Art. II. Sketch of the Geography of Epidemic Yellow Fever since the Close of last Century. By Gavin Miluoy, M.D., F.R.C.P., President of the Epidemiological Society, &c. After an absence of a good many years, yellow fever in an epidemic form manifested itself afresh about 1793 in the West India Islands, and at several points of the American Continent, between Guiana to the south, and the seaboard of Pennsylvania and New York to tho north. The imperfect data on record seem to indicate that Grenada, Dominica, Barbadoes, and Jamaica were among the British islands first attacked; but that, prior to their invasion, the disease had been pre- vailirig in Charleston and other southern cities of the United States, as well as on the coast of Guiana and the adjacent settlements. The expeditionary force under Sir Charles Grey, sent from this country soon after the outbreak of the great revolutionary war for the capture of the French West India colonies, arrived in those latitudes in the early part of the epidemic season, and at once encountered the pestilence. During the reduction of Martinique, St. Lucia and Gua- daloupe, and the subsequent occupation of St. Domingo in 1794, tho loss of life among our troops, chiefly from malignant fever, was enor- mous. Of the 10,000 men composing the force, G000 perished within a few months. Several regiments returned to Europe, after a short stay, mere skeletons of what they were. The 82nd lost within twelve months of their arrival in the West Indies upwards of 800 rank and file and officers, and mustered on their return not men enough to complete the number of their non-commissioned officers ! Part of tho " 92iul also, engaged in St. Domingo, were soon exterminated to a man." The whole of this dreadful mortality was not due to yellow 1864.] Milkoy on the Geography of Epidemic Yellow Fever. 175 fever alone, however fatal this epidemic pestilence then proved to be; if at all our for in former years, when it was scarcely prevalent, troops had still suffered disastrously from the ordinary endemic fevers of the tropics, and also from dysentery. These were the days (and unhappily of they continued for long afterwards), when the subject climatic and was never other such influences on the health of the soldier dreamt of in the chances of by governmental authorities ; and when, estimating lives were looked at in much success of a military expedition, human or the muskets and sabres the same light as the powder and shot, were and serviceable in shipped off at the same time;?if they good so other 1 one place, why should they not be in any The of in 1793-4 is memorable from being epidemic Philadelphia ' the occasion of Dr. Rush's celebrated Essay' on the disease. In 1794 Charles- the cities of New York, Newhaven in Connecticut, Baltimore, and the fever seems to have ton, &c., suffered more or less severely; next two or three reappeared in most of them during the years. Humboldt states that, after an absence at Vera Cruz of the disease in the form since 177C, and in the sporadic form since 1786, epidemic and it broke out there in 1794. This alternate cessation reappearance other is a character common to yellow fever with epidemic diseases, Dr. Chisholm and other and must have been strangely overlooked by writers of that day when they imagined that the malignant pestilence of 1793 in the West Indies, &c., was a new and foreign distemper, im- of Africa ! From that ported by a sickly ship from the West Coast it with year till towards the close of the century, prevailed varying of the Caribbean but also force not in many of the islands Sea, only of the United along the coast of Mexico, as well as in numerous parts States?from Louisiana and South Carolina to New Hampshire. Nor was the South American continent exempt from the baneful influence j for, besides Guiana and other regions within the circuit of the Mexican of Grlllf, it now appeal's from the very interesting communications Dr. Archibald Smith, recently brought before the Epidemiological Society, that a malignant fever having many of the attributes of yellow fever was prevalent about the same time in many districts of Peru, is but one and caused great mortality among the inhabitants. This infor- of many instances which show that just as our opportunities of mation respecting the occurrence of epidemics enlarge, so do we find occasion to believe that their geographical diffusion is often far more extensive than has been usually supposed. not The commencement of the present century was signalized only and the United by the return of yellow fever in the West Indies States, it has been an absence of more but also its appearance (after, stated, by It was at Cadiz than thirty in the south of Spain. that, years), it first manifested itself. according to the generally received report, is described as been The weather there, in the early part of 1800, having tho heat became unusually and, as the year advanced, extreme, irregular; from the of the and at the same time intolerably oppressive prevalence " the of a east wind, or Levanter." About beginning August fever, remarkable for the singularity and violence of its symptoms, and tho 176 Original Communications. [July rapidity of its fatal course, made its appearance in the Barrio di Santa Maria?a low, crowded, and filthy locality, the resort of merchant seamen and the lowest classes of the people. It was at first confined to this district; and not till the deaths had considerably increased and cases had occurred in other localities, was the true nature of the fever recognised. Thereupon it was rumoured that it had been brought by a vessel from South America, and introduced on shore by smugglers? an explanation that has frequently been had recourse to by quarantine authorities for solving such difficulties. By the middle of September, the daily deaths amounted to two hundred out of an estimated popula- tion of nearly 58,000. The total mortality at the end of October, when the disease had nearly ceased, was upwards of 7000. During the height of the sickness, the air was described as being so stagnant and vitiated that many of the lower animals were attacked with symptoms like those that occurred among the human race, and numbers of them died. Besides Cadiz, the neighbouring towns of Port St. Mary, Xeres, Seville, &c., and also "the city of Malaga, were the seat of the disease during the autumn. Seville lost between a sixth and a seventh part of its inhabitants ; and in Xeres the mortality was returned at 10,000. Gibraltar, too, this year was so unhealthy, although the exact nature of the sickness has not been ascertained, that the mortality in the gar- rison, then usually between four and five thousand strong, was during that season nearly four times as high as the average had been during the preceding four years. Dr. Trotter states* that in the autumn of 1799 a bilious fever, with many characters of the yellow fever of the West Indies, prevailed to a considerable extent at Gibraltar; and it is noteworthy that at tht same period the towns of Ceuta and Tangiers, on the opposite side of the Straits, were affected with a malignant fever of a similar nature. And some accounts state that other places, such as Cette in the Gulf of Lyons, and the city of Genoa, suffered much this season from a like sickness. In 1801, yellow fever reappeared during the summer months at Cadiz and Seville; and in October it showed itself at Medina Sidonia, situated thirty miles inland, and intermediate between Cadiz and Gibraltar;?the garrison of the latter place continued unusually sickly throughout the year. The islands of Martinique and Dominica are known to have been the seat of yellow fever in 1801. In the two following years (1802-3) the disease seems to have been more widely spread. Many of the West India islands suffered severely, as did also Charleston, Philadelphia, and other cities in the United States. Malaga was affected in both years?the earliest cases there always occurring in July and August?and Cadiz in the autumn of

1 ' in his work on Vide Medicina Nautica,' vol. ii. p. 428. Dr. Donald Monro, the Health of the Army, published last century, says that in the hot months?June, July, August, and September?the garrison and inhabitants of Gibraltar are subject to bilious and putrid fevers, and that new comers seldom escape them in a violent degree. 18G4."J Milroy on the Geography of Epidemic Yellow Fever. 177

1803. Some suspicious cases also occurred at Gibraltar during this season. and of the 1804 was notable for the unusual prevalence fatality fever in the south of Europe. Gibraltar was the seat of a most de- and The structive outbreak among the civil military population. June to and summer had been more than ordinarily hot from August, excessively oppressive by the stagnancy of the atmosphere and the prevalence of the easterly sirocco winds. of a crowded The first distinct cases occurred, about the end August,in that most house in one of the filthiest quarters of this (at time) filthy was to the garrison town. For some time the fever confined imme- it to diate neighbourhood, but ere long (middle of September) began manifest itself in different localities, and soon involved the whole community. It continued till towards the end of the year. Hie 864 men and garrison, about 3500 strong, lost in three months the 4SG4 officers, besides 1G4 women and children. Of civilians, fifteen and sixteen thousand. perished out of a population of between Many of the inhabitants left Gibraltar when the true nature of the others for disease became known, some for the coast of Barbary, as there was no Malta, where they were permitted to land at once, suspicion at the time of the kind of fever existing at Gibraltar. -As soon as the truth was known, the most rigorous quarantine regulations were immediately enforced, not only in Malta but in all the other ports of the Mediterranean. No ill effects, however, occurred any- where from the arrival of the fugitives. Between the months of June and December of this year, the whole ?f more or the south and south-east of Spain appears to have been le?s infected. Numerous towns in the provinces of Cadiz, Seville, (Cordova, Malaga, Granada, Murcia, Alicante,

was really that disease, there are no means now of determining. (Hennen.) In 1804-5 the fever was destructively prevalent in the West Indies and the southern ports of theUnited States. The British fleet, as well as our troops in the West Indies, appear to have sustained heavy losses in consequence. The mortality in the fleet in 1804 is stated by Sir (J-. Blane to have been nearly three times greater that year than it was in 1782, when, in addition to the ordinary causes of death on the station, the great naval action under Lord Rodney was fought. So sickly were some of the ships that in one frigate, says Sir Gilbert, there were no fewer thau 170 cases of fever, and of these 26 were fatal, on board. The deaths in the naval hospitals at Jamaica and Antigua amounted during the year to 727. Between 1804 and 1810 yellow fever, which for the first three or four years of the century had not been out of the south of Spain, was entirely absent from that country. Cases began to appear during the month of September, 1810, at Cadiz, in the very same crowded and filthy locality where it had first manifested itself in 1800 and again in 1804. The town at the time was exceedingly crowded with thousands of persons flying before the invading French forces. On this, as on the former occasions, the origin of the disease could not be traced to any extrinsic source, although the general belief then and subsequently in Spain has been that it must have been introduced from abroad. The city of Cai-thagena suffered severely during the autumn: more than 3000 died from the fever. Malaga appears to have escaped, or to have been only slightly affected, in 1810. In October of that year a pestilential fever?similar, it was stated, to the fever which had pre vailed in Spain in 1800 and 1804?broke out in Santa Cruz in the island of TenerifFe. It was believed by the islanders that the disease had been brought by a vessel from Cadiz, with French prisoners on board.1 The visitation of yellow fever at Gibraltar in 1810 was compara- tively slight, although the atmospheric peculiarities of the season are described as having been very similar to those of 1804. During 1811-12 Carthagena and several other towns in Murcia, then occupied by the French army, appear to have been the prin- cipal seats of the disease between the months of July and September. The province of Valencia also suffered in 1812. In that year a dreadful mortality occurred among a body of recruits, about seven hundred in number, that had been brought in a large transport from Alicante to Cadiz. In consequence of the delay in landing them, more than a seventh of the whole perished on board; upwards of five hundred had been smitten with the fever. was a which was still the 1813 very sickly year throughout Spain, 1 the In March of this year (1810), a dreadful mortality occurred among poor French at on board the hulks in Cadiz bay. "The ex- prisoners, captured Baylen, " treme misery and filthy state of these men," says Sir I. Fellowes, labouring under a of so a every depression and privation, gave rise to malignant fever contagious nature, that all the Spanish guards and hospital assistants who were employed amongst them caught the disorder, of which many died." 186-1.] Miltioy on the Geography of Epidemic Yellow Fever. 179 seat of war and its attendant miseries. Cadiz was again the seat of yellow fever, the earliest cases reappearing in the old locality, where the disease had first occurred before. At Gibraltar, too, there was a great amount of sickness both on shore and among the vessels of war and others in the on the accession of the summer heats. Sus- bay, " picious cases began to present themselves in Boyd's Buildings," the notorious fever-nest of the town \ and, ere long, other filthy and crowded districts became the seat of attacks of malignant fever. At this time four transports, crowded with deserters from the French army in Carthagena, arrived in the bay. As several cases of fever had occurred during the voyage, no communication with the shore was permitted, and the mass of human beings continued to be cooped up in the sickly ships until two empty hulks could be procured to separate the unattached from the sick. Almost all the men who were transferred to the hulks escaped, while most of the crew and others who were not removed were smitten, and very many died. A similar fact occurred on shore. Upon the breaking out in force of the fever, nearly SOOO of the garrison left the town and encamped in huts or tents on the neutral ground. With the exception of a few attacks soon after their removal, the whole body remained healthy. It was in the autumn of this year that several cases of what was considered to be yellow fever occurred in the depot barrack at St. Andero, on the coast of Biscay. By removing the men from the barrack, which was found to be foul and unwholesome, to a healthy locality, the disease soon ceased. In reference to these cases, Sir James MacGrigor wrote :l " As transports are but ill accommodated for the conveyance of wounded men, or those labouring under dysentery or fever, they often suffered much on the passage: hospital gangrene spread, cases embarked as synochus landed as typhus, and spme assumed the appearance of typhus icterodes. The few cases of this last disease, which appeared at St. Andero, by no means justified the our . Panish government in subjecting hospitals to the rigour and inconveniences of the Quarantine laws." In 1814, there was a partial reappearance of yellow fever in Gibraltar; the disease commenced this time in " Cavallero's " Buildings," considerably higher up than Boyd's Buildings," and rivalling the latter in impurity and general unwholesomeuess. After this year, Spain seems to have been nearly, if not quite, exempt for the more next five years. During this interval, and especially in 1817 and 1818, the pestilence is known to have prevailed in several of the West India islands, as Antigna, Dominica, Jamaica, and Guada- lupe, &c., and also in the Southern States of the American Union; but my memoranda are too imperfect to enable me to follow its course.* At Sierra Leone, it appears from some meagre notices, that an 1 vol. vi. 2 Med.-Chir. Trans., For seven or eight years after 1807-8, there seems to have been a lull in the epidemic force of the fever in the West Indies generally, and also in the Southern mted States?at least in Charleston. 180 Original Communications. [July?

epidemic commenced in 1816-17, and continued for several suc- cessive years. 1819.?" This year," remarks Dr. Hancock, in his valuable work on the Laws and Phenomena of Pestilence, "was remarkable for the general spread of epidemic and pestilential diseases over the world. Their unusual prevalence was announced from all the four quarters of the globe. India, and the east and south of Europe, as well as the north-west parts of Africa, were visited by the form of disease peculiar to their several climates. Nearly all the "West India islands, with the adjacent shores of the American Continent about Demerara and New Orleans, were ravaged with pestilential fevers. Disease was so prevalent in the cities of the United States, that the President thought it a subject deserving notice in his opening speech to Congress." In Spain, yellow fever prevailed in different parts of Andalusia, more especially in Cadiz and Seville. In the former city, it began in July, and, notwithstanding all the attempts at first to con- ceal its real nature, the truth soon became manifest, and the disease rapidly spread in the low and crowded districts in spite of the most stringent quarantine barriers around the infected localities. So great was the alarm at Madrid, that the central junta decreed the punish- ment of death against any person entering the capital from the diseased province without a proper certificate of health ! In 1820, and again in 1821, the fever reappeared in Cadiz and other towns in Andalusia, and also in Malaga. It was in 1821 that the disastrous outbreak of the pestilence occurred in Barcelona, the great seaport of Catalonia, the north-eastern province of Spain. It began in July, and by the middle of August had spread so much that all the authorities fled, and a militaxy cordon was drawn round the city to prevent the escape of any fugitives. But ere long it appeared beyond the cordon, at Tortosa on the coast to the south of the Ebro, and in the inland towns of Mequinenza and Lerida. The fever reached its acme in Barcelona about the middle of October, and ceased in December. The mortality had been enormous both there and at Tortosa. In the "West Indies and United States, 1819 had been followed by another very sickly year. Yellow fever seems to have clung to Balti- more in 1821 and 1822; and in this latter year New York was revisited. In 1823, Sierra Leone and other parts on the north-west coast of Africa, are known to have been the seat of the pestilence. Several of .the West India islands also suffered severely. The isolated partial outbreak at the port of Passages, close to St. Sebastian, in Biscay, occurred in August. It was connected with a vessel recently arrived from Havanna; there had been no sickness on board, and she had been kept in quarantine for ten days as a precaution. It was on the opening of the hold and the discharge of the cargo that the first attack Of occurred, and in the persons of strangers from the shore. twelve carpenters employed in removing the rotten timbers of the hold, six Were attacked in rapid succession. Several cases occurred on shore in 1864.] Milroy on the Geography of Epidemic Yellow Fever. 181 some filthy crowded houses near to where the ship was moored. But the disease did not spread, and soon ceased. This year occurred also the oft-quoted case of the outbreak at Ascension, in connexion with H.M.S. Bann, recently arrived in a sickly state from Sierra Leone j she had lo3t fifteen of Iter crew during the voyage, and there Were forty-five men sick on reaching the island. They were immediately landed and put under tents. The virulence of the fever among the crew speedily diminished ; but the garrison was attacked during the third week after the arrival of the ship, and of 43 cases 21 proved fatal. In 1827, the fever was very prevalent in several of the West India Islands; Jamaica and St. Thomas were particularly unhealthy. Charleston and other cities in the Southern States of the Union were also much affected. In 1828, the disease reappeared at Gibraltar after an absence ot fourteen years. The earliest cases were observed about the beginning of August, in a district thus described by Dr. Ilennen, then principal medical officer of the garrison, and who, himself, fell a victim to the epidemic :?" The population dense to a degree incredible except to those who have seen it. In sheds, without ventilation, without draiuage, and generally composed of the slightest materials ) in tiers of beds as close as in a crowded transport numerous individuals sleep ; they go out to their woi'k at an early hour and return at gun-fire, locking up their miserable places of nocturnal shelter during the day, and leaving them saturated with the steams of their bedding, their food, and the overflowing receptacles of their ordure.' Dr. Ilennen, who was also health-officer of the port, failed to trace the disease to importation from abroad, and was satisfied that it was of local origin ; and Sir W. Pym himself, having been sent out from England to the of the disease, that its investigate history acknowledged origin was very obscure. It is to be remembered that, prior to the this, last, epidemic of yellow fever at Gibraltar, sporadic cases of aggravated bilious remittent, proving fatal with black vomit, tfcc., had occurred almost every year during the autumn. The following table gives the mortality in the five successive epidemics during the present century ; Mobtalitt. Years. Military. Civil population. 1804 809 4864 1810 6 17 1813 391 508 1814 114 132 1828 507 1170 1829.?After the cessation of the fever, in the epidemic form, for several years in Sierra Leone, it reappeared there, and continued to prevail during this and the following year. Many of our ships of war on the station suffered most disastrously ; the frigates Sibylle aud Eden lost nearly a hundred of their crews, and some of the smaller vessels sustained proportionately heavy losses. 182 Original Communications. [July?

Between 1831 and 1837-3S, there was a similar lull in the pes- tilence on the African coast to that which had occurred prior to 1829. This seems to have been the case also at Charleston and other ordinary seats of the disease in the New World. 1837-38 was a remarkably sickly epoch in the history of yellow fever. It prevailed with great malignancy at Gambia, Goree, and Sierra Leone, committing terrible ravages both on shore and among our African squadron. In 1838. the island of Ascension experienced its second visitation, several weeks after the arrival of H.M.S. Bonnetta in a sickly state from the as of African coast. The surgeon of tlie garrison regarded the fever local origin; and Dr. Bryson, although of opinion that it was imported, admits the impossibility of tracing the mode of its introduction. Bx-itish Guiana, which had been nearly exempt since 1819, suffered severely during 1837-38; and for many years subsequently the colony continued to be infested with sporadic cases, or clusters of cases, of the disease, in the usual sickly season. At the same period of the year it prevailed extensively in the West India Islands, as at Cuba, Jamaica, Barbadoes (the military were the chief sufferers), Martinique, Dominica, &c. In October, 1837, the disease appeared at Bermuda, where it had not been seen, except in a sporadic form, for eight or nine years previously. All classes of the community suffered. The fever did not extend beyond the small island in which it arose, nor to any of the ships of war in the harbour, unless their crews had personal communication with the shore, as was the case with the ship's com- pany of H.M.S. Pearl, then recently arrived from England. In the naval hospital, where there were 134 cases treated, of which 21 died, it did not attack any individual belonging to the establishment, whether white, black, or coloured. The disease was regarded at the time as of endemic origin. The next visitation of the fever in Bermuda occurred in 1843, during which year, as well as in 1841?2, and again in 1844?5, New Orleans, and several other towns in the Southern States, suffered much from its ravages. In 1842, the disease appeared in the city of Guayaquil, on the West or Pacific side of South America, about 3? S. lat. It continued to reappear in that city, and its immediate neigh- bourhood for two or three successive seasons; but it did not spread to other towns on the Peruvian coast, notwithstanding the unchecked intercourse.1 Whether the pestilential fever mentioned by Ulloa to have pre- vailed at Guayaquil in 1740 was genuine yellow fever, or not, it is impossible now to determine; it was very fatal, and seems to have been accompanied with hemorrhagic symptoms. In 1845, British Guiana was partially visited; but this year is chiefly memorable in the history of yellow fever as that of the disastrous mortality in H.M.S. Eclair on the north-west coast of Africa, and the occurrence of the disease at Boa Vista, one of the a time after Cape de Verde groupe, in 17? lat. N., within short the 1 At a later date (1852), the disease reappeared in this region, and spread much more to the southward. 1864.] Milroy on the Geography of Epidemic Yellow Fever. 1S3 sliip left the islet where she had landed her sick. The previous season there, and on the African coast, had been sickly. It would bo out of place here to enter into a detailed account of this melancholy episode; suffice it to say, that the circumstances connected with the fatal sickness in the Eclair on that occasion, and of her subsequent unhealthiness for years afterwards, ought, ere this, to have led to improved hygienic arrangements generally in our ships of war. At the same time, a hope may be expressed that recourse will never be had in future to such measures as were adopted upon her arrival in this country, but that the unattacked portion of the crew on board a pest-ship may, on all occasions, be as promptly as possible removed out of her into a pure and wholesome atmosphere, so as to prevent the further extension of the disease. In 1847, a fresh epidemic occurred at Sierra Leone, which for some years previously had been comparatively exempt from the disease. Br. Lawson, then the medical officer of the troops, remarks that it commenced in June, that then the cases of the endemic remittent took on the form of yellow fever, and that subsequently, when the latter subsided, the former type began again to prevail. As on all former occasions, the disease was almost exclusively confined to the lower part of the town ; it did not appear to be contagious. It seems to have manifested itself about the same time at two or three other places on the coast, at some distance from Sierra Leone. In this year, New Orleans experienced a most destructive visitation. Some of our West India colonies were also extremely sickly. The troops at Bar- badoes suffered much from yellow fever in 1847, and again in 1848?49. Hie ill-drained barracks of St. Ann's had always been infested with the disease in epidemic seasons. In the latter year, the military at Antigua were attacked ; and, after an exemption of several years, Charleston and other Southern States in the United States were re- visited. This year was remarkable along the coast of Brazil for what are usually regarded as the evidences of a ex- cessive distempered atmosphere?viz., heat, great drought during the summer, occasioning enormous mortality among the cattle, the entire absence of thunder-storms, gene- so rally frequent during the hot months, the irregularity or total absence of the summer breezes, with a prevailing stagnancy of the air. Later in the season, heavy rains fell in many parts; but the same close and oppressive state of atmosphere remained. Gastric affections and typhoid fevers had been more than commonly frequent and severe in Bio Janeiro throughout the whole season. For two or three years previously, a change in the character of the most prevalent diseases had been observed by the resident medical men. The ordinary en- demic fever had been becoming less and less remittent, and more decidedly continued in type; so much so that many cases were regarded aa " of a new form of fever, to which the appellation of insolation fever" was given, and which resembled, it is said, in many respects, the milder cases of yellow fever. These occasional cases became from year to year of a more aggravated and fatal character, and in several instances the 184 Original Communications. [Julyj

matters vomited had much of the appearance of the true "black vomit."1 It was in the month of November, 1849, that the earliest cases of recognised yellow fever were reported in the large commercial city of Eahia, in lat. 13? S., having a population of about 140,000. The city, it was stated, had been unusually healthy?the mortality, at least, had been low?for some months previously, notwithstanding the close and oppressive condition of the air, and the more than ordinarily polluted state of the shore-water in the bay from various causes of insalubrity. Within a week or two after the first cases, the disease rapidly spread to different parts of the town and suburbs, and the shipping in the harbour became affected about the same time. It was remarked that collier vessels suffered more than others. The fever seems to have reached its acme in February and March; it lingered, however, in the place till the following September. It may deserve notice that, at the very time when the earliest cases of yellow fever occurred in Bahia, arrivals from Europe and the United States were being put into quar- rantine there on account of another pestilence, which had not then found its way to Brazil?viz., the malignant cholera; and also that clean bills of health continued to be given to vessels leaving Bahia until near the end of January. Such are the anomalous absurdities of quaran- tine, as hitherto exercised, for the defence of public health ! In the course of December, cases of the same fever were observed on the coast, both to the north and to the south of Bahia, as at the large port of Pernambuco, in lat. 8? S., at Maceio, lat. 9? 40' S., and also at Bio Janeiro, the capital of Brazil, iri lat. 23c S. It is impos- sible to determine with any exactness the earliest appearance of the disease in either place, as the resident medical men differed in opinion upon this point. The first decided attack of the fever at Rio appears to have occurred in the low lodging-houses of the town frequented by sailors, and which, as usual, were situated in a filthy, narrow street, not far from the foul beech where many of the merchant-vessels were moored, and whose abominably offensive condition will be remembered by all who have landed there. From these places the disease appeared to spread to other parts of the town, and also to the shipping. The fever attained its height in March, abated considerably on the setting in of the cool weather in May, and ceased by the end of July, after causing great mortality. The shipping, men-of-war as well as merchantmen, in the harbour suffered much during the epidemic. Some vessels escaped almost en- tirely, although they were in as frequent communication with the 1 It has been asserted, though probably upon very insufficient grounds, that Brazil had been entirely exempt from any visitation of yellow fever for more than a century prior to 1849. Other accounts state that the disease had occurred not only sporadi- cally, but as an epidemic, on various former occasions, as in 1720 and 1780. (Edin. Monthly Journal, vol. xv.) There can be no doubt that during the last fifteen years, Itio Janeiro and the other great ports have been far more unhealthy than previously. They have suffei-ed much from cholera, as well as from yellow fever. Formerly, the Brazilian station was one of the very healthiest for our ships of war ; of recent years, several vessels have sustained heavy losses from epidemic diseases. 1864.] Mil/roy on the Geography of Epidemic Yellow Fever. 183 shore as others that became infected. This was the case with H.M.S. Crescent, a dismantled frigate for the reception of liberated Africans, which lay in the harbour the whole season. Many vessels which left Rio for Monte Yideo had cases, often fatal during the voyage, and arrived with the disease on board ) but in no instance that season did the disease spread in the La Plata river, either on shore or to other vessels which communicated with the infected ones. On the other hand, it has been confidently stated that several vessels direct from neared the coast of Europe were attacked with fever when they Brazil, with cases on board. These and that some actually arrived at Rio were therefore entertained as to cases were generally mild, and doubts their true nature. Some of the physicians in that city were, however, ?f opinion that the mildness of the attacks was merely due to the greater dilution of the atmospheric poison, and to the more favourable condition of the sick out at sea than in harbour or on shore. In 1850 various other towns on the coast of Brazil became the seats Gua- of the fever, as Para, Parabibo, Paranagua, Santos, Mangaratiba, were not visited till the rapasi, and Campos. Maranham and Ceara of or French Guiana, following year. Towards the end 185G, Cayenne was and a on the north boundary of the Brazilian Empire, infected, fearful loss of life ensued. The colony is said to have expeiienced only three since 17G2. visitations of the dise.ase _ west- I" the adjoining Dutch settlement of Surinam, immediately ward of Cayenne, the fever manifested itself in 1851, and somewhat later in the same season in British Guiana,1 still farther westwaid along the coast of South America, where sporadic cases had for several years inva- before occurred, but which now became the seat of an epidemic sion which lasted, with varying intensity, throughout 1852, and did uot cease till 1853. While the low, marshy province of Guiana was under the poison-cloud, its influence seems to have been extending northward and westward over the Caribbean Gulf, and along the shores of the Spanish main to Mexico and the Southern States of the Ame- rican Union. The islands of Martinique, Guadaloupe, Barbadoes, St. as Lucia, St. Domingo, Cuba, St. Thomas, and Jamaica, as well the cities of Nexv Orleans, Charleston, and Savannah, &c., all began to suffer more or less severely during the hist six months of the year. Bio of the Janeiro had been affected in the spring; and at the end 1 in that "While in the severe outbreak of malignant cholera Jamaica, investigating fever island, I Was muci1 struck with the progressive advance of the epidemic yellow to the from Brazil towards the West Indies. In my letter addressed governor, to awaken March 31, 1851 is the following passage:?" I am the more anxious the of the public attention'to the necessity of measures being adopted for preservation that there is little or public health, as I find that an idea is very generally prevalent no with virulence in the island, in con- risk now of the yellow fever ever reappearing for so sequence of its abseuce i" the epidemic malignant form, many years past. (There or fourteen The idea is had been no epidemic for thirteen years.) utterly mischievous. I shall remark that erroneous, and may if incorrect, prove very only the a which had been for re-ieut severe outbreak of the pestilence in Brazil, country a and its existence at the couple of centuries exempt from its invasion, present moment are facts which should not be in Cayenne, and also, I believe, in Demerara, overlooked."?Official Report on the Cholera in Jamaica} 1853. 186 Original Communications. [J uly, autumn, not only was Puerto Cabello, &c., on the Spanish main, but also Callao, Lima, and other places on the Pacific coast of the South American continent were attacked.1 It visited Lima in 1852, and further south the during the next three years gradually spread along coast, not reaching the cities of Santiago and Valparaiso in Chili till 1856. a wider of the In 1853, there appears to have been still prevalence disease than in 1852 ; for not only did most places enumerated above continue to be infected, but various other West India islands, and also other cities in the United States were now visited by the disease. Among the former, Trinidad, Tobago, St. Vincent, Grenada, Dominica, Antigua, Montserrat, and among the latter Natchez, Baltimore, Brandywine, Delaware, and Philadelphia (slightly), (fee. At New Orleans, the visitation this year was one of the most dreadful the had ever sustained. Various other in Louisiana suf- city # places fered also severely during the latter months of the year. After an absence of ten years, our colony of Bermuda was revisited this year, and very fatally, more especially among the troops and the convicts ; a fourth part of the garrison was swept off in the course of a couple of months; the barracks were unwholesome and excessively crowded. The bad condition of the convict hulks, too, added much to the viru- lence of the disease. While it is known that Bahia, Rio Janeiro, and other places in Brazil, continued to be the seat of the fever," one account stated that it had extended still further south, and had appeared at Ilio de la Plata. If not genuine yellow fever, it must have been some other bad form of fever. But if there was any doubt as to the x-eal nature of the disease at La Plata, there was none respecting the sickness at Callao, Lima, and other places on the Pacific side of the South American continent, which suffered severely during the early summer of this year. In 1854 and 1855, the diffusion of the pestilence was much less extensive than in the two preceding years. The shipping at Bahia, and some other ports in Brazil, had not entirely ceased to suffer in the early months of 1854. The Dutch island of Curacoa is also men- tioned as having been attacked about this time. In the summer of 1 The reader will find an interesting account of this, the first well-observed, epi- demic visitation of yellow fever on the western shores of South America, by Dr. Archibald Smith, long resident in Peru, in the Edin. Med. and Surg. Journ. for April, 1855. The exact period of the earliest cases could not be determined. There is reason to believe that the same, or an allied fever, but in a milder form, prevailed in the country in 1818, and also in other years, both beforo and after that period. From the official returns of the health of the navy, it is clear that sporadic cases of yellow fever were frequently observed along the tropical shores of the Pacific prior to 1852. 2 It appears that many parts in the interior of Brazil were visited by a deadly " fever in this year. The Tapajos (one of the great tributaries of the Amazon, which it joins at Santarem) had been pretty free from epidemics for some years past, to be now although it was formerly a very unhealthy river. A sickly time appeared of the returning ; 1853 was the most fatal one ever experienced in this part country. A kind of putrid fever broke out, which attacked people of all races alike. The accounts we received at Santarem were most distressing ; the mortality was very large."?The Naturalist on the Amazons, by H. W. Bates. 1803. Vol. ii. p. 144. 1864.] Milroy on the Geography of Epidemic Yellow Fever. 1S7 both years, New Orleans was sickly ; Charleston and Savannah in 1854, Baltimore and Norfolk in 1855. During the spring and summer of this year, the shipping in the harbour of the island of St. Thomas suffered more severely than for several seasons previously. Port-au-Prince, on the south of St. Domingo, was, at the same time, very unhealthy. In 1856, Brazil, at various points, was still the seat of the disease. Para, from which it appears never to have been entirely absent since its first appearance there, was very sickly ; and in May of this year the fever prevailed at Rio Negro, on the River Amazon, several hundred miles in the interior. Besides Guiana, some of the West India islands, as St. Thomas, St. Domingo, Jamaica, the French Antilles, &c., were affected at different times of the year. Ihe shipping more particularly suffered. Pour ships of our "West India squadron sustained heavy losses, and particularly the j\[(il(icc&, in which a third of her entire crew were cut ofi in less than two months. Our troops at Port Royal and Kingston were sickly in June; and, later in the season, occurred that outbreak of the fevei in the bax lacks at Newcastle, nearly 4000 feet above the sea level, and of which a most valuable narrative by Dr. Lawson, the principal medical ollicer of the troops in Jamaica at the time, was published in this Review. Dr. Lawson, after a careful investigation of all the antecedent and con- comitant circumstances of the disease, came to the conclusion that its development was due to local causes of insalubrity, favoured by an epidemic constitution of the 11 It will be sufficient, he " atmosphere. remarks, to prove the existence of an epidemic constitution in the present instance to state that, the summer of 1856, fever during yellow prevailed pretty in the West Indies and around the Gulf of extensively Mejftco, and was therefore sufficiently general to warrant the conclusion of there been in mere local having something operation beyond influences." Isolated cases of the fever had occurred as thus previously, alluded to in official on Jamaica in 1853: "if other my report any proof was wanted to show that mere elevation of site will not suffice to maintain the health of in such a climate, the unex- pected troops occurrence at Newcastle of several fatal cases of fever with all the characters of yellow fever, in 1849, may well give rise to serious apprehensions. These cases were attributable to the operation of local clearly impurities in the where occurred." Vera building they Cruz was affected in the summer; nor was New Orleans en- tirely exempt, though the fever this year did not pi'evail epidemically. There was a great amount of the disease among the shipping at the Quarantine station in the harbour of New York ; and from thence it extended to the shore, not only at Staten Island, but to different out- lying points of that great commercial metropolis. Bermuda was again the seat of another visitation, but which was much less severe than in 1853. Taken in connexion with the statements, the instinc- tive preceding very narrative of the "spotted fever" of the Peruvian haemorrhagic yellow Audes in 1853-57, by Dr. Archibald Smith, in the 'Trans- 188 Original Communications. [July, actions of the Epidemiological Society,' serves to show how widely was diffused the morbific agency at this time over a large portion of the New World. The Navy Returns mention Callao as a seat of the disease in 1856. One of the most notable events this year was the appearance of the fever at Lisbon, about the beginning of September. It did not spread widely, and the mortality in the city was only 87. At Belem, where it was first observed, the deaths amounted to 35 in all. more Next year (1857), the visitation at Lisbon was much severe; it commenced in July and subsided in the latter part of October. Out of a population estimated at 200,000, the attacks were stated to be between 19,000 and 20,000, and the deaths to be 5652. So great was the general alarm during the prevalence of the disease that com- mercial business was nearly suspended for some time, and the meeting of the Legislature also was adjourned in consequence.1 What, if any, other towns in Portugal experienced a visit, I have not discovered. It appears that Ferrol, Com una, and some of the smaller towns on the seaboard of Gallicia, the north-west province of Spain, were infected in the month of August. In the West Indies generally, the summer season of 1857 was one of the most sickly known there for many years past. The royal mail steamer Oronoko,"which left St. Thomas on the 27tli of June, with a crew of 106, lost 28 out of 73 that were attacked, on her passage to England; none of the 168 passengers on board sickened. Several of our ships of war on the West India station?particularly the Brilliant, in which there were 34 deaths in the coui-se of five or six weeks?also lost many of their hands; and the American squadron too, in the Gulf of Mexico, suffered severely. In some of the ports of Brazil, the disease prevailed ?o a frightful extent in the spring; and now for the first time (presuming that the suspicious sickness in former years was not genuine yellow fever), Monte Video, in lat. 35? S., was visited by the pestilence. It seems to have commenced there about the middle of February, and to have continued till the end of May, during which interval 1800 persons died out of a population which is usually from 25,000 to 30,000; but which, from the vast numbers that had fled, could not then have ex- ceeded 8000. In 1858, and again in 1859, many of the West India islands were infected. St. Thomas was seldom free from the fever, and the result was that not a few of the vessels which were detained there coaling caught it. Among others, several of the royal mail steamers had a on Far good many cases board during their passage to Southampton. more numerous, however, were the arrivals of sickly vessels in the ports of New York and Philadelphia, in both of which places there was several fatal cases considerable mortality among the shipping, and occurred on shore also. At Charleston, the number of deaths in 1858 around the wharves, &c., was such as to warrant the term of epidemic 1 The official report of the Lisbon epidemic, by Dr. Lyons, is full of instructive details. Fever. 189 1864.] Milroy on the Geography of Epidemic Yellow In tlie latter of this fever alone being applied to the sickness. part fever at and the year, there was an outbreak of the Antigua; Navy at Panama. There returns indicate that at the same time it existed of the at Sierra appears also to have been a re-appearance pestilence a Next Leone and the Gambia, after an absence of good many yeais. more fatal on the African coast. It year, 1859, the fever was still the civil at the prevailed to a extent among population Gambia, great The French and is stated to have cut off half the white inhabitants. is said to have suffered settlement of Goree, eighty miles to the north, of our African the to an extent truly appalling."1 One squadron, of a crew of about 105 died Trident, suffered terribly \ 44 out peisons of' the fever. m ? the at Tri- A partial outbreak occurred this year among troops seen in the autumn. All the nidad ; cases had been preceding sporadic weie attacks could be traced to the barracks, which sanitanly faulty. 24 were fatal. The disease did not Of 28 cases admitted into hospital spread to the town. of In 1860, mention is made in the Army and Navy Reports St. as the seats of the fever. Panama, Honduras, and Brazil, Domingo, Mr. In reference to the sickness at Honduras, Staff-Surgeon Thornton, the time that an says: "It was exceptional, it being only epidemic of this disease has visited the place; and even at JBelize the disease of thirteen But this had not been seen for upwards years. years over the whole of central America, epidemic appears to have extended as various cities north and south ot the Honduras settlement had which over these suffered by one of those waves of the kind pass war Mexican Gulf were countries." Several of our ships of in the extremely sickly. " In four vessels, containing about 640 men, there were, in the course?of six weeks, upwards of 160 cases of yellow fever, and of these 76 terminated in death." The Icarus alone lost 39 men out of a crew of 110 men. Having, in the last part of the Transactions of the Epidemiological Society, given some details respecting the diffusiou of epidemic yellow fever in 1861, I shall now draw these remarks to a close. The geo- graphical limits of the pestilence, as hitherto recorded, have been, as regards the New World, from about 43? N. lat. to 35? S. lat., on the east coast, and about 33? S. lat., on the west coast of Soutli America. between 43? and In the Old World the limits may be said to be and 44? N. (the north 'of Spain), and 8? or 9? S. lat. (Ascension Loando). Whether yellow fever does not prevail further genuine of it is at south both the western and the eastern coasts Africa, along of it present uot to determine. The fevers Madagascar are, possible of has been stated, often attended with the characteristic symptoms us not the disease; and this circumstance may lead unreasonably to a outbreak. But it expect the occasional occurrence of pestilential of what can be con- must be admitted that, as yet, no epidemic justly observed or recorded in sidered as yellow fever has ever been any part, 1 McWilliam in tlie Trans, of the Epidemiological Society. 2 Army Reports for 1859. 190 Original Communications. [July, island or mainland, of the Pacific Ocean, until we arrive at the western shores of the American continent. That the pestilence has, within the last fourteen or fifteen years, taken a wider range than it did before, is a fact of curious and instructive import. It has appeared, also, at higher elevations, and in cooler latitudes, than used to be assigned as limiting its career. But wherever it has been seen, it has manifested the same general attributes or properties in relation to the external agencies which affect its development and spread, and which influence its virulence and fatality. It usually manifests itself in summer or autumn; from July to November, in the northern hemispheres, is the season when it most prevails, and is most deadly. In this respect, it is like alvine fluxes and enteric fevers. Like them, too, its origin and malignancy are powerfully promoted by local causes of insalubrity and atmospheric pollution. Low-lying and foul fore- shores of harbours, where the water is stagnant or nearly so, and the immediate neighbourhood of undrained, filthy wharves, &c., are the special seats of its early manifestations and most frequent recurrences. Hilly, dry, inland spots are comparatively exempt, unless where the natural advantages are counterbalanced by artificial sources of impurity, as has been the case with many military stations in the West Indies, &c., which abound with nuisances around and within them, and are, at the same time, made still more unhealthy by over- crowding and defective ventilation of the barracks. The troops have often been smitten when the civil population escaped. Overcrowd- ing in the between-decks of steamships seems to be the principal cause of the extreme fatality of the disease in the navy. What in this respect is true of typhus, may with equal force be said of yellow fever. There is no such powerful adjuvant to the virulence of the poison, and to its power of propagation, as an unrenewed atmosphere, loaded with human exhalations. Having now briefly sketched the recent geographical history of the Oriental and the Occidental pestilences, it is my wish to do the same in respect of the world-wide pestilence, epidemic cholera, since the great eruption of the disease in lower Bengal in 1817.