The Cholera Epidemic in the Kingdom of Denmark in 1853

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I860.] The last Cholera Epidemic in Denmark.. VI/ 145

Review XYI. Cholera-Epidemim i Kongeriget Danmark i Aaret 1853. Ved Dr. Th. Bricka. The Cholera Epidemic in the Kingdom, of Denmark in 1853. By Dk. Theodore Bricka 8vo, pp. 288, with Five Plans. Copen- hagen, 1855. We have in former numbers of this periodical called the attention of our readers to the details of the cholera epidemics in Sweden and in Norway, and we are now able to complete these reports by the statistics and history of the epidemic of cholera in Copenhagen and in Denmark in 1853. It was in that year that the last severe visitation of cholera occurred in England, when Newcastle-on-Tyne and many other towns suffered so much from the ravages of the disease. The admirable organization of the profession in Denmark has provided ample reports on the progress of the disorder, both in the city of Copenhagen and in the various localities of that kingdom where it manifested itself, and these reports have been very ably condensed by Dr. Bricka in the present volume. Copenhagen had up to 1853 entirely escaped the ravages of cholera during the great epidemics that had spread over Northern Europe, devastating the countries on either side of the little kingdom of Denmark. In 1848, when cholera prevailed extensively in Sweden, as well as in other parts of the Continent, a few isolated cases did indeed show themselves in Denmark, but the malady did not spread beyond the immediate vicinity of the spot where the cases first appeared. A well marked case of cholera certainly occurred on the 6th of November, 1848, at Dragoer, on the island of Amager, close to Copenhagen. The ? patient, a man of sixty, and an assistant pilot, recovered but his wife, who attended upon him, took cholera on the 11th of November, and died on the 16th. A cousin of this woman's, a female, aged thirty- eight, nursed her in her illness, and then took the disease on the 13th, and died on the 15th of November. It was ascertained that the old man in whom the malady commenced, had been on board of a ship coming from St. Petersburg, where cholera then prevailed ; but it could not be made out that any of the crew of that ship were then affected with the malady. A slight epidemic of cholera likewise showed itself at Bandholm, on the island of Lolland, in 1850, in the month of August, and this epidemic was peculiarly fatal among children; nor could it be traced to any positive importation. A schooner from Lubeck had indeed come into the harbour on the 28th of July, but none of the crew were sick, and Lubeck. was not declared to be infected till the 31st of July. The disease, however, would probably be was in the town for a few days before the fact of its presence there declared. In Corsoer, in Zealand, two or three cases of cholera were observed 49-xxv. 10 146 Reviews. [Jan. in October of the same year. The first was in the person of a sailor, who had been working on board of two vessels from suspected ports; arid the second victim was a shoemaker, who inhabited the same chamber as the first. A number of minor cases afterwards occurred in the same house, and in others in the same street, but the malady did not spread further. Copenhagen.?When cholera broke out in the capital of Denmark, in June, 1853, there was no cause for anticipating its appearance. At the time when the malady had prevailed in former years in all the neighbouring kingdoms, its vicinity to Denmark was indicated by an extraordinary prevalence of diarrhoea, both in country districts and in Copenhagen itself. In 1852, when no cholera existed in Sweden, Norway, or Germany, diarrhoea was extremely prevalent in Copen- hagen ; but in the spring of 1853, that capital was remarkably free from bowel complaints; so much so, indeed, that in April and May only four fatal cases are recorded (inclusive of infants); and in the first half of June not a single death occurred from the same cause. Cholera at that time prevailed at St. Petersburg and at Cronstadt, but this was its nearest approach to Copenhagen. On the 11th of June, 1858, a carpenter, who worked on a dredging- lighter at Nyholm, was attacked with vomiting and diarrhoea, and on the following day he was placed in the Nyboder Hospital. He recovered, and went out on the 25th of June. On the 12th of June, a man of fifty-nine years of age was brought into this hospital from the same locality ; he was placed alongside of the first-named patient, and died on the 15th of June of well marked cholera. The disease then spread through this hospital, and showed itself next in various parts of the city. It is certain that the epidemic first appeared in the Nyboder quarter, and then spread itself over the north-eastern portion of Copenhagen. The inmates of the prisons in Nyhavn entirely escaped. The small, narrow streets in the centre of the town were less severely visited than some of the larger thoroughfares; nor was the malady most intense in the dirtiest localities. In the district of the Yesterbro, where the drinking water is notoriously bad, where butchers'-shops and pigsties abound, and where drainage is scarcely possible from the want of fall, only a very few cases of cholera occurred. The epidemic lasted from the 11th of June to the 13 th of October. It was a pretty general rule that the disease died out soonest in those parts of the town where it showed itself at first with most marked severity. Two streets (the Tester gaden and the Fridriks- borg gaden) in both of which an epidemic of typhus had prevailed during the previous summer, remained singularly free from cholera. The mortality was greatest in the back rooms of sunken dwellings, and next in the rooms immediately above those, and was least in those rooms that looked into the street. The relative condition of life of the these persons inhabiting respective dwellings must not be overlooked, as the dwellers in the back rooms were mostly individuals of the lowest class and in the most impoverished circumstances. Cholerine and I860.] The last Cholera Epidemic in Denmark. 147 diarrhoea were of course extremely prevalent during the whole course of the epidemic. The total number of cases was 7219, and the deaths 4737. The aged were the readiest victims, not one individual above eighty years of age recovered when attacked, and children under a year old rarely survived. The mortality from other diseases remained during the epidemic at its usual average. In the garrison of Copenhagen, amounting to 6500 men, there occurred 116 cases, 68 of which proved fatal?a very small per-centage indeed of cases, but which has been observed to occur also among garrison soldiers in England. Cholera at this time (June, 1853)prevailed only atSt. Petersburg and Cronstadt, from which ports ships arrived almost daily at Copenhagen. Previous to its outbreak there, no cases had occurred in other parts of Denmark; it was precisely in the port at which the ships from St. Petersburg arrived that it made its first appearance. No positive evi- dence is, however, forthcoming of the importation of the disease; but once within the precincts of this large city, the proofs of direct infection were easily to be found. Thus, Dr. Bricka tells us of the great number of cases and deaths among the attendants in the cholera hospitals, though here, too, there occasionally were remarkable exceptions. None of the female attendants in the Hospital of Our Saviour fell victims to the disease; indeed, only one was attacked with cholera, though this building was ill placed in a sanitary point of view, and was constantly crowded with cholera patients. Dr. Bricka does not believe in the reputed danger of cholera hospitals as " foci" of infection. Some quarters of the town immediately in the vicinity of these establishments remained free from the disease. Nor does our author admit that the epidemic could be referred to a sudden miasm brought across the seas by the wiud, or generated in the town itself. No important changes in the condition of the city had been made for many years. The malady, he observes, crept through the streets like a contagious disorder, and did not burst at once upon the whole city, as is the case with influenza and other true epidemics. But while he denies the production of the malady by local causes, he is fully prepared to admit their important influence on the progress of the disease. Uncleanliness, overcrowding, and bad food are all disposing causes of cholera; but in Copenhagen, as was also the case in Warsaw in 1832, and elsewhere, the malady was by no means the most severe in those localities where these causes were specially in operation. In some newly-built houses the malady was especially virulent, while in others of equally recent construc- tion it made no progress at all. Among ten families living close to the water, and at the mouth of the open town sewer, on the Norrebro, there was not a single case of cholera. The measures taken by the Government and by the medical authorities, when the cholera was declared to exist in the town (June 24th), deserve our attention. A sanitary commission was established, and five offices were opened directly in various quarters of the town to receive announcements of cases of cholera. Physicians and students were in constant attendance day and night at these oflices, ready to visit the 148 Reviews. [Jan. sick in the localities indicated, to provide them with nurses, or, if necessary, to procure their immediate transport to the cholera hospitals. The hospitals were likewise duly prepared for the reception of the sick, and early in July the regular house to house visitation was duly organized by a society of medical practitioners and students. This system was at first vigorously pursued, but it had not the wished-for effect of staying the disorder ; on the contrary, the epidemic continued to in- crease, and reached its height about the third week after house to house visitation was commenced. The disease then spread so rapidly that the system could no longer be carried out, and moreover it became evident that the premonitory diarrhoea so much insisted upon by English writers did not in many cases exist. We have ourselves observed this during the great epidemic at Newcastle-on-Tyne in August and September, 1853 ; many persons were then struck down at once, without any premonitory diarrhoea, and sank rapidly without rallying from the first shock. On the 24th of July, in the very height of the epidemic, the important measure of removing all the inhabitants from the infected houses and districts was commenced. Tents were pitched on open spaces within the city, and to these tents the healthy from the infected houses were removed. In this way 345 families were removed from the foci of infection, and placed in a purer atmosphere, and to all appearance with the happiest results. Very few cases of cholera occurred in the transplanted families, and a still smaller proportion of deaths. Some of the dwellings from which these families were displaced at that time were not opened to them again, but were subsequently taken down and rebuilt. The greatest cleanliness, and the most effi- cient sanitary domestic precautions were enforced by the police ; the theatres, and even the open-air tea-gardens, were closed (we doubt the prudence of the last-named measure), and an improved rate of diet was ordered for the workhouses and for the prisons. The military and naval establishments were likewise placed under strict superintendence. Soon after the emptying of the infected houses had been commenced, the epidemic began to abate, though the weather continued close and sultry. It is more interesting, as bearing upon the great question of the contagion or non-contagion of cholera, to trace the progress of the malady in country districts, than to attempt to follow its development in large it towns. In the latter often spreads with terrible rapidity, and in a very few days the whole of a town may become so thoroughly infected, that it may be looked upon as one great focus of disease. In the country the malady is generally more slowly developed, and the mode in which it may be transported from place to place, or communicated from one individual to another, can be more easily followed. This was certainly the case in regard to the progress of cholera in Sweden and in Norway, and it also holds good in regard to Denmark. Copenhagen seems to have been here the focus from whence the malady i-adiated to different towns and villages, as no cases occurred in country districts in the prior to the outbreak capital, and in a great many instances the I860.] The last Cholera Epidemic in Denmark. 149 fact of the importation of the disease from Copenhagen seems to be dis- tinctly proved. Dr. Bricka is not an ardent contagionist himself, but he does not, on the other hand, attempt to explain away the fact of the disease having been brought in many cases into country districts previously quite healthy, by individuals coming from infected localities. The districts immediately around Copenhagen, and nearest the great centre of infection, will first engage our attention. To the south of the city, and joined to it by a narrow strip of land, lies the peninsula or Island of Amager, the kitchen-garden of the Danish metropolis. From the end of May till the beginning of July, 18-53, cholerine prevailed extensively here amongst the agricultural population. For the last six years this malady, or its equivalent, diarrhoea, had shown itself in the northern parts of the island in the months of August and September, but it had seldom commenced before the end of July. The first fatal case of cholera occurred in an aged widow, who daily visited Copenhagen to dispose of the vegetable produce of her garden. She sickened on the 8th of July, on her way back from the town, and died on the 10th inst. Her daughter, aged twenty-two, next took the disease (July 12th), and then her elder sister (aged sixty-seven), who sickened on the same day and died upon the 15th. On the 17th the nephew was attacked, and died on the same day. After this many cases occurred in the village (Sundbyvester), and on the 15th July the malady appeared in the extreme south of the island, at Dragoer. A sailor was brought thither from his vessel, which lay in the Nyhavn at Copenhagen. He died on the 16th, and his wife, who was in perfect health when her husband was brought home, took ill and died on the following day. The malady thus showed itself in two quarters at once?viz., at the villages of Sundby, in Taarnby parish, in the north, and at Dra- goer, in Hollcenderby parish, in the extreme south. In Taarnby parish the disease, when once introduced, spread with fearful rapidity, and continued its ravages there up to the 25tli of August. In Dragoer, on the contrary, it showed no disposition to spread, but confined its attacks to two or three of those about the individual by whom it was first introduced, and then no further cases occurred till a fresh importation took place from Copenhagen. Dr. Feilberg, the reporter from this district, adds, that he has obtained almost certain proof that the two or three cases that occurred in Dragoer, in 1848, were really imported, and not of spontaneous origin. It is probable that Dragoer presented sanitary conditions less favourable to the spread of cholera than the Sundby villages in Taarnby. Of the sanitary state of the latter Dr. Feildberg speaks in terms of un- qualified condemnation. The farm-houses in these villages (Gaarder), which were placed on rather more elevated ground than the cottages, were hardly attacked at all. The cottages of the peasantry, however, were packed together on ground imperfectly drained, and their position did not allow of free access of air to the dwellings. One farm-house, however, which was placed down among the cottages, and iu front of which was a filthy poof of stagnant water, did not the wss escape disease. The number of cases on the Island of Amager 150 Reviews. [Jan.

562, and of deaths 338 ; while the mortality in the affected villages was from 7 to 8 per cent, of the whole inhabitants. Of males 288, and of females 274 were attacked with the disorder; hut the deaths were 162 males and 176 females. This excess of mortality in the latter case may be accounted for by the fact that a great number of aged women took the disease, and most of these speedily died. Almost all the habitual spirit-drinkers, and those who drank to excess during the epidemic, fell victims to its ravages. "It is perfectly plain tome," observes Dr. Bricka, "that cholera did not arise spontaneously in this district. Not one of those -who laboured under cholerine took cholera, till the latter malady was imported from Copenhagen by persons who had taken the infection there, and which they brought back with them to their own families." (p. 41.) In the southern districts around Copenhagen, cholera first appeared on the 29th of June, in the parishes of Frederiksberg and Hvidovre. The first case was that of a man who had frequently visited Copenhagen, and especially had been at a house where a servant girl had died and a child lay ill of cholera. This man died at his own house on the 30th of June; his wife and children, who nursed him in his sickness, escaped, but the malady affected a family living in the same house, and from thence spread to a house over the way, and extended itself through the village. In Frederiksberg there were 48 cases and 30 deaths, and in Valby 40 cases and 27 deaths. To the latter vil- was who had lage the malady apparently brought by the widow T , been engaged as a nurse in one of the cholera hospitals in Copen- hagen. The day after her return from thence her daughter, seventeen years of age, was seized with cholera, and died on the following day. From thence the malady could be traced to the neighbouring house, where five persons out of seven were attacked. Removal of all the inmates from the infected houses was here practised with success. In Brondshoi, a parish lying directly north of Copenhagen, a charcoal porter was first attacked on the 10th of July, after returning from his daily work in Copenhagen. He died on the day of his illness, and eight days after his wife was seized, and died in two days. On the 13th of July, a woman who lived in Utterslov village was seized with cholera. She had worked daily with a gardener on the Norrebro, in whose house seven persons had died of cholera, and many still lay sick. She died on the 14th of July. After her death her husband came home from a hamlet six miles from Utterslov, and where no cholera had been. He was, however, seized with the disease after having been a day or two in the house where his wife had died, and he followed her to the grave on the 17th. In all Utterslov there were 90 cases and 27 deaths. The village lies in a hollow surrounded by hills, which im- pede the free circulation of air ; the drinking water is bad, aud in the middle of the street there is an open drain with a mossy bottom, and which had not been cleaned out for fourteen years. The next parish affected was Brondby oster, where a woman, who took children to nurse, was attacked on the 21st of July. She had been in Copenhagen the day before, in a house where a child had died 1^1 I860.] The last Cholera Epidemic in Denmark.

some of this of cholera, and she brought back to her own dwelling child's clothes. One of the nurslings, a child, aged eighteen months, was likewise seized with cholera on the 21st, and died the next day. The disease then spread into the village; there were in all 36 cases, and 14 proved fatal. In Hersted oster, a man from Frederiksberg was attacked on the 29th of July, and was immediately secluded by the authorities in an isolated house, and the disease progressed here no further. In Hersted vester, a woman upwards of seventy years of age, and who had just visited a family suffering from cholera in Copenhagen, was attacked, and died on the 3rd of August. Her husband next sickened, and died on the 17th. His body was placed in the watchhouse of the village, from which there was a current of air up into the church tower and loft. The bell-ringer and his wife, who frequented the church tower daily for the purposes of their calling, sickened on the 23rd of August, and from thence the disease spread to the neighbouring houses. We do not pretend to say that these last two caught the disease from the emanations of the dead body placed in the watchhouse under the church tower; but it does not appear to us at all improbable. " In Skodsborg, in a large house called the Lysestoberiet" (candle- stick manufactory), 14 cases occurred in rapid succession. The house was then shut up, and the other inmates, 40 in number, were located in tents, and the malady was instantly arrested in its progress. This was on the 18th of July, and no more cases occurred till the 9th of August, when a servant-girl from Taarbsek returned sick to her father's house, and four other cases then followed in rapid succession in the same house. Another village not far distant, Overrod, suffered severely from cholera. It contained only 207 inhabitants, and of these 36 took cholera, and 18 died, or nearly 9 per cent, of the whole population. The sanitary condition of the village was in every respect extremely bad ; but Trorod, another village in the same parish, and if possible worse in a sanitary respect, entirely escaped. The introduction of the disease into Overrod could not be traced. In Skovshoved, nearly due north of Copenhagen along the coast, the disease broke out on the 24th of July, in the person of a girl, a servant in a house in which a family from one of the most infected districts in Copenhagen had taken refuge. On the 27th of July the master of this girl fell sick and died, and on the 28th her mother, who had come over from Taarbsek to nurse her sick child. After this, the malady spread on all sides ; but it could be traced for some time through various channels, affecting the relatives attending on those primarily attacked. Nine per cent, of the inhabitants of Skovshoved were carried off. In Taarbsek, a bathing village a little to the north, there were 65 cases and 34 deaths. Most of these cases, according to Dr. "V"on Rosen's report, were traceable to infection. The first case of cholera in Lyngby, a village a few miles north of Copenhagen, occurred in the month of July, in an aged female, and proved rapidly fatal. No importation of the disease could be traced j 192 Reviews. [Jan. but the woman who washed the body took cholera and died in a few hours, and then her husband was attacked with the disease. In all there were 67 cases and 35 deaths. In Yangede, a small village, badly situated and ill-drained, there were 24 cases and 13 deaths. The epidemic began in a female who had been a servant in a house where cholera raged in Copenhagen, and she had nursed one of the' inmates. She came back ill of cholera to her own house in Vangede, and soon after her husband and her mother were both attacked with the disease, which then spread rapidly through the village. The town of Elsinore (Helsingor) was but little affected by the epidemic, notwithstanding its daily intercourse with Copenhagen. The town is healthily situated, there is good water, and much attention is paid to cleanliness. In the early part of July two or three isolated cases occurred ; but were almost entirely confined to persons who had come direct from Copenhagen. On the 24th of July cholera appeared in a sewing girl, who had been employed for several days in the house of an individual just arrived from Copenhagen, and whose wife had died of cholera in that city. The man himself at the time laboured under diarrhoea, and made use of a night-table in the room next to that in which the girl sat at work. There is reason to believe, too, that the girl used the same convenience. Moreover, it must not be omitted that she was employed on the clothes of the deceased wife which had been brought from Copenhagen. In the house in which this first patient died, eight fresh cases followed in rapid succession, and all were fatal. The malady then spread to two other houses ; but was arrested by the dispersion of the inhabitants. Altogether there were 34 cases and 27 deaths. Sixteen of the fatal cases were habitual drunkards. About a dozen cases occurred in the village of Sorup, a few miles from Elsinore, and subsequent to the outbreak in that town. These cases could not be traced to importation; but the malady seemed to be decidedly infectious when once established in the village. The medical attendant ascribes the outbreak of the disease to the neglect of sanitary precautions ; but while these would predispose the inhabitants to its influence, the fact of its existing only a few miles off at Elsinore would lead to the suspicion that it was imported from thence. In Hillerod, a village nearly west of Elsinore, there were 15 cases. The first was in the person of a female who arrived sick from Copenhagen, and in whom cholera quickly developed itself, proving fatal on the succeeding day. One of the corpse-bearers took ill on the day of the funeral and quickly died, and a servant in the house of the first-named patient died four days after. Out of the 15 cases of pure cholera, there were 14 deaths. In Frederiksvaerk, on the Isefjord, there were 18 cases and 11 deaths. The first was in the person of a young widow who had arrived the day before from an infected house in Copenhagen. Her lover had accom- panied her from Copenhagen and attended upon her all the time of her illness, from the 12th to the 17th of July, on which day he himself I860.] The last Cholera Epidemic in Denmark. became affected. On the 19th, the widow's mother, who had likewise been in Copenhagen, and had arrived from thence on the 16th, took in the disease. Next her husband was attacked, who had never been Copenhagen at all, but had remained much in his daughter's room, and when the second patient was removed to the hospital he had laid down in his yet warm bed. The disease then spread irregularly through the village, and in many cases communication could not be traced. Some of the infected houses were occupied by persons in easy circumstances, while in others there was a total neglect of sanitary measures. In the little village of Anderod another small epidemic of cholera occurred ; but it was confined to three houses. The first case was that of the husband of a woman who had the day before returned from Copenhagen with diarrhoea. The reporter of these cases is a strenuous anti-contagionist, and he honestly acknowledges that it is a great blow to his theory to find that the first case of cholera in Auderod was so evidently imported from the metropolis, or otherwise he would have been able to have proved most satisfactorily the spontaneous origin of the disease. As it stands, however, there are at least 10 cases out of the 18 in which strong proofs of infection may be alleged. In Roeskilde, a considerable town lying to the west of Copenhagen, and on the line of railway to Corsoer, there were 14 cases of cholera, all of which could be traced to importation or infection. In St. Jorgensby, close to Roeskilde, a case occurred, on the 15th of August, in the person of a man who had recently had a visit from his brother, a convalescent from an attack of cholera in Copenhagen. On the 22nd of August, a railway labourer, who dwelt in the same row of cottages, was attacked, and died the next day. On the 23rd, a woman who lived in the next room was confined, and two females who assisted her, and the midwife who officiated at the birth, were carried off by cholera. On the 25th, one of the newly-born twins died; but the mother and remaining child escaped. These persons were all in comparatively easy circumstances, and the houses were of a better description than ordinary. In all, there were 39 cases and 25 deaths. St. Jorgensby is a village inhabited almost exclusively by day-labourers, residing in houses which are sub-let to the utmost, and are consequently crowded to excess. Intemperance prevails much in the village, but chiefly among the other class of inhabitants, the fishing population, but amongst these, only one individual was attacked. It is remarked by the medical reporter, that the close a packing of many individuals in one room seemed to have far more deleterious predisposing influence than habits of intemperance. In the village in question, there were three dwelling-houses particularly overcrowded, and these three dwellings constituted the strongholds of the disease. The women and children suffered the most, because they were constantly within doors : the men were less affected, as their occupations took them into the open air. Holbaek, a small town on the west of Roeskilde, was twice Isefjord, lying invaded by cholera in the summer of 1853. On the first occa- sion, the disease lasted from the 21st of July to the 22nd of August; 154 Reviews. [Jan. the second was from the 28th of September to the 13tli of October. Diarrhoea and cholera had prevailed for some time previous to the first- named period, but was very amenable to treatment. The first case was an imported one from Copenhagen ; it was mild in character, and the spread of the malady was limited. After a lapse of five weeks the disease was imported afresh by a vessel from Aarhuus, where cholera then prevailed. A sailor who had suffered from diarrhoea on his voyage from that town, arrived at Holbsek on the 28th September, and on that day was admitted into the Lazaretto, with well-developed cholera. An intemperate old woman, who attended him in the Laza- retto, took cholera on the 4th of October, and died on the 6th, and then her daughter became affected with the same malady. In the whole North Zealand medical district there were rather more than 1400 cases, and 825 deaths. In the medical district of South Zealand cholera numbered but few victims; there were only 45 cases and 25 deaths. The first case occurred at Karrebaksminde, on the west side of Zealand, on the 9th of July, in the person of a cook on board of a vessel which had left Copenhagen on the 7th instant. He was attended by his father, a man of fifty, stout, but intemperate, and he took the disease from his son, and died at Appernaes. A remarkable case of suspected contagion occuri'ed at Pifesto. A captain of a vessel from Copenhagen was taken ill at Prajsto, and died of cholera at Vaagoe. This man, on the day that he was taken ill (July-23rd), had been several times in a baker's shop in Praesto, and on the 27th a weakly servant girl in the baker's house died of cholera. On the same day an apprentice of the baker's was attacked, and also the wife and two children, one of which children and the wife were carried off by the disease. The malady did not spread further. On the 23rd of July, a man from Christianshavn came to Alsted, near Sorb. Next day he took cholera, and died on the 25th. Five days after his father died of the same complaint. On the 25th of August a patient, ill of cholera, was landed from a ship at Vordingborg, and placed in the Lazaretto on Masnedoe, where he died on the 28th. The day after his death his two attendants were attacked with diarrhoea at Nyraad, and on the 3rd of September the owner of the house where they lodged had a most severe attack of cholera. Two days after an old man died of the disease at Masnedoe. Another slight outbreak of cholera occurred at Beenlose, near Ring- stedt, where a man and his wife, without apparent infection, were suddenly attacked with cholera, and died. A neighbour who had waited on them took ill, and died two days after. Next the mother of the last-named patient, who had attended on her daughter, and had washed the soiled linen after her death, was seized with cholera, and she communicated the disorder to two of her other children. These parties all lived in separate and distinct parts of a healthy village. On the Island of Bornholm, separated by a wide expanse of sea from Denmark, and lying much further to the east, several cases of cholera occurred, but all at a period subsequent to the appearance of the dis- i860.] The last Cholera Epidemic in Denmark. 155 ease in Copenhagen. It was not till the 21st of July that cholera was seen in Bornholm, the first case being that of a sailor who arrived sick from Copenhagen on that day. He was placed in a building contiguous to a hospital for aged and infirm men \ and on the 30th of July, the very day on which the first-named patient went out cured from the adjoining house, five out of the eight inmates of the hospital were attacked, and all fell victims to the disease. The remaining three were then removed to another part of the town, and remained healthy. In all there were 24 cases in Bornholm, 13 of which proved fatal. In the islands of Laaland and Falster the disease first showed itself on the 8th of July, in the persons of two sailors, who had left Copen- hagen in a sloop on the 2nd July, and had landed at Nykjobing, in Falster. Subsequent to their arrival, cases appeared among the inhabitants, and the epidemic continued till the 1st of September, num- bering 87 victims out of 174 sick. The dispersion of the inmates of the infected houses was here also put in practice, and with the best apparent results. On the Island of Fyen there occurred in all 210 cases and 97 deaths. The district physician, Mende, believes that the malady was first introduced into Svendborg, a town in the south of the island, by a family from Copenhagen. In the town of Odensee, on the north side of the island, there were four distinct outbreaks of the malady. At first 2 cases were imported from Aarhuus on the 29th July; then for fourweeks no fresh cases occurred, and after that the disease broke out afresh, in a, boy, who died on the 30th of August. No direct communication could be traced in this instance, but a journeyman blacksmith, who had just arrived from Copenhagen, was attacked on the same day with diarrhoea, which speedily ended in cholera. The malady next attacked the mother of the boy, and from thence spread to five or six of the neighbours. The journeyman blacksmith had been meanwhile con- veyed to the Grey Brothers' Hospital, in the opposite part of the town ; and here the next case occurred in the person of one of the aged inmates of the hospital, and several others of the Brethren afterwards fell victims to the malady. Out of 18 cases there were 12 deaths. That the disorder did not spread further is probably owing to the care that was taken to disperse the inmates of the houses in which cholera broke out. In twenty-two instances this was done, and only one individual of the whole of their inmates was subsequently attacked with cholera. At Villestofte, near Odensee, a weaver, who, with his wife, had been to the infected town of Aarhuus two days previously, was attacked with cholera on his journey home, and died on the 30th of July. The family, four in number, was then moved to the house of the widow's parents, about a mile from Villestofte. The weaver's son, a boy of twelve, was there seized with the disease, as were likewise the grand- father and grandmother, and all three died on the 2nd of August. The widow now returned to her own house with her three remaining children, when all were prostrated by the malady, and another of the children died. In fourteen days 8 cases and 5 deaths occurred in two houses. 156 Reviews. [Jan.

In Nyborg cholera appeared on the 18th of August, and continued for twelve weeks. There were in all 34 cases and 24 deaths. Im- portation could not be proved, but the locality in which these first cases occurred was eminently favourable to the spread of cholera. The disease broke out in a room over a cellar which had not been entered for twenty years, and was then full of water. When the water was pumped out, twenty wagon loads of accumulated filth had to be removed before the floor could be reached. The only possible way by which the disease might have been imported was, that a girl from one of the most infected houses in Copenhagen came to lodge in this house shortly before the 18th of August. On the mainland of Denmark, the ravages of cholera were confined to only a few localities. A well-marked case of importation occurred in the LjimQord on the 27th of July. A young woman came on that day by steamboat from Copenhagen to the Island of Morsoe, and pro- ceeded directly to her parents' house at Karby. On the 29th she was seized with cholera, and died on the 31st. On the 1st of August her brother was attacked, and died, and on the 3rd of August her sister and both her parents sickened of the malady ; the father and the sister died, but the mother recovered. The house was then carefully secluded, and no more cases occurred. In the town of Aarhuus the disease broke out on the 19th of July ; no direct importation could be traced, but a student of medicine, who had been attending cholera patients in Copenhagen, arrived on that day in Aarhuus, suffering from diarrhoea. A servant girl was seized with cholera on the 22nd, but it was not ascertained that she had been in communication with the student before mentioned; she was placed in the hospital of the town, and the malady then spread in a day or two among the inmates. In Aarhuus there were 336 cases and 213 deaths. Infants and old people suffered most severely, and the mortality among females was in excess of that of males. The dirtiest, narrowest, and most populous streets, were most ravaged by the disease. The population of the town is about 9000, the mortality, therefore, was about 2 per cent. Here, as elsewhere, the dispersion of the inmates of an infected house seemed to be the only effectual means of arrest- ing the progress of the disease. In the extreme north of Denmark, on the great inlet of the Ljimijord, stands the town of Aalborg. In this town, and in the surrounding country, there were 9S6 cases of cholera and 544 deaths. The town has always been noted for its unhealthiness, its annual mortality being nearly as high as that of Copenhagen. The town lies low, and close to the water; indeed, it is partly built on land reclaimed from the sea. During the month of June, and the first half of July, the health of the town had been better than ordinary. On the 27th of July, the steamer Cimbria arrived from Copenhagen. The night before reaching Aalborg, two of the crew of the steamer had died of Asiatic cholera, and their bodies were carried on shore and buried at Aalborg. On the 31st July, cholera broke out in the town, and continued from that date to the 7th of I860.] The last Cholera Epidemic in Denmark. 157

October, there being in that period 762 cases and 353 deaths. The population in 1850 was 7745, so that nearly 10 per cent, of the inhabitants were attacked. The able author of the medical report on Aalborg, Dr. Speyer, is a strenuous anti-contagionist, and he believes the malady to have arisen spontaneously. There is, however, a most suspicious coincidence between the arrival of the infected steamer Cimbria and the outbreak of the disease a day or two after. The intemperate here did not suffer more than those of sober habits. The dispersion of the inmates of the affected houses was commenced early in the epidemic ; but ere long the number of those seeking a refuge in the temporary asylums became so great, that it was thought necessary to reopen some of the earlier infected dwellings. This was done ; but the measure proved a very unfortunate one, for although the houses had been thoroughly cleansed and ventilated, cholera reap- peared among the inmates after their return. A few cases, and those chiefly imported ones, occurred further inland on the banks of the Ljimfjord. In Sebbersund, the captain of a ship, who had returned from Aalborg on the 9th of August, was attacked with cholera on the 11th; on the 19th his wife took the disease, and died on the 21st. Asister who had waited on her took cholera, and died on the 22nd. Another family resided in the same house, and the disease next appeared amongst these. Next, the malady broke out in a house at the other end of the village. A labourer who dwelt there had been ap- pointed a guard over the first affected dwelling; and it was proved that during the night he had gone to the house and had stayed there for some time; he took cholera on the 14th September, and died on the same day ? his two sons and his wife were next attacked. The disease did not appear in any other house in the town ; but a woman belonging to Vaar helped to put the above-named guard to bed when he was seized with the disorder, and then went home herself, took cholera, and died the next day. On the 17th of August, a fugitive from Aalborg arrived at Gaden- lund, a village several miles north of that town ; no cholera had been previously observed there. On the 22nd August, a peasant who had been stacking peats on the 18th and 19th, in company with the Aalborger fugitive, took the disease, and died on the 24th. On that day the woman of the house took ill, and died on the 25th. The widow of the second patient was next attacked, and also an old pen- sioner, who had been stationed as a guard at the door of the infected house. In all there were 7 cases and 4 deaths. The town of Fredrikshavn, near the extreme north point of Scaw, or Skagen, was perfectly healthy till a cholera patient from Copenhagen was landed there on the 20th July, from the steamboat Waldemar. The two succeeding cases were in persons who had been in communication with the first attacked. The first eight cholera nurses fell victims to the disease. In all there were 100 cases and 67 deaths. Of 11 cases above were seventy years of age, all died. In one house there not less than thirteen persons attacked. 158 Reviews. [Jan.

The total number of persons who were attacked with cholera in Denmark in 1853 was 10,598, and of these 6688 died. Out of the former number, 9037 were inhabitants of the capital or of market towns, and of these 5785 died ; while in the country parishes there were only 1561 cases and 903 deaths. It was in the immediate vicinity of Copenhagen, the great focus of the epidemic, that the country parishes suffered most severely. Those parishes in conjunction with Copen- hagen and the Island of Amager afforded not less than 10,293 cases, and 6500 deaths ; while the more distant country parishes only give a sum total of 305 cases and 188 deaths. With regard to the means adopted to stay the progress of the epidemic, the reporter tells us, that on the 1st of July the Medical Society addressed the Health Commission in Copenhagen, and laid before it the detail of three measures which they considered available for this purpose. These measures were :? 1. House to house visitation. 2. Evacuation of the infected houses, by removing all the healthy inhabitants to other localities. 3. The providing of eating-houses (Bespiishings ansfalteni) for the dispossessed poor, and for those unable to procure a proper daily supply of food. In regard to the first-named measure, Dr. Bricka informs us that it was far from being followed by the beneficial results ascribed to its operation in other countries, and especially in the English reports on cholera. The visiting staff organized in Copenhagen was perhaps more complete than has ever before been attempted. It consisted of 86 physicians and 42 senior students, who devoted all their energies to the accomplishment of their task. House to house visitation was commenced on the 10th of July, at the period when the epidemic suddenly increased in virulence, and rose at once from 305 to 1074 cases in the week. The next week, however, the cases rose to nearly 2000 (1907), and the week after the number was hardly diminished, for it was 1796. Dr. Bricka illustrates the inefficacy of this measure by tabular statements, and then sums up his opinion of house to house visitation in the following words :? "Although this measure (house to house visitation) was here practised earlier, and pursued more energetically and fully, than was ever done in other countries, we are bound to confess that the results were far from being so favourable as they are stated to have been elsewhere. Perhaps the success attributed to this measure in England and in other lands arose from its having been had recourse to at a later period of the epidemic, at a period when it had reached its culminating point, and the coincident cessation of the disorder was merely its natural diminution occurring at the period when house to house visitation was commenced. But if this measure failed in exercising any marked influence on the progress of the epidemic, it might at least be expected that the daily or weekly visiting lists would indicate the approach or receding of the malady, either in regard to the whole town or in particular districts. This, indeed, was partially but not invariably the case, for there were several instances where the malady invaded certain localities without any indications of its approach having been obtained by the visitors." I860.] The last Cholera Epidemic in Denmark. 159

Dr. Bricka, however, by no means denies the utility of the system of house to house visitation, for he observes? " I believe that the tranquillity of the town and the admirable order preserved bv the people amid the horrors of the epidemic, were mainly due to the confidence inspired by these daily visits, and to the good counsel and moral influence afforded by the visiting physicians. Numberless sanitary deficiencies were likewise brought to light in the daily rounds, and most speedily remedied; and the visits went hand in hand with the measures for supplying a sufficient amount of food, the visitors pointing out the localities where these supplies were to be obtained; and lastly, they prepared the way for the evacuation of the dwellings, by making known the houses from which the inmates ought at once to be removed. I am therefore of opinion that house to house visitation, if cholera should again break out amongst us, must not be omitted; but I believe it may be safely practised on a less extensive and less costly scale." (p. 245.) The testimony of Dr. Bricka as to the efficiency of the second measure ?viz., the evacuation of the infected houses?is too valuable to be omitted. This measure was likewise proposed on the grounds of its beiug recom- mended by the English Board of Health ; but all are aware how feebly it has in any case been carried out in this country. There is a difficulty in turning an Englishman out of his home, however poor that home may be, which is not experienced in more despotic con- tinental cities.

"Although," says Dr. Bricka, "this measure was not put in force until the epidemic had reached its culminating point, and although it was not so energetically and completely carried out as might have been desired, its results were very different from those obtained by the former method. The whole arrange- ments for the evacuation of the infected houses was confided to one man, Mr. Thomsen, of whose devotion and intelligence it is impossible to speak too highly. Four large asylums were opened for the dispossessed inmates ; they were partially lodged in tents and partly in some of the empty barracks of the garrison. The number of healthy persons removed from the infected houses amounted to fully 2000; and the removal was immediately followed by a most marked abatement in the epidemic " It is well known that very few cases of cholera occurred among the healthy inmates removed from the infected houses. In the tents on Cliristians- havn, whither 376 individuals were brought, there were 30 cases of cholera and 15 deaths; but eleven of these cases occurred on the day after their removal, so that in all probability they had brought the disease with them from their own homes. Many of these people, too, although they slept in the tents, yet wandered back again during the day to their old homes, or to other places where cholera was raging. In the other three asylums, wherein upwards of 1100 people found refuge, there were only two or three cases of cholera and not a single death." was in In all cases, too, where the same measure put practice in the with the like provincial towns, it appears to have been followed gratify- ing results. We regard Dr. Bricka's report as a most valuable contribution to the history and pathology of cholera. Though himself evidently not a fervent contagonist, he has faithfully reported and commented upon the great array of facts bearing upon this question, and certainly favourable to the doctrine alluded to, which are contained in these pages. From a we perusal of the more recent cholera literature, are led to 160 Reviews. [J an. believe that there are few parties at present who are disposed abso- lutely to deny all contagion in cholera, as was done in a more or less complete form in certain of the Reports of the English Boards of Health. The facts, however, that are laid before us in this present report of Dr. Bricka's amply confirm the opinion we on two former occasions expressed in this journal, that in outlying and thinly popu- lated districts the contagious character of cholera is more apparent, and its progress from house to house can be more easily traced, than amid the concentrated infection of large towns. The unsatisfactory results of the system of house to house visitation as compared with the other measure, that of separating the healthy from the sick by the speedy removal of the former from the infected houses, is only what was to be expected if cholera be really propagated by contagion. Should the disease ever revisit our shores?and there is no reason to suppose that it will not return?we would urge at once upon the authorities the evacuation of the infected houses by the healthy inhabitants as the great means of safety, though we would not altogether neglect the moral influence on the people, and the local knowledge of the habitats of the disease, to be obtained by regular house to house visitation.