gradually developed from previously existing intestinal disease of an allied but milder type. The outbreak occurred in winter, and coincided with the freezing of the filter-beds at the waterworks. The theory is worth notice, because a similar relation between the drainage and the water-supply frequently exists in places severely attacked by cholera, and it has repeatedly been observed that the latter is preceded by the prevalence of a milder form of intestinal disease. The inference is not that cholera can be developed de novo, but that the type is unstable, and that a virulent form may be evolved under favourable conditions from another so mild as to be unrecognized, and consequently undetected in its origin or introduction. This is quite in keeping with the observed variability of the micro-organism, and with the trend of modern research with regard to the relations between other pathogenic germs and the multifarious gradations of type assumed by other zymotic diseases. The same thing has been suggested of diphtheria.
Cholera is endemic in the East over a wide area, ranging from Bombay to southern China, but its chief home is British India. It principally affects the alluvial soil near the mouths of the great rivers, and more particularly the deltaEpidemicity. of the Ganges. Lower Bengal is pre-eminently the standing focus and centre of diffusion. In some years it is quiescent, though never absent; in others it becomes diffused, for reasons of which nothing is known, and its diffusive activity varies greatly from equally inscrutable causes. At irregular intervals this property becomes so heightened that the disease passes its natural boundaries and is carried east, north and west, it may be to Europe or beyond to the American continent. We must assume that the micro-organism, like those of other epidemic diseases, acquires greater vitality and toxic energy, or greater power of reproduction at some times than at others, but the conditions that govern this behaviour are quite unknown, though no problem has a more important bearing on public health. Bacteriology, as already intimated, has thrown no light upon it, nor has meteorology. Some results of modern research, indeed, tend to assign increasing importance to the relations between surface soil and certain micro-organisms, and suggest that changes in the level of the subsoil water, to which Professor Max von Pettenkoffer long ago drew attention, may be a dominant factor in determining the latency or activity of pathogenic germs. But this is largely a matter of conjecture, and, so far as cholera is concerned, the conditions which turn an endemic into an epidemic disease must be admitted to be still unknown.
On the other hand, the mode of dissemination is now well understood. Diffusion takes place along the lines of human intercourse. The poison is carried chiefly by infected persons moving from place to place; but soiled clothes, rags and other articles that have come into contact with persons suffering from the disease may be the means of conveyance to a distance. There is no reason to suppose that it is air-borne, or that atmospheric influences have anything to do with its spread, except in so far as meteorological conditions may be favourable to the growth and activity of the micro-organisms. Beyond all doubt, the great manufactory of the poison is the human body, and the discharges from it are the great source of contagion. They may infect the ground, the water, or the immediate surroundings of the patient, and so pass from hand to hand, the poison finding entrance into the bodies of the healthy by means of food and drink which have become contaminated in various ways. Flies which feed upon excreta and other foul matters may be carriers of contagion. Of all the means of local dissemination, contaminated water is by far the most important, because it affects the greatest number of people, and this is particularly the case in places which have a public water-supply. A single contaminated source may expose the entire population to danger. All severe outbreaks of an explosive character are due to this cause. It is also possible that the cholera poison multiplies rapidly in water under favourable conditions, and that a reservoir, for instance, may form a sort of forcing-bed. But it would be a mistake to regard cholera as purely a water-borne disease, even locally. It may infect the soil in localities which have a perfectly pure water-supply, but have defective drainage or no drainage at all, and then it will be found more difficult to get rid of, though less formidable in its effects, than when the water alone is the source of mischief. In all these respects it has a great affinity to enteric fever. With regard to locality, no situation can be said to be free from attack if the disease is introduced and the sanitary conditions are bad; but, speaking generally, low-lying places on alluvial soil near rivers are more liable than those standing high or on a rocky foundation. Of meteorological conditions it can only be said with certainty that a high temperature favours the development of cholera, though a low one does not prevent it. In temperate climates the summer months, and particularly August and September, are the season of its greatest activity.
Cholera spreads westwards from India by two routes—(1) by sea to the shores of the Red Sea, Egypt and the Mediterranean; and (2) by land to northern India and Afghanistan, thence to Persia and central Asia, and so to Russia. In Western diffusion.the great invasions of Europe during the 19th century it sometimes followed one route and sometimes the other. It was not till 1817 that the attention of European physicians was specially directed to the disease by the outbreak of a violent epidemic of cholera at Jessore in Bengal. This was followed by its rapid spread over a large portion of British India, where it caused immense destruction of life both among natives and Europeans. During the next three years cholera continued to rage all over India, as well as in Ceylon and others of the Indian islands. The disease now began to spread over a wider extent than hitherto, invading China on the east and Persia on the west. In 1823 it had extended into Asia Minor and Russia in Asia, and it continued to advance steadily though slowly westwards, while at the same time fresh epidemics were appearing at intervals in India. From this period up till 1830 no great extension of cholera took place, but in the latter year it reappeared in Persia and along the shores of the Caspian Sea, and thence entered Russia in Europe. Despite the strictest sanitary precautions, the disease spread rapidly through that whole empire, causing great mortality and exciting consternation everywhere. It ravaged the northern and central parts of Europe, and spread onwards to England, appearing in Sunderland in October 1831, and in London in January 1832, during which year it continued to prevail in most of the cities and large towns of Great Britain and Ireland. The disease subsequently extended into France, Spain and Italy, and crossing the Atlantic spread through North and Central America. It had previously prevailed in Arabia, Turkey, Egypt and the Nile district, and in 1835 it was general throughout North Africa. Up till 1837 cholera continued to break out in various parts of the continent of Europe, after which this epidemic disappeared, having thus within twenty years visited a large portion of the world.
About the year 1841 another great epidemic of cholera appeared in India and China, and soon began to extend in the direction traversed by the former, but involving a still wider area. It entered Europe again in 1847, and spread through Russia and Germany on to England, and thence to France, whence it passed to America, and subsequently appeared in the West Indies. This epidemic appears to have been even more deadly than the former, especially as regards Great Britain and France. A third great outbreak of cholera took place in the East in 1850, entering Europe in 1853. During the two succeeding years it prevailed extensively throughout the continent, and fell with severity on the armies engaged in the Crimean War. Although widely prevalent in Great Britain and Ireland it was less destructive than former epidemics. It was specially severe throughout both North and South America. A fourth epidemic visited Europe again in 1865–1866, but was on the whole less extensive and destructive than its predecessors.
By some writers the epidemic of 1853 is regarded as a recrudescence of that of 1847. The earlier ones followed the land route by way of Afghanistan and Persia, and took several years to reach Europe. That of 1865 travelled more rapidly, being carried from Bombay by sea to Mecca, from there to Suez and Alexandria, and then on to various Mediterranean ports. Within
