of pernicious attack, observed elsewhere, are met with in India ; but I am unable to give details of their relative frequency in the different regions of India. The choleraic form is stated to be of rather frequent occurrence on the Afghan frontier.^ The typhoid form of malarial remittent or continued fever is far from rare. It is readily mistaken for enteric fever. It usually runs a course of a fortnight or three weeks, the patient generally exhibiting the group of symptoms designated as typhoid. In fatal cases, in addition to the lesions characteristic of malarial fever, there is marked congestion, and sometimes softening of the duodenum ; and this morbid condition may extend to other parts of the intestinal tract. Other complications are by no means wanting. Tirth says that out of 1033 cases of intermittent fever, 26, or 2-5 per cent., were accompanied with jaundice ; none with icteric urine ; and only 11, or about 1 per cent., with hsematinuria. Of 221 cases of true remittent, 4 had well-marked jaundice ; 2 had jaundice with hajmatiuuria ; and 2 had jaundice, hasmatinuria, and icteric urine. The seasonal distribution of malarial fever has to be considered in reference to race, region, climate, and the form of the disease. The following, according to Bryden, is the monthly distribution per cent, of the deaths from fevers of all kinds in the European and native armies of Bengal for the period 1867-76 : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. European Army, 4-0 4 '3 3-3 7-5 12-2 11-6 8-6 12-1 14-6 9-7 7'2 4-7 Native Army, 11-6 9-1 9-0 5-8 5-5 5-9 5-2 6-1 5-5 9-5 14-5 12-2 The predominating influence of the intermittent element in the native army, and that of the remittent and continued types and of enteric fever in the case of the European troops, is to be clearly traced in these figures. Intermittent fever is everywhere in the plains of India an autumnal disease. In some of the hill stations, as will afterwards be shown, malarial fever becomes vernal ; and in many localities a minor spring rise is observable. The exact month when the maximum of admissions occurs varies in different parts of the peninsula. In Bengal it almost uniformly falls on October, if the average of a fcAV years be taken ; but the period of the maximum in individual years is regulated to a considerable extent by the •* Crawford, Army Medical Report, 1880. 320 INDIA, CEYLON, BUKMA. temperature, and, above all, by the greater or lesser intensity of the disease, which anticipates in epidemic seasons, and also in non- epidemic seasons, in localities in which for special reasons malaria may happen to be unusually prevalent. The general course, however, of the seasonal evolution of intermittent fever appears to be to a considerable extent determined by the thermal curve. The prevalence of the disease, other things being equal, is in proportion to the mean temperature of the summer months, and its monthly distribution is also modified by the amplitude of the thermal curve. When the temperature in a given region maintains for several months a pretty uniform level, the fever curve tends to follow the same form. When, on the other hand, the temperature falls rapidly and steadily after attaining its maximum, so that the ascending and descending lines of the curve form the sides of an angle, having a more or less distinct apex at the point where the maximum is attained, the fever curve exhibits the same peculiarities. The normal annual evolution of the malarial element in the pathology of India is certainly not to any large extent determined by the periods of rainfall. The extent to which the normal seasonal periodicity, essentially independent of rainfall, may be modified by it, and the influence of the amount and season of the rainfall on the prevalence and intensity of fever in different localities, will be fully considered in the following chapters. The relation of the normal fever curve to temperature and rainfall is illustrated in the following diagrams, representing the per- centage of fever admissions, ; the rainfall in inches, ; and the temperature, F., : — i 1^' 1 i S « : H DlBEXTGARH • > 1 i ^ l;l Baeeackpore JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APH MAY JUN JUL AUG iEP OCT NOV OEC 23 22 35 22 35 20 SO IS 85 IS ns 16 80 ,•■'•■•■ /•••'" y.-.v ■•»- ■"i' IB ' no ,'.'•■'■ -■,, ■'•■•.;. ',• ' ' ::.:.. .■ • v\ !■» 75 ■* «. " • 12 rz 70 (•'.. \- IZ 12 7n A' •■■■-.■ A "V 10 ro G5 ..*. . ■•/ ■■■'i '% r ■^. ^ 3 8 eo / a f) KO • 1 s." ..•' / y-w / \ B e 55 •■ / \ K G 55 / ■v i / v- ■4. * Sn ■ * . * SO <• / s/ r y ^y , 2 2 ^5 V ^.^ ". 2 2 *5 .* ', ' n <■> '- a -g «9 INDIA. — PllEVALENCE OF FEVER, ITS FOliMS AND TYPES. 321 lis - c : 1 LUCKNOW. > 1 a 1 Ferozepokk. JAN FEB M6R APR Wii JUN JUL AUG SEP OCT NOV DEC JAN FEB M/,fi APR MAY JUN JUL A'je SEP OCT NOV 0E( zn .< ,P. JJ s.< ro Sr ;n 3S .■•■•. ,.*■ ^. ,.- ■ ,■ F,', f '•-^ '•• ,. ..-f- .... ■:... !t^.'^ .... .... Pn"" ■/■■ ■''■:. *-., .... •■. ••r r- -J~X 12 IJ 70 rv; A •;.,.. 71 1 .- f.i~\- .. 1- 1 / ' • \ _,.-|... •■■;/ / ^ y.' ^^ m ,-, i^ j ■ ..I..":j\ .. ■ > ..,-, • ■!>, /•■■ ...': ■-\ f| ^ fl ....|..., ;... ■ •• 1.. . A ^/...iv -V ■y .... ■■\- .■i-i 1 . ■s ■• T/ , V ^ / 1 V/ '- \ * .^ ■^^ y 1 . ■' « 2 „ \ ■■ 2 _.. ' 1 .S- — ^ , 1 o -.0 -i;:.i:: • ••> ^ o -0 •••■- Dera Ghazi Khan. Hydehabad. Jl.V r£T Mar Apr Mav JUN Jul A.C Jr = 0=T Nov De.-. J.'- -J r ;b Men Ap:i May JUN Jul Auc Sep Oct Nov DSC :g 28 J» ,00 1 /\ J'^ .15 to So \ 20 .':o '••• ^ "7" 1 . IS s = A. \ in a.'i :••" •-V- .... 18 Sc .... .... /■\ .v.. 15 PO ■ ■■,. \ ..,.-: ...j.... ..:■•. '.f.: .V'. ••v.'. ', \ 1'. --5 1 IJ tZ TO ■' \ r '2 7r '.... ,>v' ■•.;,; ^. 1 ■0 ro GS ./... '■-. \^ n •:■ ^s /■ ^-. ';•.' B so : a E £0 / ; ' : \ / S E .■:5 .• S G ^T / 'V, ^^ .—* L^ / t ■■■ 50 -•■' * ♦ .'vO ^y Vi :• N .|-' 2 ^ 45 S^ -^ r^ / 2 2 45 v " «0 •■ ■ 40 :•.,. .'' The monthly distribution of the remittent and continued types amongst the native troops exhibits two marked maxima — the first in April, May, or June, the second in September, October, or November. In Lower Bengal the first period is that which is most distinctly marked ; while in the west of the Punjab, at Jhelum and Dera Ghazi Khan, the spring rise almost disappears, and the maxi- mum occurs in different localities from October to January. In fact, on the North-West Frontier these four months marshal into line the whole category of malarial fevers, dysentery, and respiratory diseases ; and, what is more remarkable, diarrhoea, notwithstanding the low temperature, joins to swell the endemo-epidemy. This does not 322 INDIA, CEYLON, BUEMA. hold, however, as regards the European troops, amongst whom these forms are here most prevalent in the summer or early autumn months/ Malarial fever frequently assumes an epidemic form in India. The record of these outbreaks is far from complete, especially as regards their extent, their severity, and the order in which the dif- ferent regions have been successively invaded. The following are the epidemies chiefly affecting the Bengal Presidency mentioned by Bryden. In the year 1807 fever was epidemic in Chota Nagpur. It began in August, and was at its height in September. In the two following years it appears to have extended to the jSTorth-West Provinces, and probably also to the Punjab. In 1816-17 fever was epidemic in Saharanpore, and generally in the Gangetic plain. It is said to have been of the bilious remittent type ; but it is probable that much of this epidemy was of relapsing fever. Fever was epidemic in the Gangetic districts in 1828, and at Delhi and the country to the west in 1829. In 1834—36 fever was very pre- valent in Western Piajputana, ISTasirabad, IlTeemuch, and Mhow. Malarial fever was epidemic over the whole of iSTorthern India in 1843—44; Southern Sind, however, was only moderately affected. The disease was severe at Sukker and also at Knrnaul ; the latter, long regarded as healthy, was specially affected during this outbreak. The fever of 1844 reappeared during the monsoon of 1845—46, infesting Umballa and Ghazipore. The years 1850-51, 1863, 1866-67, and 1869-70, were years when fever was extensively epidemic in India. Some of the later epidemies will be considered in detail in the sequel.^ The years 1834—35 and 1843-45 were noted fever years in Madras, and 1836-37, 1839, 1844, 1849, and 1852 in Bombay.' Bryden believes that fever epidemies begin in Lower Bengal and Chota Nagpnr, and then invade Northern and Western India. Among other instances, he states that fever was epidemic in Calcutta in 1833, appearing in Upper India in 1834. The great outbreak 1 Crawford says that the fevers prevalent in Peshawar and Khyber valleys are of the continued type in the hot weather, while in autumn and commencing winter ague and remittent fevers are the most frequent. ^ Our information respecting severe local outbreaks of fever is extremely imperfect, yet some of these are of great interest. We read, for example, of an epidemy that raged in Behar in the latter months of 1859, of which it is said : "There exists in the memory of the oldest inhabitant, or even in tradition, no recollection of any disease occasioning such a mortality. " In this epidemy it is stated that in one locality death resulted from exhaustion following perspiration. Was this fever analogous to the sweating sickness ? Ganjam suft'ered from a very fatal epidemic fever in 1815-lC, an account of which will be found in the Madras Quarterl;/ Journal for 1843. * Ind. Annals Med. Science, October 1885 and April 1856. INDIA. PEEVALENCE OF FEVER, ITS FORMS AND TYPES. 323 in Agra and Northern India of 1856 was also preceded by an epidemic extension of the disease in the East. This is a seductive theory ; but the records of past epidemics, although they seem to give it some support, are too scanty and imperfect to furnish con- clusive evidence for or against it. It is not a rule without exception, although, so far as can at present be ascertained, malarial epidemics, more frequently than otherwise, take the course described by Bryden. I add a few temperature charts exhibiting some of the types of fever observed in the North- West of India. The two following charts, 1 and 2, represent mild forms of malarial fever, such as constitute the bulk of cases treated in all but the worst fever seasons. Chart 1 is a case of tertian fever which was cut short after the second paroxysm. Chart 2 represents a mild case of irregular type. I. MuLLOO, age 19. Short attack, tertian type. Admitted, Nov. 3, 1890; discharged, Nov. 11, 1S90. II. Gharsita, age 30. Short attack, irregular type. Admitted, Nov. 5 ; discharged, Nov. 15, 1890. oZ'si 1 2 3 -»- 5 6 1 2 3 4 5 6 7 a 9- 10 Temp 104 — 1 ' \ 103 / \ \ ; / lA /l \ A r I u f\ / i^ V; \j [a \ r f. 1 / A A V v\ :\ ■■■ (■■ i/ I. A ■A \/' I V v'^ \ ^ 36 Charts 3 and 4 represent two febrile attacks in one patient, separated from each other by an apyrexial period lasting about a week. The type throughout is quotidian remittent, although the tertian impress, bearing evidence of, at least, a distinct malarial element in its character, is to be noticed, especially in the second attack, during the course of which there is exhibited a tendency to more perfect remissions every other day, as will be seen by the asterisks denoting tertian periods. The ladder-step rises of temperature, as seen in No. 4, are associated with an obstinate form of the disease, which often develops congestion of the liver and lungs, and symptoms which for the sake of convenience may be designated as typhoid. I am not 324 INDIA, CEYLON, BUEMA. aware that typhoid lesions are ever found in the form of fever, but its morbid anatomy demands further investigation. Gami, age 26. Irregular intermittent. Admitted, Sept. 2, 1890. until October 7. See No. 4. TMs first period of fever continued DAr OF Disease. Temp. 1 2 3 4 5 6 7 S 9 10 II 12 1:5 14 15 16 17 18 ■ ; ; : 1 •J i k / ; II: t i A / J : \\-- 1 ' /\ \ \\ i '■■k ■ 5 5 - / '■ i A \- i f y i^ |: ' I •'/ / i I . V 1 \ : ■57 - <95 f !; 1/1 v- ^^J: \ / L- -"r^ ■ V- • IT. Gami, age 26, Sialltote. Quotidian remittent, witli remissions every other morning, ending in irregular intermittent. Tlie di>-ease commences witli ladder-.step rises in tlie temperature. The asterisks indicate tertian morning falls in the temperature. The fli'st day of fever corresponds to October 13, 1890. Continuation of No. 3. T£MR lOS 105 104 103 102 101 100 S9 98 97 1 2 3 'i- 5 6 7 8 3 10 II 14- 13 W 15 16 17 8 19 2D 21 22 2 3 24 25 26 27 ; ' ' ? ■ ^.JiJj5^jA -k^Jli, L A pIII MU f A ^^ 1" ; rt" ■• : 5 i Al -ttt-t ■ n-- I \l r ■l" 4 -A-lV . i^ ■,' ; f ^^trfr rrv: : 1: i \ I / ' ' -14 M ■ : 7 /: ; ; "^ r : I /jjl ^, ■/ 1 f V" 1 ./ ■ ; f f I Vh f^ V4 L_ *' ■;■. ■■ ,\ : ,.: ; xi ■ *; '■■ >: ^ ?! ": 1 » : Chart No. 5 is a case of quotidian remittent and intermittent. This form is specially liable to recur after the patient has been for several days free from fever. Charts G and 7 exhibit two common forms of quotidian remittent. In case 6 the temperature attains it maximum on the first day, and a ladder-step fall in the morning temperature indicates a favourable issue and short course. In Chart 7 the maximum is attained on the second day, after which the evening temperature remains uniform, while the morning remissions become less marked INDIA. PREVALENCE OF FEVER, ITS FORMS AND TYPES. 325 each successive day. On the fifth day a marked fall of temperature takes place, after which the fever continues on a lower grade until the morning of the eighth day, when it gradually decreases. Mehrdin, age 28, farmer. Intermittent fever, irregular. Tlie asterisks mark the tertian periods. It will be seen tliat the exacerbations tend to recur at intervals to the tertian type. DISEASE 2 5 4 5 6 7 a 9 10 n IZ 13 K 13 1 , n 1 3 19 20 21 iz Timp in^ -A ; rii M' . ^ '. * :•' ■' '. * ;" ;' ■ . «■ A 101 —I ^0^ ■ . /' \ ■ 1 '■ '■ . 'I\ ■J ^h il^ A ■ %'M ^A : i V:,, f' ■: h-- ^■^ftji h i ; ■,A \ A ■ :V ^J l^ :0 ^//- /a / 1 \^ r , -A V-J V: ■ V 1- K ' =tA VI Ntjbbia, age 22, farmer, six mouths in prison. Quotidian remittent. Admitted, Oct. 16 ; discharged, Oct. 30, 1890. VII. Sher Sing, age 20, farmer, one year in prison. Quotidian remittent. Admitted, Oct. 16 ; discharged, Oct. 30, 1890 0,S[,J£ 2 3 4 5 6 7 6 9 1 on 11 1 i 3 ♦ 5 6 7 8 9 10 II a Temp 1 ^:/l ^i-i : 1 : 1 ■ J '\ :/! A ;(i y ^ : - 7 if J i ■■ ; i jA f \ /, \ il ' / ■ ^/ ]' . i -A . ; - \ i v: \ ■l\ / 1 ■ < • i ^A A iJ\ f: «: : I ['- f f ■ / t. / ' /' ^ il i i W\ A I; I y ^ /;" ': \ ^ i ■ 7 ■ i; ■4 A i. -J ik : ■ V / 9£ ' \\ - \ ■ • 1 ■ • Charts 8, 9, and 10 represent fatal cases of quotidian intermittent fever, the chief symptoms in all being vomiting and diarrhoea. Chart 11 shows the course of a case of irregular remittent, which became complicated with congestion of the lungs on the sixteenth day. It persisted, notwithstanding the administration of quinine, for thirty days. 326 INDIA, CEYLON, BUKMA. VIII. Natho, age 28. Chief symptoms : fever, purging, and vomiting. Treatment : quinine, astrin- gents, and stimulants. Admit- ted, Sept. 29; died, Oct. 5, 1890. IX. Hera, age 38. Chief symptoms : fever, purg- ing, and vomiting. Treatment : quinine, astringents, stimulants. Admitted, Sept. 80 ; died, Oct. 5, 1890. X. Pbaun, age 46. Chief symptoms : fever, purging, vomiting. Treatment : quin- ine, astringents, stimulants. Admit- ted, Sept. 29 ; died, Oct. 5, 1890. o.sIa^e ' ^ 3 4 5 6 7 1 2 3 C 4 5 2 3 4 5 6 / r... ■■. •: '■ :|l 1- ^ • - '^^-hI . \ \- \ i i i - -^ 1 - l\ V f I ft - I \ V 1 1 P \\ ■ '■h 'A \ : J : _ ■ . ■' . \- '■ \ ■ A ■ /A : y i i iM' vr ■■ \ \ '^A f jj:\ 99 — |-t^^^— frfr- : \: V: \l V : ] \ 97 ' — '■ 1 — '■ 17^ : TT : V; ; ^ ■ ■ XI. Dya Singh, age 60. Symptoms : fever, complicated with congestion of lungs from the sixteenth day of the disease. Admitted, Sept. 29 ; died, Oct. 26, 1890. o°/es°E 4 5 B 7 8 9 10 II 12 13 1* 15 IE 17 18 19 20 21 22 23 24 25 26 27 28 29 3D 31 "«•' ME ME ME M E t*-E ME ME ME ME ME ME ME ME ME ME ME ME ME ME ME ME ME W E ME ME ME ME ME 4- L 103 ' 1 t \. ii 71 ": ;■ j^ 101— 100 — i / ^ 1 r 1 1 •| /" I I. 1 ■l\ \ ; ; i. / J— t 1 \n \ ■ ' :/ l\ i |. / : ■ y. j. / ' h J / V: 'i f /: J 1/ 1 ; ■■. i; if; r h ^ J\ 95 '\ !; : Having thus briefly glanced at the place occupied by fevers generally in the pathology of India, their incidence on the civil population and on the troops, — native and European, — we shall proceed in the following chapters to consider in more detail the endemic and epidemic prevalence of malaria in the several Govern- ments, in relation to climate and other conditions; after which enteric fever and other diseases will be treated of in the usual order. CHAPTER III. EPIDEMIC AND ENDEMIC MALARIA IN THE PUNJAB. The following statement gives the ratio of fever deaths per 1000 of the population in the Punjab during the eleven years ending 1887, and the mean rainfall of thirty-two stations ^ for each year from 1877 to 1884, and of thirty-one stations from 1885 to 1887:— Annual Fever Eainfall, Years. Annual Fever Rainfall, Years. Death-rates. Inches. Death-rates. Inches. 1877, 12-54 29-1 1883, 16-25 21-9 1878, 25-19 30-5 1884, 24-71 26-9 1879, 27-04 23-5 1885, 18-40 26-7 1880, 18-74 21-8 1886, 17-85 29-1 1881, 20-32 26-4 1887, 23-78 24-1 1882, 18-40 26-5 The mean death-rate for the eleven years was 20-29 ; the mean rainfall, 26*05 inches. We shall consider in detail the various circumstances affecting the epidemic and endemic prevalence of malaria in this government, and at the same time glance at the influence of meteorological con- ditions on the spread of epidemic malaria in India as a whole. The above table shows that the Punjab has a high mean fever mortality, but one fluctuating greatly from year to year. The lowest fever death-rate was in 1877, a year of moderate famine, marked by heavy rains in the earlier part of the year, a scanty rainfall in July and August, and a moderate rainfall in September, followed by rainy weather. The highest fever death-rate was in 1879. This year is thus described: "Eains bad. Crops below average. Prices high, but great demand for labour. Health worse than in 1878. Fever, smallpox, and cholera epidemics." ^ Let us see how far this 1 The rainfall for the years 1884-87 are from S. C. E. for each of these years ; the others are deduced from a table of the aj:rgregate rainfall in the S. C. R. (Puujab) 1883, dividing the total fall by thirty-two, which is the number of stations. " Report on the Sanitarij Administration of Punjab, 1883, p. 7. 328 INDIA, CEYLON, BURMA. high fever mortality can be explained by the meteorology of this year. I find that the temperature during the first five months of 1879 in the Punjab was high. Up to the end of May the rains were scanty. June was rainy ; the July rains were below the normal, the August rains above the normal ; September, October, and November very dry ; the December rains normal. I see nothing in the amount or distribution of the rainfall that explains satisfactorily the altogether exceptional mortality of that year. It is thought by some that abnormally dry weather in September, October, and November following the rains of June, July, and August tends to the increase of fever. But it will be observed that the following year, 1880, which had a fever mortality considerably below the mean, had very much tlie same meteorological characters as those of 1879. In 1880 the earlier part of the year was dry, as were also the months of September, October, and November. In order to understand the extreme unhealthiness of the Punjab in 1879, it is necessary to consider it in connection with the meteorology and health of the peninsula generally at that time. Respecting the meteorology of this year, Elandford says : " The rainfall was below the average in the Punjab, Western Eajpootana, and Sind, also in the Gangetic delta and Western Bengal. In all the other provinces it exceeded the average, and specially so in the Gangetic plain, comprehending the North- West Provinces and Behar. This excess was due entirely to the very copious rainfall of the summer monsoon, for both the earlier and later months of the year were remarkably dry. "Air Temjjerahire. — The mean of all stations slightly below average, but it was by no means generally so in Northern India. In the North-West Provinces and Bengal the mean temperature of year was slightly excessive, and in the Punjab this was the case at as many stations as show the opposite variation. This excess was due to the preponderance' of the high temperature of the first five months of the year. ... In Eajpootana and the Central Provinces the great depression of the closing months more than counterbalances the excess of temperature in the earlier months, and in the Deccan and the peninsula generally a depression of temperature characterised the greater part of the year. In Burma and Arakan only the first three months of the year showed an excess of temperature." From the above it appears that the climate of the Punjab in 1879 was marked , by a low rainfall and a high temperature from January to May ; that of the North- West Provinces by an excess of rain in summer, with a high temperature in the earlier I^^DIA. EPIDEMIC AND ENDEMIC MALARIA IN THE PUNJAB. 329 part of the year. In the Central Provinces and eastern Rajputana there was an excess of rain for the year ; in western IJajputana the rainfall was deficient, and in both regions there was a defect of temperature in the closing months. From the Bombay meteoro- logical returns we learn that in Gujarat, the Konkan, the Sahyt'idri range, North, South, West, and East Deccan, the rainfall in 1879 was° above the normal. In Sind only was it below the normal. Now, in 1879, fevers prevailed in an epidemic form not only in the Punjab, where the rain was scanty, but also in the North- West Provinces and in many parts of the Bombay Presidency, where, as we have seen, the rainfall was above the average. From the military returns we tind that at Haiderabad in Sind, where the rains in that year were below the normal, the admissions from paroxysmal fevers were 1201-0 per 1000 compared to 810-3 per 1000 in 1878, and 595-1 per 1000 in 1877. ■ Baroda, Indore, Neemuch, Satara, Poona, Mhow, Ahmednagar, Nasirabad, Karachi, all with an excess of rainfall, equally with Haiderabad, where the rains were scanty, returned excessive admissions that year from paroxysmal fevers. In Madras the deaths from fever among the civil population were 285,477 as against a ten years' average (1872-81) of 268,798. In _ the Army Medical Report it is stated that the rains " at some stations, if not generally," were heavy, and the admissions from paroxysmal fevers were about a third greater than in 1878. Fever is also stated to have been unusually prevalent in Eajputana, and it was certainly so in British Burma. In Lower Bengal, the Central Provinces, and Berar, the mortality from fever in 1879 was under the average. It is evident that we are here in presence of a wide- spread outbreak of malarial fever, and it would be futile to seek for a full explanation of the Punjab fever death-rate in the local meteorology of that province, although this may not have been without ils influence on its intensity and its local distribution. But we see here a general outbreak of fever occurring under very diverse conditions of temperature and rainfall. If in the Punjab the rainfall was scanty and abnormally distributed, we are not to forget that fever raged that year with great severity in many parts of Bombay and Madras, where the rains were heavy. The mean temperature of the year was slightly excessive in the North-Western Provinces and at many of the Punjab stations, but it was so also in Bengal, which was exempt from the epidemy of 1879. But this epidemy of 1879 cannot be fully understood without considering the fever history of the two previous years. The year 1877 was a disastrous year in Madras. The registered fever deaths 330 INDIA, CEYLON, BUEMA. rose to nearly double the average, but the mortality was due in a great part to the famine. The total rainfall in Madras, Mysore, and Hyderabad was in excess of the normal, but the earlier months of the year were, as a rule, excessively hot and dry. The south- west monsoon was late, and even scanty ; the north-east monsoon was copious. In Madras a cyclone in the middle of May, lasting for three days, was accompanied by a fall of 22 inches. The year was a fairly healthy one for the military throughout the Presidency ; this will be seen by examining the admission-rate of the European troops from paroxysmal fevers for the years 1876-79:— Years. Presidency. Mysore. Hyderabad. Burma. Admis- sions. Deaths. Admis- sions. Deaths. Admis- sions. Deaths. Admis- sions. Deaths. 1876, 40-2 0-00 28-50 0-00 102-90 0-30 23-40 0-00 1877, 57-06 0-46 31-70 0-00 129-27 0-00 38-99 0-00 1878, 306-24 0-97 54-03 0-41 204-22 0-89 86-50 1-06 1879, 505-51 0-65 112 52 0-00 392-28 0-64 ,163-96 0-36 A slight rise in the fever admission-rate is observed to have taken place in 1877 at all the stations in Madras. In Bengal, on the other hand, the fever admission-rate was lower in 1877 than in 1876 in every circle from Calcutta to Peshawar, excepting in Oudh, where there was a slight excess. The fever mortality was also remarkably low that year in the Central Provinces and Berar. The same low rates of fever admissions also obtained among the troops stationed in the Bombay Presidency. The city of Bombay was visited with a severe outbreak of fever, and the fever mortality among the civil population throughout that Government was high. These facts point to the conclusion that malarial fever was not epidemic in any extensive region of India in 1877, with the exception of Bombay. It is different when we come to the year 1878. Now we find paroxysmal fevers to prevail in Madras and Burma, and the increase iu the fever admission-rate is seen to be accompanied by a marked rise in the death-rate. This year, again, we find the fever prevailing under different meteorological conditinns. At Bangalore, in Mysore, the rains were very heavy. At Hyderabad they were much above the normal, while at Madras itself they were 19 inches INDIA. EPIDEMIC AND ENDEMIC MALARIA IN THE PUNJAB. 331 under the normal. The rainfall in British Burma was mucli below the normal. But equally where there was excess or defect of rainfall, fever was epidemic. In the Bengal command a great increase in the fever admissions is signalised in every military division, except in Allahabad and Oudh. In some places, as at Jullundur and Ferozepore, this increase is ascribed to the heavy rains, while just the opposite condition obtained over a great part of Bengal. The disease this year was also specially fatal at the various military stations in Bombay, with the single exception of Ahmednagar ; the admission-rate had increased, and in some in- stances the increase on that of the previous year was threefold. The civil population suffered in a corresponding degree. In Bombay, the year 1878 was marked by a total annual rainfall above the average, by a general deficiency of rain in January, February, and March, a general excess in April, a general deficiency in June, and a general excess for all the other months, excepting December. The temperature was under the normal. In the Central Provinces and Berar, when there was also an excess of rain, the fever deaths were nearly double the average. We may say that fever was epidemic throughout the whole of India in 1878, from the Himalayas to Cape Comorin, and from British Burma to the borders of Baluchistan, and under many diversities of temperature and rainfall. We do not have the means of tracing the epidemy beyond the limits of India for that year, but it will be remembered that 1878 and 1879 were years in which malaria was specially prevalent in Cyprus and the Levant generally. That the scarcity, amounting in many districts to famine, augmented enormously the mortality among the natives of India in 1878, cannot be doubted; but the epidemy extended to districts untouched by the famine, and affected the troops who did not suffer want. This shows that the famine was an aggravating element, and not the essential cause of the outbreak. The epidemy of 1879, the distribution of which we have traced, is only a continuation or recrudescence of that of 1878 — striking with particular severity on the two Governments of the Punjab and IsTorth-West Provinces, but by no means limited to these. Ej)idemies of malarial fever, more frequently than otherwise, extend over two years. If the i'acts respecting the order in which the fever appeared in the different regions are correctly stated above, this epidemy did not conform to Bryden's theory of epidemic diffusion, for it does not appear to have extended from east to west, but to have appeared about the same time in Burma, Bengal, and Bombay, the last beinfj that in which it first showed itself in force. The 332 IXDIA, CEYLON, BURMA. epidemy was preceded by an exceptionally low mortality over a great part of the peninsula; a circumstance which is often noticed as precursory to fever epidemics. Is this fever epidemy of 1878 and 1879 fully explained by any peculiarities of the weather during these years ? I tliink not. In our ignorance of any evident cause for this extensive diffusion of malaria during these years, we must content ourselves with speaking of the real but unknown cause as an epidemic influence. iSTo very close relation can be traced between the rainfall of different years and the fever death-rate. In the Punjab, as a whole, the years 1880 and 1883 were years of low rainfall, and the fever deaths during those years were also below the average. The rain- fall in 1884 was almost equal to that of 1885, but there was a great difference in the extent of the annual fever mortality in these years. Much more depends upon the distribution of the annual rainfall as regards the months and localities than upon the actual number of inches. The annual amount of fall and its distribution are not the sole factors in determining the death-rate from endemic fever, although the influence of the former on the endemic disease is much more marked than on the epidemic form. Let us now see the average monthly distribution of fever admissions in the Punjab in relation to rainfall and temperature for the ten years 1870—79. The percentages are calculated upon 536 admissions from enteric fever, 76,981 admissions from inter- mittent fever, and 31.358 admissions from remittent and continued fevers : — Monthly Percentages of Admissions from Fevers among European Troops, 1870-79. Months. Monthly Percentage 1 of Rainfall, 1 Eemittent 1870-79. Enteric Intermittent and Fever. Fever. Continued Fever. January, 3-5 4-0 5-2 1-3 February, 5-3 4-0 3-6 1-4 March, . 4-3 4-0 3-3 2-0 April, . 3-0 8-0 3-9 6-1 May, 4-2 16-0 5-1 13-8 June, 9-7 18-0 5-7 12-3 July, . . 27-2 12-0 6-4 13-4 August, . 250 8-0 8-1 13-1 September, 11-8 10-0 14-4 16-3 October, . 1-8 8-0 19-2 12-(; November, 1-1 4-0 15-7 5-2 December, 3-1 4-0 9-4 2-5 INDIA. EPIDEMIC AND ENDEMIC MALAUIA IN THE PUNJAB. 333 Enteric fever in the Punjab will be seen to have pretty much the same seasonal incidence as the remittent and continued forms. In both a sudden rise in the admission-rate occurs in May, which in the Punjab is one of the very hot months, the temperature attaining its maximum in June, when enteric fever also attains its maximum, liemittent and continued fevers attain their maximum in September, when intermittent fevers commence to prevail ; but apart from this September increase, the admission-rate for remittent and continued fevers remains nearly stationary from May to October, after which tlie admissions decrease, to attain their minimum in the cold season. Intermittent fever has a distinct period of maximum intensity limited to September, October, and November. The increasing heat of May, June, and July scarcely affects them. They are essentially autumnal, beginning in the Punjab, not when the drying-np process is going on, as is often said, for in September this type of fever has become general, while a considerable fall of rain still continues, and when the humidity of the air has scarcely diminished from its maximum. AtMooltan in the west, and at Delhi on the east of the Punjab, the maximum humidity is attained in August. At Mooltan the maximum relative humidity is 6-4, and in September it is still 62. At Delhi the August maximum is 67, and it stands at 65 in September. If we allow a certain period of incubation for the fever, it may be doubtful whether the disease is not in many instances contracted in July and August, when the rains are at their height. Yet those who have studied the disease only as it presents itself in India, have not unnaturally come to regard the drying up of the rain as in some way a cause of the autumnal maximum. But we have only to cast our eye on the fever and rainfall curves of Piome to make us hesitate to subscribe to this doctrine. The maximum of admissions in the Punjab Irom intermittent fever certainly coincides with the drying up of the rains in October, and this may not be without an effect ; but essentially the disease is not due to the drying-up process, as we shall presently see. In the mean- time it must be remarked that there is one thing which distinguishes • these autumnal fevers from the others. So far as I know, malarial fever never becomes truly epidemic in any other season than autumn. I do not remember coming across an instance of an epidemy of true malarial fever occurring in India during spring or summer, although it is no less important to observe, that in epidemic years the fever deaths begin to increase in the earlier part of the season. We shall now inquire into the distribution of malarious diseases 334 INDIA, CEYLON, BURMA. in the different parts of the Punjab, and trace their connection with rainfall, irrigation, altitude, soil conditions, and temperature. The Punjab was composed, until recently, of 10 divisions, com- prising 32 districts, containing in 1881 nearly nineteen millions of inhabitants. We shall give the average fever death-rate for the ten years ending 1887 for each of these districts (that of Sirsa for seven years only). In order to give a general idea of the rainfall of these districts, I shall add the average annual rainfall. It must be noticed that the registration is known to be defective in Peshawar, Dera Ismail Khan, and Dera Ghazi Khan ; hence little reliance can be placed on the figures given for these districts. Fever Death-rate, 10 years. '3 P5 Fever Death-rate, 10 years. 3 P=l Delhi Division. Lahore Division. Delhi, . Gnrgaou, Karnal, . 32-68 32-42 28-93 37-3 29-8 37-8 Lahore, Gujranwala, . Ferozepore, . 20-86 19-08 20-87 20-8 22-2 13-5 HissAE. Division. Hissar, . Rohtak, Sirsa, . 20-48 27-79 18-06 20-7 28-3 14-81 RXwAL Pindi Drv. RaAval Pindi, Jlielum, Gujrat, . Shahpur. 22-92 18-59 16-16 16-37 34-1 24-6 22-5 11-3 Umballa Division. MooLTAN Division. Umballa, Ludliiana, Simla, . 24-37 23-77 8-23 37-8 29-9 63-9 Mooltan, Jhang, . Montgomery, Muzaffargarh, 19-83 11-63 14-53 25-22 5-8 7-8 9-6 6-1 JuLLUNDUE Division. JuUundur, Hoshiarpur, . Kangra, 24-25 22-07 17-12 26-4 34-0 96-52 Derajat Division. Dera Ismail Khan, Dera Ghazi Khan, . Bannu, 17-72 14-37 17-05 6-7 6-8 12-6 Amritsar Division. Peshawar Division. Amritsar, Gurdaspur, . Sialkot, 21-79 21-22 17-09 20-6 42-1 29-9 Peshawar, Hazara, Kohat, . 12-60 16-34 13-34 13-8 50-62 16-8 Tlie fever death-rates in this table are the means of two series of five years, viz. five years previous to 1883, and the five years 1883-87. The rainfalls are the average of four years, 1884-87. It will be seen that the most feverish districts in the Punjab are those in the east, north-east, and central parts of the province. The western districts, with some exceptions, such as Muzaffai'garh, are upon the whole more healthy. ' For 1884 only. - For 1885 only. INDIA. EPIDEMIC AND ENDEMIC MALARIA IN THE PUNJAB. 335 The prevalence of endemic lever in different districts seems to depend to a considerable extent upon one or more of the foUowin^^ conditions : — {(() General conditions, such as the amount of rainfall, and the period of the year when the fall takes place ; the manner of its distribution — whether equably in moderate showers over the rainy season, or unequally in torrential rains, submerging large tracts of country. Tlie effect of the rainfall, whatever may be its amount or distribution, depends greatly upon the nature of the soil and subsoil, and upon the fact as to whether the ground is already surcharged with moisture, as happens in the irrigated areas. Temperature has also a certain influence. A high temperature appears to favour the prevalence of the remittent form of the disease. (h) Local conditions, affecting the amount of water distributed to the soil, especially canal irrigation and river inundations. The extension of irrigation canals has materially raised the subsoil water level over large areas within the last thirty or forty years. Local conditions, natural or artificial, facilitating or hindering the discharge of water and the drainage of the soil. On the one hand, we find some districts where the natural configuration of the country enables the heaviest floods to be harmlessly carried off, and others in which the level or hollow configuration of the country is a bar to the rapid discharge even of moderately heavy rains, which convert such localities into temporary swamps. Artificial obstructions, caused by embankments, tend in numerous instances to obstruct the natural drainage, and cause waterloo'o-in"' O ' DO O of the soil. (c) Altitude has also a very perceptible influence upon the extent to which, and the season during which, fever prevails in different regions. That the distribution of malarial diseases in the Punjab, and its varying degree of prevalence in the different districts, is, to a considerable extent at least, determined by these causes, cannot admit of a doubt. We shall first consider the local conditions to which fever is attributable in individual localities, and then inquire into its relation to rainfall and temperature. Delhi stands in the first rank of fever-stricken districts. The drainage of this district " is quite inadequate to meet ordinary rain- fall, and when the rainfall is excessive, all the evils arising from bad drainage are greatly aggravated " (>S''. C. R. 1887). This explains the marked difference in the health of wet and dry years in Delhi. In the dry year 1883 the fever death-rate in this district was 15*99 ; in the rainy year 1884 it was 36*54. A large area is 336 INDIA, CEyLON, BUKMA. under irrigation, and, as a rule, the irrigated districts suffer most in fever years. The more elevated tracts, when well drained, are less malarious.'^ The evil effects of malaria attain their maximum in badly drained localities such as Balabgarh. Water, we are told, stands to a considerable depth in and about the town for some time after heavy rains. It is stated that during the rains of 1887 the town was like an island, the country around being flooded, and the inundation had caused many houses to fall. It is not to be wondered at that many of the inhabitants are reported to have died of fever, and that the survivors were sickly and anaemic, with enlarged spleens, A proof that canal irrigation influences materially the preval- ence of fever, is afforded by the statistics collected for some years of the death-rate in forty-eight villages situated along the West Jumna Canal in Delhi and Karnal. It was found that in these forty-eight villages the average fever death-rate for the five years 1879—83 was 36"6, while that of the province as a whole was 19"2.^ Gurgaon has nearly the same fever death-rate as Delhi, and the same conditions here exist — canal irrigation, large " jhils " or ponds, and deficient drainage. In Karnal the localities that suffered most during the epidemy of 1884 were those in which natural drainage was deficient or obstructed. Dr. Stephen, in visiting, in 1886, the village of Namandah, in the south of the district, situated near the banks of the New Jumna Canal, two and a half years after the canal was opened, found every one suffering more or less from enlargement of the spleen, the result of malaria which was apparently intensified by the increased humidity of the soil caused by the canal.^ Eohtak is another district with a high fever death-rate ; and, like Karnal, Delhi, and Gurgaon, it is one in which there is exten- sive canal irrigation. Eespecting this region we learn that in 1886 the fever death-rate in the Gohana and Sampla tahsils was 26 per 1000 ; while in the Jhajjar and Eohtak tahsils it was only 15 per 1000. It is added that in the Gohana and Sampla there is much canal irrigation, and little in the Eohtak and Jhajjar tahsils. In Ilissar, the Hansi and Hissar divisions, which are under irrigation, and those parts of the country inundated by the overflow of the Ghaggar river, suffered most in 1887 {S. C. R. 1887). Umballa, Ludhiana, Jullundur, and Amritsar, although more healthy than the districts above mentioned, show, nevertheless, formidable ' "III tlie dry aud niountaiuous parts of tin; district, wliore the Avulls arc generally sunk in rock, and are fess liable to surface iniiltration, tlie epidemic prevailed with less severity."— >'DI. Peshawar. Adm. Died. Adm. Died. Adm. Died. Adm. Died. 1881, 363-0 1-04 820-7 2-48 567-3 0-90 1272-5 0-00 1882, 222-0 0-47 1201-0 0-87 440-1 0-84 1144-9 1-52 1883, . 152-1 0-68 647-6 0-00 390-4 0-59 800-3 0-00 1884, 524-3 0-47 1413-4 1-11 282-0 1-03 741-6 0-00 1885, 446-8 1-11 1091-6 0-67 182-7 428-1 1-22 1886, Means, 226-1 1-52 584-2 1-18 238-5 0-38 194-4 1-47 322-4 0-88 959 7 1-05 350-1 0-62 763-6 0-70 SlRHIXD. Lahore. Eawal Pii^di. Peshawar. TJmballa. Mean Meer. Eawal Pindi. Peshawar. Jiillundur. Fort Lahore. Campbelliiore. Xowshera. Subathu. Amritsar. Sialkot. Cherat. Dagshi. Fort Govindgarh. Dera Ismail Khan. Hoti Murdan Jutogh. Ferozepore. Fort Attock. Solon. Mooltan. Fort KanOTa. Khyra Gully. From the above table it will be seen that Lahore is, both as regards admissions and deaths, the most malarious, as Eawal Pindi is, as regards the death-rate, the most healthy of the Punjab circles. We shall now see in what manner rainfall affects fever mortality. This subject has already been to some extent considered so far as the effects of annual rainfall are concerned. The numerous circumstances modifying the influence of rainfall in particular localities have also been mentioned. These remarks have been confined to the influence of the amount of rain falling annually on the annual prevalence of fever, and have not dealt with the influence of the seasonal distribution of the rain on the monthly distribution of the fever mortality, a point which we shall presently consider. But before leaving this part of the subject, it may be well to bring the reality of the influence of the local rainfall of a district upon the fever mortality more distinctly into relief. We shall therefore reproduce the following table of the rainfall and fever mortality of four districts for a series of years. These are, as we have already pointed out, districts where canal irrigation is extensively carried out, and w'here there is a tendency to water- logging of the soil after heavy rainfalls : — EPIDEMIC AND ENDEMIC MALAUIA IN THE PUNJAB. 143 Statement showing the R.a.infall in inches Registered in the Thiui> Quarter, and the Number of Deaths from Fevers Registered in the Fourth Quarter, during the Years 1881 to 1887 inclusive, in the Districts of Delhi, Gurgaon, Rohtak, and Karnal. District. 1881. 1882. 1883. 1884. 1885. 1886. 1887. Delhi, ( Rainfall, 21 21 11 35 241 17 30-7 } Fever mortality, . 5,612 3,143 2,878 13,519 11,828 5,460 14,638 Gurgaon, J Rainfall, 18 12 13 21 30 12 26-3 Fever mortality. 6,515 3,751 2,440 6,973 10,379 5,804 15,183 Rohtak, 1 Rainfall, 16 11 9 14 29 15 28-2 ( Fever mortality, . 4,508 2,859 1,833 6,951 7,472 3,129 8,698 Karnal, 1 Rainfall, 15 16 12 33 20 18 41-9 1 Fever mortality, . 4,771 3,225 2,486 14,975 6,470 4,670 9,698 Althouo'h the influence of rainfall in increasino; the annual prevalence of fever is evident, it will be noticed that the fever deaths are not always m proportion to the rainfall, for 33 inches in Karnal, in 1884, gave rise to a much heavier mortality than did 41 '9 inches in 1887. This much, however, may be said, that in this region years of small rainfall are years of low fever mortality, and vice versa. The following tables will show the relation of the monthly distribution of rainfall to the monthly fever mortality for a series of years in Delhi, Eohtalc, Umballa, Ferozepore, Amritsar, and Ludhiana : — Delhi. Months. 1883. 1884. 18S5. 1880. 1887. Means. 3 sp >- ,-1 3 1 i3 (E V Q 3 a "5 Q-6 0-0 0-0 0-4 2-4 6-2 9-2 15-3 0-0 0-0 0-0 1-3 1 m T III 1 2-6 0-0 0-0 0-0 0-0 1-6 11-2 15-7 3-8 0-0 0-0 0-2 ill 3 ^ Jan. , Feb., March, . April, May, Juue, July, August, . Sept., October, . Nov. , Dec, Total, . 1-58 1-33 1-51 1-38 1-42 1-43 0-89 1-00 0-99 1-06 1-23 2-17 1-7 0-0 1-8 0-1 0-7 3-5 2-5 0-0 6-5 0-0 0-1 0-0 1-43 1-25 1-68 1-69 2-37 1-86 1-25 1-57 2-43 7-85 9-00 4-16 0-0 0-0 0-1 0-0 0-0 7-5 5-7 9-2 19-8 0-0 0-0 0-0 2-34 1-38 1-48 1-49 2-40 2-29 1-51 1-79 3-07 7-13 6-44 4-81 2-74 2-21 2-04 2-27 2-91 2-26 1-85 1-81 2-16 2-66 2-73 3-08 1-7 0-1 0-8 0-0 0-8 9-7 9-5 7-4 0-5 1-1 0-0 0-1 1-85 1-71 2-29 3-24 2-87 2-22 1-68 1-64 3-37 10-09 6-76 5-89 1-98 1-57 1-80 2-01 2-39 2-01 1-43 1-56 2-40 5-75 5-23 4-02 2-52 0-02 0-54 0-06 0-78 5-70 7-62 9-52 6-12 0-22 0-02 0-32 15-99 16-8 36-54 42-3 36-13 41-4 28-72 31-7 43-61 35-1 32-19 33-46 ■^ A fall of 6 inches was registered in June in addition to this. 344 INDIA, CEYLON, BURMA. EOHTAK. Months. 1883. 1884. 1885. 1886. 1887. Means. 3 a 'S R 3 a "3 P3 (D fp o P '^ 3 1 ■1° ti ?i o p c2 c " -So P^ a 1 P^ i 1 Jan. , Feb., March, . April, May, June, July, August, . Sept., . October, . Nov., Dec, Total, . 1-89 1-89 2-16 1-65 1-37 1-60 0-99 1-05 0-97 0-89 1-11 1-31 1-11 1-11 1-08 1-30 1-39 1-40 1-15 1-27 2-15 5-82 4-09 2-64 0-0 0-0 0-4 0-0 0-0 7-3 2-7 6-4 5-0 0-0 0-0 0-0 1-58 1-09 1-45 1-69 2-16 2-49 ]-68 1-73 5-07 5-60 4-68 3-20 2-8 0-0 0-1 0-3 2-2 5-3 6-7 20-7 1-3 0-0 0-0 1-6 1-74 1-43 1-73 1-67 1-98 1-79 1-32 1-54 1-83 1-57 2-01 2-07 1-0 0-0 0-9 0-0 0-4 2-4 10-2 4-3 0-5 0-5 0-0 0-0 1-45 1-35 2-07 2-22 2-49 1-76 1-17 1-74 5-59 7-77 4-79 3-15 1-0 0-0 0-0 0-0 0-0 0-4 10-4 16-6 1-2 0-0 0-0 0-7 1-55 1-37 1-69 1-70 1-87 1-78 1-26 1-46 3-12 4-33 3-33 2-47 1-20 0-00 0-35 0-07 0-65 3-85 7-50 1-20 2-00 0-12 0-30 0-57 16-80 24-51 21-8 1 32-42 41-0 20-68 20-2 35-55 30-3 25-99 28-32 Umballa. Months. 1883. 18S4. 1885. 1886. 1887. Means. P^ 3 1 ^. =e o O V o p '^ cares. Bare ILLY. Sitapur. Bijnor. c a ^1 if ^1 |3 1 ^1 C «-D- Aligarh. SHAHR. 1 •ai "5 sl >)§j '^5 3 :&i si a ■3g c ^ ^Q i si. g Op5 ^a C3 ^a i ^O K Jan., 2747 0-66 ' 63-2 27-5 2936 0-56 59-7 31-8 1562 0-10 1738 0-20 Feb., 1762 0-11 68-9 26-0 2230 1-32 65-0 29-0 1271 0-60 1452 0-00 Mar. , 1515 0-15 :78-6 27-2 2424 0-75 74-1 28-0 1211 0-10 1387 0-20 April, 2227 0-03 ; 92-6 30-4 2963 0-30 87-2 32-0 1451 0-00 1368 0-00 May, 2757 0-00 99-9 26-7 4195 0-05 94-7 29-1 2591 0-00 ; 2229 0-00 June, 2053 3-02 93-9 18-7 ; 3188 1-87 91-3 18-9 2690 3-10 2452 5-80 July, 1680 7 -93, 87 -3 11-7 2690 12-49 85-9 11-7 ! 1736 18-60 1716 14-80 Aug., 8154 10-62 84-2 8-6 8473 13-81 83-4 9-3 6388 14-40 10,778 11-30 Sept., 13,623 6-60 ' 84-1 14-2 20,386 3-10 83-2 16-9 15,537 7-00 23,861 2-40 Oct., 18,211 0-28 79-8 23-2 1 29,416 0-40 77-1 25-8 36,263 2-20 40,583 1-20 Nov., 10,340 0-00 i 69-3 30-5 18,568 0-00 64-1 35-3 24,727 0-00 25,772 0-00 Dec, 6370 0-20 61-7 29-4 12,282 0-92 57-1 31-7 13,933 109,360 1-50 13,830 1 0-60 71,439 29-60 80-3 22-8 109,751 35-57 76-9 24-9 47-60 127,166 36-50 It will be observed that in the fever districts ^3rt?' excellence the epidemic had made headway before the period when it could have been affected in one way or another by the weather prevailing in the end of September and October. In all the worst fever centres it had begun to show unmistakeable signs of its virulence as early as August. This is sufficient to prove that the epidemic was due to other causes than the distribution of the September and October rains. The tables appear, indeed, to show that as early as May the epidemy had declared itself in some of the districts. While we are upon the question of the influence of rainfall in the development of this epidemic, and having observed that the epidemic had begun in force as early as August, let us see whether there was any such great excess of rainfall in July and August in the worst affected centres as would, either by itself or as an addition to an irrigated area, account for the outbreak. The meteorological reports do not give the data necessary for comparing the monthly rainfall of 1879 with the average for all the districts noticed in the above table. But we find that at Agra there had been a deficiency of 1-2 2 inches in July, and an excess of 4-13 in August. At Etawah, another affected district, the rainfall in July was 1-25 inches in excess ; and in August and September there was an excess of only 0-50 of an inch. Yet these, as well as others, with a heavy July and August rainfall, experienced a marked increase of mortality in August which cannot be explained in every instance by any great rainfall in July and August. We are thus compelled to conclude MALARIA IN THE NOUTII-WEST PROVINCES AND OUDII. ouJ tliat the intensity and distribution of this epidemic are not explained by the excess of the rainfall that year, by its monthly distribution, by the scarcity of food, or by the water-logging of the soil. All these may have had a certain influence upon its intensity or localisation, but, separately or together, they do not fully account for either. We have to recognise here again the presence of an unknown influence. We have to do with true epidemic malarial fever, and such epidemics are comparatively little influenced by known meteorological conditions. They show a marked preference to water-logged localities, and yet they often extend, with great intensity, to others that are dry. We are not to conclude from this that endemic fever is as little influenced by the character of the weather. Epidemic and endemic malarial fever are governed each by its own laws. In 1883 the rainfall was very scanty, and the fever deaths were correspondingly few. In what may be called fever years, the maximum of fever deaths in these Provinces occur in October, but in 1883 the maximum occurred in December. We shall give the percentage of fever deaths for the entire Province in 1883 and 1886, as illustrating the monthly incidence of fever in a healthy and an unhealthy year in the North- West Provinces : — Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Healthy year, 1883, . 8*9 7-6 8-1 8-6 87 8-5 7-5 7-9 7-6 S'l 8-9 9-3 Unhealthy year, 1886, 7-4 6-0 6-1 7-3 8*0 7-1 6-8 8-5 10-2 11-4 11-2 9-6 The spring rise in' both years attains its maximum in May. The second rise is well marked in September in the unhealthy year, while this month was one of the healthiest in 1883. This anticipation of the second and true maximum of the fever curve is highly characteristic of fever years. Even in healthy years the fever mortality, in any district that may happen to be more severely affected, tends to attain its maximum at an earlier date than in those less severely affected. Thus, while in the North- West Provinces fever, in 1883, attained its maximum in December, yet if we take some of the more unhealthy districts during that year, such as Saharanpur, Muzaffarnagar, and Farukhabad, the highest fever mortality was not in December, but in November. In epidemic years the rise, as we have seen, begins in August, or even earlier. In 1883 every district in the North-West Provinces and Oudh except the Tarai had a fever death-rate below the average. In the midst of this general salubrity, the small town of Chibramau, in the Farukhabad district, had a fever mortality of 71-3 per lOOU. The z 354 INDIA, CEYLOX, BUKMA. fever deaths numbered 570 in a population of 7990, and of those deaths GO per cent, occurred in the last four months, and no fewer than 135, or about one-fourth, happened in October.^ Here, where the fever assumed an epidemic character, the maximum, as usual, occurred in October, although that year, being a healthy one, the maximum in the iSTorth-West Provinces generally was in December, and in a few of the more feverish districts in Xovember. As respects the cause of this outbreak, we are told that the rainfall at Chibramau had not been deficient, as was the case in the Province generally — 25'6 inches having fallen from June to September, which, although about the average, was more than double what fell at many other places. There were heavy falls between the 3rd and 20th August, and again on the 13th September. These rainfalls are said to have caused flooding of a considerable part of the town for many days together. " The town and its neighbourhood contains numerous pits, which are receptacles of refuse during the dry season, and of water during the rainy months." Again, at Barwala the people were found to be sickly and suffering from fever ; while at Basauli, a village about a mile distant, the people were healthy. The cause was ascribed to the number of excavations surrounding Barwala containing filthy water. This is a good example of a local outbreak in a generally healthy year due to local con- ditions. The year 1884 was a year of excessive autumnal rainfall, and marked especially by heavy rains in the first week of October, which, we are told, resulted " in much persistent flooding of the precincts or even the inhabited sites of centres of population. Late heavy rainfall of that character is followed in all years by a record of excessive fever mortality, and so it was in 1884 " (S. C. JR. 1884). This statement is equally difiicult to support by facts, as that which ascribed the fever of 1879 to defect in the rainfall of the later months of that year. This will be seen by comparing the fever mortality and rainfall of 1884 with those of 1885. In this year (1884), omitting the Terai, the division most affected was Meerut, and the district in Meerut which suffered most was Saharanpur, where the fever mortality was 48*28, as against a five-yearly average of 29'69. In the Meerut division the September rains were 10*2 inches in excess of the average. In Agra they were 6 inches in excess. The rainfall, we are told, was fairly distributed in time, and there were no long breaks. The rainfall in October was also in excess in all the divisions. We observe also that Saharanpur district had a total rainfall of 48"52 inches that 1 .S'. C. /.'. 1883, p. 10a. MALAltlA IN THE NOUTIl-WEST rUOVlNCES AND OUUII. 355 year, against an average of o4'79. In fact, it appears to liave been at once the most rainy and tlie most feverish locality in the North-AVest Provinces in 1884. The year 1885 was remarkable for its heavy June, July, and August rainfall, and for a deficient fall in September and October. Tliere was great flooding of the Bulandshahr district in July, and many districts were inundated during August. The distribution of the rainfall was thus very different from that of the preceding year, when September and October were rainy. The total annual rainfall for 1885 was about 3 inches higher than that of 1884. The fever death-rate was also higher, although it was confined more ex- clusively to water-logged localities in 1885 than in 1884, when malaria was prevalent over a great part of India. To see what effect this different distribution of the rainfall had in modifying the monthly incidence of the fever mortality, let us compare the two districts which had the heaviest fever mortality in 1884 and 1885 ; these were Saharanpur and Bulandshahr. Jau. Feb. J[ar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. Percentage of Fever^ Deaths at Saharan- I ^Wttfi'i"'^^^ 3-S ^-^ ^-^ 6-0 o-O 3-7 0-0 12-2 22-3 lOl lO'S August, September, | and October 18S4. J Percentage of Fever~\ Deaths at Buland- I shahr. Rainfall being | above thft average in ^- 4-3 2-S 3-3 :i-2 S'O 4--i 3-3 4-3 10-5 24-2 22-1 13-6 August, below aver- i age in September | and October 1885. J It does not appear from these figures that the different distribution of the rainfall goes far in explaining the different monthly dis- tribution of the fever mortality. The rise of the fever mortality in April, May, and June of 1884 was only what is usually seen in ejoidemic years. The autumn rise appeared earlier and was less abrupt in 1884 than in 1885. The only peculiarity in the table that can be ascribed to the heavy summer rains followed by dry weather in 1885, is the higher rise of the curve in October and November. The geographical distribution of malaria in these Provinces will be understood from the followino; table : — 156 INDIA, CEYLON, BURMA. Distribution of Fever in the North-West Provinces and Oudh (Death-rates per 1000). Hill Stations, ( Kumami, Garhwal, Delira Dun, The Tarai, ..... Rohilkhand (not irrigated), 6 Districts, Sitapur (not irrigated), 3 Districts, . Meerut (irrigated), 5 Districts, excluding Dehra Dun, ...... Agi'a (irrigated), 6 Districts, . L\rcknow (not irrigated), 3 Districts, Allahabad (not irrigated), 5 Districts, excluding Caw n pore, . . , . . Cawnpore (irrigated), Kae Bareli (not irrigated), 3 Districts, Fyzabad (not irrigated), 3 Districts, Benares (not irrigated), 7 Districts, . Jhansi (not irrigated), 2 Districts, omitting Lalitpur, . Lalitpur (not irrigated) S3 2 00 1883. 1884. •58 13- •65 10- •53 13^ •61 45 • •18 28 • •37 24- •86 39^ •50 31 • •81 20 • •93 21- •38 34 • •94 17^ •94 17- •25 17- •41 26^ •57 7- 1885. 11-78 11-86 13-21 34^79 32^91 22-93 40-63 31-13 24-14 18-8 30-14 20-80 20-43 19-63 20-45 7-75 1886. 12-56 11-09 12-38 47-99 41-56 26-47 34-09 27-71 27-50 22-76 27-09 24-00 25-03 22-98 26-65 10-45 The comparative healthiness of the hill stations and the excess- ive unhealthiness of the Tarai require no explanation. The most interesting point regarding the Tarai is the immunity from fever enjoyed by the aboriginal inhabitants, named the TariLs (S. M. I. 1882). The following is the monthly incidence of fever in the Kumaun and Tarai districts, the one in the hills, the other at their base : — Kumaun, Tarai, . Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 7-35 6-Sl 5-75 7-82 10-43 12-6 10-SO 0-0t» 7-07 7-(i0 7-40 7-14 8-92 6-91 6-57 7-32 8-57 9-60 5-70 5-38 G-12 10-70 13-79 10-3!> The autumnal rise in the fever death-rate in the excessively malarious Tarai presents a striking contrast to the summer rise in Kumaun. Lalitpur, in the Jhansi division, is also a non-malarious locality. In the other districts the most important factor in determining fever prevalence appears to be canal irrigation. The canal irrigated dis- tricts are : — Saharanpur. Bulandshahr. Fandchabad. Cawnpore Muzaffarnagar. Aligarli. Miiin])uri. Rluttra. Meerut. Etah. Eti'uvah. Agra. The following are the ratios of fever deatlis for these districts and for the entire Province : — MALARIA IX THE NORTH-WEST I'llOVINGES ANM) CUD II. 357 Noiuh-West Puovincks and OuDii — Ratio ok Fever Deaths in Twelve luiuGATEi) Areas and fou the Pkovixce, 1878-1884. Fever Deaths per 1000. Years. 12 Irrigated Districts. Corresponding Provincial Rates. 1878, 1879, 1880, 1881, 1882, 1883, 1884, 29-1 67-9 28-0 26-5 26-3 22-5 35-33 22-9 37-8 23-1 24-9 24-9 18-8 24-35 Aggreg ate, 235-63 176-75 It is scarcely possible to misinterpret these figures. In the North-West Provinces it is not a question of the amount of rainfall so much as the facilities for drainage. Sweeney has pointed out that when obstruction to drainage raises the water-level to within six or eight feet of the surface in the Doab, the fever death-rate is immense ; but if it never reaches at any time this point, its height is immaterial as respects its influence on fevers. " In years of ordinary rainfall the artificial substitutes for obstructed natural drainage are nearly, if not quite, sufficient ; but when the rainfall is heavy, obstruction ensues, and in almost direct proportion to it will be found the fever death-rate. In the non-irrigated districts, the direct proportion between the fever deaths and the excess of rainfall is not observed, even although the rainfall in the non- irrigated is greater than in the irrigated districts ;" from which he draws the conclusion that, " where natural drainage exists, rainfall is harmless ; but rainfall, where surface drainage is obstructed, becomes a fertile source of death " (*S^. C. B. 1885). This conclusion respecting the influence of rainfall on the pre- valence of endemic, as distinguished from epidemic, fever is sup- ported by the observations of Dr. Eichardson, to be found in the report quoted above. "Where fever," he says, "had stricken down the majority of the inhabitants of a town or village, inquiry invari- ably showed defective drainage to exist or flooding to have taken place. Where fever prevailed to a slight extent, the natural con- figuration of the inhabited site permitted the storm water to escape quickly, or cuttings had been made which effected the same result." Notter, in writing of Meerut, says, "Malarious fever lias increased since 1870. It has more than doubled among the 358 INDIA, CEYLOX, BUKMA. European soldiers, trebled among the native troops, and c[uad- rupled in the Central Prison. The subsoil water has been gradually rising since 1869. At the close of the rains in that year it was 14 feet 2 inches below the surface; on the 30th September 1885 it was 8 feet 11 inches." He remarks that the presence of excess of moisture in the soil is due in part to the obstruction to the natural drainage by the canals as well as to the railway {Army Medical Report, 1880). The evil effect of water-logging of the soil, whether brought about through irrigation, or inundation, or by excess of rainfall, is a point past dispute. It must be counted as a potent factor in increasing malarial prevalence. Endemic malaria in such circum- stances seems to vindicate its title to the name of marsh fever, for all these conditions bring about a marshy state of the soil; doubtless there are localities in the ISTorth-West Provinces which, like Meean Meer, are malarious without being marshy ; but of these I know nothing. The following table gives the distribution of paroxysmal fevers in the military circles of the North -West Provinces and Oudh from 1881 to 1886:' — Malarial Fevee. Allahabad. Oudh. KOHILKHAND. Meeelt. Adm. Died. Adm. 1 Died. 1 Adm. Died. Adm. Died. 1881, .... 1882, .... 1883, .... 1884, .... 1885, .... 1886, .... 433-8 318-3 187-8 301-4 240-9 398-6 0-84 2-32 0-97 0-00 0-98 1-22 248-8 457-0 176-2 114-2 221-6 110-6 0-00 0-00 0-00 0-00 0-28 0-30 312-9 1398-3 518-7 136-4 347-6 279-0 1-08 0-61 1-83 0-00 0-00 000 711-7 599-4 412-4 957-8 1263-3 666-0 1-13 0-20 0-22 0-00 0-62 0-55 Means, .... 313-4 1-05 •221 -4 0-09 498-8 0-59 786-4 0-45 Allahabad. Allahabad. Fort Allahabad. Dinapore. lienares. Chiinar. Cawnpore. Oudh. Lucknow. Fyzabad. Sitapur. Rohilkhaxu Bareilly. Shahjelianpur. I\Ioradabad. Ranikliet. Choubatia. JIeeuut. Meerut. Fatehgarh. Agra. Muttra. Delhi. Roorkee. Chakrata. ^ The comparatively small nuinlxTs on which the death-rates are calculated is a fact to be borne in mind, especially in drawing inlcrcnccs from the results of one or two years. MALAFJA IN THE NOUTII-WEST riiOVINCES AND OUDU. 350 Oudli has the lowest ratio of fever admissions, and also the lowest fever death-rate. Allahabad, which ranks next in respect to the number of admissions, has (perhaps from exceptional or local causes) the highest fever death-rate; the prevalence of fever at Meerut among the troops is out of proportion to its fatality. Dysentery is most prevalent and fatal at Allahabad, and ]\Ieerut takes the second place. While Oudh, with a low fever death-rate, has also the lowest death-rate for dysentery. This warns us, notwithstanding numerous instances in point, not to conclude that fever prevalence and fatality necessarily bear an inverse relation to dysentery prevalence and fatality. Notter states that purpura, closely resembling scurvy, occurs at Meerut, where vegetables are abundant. He thinks it is the effect of a hepatic germ of the malarial type ! In other words, that it is in some way related to malaria. This deserves to be remembered in connection with the Cyprus epidemic, where a species of purpura was one of the leading symptoms. The same author also notices the occurrence at Meerut of an intermittent h?ematoglobinuria, the urine being one day clear, of normal specific gravity, containing no albumen, and depositing no lithates ; the next day of a chocolate brown colour, of high specific gravity, containing albumen and sugar, and depositing lithates. (Army Medical Re-port, 1885, p. 37.) CHAPTEE V. ENDEMIC AND EPIDEMIC MALAPJA IN BENGAL. The registration in this Province was so defective during the decade 1870— V9, that it would only be misleading to make use of the earlier ratios given in the official returns. The later years show an improvement in this respect, but it is certain that the ratio of fever deaths is still considerably understated. The mean fever death- rate of the civil population during the four years 1881—84 was 14"54 per 1000. This, no doubt, is a high fever death-rate, but it is trifling compared to that returned from the ISTorth-West Provinces or the Punjab. There are, however, districts in Bengal where malarial fevers attain a high degree of prevalence and intensity. The most unhealthy, that is, most feverish, regions in Bengal are : — Eajshahye, Dinagepore, Jalpaiguri, Maldah, Eungpore, Bogra, Pubna, Murshedabad. Gregg believes that the region comprised in the great triangle lying between Gunduck and the Ganges on the south, the Berhampooter (Brahmapootra) on the east, and the Himalayas on the north, will be found to be that specially affected by severe malarious fever (S. C. B. 1877), Beerbhoom, Bankoora, Burdwan, Jessore, Hugli, the 24 Pergunnahs, and Midnapore, Hazaribagh, in the west, and Darjiliug, in the north, have also high fever death-rates. In almost every locality fever is most severe in the water- logged jungly districts, and in villages where the drinking-water is bad, and where foul tanks, interments in house compounds, and similar insanitary conditions prevail. The localities that suffer least are those where the country is free from jungle, the soil porous, the drainage good, and the general sanitary conditions fair. This is only a general statement, but it is supported by the concurrent evidence of all observers. The annual variations in the prevalence of malarial diseases in Lower Bengal may' be roughly estimated by the annual fluctuations in the admission and death - rates among the European troops stationed in the Presidency circle, which includes the stations of ENDEMIC AND Kl'IDEMIC MALAKIA IN I5ENGAL. 361 (liiiissioii. Dt-a til -rate 2r>4-40 0-00 439-06 0-97 '279-80 1-40 53'2-50 3-51 565-50 1-04 248-70 0-47 130-40 0-00 179-10 0-00 288-40 1-03 Calcutta, Barrackpore, Duin-Dum, Darjiling, and, for a part of the period, tlie station of Hazaribagh. Year. 1877, . 1878, . 1879, . 1880, . 1881, . 1882, . 1883, . 1884, . 1885, . The monthly distribution of fever deaths in Bengal, with reference to rainfall and temperature, will be gathered from the following table, which gives the monthly percentage of 819,297 fever deaths occurring from 1879 to 1883, and the average monthly rainfall and temperature of the Province:^ — Monthly Percentage of Fever Deaths in Bengal, 1879-1883, and Average Rainfall and Temperature. Jan. Fell. Mar. April. May. June. July. Aug. Sept. Oct. Kov. Dec. Monthly percentage of). ^.^ -.q .^.-^ ..3 ^.^ g.g g.g 7.7 g-l 9-8 12-1 12-2 Fever Deaths, . .) Average Rainfall. . . 0-o4 0-9i l"2i 2-33 fyU 12-14 13-94 18-09 10-.03 4-03 0-4S 0-16 Average Temperature, . 03-0 64-2 7ii-3 70-4 S3-5 83-1 81-3 81-2 81-2 78-4 71-4 64-0 A slight rise in the number of fever deaths takes place in March and April. In May, June, and July, which are the w^arraest months, the minimum fever mortality is attained, the actual minimum occurring in June, coincident with the commencement of the heavy rains and a temperature only a few decimals below the maximum. August, September, and October are marked by a gradual increase in the fever death-rate, which attains its maximum in November and December, wdiich are cold and dry months. In January a consider- able reduction in the number of deaths takes place, which continues during February, when the slight spring-rise begins. The annual course of the fever for Lower Bengal mortality is thus graphic- ally depicted by Gregg : — The monthly admission - rates per 1000 for intermittent and for remittent and continued fevers amongst the Euro- pean troops in Bengal proper, for the ten years 1870—79, as given by Bryden, show that the period of the maximum June prevalence of intermittent fever extends in this region from October to December, and that of remittent and continued fevers from June to August :— June. ^ Tlie averages of temperature and rainfall which refer to the rrovince are deduced from a tahle on Sanitary Measures in India, 1881-82. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 9-7 V'T 9-6 9-4 9-S 12 "2 14-5 12-6 18-7 26-3 30-6 T-7 10-6 15-3 is-s 27-4 31-4 33-2 22 -S 22-5 23-6 12-1 362 INDIA, CEYLON, BUKMA. Jan. Intermittent Fever, . 19 '6 Remittent and Con-) ...„ tinued Fever, . . . )" By comparing these figures with the chart already given of the monthly distribution of fever admissions among the native troops at Barrackpore, they will be seen to differ chiefly in the absence of the spring rise in April, — so marked in that chart, — and in the autumn maximum being attained in October instead of December. In both armies the remittent and continued forms are most common in the hot season. It is probable that the period of malarial prevalence varies somewhat in different localities in the Province. Of 4644 cases of malarial fever observed by Wise at Chittagong,^ 1634 occurred in May, June, and July, and 1119 only in the months of October, November, and December. Perhaps these may have been observed during an exceptional season. The district is said to be one where numerous canals and creeks render the locality very malarious. In Darjiling the maximum of fever deaths occur in May, and in the hilly Hazaribagh district there is a great rise in the death-rate in April. The upper delta of the Ganges is distinguished from other parts of India by the outbreak of local epidemics of fever of a very fatal character, shifting their centres from time to time, and spreading from such centres circumferentially in a progressive way from year to year. Our information respecting the history of these outbreaks is imperfect ; but a few general facts are known referring to epidemics that have been observed during this century. Thus we hear of a fever, called by the natives " jur beekar," as prevailing in an epidemic form at Mahomedpore, on the river Ellen Kallee, in Jessore, in 1824 and 1825, from which it spread to Dalga and Nuldanga, reaching Chashra in 1831, passing into ISTuddea about 1832, attacking successively Gudkhally, Goatallee, Khandbeela, and Sookpokooria, and returning upon Gudkhally in 1840. The fever is next heard of at Sreenuggur, about 25 miles south-west of Gudkhally, in 1845, continued in that neighbourhood for years, and after carrying off nearly three-fourths of the population, extended eastwards and southwards. About the year 1850 it was raging at Gaurpotlia, twelve miles uorth-east of Sreenuggur ; then it spread westwards, and reached Oolah in 1856, cutting off 10,000 out of a population of 18,000 inhabitants. The fever then diffused itself over the southern part of ISTuddea, tlie north-eastern part of Hoogly, and pretty generally over the district of Baraset, com- mitting fearful ravages in many places. ^ In