KING’S College LONDON (It ( -1 'I' 6" 6 Library N/i'6UUr oZ-irtoVAA mz Digitized by the Internet Archive in 2015 https://archive.org/details/b21308251 REPORT 7fliww 5 LVVUTVV- 1 dxr*- eLtn^- ■ f'l s/ 7/ ON THE MORTALITY OE CHOLERA IN ENGLAND, 1848-49. LONDON : PRINTED BY W. CLOWES AND SONS, STAMFORD STREET, FOR HER MAJESTY’S STATIONERY OFFICE. 1852. /‘efts' t$ CONTENTS. LETTER OF THE REGISTRAR-GENERAL TO THE RIGHT HONOURABLE SIR GEORGE GREY, Bart., M.P., Her Majesty's Principal Secretary of State for the Home Department. Letter to the Registrar General, by William Farr, Esq. PART I. Page REPORT TO THE REGISTRAR-GENERAL on the MORTALITY OF CHOLERA. Importance of having a complete Abstract of the Facts connected with the Cholera Epidemic from the Register Books of Deaths ii Method of making the Abstracts, and Explanation of the Tabular Results . . . ii-iii England devastated by Plagues from the earliest times : — Plagues of the 6th and 7th Cen- turies ; Black Death of 14th ; Sweating Sickness of 16th; Plagues of 17th Century . iii Practical Effect of the Diffusion of the true Doctrines of Public Health .... iv Examples showing that the Health of various parts of the Kingdom is not equally Bad . iv Mortality at Different Ages .......... iv The Health- of the People is Worst in Large Town Districts . ..... iv Deaths at Different Ages, contrasted in Districts where the Mortality is Low and where it is High .............. v Names of some Healthy and Unhealthy Districts ........ vi-vii England the Healthiest Country in the World ........ vii Cholera more Fatal in Asia than in Europe ........ vii Course and Progress of Cholera — Dates of its reaching different Places . . . . vii-viii Survey of the prevalence of Cholera and Diarrhoea in England since the Registration Act came into Operation ............ viii-xi Progress of Cholera in London in 1848 ......... xi Extracts from the Registrars’ Weekly Returns; Distinction between Summer Cholera and Asiatic Cholera ; time when the former merged into the latter ..... xii-xvi Table showing the Comparative Duration of Fatal Attacks of Diarrhoea, Summer Cholera, and Asiatic Cholera ............ xvii Cholera in the South-Eastern and South-Midland Divisions in 1848 . . . xvii-xviii Great Mortality from Cholera in the Chesham Sub-District of Amcrsham in 1848, and Abstract of the Fatal Cases .......... xvii-xviii Cholera in the Eastern, South-Western, West-Midland, North-Midland, North-Western, A ork, Northern and Welsh Division — Names of the Districts in which it was most Fatal in 1848 .............. xviii-xx If IV CONTENTS. Page Cholera in England, 1849— Remarks on its'Progress — >ts prevalence in Public Institu- tions, and Dates of its Appearance in particular Districts ...... xx-xxiii London Cholera Field, 1849 — London the Centre of a Great System of Attack: the Extent of the London Cholera Field shown ...... . xxiii Cholera broke out as the Temperature advanced in London : its Progress traced— Ex- tracts from the Weekly Reports — Proportion of Deaths from Cholera and Diarrhoea to 10000 Persons Living ........... xxiii-xxviii While Cholera prevailed in London, all the region around suffered — Names of Districts which were Attacked, and Proportion of Deaths to 10000 Inhabitants . . . xxviii-xxx Portsmouth Cholera Field.— Names of Districts which Suffered, and Rate of Mortality xxx Plymouth Cholera Field. — Names of Districts which Suffered, and Rate of Mortality- Places on the Coast severely Visited ........ xxx-xxxi Bristol Cholera Field. — Names of Districts which Suffered, and Rate of Mortality . xxxi Merthyr Tydfil Cholera Field. — Names of Districts which Suffered — Progress of the Epidemic and Rate of Mortality . ........ xxxii -xxxiii Wolverhampton Cholera Field. — Names of Districts which Suffered, and Rate of Mor- tality xxxiii Liverpool Cholera Field. — Names of Districts which Suffered ; Progress of the Epi- demic in Large Town Districts of Lancashire, and Rate of Mortality . . . xxxiii-xxxvi Hull Cholera Field. — Names of Districts which Suffered; Progress of the Epidemic, and Rate of Mortality xxxvi-xxxviii Tynemouth Cholera Field. — Names of Districts which Suffered ; Progress of the Epi- demic, and Rate of Mortality xxxviii-xxxix Influence of Sex on the Mortality from Cholera. — Proportion Dying among Males and Females in England from Cholera and from all Causes : when the Mortality from Cholera attained a High Rate, the Deaths of Females exceeded those of Males. Table showing the Number of Fatal Cases of Cholera in London among Males and Females at different Ages, in each of 15 Weeks in 1849 ...... ... xxxix-lxi Mortality from Cholera and Diarrhoea at Different Ages. — Comparison of the Deaths among Males and Females at Different Periods of Life: after the Age of 25 the chances of dying increase with age. Table showing the Mortality per Cent, amoug Males and Females from Cholera and Diarrhoea in 1849, ai‘d from all Causes, 1838-44, at Dif- ferent Ages, in England ........... xli-xlii Duration of Fatal Cases of Cholera.— Explanation of the Chances of Dying within a given Period from the Time of Attack. Table supplying a ready Means of Calculating the future Duration of Fatal Attacks at any Stage of the Disease . . . • xliii-xliv Cholera Epidemics of 1832 and 1849 Compared. — Tables showing the Population and the Deaths from Cholera in different Districts, during the Uo Epidemics . . xliv-xlvi Influence of the Seasons in 1831-2 and in 1848-9. — Remarks on the Prevalence of the Epidemic in Different Months, and Tables showing the Mortality, during each Month, in England, London, Paris, and Liverpool .... ... xlvi-xlvii Meteorological Influences. — Explanation of Diagrams illustrating the Progress of Cholera, and the Meteorological Phenomena, on each Day of 1849 — Remarks on the Circular Diagrams, showing the Mortality and Temperature in each Week of 1 1 Years, 1840-50 ............. xlvi-xlviii Plague and Cholera Years in London. — Remarks on the Diagrams showing the Mor- tality in London during the Great Plague Years ...... xlviii-xlix Fatal Days of the Week. — Table showing the Number of Deaths on each Day of the Week in all England, in London, and in the other parts of England .... xlix Locality. — Remarkable Variation in the Mortality of different Localities, illustrated by several Tables, showing Population, Deaths, and Area, in Districts and Groups of Dis- tricts on the Coast and Inland; in the Seaports, in large Inland Towns, and in the Coal Districts ............. xlix-lvii Cholera three times more Fatal on the Coast than in the Interior of the Country . li-lii Names of Large Inland Towns in which Cholera was only Slightly Fatal in 1849 . liv CONTENTS. V Page Great Mortality in Merthyr Tydfil : Filthy State of the Town described . . . . Iv-lvi Dates of the Epidemic Attacking certain Districts ....... lvi Causes of the Mortality in London .... Ivii (i.) The Thames and the Water Supply.— Mortality in Districts supplied by each Water Company — Number of Gallons raised by evaporation from the Thames . lviii-lxi (2.) Elevation. — Elevation of the Soil has a more constant relation with the Mortality from Cholera than any known element : Mortality from Cholera is in the Inverse Ratio of Elevation — Remarks — Tables and Diagram illustrating the Comparative Mortality of Districts at different Elevations .... lxi-lxv (3.) Density. — Density a less Important Element than Elevation — Remarks and Tables illustrating the Influence of Density of Population on the Mortality from Cholera. ............ lxvi (4.) Wealth and Poverty. — Remarks and Tables illustrating the Influence of Wealth and Poverty on the Mortality from Cholera ...... lxvi-lxviii Mortality in London from Ordinary Causes ........ Ixviii Conditions in which Cholera is Most Fatal. — Comparative Influence of Density, Wealth, and Elevation of the Soil ......... lxix-lxxi Number of Persons Attacked by Cholera in England ...... lxxi Cause of Cholera is some Chemical Modification of Organic Matter .... lxxii Origin of Epidemic Cholera in the Delta of the Ganges. — Extracts from Reports of Army Medical Officers in India ......... Ixxii-lxxiii Theories and Analogies — (1.) The Theory of Volcanic Agency ........ Ixxiv-lxxv (2.) The Electrical Theory ......... lxxv-lxxvi (3.) Bad Water — Practice among Native Indians of using Boiled Water . . . lxxvi (4.) The Fungus Theory ........... lxxvi (5.) Theory that Cholera is Propagated by Human Intercourse, and that it is a Local Affection of the Alimentary Canal ....... Ixxvi-lxxviii (6.) Theory of Contagion .......... lxxviii-lxxix (7.) Hypothesis of Spontaneous Developement lxxix-lxxx (8.) The Zymotic Theory . _ . . . . . . . . . lxxx-lxxxiii The Pestilences of the Present Day are most Fatal in Low Places : — (1.) Ague and Remittent Fever. — The Fever of the Mediterranean and the Tuscan Maremma ........... lxxxiv-lxxxv u (2.) Yellow Fever; its Prevalence in Lands of Low Elevation — The Delta of the Mississippi in the Gulf of Mexico its Great Centre ; — Fever in the West Indies and the West Coast of Africa ....... lxxxv-lxxxvii (3.) Plague; its Prevalence in Lower Egypt on Alluvial Ground; on the European Shores of the Bosphorus ; in Syria, Persia, and the Coasts of the Mediter- ranean— Table showing the Excess of Mortality, in different Parishes of Loudon, in the Plague Year, 1665 ......... ]xxxvii-xc The Human Race Destroyed Periodically by Five Pestilences. — Conditions under which they are most Prevalent — Moral and Physical Characteristics of the Inhabitants of Healthy and of Unhealthy Localities ; in High Lands and on Low Marshy Coasts . xc-xciv Sanatory influence of Healthy Localities on the Human Frame — Effects of Elevation on Health, Mortality, and Race ......... xciv-xcv The Finest Races of Animals are bred in the most Healthy Localities . . . xcv-xcvi Pestilence a great Warning as well as a great Calamity ...... xcvii Salubrity one of the Causes of the Greatness of England— The Importance and the Means of Preventing a Deterioration of Race ........ xevii-xcviii VI CONTEXTS. Conclusion — Practical Suggestions : — (i.) Safety is enjoyed by removal from Infected Places to the high Salubrious Districts (2.) Strangers should avoid visiting Towns in an Epidemic ..... (3.) When the Population is removed, it should be to High and Dry Ground, where Good Water can be procured ......... (4.) High Places away from Marshes are also generally Sait; Asylums from Plague, Yellow Fever, Remittent Fever, and Ague ....... (5.) Armies Suffer more on the March than iu Station — Danger of Encamping on Low Grounds by Rivers . . . . . . . (6.) Travellers in Unexplored Countries should not Rest on Low Swampy Spots (7.) Intercommunication. — Quarantine of little avail ...... (8.) Food ............. (9.) Water ............. (10.) Removal of Refuse . . ... . . . - (11.) Air .............. (12.) Earth. — Importance of Good Sites for Dwellings. . (13.) Colonies. — Importance of the Selection of Good Sites for New Towns (14.) Climate. — The necessity of Sanatory Measures in India . . . . . (15.) The Medical Profession. — The Office of Medicine is to raise Men to a IIich Standard of Health ; and to Prevent as well as to Cure Sickness . Pace xeix xeix xeix xeix xeix c c ci ci cii cii cii -cii i ciii ciii ciii— civ TABLES : — Annual Mortality per Cent, from All Causes in the Seven Years, 1838-44, in each of the Statistical Districts of England, arranged in the order of the Mortality of Females cvi-cxi Annual Mortality per Cent, from All Causes at different Ages 1838-44), in each Statistical District of England, arranged in the order of the Mortality of Females, in each of the 11 Divisions of England ....... cxii-cxxv Annual Mortality per Cent, from All Causes at different Ages (1 38 44', in 21 Healthy Statistical Districts of England ....... cxxvi Annual Mortality per Cent, from All Causes at different Ages (1838-44), in 33 Unliealthy Statistical Districts of England ....... cxxvii Mortality per Cent, from Cholera among Males and Females, at different Ages, in each of the 11 Divisions of England in 1849 ....... cxxviii Mortality per Cent, from Diarrhcea among Males aud Females, at Different Ages, in each of the 1 1 Divisions of England in 1849 ..... exxix Mortality from Cholera and Diaurikea in some of the Most Fatal Districts in 1849 exxx Deaths from Cholera in England aud in London ou each Day of each Week of the Year 1849 cxxxi Mortality from Cholera and Diarrhcea in each Division, County, and District of England, 1849 .......... cxxxii-cxxxix Districts in which there were No Deaths from Cholera in 1849 . . . cxl-cxli Area, Population, and Deaths from Cholera and Diarrhcea, in 1849, and from All Causes in the 10 Years 1841-50, in 47 Seaport-Town Districts .... cxlii Area, Population, and Deaths from Cholera aud Diarrhcea in 1849, and from All Causes in the 10 Years 1841-50, in 41 Inland Town Districts .... cxliii Deaths from Cholera and Diarrhcea on each Day of the Most Fatal Months of 1849 in the following Groups of Districts: — (1.) Portsea Island and Alverstoke. (2.) Salisbury ..... cxliv (3.) Plymouth, East Stonehouse, and Stoke Damerel. (4-) Bristol, Clifton, aud Bcdminster ........... cxlv (5.) Wolverhampton and Dudley. (6.) Liverpool and West Derby . . . exlvi (7.) Manchester, Chorlton, and Salford. (8.) Leeds and Ilunslet . . . cxlvii (9.) Hull and Sculcoates. (10.) Tynemouth, South Shields, Newcastle-upon- Tyne, and Sunderland . . (11.) Merthyr Tydfil, Cardiff, and Neath. cxlviii cxlix CONTENTS. Vll Deaths from Diarrh<ea, Dysentery, and Cholera, registered in London in each Week of the ii Years 1840-50 Elevation, Area, Number, and Annual Value of Houses, Population, and Deaths from Cholera, in the London Districts ........ (1.) Districts of London, arranged in the order of Mortality from Cholera in 1849, and exhibiting the coincident Results derived from the Facts given in the previous Table ...•••••• (2.) Districts of London arranged in the order of their Elevation above the Trinity High-Water Mark, of the Thames, and coincident Results cor- responding with those in the previous Table (1) .... clvi-clvii (3.) Districts of London arranged in the order of their Density of Population, and coincident Results corresponding with those in the previous Tables (1 and 2) .......... clviii-clix (4.) Districts of London arranged in the order of the Annual Value of House and Shop-room, and coincident Results corresponding with those in the previous Tables (1, 2, and 3) ...... clx-clxi (5.) Districts of London arranged in the order of their Annual Mortality from All Causes (1838-44), and coincident Results corresponding with those in Tables (r, 2, 3, and 4) ...... clxii-clxiii Diagram of the London Districts, showing their Elevation, their Mortality from Cholera, and from all Causes; their Density of Population, Value of Houses, and Amount paid for Relief of the Poor ; also their Water Supply .... clxiv Diagram of the London Sub-Districts, showing their Elevation and Mortality from Cholera .......... ... clxv Sub-Districts of London arranged in the order of their Elevation, showing the Mortality from Cholera to 10000 Inhabitants ..... clxvi-clxviii Average Mortality from Cholera in Groups of Sub-Districts of London, arranged in the order of their Elevation ....... . clxix Deaths from Different Causes in London during the Week when the Mortality from Cholera was Highest ......... clxx-clxxii Meteorology of the 11 Years 1841-5 1 ........ clxxii Weekly Number of Burials from All Causes in London during Plague Years, compared with the Average of 7 Years (1640-46) and with the Cholera Year 1849 * clxxiii Deaths of Males and Females from Cholera, in London, in each of 65 Weeks (October, 1848, to December, 1849) ..... .... clxxiv Page cl clii-cliii cliv-clv MAP AND DIAGRAMS. [To be placed at the end of Part J.] Plate Map of England, shaded, showing the prevalence of Cholera in different localities, and the dates of its appearance in 1849 ........... 1 Diagram, in Colours, representing the Deaths from Cholera and Diarrhcea in England on each Day of the Year 1849 ; also the Meteorological Phenomena recorded at Greenwich on the corresponding Days ............ 2 Diagrams, Coloured, representing the Deaths from Cholera in each of the 11 Divisions of England on each Day of the 7 Months, May to November, 1849 • • . • . .3 Diagrams, in Colours, representing the Temperature and Mortality from all Causes in London for each Week of ii Years, 1840-50 4 Diagrams representing the Deaths in London in each Week during the Plagues, and con- trasting the same with the Average Mortality in 7 ordinary Years (1640-46), and with the Cholera Year, 1849 ............. Mil CONTENTS. PART II. — TABLES. Page 184b. — Deaths from Cholera in the Divisions and Counties of England during the year 1848, and in the Months of October, November, and December . . . 1-2 , , Deaths from Cholera in the Divisions of England, in each Week of the last Three Months of 1848 ........... 3 , , Deaths from Cholera at different Ages, in the Divisions of England, during the last Three Months of 1848 .......... 4 1849. — Deaths from Cholera and Diarrhoea (distinguishing Sex) in each of the Divisions, Counties, and Districts of England, during the Year 1849 .... 5-19 , , Deaths from Cholera and Diarrhoea in England, on each Day of each of the Twelve Months of 1849 .......... 20-21 , , Deaths from Cholera and Diarrhoea in the Eleven Divisions of England, on each Day of each Month of 1849 .......... 22-33 , , Deaths from Cholera and Diarrhoea in the several Counties of England, on each Day of each Month of 1849 ......... 34-105 , , Deaths from Cholera and Diarrhoea in London, on each Day of each Month of 1849 106-107 , , Deaths from Cholera and Diarrhoea, at different Ages (distinguishing Sex), in each of the Divisions and Counties of England, during the Year 1849 • • 108-119 , , Deaths from Cholera in England, and in each of the Eleven Divisions in 1849 ; show- ing the Duration of the Attacks among Males and Females at different Ages . 120-165 , , Notes on Cholera, giving a brief Sketch of remarkable Facts connected with the Epidemic ; also showing the Population, 1841, and the Number of Deaths from Cholera and Diarrhoea in 1849, in each of the 2189 Sub-Districts of England . 166-300 TO THE RIGHT HON. SIR GEORGE GREY, BART., M.P. *4 Her Majesty's Principal Secretary of State for the Home Department. General Register Office, 10 th February , 1852. Sir, I have the honour to submit to you the following Report on the Mor- tality of Cholera in England. I was requested in 1850 by tbe General Board of Health to make out a “ Return of all Cases of Cholera that had occurred in England and Wales, distinguishing Sex and Age.” After well considering the subject, I thought it desirable, not only for the use of the General Board of Health, but for circulation throughout the country, that a complete history of the late epidemic should be drawn up from the facts recorded in the register-books of deaths, distinguishing not only sex and age, but also the profession, the date of death, the place of death, and the duration of illness of all persons who died of Cholera or Diarrhoea in the years 1848 and 1849; giving not only the bare facts but exhibiting in Tables the various combinations of age, profession, locality, &c. This duty has been confided by me to Mr. W. Farr, the Examiner and Com- piler of Abstracts in this department. The Tables have been framed under his direction with the greatest care and accuracy, and are illustrated by various ingenious Diagrams ; and the following Report has been written by him after much research and great attention given to the subject. I have the honour to be, Sir, Your faithful Servant, GEORGE GRAHAM, Registrar- General. TO THE REGISTRAR-GENERAL. Sir, In the Report which I have the honour to submit to you, I have endea- voured to carry out the investigation which you deemed desirable ; and to show the effects of all the circumstances recorded in the Registers on the fatality oi the greatest epidemic that has for many years infested England. In conformity with the plan sketched in your letter the abstracts were care- fully made under the superintendence of Mr. J. T. Hammack ; the tabling was superintended by Mr. J. Thornton ; the calculations by Mr. W. Clode. The diagrams on Plates 2, 3, were drawn by Mr. C. A. Cocke ; the other dia- grams by Mr. J. R. Sowray. The notes and observations in the London Weekly Tables were greatly extended during the progress of the epidemic ; and were, except in the interval from August 11th to September 22nd, under the charge of Mr. J. Angus. All these duties were discharged with great care and ability. The Census of March 31, 1851, was published after the first calculations of the mortality of the epidemic were made ; and advantage was taken of the new Population Returns to determine, accurately, the mortality of the districts of London and of the country, in which the disease had been most fatal. When the numbers and ages of persons living in tbc different professions and occupa- tions are ascertained from the Census Returns, the influence of occupation on health, on this and on other diseases, can be determined. I have the honour to be, Sir, Your obedient Servant, WILLIAM FARR. Statistical Branch, General Register Office, February 7, 1852. PART I.— MORTALITY OF CHOLERA. I REPORT ON THE MORTALITY OF CHOLERA IN ENGLAND, 1848-49. If a Foreign Army had landed on the coast of England, seized all the seaports, sent detachments over the surrounding districts, ravaged the population through summer, after harvest destroyed more than a thousand lives a day for several days in succession, and, in the year it held possession of the country, slain rifty-three thousand two hundred and ninety-three men, women, and children — the task of registering the Dead would be inexpressibly painful; and the pain is not greatly diminished by the circumstance that in the calamity to be described the minister of destruction was a Pestilence that spread over the face of the island, and found in so many cities quick poisonous matters ready at hand to destroy the inhabitants. In following cholera through its fatal way, however, the inquirer meets with some grounds of consolation. He sees places on every side which the epidemic passed over, leaving the inhabitants in the serene enjoyment of health and complete immunity. And the hope is perhaps not fallacious, that an examination of the results of the second may be the means of mitigating, if not preventing_a third invasion ; for whatever may be the immediate cause of cholera, it will appear evident that in England it is only seriously fatal under certain known physical conditions, which admit to a great extent of remedy. It is not necessary to describe here the nature of the disease. The task devolves on others of analysing- the changes which the frame suffers under cholera ; of investigating the effects of medicine; of relating the steps which were taken to relieve the population attacked in various places; of discussing in detail the various theories which have been produced to explain the phenomena ; and finally of portraying in this epidemic the moral effects, which, as historians have not failed to perceive, possess the highest interest in the great catastrophes of moriality.* Under the Act for the Registration of Births, Deaths, and Marriages, the name, sex, age, and occupation of every person who dies in England — as well as the time, place, and cause of death — are registered. The whole of this system of observation and record was in operation when cholera broke out. The quarterly abstract of deaths for the whole kingdom, and the London tables which are published weekly — presented notices of its rise, progress, and decline in particular di-tricis. When the epidemic was over, it appeared desirable to give a complete abstract of the facts. Accordingly a list of every case of death from cholera and diarrhoea, in 1849, was transcribed from the * See the Report of the Board of Health ; and the appended Reports of Dr. Sutherland and Mr. Grainger, whose active and arduous labours in the epidemic deserve the highest praise. The College of Physicians has, it is understood, appointed a learned committee to report on the subject. The chemistry of the disease is ably discussed by Dr. It. D. Thomson, Trans, of Royal Medical and Chirurgical Society, vol. xxxiii. The disease is well described by Dr. Budd, in the Cyclopaedia of Practical Medicine, and sketched in the Lectures of Dr. Watson, with his accustomed felicity and accuracy. b IX Cholera Tables. Registration volumes which for that year contained 440853 deaths. The roll of deaths was in the following form : — Population. No. District. Sub-district. 1 83 1 1 841 45852 Nantwich. Nantwich. 8560 9431 Date of Death. Place. Sex. Age. Profession. Cause of Death. 1849. July 10 Wych House Bank, Nantwich M. 6 Salt-boiler's Son Cholera, 13 hours. >> 9 Welch Row F. 5 Confectioner’s Daughter Cholera, 6 hours. ,, 10 Vauxhall M. 72 Labourer .... Cholera, 28 hours. ,, 8 Wood Street F. 48 Basketmaker’s Wife Cholera, brought on for ,, 10 Wood Street 9 9 M. 67 Shoemaker .... want of the common necessaries of life. — Inquest. Cholera. — Inquest. The whole forms a large mass of manuscript, which contains the particulars of 72180 deaths. Upon inquiry it was found that the list of persons who died of the two diseases would fill a tliick octavo volume of about 2500 pages. Three courses were open ; (1) to publish those facts simply; (2) to publish the tabular abstracts in detail ; or (3) to publish the abstracts and the salient facts relating to each locality in a condensed forim The publication of the cases in detail would have been attended with several advantages ; it would have enabled the medical men of the country to study the particular facts in their respective districts, surrounded by the circumstances which affect and modify the mortality ; and the publication of an extended tabular summary ol the daily deaths in each of the 2189 sub-districts of the country would also have possessed interest. As the work on e-ther plan would, however, have been exceedingly voluminous, the third course was adopted : in the meantime the manuscript list of the 72180 cases, and the extended tabular abstracts, are preserved among the records of the General Register Office, and will always be accessible to the local inquirer, as well as to the general student of this great and extraordinary epidemic. The first of the following series of tables shows that 1057 males and 877 females died from cholera during the year 1848, and that of those numbers 612 males and 493 females, died in the three months of October, November, and December. '1 he numbers in each county and division are shown separately (pp. 1 — 2). The weekly deaths from cholera in each division, and the ages at death in the last three months, are added (PP- 3—4)- The second series of tables shows of the 53293 deaths from cholera, and 18887 fr°ni diarrhoea during the year 1849, how many occurred in each of the 11 divisions, 44 counties (or groups of counties), and 623 districts of England (pp. 5 — 19). The districts are here arranged in the same topographical order as is adhered to in all the Reports of this Office. Each district stands in its place, although no death from cholera was registered within its limits ; the population of 1841 is set forth in a distinct column, and shows the lowest numbers that could have been exposed to the attacks of the disease. In the towns, and in the manufacturing and mining districts, the population was, of course, much greater in 1849 than in 1841. The third is a remarkable series of tables. It shows the number of deaths from cholera and from diarrhoea on each day of the year 1849, in all England, in 11 divisions, and in 44 registration counties (pp. 20 — 107 ). Thus the march of the epidemic through every county can be followed day by day. In the returns that have previously been made of the mortality of cholera in this and in other countries, only the deaths from that disease in parts known to be severely in'ected have been inserted, and it is evident that under such a system — based- on imperfect registration — many deaths must have escaped observation. But the causes of nearly all the deaths in England are registered, and all the deaths of 1848 and 1849 are Health of England. iii recorded in the volumes from which the present return is derived ; so that the reader can now trace the progress in place and time of the great epidemic through 17 millions of people, settled over a wide extent of country, in all the various circumstances of life. And the difference in the time of invasion, as well as the absence or the inconsiderable mortality of the epidemic in places lying by the side of' districts overwhelmed by its effects — is undoubtedly one of the circumstances which most deserve attention in the study of cholera. The fourth series of tables shows how many males and females died at various ages of cholera and diarrhoea in the divisions and counties cf England. Taking 100 years as the limit, the lifetime is divided into twenty equal quinquennial periods; and the tables show that the deaths were distributed unequally over the whole of these periods. The deaths in each of the first five years of life are separately given ; as in that short interval of age a remarkable change takes place in the form and fatality of the disease. (Tables pp. 108 — 119.) A swift and precipitate course ending in dissolution, is a characteristic of all plagues, and fixes attention in cholera. The duration of 39468 fatal cases of cholera, and of 7896 fatal cases of diarrhoea, is shown in the fifth series of Tables. The duration in hours and days is exhibited at the quinquennial ages that have been already named. Tables are given for all England, for England exclusive of London, and for each division of the country (pp. 120 — 165). The 623 districts of England are divided into 2189 sub-districts. The population (1841), the deaths from cholera, and the deaths from diarrhoea in each sub-district, are given in the notes (pp. 166 — 300) which close the volume. The London Registrars returned every case of death from cholera or diarrhoea weekly, and, in the height of the epidemic, daily, accompanied by any information which either the informants, or their own observation, supplied, respecting the state of the streets or houses in which the deaths occurred. This information was necessarily col- lected in haste; but was found to be substantially correct, and had an excellent effect at the time, in directing the immediate attention of the authorities to some of the most crying evils that induced and aggravated the disease. A digest of these Registrars’ local reports is embodied in the notes, which contain many curious ar.d suggestive facts ; and the gentlemen who abstracted the cases were requested to compile from the transcripts short notices of the first and last deaths, distinguishing the dates of such deaths ; as well as the professions of the persons who died, and the localities which suffered most in every sub-district. The local inquirer is requested not to accept any opinions expressed in the notes, or the summaries of the facts themselves, as ultimate results ; but to consider them only as indications of the direction in which investigation may be advantageously employed. Upon the number of deaths returned, and the tabular results, lull reliance may be placed ; as they have been derived directly from returns, and have been duly checked. It may increase the usefulness of this Report to give, from the registration returns, a brief, connected summary of the progress of the epidemic, and to describe its effects on the health and population of England. But it will be convenient to notice, first, what the health of the country has been, and what it was immediately before this great disturbing cause appeared. HEALTH OF ENGLAND. Although no regular Registers of Deaths were kept before the Reformation, the chro- nicles show clearly enough that England has been periodically devastated by famines and plagues from the earliest times. A large proportion of the population of the island has been more than once swept away by these visitations. The great plagues of the sixth and seventh centuries — which destroyed, according to some estimates, half the inhabitants of tbe Eastern empire — extended to Britain. Besides the Black Death in the fourteenth century, the sweating sickness of the sixteenth century, and the plagues of the seventeenth century, terminating in the plague of 1663 described in detail by the historians — a long catalogue of famines and epidemics may be given, which, though briefly and imperfectly noticed in the chronicles, were perhaps not much less fatal. After the Revolution the great plagues ceased; but the mortality was kept up by b 2 IV Health of England. typhus, small-pox, influenza, and other zymotic diseases. The writings of Mead, Pringle, Lind, Blane, Jackson, Price, and Priestley, — the sanatory improvements in the navy, the army, and the prisons, — as well as the discovery of vaccination by Jenner, — all conduced to the diffusion of the sound doctrines of public health, and had a practical etfect, which, with the improved condition of the poorer classes, led to a greatly reduced mortality in the present century. Since 1816 the returns indicate a retrograde move- ment. The mortality has apparently increased. Influenza has been several times epidemic, and the Asiatic cholera reached England, and cut off several thousands of the inhabitants in 1832. It reappeared and prevailed again, as we have seen, with no miti- gated violence, in 1849. The health of all parts of the kingdom is not equally bad. Some districts are in- fested by epidemics constantly recurring ; the people are immersed in an atmosphere that weakens their powers, troubles their functions, and shortens their lives. Other localities are so favourably circumstanced that great numbers attain old age in the enjoyment of all their foculties, and suffer rarely from epidemics. The variations in the mortality are seen in’the Tables (pp. cvi-cxxvii), which have been extracted and arranged from the Ninth Annual Report. The rate of mortality is calculated on 2,436,648 deaths in the 7 years, 1838-44 ’ and on the population taken at the Census of 1841, in the middle of the period. On tracing over 324 sub-divisions of the country, the force of death in males and females of different ages, the most remarkable differences are discovered. Here of 1000 young children under 5 years of age forty die, there a hundred and twenty die annually; here, of 1000 men of mature age (35-45) nine die, there nineteen die yearly; of 1000 men of 45-55 years of age twelve die in one district, thirty in another; at the more advanced ages of the next decennium (55-65) twenty-four die annually in one, fifty in another district: of 1000 females of all ages without distinction, 14 die annually in three districts, 15 die in eighteen districts, 17 (or less) in forty-eight districts. And in strong contrast, 23 in 1000 females die in twenty districts, 26 in 1000 in three districts, 27 in seven districts, 31 in two districts. The mortality at all ages, without distinction, differs much less than the mortality of children, and less even than the mortality of men and women of the age of 35 and upwards in the several parts of the country. The population from the age of 15 to 35 is unsettled ; at that age the emigration of servants and artizans from the country to the towns takes place; and as consumption, the disease then most fatal, is slow in its course, its victims in many cases retreat from the towns to their parents’ homes in the villages to die. And the death is registered where it happens, not where the fatal disease begun, so that, on comparison, it is told twice in favour of the towns; once in being withdrawn from the town register, and a second time in being added to the country register, to which it does not properly belong. Independently of external causes, and by the force of a natural law, the mortality varies at different periods of life: so that the rate of dying in two mixed popula- tions may differ according to the varying proportions of children, young persons, or old people. The series of tables (pp. cxii-cxxvii) shows the rate of mortality at six periods of life, under five years, at 10-15, 35-45, 45—5 5 , 55—65, and 65-75. ^ *s shown in the extreme cases, that when the general mortality is either high or low, the mortality at nearly all these ages is high or low ; and a collation of the whole leaves little doubt on the question of the relative insalubrity of the various parts of the country. Upon looking generally at the health of the population, it will be found that people suffer most in the great town districts. Liverpool and Manchester are the places of highest mortality, then follow some of the districts of London, Merthyr Tydfil, Bristol, South Shields, Macclesfield, Hull, several districts of Lancashire, Sheffield, Nottingham, Leicester, Stoke-upon-Trent, Wolstanton and Burslem, Leeds, Newcastle-on-Tyne, Birmingham, Coventry, Wolverhampton, Newcastle-under-Lyme, Derby, Salisbury, Northampton, Bradford, Gateshead, Shrewsbury, Walsall, Norwich, Colchester, Sun- derland, Exeter, Worcester, Bedford, Dudley, Bath, Ipswich, Carlisle, Lancaster, Cambridge, Aylesbury, Maidstone, Canterbury, Wycombe, Gloucester, Wakefield, and Reading. The mortality is not increased equally at every age in these districts. And it varies V Healthy and Unhealthy Districts contrasted. considerably in the two sexes ; the returns for childhood, manhood, and old age, males and females, conspire in proving the prevalence of general causes of insalubrity operating with different degrees of intensity, but with much greater force than in other parts of the country. It is probable that under any circumstances a certain number of children born will never reach maturity ; that in a numerous population there will every year be deaths at all ages, from internal or external causes. In the present state of mankind it is im- possible to say how small the inevitable loss by death is, as in every place, and among all classes of people, certain known sources of insalubrity exist, which unquestionably account for a part of the prevalent mortality. The annual mortality of males and females of all ages in England is at the rate of 22 in 1000; in Glendale, Bellingham, and Haltwhistle, three districts of Northumberland, the mortality in the same seven years was 14 in 1000. Not to take an extreme case, a group of 21 statistical districts has been formed, and a table of the mean mortality has been deduced from the whole; which, as it represents the lowest rates of mortality hitherto observed, over a period of seven years in a considerable population, may for the present be called the mortality of man from natural causes. The excess of mortality over this standard may be un- hesitatingly referred to artificial, unnecessary causes, in such tables as the following, showing the waste of life and health in 40 town and city districts. An equal popu- lition (100000) is saken at six ages; and it will be observed that the insalubrity tells with most effect against childhood: the mortality under 5 years of age is raised 124 per cent. ; in manhood it is raised 77, 83, 70 per cent, at three ages, and in puberty and old age 45 per cent. Out of a given number of men, at different ages, the deaths by unnatural causes increase every year; for the table shows that to 100000 living in each period, the deaths are 700 by unnatural causes at the age of 35-45 ; and 1060 at 45-55 ; 1682 at 55-65. The rate of mortality is raised in a less ratio, but to a much greater extent in old than in middle age, for the natural mortality in old age is high. The absolute number of deaths is greatest in infancy, as the number of old persons living is small compared with the number of children living in every popula- tion ; so that whether the ratio of increase on the natural rate of mortality, the actual increase in the rate of mortality, or the number of deaths be regarded, children are the most cruelly treated by the destroyer. Yet of- every 17 men w’ho die in towns, 7 die by unnatural causes ; and of 1000 living at the age of 40, seven die ; at the age of 50, eleven die ; at the age of 60, seventeen die; at the age of 70, twenty-six die every year from causes evidently external and unnatural. Women escape with the least loss ; yet five in every fifteen annual deaths would not happen in healthy places. Annual Rate of Mortality per Cent, [or per 100000J in Healthy and Unhealthy Districts, also the Excess of Mortality due to Unhealthiness. MALES. FEMALES. Age. Districts in which the Mortality is Low. High. Excess, Low. High. Excess. 0—5 IO-15 35-45 45-55 55-65 65-75 4- 323 •393 •913 1*276 2*396 5- 657 9*678 •572 1*613 2*336 4*078 8*224 5-355 •179 • 700 1 *060 1 • 682 2*567 3 *66o •460 •992 1*172 2*131 4-799 8-405 •603 I'4II 1*895 3-323 6*964 4*745 •143 •419 •723 1 * 192 2 • 165 The table may he read thus without reference to decimal points. To 100000 boys living, 4323 die in comparatively healthy places, and 9678 in unhealthy places, the excess of deaths chargeable on the latter is 5355- It often happens that unhealthy and healthy villages, streets, parishes, and towns are in immediate juxtaposition ; and constitute parts of the same district. The effect of vi Sanatory Survey of England. this admixture on the results is, that the unhealthy districts are less unhealthy , and experience a lower rate of mortality than they would if all the healthy parts were eliminated. Upon the other hand, the healthy districts are made to appear less healthy than they would if they consisted only of healthy places, inhabited by people in good circumstances, under a proper course of diet, discipline, and exercise. The difference in the mortality of the two classes of districts is therefore understated. The healthiest districts of the country can readily be pic ked out of the tables. But some may be named, as it is of importance that they should be generally known ; not only for the sake of those who wish to resort to healthy localities, but that the precise condition of the parishes and populations that live in the best health may be studied. Among the healthiest Registration Districts in the country are Glendale, Bellingham, Hal twhistle, Morpeth, Rothbury, Alnwick, Belford in Northumberland; Brampton and Longtown in Cumberland ; Bideford, Holsworthv, South Molton, Torrington, Crediton, and Barnstaple, in North Devon; Anglesea, Tregaron, Lampeter, Newcastle-in- Emlvn, D<dgelly, Conven, Bala, Festiniog, Aberystwith, in Wales; Hendon and Barnet in Middlesex ; Ciodstone, Reigate, and Dorking, in Surrey ; the Isle of Tnanet (including Margate and Ramsgate*) and Eastry (including Deal) in Kent ; the Isle of Wight; Blything, Mutford, Wangford, in Suffolk ; Havant, Catherington, Fareham, Droxford, South Stoneham, New Forest, Lymington, Christchurch, Ringwood, Fording- bridge, and Uomsey, in Hampshire; Steyning, Thakeham, and Worthing, in Sussex. If the degrees of mortality are represented by shades on a map, or shadows on the face of the country, Berwick-on-Tweed is slightly shaded, nearly all Northumberland is white from the Cheviot Hills and Flodden to Otterbum and Hexhain away over the forests, wastes, and fells, to Longtown, Brampton and the hilly regions, round the lakes of Cumberland and Westmorland, to Ulverstone, north of Morecambe Bay. A dark shade rests on Carlisle, and extends, growing lighter, over Cockermouth and Whitehaven. From Newcastle down the Ty ne on both sides, the shades are thick and dark, and over D irham along the west the lessening shadow reaches Barnard Castle. The shadow over Yorkshire is light, the hilly north region is scarcely stained, and generally the great basin of the Humber, with the Ouse and Trent, is clear, but darken- ing shadows extend along the Ouse, the Aire, and the Don, becoming black over Sheffiidd, Leeds, and Hull the great port of the Humber. Derby, Leicester, and Nottingham, form a black triangle, sending a prolongation of shadow towards Sheffield and Stoke-on-Trent, but surrounded on the other side by light spreading over Buxton, the Peak of Derbyshire, much of Leicestershire, Nottinghamshire, and Lincolnshire. Lancashire is covered with a mass of darkness, that the light points along the coast can scarcely pierce. The blackness extends to Macclesfield, Stockport, Newcastle- under-Lyme, Wolstanton and Burslem. Shadows extend in a line through Shrews- bury, Wolverhampton, Dudley, Birmingham, and Coventry, with light on both sides, and the shade descends to Tewkesbury, darkening over the Severn and Gloucester. A shadow of some density stretches out in a south-westerly direction from Ely, Wisbeaeh, and Kings Lynn, over Cambridge, Bedford, and Northampton, to Buck- ingham. Norfolk, with the exception of Norwich, is made light by the contrast with this region and another on the borders of Norfolk and Suffolk, extending from Colchester, Ipswich, and Yarmouth, to Saffron Walden. Essex and Hertford are light ; Middlesex white, out of London, which is darkly shaded. Kent has over it a light shade, which turns dark over Chatham, Canterbury, Maidstone, and Dover. There is a general whiteness over Surrey, Sussex, Hampshire with the Isle of Wight, and parts of Berkshire, from the Thames to the sea; Reading, Brighton, Portsmouth, and South- ampton, are the dark spots in this field. The misty shadow is quite visible over Dorset, and grows cloudy over Wiltshire, of which Salisbury is the black centre; but the mist clears away in North Wilts, and disappears m whiteness over the Cotswold Hills, Westbury, and \\ heatenhurst in Gloucestershire, divided by the Severn. Tew kes- bury, Newent, Cheltenham, and Gloucester, make the northern borders of Glouces- tershire dark, and the shadow from Wiltshire descends on the southern border from Some of these districts suffered from Cholera, as will be subsequently 6hswn. Cholera. vii Devizes down the Avon, thickening over Bath, Clifton, Bedminster, and turning into a black mass over Bristol. Somersetshire is shaded on the side next Wilts and along the Avon, but is lighter towards the sea channel, and the whiteness is diffused over Exmoor, Dartmoor, and the whole of North Devon. Dark shadows rest on Exeter, and extend, growing much lighter, up the Yale of the Exe, to Tiverton. Plymouth, Devonport, and Stoke Damerel are enshrouded in black mist ; but the expanse of this great county is white, and so is Cornwall as far as Falmouth, but the parts to the south- west, studded with mines, are shaded to the Land’s End. A tract of whiteness, sixty miles in breadth, stretches from Devon, Somerset, and Cornwall, over the Bristol Channel, and covers the western half of Wales, from the sea-shore to the mountains, as far as Anglesea, Conway, and St. Asaph* Newport is dusk, Merthyr Tydfil is a black mass, and the shades spread over Glamorganshire and Brecknockshire, the field of the Welsh coal and iron works. The light parts of the country in the map represent a population in health and vigour, rarely attacked by zymotic diseases, living in considerable numbers to an advanced age ; the dark parts are real “ valleys of the shadow of death,” where the population is sickly, feeble, short-lived,- — where thousands of the infants are convulsed, the children’s brains inflamed, tuberculous, distended with water, — where small-pox, measles, and scarlatina, instead of being light eruptions, destroy the structure of the skin, putrefy the throat, inflame the lungs, — where the natural process of teething is often fatal to the child, childbearing to the mother, — where typhus, pneumonia, bronchitis, asthma, and consumption, destroy thousands of lives, beieaving families, and leaving multitudes of widows and orphans, following in the train of untimely death. England, according to the latest observations, is the healthiest country in the world,* yet it is not easy to calculate in ordinary times her losses by diseases, from which parts of the country are free, and which the progress of social improve- ment and medical science may remove. How can the sufferings of a large part of a nation be estimated ? How can the effects of disorderly morbid states on the passions and conduct of the people be weighed ? How can the value of time wasted, of great plans perishing unmatured, of works cut short by death, of men taken from the service of their country and mankind before their time, be measured ? If the loss is indefinite, its magnitude is unquestionable. We have now to describe its increase by the invasion of a foreign plague, which displayed a similar, but not the same partiality, in the selection of its victims, as the ordinary endemics of the country. CHOLERA. Cholera is more fatal in Asia than in Europe ; and several partial epidemics are described in the annals of India before the rise of that great epidemic of 1817, which encircled the world, and destroyed men wherever it found them in the circumstances that lend it power. The slow diffusion of that epidemic and its ravages through 1832 and 1833 in England have been frequently described. Since 1817 India has experienced several partial epidemics. I11 1845 cholera was epidemic in Cabul, which from 1839 to 1842 had been the seat of war, and the scene of great triumphs and great disasters. Bombay was attacked in the spring of 1846, and a part of the army of Scinde at Kurrachee was assailed by the disease in its most fatal forms. From Affghanistan, the Punjaub, and Sinde, the epidemic extended over Persia and Syria in 1846, reached Astrakhan at the mouth of the Volga on the Caspian Sea in June 1847, Moscow in September 1847, Petersburg and Berlin in June 1848, Hamburgh in September 1848, Edinburgh at the beginning of October 1 848. f The epidemic * The following Table is from the 6th Animal Report, p. xxxix. where the data will be found for these and other estimates. England 22 deaths annually to 1000 living. France 24 , , , , xooo , , Prussia 27 ,, ,, 1000 ,, Austria 30 ,, ,, 1000 ,, Russia 36 ,, ,, 1000 ,, f See Report of the Board of Health. Map. viii Cholera in England. travelled at the same rate as the epidemic in 1830—1 ; the dates of the attacks of which are given by Dr. Kennedy.* The first epidemic starting from Bengal in August 1817, reached Bombay on August 10th, 1818, and Astrakhan on September f 8th, 1823, and there it died away. In Persia, several local epidemics appeared at intervals in the 7 years, 1823-30. The great epidemic that traversed Europe is said to have sprung up in June 1830 on the low western shores of the Caspian Sea. The velocity of the two epidemics only differed in Asia: it was the same in Europe. It is worthy of remark, that in the hot season of 1846, when the cholera epidemic acquired great force about the Indus, summer cholera and diarrhoea prevailed with great violence in England. CHOLERA IN ENGLAND. The deaths from cholera in England were 331 in 1838 ; 394 in 1839 ; 702 in 1840 ; 443 in 1841: and 1620 in 1842. The deaths from diarrhoea in the 5 years (1 838-42) were 2482, 2562, 3469, 3240, and 5241. I shall trace the progress of the'-e diseases from 1842 by the help of the Quarterly Returns. The slight increase of mortality in the quarter ending September 30, 1842, was referred to diarrhoea and cholera, which “was more preva'ent than usual in the season, though in a mild form.” According to the Registrars (Reg. Gen. Quar. Rep. 1842, 3rd Qu ), “bowel complaint” prevailed at Brighton, Plymouth, Dudley, Wolverhampton including Bib-ton, Birmingham, Liver- pool, Manchester, several Lancashire districts, Leeds and Sunderland. English cholera was fatal to 3 aged men at Northampton ; 1 person at Ipswich. It prevailed at Deritend and Bordesley near Birmingham, Basford, Macclesfield, Liverpool (where 1 death was registered “Asiatic cholera” of 4 or 5 hours’ duration), West Derby, Black- burn (where “ 29 persons died of cholera”), Bury and Bolton (where an “epidemic of diarrhoea or English cholera prevailed among all classes”), Chorlton, Manchester, Salford, Dukenfield sub-district of Ashton and Oldham, Bradford. In London (1842) 704 deaths were referred to diarrhoea, 1 1 8 to cholera. Wages were reduced, and there was consider- able manufacturing distress in this year. The men “ turned out ” in many districts. 1 843. In the summer quarter (July, August, September), “ bowel complaints ” were noticed in Exeter, Wolverhampton, Lincoln, Nottingham; “an extensive mild fever prevailed ” in Macclesfield, “ together with English cholera, but not of a fatal character.” Diarrhoea was prevalent in Liverpool and West Derby ; 40 of the 95 deaths in Chorlton-upon-Medlock were “ from diarrhoea, cholera, or other diseases of the bowels.” The symptoms, the Registrar states, were, in many cases — “ diarrhoea, vomiting, and colic ; often with coldness of the skin, and sometimes of the breath ; blueness of the skin and sunken eyes; the dejections sometimes colourless, with white flakes, but generally bilious and feculent.” Cholera was fatal to 43 persons in the Hulme sub-district. English cholera prevailed so far as to constitute an epidemic in Manchester ; 1 case terminated fatally in 24 hours. Ashton, Oldham, and Halifax were attacked by diarrhoea and “English cholera.” In the year 1843, 834 deaths were referred to diarrhoea, 85 to cholera, in London. 1844. In the summer quarter, 47 cases of cholera were registered in London, 414 of diarrhoea. A case of English cholera was registered at Kingston in Portsea Island. Diarrhoea was prevalent and fatal in Bedford, Clifton, Stroud, Dudley, Wolverhampton, Coventry, Macclesfield, Chorlton, Manchester, and Huddersfield. In the quarter ending December, 5 cases of cholera were registered in London ; 3 at Sedgley in the Dudley district, where “ bowel complaint” continued prevalent. In the year 705 deaths were referred to diarrhoea, 65 to cholera, in London. * See the valuable and lucid History of Contagious Cholera, p. 198. Report of Hoard of Health. Map. Astrakhan .... July 20, 1830 Moscow Sept. 1830 Petersburgh .... June 26, 1831 Berlin Aug. 31, 1831 Hamburgh .... Oct. 1831 Sunderland .... Oct. 24, 1831 Edinburgh .... Jan. 22, 1832 by J. Kennedy, 3rd edit. 1832. June 1847 Sept. 18, 1847. June 1848. June 1848. Sept. 1848. Oct. 4, 1848. Oct. 1, 1848. Map, IX Cholera, 1845-6. 1845. Only 26 deaths from cholera were registered iri London during the summer quarter: 2 deaths from cholera occurred in St. George’s, Clifton; 1 in Sedgley, Dudley. In the autumn quarter of the year 2 deaths from cholera happened in Sheffield North. Cholera and diarrhoea were rare, and attracted little attention. In this year 841 deaths were referred to diarrhoea, and 43 to cholera, in London. 1846. The winter quarter (January, February, March) was exceedingly mild, the mortality low. In the remarks attached to the June quarter, it is stated that there was an evident tendency in the mortality to decline through the 7 spring quarters 1839-45; kut that in the spring of 1846, this tendency was counteracted, and the deaths exceeded the average. The deaths in London, at the close of June, from diarrhoea, dysentery, and common cholera, rose to 40 weekly. The progress of the epidemic abroad, and the bad sanitary condition of London and many towns, justified the warning in the remarks of this quarter, — not to wait until cholera reached the country, but to look before, and to remove the nuisances which give the disease breath, life, and being, Tne air was 2° above the average temperature, and the horizontal movement was less than it was in spring, 1844, in the proportion of 655 to 948 miles weekly. In the summer quarter (July, August, September) of 1846, an extensive epidemic prevailed. The 5 weeks from July 11 to August 15 were the most fatal in London. Young children were the principal sufferers : it had the usual symptoms of cholera infantum. “The disease also proved fatal to many old people; and some adults died of attacks which could not in their symptoms be distinguished from Asiatic cholera. It was, however, quite evident from the first that the epidemic had not the characters of (hat malady which broke out here in the winter of 1832, but was closely allied to the cholera described by Sydenham, which he says lasted a month and — “ earn anni 'partem , quae cestatem fugientem atque autumnum imminentem complectitur (unice ac eadem prorsus fide , qua veris primordia hirundines, aut insequentis lempestatis fervorem cucidus), amare consuevit.”* While the deaths in London were little more than 14 per cent, above the return of 1845, the deaths rose from 25,166 to 38,826 — or about 52 per cent, after a correction fir increase of population— in the towns and other districts of the kingdom, included in the return. In some of the densely-peopled towns the mortality was doubled. The deaths in the corresponding summer quarters of the past and present year were, in Maidstone, 124 and 239; Brighton, 219 and 364; Portsea Island, 239 and 433; Winchester, 89 and 141 ; Oxford, 89 and 194; Northampton, 182 and 220; Bedford, 182 and 255 ; Ipswich, 119 and 240; Norwich, 308 and 454; Plymouth, 191 and 279 ; Clifton, 323 and 436 ; Worcester, 106 and 173 ; Dudley, 457 and 745 ; Walsall, 1 57 and 288 ; Wolverhampton, 438 and 687 ; Wolstanton and Burslem, 164 and 315* Coventry, 188 and 300; Nottingham, 285 and 467 ; Lincoln, 154 and 246. No such mortality has been witnessed in Birmingham for many years; the deaths in 1845 were 694, in 1846 they amounted to 1623. In Liverpool and the adjacent district of West Derby, the deaths in the summer quarters of 1845 and 1846 were 2596 and 4090; in Manchester, and the contiguous districts of Salford and Chorlton, 2408 persons died in 1845, and 4297 in 1846. Stockport, Macclesfield, Chester, Blackburn, Preston, Bury, Bolton, Wigan, Prescot, Ashton, and other districts of Cheshire and Lancashire, suffered to an equal or a greater extent. The districts of Yorkshire did not escape ; 1039 persons died in Sheffield, where only 446 died in the summer quarter of 1845, and the mortality in any preceding summer since 1838 had never exceeded 647. Hudders- field, Leeds, Hull, and York suffered severely. In Sunderland, Gateshead, Tyne- mouth, and Newcastle-on-Tyne, 1170 deaths were recorded in the summer quarter of 1845, and 2313 in the corresponding quarter of 1846. The epidemic was apparently as fatal in the inland towns as in the ports. Upon the other hand, the mortality of the quarter was below the average in Pontypool and Newtown; but slightly above the average in the other districts of Wales; and generally the country and southern districts suffered comparatively little. f * Sydenham Opera. Obs. Med. Anni 1669. He also describes the severer epidemic of 1676, “ Insueto tempestatis calore evectus.” t Reg. General's Report on the State of the Public Health in the quarter ending September 30, 1846. X Cholera and Influenza, 1847-8. The diarrhoea was in some districts of a dysenteric character, but generally chole- raic, and often terminated in English cholera. At Nottingham a case was returned as Asiatic cholera, terminating in 12 hours. In London 1549 deaths in the quarter were referred to diarrhoea, 75 to dysentery, and 197 to cholera. In the last quarter of the year diarrhoea, dysentery, cholera, influenza, and typhus were unusually common in London, and in many other town districts. The iron, coal, pottery, cotton, and woollen districts, and generally the counties north of Staffordshire, were severely visited. Scarlatina was fatal in the northern districts. In the year 2152 deaths were referred to diarrhoea, 228 to cholera, in London-. 1847. The temperature of the winter quarter was below the average; inflammation of the lungs aud typhus prevailed. Diarrhoea and fever raged among the poor starv- ing Irish, who flew from the famine caused by the potato failure to England. From the same cause provisions were dear; there was much distress in many parts of the country. In the spring quarter (April, May, June), the mortality, in the words of the Quarterly Report, “ increased ; common cholera was fatal ; scurvy prevailed more or less over the country from the want of vegetable food, the potato having failed; all food became scarce and dear; typhus broke out, is still epidemic, and shows no sign of decline.” In the summer quarter (July, August, September), the mortality slightly decreased in the country ; in London there was no sign of improvement. Small-pox, measles, scarlatina, diarrhoea, dysentery (slightly), typhus, and ervsipelas prevailed: ill persons died of typhus in one week ; epidemics of typhus and influenza set in, and made the mortality in the last quarter of the year higher than in any quarter of any year since the registration commenced. The mortality in London was raised by influenza from 1086 in the week ending November 20, to 1677 in the week ending November 27; 2454 in the first, 2416 in the second week of December: the epidemic and the mortality then gradually declined. The deaths, directly or indi- rectly caused by influenza, were not less than 5000 in six weeks. In the year diarrhoea was fatal to 1976, cholera to 1 1 7 persons, in London: 307 deaths were referred to dysentery. 1848. The influenza epidemic extended into the winter quarter of 1848 (January, February, March), and the mortality was greatly above the average. Typhus, scarla- tina, hooping-cough, and small-pox were epidemic in many parts. The mortality of Birmingham, Sheffield, Manchester, and Liverpool remained exceedingly high. Inthe next three months “ a very remarkable improvement in the state of the public health ” was observed ; the mortality was but slightly above the average of the season. In- fluenza was no longer epidemic in London. Typhus, which was fatal to 1279 persons in the last quarter of 1847, declined from that time, and in the June quarter of 1848 was only fatal to 882 persons. “ There is as yet no trace of the epidemic of cholera, which is ravaging Russia from Moscow to St. Petersburgh, and is ascending the Danube.”* The mortality in the summer quarter (three months, July, August, Sep- tember) was below the average. “ The improvement in the public health is consider- able, in all the divisions of the kingdom, except London.” * The principal seats of the carpet, iron, pottery, silk, and cotton trades are particularly cited ; and the improve- ment is ascribed to the comparative cheapness of provisions, and the infrequency of fever consequent upon the diminution of Irish immigration. Diarrhoea was, however, prevalent in Brighton, Ipswich, and Yarmouth, in Dudley, Walsall, Co- ventry, Birmingham, and Leeds. Dysentery was rather more fatal than usual ; it caused 65 deaths in Penzance, and was also fatal to many persons in Marazion, the neighbouring sub-district. The mortality of the autumn quarter (October, November, December) was “ below the average;” yet cases of “Asiatic” or “ epidemic” cho- lera occurred in October, and in the remaining months of the year. 1934 deaths were referred to cholera; 829 in the first nine months, and 1 105 in the last three months of the year 1848. The former were generally considered cases of common “English” cholera; many of the latter were universally held to be “Asiatic” cholera. The two forms are often not distinguished in the rcturus. The cases, sepa- Registrar-General's Quarterly Report*, 1848. What is Diarrhoea ? xi rately considered, run so insensibly into each other, that the attempt at distinction would have been fruitless. They differ perhaps, in fact, no more than distinct and confluent small-pox, simple and malignant scarlatina, simple and phlegmonous erysipelas, which are properly held to be varieties of the same maladies. Without entering into any disquisition in pathology, it is also necessary to notice here the connexion of diarrhoea and sporadic cholera with Asiatic cholera. Diarrhoea, in the sense of u dejectio frequens ,” frequently accompanies teething in children; it is the result of a whole class of medicines, and of irritating, indigestible food. Many poi- sons induce it. It is one of the most constant symptoms of typhus, and runs insensibly into dysentery. The last stage of consumption is marked by colliquative diarrhoea. Like pain and “ fever,” it is a symptom of many diseases. “ It is often brought on by that power which is exerted in every part of the body of freeing itself from any- thing painful and oppressive” (Heberden’s Commentaries). The ulceration of the intestines in typhoid fever, in consumption, and in dysentery, are its common causes ; in many cases no structural change can be detected in the mucous membrane ; and many of the purgative medicines are first absorbed and taken into the blood before their specific action is induced. In abstracting the cases of 1849, for the series of tables in this volume, all cases returned as “ cholera,” whether English or Asiatic, cholerine, “ bowel complaint,” and diarrhoea simply, or as a complication of other diseases, were transcribed. All the cases in which the term “ cholera” or “ choleraic diarrhoea” occurred, were re- ferred to cholera; about 300 cases, in which diarrhoea was evidently a symptom of consumption, or some other disease, were struck out; the residue of the cases was classed under diarrhoea. Excluding the symptomatic affection, such as is observed in fever, consumption, and enteritis, there is evidently an idiopathic disease, which may properly be called diarrhoea, and is as constantly observed in English towns when the temperature rises above 6o° as bronchitis and catarrh when the temperature falls below 32 ’. Again, wherever dysentery is epidemic, a great number of cases occur which exhibit all the intermediate symptoms between simple purging without fever and the cha- racteristic fever, pain, and bloody mucous discharges of dysentery. The dysentery often begins as simple diarrhoea. In such circumstances the diarrhoea is really a con- stituent part of epidemic dysentery, modified by the condition, place, and age of the patients. In like manner, the diarrhoea which is generally prevalent at the same time as cholera, often painless, with rice-water evacuations,* vomitings, and slight spasms, is to be held, in its various shades, a constituent part of the cholera epidemic. Many of the cases of diarrhoea in 1 849, it maybe held, however, were of a simple character, and of the same nature as the diarrhoeas of other years. We shall now give a more particular account of the progress of cholera in 1848, and of the first appearance of the new epidemic form. CHOLERA IN LONDON, 1848. London. — In London deaths \vere referred to cholera in every month of 1848: 3 were registered in the weeks of January, 3 in February, 2 in March, 4 in April, 3 in May, 8 in June; the increase taking place in the third week of June, when the mean daily temperature rose and remained above 6o°. The disease was epidemic, and the deaths registered in July were 66, in August 64, in September 31. The deaths from cholera registered in each week of these three months w’ere, 3, 7, 9, 21, 26, 21, 19, 17, 7, 7, 7,6, 7, 4. This epidemic subsided in September; it presented little that w;as extraordinary in its course, or in the number of cases. The deaths registered from cholera in the first week of October were 13, and in the twelve subsequent weeks of the quarter, 30, 45, 34, 65, 62, 54, 34, 20, 21, 29, 31, and 30. The temperature was * Dr. R. D. Thomson has shown that this fluid is not the serum of the blood, but has the same chemical qualities as the effusions into serous membranes. The light flakes are the epithelial scales of the intestine. — On Cholera, Trans. Royal Med. Chir. Soc., London, vol. xxxiii. Xll 1848. Summer Cholera in London. declining; yet the mortality increased rapidly in October, and 65 persons died from cholera in the first week of November. The cases were severe and rapidly fatal. It was evidently the epidemic cholera — the Asiatic cholera. To every one accustomed to observe popular disease the difference in the two forms was striking. Some extracts from the weekly table will show their different characters. The following is from the notes to the week when the common summer epidemic of cholera was at its height : — Cases of Cholera Registered in the Week ending July 29 th. In Bel "rave (sub-district) F. 54, “Asiatic cholera (58 hours' duration).'' Mr. Jorden, the Registrar, states that “ this was a distinct case of Asiatic cholera (?), occurring in his own practice, of whicli he had seen much both at home and in the East. The patient was said to have suffered from a severe attack, when it prevailed before, some 16 years ago. She was of delicate health, and suffered from psoriasis inveterata. She was attacked suddenly in bed at 4 o’clock in the morning, having the day before dined on half-boiled cabbage and some sort of dumpling.’’ In St. John the Evangelist, Westminster, a boy, aged 4 months, “ cholera infantum (4 dags’ duration)." In the same sub-district, a boy, 3 months, “cholera infantum (4 dags).’ ’ No breast-milk after the first six weeks. In Gray’s Inn-lane (sub-district), a boy aged 11 months, “diarrhoea — cholera (4 dags)." In Somers Town, a boy aged 4 months, “ cholera (2 dags' duration), typhus (1 dag)." In Camden Town, M. 62 years, “dysentery (11 dags), cholera (3 dags)." In West sub-district of Islington, a boy, 7 weeks, “ cholera (5 dags)." In East sub-district of Islington, a woman aged 29 years, “cholera (4 dags), collapse on the 4th day.” She was the wife of a shoemaker, and lived in one of the dirty confined courts out of the High-street.” In St. Anne, Westminster, a boy aged 16 months, “cholera infantum (7 or 8 dags).” In Saffron Hill, a boy aged 22 days, “cholera infantum (6 dags), convulsions (4 dags)." In sub-district of Goswell-street, M. 77, “diarrhoea (6 dags), which assumed symptoms of cholera, exhaustion (3 dags).” In North sub-district of West London, a boy aged 6 months, “ cholera (24 hours)." In Haggerstone West, a carpenter, 76 years, “natural death, sudden, from English Cholera." (inquest). In Bethnal Green (Town), at No. 12 Carlisle-street, son of a brewer’s servant, aged 7 weeks “cholera 2 dags').'' In St. Mary, St. George-in-the-East, M. 59 years, “English cholera (6 dags).’’ In Limehouse, F. 40 years, “ cholera (3 dags), collapse (25 hours).” In Ratclifl'e, M. 51 years, “ cholera maligna (30 hours).’’ In Lambeth Church sub-district (2nd part), at 137 Regent-street, F. 16 years, “English cholera (2 dags), exhaustion.” In Camberwell, at 4, South-street, daughter of a letter-carrier, aged 2 years, “English cholera (6 dags).” In Holywell and Moorfields, Shoreditch, a boy aged 19 months, “ English cholera (4 dags)." In same sub-district, M. 24 years, “spasmodic cholera (4 dags).” In East sub-district of Greenwich, M. 61 years, “cholera.” In same sub-district, M. 71 years, “cholera ^4 dags)." In same sub-district, M. 60 years, “ asthma (20 gears), cholera (4 dags)." In same sub-district, a girl, 1 year, “ cholera.” In Battersea, a boy, 1 year, “cholera (4 dags)." In all the cases of cholera, except one returned by the coroner, the cause of death was certified by the medical attendant. Cases approaching the Asiatic form occurred early in the year. I11 the week ending May 6th, a woman of 75 died of cholera in Rotherhithe, after 5 days’ illness ; another, aged 43, died of cholera in Oxford Terrace, after 2 days’ illness. In the following week ending May 13th, a woman aged 40 died in Aldgate, Whitechapel. A note stated that “the case presented the appearance of Asiatic cholera, viz., purging constant, no bile in stool, cholera voice, suppression of urine; died in four days, in a state of collapse.” In the week ending June 3, a boy aged 12 years, died of cholera in Rotherhithe, after 48 hours’ illness. A man aged 51, died of Asiatic cholera, according to the return of the week ending June 17th, in the Hanover Square sub-district, after 36 hours’ illness. In the week ending July 8th, a man aged 68, was returned as having died of Asiatic cholera in Greenwich East. Again, on September 12th, a pilot, aged 55, died of Asiatic cholera (36 hours’ duration), at 8, Frederick Street, Greenwich West; and was registered in the week ending September 1 6th . On September 22nd, a mariner, aged <2, died aft* r 11^ hours’ illness of “Asiatic cholera,’’ at 8, New Lane, St.John, Horsleydown, in the district of St. Olave. These were probably two real cases of the new epidemic form ; still the contrast of the October returns with that of the last week of September is striking. t 1848. Asiatic Cholera in London. xiii Cases of Cholera returned in the Week ending Sept. loth. — (All are certified by Medical Attendant.) In Belgrave (sub-district), St. George, Hanover-square, F. 74 years, “English cholera (18 days' dura- tion) .” In South sub-district, St. Giles-in-the-Fields, F. 4 years, “English cholera (to hours’ duration).” In Amwell-street, Clerkenwell, F. 40 years, “ bronchitis (23 years’ duration), English cholera (1 week).” In Mile End Old Town (Upper), a girl, 8 months, “ cholera infantum.” The great change now takes place. Fatal Cases of Cholera Registered in the Week ending Saturday, October the 7th. — (All are certified by the Medical Attendants.) In Old-street (sub-district), St. Luke, at 39, Rahere-street, died on September 29, wife of a gentleman, 59 years, “ disease of the bowels, simulcting Asiatic cholera (38 hours’ duration).” In south sub-district, West London, F. 27 years, at 3, Harp-court, St. Bride’s, on October 2, a porter’s wife, “cholera (13 hours’ duration).” In St. Bartholomew’s Hospital, West London, M. about 40 years, a porter, on October 4, “ Asiatic cholera.” In Town (sub-district), Bethnal-green, at 4, Cheshire-street, on September 28, a weaver, F. 21 years, “ enlargement of the heart (12 months’ duration), cholera spasmodic (12 hours).” In Spitalfields, Whitechapel, M. 23 years, mariner, at 21, Princes-street, on October 5, “ cholera (12 hours’ duration).” In Whitechapel North, a girl, 4 years, a labourer’s daughter, at 14, Thames-street, on October 2, “ English sporadic cholera (7 days' duration).’’ In St. Paul (sub-district), St. George-in-the-East, M. 38 years, a coal-whipper, at 3, Lower Chapman- street, on October 3, “ cholera (2 days' duration) .” In Mile-end Old-town Lower, Stepney, M. 47 years, a coal-meter, at 6, Globe-terrace, on October 6, “ cholera (36 hours' duration).” Mr. Castleden, the Registrar, states — “ Mr. Todd, the surgeon in this case, certifies, that the above was a case of Asiatic cholera ; and the informant states, that her father (the deceased) got up on Thursday morning, about 4 o’clock, with a bowel complaint, for which he took some gin and ginger, and then went to his work, on board ship, which he was compelled to leave about mid-day. He returned home in a cab, and died yesterday morning at 4 o’clock. The medical gentleman was in close attendance to the very last.” In Lambeth Church, 2nd part (sub-district), at 2, Orsett-street, on September 30, daughter of a chair- maker, 11 months, “ cholera (3 days’ duration): convulsions (1 hour).” Mr. W. H. Wheatley, the Registrar, states, “ that at otie end of the street mentioned above, in the centre of the road, is an open drain, which is very offensive at times — drainage to houses very bad. Scar- latina has been very prevalent there.” In Rotherhite, at 2, Lower Queen-street, on October 2, a boy, 11 years, son of a carpenter, “ cholera (9 hours' duration).” In same sub-district, at 11, Silver-street, on October 1, F. 38 years, wife of a mariner, “ cholera (19 hours’ duration).” In same sub-district, at 17, Hanover-street, on October 4, a girl, 2 years, “ cholera (2 days’ duration).” In Greenwich West, sub-district, at 9, Skinner-street-row, on October 1, F. 37 years, widow of a black- smith, “ cholera (4 days’ duration).” Fatal Cases of Cholera Registered in the Week ending Saturday, October the 14 th. — (Five are cases in which Inquests were held : of the remainder, all are certified by Medical Attendant except two.) In London Hospital, Whitechapel Church (sub-district), on October 8, Henrick Vandershaaff, a cattle drover, aged 65 years, “ diarrhoea (7 days’ duration) ; Asiatic cholera (36 hours’ duration).” In Aldgale, a boy, 1 year, a labourer’s son, at 6, Cow-yard, Rosemary-lane, on October 10, “ Asiatic cholera (24 hours’ duration).” In St. John (sub-district), St. George-in-the-East, M. 28 years, a labourer, at 5, Green-bank, on October 10, “ Asiatic cholera (11 h >urs’ duration)” In the Leather- Market (sub-district), St. Mary Magdalen, Bermondsey, at 1, Friendly-place, on October 8, M. 40 years, a labourer, “ Asiatic cholera). In Kennington, 1st part (sub -district), Lambeth, M. 39 years, a labourer, at 18, Kennington-place, on October 9, “ Asiatic cholera (4 days’ duration) ; collapse (16 hours).” In Woolwich Arsenal (sub-district Greenwich), on October 3, M. about 60 years, a convict, “ cholera (8 hours’ duration).” Inquest. In same sub-district, on October 7, M. 48 years, a convict, “ Asiatic cholera (11 hours’ duration).” Inquest. In same sub-district, on October 7, M. 31 years, a convict, “ Asiatic cholera (4 hours’ duration).’’ Inquest. In same sub-district, on October 8, M. 42 years, a convict, “ Asiatic cholera (13 hours’ duration).” Inquest. In same sub-district, on October 10, M, 55 years, a convict, “ Asiatic cholera (8 hows’ duration).” Inquest. XIV 1848. First Cases of Asiatic Cholera in London. Mr. Richard Rixon, the Registrar, states, that “ The above five deaths occurred on board the “ Unite” Hospital Ship, in the River Thames, oft’ the Royal Arsenal. There have been no cases in the Arsenal, or in any part of the town, to his knowledge, and he has made every inquiry.” In St. Olave and St. Thomas (sub-district), at n, Magdalen-court, Tooley-street, on October 12, F. 49 years (kept a fruit stall in Bermondsey-street), “ Asiatic cholera, (18 hours' duration)." In Chelsea South (sub-district), at White Hart-court, on October 7th, M. 14 years, a mason’s son, “cholera morbus (16 hours’ duration)." In same sub-district, at White Hart-court, on October 7, M. 40 years, a stonemason, “cholera morbus (30 hours’ duration).” In same sub-district, at. the Royal Hospital, on October 10, M. 68 years, a soldier, p. m.., “ cholera morbus (12 hours’ duration).” In same sub-district, at 5, White Lion-street, on October 13, M. 46 years, a pensioner, “ cholera Anglica (1 week's duration)-, delirium tremens, cirrhosis.” In same sub-district, at. White Hart-court, on October 8, F. 13 years, daughter of a baker (deceased) p. m., “ cholera morbus (3 7 hours' duration).’’ In the Green (sub-district), Bethnal -green, at 3, Chester-street, on October 8, a boy, 11 weeks, a weaver’s son, “ English cholera (1 month’s duration).” In Spitalfields (sub-district), at 17, Wilson’s-place, on October 9, F. 32 years, wife of a joiner, “ malig- nant cholera (29 hours’ duration).” In St. John (sub-district), St. Olave, at 3, Cross-street, oti October 4, M. 77 years, a cooper, “ cholera (65^ hours’ duration).” In same sub-district, at 13, Sard’s-rents, on October 14, M. 30 years, a carpenter, “ cholera maligna (32 hours’ duration).” In the same house, on October 6, F. 2 years, daughter of a carpenter, “ diarrhoea, convulsions.” Mr. Beusted, the Registrar of St. John, Horsleydown, states, “ These two cases were those of a father and daughter, who lived at No. 13, Sard’s-rents, Church-street, St. John’s, Southwark; the latter died of 1 diarrhoea, followed by convulsions ;’ the former of ‘ malignant cholera,’ was attacked at 12 o’clock on Friday, October 14th, and died at 4 p. m, on Saturday. From inquiries I have made, it appears that he was a very sober and industrious man; that he and his wife were cleanly in their habits, but that one or other of the family has been constantly ill since they lived in their present residence. There are, 1 believe, upwards of 20 houses within 4 or 5 feet of a filthy open sewer, and this fact has been constantly repre- sented to me (as Registrar) by the inhabitants of those houses. The illness which is caused by so great a nuisance can hardly be wondered at, for in some places I do not think it is above 3 feet from their doors. The deceased lias left two children, one not out of danger, and the other very ill. These circum- stances have been the more impressed on my attention by a visit from the medical gentlemen (Messrs. Phil- lips and Button) who atteuded the cases, and state, as their opinion, that this open sewer was the prin- cipal cause of the illness.” In St. James, Bermondsey, at 1, Matilda-place, on October 12, F. 7 years, a labourer’s daughter, “ cholera (13 hours' duration).” No medical attendant. In Lambeth Church, 1st part (sub-district), at 26, Lower Fore-street, on October 1, M. 22 years, a labourer, “ cholera (9 hours’ duration V’ Not certified. In same sub-district, and in the same house, on October 12, M. 23 years, a labourer, “ cholera (2 days' duration); consecutive fever (6 days).’’ In Rotherhithe, M. 29 years, caipenter of the brig “Malta,” died on board, in the River Thames, on October 7, “ English cholera (24 hours' duration).” In same sub-district, at 15, Spread Eagle-court, on October 1 2, a boy, 6 years, a labourer’s son, “ cholera (24 hours' duration).’’ In St. Paul, Deptford, Greenwich, at 23 Griffin-street, on October 10, F. 31 years, a labourer’s wife, “ cholera (4 days’ duration)." In “ Dreadnought,” Hospital Ship, Greenwich West sub-district, on October 9, M. 21 years, an apprentice, “ cholera.” In same ship, on October 9, M. 23 years, an apprentice, “ cholera.” In same ship, on October 6, M. 16 years, an apprentice, p. m., “ recovery from small-pox, diarrhoea 27 daps’ duration; sudden vomiting, purging, and collapse about 24 hours." In Clapbam (sub-district), at Prescolt-place, on October 10, M. 44 years, a bricklayer, “ malignant cholera 9 hours’ duration." Fatal Cases of Cholera Registered in the Week ending Saturday the 21 st of October. Ten are cases in which Inquests were held: the remainder are all reported to be certified by Medical Attendants, except one. li Woolwich Arsenal (sub-district Greenwich), on Oct. 13, M. 30 years, a convict, “Asiatic cholera ,2 > hours’ duration).” Inquest. In same sub-district, on Oct. 14, M. 58 years, a convict, “Asiatic cholera (52 hours' duration).” Inquest. In same sub-district, on Oct. 16, M. 67 years, a convict, “ Asiatic cholera (19 hours’ duration).” Inquest. In same sub-district, on Oct. 16, M. 62 years, a convict, “Asiatic cholera (100 hours’ duration).” Inquest. 1848. First Cases of Asiatic Cholera in London. xv In same sub-district, on Oct. 17, M. 26 years, a convict, “Asiatic cholera (6 hours’ duration).” Inquest. In same sub-district, on Oct. 18, M. 25 years, a convict, “ Asiatic cholera (4 days’ duration).” Inquest. In same sub-district, on Oct. 19, M. 23 years, a convict, “Asiatic cholera (4 days’ duration).” Inquest. Mr. Rixon, the Registrar of the sub-district, Woolwich Arsenal, makes the following statement: — “ The seven deaths from Asiatic cholera, registered by me last week, occurred in the “ Unite ’’ hospital ship, among convicts from the “ Justitia’ hulk, lying oft the Royal Arsenal wharf. The surgeon attributes the disease to the unhealthy state of the atmosphere and to the locality, a common sewer being in the immediate vicinity. The captain of the ship ascribes it to the rotten condition of the hulk, and to heat generated during the night by so many men being closely packed together, a ward having from ten to twenty-four men sleeping in it, according to its size. The last two cases were of athletic young men, and lasted four days. The former patient was pulseless from the first, and comatose during lour hours previous to death — the latter was sensible to the last. They were carefully attended to, visited every hour night and day; and were treated witn mercury, mustard poultices, stimulants, and all the usual remedies. The whole of the convicts were removed yesterday (the 20th instant) from the “Justitia,” and put on board the “Hebe” and “Sulphur” receiving vessels, opposite the Royal Dockyard, which arrangement, I find, has created some alarm in the yard. This morning (Saturday) a rigger was taken home from the Dock- yard very ill, and afterwards a shipwright, and both cases are pronounced by the surgeons as decided cholera. Otherwise, the town remains free. Scarlatina is still very prevalent.” In Chelsea, North East (sub-district), M. 15 years, “epidemic cholera (3 days’ duration).” In same sub-district, a boy, 6 years, “epidemic cholera (9 hours’ duration) .” Mr. Smith, the Registrar of the north-east sub-district of Chelsea, states that “ the two boys belonged to the same family. The elder was employed on board a lighter at Isleworth, and had eaten heartily of mussels on the day before the attack. Finding himself ill, he returned home under heavy rain, which wetted him to the skin. His parents, who are in poor circumstances, procured medical aid, but were not able to provide the comforts necessary for his case; and to the want of these, the surgeon thinks, is principally owing the fatal termination. The younger was constantly in the room during bis brother’s illness, but was not seized till after his death. His illness is attributed by the medical attendant not merely to contagion, but to miasma generated in a badly ventilated and comfortless apartment, and increased by the presence of a sick person.” In Islington East (sub-district), son of a paper-stainer, 3 years, “ cholera epidemica (18 hours’ duration).” Mr. Butterfield, the Registrar of the East sub-district of Islington, states that “ the boy who resided at 15, Lower Queen-street, New North Road, was taken ill at hall-past 6, A.M., with rigors, bilious vomiting, and purging with rice-coloured evacuations, and all the symptoms of true cholera. Medical advice was not obtained till half-past twelve, when it did not avail. The patient died at halt-past one, a.m., on Saturday, after an illness of 18 hours. Miasma issuing from an open, offensive drain in the backyard, seemed to be the primary cause.” Dr. Bossy, who attended the above, has another decided case in an adult, which has not been fatal.” In Christchurch (sub-district), Marylebone, seaman, 22 years, “ malignant cholera (2 days’ duration), secondary fever (3 days).” Mr. Obre, the Registrar, states that the deceased was a seaman who had arrived from Sunder- land, in the brig “ Marsden,” on the loth: had febrile symptoms, with diarrhoea, till the 13th, when he removed to Lisson Grove. These symptoms continued till the 15th, when the choleraic poison showed itself, and he died on the 17th. Dr. Miller adds, that “ the patient was brought home on Friday evening in a state of collapse, and died of ‘ Asiatic cholera,’ in the stage of secondary fever.” In Whitechapel North (sub-district), seaman, 43 years, “Asiatic cholera (3 days’ duration).” Mr. Chapman, the Registrar, states that “this sailor was brought from a lodging-house, 118, Rose- mary-lane, to the Whitechapel Workhouse, on the 16th October, and died on the 18th. It appears he had not been many days from on board ship.” In Ratcliff (sub-district), Stepney, on board a collier in the River Thames, M. 19 years, “ diarrhoea (4 days’ duration), Asiatic cholera (9 hours).” Mr. Wells, the Registrar of Ratcliff, mentions that “ besides the above case, he had three others (one English, two Asiatic), on which inquests had been held; but they were not yet registered, as he had not obtained the coroner’s signature. The four cases occurred on board colliers in the Thames. In St. Paul’s, Deptford (sub-district), Greenwich, M. 66 years, “ cholera Asiatica (17 hours’ duration).’’ Mr. Marchant, the Registrar of St. Paul’s, Deptford, states that “ this person resided in a very healthy, airy situation, and was of steady habits; by trade a carpenter, but only working at. his trade occa- sionally, having other resources. He ate a hearty dinner of boiled mutton, spinach, and potatoes, on the day previous to that on which he died.” In Islington East (sub-district), a labourer, 15 years, “ diarrhoea (5 days' duration), spasmodic cholera.” In same sub-district, a boy, 6 years, son of a pauper stonebreaker, “ natural, with symptoms of spasmo- dic cholera (11 hours’ duration), ill fed and poorly clothed.” Inquest. Mr. Butterfield, the Registrar, states that “ these two were brothers, and died in Ward’s Place, a close confined, badly ventilated place, off' the Lower Road.” xvi 1848. Quick Course of Asiatic Cholera in London. In Goswell-street, Clerkemvell, F. 24 years, “ Asiatic cholera (36 hours' duration).’’ In Cvipplegate sub-district, M. 45 years, “Asiatic cholera (4 days’ duration)" In South-east sub-district, City of London, M. 27, “ cholera Asiatica (12 hours’ duration).’’ In Aldgate sub-district, M. 50 years, “died by the visitation of God from Asiatic cholera (20 hours' duration).” Inquest. In St. Saviour (sub-district), a boy, 7 years, “Asiatic cholera (15^ hours’ duration).” In St. James, Bermondsey, at 17, Mary gold-street, 011 Oct. 14, Thos. Daws, aged 20 months, “ Asiatic cholera (20 hours' duration).” He was attended by the wife of John Elliott. In same sub-district, at 17, Marygold-street, on Oct. 17, John Elliott, aged 26 years, a nail-caster, “Asiatic cholera (60 hours’ duration .” In Camberwell, a spinster, 21 years, “spasmodic cholera (7 hours' duration).” In same sub-district, a spinster, 25 years, “spasmodic cholera (11 hours' duration).” In same sub-district, widow of an Italian warehouseman, 42 years, “spasmodic cholera (13 hours’ duration)." In same sub-district, a widow, 45 years, “spasmodic cholera (40 hours’ duration).” The above 4 cases occurred in Peckham House Lunatic Asylum. In Chelsea South (sub-district), at White Hart-court, on Oct. 13, F. 46 years, soldier’s widow, “ cholera morbus (24 hours’ duration).” In same sub-district, and at the same house, on Oct. 16, a girl, 10 years, “cholera morbus (9 days’ duration), lever consecutive (7 days). Daughter of the above. In Islington West (sub-district), a labourer, 40 years, a pauper in Islington Workhouse, “ cholera Anglicu (1 month's duration), dysentery (7 days).” In St. Paul (sub-district), St. George-in-the-East, a girl, 10 years, “natural death by the visitation of God, viz., cholera (18 hours’ duration).” Inquest. In Limehouse (sub-district), Stepney, M. 25 years, “cholera biliosa, cerebral congestion.” In St. Saviour (sub-district), F. 15 years, “ansemia (4 months' duration), diarrhoea (2^ days), spasms and cramp (24 hours).” In Christchurch (sub-district), St. Saviour, son of a weaver, 5 years, “destitution, cholera (12 hours' duration).” In same sub-district, wife of a weaver, 36 years, “destitution, cholera (6 days' duration).'' In same sub-district, daughter of a weaver, 3^ years, “destitution, cholera (96 hours' duration).” In same sub-district, daughter of a weaver, 1^ years, “ destitution, cholera (34 hours' duration).” The above 4 cases occurred in Christchurch Workhouse; all members of one family. In same sub-district, 59, John-street, daughter of a tinman, 8 years, “ cholera (12 hours’ duration).’’ In the Leather Market sub-district, Bermondsey, at 27, I’age's-walk, on Oct. 17, M. 51 years, a cooper, “cholera spasmodica (135 hours' duration).” In same sub-district, and at the same house, on Oct. 15, F. 53 years, a cooper’s wife, “spasmodic cholera (46 hours’ duration).” In Kent-road (sub-district), St. George, Southwark, son of a haruess-maker, 21 months, at 5, Williams- place, “cholera morbus (6 hours’ duration).” In Lambeth Church, 2nd part (sub-district), a waiter, at 6r, Devonshire-street, aged 41 years, “cholera, accompanied with spasms, cramp, and hiccup ( attended 12 hours)-, disease existed 5 days.” In Battersea (sub-district), daughter of a carman at Nine Elms, aged 1 year and 8 months, “cholera (9 hours' duration) ” In Greenwich YVest (sub-district), in “ Dreadnought” hospital ship, M. 39 years, “bronchitis (4 weeks' duration), cholera.” In St. Paul. Deptford (sub-district), Greenwich, at Florence-road, on Oct. 16, M. 66. a carpenter, “Asiatic cholera (17 hours’ duration).” In St. George (sub-district), Camberwell, at 4, Thomas-street, Wyndhani-road, wife of a fish-vender, 58 years, “spasmodic cholera (15 hours' duration).” The term “ English” cholera is objectionable, as it implies that the disease is peculiar to England ; whereas it prevails, in nearly ttie same form, all over the world, and is described by Celsus and the ancient writers, as well as by Sydenham. For the sake of distinction, as it is so much under the control of temperature and season, it may be called “ Summer Cholera.” About half the fatal cases of Asiatic cholera terminate within 24 hours of the appearance of its characteristic symptoms: it will be shown here- after that the average duration of 19232 fatal cases in males was 2 *06 days, and of 20236 cases in females 2 ’ 10 days. The average duration of 4045 fatal cases of diarrhoea in males was i6’04 days, of 3851 females 16*69 days. The summer cholera has an intermediate duration of about five days. The difference is seen in the subjoined table of cases taken indiscriminately from the Returns of 1848 : more than half the cases of Asiatic cholera terminated in less than a day ; half the cases of summer cholera did not terminate in three days; and half the cases of diarrhoea lasted more than six days. This is a new and important element in the diagnosis. 1848. South Eastern and the Midland Divisions. xvii Duration of Fatal Cases of Diarrhoea, Summer Cholera, and Asiatic Cholera, in London, 1848. — Total Deaths. Under one Day. Number of Cases terminating in the several Days. I 2 3 4 5 6 7 8 Diarrhoea .... Il6 I I 8 l6 9 5 9 13 8 Summer Cholera . Il6 9 12 14 17 23 II 6 7 4 Asiatic Cholera 129 66 21 12 4 12 6 I 5 Number of Cases terminating in the several Days. 9 IO II 12 13 14 — 21 21 — 28 28—35 35 & up. Diarrhoea .... Il6 I 5 12 13 7 8 Summer Cholera . . 116 4 I . . 2 I 2 I 2 . . Asiatic Cholera . . . 129 I • • • * * * I * * CHOLERA IN THE COUNTRY, 1848. 2. South Eastern Division. — Deaths from cholera occurred in every month of 1848, except February; namely, 3 in January, 4 in March, and 2, 2, 5, 11, 15, 14, 18, 12, 2 2, in the subsequent nine months, making a total of 108 fatal attacks. Guild- ford and Kingston in Surrey, each furnished 2 deaths. In Kent 4 deaths took place at Bromley; 2 at Dartford ; in Gravesend 7; North Aylesford 3 ; Hoo 2; Medway (including Chatham) 13; Sevenoaks 3 ; Sheppev 4 ; and Eastry 2. In Sussex, there were in Uckfield 2 deaths; Cuckfield 5; and Brighton 3. In Hampshire, in the great naval station of Portsea Island and the adjoining district of Alverstoke there were 6 and IO deaths respectively; in the Isle of Wight 4; Stockbridge 2 ; Basingstoke 3 ; and Andover 2. In Berkshire, there were in Newbury 2. deaths; Wantage 2, Wal- lingford 2 ; Reading 3 ; and Windsor 2. 3. South Midland Division. — Cholera which was fatal in each month of the year 1848 was most prevalent after July, and destroyed 150 lives by the end of December. In January 1 death occurred; in February 2 ; and 1, 2, 5, 5, 8, 17, 12, 22, 31, and 44 respectively, in the subsequent months. I11 Middlesex 4 fatal cases took place at Staines ; at Uxbridge 10 ; Brentford 13 ; Hendon 8 ; and Edmonton 8. In Hertford- shire, Bishops Stortford furnished 3 deaths; Iloyston 3; Hertford 2; Watford 4; Hemel Hempstead 5 ; and Berkhampstead 3. In Buckinghamshire a remarkable mor- tality took place in the Amersham district, where cholera was fatal to 46 persons (population 18212 in 1841), 43 of whom died in the Chesham sub-district (which con- tained a population of 5811 in 1841); excepting 2 children who were attacked early in September, all the deaths occurred subsequent to November 10th : in many instances the attacks were of short duration. The following is an abstract of the deaths from cholera in the Chesham sub-district : — F. 2 years and 9 months, hawker’s daughter, named Hearn, “ cholera, (8 days’ duration),” Chesham September 14. > F. 10 months, labourer’s daughter, “ cholera (8 days’ duration),” Chesham, September 16. F. 62 years, miller’s widow, “cholera, (2 days’ duration)," Waterside, Chesham, November 11. M. 10 months, labourer’s son, “ cholera (1 day’s duration),” Waterside, Chesham, November 13. M. 1 year and 10 months, labourer's son, “cholera (2 days’ duration),” Waterside, Chesham, November 14. M. 1 year and 7 months, Hawker’s son, named Aris, “cholera (2 days’ duration),” Waterside, Chesham, November 14. F. 49 years, labourer’s wife, “cholera (28 hours’ duration)," Chesham, November 15. F. 3 years and 11 months, hawker’s daughter, named Aris, “cholera,” Waterside, Chesham, November 16. F. 29 years, brush-handle makers wife, “cholera (60 hours’ duration),’’ Waterside, Chesham, November 16. F. 55 years, labourer’s wife, “ cholera (12 hours' duration)," Waterside, Chesham, November 16. M. 8 years, “ cholera (38 hours’ duration)," Waterside, Chesham, November 18. M. 13, baker’s (deceased) son, “cholera (36 hours' duration),” Waterside, Chesham, November 18. F. 46 years, labourer’s wife, “ cholera (19 hours' duration),” Waterside, Chesham, November 18. c xviii 1848. The Eastern, South Western, and West Midland Divisions. M. 51 years, labourer, “ cholera (28 hours’ duration),’’ Waterside, Chesham, November 19. F. 49 years, gamekeeper’s widow, “cholera (26 hours’ duration),’’ Waterside, Chesham, November 20. F. 20 years, single woman, “ cholera (32 hours’ duration),” Waterside, Chesham, November 21. F. 28 years, single woman, “ cholera (15 hours' duration),’’ Waterside, Chesham, November 21. M. 69 years, labourer, “ cholera (4 days’ duration) ; relapse (8 days),’’ .Waterside, Chesham, December 2. F. 55 years, bricklayer’s widow, “cholera (20 hours’ duration),” Waterside, Chesham, December 3. M. 43 years, labourer, “ cholera (3 days' duration),” Waterside, Chesham, December 3. F. 60 years, labourer’s wife, “cholera (2 days’ duration); feverit(4 days),” Waterside, Chesham, December 4. F. 36 years, miller’s wife, “cholera (22 hours’ duration),” Waterside, Chesham, December 4. M. 8 years, labourer’s son, “ cholera ; fever (9 days’ duration),” Waterside, Chesham, December 5. F. 42 years, labourer’s widow, “ cholera (2 days’ duration),” Waterside, Chesham, December 6. M. 19 years, labourer’s (deceased) son, “ cholera (10 days’ duration),” Waterside, Chesham, Dec. 8. F. 1 year aud 7 mouths, labourer’s daughter, “ cholera (4 days' duration),” Waterside, Chesham, December ir. M. 1 year and 10 months, butcher’s son, “cholera (6 hours’ duration),” Chesham, December 11. M. 4 years, butcher’s sou, “cholera (n hours' duration),” Chesham, December 13. M. 4 years, shovel-makers son, “cholera (4 days’ duration)” Waterside, Chesham, December 14. F. 2 years, labourer’s daughter, “cholera (108 hours' duration),” Chesham, December 15. F. 76 years, widow, “cholera (46 hours’ duration),’’ Waterside, Chesham, December 16. M. 10 years, tailor’s son, “cholera (17 hours' duration),” Chesham, December 17. F. 8 years, sawyer’s daughter, “cholera (7^ hours’ duration),” Chesham, December 17. M. 11 years, paper-maker’s son, “cholera, relapse (8 days' duration),” Waterside, Chesham, December 19. M. 6 years, labourer’s son, “cholera, fever (5 days’ duration),” Chesham, December 19. F. 74 years, gardener's widow, “cholera (3 days' duration),” Chesham, December 20. M. 12 years, shovel-maker’s son, “ cholera (18 hours’ duration),” Chesham, December 21. M. 65 years, paper-maker, “cholera (22 hours’ duration).” Waterside, Chesham, December 21. F. 52 years, hawker's wife, named Moore, “cholera (8 hours’ duration),” Chesham, Dec. 25. F. 70 years, labourer’s wife, “cholera (42 hours’ duration),” Chesham, December 25. F. 56 years, labourer’s wife, “cholera (11 hours’ duration),” Chesham, December 28. F. 39 years, single woman, “cholera (24 hours’ duration),” Latimer, Chesham, December 29. M. 38 years, sawyer, “cholera (11 hours' duration),’’ Chesham, December 30. Iii Eton there were 2 deaths; in Aylesbury 8 ; and Newport Pagnell 2. In Oxford 2 fatal cases are recorded. In Northamptonshire there were 2 deaths in Towcester; Northampton 2; Wellingborough 6; Oundle 2; Peterborough 3: In Huntingdon 3 deaths took place. In Bedfordshire 2 deaths occurred in Bedford; 5 in Biggleswade ; 2 in Ampthill ; and 2 in Leighton Buzzard. In Cambridgeshire, Chesterton fur- nished 2 deaths; Cambridge 6; Newmarket 8; Ely 6; North Witchford 3 ; and Wisbeach 18; of which 15 took place in the Upwell sub-district, where the epidemic commenced on November 25th, and prevailed throughout December amongst labourers: 13 of the 1 5 deaths were of males, most of them in the prime of life, aud in no instance is the duration of the attack stated to have exceeded 30 hours. 4. Eastern Division. — Cholera was fatal to 65 persons in 1848, and deaths occurred during every month of the year, viz., 3 in January, and 1, 1, 3, 4, 2, 3, 5, 9, 14, 6, 14, respectively in the subsequent months. In Essex 6 of the deaths occurred in West Ilam ; 2 in Romford; 2 in Orset ; 4 in Chelmsford ; 2 in Tendring; and 2 iu Saffron Walden. In Suffolk 2 deaths took place in Thingoe; 2 in Samford ; 3 in Wood- bridge ; 2 in Blything ; and 5 in Mutford. In Norfolk 2 deaths happened in Tuns- stead ; 2 in Aylsham; 4 in Norwich; 3 in Mitford; 4 in Kings Lynn; 4 in Down- ham; 2 in Depwade ; and 2 in Docking. 5. South VVestern Division. — There were 68 deaths from cholera in 1848; and February was the only month during which no fatal case was recorded : 1 death took place in January; 1 in March, and 1, 2, 2, 7, 6, 20, 1 1, 9, 8, in the subsequent months. 2 deaths occurred at Pewsey, in Wiltshire. In Devonshire it was most fatal at Plymouth, where 15 persons died of the disease, 3 of them being female convicts on board the “Cadet,” on Nov. 23rd, 26th, and Dec. 7th respectively: 3 fatal cases happened at East Slonehouse, adjoining Plymouth, and 1 in Stoke Damerel; St. Thomas furnished 2 cases; Exeter 3; Kingsbridge 2; Plympton St. Mary 2; Tavis- tock 2; and Bideford 2. In Cornwall cholera was fatal to 12 persons in Penzance, chiefly in miners’ and mariners’ families, and during the autumn ; at Redruth 5 deaths occurred. In Somersetshire 3 deaths took place in Wells and 2 in Bath. 6. West Midland Division. — The number of deaths from cholera was 101 in 1848. North Midland, North Western, York, and Northern Divisions, xix 1848, distributed over every month; there were 5 fatal cases in January, and 1, 1, 6, 4, 4, 6, 26, 1 6, 11, 11, 10, in the succeeding months. In Gloucestershire 4 deaths happened at Bristol; 2 in Clifton; 2 in Stow-nn-the-Wold, and 2 in Cheltenham. 3 cases occurred at Clun, in Shropshire. In Staffordshire it was fatal to 2 persons at Stone; at Stoke-upon-Trent to 4; Cheadle 3; Uttoxeter 4; Penkridge 2; West Bromwich 3, and Dudley 6. In Worcestershire 4 deaths happened in Stourbridge and 3 in Kings Norton. In Warwickshire, Birmingham furnished 10, and Aston 8 fatal cases (the number of deaths which occurred at these places in 1849 was — in Birming- ham 29, and Aston 6). In Foleshill there were 2 deaths; Rugby 3; Warwick 6, Alcester 2 ; and Shipston-on-Stour 4. 7. North Midland Division. — Cholera was fatal in 85 cases during 1848, there being in January 4 deaths, and 3, 1, 3, 2, 3, 15, 10, 4, 11, 16, 13, in the subsequent 11 months. In Leicestershire 4 deaths happened in Lutterworth ; 3 in Blaby ; 3 in Loughborough ; and 5 in Leicester. In Lincolnshire there were in Bourn 3 deaths ; in Boston 2 ; Horncastle 3 ; Spilsby 5 ; Caistor 10: of which 5 took place at Great Grimsby on the coast, and 5 at Market Rasen in the interior ; in Glandford Brig 3 ; and in Gainsborough, on the River Trent 13. In Nottinghamshire 2 deaths took place in East Retford ; 3 in Basford, and 3 in Newark. In Derbyshire 5 fatal cases occurred in Derby ; 2 in Ashborne, and 2 in Bakewell. 8. North Western Division.' — Cholera was prevalent in this division in 1848, it having been fatal in 227 cases, chiefly in the latter half of the year. The number of deaths in each month was, in January 3 ; and in each of the succeeding months, 2, 7,7, 10, 7, 52, 41, 31, 35, 12, 20, respectively. In Cheshire it was fatal to 7 persons in Stockport; 10 in Macclesfield; 2 in Altrincham; 4 in Northwich on the River Weaver; 8 in Wirrall, situated on the coast, and including the town of Birkenhead ; and 5 in Great Boughton, including Chester on the River Dee. In Lancashire the districts on the coast in which cholera was chiefly fatal were, Liverpool 33 deaths; West Derby 16 ; Ormskirk 2 ; Ulverston 2 ; and Preston oit the Ribble 2. Also, in Prescot 2 ; Wigan 4 ; Leigh 5 ; Bolton 10 ; Bury 9 ; Chorlton 2 2 ; Salford 7 ; Man- chester 21 ; Ashton 18; Oldham 8; Rochdale 6 ; Haslingden 4; Burnley 2 ; Black- burn 12, and Chorley 3. 9. York Division. — Cholera, which was prevalent in the early part of the year 1848, increased perceptibly after June, and by the end of the year caused the deaths of 207 persons. There were in January 5 fatal cases, and 2, 8, 6, 6, 4, 24, 25, 33, 49, 24, 21, in the following 11 months. Of the districts bordering on the coast there were in Hull 20 deaths; Scnlcoates 8 ; Scarborough 4; Skirlaugh 3; and Patrington 2. York furnished 14 cases ; Selby 6, of which 4 were quickly fatal, viz., in 12 hours, 12 hours, 16 hours, and 24 hours respectively; Settle 2; Pateley Bridge 3; Otley 6; Keighley 4; Todmorden 6; Saddleworth 7; Huddersfield 7; Halifax 8; Bradford 28 ; Hunslet 12 ; Leeds 6 ; Dewsbury 15 ; Wakefield 5 ; Pontefract 7 ; Ecclesfield 4 ; Wortley 2 ; Sheffield 3 ; Doncaster 3 ; Driffield 6; Maldon 4; and Whitby 2. 10. Northern Division. — With the exception of March and May cholera pre- vailed during each month of the year 1848, and was fatal to 163 persons, viz., in January 4; February 1 ; April 2 ; June 5 ; and 7, 12, 10, 17, 3 6, 69, in the subse- quent 6 months. Cholera appeared at Sunderland in an epidemic form on October 4th, and was fatal to a mariner aged 56 on board the ship “ Valiant,” after an attack of 9 hours’ duration ; he is represented as having been drunk on the previous day. On October 12th the next death took place; it was followed by two others on October 14th ; from this time its prevalence increased, and it was chiefly fatal among coal-miners and mariners : the duration of most of the attacks was short, and varied from 6 hours to 3 days. The last death was that of a coal-miner’s son, aged 1 year, on December 26th, at the colliery Monkwearmouth, where 20 fatal cases occurred out of the 37 deaths from cholera registered in the Sunderland district. In South Shields there were 7 deaths ; in Stockton 8 ; Darlington 2 ; Teesdale 2 ; Durham 5 ; and Gateshead 3. In Northumberland cholera was most fatal in the districts on the coast ; it destroyed 32 lives at Tynemouth, commencing on October 3rd in a keelman’s daughter, aged 1, c 2 XX 1849. Cholera in England. at Skipsey’s Quale, North Shields; 3 other cases were fatal in October. In November its prevalence increased, and it became very fatal among keelmen at Quay Cowpen, and mariners and others at Blyth ; instances are recorded of 2 persons in the same family dying. The epidemic continued fatal up to the end of the year; 3 deaths occurred on December 30th, two of which were in the children of a keelman at Quay Cowpen, after attacks of 14 hours’ and 22 hours’ duration. In Newcastle-upon-Tyne cholera was fatal to 12 persons, chiefly in the latter part of the year. In Berwick- upon-Tweed the epidemic was first fatal on December 7th, in a labourer’s widow, aged 79, at Hutts Norham. It continued prevalent throughout December, mostly among fishermen, labourers, and quarrymen : 3 deaths occurred at the workhouse, Berwick ; 6 at Donaldson’s Lodge, Cornhill ; and 4 at Hutts Norham: the total deaths in the district were 19. Morpeth furnished 9 deaths; Castle Ward 3. In Cumberland cholera was chiefly confined to the following districts, viz. : — Brampton 2 deaths; Longtown 3 ; Carlisle 4; Cockermouth 5; and Whitehaven 5. 11. Welsh Division. — Cholera was not fatal until April 1848, when one death took place, and 5, 4, 4, 5, 4, 6, 4, 8, in the subsequent 8 months, making 41 deaths during the year. In South Wales, on the coast, there were in Cardiff 7 deaths; Swan- sea 2 ; and Haverfordwest 2. Also in Merthyr Tydfll 3; and Abergavenny 2. In North Wales, Holywell had 5 deaths; Newtown 2; Wrexham 2; Carnarvon 4; and Anglesey 3. The deaths from cholera in England were 41 in the week ending October 7 ; and 78, 99, 88, 1 12, in the 4 weeks following; the numbers varying little in the subsequent weeks, were 91, 89,82,71, 84,97, 85> 88. The total number during the year was 1934. Such was the course of the epidemic cholera in England to the close of the year 1848. CHOLERA IN ENGLAND, 1849. 1849. The tables, pp. 20-107, and the notes, pp. 166-300, show the progress of cholera through the year 1849. The state of the public health was described in the quarterly and weekly returns; and it is now possible, from all these sources, comprising facts recorded and observations written at the time, to trace the effects of the epidemic, and the extent of its ravages through the year. The deaths in England from cholera were, in January, 658; in February, 371 ; in March, 302 : yet, it was remarked, in the quarterly return, “ although epidemic cholera has been in England since October, 1848, and has prevailed more or less up to the present time in parts of the country, the general mortality has been and is considerably below the average. This is encouraging, and should stimulate all sanatory improve- ments, for summer is the season in which the epidemic is most to he dreaded.* The deaths from cholera in London were 292 in January, 180 in February, 40 in March. It will be recollected that in October 1848, the epidemic attacked the convicts crowded in the decaying “ Justitia” hulk, lying off the Royal Arsenal wharf, Woolwich, in the immediate vicinity of a common sewer ; subsequently it was fatal to convicts in Millbank Prison and to lunatics in thePeckham House Asylum ; the registrars stated that many of the houses in which patients were attacked were crowded, and in dirty un- drained sites. In the last week of December the epidemic broke out in Mr. Drouet’s Infant Poor Establishment, Surrey Hall, Tooting, where 48 of the 61 deaths registered from cholera in the first week of January occurred. In the week following 69 deaths from cholera were registered at the same establishment. It is stated in a note to the Weekly Return (January 20th 1849), that “ the total deaths which have occurred in the institu- tion, or amongst children who have been removed from it since the appearance of the epidemic, amount to 182, of which 155 were returned as caused by cholera.” The children at ages from 4 to 14, were paupers fanned out, and the building was over- crowded. In the week following 13 persons died of the epidemic cholera in the Holborn Union workhouse, where a few more cases occurred in the subsequent week. Some of the children of this Union were in Drouet’s Establishment. Several of the children belonging to Pancras were removed and died in the workhouse, Camden Town. Mr. Quarterly Return, No. I, pp. 4, 5, 1849. XXI 1849. Progress of Cholera. Holl, after stating that “ three children who died in the workhouse had been brought from Tooting while under the influence of the disease,” adds: — “ The woman, aged 64, died in the infirmary of the workhouse quite unconnected with that part of the house which the children occupied, and not allowed to have any communication with it.” * Mr. Steib, the registrar of Hackney, registered two deaths from cholera in the same week. “ The former was a decided case of Asiatic cholera in a servant who belonged to the Islington poor-house, and had been brought to Hackney to nurse the sick children. The second was in a girl belonging to the Islington poor-house, who had been brought to Hackney from Drouet’s Asylum, Tooting.” In the week ending February 3rd, 9 out of 10 cases registered in Kensington town occurred in Jennings’ Buildings. In the week ending February 24th, the deaths of the matron, the temporary matron, seven servants, and a girl aged 11, were registered at the Female Refuge for the Destitute, in St. Leonards, Shoreditch; and, in the same week, 16 deaths from cholera were registered in Warburton’s Lunatic Asylum. A great number, then, of the deaths from cholera in the early stage of the epidemic occurred in institutions of various kinds. The work- house of Edmonton and the gaol of Hertford were attacked in January. Two parishes in Norfolk were attacked early in the year. A labourer’s wife, aged 48, died of the disease on January 5 th, at West Rudliam, where four more persons died, and 12 in East Rudham, before February 14th. Eleven of the 17 deaths were in labourers’ families. The parishes are inland, and contained 1 494 inhabitants in 1841. No other deaths from cholera occurred there. At Wakefield, in Yorkshire, there w'as a partial outbreak ; 1 9 deaths from cholera happened between the 9th and 24th of January, 16 of them in the House of Correction. In August the epidemic recurred in this house, and 86 deaths from cholera, 36 from diarrhoea, took place in the year. The epidemic, which began at Selby in the latter part of 1848, prevailed until February 5th, and was fatal to some persons at Goole. In the Union workhouse of Howden, cholera was fatal to 10 persons between January 5th and February nth. The epidemic was fatal at Gateshead in January and February ; at Sunderland in March and April. The epidemic continued to prevail in Berwick-upon-Tweed; at Shore- houses, Spittal, a fisherman, his wife, and three children died of the disease between January 6th and 12th. In April the epidemic very much subsided, and only 107 deaths were referred to cholera in England. There were no deaths from the disease upon the 8th, 14th, and 26th ; the only days which enjoyed this exemption in the year. There were in the month only 9 deaths from cholera in London, and the mortality was chiefly in the north-western and northern divisions of England. In May the deaths from cholera were 327 ; the fatal period of the epidemic set in at Liverpool, and went on through June, when the deaths were 2046 in all England- South Wales was now suffering, and at the end of June the deaths from cholera rapidly increased in London. Some alarm was felt, but, practically, little progress was made in the sanatory defences of the country. This was adverted to in the Quarterly Return as well as the mortality which the epidemic might cause : — “ The epidemic cholera, which reached England in October, 1848, and is now causing many deaths in London, Liverpool, and other places, will, it is true, increase the general mortality in the months of July, August, and September as it did before; but the ravages of cholera, of typhus, and of the insidious influenza, which threaten the country, may be greatly mitigated if the same talent and energy are applied to the im- provement of the public health, as have been applied to other great undertakings in which England has engaged. “ Registration did not exist in 1832; hut it appears from the returns then made to the Board of Health, that in London 994 persons died of cholera in the first part of the epidemic, extending from February 14 to May 15, 1832; 4266 in the second part, extending from June 15 to October 31; and 15 in November and December. Allowing for defective returns in 1832, it is not probable that the fatality of cholera will be greater in 1849 than it was then ; or that the danger will amount to more than * Notes to Weekly Table, January 20th, 1849. xxii 1849. Progress and Decline of Cholera. this, that for a few weeks an inhabitant of London will incur the same chance of dying in one week as he usually incurs in two or three weeks.” — Report for Quarter ending June 30 th, 1849. The epidemic broke out at Gloucester in May; two cases were fatal on May 8th, in the sub-district of St. Nicholas. The disease spread, and continued through the following months ; the last death occurred on November nth. In the Union work- house at Keynsham, which lies between Bristol and Bath, an agricultural labourer died on May 5th of a diarrhoea, said to be of 4 weeks' duration ; on the same day a labourer, aged 32, died of cholera after 12 hours’ illness. Between May 6th and May I2th, 9 more paupers died in the Union workhouse. On May nth a solicitor in Keynsham died: the disease then attacked the other inhabitants of the place, and was fatal to 56 persons in May and June, 13 of whom died in the Union workhouse. Clifton and Bristol were attacked in June, the first case occurring at Bristol on June 1st. Cardiff, on the other side of the Bristol Channel, was attacked in May, and Merthyr Tydfil very fatally in June, a few cases only having happened in two sub-districts in May. The deaths from cholera in Liverpool were 18 in March, 19 in April, 96 in May, and 424 in June; in West Derby 6 in May, 92 in June. In Sunderland the deaths which had been 133 in March were 12 in April, o in May, 1 in June. Durham experienced the highest mortality in June ; the deaths from cholera were 3 in March, 2 in April, 15 in May, 75 in June, 31 in July, 8 in August. In the summer, the epidemic advanced rapidly ; and in all England cholera was fatal to 7570 persons in July, 15872 in August, and 20379 in September; or dividing the quarter into weeks, the deaths in the 13 weeks from the 27th to the 39th inclusive, were 822, 1535, 2202, 2164, 2565, 2959, 4092, 3921, 4691,7148,5444,3458,311(1 2724. The mortality was highest in the 36th week of the year, when cholera alone de- stroyed 7148 !i\es. On Wednesday, September 5th, it was fatal to 1120, on Thursday, September 6th, to 1121 persons. On these two days the epidemic was at its highest point. The deaths on August 31st were 570 ; the increase in September was remark- able: the deaths on Saturday, September 1st, were 739, and on the 9 days following 866, 888, 969, 1120, 1121, 1000, 992, 1058, 891. The fatality of the disease sensibly decreased on September nth; on that and the 9 following days the deaths were 792, 793, 876, 731, 717, 644, 615, 604, 554, and 471, gradually subsiding to 380 on the last dav of the month. The epidemic was at its maximum on August nth in Wales, on September 4th in London, on September 5th— 6th in the West-Midland, the Nortu- Western, and York divisions, on September 1 4th— 1 5 th in the Northern division. The decline of the epi lemic was more rapid than its increase; while it was fatal to 2°379 persons in September, 4654 died of it in October, 844 in November, and 163 in December. The mortality in October was chiefly in the South-Western, Wfst- Midland, North-Western, York and Northern divisions; in London, the South- Eastern, the Eastern, the North-Midland and Welsh divisions, the mortality was much less considerable: while 54 deaths from cholera occurred in England on the last, day of October, 11 occurred on the last day of November; and on the last day of December 2 persons died, one in Shropshire, and one in Durham. Diarrhoea was more fatal than cholera in the months of January, February, March, April, and May ; in June the mortality from cholera was twice as great as the mortality from diarrhoea; in July, August, and September the mortality from diarrhoea and cholera increased ; but the mortality from cholera became fourfold that from diarrhoea; in October it was only twice as great; in November the deaths from diarrhoea exceeded in number the deaths from cholera, and in December the deaths from diarrhoea were 592, from cholera 163. The annexed table (p. xxiii) exhibits the deaths in each month from the two forms of disease. Many of the cases of diarrhoea were such ordinary cases as every year occur ; but diarrhoea is one of the earliest and most common symptoms of cholera, and many cases differed only from cholera in the absence of “spasms,” or of some of the striking rather than the essential symptoms. 12045 of the 18887 deaths referred to diarrhoea were in children under 5 years of age; and the symptoms of cholera as well as of other diseases at that early age undergo considerable modification. The London Cholera Field , 1849. xxiii Deaths from Cholera and Diarrhoea in England, in eacli Month of the Year 1849. Jan. Feb. March. April. May. June. July. August. Sept. Oct. Nov. Dec. Cholera . 658 371 302 107 327 2046 75 70 15872 20379 4654 844 163 Diarrhoea . 810 698 00 O r>. 666 721 926 2124 3599 4928 2244 871 592 Cholera &) Diarrhoea/ 1468 1069 IOIO 773 1048 2972 9694 19471 25307 6898 1715 755 THE LONDON CHOLERA FIELD, 1849. The distribution of the epidemic over the country may now be shown. London was the centre of a great system of attack which extended to Hertford and Hitchin, West Ham, Romford and Rochford on the north side of the Thames ; to Dartford and Graves- end, Margate and Ramsgate, Dover, Croydon and Brighton, in Kent and Sussex. The disease, like a smouldering fire, broke out as the temperature advanced in London. The return for the week ending May 12th “ indicated a continued tendency in the public health to improve. The deaths from all causes were 905, or 58 less than the average; the deaths in the week following were 1033; the wind was S.W., rain fell to the extent of *67 inches, and the mean temperature of the air was 54°* 9, which is 2° ’6 above the mean temperature of the week. In all London, only one little girl, aged 5 years, died of cholera in 6 hours.”* In the week ending May 26th, the deaths in London were only 897. “ The deaths are fewer than in the corresponding week of any former year since 1846.” Three women, however, died of cholera; one in St. John, Westminster; one a milliner in a large house of business (246 Regent-street); and one, a tailor’s wife, at the German Hospital, Dalston. Two children died of choleraic diarrhcea. The temperature was 56°'9, or i0,9 above the average ; the fall of rain was 1 *37 inches. In the week ending June 2nd, 895 deaths were registered; 9 from cholera. The mean temperature of the air was now 6oD’3, of the Thames water 63° • 5. The fall of rain was i"6 inches; the wind sluggish N. and S.W. Negative electricity was exhibited during heavy rain on Monday ; positive on Friday and Saturday. The deaths from all causes were 971 ; and 22 were by cholera in the week ending June 9th. The mean temperature of the air was 59°' 7 ; the temperature of the Thames was 6 50 • 7 . 1- The deaths in the week ending June 16th were 912, which is less than the average number; while the deaths in the tubercular class, diseases of the nervous system, and diseases of the respiratory organs declined, zymotic diseases increased ; and cholera was fatal to 42 persons. The temperature of the air was low, 53°’ 5 ; of the Thames 62°. The deaths in the next week were 985, only 22 above the corrected average; 49 were from cholera. The temperature of the air was 590' 2 ; of the Thames 62°. In the week ending June 30th, 1217 deaths were registered ; 124 by cholera. The cholera was by far the most prevalent on the south side of the Thames. The tem- perature of the air in the beginning of the week was much above the average; the temperature of the Thames was 66° ’6 during the week. The deaths in the week ending July 7th were only 1070; but cholera increased, and the deaths which it caused were 152. The mean temparature of the air was 62°’ 7 ; on Saturday the thermometer reached 82° in the shade, I03°’ 5 in the sun. In the second week of July, the mortality first rose sensibly above the average ; the deaths were 1369; and the increase was referrible to cholera, which was the cause of 339 deaths; 102 deaths of children under 15 jears of age, 192 adults of 15 and * The number of deaths cited in the weekly tables of London invariably refer to the deaths registered in the week. The deaths are registered at a certain interval after their occurrence ; consequently the deaths registered in a week are not all deaths that occur in the week. The deaths occurring on every day are given in the subsequent tables. XXIV The London Cholera Field. under 60, and 45 of aged persons. The northern districts suffered least, the southern most. The air was stagnant, and the wind in the N.N.E. ; the sky was cloudless, and no rain fell. The mean temperature of the air was 66° • 8 ; of the Thames 68° • 7 . The mortality increased, and the deaths from all causes were 1741 in the third week of July ; 678 of the deaths were by cholera, 1 31 by diarrhoea. The high north districts still enjoyed comparative immunity (7 deaths from cholera) ; the hottest attack was directed to the south side of the Thames, where 443 of the deaths occurred. Poplar, in the east, suffered severely ; 37 deaths from cholera were returned. The mean tem- perature of the week fell to 6o°*5 ; the winds were stirring, the sky was overcast, lightning flashes were seen on the 19th and 20th; the thunder was followed by showers and heavy rain. July 22nd to July 28. “ Again the return indicates an increase on the excessive mortality of the previous week. The deaths from all causes rose to 1931 ; a num- ber which is almost double the weekly average, and exceeds that of the previous week by nearly 200. Influenza in 1847 raised the mortality more rapidly; the deaths from all causes, in the first 4 weeks of that epidemic, were 1086, 1677, 2454, and 2416; while, in the 4 first weeks of the cholera epidemic, the deaths Irom all causes have been 1070, 1369, 1741, and 1931. The deaths from cholera are 783, from diarrhoea 224. The districts on the south side of the river still form the field on which the disease is most active. There is a slight decrease in the eastern districts.” In the whole of the western and northern districts the deaths are only 68. Cholera is, for the first time, more fatal to females than to males; the deaths having been 383 males, 401 females. The mean temperature is 58°' 9 ; the fall of rain in the week is 2°’ 1 5 inches. The wind is S.W., and moves at a rate of about 100 miles a-day. On the afternoon of the 26th a violent thunder-storm occurred, the flashes of lightning were vivid and in quick suc- cession, followed by loud thunder at intervals of 15 to 20 seconds generally. Rain was falling heavily during the storm. July 29 to August 4th. The deaths registered from all causes are 1967, from cholera 926. Diarrhoea has decreased ; it is the cause of 179 deaths. “ Other epidemics are under the average, except hooping-cough, which a little exceeds it.” The epidemic is still chiefly on the south side of the Thames, where 621 of the 926 deaths occurred. The temperature of the air (59°* 5) still remains below the average. The mortality from all causes increased little ; and, in the week following, the mortality from cholera declined. The people generally were ready to believe that the epidemic was giving way; and the efforts which had been commenced without much vigour, and with little confidence in their efficacy by the local authorities, were sus- pended. Looking at the course of the epidemic in 1832, at the preceding low and now high temperature, at the field of operations which had hitherto been very much confined to the south side of the river, and were now extended to the north, it was evident that the danger was increasing, and that more active exertions were required. The registrars were requested to extend their returns; and the weekly tables were accompanied by such observations as, in the emergency, appeared likely to be useful and to save life. The following extracts from the Weekly Tables exhibit the progress and effects of the epidemic at its height: — Auanst ^th-Xlth. — The deaths in London during the week ending Saturday, August nth, are 1909. The mortality it somewhat less than it was in the previous week. The deaths from all causes in the last six weeks were 10,0. 1569, 1741, 1931, 1967, and 1909; of which 393, 630, 1002, 1173, 1308, and 1185, were by diseases of the zymotic class. Small-pox, scarlatina, and hooping-cough are comparatively quiescent ; typhus is more fatal than it was. The excess of 901 deaths over the average is due to diarrhoea and cholera, which were fatal to 173 and 823 persons. The deaths from cholera during the last six weeks were 152, 339, 678, 783, 926, and 823. The decrease is gratifying; but it is right to observe that the improvement is chiefly confined to West Loudon, Poplar, St. George Southwark, Newington, Camberwell, and Lambeth. The deaths from cholera in the two last weeks were 29 and 48 in Wandsworth ; 9 and 21 in I’aucras; 4 and 14 in Islington; 3 and 10 in London City; 16 and 35 in Bethnal Green; 15 and 35 in St. Giles. The deaths from all causes on the north side of the Thames (1118) were 89 more than the deaths (1029) of the previous week. The parishes which have not yet been visited must be on their guard. Those in which the epidemic has partially subsided should redouble their precautions. The epidemic of 1832 broke out in three successive eruptions; the first commencing in February, was at its maximum in XXV London Weekly Reports , 1849. April and subsided ; the second rose rapidly from June to July, and sunk again down to the second week of August; its course was very much like that pursued by the present epidemic. The deaths returned by the parish clerks in the three weeks from July 17 to August 7, in 1832, were 968, 793, 661 ; which, allowing for the defects in their returns and for increase of population, are equivalent to 2323, 1903, 1586, or 5812 deaths in 1849, when the deaths registered in the corresponding weeks were 1931, 1967, 1909, or 5807 in the three weeks July 21st to August nth. A third eruption in 1832 broke out at the end of August, and extended to the first weeks of September ; a fourth in 1833. ft is satisfactory to find that the deaths of 819 out of the 823 persons who died last week of cholera are certified. They were seen by qualified medical attendants. But it is to be feared that the advice was not obtained in time. The accounts of the sudden stoppage of the epidemic by prompt medical treatment and the house-to-house visitation are perhaps over-coloured. But a mortality as high now as in 1832 should not take place: it may be prevented by improvements in the treatment — by arresting the premoni- tory symptoms — by still earlier attention to the general health. Medical men are called when the people are dying; but it is then too late. If the families of the middle and higher classes were seen at intervals during the epidemic by their medical attendants, and a corps of medical officers employed by the Guardians to visit the poor at short intervals, the present epidemic might very probably be cut short, and a third eruption be averted. The precise locality in which almost every victim of cholera lived is given in the present return under each district; would it not be practicable for the authorities to have all these and the neighbouring localities inspected ? If this were done, and proper precautions taken, the tragedy of Albion-terrace, Wandsworth-road, where 17 persons died in two weeks in ten houses, could scarcely recur. The particulars of the 17 deaths will be found in the notes under Wandsworth and Clapham. Another case appears this week in the note under Hampstead. In the house, No. 6, Albion-terrace, Wandsworth, 5 deaths had been registered — a Wesleyan minister’s wife, aged 59 ; his mother, 80 ; a widow, 49 ; and two old servants. This is all we learn from the Clapham Registrar. The Registrar of Hampstead adds, that, during the week, an aged man came with a friend to Hampstead for change of air, — breakfasted, dined, went to London to transact business at the Bank of England, and after his return seemed “ pretty well.” At six o’clock the next morning he felt ill, and had medical advice, but died in eight hours. This old minister was apparently the last of his family, for he had seen his mother, wife, and servants die before him in Albion-terrace, and could not fly from the poison which he carried in his breast. Such desolation could scarcely happen without great negligence on the part of the people them- selves and on the part of the authorities. August l2tli-if>tli. — It is one of the characters of epidemic diseases, that in some years their fatality is inconsiderable, in other years excessive. Since 1832 and 1833, cases of cholera have appeared in the Tables, — but the deaths in the second week of August during the past five years have fluctuated from 1 to 23. In the week ending Saturday, August 1 8th, the deaths in London were 2230; of which 1230 were by cholera, 188 by diarrhoea. The deaths from all causes in the last seven weeks were 1070, 1369, 1741, 1931, 1967, 1909, and 2230; the deaths from cholera, 152, 339, 678, 783, 926, 823, and 1230. The deaths from cholera exceed those in the previous week by 407; but in that week the mortality declined. The population is about 2,206,000 ; so that nearly 1 in rooo of the inhabitants now die weekly. The deaths from all diseases, except cholera, are 1000, which is the average number of the season; and 539 were at ages under 15, 256 at the ages 15-60, 205 at the age of 60 and upwards. Of the 1230 persons who died from cholera, 318 were under the age of 15, 721 were 15-60, and 191 were 60 and upwards : it carries off an excessive proportion of people in the prime of life. 597 males and 633 females died of the disease last week ; at an earlier period of the epidemic, the deaths of males exceeded those of females. Of 6194 persons who have died of cholera in London since September 1848, 3524 have died on the south side of the Thames. It has now crossed the River. The mortality last week increased in the districts of St. George Southwark, Newington, and Lambeth : it broke out with extraordinary violence in Greenwich ; and on the north side of the Thames — in Stepney, Shoreditch, and Bethnal Green — 55,98, and 125 deaths were registered. The deaths from cholera in the last two weeks were 35 and 125 in Bethnal Green, 21 and 98 in Shoreditch, 24 and 55 in Stepney, 42 and 76 in the districts of the East, West, and City of London, comprehending the jurisdiction of the City properly so called, 7 and 24 in Marylebone, 1 7 and 34 in Westminster district, 5 and 20 in Chelsea. This excessive mortality must be viewed with great regret. Looking to the authentic reports of the effects of general sanatory measures, and of efficient medical relief placed within the reach, or carried to the homes of the people, it is quite evident that the measures now in operation are unequal to the emer- gency. The classes which have the greatest claim for public succour are not idle, habitual paupers, but tiie hard-working artizan : yet it is stated that in some parishes the arrangements are such that medical relief is not procurable directly from the district medical officers, who are, to the utmost extent of their powers, discharging their painful duties with praiseworthy diligence and humanity. In a disease which so often attacks in the night, and is fatal in twenty-four hours, the poor have to procure orders before they can be treated. Unless some change be made in these simple administrative arrangements, the mortality from cholera may be higher than it has yet been in London. To render all the assistance which the registration system can afford for the discovery and removal of the causes of cholera, the Registrars were last week requested to state in each case — “ whether the house or street in which the death occurred was close, ill cleansed, over-crowded, or otherwise unfavourable to health.” The results will be found in the Notes [to the Weekly Table], which show, besides, the sex, age, profession, duration of disease, date and place of death — in every fatal case of cholera and of diarrhoea registered during the week. August iqth-25th. — In the week ending Saturday, August 25th, the deaths registered in London were XXVI 1849. London Weekly Reports. 2456 ; of which 1272 were by cholera, 240 by diarrhoea. The deaths from all causes in each of the last eight weeks were 1070, 1369, 1741, 1931, 1967, 1909, 2230, 2456; rhe deaths from cholera 152, 339, 678, 783, 926, 823, 1229, and 1272. Although the number of deaths last week is greater than any number yet recorded, it is gratifying to learn that active measures are now in actual operation, or commencing in every district, to combat the great epidemic which has already destroyed 7466 lives in London. The energy with which parts of our institutions work makes the defects of the rest more evident. On August 9th last, a man was murdered in Bermondsey, and before his death, reported by the coroner, will appear in these returns, one— and it is probable both the persons charged with the murder will be in custody. Steam-ships, the electric telegraph, the heads of the police, and professional agents, specially chosen, were all employed to arrest the destroyers of this life; the columns of the newspapers were tilled with the details of the death. On the same day a stock-broker died at No. 12, Albion-terrace, Wands- worth-road ; a widow lady, and an old domestic servant at No. 6 ; in the five preceding days, in the same terrace, the daughter of a grocer, a child of 5 years of age, had died at No. 1 ; the willow of a coach- proprietor, and a commercial clerk, at No. 2 ; a gentleman’s widow at No. 3 ; a surgeon’s daughter at No. 4 ; a spinster of 4: at No. 5 ; the wife of a dissenting minister, his mother, a widow lady, and a servant at No. 6; a young woman of 2t at No. 10; a gentleman at No. 12, where the stock-broker died; a commercial clerk and a young woman of 19 at No. 13, where a young woman also died on July 28th; a gentleman’s wife at No. 14, who had seen her daughter die there the day before. The 19 persons died of cholera, many of the inhabitants of the Terrace were dispersed ; and the deaths of several have been registered elsewhere. “It appears,” says the Registrar, Mr. Frost, “that at No. 13, where the first death occurred, and where 2 deaths were afterwards registered, the refuse of the house had been allowed to accumulate in one of the vaults (which is a very large one) for about two years, and when removed last week, the stench was almost intolerable, there being about two feet of wet soil, covered with maggots. The drains also had burst, overflowed into the tank, and impregnated the water with which the houses were supplied. On the back ground, in the distance, was an open ditch, into which nearly the whole of the soil of Clapham runs.” As turpentine to flames, so is the exhalation of such cellars, tanks, and sewers, to cholera; it broke out — it diffused itself rapidly — it attacked many; and 19 inhabitants — after some hours of suffering, sickness, and spasms — expired. The effects of decomposing refuse and water on health were well known — these fatal subsidies to cholera had been heard of every day; yet no steps had been taken for their removal from Albion-terrace in July — no medical police had interfered to disturb the contents of Mr. Biddle’s cellar — and now the 19 masters, servants, parents, children rest in their graves, it appears to be taken for granted that blame attaches to nobody — to nothing — not to the householders themselves — to the Guardians of the district — to the institutions of the country 1 Such mean inanimate instruments of death can be invested with nr. dramatic interest ; but fixing otu eyes on the victims, it is well worth considering whether substantially it is not as much a part of the sound policy of the country that lives like those in Albion-terrace should be saved, as that the murderers of the man in Bermondsey should be hanged. The revelations of the state of their districts in the Registrars’ notes of this and last week prove that it will be no easy task — not to stay the plague of cholera for it will subside — but to remove the evils which make cholera and all epidemics fatal. The vast task of the physical amelioration of the population demands the energies of the best men in Her Majesty's dominions. When, in the country from which Asiatic cholera came, our armies seemed for a moment worsted, and the empire threatened, the great captain of the age is reported to have addressed to another the memorable words, “ If you do not go I must.” That enemy was distant. We have one now very near, in our streets, of which cholera, a servile minister, has destroyed already 7466 lives in London, and thousands mme in the rest of the kingdom. Who will go out against this enemy ? Is it too powerful or too feeble for the arm of the greatest? W ill no glory crown its conquest? Is the country insensible to its magnitude? Will not all the national strength and resources be put forth to improve the hygienic condition of the people, and to rid England of the causes of the fatality of epidemics? This may yet be done by the Government, if aided by the force of facts, and of enlightened public opinion. Auqust 26 th to September 1st. — The deaths registered in London in the week ending September 1st were 2796 ; of which 1 663 were by cholera, 234 by diarrhoea. The mortality exceeds that of any previous week. The greatest number ever registered before in any week since 1840, was 2454 deaths, in the week ending December 4, 1847, when the last epidemic of influenza prevailed. In the cholera epidemic of 1832, the parish clerks, in the old Bills of Mortality, returned 1021 burials for the week ending August 28th ; which, allowing for the defects in their returns, and for increase of population, are equivalent to 2430 deaths at the present time. The burials after that week in 1832 declined. The mortality is nearly three times the average of the season, and is sensibly felt all over the metropolis; but the inhabitants of the north and west districts, and people in the distance, can yet scarcely form a notion of the suffering on the south side the Thames, and, since the middle of August, in the east districts. “The 12th, 13th, and 14th of August,” says one of the Registrars of Bethnal Green, “will long be remembered in this neighbourhood, the outbreak of this fatal disease being without any adequate preparation ; surgeons were wanted in many places at once : the hurried passing and repassing of messengers, and the wailing of relatives tilled the streets with confusion and woe, and impressed on all a deep sense of an awful calamity.” Cholera has already destroyed, in this epidemic, nine thousand one hundred and twenty-nine lives in London. As it is one of the purposes of the Registration Act to ascertain the “causes of death,” and of the Weekly Tables, not to gratify idle curiosity, but to point these out to the public, the Registrars have been requested to give all the information they cau respecting the state of every part of their districts. This London Weekly Reports. xxvii many of them have taken considerable pains to do, and their notes will, it is hoped, be found serviceable to the guardians and medical inspectors, now and at future times. For it is important to bear in mind that cholera only brings into a strong light the localities, which elaborate calculations in the Annual Reports prove are at all times fatal to the health and life of the inhabitants. Alter the perils of this terrible week we seem to see land ; but as many thousands of lives may be lost in an epidemic by negligence, so, many thousands may be saved by skill, vigilance, and energy — by more ample supples of water — by the rapid removal of nuisances from the houses and streets — by the prompt administration of medical appliances and other comforts, by the active co-operation of the medical profession, of the Boards of Guardians, of employers, of every householder, of every individual, with the Board of Health and health officers. On the clay the above remarks were written, Tuesday, September 4th, the mortality in London was highest; 336 persons died of cholera during the day, 314 died on Wed- nesday, 297 on Thursday, 284 on Friday, and 31 1 on Saturday. As the decline of the epidemic was slow, and the registration takes place 3 or 4 days after death, the return for the week ending September 8th was heavier than the return on the week preceding. The mortality was now 3 times as high as the average; many people had lost friends or acquaintances that they had lately seen alive : and the uninterrupted increase inspired feelings of terror in some minds — a general uneasiness in all. Under these circumstances it was deemed right to advert to the epidemic’s decline, which its previous course, the law which governs its progress, its actual operations, and the season of the year — all rendered probable, and next to certain. The natural tendency of the public mind is to make no timely provision against distant dangers, and to exaggerate dangers present; apathy had now given way to excitement, which the announcement of the next week was unfortunately calculated to increase. September 2nd to September 8 th. — The Bills of Mortality were commenced in the reign of Queen Elizabeth; and ever since the year 1603, have been published by authority in London. In this respect the English metropolis stands alone; no Weekly Tables of the causes of death of every inhabitant are published in the capital of any other European state. Various motives for the measure have been assigned ; but the fact of continuous publication, from a period anterior to the appearance of newspapers and gazettes, is remarkable and characteristic. It may be fairly referred to the natural inclination of the English people, when they are in trouble, to know the truth ; and to see in figures the precise extent of their losses; although at times the sight might well make the courage of the bravest quail. On the Continent “ precautions have been used ” in publishing the mortality of cholera in 1849 ; and the deaths from all causes have not yet been made known. The parish clerks of London in the seventeenth century, when the plague was at its height, counted the deaths and recorded their supposed causes ; and the citizen, when the death-cart traversed the streets, anxiously studied the bill, surrounded by its gloomy symbolical border, announcing 8297 deaths in a week out of a population of 600,000. In the hands of Price, Heberden, Willis, Bateman, and other statists, these records have disclosed the laws of mortality, and the causes of the insalubrity of the present cities. One of their immediate advantages, however, is the evidence which they furnish that the most fatal and threatening plagues go through, with some perturbations, certain prescribed orbits ; and after raging for a given number of weeks, disappear. Plague, influenza, and cholera have been vanquished before; and to despair now would be as unreasonable as it was in the beginning of the year to deny that the cholera epidemic was impending. Those officers who are struggling with the triumphant enemy under every disadvantage will yet be victors; for if they have art, they have also nature on their side. The mortality in the week ending Saturday, September 8th, declined in the west and east districts of London, and increased slightly 111 the north and central districts, so that the deaths registered (1741) on the north side the Thames were 19 less than in the previous week. It was otherwise on the south side the river, where the deaths registered in the week were 1442! The total deaths registered in London were 3183: of males, 1460; females, 1723. The deaths of females exceeded the deaths of males by 263 ; the reverse of the usual proportions. The deaths from cholera were 2026 ; the numbers decreased in the districts of Shoreditch, Bethnal Green, Whitechapel, Stepney, Westminster; increased in Bermondsey, St. George Southwark, Newington, Lambeth, Wandsworth, Camberwell, and Rotherhithe. The epidemic, which had been partially subdued, broke out again with terrible violence in Lambeth, where 279 persons died of cholera in the week. Mr. Daws, one of the Registrars of Lambeth, who has made careful inquiries on the subject, says : “At least half the cases I have registered were allowed to proceed unchecked, until the most alarming and dangerous symptoms had manifested themselves ; but lately more circumspection seems to have been used. Nevertheless, the cases are still numerous, in which persons seem (from the painless nature of the attack) to be unconscious how highly necessary it is that immediate attention should be paid to it.” People are so much accustomed to associate danger exclusively with pain, that the most fatal symptom unaccom- panied by pain is neglected. They must, however, be taught to look upon paiidess diarrhoea with the anxiety that people in the plague looked upon the swellings, called tokens — which were also pain- less— but with less fear ; for the premonitory symptom now seems to be sent not so much to announce death as to give timely warning, and to call attention to that stage of the malady in which medicine can heal. xxv iii London Weekly Reports. As medical skill is of most avail at the beginning and end of a fever, as the effect of the engines is most conspicuous at the outbreak anil end of a conflagration, and as most energy is demanded when the wreck nears the shore, so it is in an epidemic ; which, if it has not been checked at first, may yet be cut short, and combated with effect, as it declines. None of the measures of relief in any district should therefore be discontinued, but be prosecuted with redoubled vigour, until it has been completely subdued; and the districts which have not yet suffered greatly should immediately complete their preparations. For the time is short ; the evils of delay irreparable. September yth to the l^th. — A daily return of the fatal cases of cholera and diarrhoea was now made to the Registrar-General. The particulars of all the deaths from these causes on Monday, September ioth, were printed on Tuesday, Sep- tember nth, and thus facilitated the house-to-house visitation, which had been set on foot by the Board of Health, and was efficiently carried out in several districts. The mean temperature, which in the two previous weeks had been 64°*o and 64°" i fell to 5 6C • 5 . The wind, which had been north, blew from the south-west. Electricity was as it had been for the two previous weeks, positive and stirring ; frequent flashes of lighining were seen during Monday, Tuesday, and Wednesday evenings. The sky was often overcast, and showers fell. The deaths in the week fell to 2865 ; of which 1682 were by cholera, 280 by diarrhoea. From this date the epidemic rapidly declined : the deaths from all causes in the 8 weeks following were 1981, 1616, 1290, 1075, 1028,902, 837, and 893; the deaths from cholera in the same weeks were 839, 434, 288, no, 41, 25, II, and 6. The remarks in the table of this last week are: — In the week ending Saturday, November loth, the deaths registered in the metropolitan districts were 893 ; a number which shows an excess of 56 on the return of the previous week, but a reduction of 269 on the corrected average of five autumns. If the present return be compared with that made in the same week of each of the years 1840-8, it will be found that, with but one exception (in 1841, when the deaths were 841), the mortality ranged formerly from 910 to 1165, and therefore was considerably higher than in last week, though the population in those years was less. The increase of 56 now observed on the week ending November 3, partly arises from pneumonia and bronchitis, the deaths from which become more numerous as the winter advances, having been 104 in the previous week, 127 in the last. The total number of deaths from cholera in the week was only 6 (5 less than in the previous week); in the same week of 1848 there were 62. The steady decline of diarrhoea and dysentery is shown by the numbers of the last five weeks, which were respectively 105, 63, 5 1, 40, and 29. A boy died of diarrhoea in Peter- borough-row, Fulham, whose father had been carried oil' by cholera in September; a boy of the same disease at Brudenell-place, New North road, from an unwholesome condition of the house; and a girl at Maidstone-place, in the house in which a death from cholera, reported in the former week, occurred, and in a locality then described as “ low and ill-drained.” Of the 6 deaths from cholera, one occurred at Water-lane, Homerton ; one at Wealherhead-gardens (Hackney-road), a place low, undrained, and drenched by waste water ; one in Christchurch, St. Saviour; one at Drummond-road, St James, Ber- mondsey ; one in Walworth; and one in Lambeth. A death from apoplexy, on which an inquest was held, occurred in Huntingdon-street, Hoxton The deceased was a female of 65, who for the last four years had lived in an underground cellar, which is only 11 feet in length, 8 feet 6 inches in width, 5 feet 9 inches in height, and sunk 5 feet 7 inches below the surface of the street. A small window scarce gives light or ventilation, and “ the walls ” (says the Registrar) “ are so damp that you might brush the water from them.’’ The mean daily reading of the barometer was above 30 inches on the last three days of the week. The mean of the week was 29*732. The temperature on the last three days was considerably higher than the average of the same days in 7 years. The mean of the week was 50°' 2, which is higher than the average by 4°* 1. In the three last months of the year 1848, 478 persons died of cholera ; which in the year 1849 destroyed 1 41 37 lives in London. In the year 1849 not less than 3899 deaths were referred to diarrhoea. The deaths from the two causes were 18036. One in 161 of the inhabitants was cut oft" bv the epidemic in its severest form. Of every 10000 persons living 62 were killed by cholera, 17 by diarrhoea. * While London was suffering, all the region round was assailed ; all the country in the basin of the Tiiames, Suffolk, Norfolk, the south midland counties, and Sussex, were involved in the attack. Some districts suffered severely, others escaped entirely, or, taking the population into account, only lo^t an inconsiderable number of lives. The scale on which the mortality is measured is IOOOO living, and the deaths in London by cholera out of this number were, as we have seen, 72 ; in all England, 33. The * See Table, j>. exxx, where the mortality of districts in which cholera was most fatal is given, derived from the population enumerated March 31, 1851. The mortality of these districts is frequently alluded to. Cholera Field round London. XXIX population of 1841 is the basis of the calculations; and where the range of mortality is so great as it is in this case, the variation in the rates of increase of population will not materially affect the results. In the metropolitan districts of Surrey the mortality from cholera ranged from Rotherhithe 253 (in 10000 inhabitants is understood throughout) to Wandsworth 122 : out of London, the districts of Eps«'m, Guildford, Farnham, Dorking, Reigate, and Godstone lost only 4 to 6 (in 10000) ; Hambleton and Farnborough lost none; Croydon 34; Richmond 35, Kingston 13, and Chertsey 24, the three latter districts lying on the south bank of the Thames. In Middlesex, on the north side of the Thames, Brentford lost 50, Staines 31 ; Uxbridge 21, Hendon 9, Barnet 20, Edmonton 24. In Hertfortshire, the districts of Hertford and Hitchin suffered severely ; 57 in 10000 were destroyed. Hertford is on the River Lea and near the source of the New River; Hitchin is further north, and is interspersed with hills; 24 deaths from cholera took place in the Hitchin Union workhouse. The first case at Hertford wras in the Union workhouse ; many of the deaths took place in the county gaol, at Butcherley Green and at Old Cross. In the Watford district 25, Hemel Hempstead 18 (in 10000) died of cholera. In Bishop Stortford, Royston, Hat- field, St. Alban, and Berkhampstead the mortality was inconsiderable, ranging from 2 to 7 in 10000. The mortality was equally low in the districts of Buckinghamshire, except Eton, where 20, and Wycombe, where 31 in xoooo died (chiefly at Great Marlow and High Wycombe). The latter districts are on the Thames. Windsor lost 28, and, ascending the Thames, Abingdon 18, Headington 22, Oxford 22, Witney 14. At Wokingham, Bradfield, Wallingford, Woodstock, Faringdon, and Cirencester in Gloucestershire, near the source of the Thames, the mortality was inconsiderable, not exceeding 2 in 10000. The counties of Northampton and Huntingdon escaped with few deaths ; at Northampton 17, Hardingstone 28, Peterborough 19 in 10000 died. Hardingstone adjoins Northampton; the first case occurred in a -boatman; 20 of 24 deaths fronf cholera in this district took place at Piddington. In Bedford 12, in Biggleswade 14 in 10000 died ; the rest of Bedfordshire lost less than 2 in 10000. In Essex, descending on the north side of the Thames, West Ham lost 50, Romford 67, Orsett 28, Rochford 66, Maldon, round the Blackwater River on the east coast, 15, Tendring 27 in 10000. Tendring includes Harwich, where nearly all the cases occurred, chiefly in the families of mariners, fishermen, and dredgermen. The population of Harwich was 3829 in 1841, of whom 69 died of cholera; 25 in the week ending Sep- tember 8. The rest of the county of Essex — except Epping, where 13 in 10000 died — suffered inconsiderably. The same may be said of the whole of the counties of Suffolk and Norfolk. Some districts of Suffolk had no deaths; others had 1 or 2 in 10000; Ipswich lost only 7 in 10000 by cholera, but suffered severely from diarrhoea; Wang- ford 7, Muttord 16 in 10000. The deaths in the latter district were chiefly at Lowes- toft, which is included in the port of Yarmouth. In Yarmouth itself 36, Norwich 6, Mitford7in 10000 died. Two parishes in Docking have already been referred to, p. xxi. Buxton, a parish in the Aylesham district, suffered from a similar circumscribed attack. Norwich and Kings Lynn and Yarmouth suffered a good deal from diarrhoea. In five districts of Norfolk no deaths were referred to cholera, in all the rest except those already named the mortality was inconsiderable. In Cambridgeshire, North Witchford lost 58, Whittlesey 17, Wisbeach 44 in 10000: like Peterborough they are marshy and unhealthy districts, lying about the embouchure of the Ouse and the Nene. The rest of the districts of Cambridgeshire suffered little. Gamhngay in Caxton was the seat of one of the circumscribed attacks, fatal to 12 persons. In Kent, the districts on the south bank of the Thames, and the coast down to the North Foreland, suffered from the epidemic; the deaths in 10000 were, in Dartford 46, North Aylesford (containing North- fleet) 50, Hoo 25, Medway (including Rochester and Chatham) 34, Milton 59, Sheppey (including Sheerness) 50, Faversham 10, Blean 17, Thanet (including Margate and Ramsgate) 65. Of the districts on the coast from the Isle of Thanet to Dungeness, Dover alone was attacked with any severity. The attacks were often circumscribed : thus of 1 17 deaths in Dartford, 35 occurred in the parish of Crayford, 17 deaths in the Union work- house Dartford, and 20 at Waterside. At Dartford a labourer, his wife, and four children were cut off by the pestilence. At Gravesend 1 96 deaths from cholera were registered ; 26 of persons who died on board vessels lying off Gravesend, 34 in the workhouse, 9 in XXX Portsmouth and Plymouth Fields. Passengers’-court, and 8 in Kempthorne-street. “The whole of the surface and under- ground drainage falls into rudely-constructed cesspools.” Of 73 deaths from cholera in North Aylesford 32 were at Northfleet. All the districts in the interior of Kent escaped with few or no deaths. But in Loose, a sub-district of Maidstone, 43 deaths occurred in the parish of East Farleigh, chiefly among the Irish hop-pickers. The remaining deaths in Maidstone amounted to 55. The decrease of the mortality on the high grounds of the county is shown by the districts traversed by the River Medway; ascending that river, in Sheppey the mortality in 10000 was 50, Milton 59, Medway 34, Mailing 11, Maidstone (including the hop-pickers at Loose) 30, Tunbridge 8, Seven- oaks 2. In Sussex only three districts lost more than 10 in 10000 of the inhabitants; namely, Hastings, where 34, Brighton, where 41, and Steyning, where 17 died of cholera to every 10000 inhabitants enumerated at the previous census. In Cuckfield there was a circumscribed attack. 83; 3 Cuckfield; Hurstperpoint. Pop. 5711. Clio. 14. Diarr. 5. — The whole of the deaths from cholera took place at Pyecombe (one of 7 parishes forming the sub-district), where the epidemic broke out with great malignancy in June. Its first victims were three children of labourers, on the 20th, and a fourth on the 22nd. Four cases terminated fatally on August 1st, and 2 on the following day; a shepherd died on the 6th, and his widow on the 10th. The recorded duration of attack was in some instances remarkably short — 4, 5, and 6 hours — 7 hours being the average. On this wide field, extending over the counties of Middlesex, Surrey, Kent, Sussex, Berks, Hertford, Buckingham, Oxford, Northampton, Huntingdon, Bedford, Cam- bridge, Essex, Suffolk, and Norfolk, the epidemic committed great ravages: and 18502 lives were destroyed by cholera alone. But its successes were only partial ; of 241 5 1 59 persons and more living, 16285 lost their lives in 36 London and 18 country districts, having an area of 1144 square miles; while only 2217 persons died in a population of 2843183 on 13370 square miles. The poison, or whatever it was, pervaded the whole field ; for in almost every district it caused one or more deaths, either in the aggravated form or in the masked shape of diarrhoea. PORTSMOUTH CHOLERA FIELD. Portsmouth, Southampton, and Salisbury, formed the basis of a less extensive attack ; but to 10000 living enumerated in 1841,* Portsea Island lost 107, Alverstoke (Gosport) 93, Southampton 88, the adjoining district of South Stoneham 27, Romsey 14, the Isle of Wight 36 (where nearly all of the deaths occurred in the low ports on the north slope of the island, in Cowes, Newport, and Ryde), Winchester 18, Salisbury 174, the two adjoining districts of Alderbury 19, Wilton 12, Devizes 30. In all the other districts of Hampshire and Wiltshire the mortality was inconsiderable, although nearly all were visited in one form or other: 1251 deaths occurred in Portsea Island, Alver- stoke, Southampton, the Isle of Wight, and Salisbury, to 1457 n living in 1841, on an area of 163 square miles; while on the rest of the two counties only 309 died of cholera to a population enumerated in 1841 at 449109 on an area of 2584 square miles: so circumscribed was the fatal working of the malady. PLYMOUTH CHOLERA FIELD. Plymouth is the centre of a cholera field which extends along the southern coast of England from Purbeck Bay, in Dorsetshire, to the Laud’s End. No deaths from cholera were registered in Shaftesbury, Sturminster, Blandford, Wimborne, or Bea- minster districts, in the interior of Dorsetshire; owe death was registered in Sher- borne, and owe in Warcham, on the coast. In Dorchester, separated from the sea by the Black Down, 16 deaths occurred, 10 at Fordington, 2 at Holloway-row, 1 at Bohmston Stinsford, 2 at Piddlctown, 1 at Stafford; 11 deaths were recorded at Bridport on the coast; and at the ports of Poole and Weymouth the mortality was 26 and 32 in IOOOO. Proceeding along the sea-side districts of Devon, certain small detached places on the coast were visited severely : thus at Torquay there were 72 deaths, Brixham 75 deaths; 11 at South Brent, 13 at Modbury; in Exeter the deaths were 44, the mortality 14 in 10000. At Plymouth, East Sonehouse, Stoke * A Table of the Mortality in many of these districts, calcnluted from the population enumerated in 1851, is gwen at page exxx. Bristol Cholera Field. XXXI Damerel, and the surrounding districts of Plympton St. Mary, Tavistock, St. Germans, and Liskeard, round the harbour — the Tamar and the Tavy — 2381 cases of cholera were fatal.* The mortality in the 4 districts lying against the sea was excessive, and approached 2 per cent, of the population. Whole families were swept away. Many emigrant ships sail from Plymouth, and others touch there. The epidemic was diffused among the unhappy emigrants, and many perished. The “ American Eagle,” on board of which 6 deaths from cholera occurred, attracted attention at an early period, and was visited by officers of the Board of Health. The healthy districts of North Devon had few or no deaths. Barnstaple and Bfracombe were exceptions ; these two ports had several deaths, which made the mortality from cholera in the Barnstaple district 14 in xoooo. This belongs properly to the Bristol Channel field. The action of the epi- demic was prolonged down the south coast of Cornwall, and fell with intense violence on certain spots. At Mevagissey, in St. Austell, 126 deaths from cholera were recorded out of a population in 1841 of 2310. The mortality of St. Austell was 43, Truro 19, Falmouth 34, Redruth 28, the Scilly Islands 15 in 10000. The districts of Stratton, Camelford, Launceston, Bodmin, St. Columb, Helston, and Penzance escaped: the mortality in these large and populous districts was quite inconsiderable. BRISTOL CHOLERA FIELD. The country on both sides of the Bristol Channel was attacked by the epidemic. Bristol was one of the centres of attack; Merthyr Tydfil, in Glamorganshire, the other. Bristol is surrounded on the north side by the Clifton district, which extends to the Channel ; and is separated to the south from Bedminster, in Somer- setshire, by the river Avon. The mortality in the Bristol district was 90, the Clifton district 75, the Bedminster district 74 in iocoo. Ascending the Severn, the mor- tality in the Thornbury district was 5, in Dursley 35, Wheatenhurst 21, Gloucester 44, Tewkesbury 39. Here it may be convenient to trace the epidemic up the Severn, out of the bounds of the Bristol field, through Worcestershire, Shropshire, and Montgomeryshire. The mortality in Upton-on-Severn was 8, Worcester 16, Martley '8, Droitwich 13, Kidderminster 4, Bridgenorth 47, Madeley 23, Shrewsbury 54, Atcham 8, Montgomery 18, Newtown, extending up to the sources of the Severn, 3. Nearly all the deaths in the Dursley district occurred at Wotton-under-Edge and Kings- wood, among labourers, weavers, and their families. Of the 13 deaths from cholera in Upton-on-Severn, 8 were in the Union workhome. The Bridgnorth district consists of three sub-districts : in the Bridgnorth sub-district, with 6199 inhabitants, 70 deaths occurred, in Worfield 5, in Chetton none. Of 15 deaths in the Atcham district, 13 occurred in the Union House at the Cross Houses; 34 of the 37 deaths in the Mont- gomery district were in Pool. None of the other districts of Gloucestershire, Worces- tershire, Shropshire, or Montgomeryshire, were assailed with any sensible effect by tne epidemic, if we except Stourbridge, which is involved — as well perhaps as Madeley, Bridgenorth, and Shrewsbury — in the Wolverhampton field. No deaths were returned in the districts of Tetbury, Northleach, Stow-on-the-Wold, Wmchcomb, in Gloucestershire; in any district of Herefordshire, except Leominster, where 1 death from cholera was recorded ; in Ludlow or Clun, in Shropshire ; in Evesham, Tenbury, or Pershore, in Worcestershire. All these districts escaped. The deaths from diarrhoea in Hereford were 21 ; in the other districts few or none. I11 Northleach, having 10661 inhabitants, in 1841, no death either from diarrhoea or cholera was registered. In Somersetshire, proceeding from Bedminster, the mortality was 35 in 10000 in Keynsham, 13 in Bath, 39 in Clutton, 13 in Wells, 23 in Shepton Mallet, 74 in Bridgewater on the Parrot, and 18 in Taunton on the Tone, which flows into the Parrot. In Langport, higher up the Parrot, no death from cholera was registered ; and generally the interior districts, as well as Williton and Wellington on the Channel coast, leading to the healthy districts of Exmoor Forest, were left unscathed. Crossing the Bristol Channel, we arrive in Glamorganshire on — * See an exceedingly interesting and instructive account of the epidemic in a sub-dislrict of Plympton St. Mary, by A. C. Maclaren ; “ M'Culloch and Maclaren on Cholera,” 1850. XXXll Merthyr Tydfil. \ THE MERTHYR TYDFIL CHOLERA FIELD. ' In the Cardiff district, embracing the feet of the great coal and iron district, the mortality was 90 in 10000; Merthyr Tydfil, further in the interior, 234; in Bridgend, lower down the Channel, the mortality was 41, Neath 169, Swansea 68. Round Car- marthen Bay, in Carmarthenshire, the mortality in Llanelly was 22, in Carmarthen 38 in 10000; in the interior, Llandilofawr 23, and Llandovery 10 in 10000. Ascend- ing the Usk, Newport lost 75, Pontypool 28, Abergavenny 86, Crickhowel 54, Breck- nock, round the sources of the Taf and (he Usk, 4 in 10000 inhabitants. The districts on the lower section of the Wye, which enters the Severn above the Channel, suffered little more than Herefordshire and Radnorshire; the deaths in the Chepstow district were 1, Monmouth 9 in 10000. A few deaths from cholera were registered in Pembrokeshire. No deaths from cholera, few from diarrhoea, were registered in Cardigan, Newcastle-on-Emlvn, Aberayron, Aberystwith or Tregaron, in Cardigan- shire; Presteigne or Rhayader, in Radnorshire; Machynlleth, in Montgomeryshire; Llanrwst, in Denbighshire ; Bala or Dolgelly in Merionethshire ; Conway, in Car- narvonshire. Except the districts named, Holywell and Flint, on the Dee, Amlwch and Holyhead, in Anglesea, were the only districts in Wales where cholera produced any number of deaths. In Cardiff 2 male infants died of cholera on January 3rd and February nth, after attacks lasting 12 days and 3 days respectively : epidemic cholera did not appear until May 13th, when it was fatal to a navigator, aged 19, at 39 Bridge-street, after an attack of 24 hours’ duration, preceded by diarrhoea for 3 days. Towards the end of May a considerable increase of mortality took place, and the epidemic was at its height on June 7, when 14 persons died, and during the month it was fatal to 135 persons. The Registrar of the Cardiff sub-district, in his return for the quarter ending June, 1849, in alluding to the increase of the number of deaths, says: — “This mortality may in some degree be ascribed to inadequate drainage, partly to the letting out of a canal which passes through the town, thereby exposing the mud and matter at the bottom to the action of the sun, but still more to the very crowded state of the streets and houses in the poorer localities, to which the disease (cholera) has thus far chiefly confined itself.” In July the number of deaths fell to 69, but rose again to 91 during August ; in September 55 persons died; in October 3 ; and the epidemic finally disappeared alter being fatal to a labourer’s widow, aged 83, at Great Frederick-street, on Novem- ber 19, and to a carpenter’s son, aged 5 months, at Homfray-street, on December 7th. During the year 1849 cholera destroyed 396 lives (206 males; 190 females), being at the rate of 90 deaths to every 10000 persons living. Diarrhoea was latal to 75 persons (43 males; 32 females), being at the rate of 17 to every 10000 persons living. Merthyr Tydfil, with the exception of Hull, suffered more severely from cholera than any district in the kingdom. Its first appearance was on May 21st, when a labourer’s son, aged 4, died after an attack of 14 hours’ duration, at Heolygillor, and by the end of the month it was fatal to 16 persons. In June a rapid spread of the epidemic look- place; on June 7th and 9th the daily deaths amounted to 22, and 349 persons died during the month. In July the number of fatal attacks was 539, and as many as 32 persons died on July 26. In August the epidemic w-as at its height ; the daily mor- tality reached 36 on August 2nd; as many as 30 died on August 15th; during the month it was fatal to 548 persons. In September the deaths fell to 190, and further declined to 37 in October. In November 3 persons died; the last fatal case being that of a miner’s widow, aged 73, at Fynnon Tydfil, on November 21st. The fol- lowing places suffered severely from cholera : — Pont-y-Pridd, Llanwonno ; Pedwranfach ; Caedraw ; George Town; Market-field; Pont-y-Storehouse ; Penydarran ; Cae Pant Twvll ; Quarry-row; Cefn Coed, C\ mmer ; Fynnon Tydfil; New Souih Wales, Dow- lais ; High street and Well-street, Dowiais ; Hirwain, Peuderyn. Cholera was fatal to 1682 persons (884 males; 798 females), being at the rate of 234 deaths to every 10000 persons living ; diarrhoea was not fatal to more than 97 persons (53 males; 44 females), being at the rate of 14 deaths to every 10000 persons living. In Neath 2 persons died of cholera in February 1849; but it was not until May Wolverhampton Cholera Field. xxxiii 2 1 st that the epidemic began to be fatal, when it appeared among the labouring population at Aberdylais, Blaen Louddan. Throughout June the epidemic prevailed, and 80 persons died during the month. After the first week of July a rapid in- crease of mortality occurred; on July 17th as many as 18 persons died, and on several days it was fatal to 16 persons daily ; during the month 296 deaths took place. The mortality continued high during the first three weeks of August, and the deaths in the month amounted to 260 ; the deaths declined to 84 in September, and to 10 in October. The last fatal attack took place on November 10th, when a labourer, aged 47, died after an illness of 13 hours, at Lonlase, Llansamlet Higher. During the year 1849 cholera was fatal in Neath to 738 persons (353 males; 385 females), being at the rate of 169 deaths to every 10000 persons living. Diarrhoea destroyed 61 lives (28 males; 33 females), being at the rate of 14 deaths to every 10000 persons living. A table is given in another part of the Report showing the progress of the epidemic during each day of its prevalence in the districts of Cardiff, Merthyr Tydfil, and Neath. THE WOLVERHAMPTON CHOLERA FIELD. At the southern extremity of Staffordshire, on a space 12 miles square, 3275 persons died of cholera and of diarrhoea. The mortality from cholera was in the district of Wolverhampton 137, Walsall 54, West Bromwich 48, Dudley 48, Stourbridge ex- tending into Worcestershire, 65 in 10000. It is the Midland coal-field. The Potteries to the north, comprising Wolstanton, Stoke-upon-Trent, and Newcastle-under-Lyme, where the mortality was considerable, and Nantwich in Cheshire, Shrewsbury, and Bridgenorth to the west, Coventry to the east, may be considered out-lying districts, connected more or less with this field, which is in direct communication with Liverpool and Manchester. The field is near the centre of England; and it is worthy of remark, that the outbreak of the great epidemic may be set down so late as July for Wolverhampton, August for the other central districts. The districts immediately surrounding those infected escaped unscathed : thus the mortality in 10000 was only 5 in Penkridge, 2 in Lichfield, 2 in Tamworth, 2 in Burton-on-Trent, 1 in Cheadle, 1 in Leek, 4 in Stone, 1 in Stafford. In Uttoxeter, with 14932 inhabitants, no death from cholera, and only 1 from diarrhoea occurred. Warwickshire, with the ex- ception of Coventry and Foleshill in its vicinity, suffered as little as the exempted districts of Staffordshire ; the mortality from diarrhoea in Birmingham and Aston was however considerable. In Atherstone and Solihull there was no death from cholera; in Meriden 1, Nuneaton 2, Rugby 1, Stratford-on-Avon 2, Alcester 1, Shipton- on-Stour 1, Southam 1. Rutlandshire and Leicestershire enjoyed an extraordinary immunity : in Melton Mowbray there was no death from cholera, only 8 from diarrhoea; in Leicester 2 from cholera, 75 from diarrhoea. Six of the districts of Lincolnshire scarcely suffered at all; the deaths ranged only from 1 to 3 in 10000. Gainsborough, on the Trent, flowing into the Humber, was visited heavily; the deaths from cholera were 246, diarrhoea 63 ; the mortality from cholera was 91 in 10000. Caistor lies south of the Humber over against Hull, and the mortality was 1 1 ; in Glandford Brigg 9 in 10000. In Lincoln the mortality was only 2 from cholera, 12 from diarrhoea in 10000. Nottinghamshire escaped with few deaths; the mortality from cholera was in East Retford 10, Newark 10, Bingham 9, Basford 7, Radford 3, Nottingham 3 in 10000. In Nottingham the mortality was 18, in Radford 17 in 10000 from diarrhoea. In the district of Southwell, including part of Sherwood Forest, no death Irom cholera occurred among the 25014 inhabitants. Derbyshire suffered still less than Nottinghamshire ; the mortality in the district of Derby was 5 in 10000 from cholera, 11 from diarrhoea. In the rest of the county the mortality was inconsiderable. THE LIVERPOOL CHOLERA FIELD.] The epidemic fixed itself firmly in Liverpool as early as March, and around this centre infested several of the districts of Cheshire and Lancashire; the mortality diminishing in the distance. Thus the mortality in iooco was 167 in Liverpool, 82 in West Derby, 40 in Prescot, 22 in Ormskirk, "5 in Wigan, 19 in Warrington, d xxxiv Liverpool Cholera Field. 4 only in Leigh, 13 in Bolton, 7 in Bury, 7 in Worsley. Here the epidemic assumes a somewhat more severe form ; the mortality was at the rate of 40 in 10000 in Manchester, 28 in Salford, 30 in Chorlton. The mortality was 27 in 10000 in Lancaster : in the remaining districts the mortality was inconsiderable. Crossing the Mersey, the mor- tality in iocoo was 44 in Wirral, including Birkenhead ; 19 in Great Boughton, including Chester, on the Dee; 36 in Runcorn, on the south bank of the Mersey ; 1 6 in Northwich, on the Weaver, flowing into the Mersey. In Stockport only 8, Maccles- field 6, Congleton in 10000 died of cholera. It will be right to give here a more particular account of the ravages of the epidemic in the populations of Liverpool and Manchester. Liverpool suffered two visitations of epidemic cholera ; the first was comparatively slight, prevailing from the end of July to the close of 1848, and was fatal during that year to 33 persons, of whom 12 were males and 21 females, mostly children of labourers and artisans. In 1849 no fatal attack is recorded until January 9, when a widow, aged 76, died at No. 1 Court, Upper Pownall-street, of cholera and consecutive fever, 7 days’ duration. On January 15th, a sawyer’s wife, aged 44, died at 32, Eldon-street ; the death of her husband followed, on January 21st, after an attack of 19 hours’ duration. The next two cases occurred at 14, Hornby-street, on January 29th and 30th, of a sawyer’s wife, agpd 42, and an unmarried female aued 21. Diarrhoea was fatal to 29 persons during January. In February 7 deaths took place from cholera, occurring at intervals of a few days. Diarrhoea, which became more prevalent towards the latter part of the month, destroyed 36 lives. In March the deaths from cholera increased to 18, chiefly occurring in the courts of Arley, Oriel, and Chisenhall-streets, and also in the workhouse in the Mount Pleasant sub-district. The first death in the cholera hospital, Queen Anne-street, was on March 1st, when a labourer’s wife, aged 30, died, after an attack lasting four days ; and another labourer’s wife, aged 30, died in a van near the cholera hospital on March 25th. Diarrhoea remained nearly stationary during this and the two following months. In Apiil there were 19 deaths from cholera, 5 of them occurring in the cholera hospital, Queen Anne-street, and 3 in the workhouse. In May the mortality from cholera increased to 96, and the epidemic had now completely established itself, increasing daily in each of the sub-districts. In June 424 fatal attacks are recorded, and the daily number varied from 5 on June 6th, to 25 on June 29th. In July 1085 were added to the deaths pre- viously recorded. On one day, July 18th, the number of fatal cases was 59, the average during the month being 35 daily. In August the epidemic greatly increased, and the daily mortality reached 84 on August 13th, this being its maximum. Its decline now became perceptible, although it was not regularly progressive. Thus the deaths declined to 31 on August 30th, and afterwards increased for a few days, until, on September 5, no fewer than 66 deaths took place. From this point its decline became more steady, the deaths, which amounted to 1575 in August, were reduced to 874 in September, and further declined to 62 in October, 58 of which took place prior to October 12, when the epidemic, which had been so fearfully prevalent among the labouring, maritime, and trading classes, might be regarded as at an end, 2 deaths only taking place in November and 6 in December. Cholera hospitals were established in Vauxhall-road, in the Dale-street sub-district, in Ansdell-street, in the St. Thomas sub- district, and in Queen Anne-street in Islington sub-district. Many deaths took place in these hospitals, and also in the workhouse in the Mount Pleasant sub-district. A book- binder, his wife, and son died at 3 Dukinfield-street, on August 15th, a female relative, aged 2, having previously died in the same house on August 13th. Many instances occurred of more than one member of the same family dying. During the year 1649 cholera was fatal to 4173 persons (1895 males, 2278 females), being at the rate of 167 deaths to every 10000 persons estimated as living in 1849. The deaths from diarrhoea amounted 10 981 (459 males, 522 females), or 39 deaths to every IOOOO persons living.* * A Report on the Health of the Town of Liverpool during the years 1847-50, by the Health Officer, W. H. Duncan, M.D., has appeared since this paragraph was written: it contains an interesting account of the epidemic. Manchester. xxxv In West Derby (surrounding Liverpool) no case of epidemic cholera appeared prior to March 29th, when an anchorsmith’s son, aged 5, died at 3, Abstinence-street, after an attack of 21 hours’ duration. The next 2 cases followed on April 7th, at Henderson- street, where a mariner’s wife aged 24, and a spinster aged 26, died after attacks lasting 17 hours and 15 hours; both are said to have been in a state of collapse when first seen by the medical attendant, as was a cordwainer’s wife aged 30, who next died, on Aprilnth,at 14 cellar, Henderson-street, after an attack of 28 hours’ duration. Eightother deaths occurred at intervals up to the end of May. Early in June the epidemic began to spread, and the daily deaths amounted to 1 1 on June 21st, and the mortality during the month was 92. No considerable increase in the number of deaths took place until the middle of July, when they became more frequent, and amounted to 245 during the month; they increased to 409 during August. In the early part of September cholera continued to increase, and attained its maximum severity on September 5th, when it was fatal to 27 persons. It declined slowly during the following 10 days, anil after- wards more rapidly, until, on October 9th, only 1 death occurred ; another followed on October 2 2nd, and on October 29th the last fatal base of cholera is recorded in the death of a mariner, aged 49, in the cholera hospital. In another part of the Report a table will be found showing the deaths in Liverpool and West Derby combined, on each day of the four months during which the epidemic was most prevalent. During the year 1849, 1135 persons (488 males, 647 females) died from cholera, which was at the rate of 82 deaths to every 10000 of the population. Diarrhoea was fatal to 279 persons (141 males, 138 females), being 20 to every 10000 persons living. In the sub-district of Toxteth Park, which comprises less than half the population of the whole district, 91 2 deaths (383 males, 529 females) from cholera and diarrhoea were registered. The cholera hospital was in this sub-district. Manchester , Chorlton, and Salford form a group of districts lving contiguous ; and a table is given elsewhere, showing the deaths from cholera and diarrhoea in the three districts combined, on each day of the four months during which the epidemic was most fatal : it will be seen that the mortality was very high throughout September, and the first few days of October : on several occasions the deaths exceeded 40 daily; and on September 14th, 45 fatal cases occurred. It is worthy of note that in the whole of England the deaths from cholera were nearly three times as numerous as those from diarrhoea; while in this group of districts the mortality from these diseases was nearly equal, viz., from cholera 1395 ; diarrhoea, 1331; and while cholera destroyed 594 males, and 801 females, diarrhoea was fatal to 701 males, and 630 females. In Manchester* no fatal case of epidemic cholera occurred until June nth, 1849, when a packer, aged 20, died of an attack of diarrhoea 20 hours, and cholera 21 hours, at Bird-in-hand, Redfern-street ; the next four cases took place on June 25th, 26th, 28th, 29th ; of which three were at the workhouse, Canal-street, and one at No. 7, Nield-street ; the attacks being of short duration. Not more than 6 deaths happened during the first three weeks of July ; after this an increase was observed, and the deaths during the month amounted to 23; diarrhoea became very pre- valent, and was fatal to 149 persons. No further increase in the mortality occurred in the early part, of August; towards the end of the month, however, the epidemic began to spread. The deaths amounted to 93 during August, and diarrhoea was also very fatal, causing 208 deaths. The deaths from cholera were further augmented by 622 during September, when they averaged 20 daily, and on September 11 amounted to 34. The mortality continued very high until after October 4th, and no fewer than 27 fatal cases happened on October 2nd; after this its decline became more marked, and the deaths throughout October did not exceed 147 : to this number only seven were added during November, the last being on November 23rd, when a cordwainer’s daughter, aged 7, died at 3 Back Hatters’-lane, after an attack of 16 hours’ duration : no other fatal case is recorded afterwards during the year. * For a valuable and elaborate account of the progress of cholera, see “History of Cholera in Man- chester,” by J. Leigh, Esq., M.R.C.S., one of the Registrars, and Ner Gardiner, Esq., Superintendent- Registrar of Manchester. d 2 XXXVI Hull Cholera Field. Cholera destroyed 878 lives (374 males ; 504 females) in 1849, being at the rate of about 40 deaths to every 10000 persons living. Diarrhoea was fatal to 765 persons (404 males; 361 females), or 35 deaths to every 10000 persons living. Cholera did not visit Manchester until full three months after it had prevailed in Liverpool; it was also much less fatal. For while in Liverpool there was one death to every 60 persons living ; in Manchester there were 252 persons living to every fatal case of cholera. In Salford, as in Manchester and Chorlton, the cholera epidemic did not appear until June, 1849. At 5 Paradise-row, on June 24, a colour-mixer, aged 57, died of cholera live days’ duration, and typhus gravior two days; on June 27, a porter’s daughter, aged 5, died at Cleminson-street, of cholera after an attack of 12 hours’ duration. In July seven fatal attacks occurred at intervals, and the deaths from diarrhoea, which were 6 in June, increased to 2 6 in July. After August 1 2 th , both cholera and diarrhoea became more prevalent, and the deaths during the month were respectively 50 and 91. Throughout September cholera continued at its height: the number of deaths on September 1st was 6; on September 13th they increased to 9, which was the highest number in any one day ; on the last three days of the month the deaths were 7, 6, and 8 respectively : the mortality during the month was, cholera 148 deaths ; diarrhoea 62. After the first week in October the epi- demic subsided more rapidly, and the last death took place on October 19th, at Back Oak-street, when a shoemaker’s wife, aged 33, died of cholera of 3 days’ duration, effusion on brain 1 day. The deaths during October were of cholera 30 ; diarrhoea 31. In November diarrhoea was fatal to 9 persons, and in December to 6. The fatal attacks of cholera in most cases were of short duration, and in a great number of instances ranged from 6 to 12 hours. During 1849 cholera destroyed 237 lives (98 males; 1 39 females) ; and diarrhoea was fatal to 261 persons (141 males; 120 females). In Chorlton, cholera was very prevalent in July, 1848, among young children in the ITulme sub-district, though it was apparently only the ordinary summer cholera ; but on December 1st, a female servant, aged 24, died at 2 Knibbs-place, Victoria Park, of cholera, attended with purging, vomiting, cramps, and collapse, 24 hours’ duration. In 1849 no fatal case of cholera is recorded until June 1st, when a female, aged 27, died at 57 Park-street, of cholera and apoplexy, 36 hours’ duration ; on June 4, a female factory-hand, aged 28, died at Timothy-street, Eccles, after an attack lasting 12 hours. 2 other deaths occurred during June; and towards th elatter part of July the epidemic began to spread, and was fatal to 1 5 persons during the month ; diar- rhoea was still more prevalent, and caused 57 deaths in July. In August cholera caused 67 deaths, and diarrhoea 70. During September the epidemic was at its height: the greatest number of persons dying of cholera in one day was 13 on Sep- tember 1 8th, and during the month it was fatal to 163 persons. After the first week in October a perceptible decrease took place, and no death occurred after October 25th, excepting that of a weaver, aged 65, at the Union workhouse, Hulme, on December 25th, of debility consequent on cholera. Many instances are recorded of more than one death happening in the same family ; and at No. 3, Islington-place, 4 .adult persons died. At the Union workhouse numerous deaths, both from cholera and diarrhoea, took place. The deaths from diarrhoea exceeded those from cholera, viz., cholera 280 (122 males; 158 females); diarrhoea 305 (156 males; 149 females). THE HULL CHOLERA FIELD. In Yorkshire cholera destroyed 6346 lives, and 1955 deaths were ascribed to diarrhoea. This great county extends over the basin of the Ouse, which constitutes, by its junction with the Trent, the Humber, on the north side of which lies the port of Hull, the gate of the commerce of Leeds and the woollen districts. The mortality in the district of Hull was 241 ; Sculcoates, round Hull, 152 ; Beverley, north of Sculcoates, 1 1 in 10000. In the four coast districts, Patrington, Skirlaugh, Driffield, and Bridlington comprising Holdcrness, and lying higher than Hull, the mortality was only 5,4, 1, and 6 in 10000. Up the Ouse, Howden lost 41, Selby 73, York 36; Pocklington, west of York, 24 in 1 0000. Hull is intimately connected with the district of Leeds by the railway passing through Selby, by the roads and the River Ouse. The mortality in the district of Leeds Hull and Sculcoates. xxxv u was 145, and only inferior to that of Hull and Sculcoates. In Hunslet, adjoining Leeds, the mortality was also great, 102. Dewsbury, Wakefield, Pontefract, and Eccles- field, south of Leeds, suffered less. In Goole the mortality was 59, Thorne 46, Doncaster 24, Rotherham 10, Sheffield 13, Ecclesall-Bierlow n, Wortley 2 in 10000. These districts are south of the Ouse, and are chiefly on the Don. The districts on the Nidd, the Ure, the Swale, and the Derwent, the other tributaries of the Ouse and Humber, exhibit few or no deaths. The mortality in Huddersfield was 5,* Todmorden 4, Saddleworth and Pateley Bridge 3, Halifax, Keighley, Otley, Ripon, Skipton, 2 in 10000. Cholera produced no deaths in Sedbergh or Settle on the high grounds. In the North Riding the mortality was, 6 in Thirsk, 5 in Whitby, 4 in Scarborough, 3, 2, or 1 in eight districts; none in Helmsley, Leyburn or Reeth. In October, as the great epidemic was declining, a sudden outbreak occurred in the district of Knaresborough, where the mortality was 19 in 10000. The ravages of the epidemic in Hull, Sculcoates, Leeds, and Hunslet must be more particularly described. Hull , in proportion to its population, suffered more from cholera than any district in the kingdom. The epidemic appeared here in the autumn of 1848, and was fatal to 4 persons in September, to 13 in October, and to one in each of the follow- ing two months. A fatal case was recorded in a mariner, aged 36, at Anne-street, Myton, on March 9th, 1849, after an attack of 4 days’ duration. A month inter- vened before any other case took place. On April 9th a labourer’s widow, aged 62, died at 2, Joseph’s-place, Anne-street, after an attack lasting 2 days. Four weeks elapsed before any other death occurred, when a fisherman’s son, aged 6, was attacked on May 7th, at 19 Mill-street, and died after an illness of 12 hours. In June 2 deaths took place. In July cholera broke out in Little Passage-street, and was fatal to 3 females on July 7th, 8th, 9th, after attacks of short duration. In the course of the month 36 fatal attacks are recorded. No material spread of the epidemic was observed until August 1 3, from which date it began to increase, and the mortality during the month amounted to 254. In the first two weeks of September cholera was at its height, destroying 69 lives on September 6th ; it was fatal during the month to 843 persons. After the first week in October but few deaths occurred, and only 40 fatal cases happened throughout the month, the last being on October 30th, when a farmer’s wife, aged 70, died at 22, Sewer-lane. In many instances two or more deaths took place in the same family ; and during the latest prevalence of the epidemic it was fatal to a lath-render’s wife, daughter and son, on October 6th, at Spring-street, Myton, after attacks of 24 hours, 12 hours, and 5 hours respectively. Among the places severely visited by cholera were Middle-street, Mill-street, Ade- laide-street, Vagrant Office Humber-bank, English-street, High-street, Myton-gate, Humber-street, the neighbourhoods of Blackfriar-gate and Whitefriar-gate, Cleveland- street Groves, Chaffers-allev. Cholera was fatal, in 1849, to 1178 persons (571 males ; 607 females), being at ihe rate of 24 r deaths to every 10000 persons living. Diarrhoea destroyed 194 lives (91 males ; 103 females), being 40 deaths to every 10000 inhabitants. In Sculcoates , adjoiningHull, a female servant, aged 39, is stated to have died of cholera, on February 1st, 1849, at Popple-street, Drypool, after an attack lasting 12 days. On April 19th, a sailmaker, of intemperate habits, died of cholera and diarrhoea at Bethel- place, Caroline-street, Hull. No other death is recorded until July 23rd and 24th, when, in addition to a mariner, aged 33, at Kingston-place, it was fatal to a factory overlooker, aged 41, his wife, aged 39, and his daughter, aged 13, at 6 Cottonmill- street : by the end of the month 9 deaths occurred. In August 1 5 1 fatal cases took place, and the epidemic was at its height on September 6th (same day as in Hull), when it destroyed 28 lives. During the following week the mortality continued high : on two occasions the deaths amounted to 27 daily. Its decline became more percepti- ble towards the end of the month, in the course of which 464 fatal cases took place. In the first five days of October the deaths were uniformly 4 daily. The last death * The Report of Dr. John Taylor, on the Epidemic Cholera in Huddersfield, is a model which the local inquirer should consult. xxxviii Leeds, Hunslet , Tynemouth. occurred on October 19, at New Village, (Nottingham, in a carpenter, aged 28, after an attack of 18 hours’ duration. A table is given in another part of this Report, in which the progress of cholera and diarrhoea, in Hull and Sculcoates combined, is shown on each day of the four months during which the epidemic prevailed. In Sculcoates 656 persons (297 males; 359 females) died of cholera, being at the rate of 152 deaths to every 10000 of the popu- lation. Diarrhoea was fatal to 144 persons (74 males ; 70 females), being 33 deaths to every 10000 persons living. In Leeds , and also in the adjoining district of Hunslet, epidemic cholera first appeared about the middle of June, was at its height during the first two weeks in September, and finally disappeared in the last week of November. From the contiguity of the two districts, and from the simultaneous appearance and departure of the epidemic, they may he spoken of in conjunction ; and a table is given elsewhere exhibiting the progress of cholera and diarrhoea each day during the months when it was most fatal. The first two fatal cases of cholera took place in Leeds on June 14th, in a cap-manu- facturer, aged 39, at 16 Market-street, after an attack of 12 hours’ duration ; and in a stuff- weaver’s son, aged 9, at 32 Brass-street, cholera 6 days, and typhus 3 days. His brother, aged 7, next died, on June 15, of cholera 5 days, typhus 2 days. Two other deaths in Leeds and 3 in Hunslet took place during the month. In July only 4 deaths occurred at intervals up to the 17th ; the mortality then began to increase, and the fatal cases amounted to 23 during the month. On August 10th a stdl further spread of the epidemic commenced. On August 30th as many as 32 deaths happened, and in the course of the month it wras fatal to 426 persons. The mortality was at its height during the first two weeks of September, and on two occasions the daily deaths reached 89, viz., on September 7th and 9th; it then declined slowly for a few days, but afterwards more rapidly, and after destroying 1543 lives during September, the number fell to 309 in October : the epidemic entirely ceased in November, during which month it was not fatal to more than 14 persons. The last death in Leeds was that of a hairdresser, aged 36, at Swinegate, on November 27, alter an attack of 2 days’ duration. In Hunslet the last 2 deaths took place on November 29th, when cholera was fatal to a butcher’s daughter, aged 15, at Stocks-hill, after an attack of 16 hours, and to a joiner, aged 42, at Stanningley-road, Wortley. The following places in Leeds may be mentioned as having suffered much from cholera: — Grantham-street (No. I in this street was used as an hospital for cholera patients), Cavalier-street, Accommodation-road, Marsh-lane, Richmond-street and road, Wellington-yard, York-street, Acorn-street, Byron-street, High-street, Bateson- street, where 3 persons died on August 28th, at No. 7, and Stainburn-square. In Hunslet the epidemic severely visited Upper and Lower Wortley, Seacroft, Halton, Rothwell, Mint Holbeck ; Moor-street, Sdver-street, where 3 female children died at No. 1 3, in the first week of September ; Water-street, Thwaite-gate, Carr-place, Low- road, and Pitfield-street. The number of deaths in Leeds was : — Cholera, 1439 (649 males; 790 females) ; diarrhoea, 267 (124 males ; 143 females). In Hunslet ; cholera, 884(433 males; 451 females); diarrhoea, 120 (38 males; 62 females). To every 1 OOOO persons living in Leeds there were from cholera 145 deaths ; and from diarrhoea 27 deaths. In Hunslet the proportion was — from cholera 102 deaths, and from diarrhoea 14 deaths, to every 10000 of the population. THE TYNEMOUTH CHOLERA FIELD. On both sides of the Tyne, and up the Tees, the epidemic entered Durham and Northumberland, devastating the ports and the coal districts. Ascending the north banks of the Tyne, the mortality was 129 in Tynemouth (including North Shields) ; 41 in Newcastle-upon-Tyne; 12 in Castle Ward, the surrounding district. On the south side of the Tyne the mortality in South Shields was 69 ; in Gateshead, against Newcastle, 66 in iocoo. Higher up the Tvne, and round the soum-s of its chief tribu- taries, the mortality was in Hexham 5 ; in Haltwhistle 3 ; in Bellingham none. Morpeth, Alnwick, and Berwick on the coast suffered to some extent ; in Belford the mortality was only 5 ; Glendale 8 in 10000 : there was no death either from cholera or diarrhoea Mortality of Males and Females. xxxix in Rothbury, extending to the forests and moors around the sources of the Coquet. Teesdale presents one of those sharp contrasts which we have so often seen. In Barnard Castle, with a population of 8591, the epidemic killed a carpet-weaver, aged 23, on August 17th; 137 more persons before November 7th. Two or three members of the same family were in many instances seized and destroyed. The 4954 inhabitants of Staindrop, and the 6028 dwellers in Middleton entirely escaped, although the three sub-districts are in the same district. It is necessary to give a more particular account of the course of the epidemic in Tynemouth and Newcastle-upon-Tyne. Tynemouth suffered in 1848 from epidemic cholera, which commenced on October 10th, and destroyed 28 lives by the close of the year, in addition to a few from summer cholera, which took place at intervals during an earlier period. In January, 1849, cholera subsided after causing 5 deaths. Three deaths took place in Pumpwell-lane, on March 22nd, 25th, and 27th. In April, 2 deaths occurred. No other case is recorded until July 1st, when the epidemic again appeared, and was fatal to a mariner’s wife, aged 53, at Dawson’s Quay, after an attack lasting 13 hours. During July 11 deaths occurred. In August the epidemic greatly increased ; the deaths during the month amounted to 167, and further increased to 429 during September. Ttie daily mortality reached 26 on September 12th and 15th; but on September 19th, 20th, and 2 1 st the number of deaths averaged only 6 daily; but afterwards increased to 22 on October 2nd; when the subsidence of the epidemic became more steady, and the deaths during the month fell to 180; during November only 18 deaths took place, cholera ceasing to be fatal after November 26th. Cholera was fatal during the year 1849 to 81 5 persons (384 males ; 43 1 females), being at the rate of 1 29 deaths to every 10000 persons living. Diarrhoea was fatal to 89 persons (46 males ; 43 females), being at the rate of 14 deaths to every 10000 persons living. A table is given in another part of the Report, showing the progress of the epidemic during each day of its prevalence in Tynemouth, and the adjoining districts of South Shields, Newcastle-upon-Tyne, and Sunderland. In Newcastle-upon-Tyne cholera was prevalent in the latter part of 1848 ; 7 fatal cases occurred subsequent to October 16th. During the first 9 days of January, 1849, there were 12 deaths; in the succeeding n days only 3 fatal attacks are recorded; a sudden increase then took place, and from January 21st to 31st, the number of deaths was 26. During February 22 deaths occurred; 30 in March, and n in April. In May the only death was that of a weaver’s wife, aged 46, at Gardner’s-building, on May 1 5th, after an attack of 14 hours’ duration. The epidemic, for a time, discontinued its ravages, and during the whole of June no fatal case is recorded ; on July 4th, how- ever, a joiner’s daughter, aged 6, died, at Dent’s-hole, after an attack lasting 3 days ; this was followed on July 30th, by the death of a miller’s son, aged 18 months, of measles 6 days, and cholera 3 days’ duration. During August 28 deaths occurred, and in September the epidemic was at its height, and the deaths during the month amounted to 127, the greatest number occurring on September 5th, when 14 persons died. In October the deaths fell to 30; and in November to 3, the last being on November 16th, at Stepney-square. During the year 1849 cholera was fatal to 295 persons (147 males ; 148 females), the mortality was at the rate of 41 deaths to every 10000 persons living. Diarrhoea was fatal to 1 17 persons (61 males ; 56 females), being at the rate of 16 deaths to every 10000 persons living. INFLUENCE OF SEX ON THE MORTALITY FROM CHOLERA. The deaths from cholera among males were 26,108, females 27,185 ; it consequently destroyed 1077 more females than males. The proportions were reversed in diarrhoea, which was fatal to 9637 males, and to 9250 females. The population of England and Wales returned at the Census without revision was on March 31, 1851, males 8,762,588 ; females 9,160,180. And correcting for increase of population, the mortality from cholera at all ages in 1 849 was — Males 30^2 to 10000 living, or 1 in 331. Females 30'0 to 10000 living, or 1 in 333. xl Mortality of Males and Females. The mortality is thus a shade less among females than it is among males; but the difference is much less than it is from all other fatal diseases in ordinary years ; when the total deaths among males is invariably greater than the deaths among females. Thus in the year 1848 the deaths of males from all causes amounted to 202,949, °f females to 196,851. And in the seven years 1838-44 the annual rate of mortality among males was 2'2"]0, females 2'ic>4 per cent. In the Middlesex districts of London 3388 males, and 3612 females, died of cholera; in the Surrey districts the discrepancy was much greater, for 2814 males and 3509 females died of the disease. In many districts of the kingdom the mortality was much more fatal to males than to females. In some districts the disease was most fatal to females. Thus the deaths in Dartford (Kent) were males 68, females 49 ; and the deaths of males exceeded the deaths of females in other districts on the river and coasts of that county. In Portsea and Alverstoke 343 males and 351 females died of cholera; in Yarmouth 53 males and 34 females; Norwich n males and 27 females; Salis- bury 88 males, and 77 females; Plymouth, Plympton St. Mary, East Sionehouse, and Stoke Damerel, 907 males and 966 females; Bedminster, Bristol, and Clifton, 695 males and 740 females. In Gloucester, as well as in Wheatenhurst, Stroud, and Tewkesbury, the number of males that died exceeded the females in the proportion of 1331096. The same or a greater discrepancy occurred at Madeley and Shrews- bury, where 106 males and 71 females died. Upon the other hand, 94 males and 147 females died of cholera at Newcastle-under- Lyme. In Stoke-upon-Trent, Wolverhamp- ton, West Bromwich, and Dudley, the deaths of males considerably exceeded the deaths of females in number. In Boston, Lincolnshire, 25 males and 10 females died of cholera; in Caistor 24 males and 5 females ; in Gainsborough no males and 136 females. In Liverpool, Manchester, and the adjacent districts, the deaths of females exceeded the deaths of males in number. 1895 males and 2278 females died from cholera in Liver- pool. The mortality was at the rate of 154 to 10000 in males, and 180 to 10000 in females; about one-fifth greater therefore in the female than in the male sex. In Knaresborough 33 males and 20 females; Huddersfield 33 males and 19 females died of cholera; in Leeds and Hunslet, on the other hand, 1082 males and 1241 females died of the epidemic. In Wakefield 145 males, 96 females; Rotherham 20 males, 10 females; Thorne 42 males and 28 females; Pocklington, Howden, and Beverley, near Hull, 76 males, 39 females; in Hull and Sculcoates 868 males, 966 females — the deaths of the latter being 98 in excess. In Tynemouth and South Shields, Sunderland and Chester- le-Street, the deaths of females were in excess ; in Newcastle-upon-Tyne nearly equal. In Cockermouth and Whitehaven the deaths of males were 152, females 209. In the Welsh districts — Abergavenny, Pontypool, Cardiff, and Merthyr Tydfil — the deaths of males were in excess. It is worthy of remark, that at the beginning of the epidemic the deaths of males exceeded the deaths of females very considerably ; the numbers in the months of October, November, and December, 1848, were, males 61 2, females 493 ; or in the pro- portion of 100 to 80. In the prior nine months of that year before the great epidemic had set in, the deaths of males in England ascribed to cholera were 445, of females 384; numbers in the proportion of 100 and 86. As a genera! rule, when the mortality from cholera attained a very high rate, the number of deaths among females exceeded the deaths among males. In London a remarkable change was observed in the proportion of the sexes affected in the course of the epidemic. In four weeks of October 1848 the deaths of 80 males and of 42 females by cholera were registered ; in the thirteen last weeks of the year the deaths of 258 males and 210 females were reuistered ; and there was an excess of males at all ages, but particularly in the ten years of age 15-25. In the quarter ending March 1849, the deaths of males amounted to 250, of females to 266 : at the age of 25 and upwards the excess of deaths among females was considerable. In June, at the com- mencement of the t/real outbreak , the males again furnished the most numerous victims. At the close, of July the females died in greater numbers than males, and continued to do so to the end. In the week that the mortality was highest the deaths of 895 males and of 1131 females were returned. In the September quarter the deaths of males xli Influence of Age. under the age of 25 exceeded the deaths of females; hut after that age the proportions were reversed. The annexed table, as well as a similar table at page clxxiv, is well worthy of careful study, (a). MORTALITY AT DIFFERENT AGES. Cholera was fatal to persons of all ages: it carried off 38 66 boys under 5 years of age; 3837 men of 25 and under 35; and 2 old men of the age of 95 and upwards. Dividing the lifetime into 3 stages, the disease carried off 7673 boys and 7045 girls under 15 years of age; 14861 men and 15767 women of 15 and under 60 years of age; 3546 men and 4355 women of the age of 60 and upwards. The deaths were thus most numerous in the middle and most active period of life. The proportions of deaths at the several ages are different in diarrhoea ; the deaths of children and of old people being much more numerous than the deaths of persons in the middle period of life. Thus the deaths of 6794 hoys and 6058 girls under 15, of 1235 men and 1398 women of the ages 15-60, of 1607 men and 1791 women of the age of 60 and upwards, were referred to diarrhoea. It appears to be exceedingly probable that the cases of diarrhoea in 1849, barring a certain deduction, are cases of cholera, with the striking but not essential symptoms suppressed. And it is worthy of observ- ation that this suppression of morbid action occurs at the ages when the organization is most feeble, either because the system is not fully developed, or because it is worn out. Treating the mortality from diarrhoea as complementary to the mortality from cholera, the annexed table shows that under 5 years of age boys died in the proportion of 88, and girls in the proportion of 78, to 10000 living; the rate of mor- tality then rapidly declines to the ages of 10-15 and 15-25; in the next decennial period 25-35, mortality is of 31 males and 32 females to icooo living of each sex. At the period 35-45, the mortality to the same numbers living is 41 males and 44 females. Thus at the child-bearing age the mortality is rather greater among women than among men. From the age of 45 through the subsequent decennial periods of life, the mortality to 1000c men living increases in the ratios 54, 70, 92, 1 14, 135, which is the maximum at the ages 85-95. The mortality of females increases jn somewhat different ratios. (See Table page xlii.) (a) London. 1849. Deaths by MALES. FEMALES. Cholera Registered in Males. Females 0 15 60 Age 0 15 CO Age the Week to to and not to to and not ending 15. 60. upwds. Stated. 15. 60. upwds. Stated. J une 2 6 3 _ 5 I _ I _ 2 _ ,, 9 - 15 7 5 8 2 - 2 5 - - „ 16 29 13 2 25 2 - 4 8 I - ,> 23 22 27 6 13 3 - 5 19 3 - 30 - 76 48 18 56 2 - 8 32 8 - July 7 94 58 28 54 10 2 21 34 3 - „ *4 - 189 150 5i 12 I 17 - 51 7i 28 - 21 - 355 323 115 193 47 “ 108 170 45 8 Weeks 786 629 225 475 84 2 200 339 90 - July 28 382 401 119 213 5° - 98 243 60 - Aug. 4 452 474 i59 252 41 - 12 1 2 70 83 - „ 11 413 410 i34 229 49 I 106 234 70 - „ 18 597 633 172 348 74 3 145 37i 117 - », 25 - 590 682 l6l 348 81 - 148 403 131 - Sept. 1 770 893 236 438 96 - 189 536 168 - „ 8 - 895 1131 283 5°5 IO7 - 247 663 220 I 7 Weeks 4099 4624 1264 2333 498 4 1054 2720 849 I xlii Influence of Age. The table is obtained by dividing the deaths from cholera and diarrhoea respectively by the numbers living at the corresponding ages in 1841; and further dividing the whole of the results by 1-11169,* as a correction for the probable increase of population in the 8 years 1841-9. This is an approximation to the exact result. It may be fairly inferred from the table that men of the age of 25-35 are in a cholera epidemic twice as likely to die as men 10 years younger (15 -25) ; and that from this period the danger increases with age. The table does not express the liability to an attack of cholera ; nor the attack having supervened, does it express the chances of re- covering or of dying. The attacks of disease are not registered ; consequently, there are no means of throwing light on this question, which falls particularly within the scope of medical inquiry. If persons are equally liable to attack at all ages, or if the same proportions of the living are attacked, the table show's the relative mortality of those attacked at different ages. If more than an equal proportion of the living are attacked in the early, and less than the due proportion are attacked at the later ages, the mortality of the table does not represent the moitality of attacks ; but overstates the mortality of attacks at the earlier ages. The mortality from all causes at the same ages, in the 7 years 1838-44, is inserted in the table (b). Upon comparing this mortality with the mortality from cholera, it will be seen that the epidemic did not prove fatal to life at different ages in the same degree as other diseases. If we divide the numbers in column 3 by the numbers in column 4, the ratio of the two rates of mortality is obtained : it varies at different ages. Thus under 5 years of age in males the mortality from cholera is equal to 12 per cent, of the mortality from all ordinary causes ; and the greatest relative effect is attained at the age of 35-45, when the mortality from cholera is equal to 33 percent, of the mortality from all ordinary causes. At the advanced ages, when the absolute mortality from cholera is highest, its relative effect is least; for the mortality from other diseases increases much faster than the mortality from that malady. This is shown in the columns 9, 10. * The derivation of the value r in 1* = 1 • 11 169 is given iu the Ninth Annual Report of the Registrar General, 8vo, p. 168. (6) Annual Rate of Mortality, at 12 different Ages, from Cholera and Diarrhoea in England, in the Year 1849, compared with the Mortality from all Causes in the Years 1838-44. Katio of Deaths to 100 Males living, at each Age, Deaths to 100 Females living, at each Age, Deaths from Cholera to 100 Deaths from AGE. all Causes, at each Age. Cholera Cholera All Causes Cholera Diarrhoea ami All Causes Cholera Diarrluea and Males. Females. ( 1 649). (IS49). Diarrhoea (183S-44). (1849). (1849). Diarrhoea (1838-44). (1849). (1849). O •332 •549 •881 7-072 j -295 ■480 •775 6-037 22-458 12-838 5 — •232 •028 • 260 •926 •223 •028 •251 •900 28-078 27-889 10 — •138 •oir •149 •504 •128 •012 ‘ 140 •548 29-563 25-547 15 — •154 •on •165 •805 •142 •012 •254 •833 20-497 18-487 25 — •293 •018 •311 •968 •303 •021 •324 I *009 32-128 32* III 35 — •383 •027 •410 I * 249 •405 •032 •437 I*242 32-826 35-285 45 — •495 •048 *543 2-776 •467 •046 •513 2-548 30-574 33 • 140 55 — •587 •21 4 •701 3-24I •604 • 106 •710 2-782 22-318 25-521 65 — • 644 •272 •916 6-613 •678 •268 •946 5-885 23-852 16-075 75 — *597 •540 2-237 24-394 •717 •521 1-238 13 • 201 7-899 9-378 85- •498 •847 I ‘345 29-646 •487 •623 1*110 27-553 4-537 4-029 95 and ) upwards/ •311 •777 i* 088 42-697 •330- •742 I'O-Jl 40-795 2-548 2-628 All Ages •302 • III •413 2 *270 # 300 •102 •402 2*104 18-194 19-106 No.of Col I 2 3 4 5 6 7 8 9 IO Time in which Life is Extinguished. xliii DURATION OF CASES OF CHOLERA. All diseases have natural stages in which they develop their phenomena, and either obstruct and destroy life, or give way before its regular healthy processes. The sick may therefore be classed together, and traced, like the living in a life table, through all the stages of the malady, until it is extinct, either by the death or recovery of the patient. Upon this basis a form of sickness table has been constructed, which shows the probability of death or recovery at every period of disease. The half of such a table for cholera has been framed from the returns of death, which in 39468 instances state the duration of the cases in hours and days. If we assume that 100000 per- sons are attacked by cholera, that 60532 recover, and that 39468 die at the several periods of the disease indicated in the table, some of the properties of the complete tables become immediately apparent. Thus the probability that a person attacked will die in less than 24 hours is expressed by the fraction — = ’20684; the chances T 100000 are, therefore, nearly 4 to 1 that he will not die in 24 hours. The chance that he will die in 3 days is expressed by — = ’31186; and the chance that he will 1 00000 not die before but after 3 days is *08282. The chance that, having survived the dangers of the first 3 days, he will yet die of cholera, are 4— It J 100000 — 31186 68814 is 60532 to 8282, or more than 7 to I, that the patient will recover if he does not die in 3 days after the first attack. The table (c) p. xliv. supplies a ready means of calculating the future duration of fatal cases of cholera at any stage of the disease. Thus it is found that the mean dura- tion of the fatal disease in females is 2’i02 days, in males 2' 060 days; or 50*44 hours in females, and 49*44 hours in males. The woman attacked lives on an average an hour longer than the man. The duration of life, alter well-marked symptoms of a fatal attack of cholera have set in, appears to diminish as age advances. Dividing the cases into three groups, the following results are obtained : — • Duration of Fatal Cases of Cholera at various Ages. Mean Duration Persons of the age of 15-35 • Persons of the age of 35-55 . . . Persons of the age of 55 and upwards Days. Hours. 2*121 = 50*904 1*954 = 46*896 1 ‘ 97 3 = 47*352 The stated duration differs more than 4 hours, and is in excess in the first 20 years of adult age. Fatal diarrhoea is a disease of much longer duration; and it agrees with cholera in being of somewhat longer duration in females than in males ; in both sexes, at the age 15-35# than at a8es further advanced. Duration of Fatal Cases of Diarrhcea at various Ages. Days. Males, all ages 16*044 Females, all ages 16*692 Males and Females, age 15-35 18*668 Males and Females, age 35 and upwards . . 17*544 The fatal cases of cholera were preceded frequently, if not invariably, by a stage of diarrhoea, which attracted little or no attention. That stage is, it is believed, not. included in the cholera duration, which was reckoned, by the medical attendants who made the returns, from the manifestation of the first characteristic symptoms of the epidemic. xliv Cholera in 1832 and Cholera in 1849. (c) Duration of Fatal Cases of Choj.eka in 1849. Time from Males Females Persons mencement of Cholera. Dving Dyinjr Dying: Surviving. in the period following. Surviving. in the period following. Surviving. in the period following. Hours. O 19232 315 20236 214 39468 529 6 18917 3030 20022 2677 38939 5707 12 15887 4965 17345 5 3 3 1 33232 10296 18 IO922 1877 12014 2275 22936 4152 24 • • • • • • • • • • • • Days. O 19232 10187 20236 10497 39468 20684 J 9045 3327 9739 3928 18784 7255 2 5718 1629 5811 1618 11529 3247 3 4089 1256 4193 1226 8282 2482 4 2833 822 2967 812 5800 1634 5 201 1 564 2155 532 4166 1096 6 1447 351 1623 334 3070 685 7 1096 449 1289 490 2385 939 8 647 136 799 186 1446 322 9 511 103 613 104 II24 207 IO 408 67 509 80 917 147 II 34i 57 429 68 770 125 12 284 47 361 54 645 IOI 13 237 37 307 43 544 80 14 200 26 264 36 1 464 62 15 174 24 228 32 | 402 56 l6 150 22 196 29 346 51 17 128 20 167 26 295 46 18 108 18 1 41 23 249 41 19 90 l6 u8 21 208 37 20 74 12 97 29 171 31 21 62 12 78 15 140 27 22 5° 8 63 13 113 21 23 42 7 50 IO 92 17 24 35 6 40 8 75 14 25 29 5 32 5 6l IO 26 24 4 27 3 51 7 27 20 2 24 I 44 3 28 l8 4 23 2 41 6 29 14 4 21 3 35 7 30 IO 3 18 4 28 7 31 7 2 14 4 21 6 32 5 2 IO 5 15 7 33 3 2 5 2 8 4 34 I I 3 2 4 3 35 ’* * * I I I 1 Mean duration of fatal attacks Mean duration of fatal Mean duration of fatal of Cholera in males = 2 'o6o days. 1 attacks of Cholera in 1 females = 2' 102 days. attacks of Cholera in males and females = 2 • 08 1 days. Note. — The table is read thus : — Of 19232 fatal cases of cholera in males, 315 terminated in 6 hours, leaving 18917 alive; 3030 died in the next 6 hours, leaving 15887 alive at the end of the 12th hour; 4965 died in 12 and less than 18 hours, leaving 10922, or rather more than half the number of those who die, alive at the end of 18 hours. If a man is to die of epidemic cholera, it is probable that he will die in the first day (24 hours), as out of 19232 males who die, 10187 die within, and 9045 survive that period. THE CHOLERA EPIDEMIC OF 1831-2 AND THE EPIDEMIC OF 1848-9 COMPARED. The Board of Health in 1831-2 collected much information respecting the epidemic which it was their office to combat. A table was prepared showing the names of places Places in which Cholera teas Fatal. xlv attacked, the date of the first case, the date of the last case, the number of days’ dura- tion, the total deaths, the total recoveries, the proportion of deaths to cases, the popula- tion, the proportion of population attacked, and the proportion of deaths in population ; and all the places were numbered on one of Arrowsmith’s large maps. The table and map are now in the library of Her Majesty the Queen. At the instance of Sir James Clark copies have been made of these valuable documents, jand are deposited in the General Register Office. According to the returns the deaths from cholera in “London and its vicinity,” between February 14th and December 1 8 th , 1832, were 5275; the deaths in “the country” were 26101; the total deaths in Great Britain, 31376. The deaths in Ireland up to March 1st, 1833, were 21171 ; making the deaths in the United Kingdom 52547. The deaths of the year 1832 in England and Wales amounted to less than half the number which were registered in 1849. But the returns which the Board of Health in 1832 procured were voluntary, partial, and evidently defective. The population of the places in Great Britain which made returns was 5223657 ; so it would appear that a majority of the places in the country altogether escaped attack or notice. Notwithstanding the defects of the returns of 1832, they furnish us with the means of satisfactorily showing that the epidemic generally followed the same track in 1848-9 as it did in 1831-2, but that it was much more fatal in some places, and less fatal in others at the two periods. Thus, in the following districts the mortality from cholera was greater in the year 1849 than in the year 1832 ( d ). The places for 1832 are towns or cities, and do not often include all the same parishes as the districts of 1849 ; but as the populations at the two nearest censuses are given, the rates of mortality during the two epidemics can be fairly compared. In the following places the mortality was much less in 1849 than in 1832 ; and there can be no doubt about this result ( e ). 0 d ) Districts in which the Mortality from Cholera was greater in the Year 1849 than in the Year 1832. Place or District. 1832 1849 Population, 1831. Deaths from Cholera, 1832. Population, 1831. Deaths from Cholera, 1849. London .... 1424896 5275 2361640 14137 Portsmouth . . 46282 86 72676 568 Bristol and Clifton . 132331 694 143704 1154 Shrewsbury . 21277 75 23095 Il6 Wigan .... 20774 30 77545 563 Liverpool . . . 165175 1523 255055 4173 Leeds, &c. . 123393 702 189987 2323 Hull 28591 300 50552 1178 Merthyr Tydfil . - 22083 160 76813 1682 (e) Districts in which the Mortality from Cholera was less in 1849 than in 1832. Place or District. Population, Deaths from Population, Deaths from 1831. Cholera, 1832. 1851. Cholera, 1849. Exeter .... 28201 347 32810 44 Plymouth . . 3 ro8o 702 52223 830 Gloucester . II933 123 32062 119 Kings Lynn . . 13370 49 20528 2 Norwich .... 61 1 10 J29 68196 33 Nottingham . . . 50680 296 5841 8 18 Sheffield .... 5 901 1 402 103602 114 Carlisle .... 20006 265 41566 5X Newcastle-upon-Tyne 42760 801 89145 295 Sunderland . 17060 215 70561 363 xlvi Seasons — Meteorology — Diagrams . The difference in the rates of mortality was not considerable in the next districts ( f ). From Salisbury, Southampton, and some of the other districts in which the cholera was most fatal in 1849, no return was procured in 1832. (/) Place or District. Population, 1831. Deaths from Cholera, lb32. Population, 1831. Deaths from Cholera, 1849. 1 Manchester and \ Salford . . / 182812 890 315951 South Shields 19756 147 35787 2or INFLUENCE OF THE SEASONS IN 1831-2 AND 1818-9. The two epidemics of cholera in England continued fifteen months; they began in October, spread gradually, increased, and then as spring advanced partially subsided. The first eruption in 1848-9 extended pver seven months; it attained its greatest intensity on the fourth month. The mortality in this eruption was not considerable. If the total deaths in the 15 months be represented by 1000, the deaths in the 7 months from October, 1848, to April, 1849, are expressed by 47 ; the deaths in the 7 months of 1849, from May to November, by 950; the deaths in December by 3 ; or the deaths in the first 7 months were less than 5 per cent, of the total deaths, and two-thirds of the total deaths happened in August and September. The returns of 1831-2 were made to the Board of Health, and were necessarily imperfect, but their general indications are probably correct; and the distribution of 30924 deaths over 14 months, given by Sir David Barry, represents with sufficient accuracy the distribution of all the deaths from cholera over the 14 months, from November, 1831, to December, 1832. If the total deaths in this epidemic be represented by 1000, the deaths in the first eruption, from November, 1831, to May, 1832, are expressed by 174, and the deaths in the second eruption, extending from May, 1832, to December, by 826; or the deaths in the first eruption were about 17 per cent, of the total deaths, and the deaths in August and Sep- tember were somewhat less than half (4 6 per cent, of) the total deaths. The first epi- demic descended to the lowest point in May, 1832, and rose to the highest pitch in August, when it caused 29 per cent, of the total deaths. The second epidemic descended to the lowest point in April, 1849, and was most fatal in September, when it caused 37 per cent, of the total deaths. It is worthy of remark, that the cholera in both epidemics entered England after the wheat harvest was over, at the close of the hot season, and that it was most fatal in and after the wheat harvest of the year following. The annexed Table ( g ), p. xlvii, shows the distribution of the deaths in the two epidemics over the several months; and Table (/<) is added for a comparison of the distribution of the deaths in Loudon and Paris over the monthly periods of the epidemic. In both cities each epidemic had a double eruption. The epidemic began earlief in London than in Paris, yet the maximum mortality was attained two months sooner in Paris than in London. The population of Paris is more dense than the population of London; and the mortality in both the epidemics was about three times as great in Paris as it was in London. In 1849 the mortality was greater in Paris than in Liverpool. METEOROLOGICAL INFLUENCES. Diagrams. Two diagrams, illustrative of the progress of cholera, and of the meteorological phenomena on every day of the year 1849, are appended to the Report. The second Plate shows the temperature, the fall of rain, the direction of the wind, and the height of the barometer on every day at Greenwich. The meteorological phenomena admit therefore of strict comparison only with the line of cholera in London, Plate III.; but the general character of the weather all over the country is indicated by this series of observations. Thus, the weather was cold in the first half of January; and the line xlvii Cholera in Paris, London , and Liverpool. fluctuates, but does not rise in January, February, March, April, while the cholera line falls ; the lines of temperature and of cholera rise in May, June, and July ; in August the (?) Deaths in England from Choleka during each Month that the Epidemic reigned. MONTHS. Deaths from Cholera in England. Of the Total Deaths from Cholera, the Proportion per Cent, in each Month. 1831-32 1848- 49 1831-32 1848-49 1831-1848. October . • ? 354 2 •651 November . . 97 376 •314 ■691 December . • 282 375 •912 •689 1832-1849. January . 614 658 1-986 I *210 February . 708 37i 2*289 •682 March . 15 r9 302 4*912 *555 April 1401 107 4'53° •197 May . 748 3^7 2*419 •601 June. . 1363 2046 4*408 3*761 July . 4816 757° I5-574 13*916 August . 8875 15872 28*699 29*178 September . 5479 20379 17*718 37-463 October . 4080 4654 I3-I94 8-555 November . 802 844 2*593 1-552 December . 140 163 •453 •300 Total . • 30924 54398 IOO’OOO | 100*000 Note. — The deaths from cholera in each month of 1831-2 are from tables compiled by Sir David Barry, from the returns to the Board of Health. The return includes the deaths in London and the principal towns. — British Med. Almanac. Qi) Deaths in London, Paris, and Liverpool, during each Monlh that the Epidemic reigned. MONTHS. London, 1848-49 Paris, 1849 Paris, 1832 Liverpool, 1849 1848. October . , 150 • . • « . . November . . . 190 . . . . . . December . . • • 133 • • • • 1849- January . 292 7 f 5 February . 180 2 2 7 March . • . 40 573 90 18 April . 9 1929 12733 19 May . . 24 4509 812 96 June . • . 279 8669 868 424 July . 2555 865 25 73 1085 August . 5368 1382 969 15 75 September . 5031 II42 35 7 874 October 337 115 62 62 November . 20 ? 2 2 December . 2 2 2 6 Month not stated . . 14610 19184 18464 190 4173 Census • • 1851 1846 1831 1851 Population . • • 2361640 1053897 785862 255055 Deaths to ioooo Living 62 172 233 167 Note. — The returns for Paris are from the “ Rapport sur les Epidemies Choleriques de 1832 et de 1849, dans les Etablis- semens dependant de l’Ad ministration Generate de P Assistance Publique de la Ville de Paris. Par M. Blondel, 1850.” The garrison and the hospital population and deaths are included. xlviii Plague Years — Diagrams. temperature remained high, then cholera rose much higher ; in September the temperature begins to descend, and the cholera line shoots up its highest points, attaining the greatest elevation when the curve of temperature is descending. The form of the cholera curve for all England is very remarkable: the successive terraces and pinnacles of the Plate resemble sections of the primitive mountain formations, surmounted by spires and aiguilles of granite; or recall the lines of a strange Gothic architecture. The circular diagrams are of a new form, which may serve very well to illustrate periodic phenomena. From the observations of 79 years (1771-1849), Mr. Glaisher had represented the mean temperature of each day of the year by a curve laid down in the usual way on a straight line; and it appeared natural to join the two ends of the line by substituting the radii of a circle for the ordinates, and the angular divisions of the circle for the abscissas. By this arrangement a diagram of a compact form is obtained. It is a modification of the simple dial arrangement in general use. The circle struck round the radii representing the averages — with the different colouring of the radii extending beyond and falling short of the circle — makes the diagram represent the facts in a striking manner to the eye. The diagrams of Plate IV. are described at the foot of the sheet.* A separate diagram for London is given for each of the 11 years from 1840 to 1850. The last diagram represents the average result of the io years 1840-9 ; and a new element in the centre — the average length of the day in each week. The radiating power of the sun depends (1) on the time it is above the horizon, and (2) on its angular elevation. As both these elements attain their maximum in the summer solstice, the greatest heating power of the sun is then exerted, but its effect on the atmosphere goes on accumulating, and the temperature of the air is highest later in the year. The red crescent representing heat on the diagram is deflected 3 weeks to the right ; and the blue crescent representing cold is deflected to the same extent. As the greatest effect on the air appears some weeks after the sun has exeited its utmost power, so the diseases which excessive heat favours appear some time after the temperature of the air has been highest. Thus the temperature rises above the average at the 17th week, and falls below the average at the 42nd week ; the mortality from summer diseases rises above the average at the 30th, and falls below the average at the 40th week. In the years 1844, 1846, 1847, 1848, and 1849, it will be seen that the summer mortality exceeds the average when the temperature is for sometime above 6o° ; and in every year the mortality exceeds the average when the temperature descends below 40° Fahrenheit. London has two healthy and two unhealthy seasons; the first healthy season extends from the 14th to the 29th week, through April, May, June, and the greater part of July ; the. second healthy season extends from the 40th to the 47th week, through October and November. The first unhealthy season extends over December, January, and February ; the second over August and September. PLAGUE AND CHOLERA YEARS. The fifth Plate, in a series of eight circular diagrams, presents a view of the mortality of London in the seasons and weeks of ordinary and plague years. The first two diagrams deserve particular attention ; the radii of the inner circles represent the relative average weekly mortality of the years 1840-9 and 1640-6. How much London in the nineteenth is less fatal to its inhabitants than London in the seventeenth century, is evident from these lines ; and the improvement is still more striking, when the mortality of cholera — great as it was — is compared with the mortality of the five plagues in the 73 years, 1593-1665. The years 1640-6 have been selected to represent the ordinary city mortality of the 17th century, because the weekly returns are still extant, and are comparatively free from plague. The second diagram represents the average weekly mortality of these years ; and it will be observed that there is a great excess of mortality in August, September, October, and part of November. It was the unhealthy season. April, May, and June * The lirst circular diagrams representing the mortality and temperature in London during each week, and the diagrams of the plugues in London, were constructed in February 1850. The diagrams showing the daily mortality from cholera in England and in the 11 Divisions were constructed in September 1850. xlix Fatal Days. were the healthiest months, but the mortality was then little lower than in winter. The mortality in winter was higher than it is in the present day; but the mortality from the diseases of summer was raised so much higher in proportion than the mortality from winter diseases, that it made tiie winter look comparatively healthy. The circles are divided by two diameters into four quarters; and it will be observed that all the plagues are projected on the same side, four of five in the same quadrant of the circle. The harvest months were the death months of the year. It was the same in the 14th, 1 5th, and 16th centuries, when the black death and the sweating sickness were rife. As a population grows healthier, the annual mortality fluctuates less and less from year to year: the fluctuation in the mortality of the seasons also diminishes. The eccentric figure which circumscribes the radii representing the relative force of mortality in the 52 parts of the earth’s orbit, gradually tends to become a circle, or a figure of the ellipsoid type. In its first stage it has some resemblance to the cometary orbit ; in its second to the regular orbits of planets. It maybe stated as a general result of many observations in Europe, that whenever the mortality of the 6 mouths after the summer solstice is much greater than the mortality of the first 6 months of the year, the absolute mortality of the place is high. FATAL DAYS OF THE WEEK. On Saturday, Monday, Tuesday, and Wednesday, the deaths from cholera were above, and on Thursday, Friday, and Sunday below the average. In the whole country Tuesday was the most, Friday the least — fatal day of the week. The disparity in the deaths was greatest in London, where 2194 persons died on Mondays, 2136 on Tuesdays, and only 1927 on Thursdays, and 1824 on Fridays. The distribution of the deaths over the days of the week is shown below, in the table («). In reading the table it must be recollected that the days given are the days on which deaths occurred , and that half the deaths happen in the twenty-four hours after the attack. The weekly wages are generally paid on the Saturdays ; and the Mondays in London and other cities are days on which a certain proportion of the population indulge in intoxicating drinks. The Fridays are days of comparative abstinence. LOCALITY. Many instances have been given of the partial ravages of cholera. The influence of locality, however, is so great, that it requires further illustration. By collecting the districts together in which the mortality was high, we find this striking result : that CO All England and) Wales . . ./ London .... Other parts of Eng.) land and Wales . J Mondays. Tuesdays. Wednesdays Thursdays. Fridays. Saturdays. Sundays. Average. 7693 7826 7621 7607 7167 7769 7610 7614 2194 5499 2136 5690 1978 5643 1927 5680 1824 5343 2067 5702 2011 5599 2020 5594 All England and) Wales . . . J London .... Other parts of Eng-) land and Wales . J + 79 +212 + 7 - 7 -447 + 155 -4 1 + M +n6 + 96 -42 +49 -93 + 86 — 196 -251 + 47 + 108 _ 9 +5 Note. — The minus sign (-) denotes below ; the plus sign ( + ) above the average. 1 Influence of Locality. 46592 of the 53293 deaths from cholera in the year 1849 occurred in 134 of 623 districts; or in less than a seventh part of the area of England and Wales, among four parts in ten of the population. Only 6701 deaths took place out of 10 millions of people on 49228 square miles of territory. The area of England and Wales is equal to 57067 square miles, and may be repre- sented by a square of 239 miles to the side; now the districts comparatively free being represented by a square of 222 miles to the side in the centre, the band miles broad round this inner square represents the extent of area on which 46592 of the deaths happened. The facts are shown in the Table (A). Again, in 85 districts of England and Wales no death from cholera was registered in 1849; not a single death from either cholera or diarrhoea was registered in 12 of those districts; namely, Christchurch and Alresford, in Hampshire , Northleach, in Glou- cestershire; Ledbury, in Herefordshire ; Sedbergh, in Yorkshire; Bellingham and Rothbury, in Northumberland ; Bootle, in Cumberland ; Newcastle-in-Emlvn, Aber- ayron, Tregaron, in Cardiganshire ; and Dolgelly, in Merionethshire. No death from cholera took place in 8 out of 37 districts of Hampshire and Berkshire; while only 3 in 38 districts of Kent and Surrey (exclusive of the part in London) were exempt : there was one or more deaths in every district of Sussex, Middlesex, Hert- fordshire, Huntingdonshire, Bedfordshire, Cambridgeshire, Rutlandshire, Lincolnshire, Derbyshire, Cheshire, Lancashire, East Riding of Yorkshire, Durham, Monmouthshire, and Cornwall. One district escaped in the 7 districts of Buckinghamshire ; 7 in 21 of Oxfordshire and Northamptonshire; 2 of 17 in Essex; 9 in 39 of Suffolk and Norfolk; 5 in 54 of Wiltshire, Devonshire, and Somersetshire; 5 in n of Dorsetshire ; 5 in 6 of Herefordshire; 7 in 28 of Gloucestershire and Worcestershire; 4 in 29 of Shropshire and Warwickshire; 1 in 16 of Staffordshire; 1 in 9 of Nottinghamshire; 4 in 11 of Leicestershire ; 2 in 28 of the West Riding of Yorkshire ; 7 in 36 districts of Northumberland, Cumberland, and the North Riding of Yorkshire ; 2 in 3 of West- morland ; and 12 in 43 of the districts of Wales. The only town of any magnitude in the 85 districts is Hereford. The other districts arc made up of villages or small towns. The 85 districts are given in the Table, pp. cxl-cxli. The population, the deaths from diarrhoea, and the deaths from all causes in the 10 years 1841-50, are annexed (/). It is worthy of remark that the population in the 12 districts which were unvisited by cholera or diarrhoea was nearly stationary; it amounted to 120792 in 1841, and 1213671111850. There must have been emigration, and little immigration. The annual mortality in the 10 years 1841-50 was also exceedingly low; it did not (A) Akea, Population, and Mortality from Ciioi.kka in different Districts of England. — Area in Square Miles. Population 1851. Deaths from Cholera 1849. Persons to one Square Mile in 1849. Deaths from Cholera to I OOOO persons living 1849. 134 Districts in 11 Cholera) Fields j 7839 7417817 46592 915 65 The other Districts of England) and Wales J 49228 1050495 1 6701 21 1 6 EnolandandWai.es. . . 57067 17,922,768 53293 308 3° Name, of the 131 Districts: — All the Ixindon Districts, and Edmonton, Hitchin, llrentford, Hartford, West Ham, Horn- ford, Koch ford, Gravesend, Medwny, Thanet, Brighton, Headington, Oxford, W\ combe, Yarmouth, North Witchford, Whittlesey, Wisbeach, Portsea, Alverstoke, Southampton, Isle of Wight, Salisbury, Totnes, I’lvmpton St. Mary, Plymouth, East Stonehouse. Stoke Damerel, Tavistock , St. Germans, Uskeard, St. Austell, Truro, Falmouth, lied ruth. Great Houghton. Wirrall, Liverpool, W est Derby, Prescot, Wigan, Holton, Chorlton, Salford, Manchester. Hradford, Hunalet, I,eods, Dews- bury, Wakefield, Pontefract, Wortlev, Ecclcstteld, Sheffield, Selby, York, Sculcoates, Hull, Stockton, Teesdale, Durham, Chcster-le-Street, Sunderland, South Shields, Gateshead, Newcastle-upon-Tyne, Tynemouth, Alnwick, Carlisle, Cocker- mouth, W lute have n, Bridgwater, Hedminster, Bristol, Clifton, t llouceater, Shrewsbury, Newcastle-under- I.vme, Wolstanton, Stoke-upon-Trent, Nanlwich, Wolverhampton, WalsalL West Bromwich, Dudlei, Stourbridge, Bridgnorth, Coventry, Newport, Pontypool, Abergavenny, Crickhowell, Cardiff, Merthyr Tydfil, Bridgend, Neath, Swansea, Carmarthen. Free Districts. li approach in any district to 2 per cent., and was 1*750 per cent, on an average. In the 73 districts which escaped cholera, but lost some lives by diarrhoea, the popu- lation increased only 3 per cent, in 10 years; and the annual mortality was on an average 1 *905 per cent. In the county of Hereford only one death from cholera was registered in 1 849. A labourer’s son, aged 9, died 'of cholera at Bargates, Leominster, on September 30. This county lies high ; the population is scattered over the country, and engaged in agri- culture : it is out of the line of railways. The common drink of the people is cider. A straw-bonnet maker, aged 27, died of cholera in Kirkbv Stephen on July 26th, 1849. It was the only death from cholera in Westmorland. The 85 districts which escaped the epidemic cholera in 1849, lay in general high, round the sources of rivers, and were thinly peopled. Cardigan, Aberystwith, Abe- rayon, Machynlleth, Dolgelly, Conwav, in Wales ; Bootle, in Cumberland ; Lvmington and Christchurch, in Hampshire; Blotield, Wabingham, and Freebridge L\nn, in Norfolk ; and Plomesgate in Suffolk, though thinly peopled, are on the coast, or on the navigable parts of rivers, which 208 districts adjoin. Thus 13 in 208, or 6 percent, of the districts on the coast escaped, while 72 in 415, or 17 per cent, of the inland districts, enjoyed immunity ( m ). (Z) Population, Deaths, Annual Rate of Mortality, 1841-50, and Deaths from Diarrhoea, in 85 Districts, where there was no Death from Cholera, in 1849.* 12 Districts in which' there was no Death from Cholera or Diar- rhoea 73 Districts in which there was no Death from Cholera . Total . . Population. Deaths in the IO Y ears, 1841--50, from all Causes. Annual Mortality Per Cent, from all Causes, 1841-50. Deaths 1841 1851 Diarrhoea. 1849. 120792 121367 21220 1-750 • • 9991 79 I0294I2 195 105 i‘9°5 37r III997I 1150779 216325 1-889 3/i ( m ) Mortality from Cholera in the Inland and the Coast Districts. — Population June 7th, 1841. Population March 31st, 1851. Deaths from Cholera 1849. Deaths from Cholera to roooo persons living* 1849. England and Wales . I5,9I4D48 17,922,768 53,293 3° 415 Inland Districts 9,478,050 10,433,333 17,052 17 208 Coast Districts ..... 6,436,098 7,489,435 36,241 5° 100 East Coast Districts-)- 3,425,267 4,052,082 20,844 53t 47 South Coast Districts . . 1,081 ,588 I,2I2,5Q6 4,685 39 61 West Coast Districts . . . 1,929,243 2,224, 757 10, 712 49 Names of One Hundred Districts on the East Coast: — Berwick, Belford, Alnwick, Morpeth, Tynemouth, Newcastle- on-Tyne, South Shields, Gateshead, Sunderland, Easington, Stockton, Guisborough, Whitby, Scarborough, Bridlington, Skirlaugh, Patrington, Hull, Sculcoates, Howden, Selby, York, Goole, Glandford Brigg, Caistor, Gainsborough, Louth, Spilsby, Boston, Holbeach, Wisbeach, Kings Lynn, Freebridge Lynn, Docking, Walsingham, Erpingham, Tunstead, * For the names of Districts see table pp. cxl - cxli. f Excluding London (36 Districts) from the East Coast Districts the Mortality wiU be 41 to 10000 persons living. e 2 lii Coast Districts. The cholera was three times more fatal on the coast than in the interior of the country. This is shown clearly in Table (m). 36241 of the deaths from cholera occurred in the districts lying against the low navigable rivers and the seas ; 17052 in the interior of this circle ; and as the population of the coast districts was nearly 77 mil- lions, and that of the part of the country within this circuit, 10J millions, the mortality in the coast districts was at the rate of 50, in the inland districts at the rate of 17 in 10000. The character of the coast varies; and by a further analysis it is found that the fatality of cholera on the coast was greatest in the chief seaport districts. Thus 26773, or more than half the deaths in the country from cholera, happened in the districts of or about London, Liverpool, Hull, Bristol, Plymouth, Portsmouth, Southampton, and Tynemouth. London, having the mixed character of a seaport town and an inland city, may for the present, be set aside : we have then three groups of coast districts (»). The mortality in the great ports was at the rate of 125 in 10000 inhabitants ; in the 125 coast districts with small ports, often inaccessible to ships, the mortality in 10000 was only 1 5 ; which is one-eighth part of the mortality in the great, one-third part of the mortality (47) in the secondary ports. Cholera reigned wherever it found a dense population on the low alluvial soils of rivers, round the estuaries of the Thames, the Humber, the Mersey, the Severn, the Tamar, and their tributary waters. Certain cities and towns lie on the same rivers at different elevations, and are inti- mately connected ; the one is the port and entrepot, the other the manufacturing seat and centre of the surrounding country. Liverpool, Manchester, and other districts are thus related. It will be found that cholera prevailed at both extremities of the con- necting line ; but that it was almost invariably most fatal in the port or district lying lowest down the river (0). Two large groups of districts have been thrown together. 1st. The 47 districts on the river and sea margins, which comprise the principal ports except London ; and 41 of the large town districts in the interior of the country, seated also on rivers, but nearer their sources, and at higher elevations. The inland districts are more densely peopled than the maritime districts ; and the mortality, in ordinary times high in both regions, Flegg, Yarmouth, Blotield, Norwich, Mutford, 131 y thing, Plomesgate, Woodbrulge, Ipswich, Sam ford , Tendring, I.exden, Maid on, Koch ford, Billericay, Orsett. Romford, West Ham, Thirty-six London Districts, Hartford, Gravesend, North Aylesford, IIoo, Medway, Milton, Sheppev, Faversham, Blean. Names of Forty-seven Districts on the South Coast: — Thanet, Eastry, Dover, Elham, Romney Marsh, Rye, Hastings, Battle, Eastbourne, Lewes, Brighton, Steyning, Worthing, Westhampnett, Westboume, Havant, Portsea Island, Alver- stoke, Fareham, South Stoneham, Southampton, New Forest, Isle of Wight, Lvmington, Christchurch, Poole, Wareham, Weymouth Bridport, Axminster, Iloniton, Exeter, St. Thomas Newton Abbott, Totnes, Kingsbridge, Plympton St. Mary, Plymouth, East Stonehouse. Stoke Damerel, St. Germans, Liskeard, St. Austell, Truro, Falmouth, Helston, Penzance. Names of Sixty-onk Districts on the West Coast: — Redruth, St. Columb, Bodmin, Camelford, Stratton, Bideford, Barnstaple, Williton, Bridgwater, Axbridge, Bedminster, Bristol, Clifton, Thornbury, Durslev, Wheatenhurst, Gloucester, Westbury-on-Severn, Chepstow, Newport, Cardiff, Bridgend, Neath, Swansea, Llanelly, Carmarthen, Narberth, Pembroke, Haverfordwest, Cardigan, Aherayon, Aberyswith, Machynlleth, Dolgelly, Festiniog, Pwllheli, Carnarvon, Anglesey, Bangor, Conway, St. Asaph, Ilolvwell, Great Boughton, Wirrall, Runcorn, Liverpool, West Derby, Prescot. Warrington, Ormskirk, Preston, Fylde, Gars tang, Lancaster, Ulverstone, Bootle, Whitehaven, Cockermoutli, Wigton, Carlisle, ling- town. The above include some districts situated on navigable parts of chief rivers. (») POPULATION. Deaths from Cholera Annual Rate of Increase per Cent, of Population. Deaths from Cholera to 10000 persons living. 1849. 1841 1851 1849. 17 Districts, including seven of the) above great Ports* ) 849559 1047210 12636 2' 008 125 30 Districts, comprising the secondary ) Portsf ) 929255 I 106109 5067 1-648 47 12$ other Coast Districts .... 2708915 .2974476 4401 •940 15 * The 17 districts comprise (1 ) Liverpool, West Derby ; (2) Hull, Sculcoates ; (3) Bristol, Clifton, Bedminster; (4) Ply- mouth, Plympton St. Mary, Knst Stonehouse, Stoke Damerel, St. Germans; (5) Southampton; (6J Portsea Island, Alverstoke ; (7) Tynemouth, South Shields, f The 30 districts are all thoie given in Table page cxlii, except the above 17 districts. liii Inland and Seaport Districts. is highest in the inland towns ; yet the cholera in the low sea-side districts destroyed 85 in 10000 of the inhabitants, while in the inland towns it was fatal to 38 in 10000 of the inhabitants. The fatality was as 2j to 1. The metropolis, with its mixed popu- lation, experienced an intermediate mortality ; 62 in 10000 of the inhabitants died of cholera. The mortality from cholera in the rest of the kingdom, on smaller streams and higher ground, was at the rate of only 12 in every 10000 of the 11 millions of people. It is worthy of observation, that while diarrhoea was fatal to 7 in 10000 of the people in those districts, it was fatal to 17 or 18 in iooooof the people inhabiting each group of the town districts ( p , q). From the want of data, we cannot give the exact elevation of the districts ; but we have here the facts that while the mortality from cholera was much higher in the three groups of dense town districts, rapidly increasing by the influx of immigrants, than in the rest of the country, the other elements — (1), of depression, (2), of alluvial soil, («) Deaths PORT DISTRICTS. Population DISTRICTS LYING HIGHER Population 1851. Cholera UP THE RIVERS. 1851. Cholera Tynemouth and South Shields IOOGI7 1016 i Newcastle-upon-Tyne Gateshead . and j 137230 552 Sunderland 70561 363 Durham .... 55952 192 Hull and Sculcoates . 95266 1834 Leeds and Hunslet . • , 189987 2323 Liverpool and West Derby . 408298 5308 Manchester, Salford, Chorlton . and j 439757 1395 {/,) Mortality from Cholera in Seaport, Inland Town, London, and Country Districts. Area in Acres. Population Enumerated. Deaths of Persons in 1849 from Persons. June 7th, 1841. March 31st, 1851. Cholera. Diarrhoea. 47 Districts, including the principal) Seaport Towns (except London) . j 41 Districts, comprising the principal | Inland Towns / London (comprising 36 Districts) . The remaining 499 Districts of the) Country J 2,333,290 1,663,288 77.964 32,448,338 1,778,814 1,930,37! 1,948,369 10,256,594 2,153,319 2,243,183 2,361,640 11,164,626 17,703 8,193 14,137 13,260 3,499 3,840 3,899 7,649 Deaths of Persons from all Causes. Annual Mortality per Cent, from all Causes. 10 Years 1841-1850. In the Year 1849. In the Year '1847. In the Year 1847. In the Year 1849. 47 Districts, including the principal 1 Seaport Towns (except London) . ) 41 Districts, comprising the principal) Inland Towns J London (comprising 36 Districts The remaining 499 Districts of the) Country j 495,752 532,590 529,289 2,213,067 69,413 63,017 68,899 240,129 61,968 61,554 59,131 240,651 3-079 2-906 2-691 2-226 3-327 2-886 3-oi7 2-183 liv Seaside and Inland Districts. or (3), of whatever else characterises our seaport towns, are of primary importance. In some of the large inland towns the cholera was scarcely at all fatal ; the deaths it caused in 1849 in Cambridge were only 5, Colchester 4, Cheltenham 6, Hereford o, Stafford 3, Birmingham and Aston 35, Leicester 2, Lincoln 7, Nottingham 18, Derby 18. It destroyed 202 lives in Coventry, 116 in Shrewsbury, 174 in York, and 165 in Salisbury; but of the 8193 deaths from cholera in the Table (r), 3438 took place in Leeds, Hunslet, Manchester, and Salford, which are great towns intimately connected by railways, canals, and roads, with Liverpool and Hull ; and 3047 in Wolverhampton and Merthyr Tydfil. Subtracting the 6485 deaths from cholera in these 6 districts, 1708 deaths remain, which represent the deaths from cholera in 35 of the largest inland town dis- tricts of the kingdom (r). The low-lving towns on the coast were all attacked by cholera. Scarborough, Kings Lynn, and Deal in the Eastry District, on the coast, enjoyed as much immunity as the inland towns; thev were the only considerable towns on the coast that escaped. Cardiff is the port of the Merthyr Tydfil district. Situated in the interior, the centre of the great Glamorganshire iron works is about 20 miles from Cardiff, with which the Cardiff Canal, the Taf River, and the roads connect it. Cardiff and Merthyr Tydfil are (?) POPULATION. Annual Rate of Mortality per Cent. Annual Increase per Cent. 1841-50. Density — Persons to IO Acres. in 1849. From all Causes. 1841-50. Cholera in 1849. Diarrhoea in 1849. 47 low River and Sea-side Dis- 1 tricts ) 1*822 9 2*531 •849 • 168 36 London Districts 4: inland Town Districts .... i‘945 1*542 293 13 O co Tt" CTl CJ c» •619 •375 •171 •176 499 Districts, including chiefly small) towns, and the country population ./ •86r 3 2*073 •121 •070 (r) GROUPS OF TOWNS. Area in Acres. Population. Deaths in 1849. June 7, 1841. March 31, 1851. From Cholera. From Diarrhoea. 6 Large Inland Town Districts : — Wolverhampton, Merthyr Tydfil, ) Manchester, Salford, Leeds, and 1 Hunslet j 205,247 564,907 686,913 6485 1753 35 other Inland Town Districts . . 1,458,041 1,365,464 1,556,270 1708 2087 Persons to 10 Acres. Annual Rate of Increase of Population per Cent. Mortality from Cholera to 10000 living 1849. Mortality from Diarrhoea to 10000 living 1849. 6 Large Inland Town Districts: — Wolverhampton, Merthyr Tydfil,! Manchester, Salford, Leeds, and > Hunslet J 7 •013 98 26 35 other Inland Towns .... 10 •341 II »4 Coal Fields. lv therefore connected with each other in the same way as the towns previously mentioned (p. liii., Table o) ; but in this respect they differ, that the mortality is greater in the high district than in the low port town ( s ). The mortality, great in both places, was considerably greater in Merthyr Tydfil than in Cardiff.* The epidemic, however, began first at Cardiff. The canal at Cardiff was emptied, and the mud lay exposed to the sun in the spring. On May 13th a navigator died of Asiatic cholera at Cardiff; the first death in Lower Merthyr Tydfil was on May 2 1 st; the first death in Upper Merthyr Tydfil on May 26th. The epidemic broke out a few days earlier, and subsided sooner in the port than in the inland mining district. The canal mud lay exposed, and the houses were crowded and dirty in the poor streets of Cardiff, but the insalubrious condition of Merthyr Tydfil exceeds that of the old settled town. The place is thus described in the Quarterly Report :f — “ The most populous parts of Merthyr-Tydfil are well situated on sloping ground, a very small portion being on a level. Merthyr church is 500 feet above the docks at Cardiff, Pen-v-Dran higher, and Dowlais about 400 feet above Merthyr.” “ Hence,” says Sir H. T. De la Beche, “ the situation of Merthyr is open, airy, and well exposed.” Such is the natural situation. The evidence collected by the Health of Towns’ Commissioners shows by what process the advantages of situation have been sacrificed by the men and the iron-masters — “ From the poorer class of the inhabitants, who constitute the mass of the population, throwing all slops and refuse into the nearest open gutter before their houses, from the impeded courses of such channels, and the scarcity of privies, some parts of the town are complete networks of filth emitting noxious exhalations .” “During the rapid increase of this town, no attention seems to have been paid to its drainage ! ” “ There are no regulations for draining the town ; the surface water is retained ; there are stagnant pools and ditches contiguous to the dwellings.” There are “no dust-bins,” “no scavengers,” “the liquid refuse is allowed to remain on the surface,” or “thrown into the water courses,” which are “cleansed by the rain only.” “ The main streets — not the courts and alleys — are occasionally cleansed by the Turn- pike Trust Commissioners some of the “ town refuse” is carried to “ waste parts of the town, and the beds of the rivers Taf and Morlais; after a long drought the stench is almost intolerable in many places. ”f The houses of small but respectable trades- people are unprovided with privies. The interior of many of the houses is cleanly and well kept ; the Dowlais Company undertake to carry away the ashes of the inhabitants of Dowlais at the rate of id. per week for each house. The houses are chiefly supplied * Cholera, 1849. — Deaths in each Month. Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. Cardiff I I 39 135 69 91 55 3 I I l6 349 539 548 190 37 3 • • f Reg. Gen. Quarterly Report, 1849, No. 3, pp. 14, 15 + 2nd Report of Health of Towns Commissioners, vol. i,, 8vo., pp. 316-324. (*) Population. Deaths in 1849. Deaths to 10000 Persons living in 1849. 1841 1851 From Cholera. From Diarrhoea. From Cholera. From Diarrhoea. Cardiff ....... 32,557 52,863 46,484 396 75 90 17 Merthyr lydvil .... 76,813 1,682 97 234 14 M Invasion of the Inland from the Coast Districts. with water by pumps and wells ; the supply is scanty, and as most of the wells are fed by surface waters, it may be doubted if they can be free from a mixture with impurities derived from the bouse refuse soaking into the ground in all directions. The most wretched part of Dowlais is “ the cellars,” a collection of small houses in a depression between a line of road, a cinder heap, and the river Taf. “ An open, stinking, and nearly stagnant gutter, into which the house refuse is as usual flung, moves slowly before the doors.” While there were no deaths from cholera in, the small towns of Christchurch and Ringwood on the lower part of the Avon in Hampshire, the epidemic was excessively fatal higher up the riveT, in Salisbury, which is connected with Southampton and Ports- mouth by a line of railway. Salisbury is always an unhealthy place ; it is on a low damp valley, in the midst- of water meadows ; the courts and alleys where the lower classes reside, are in a filthy state, and derive no benefit from the general system of cleansing carried on in the main streets. There is a mill-dam ; “ and any attempt,” says Captain Denison, “ to improve the general drainage w'ould be imprac'icable; it would interfere w ith too many interests.”* The population of the town has slightly decreased in the io years 1841 -51. Newcastle-under-Lyme is another instance of mortality from cholera on high land. This district suffered severely. Out of a population of about 20000, there were 241 deaths from cholera. The town, on some of the highest ground in the interior of England, is about 400 feet above the level of the sea, and not far from the sources of the Trent; it is in a basin, and the Lyme, dammed by a mill, is an open sewer running through the town and sending up from its polluted, black, muddy bed exhala- tions w hich poison the inhabitants. The mayor was one of the victims. Bilston, in the Wolverhampton District, also in the interior of the country, sufFered severely from the epidemic. The place and the people have often been described: nothing can be worse than the circumstances in which they live or die. Epidemic cholera w'as raging in Hamburgh when the first cases were noticed in the ports of London, Hull, Sunderland, on the east coast of England, opposite, and in con- stant commercial relation with that continental port. The epidemic appeared in an unequivocal form at the commencement of October, 1848 ; yet it made little progress until the spring of 1849, when it gradually spread from the coast and river mouths to the interior oi the countrv. Noiicing only the great eruption, it appeared at. Liver- pool, on the Mersey, March 10th; Manchester, in the interior, June 25th; and Wigan, July glh. As it went from Cardiff to Merthyr Tydfil, so ascending the Usk, it broke out at Newport, on May 291I1 ; Abergavenny, on June 3rd; Crichhowell, on July 2 1 st. On the Lower Avon it was at Clifton on May 24th; Bristol, June 1st; Bcdminster, July 8th. Gloucester, on the Severn, was attacked on May 4th ; Shrews- bury, higher up the river, on July 25th. The great Wolverhampton cholera field, in the interior of the country, was attacked late; Wolverhampton, on July 17th; Stourbridge, August 10th; Walsall, August 25th; West Bromwich, August 31st. On the south coast the chief epidemic broke out at Plymouth, on June 3th ; Stoke Damerel, July 4th; Tavistock, higher up the country, July 24th. Southampton was attacked on June 30th ; the low Portsea Island, July 2nd; Alverstoke, July 6lh; Salisbury. July 10th. The epidemic in the London field began to be fatal in London itself about May 25th; in Brighton, June 13th; Gravesend, June 29th; Brent- ford, June 29th; Rochf’ord, July 51b; Thanet, including Ramsgate and Margate, July 14th. Up the river Lea, Hertford was attacked August 21st; Hitchin, further north , August 27th. The first cases on the Humber, and its tributaries, occurred at Hull in 1848; but the outbreak of the great epidemic occurred first at Leeds, on June 14th; Hull, July 7th ; Sculcoates, July 23rd; Gainsborough, August 4th; Howden, August 2nd ; Selby, August 13th; Goole, August 6th ; Thorne, August 19th. On the river Tees the epidemic began at Stockton, July 7th; at Teesdale, higher up the country, on August 17th. * Reg. Gen. Quarterly Report, No. J, 1849, and Appendix, p. 241, lo and Report of Health of Towns Cuiomlstionert. lvii Causes of the Mortality in London. The epidemic appeared, it will be recollected, at the port of Sunderland, on the Wear, October 4th, 1848. The epidemic of 1849 broke out at Durham, higher up the river, on May 12th; at Sunderland there was one outbreak on March 4th, and a second on June 28th. The seaport was first invaded; and in the great outbreak, the inland town, on the Wear, was neither the first nor the greatest sufferer. The low ports of the Tyne were the first attacked on that river; the epidemic appeared at South Shields on June 2nd; Tynemouth, July 1st; higher up the river, at Newcastle-upon- Tyne, on July 30th; Gateshead, August nth. The shaded map, showing the rivers and the dates of attack, may be advantageously studied. The cholera epidemic then first appeared in the ports of England, and gradually extended into the interior of the country. Cholera attacked the greater part of the districts on the coal-fields of England, and was most fatal in the denser masses of the mining population. Mining operations have, in all times, and in all places, been fatal to man: chiefly in consequence of the neg- ligent habits of the people, and the absence of the health regulations which exist in towns possessing a municipal organization. The ground on the coal formation may have lent the epidemic fatality. The annexed Table shows the population and the deaths from cholera, and from all causes, in the principal districts on the coal-fields of the country. The mortality from cholera was 46 in 10000, from diarrhoea 13, in these districts; which, it will be noticed, increase at the rate of i'8 per cent, annually, and every year lose 23 in IOOOO of their inhabitants by death of one kind or other ( t ). The epidemic was not generally fatal on the primary geological formations — on the granite, the Silurian, or the Devonian systems ; while Herefordshire, however, on the old red sandstone, escaped, Cornwall and the south of Devon, on the same formation suffered severely. Plymouth, and the districts around the Sound, into which the Tamar flows, was one of the principal cholera fields ; but it is a port, and the mouth of a river which rises partially in the millstone grit, forming a part of the carboniferous system. A few scattered cases occurred in the marshy districts of Lincolnshire ; but the mor- tality was inconsiderable, and below the average. The marsh districts in the interior of Cambridgeshire also escaped, down to the Ely district; North Witchford, Whittlesey and Wisbeach suffered. So did some of the marsh districts of Essex and Kent on the estuary of the Thames. In the Romney Marsh district only one death from cholera occurred. THE CAUSES OF THE MORTALITY IN LONDON. Much information is accessible respecting the districts of London, and during the progress of the epidemic, opportunities were afforded of observing the effects of the ( t ) Mortality from Cholera on the Coal Fields of England. Population Enumerated. Annual Rate of Increase of Population per Cent. Deaths. Deaths to 10000 persons living. June 7, 1841. March 31, 1851. From all Causes in the 10 Years, 1841-50. From Cholera, 1849. From Diarrhoea, 1849. Annually from all Causes in the 10 Years, 1841-50. From Cholera, 1849. From Diarrhoea, 1849. 42 Districts om the Coal Fields in [ England* .j 2269786 2707340 1*813 6nro6 II97O 3306 233 46 13 * Chipping Sodlury, Madeley, Newcastle-under-Lyme, Wolstan ton, Stoke- upon-Trent, Tam worth, Wolverhampton, Walsall, West Bromwich, Dudley, Stourbridge, Belper, Chesterfield, Wigan, Bolton, Ashton, Oldham, Rochdale, Burnley, Blackburn, Todmorden, Huddersfield, Halifax, Bradford, Hunslet, Leeds, Dewsbury, Wakefield, Sheffield, Rotherham, Chester-le-Street, Gateshead, Newcastle-upon-Tyne Tynemouth, Castle Ward, Morpeth, Whitehaven, Abergavenny, Pont y pool, Merthyr Tydfil, Neath, Llanelly. lviii The Thames and the Water Supply. varying conditions of place and population on the mortality. The first cases of the epidemic appeared in the heart of the port ; and it was noticed at an early period that the mortality was much higher on the south side than on the north side of the Thames. The south side of the river is low and badly drained ; and it was deemed desirable to ascertain if possible the state of the sewers and drainage in every district, in order to determine the effects of emanations from the soil. The principal elements which are likely to influence the mortality of an epidemic, and which we have the means pf investigating, are the water supply, the drainage and elevation of soil, the density of population, and the poverty of the inhabitants. Lon- don consists of 36 registration districts — which are here made 38 — as for the purpose of ttds inquiry we separate the low Belgrave sub-district from the rest of St. George Hanover Square, and detach Paddington from the Kensington district. The popu- lation of each of the 38 districts was returned in 1841 and 1851, and the rate of increase among females furnished a means of estimating the population in 1849. The deaths from cholera in 1849 divided by the population gave the rate of mortality for each district, as shown in the column headed c in the tables. The elevation and are a of each district have been estimated by Major Dawson, R.E., from the maps furnished to the Sewers’ Commission by the recent Ordnance Survey. The area of districts adjacent to the Thames includes the river. The relative density, expressed by- persons to an acre, is obtained by dividing the population of 1 849 by the number of acres in each district. The number of persons to an inhabited house is foriheyear 1841, and has not since greatly varied. The relative wealth or poverty of the districts of the metropolis bears a c rtain relation to the annual value of the houses ; which was ob- tained from the parliamentary return of the value of houses as assessed under the Income Tax for the year 1842-3. The division of this value in pounds by the number of inhabited houses, and by the population of 1841, gives the average annual value of houses, and the annual value of house and shop room, sufficiently near for the present purpose. The poor rate in the £ is added for 1842-3. The mortality of each district from all cau.-es in the 7 years 1838-44 is also given. After these calculations had been made, the 38 districts were arranged in five dif- ferent orders ; — ist, in the order of their mortality from cholera ; 2nd, in the order of the elevation of the soil above the Trinity high-water mark ; 3rd, in the order of their density ; 4th, in the order of their wealth deduced from the value of the houses ; and, 5th, in the order of their mortality from all causes in the ordinary years 1838-44. The sources of the water supply are also indicated in the tables. In the various combinations of the results, each district, whatever may be its extent, is considered to represent a certain state of things, and is therefore treated as of the same average extent ; which is equivalent to dealing with an equal amount of the average population of the 38 districts. The Sewers* Commission had an underground survey in progress, but it was in- complete. The Ordnance Survey supplied the elevation of the different parts, and in the absence of more precise information, it was thought that the elevation would at least furnish a good general notion of the natural drainage of the London districts. THE THAMES AND THE WATER SUPPLY. But before proceeding further in this branch of the inquiry, the effect of the river Thames and of the w’ater supply on the health of London must be noticed. The Thames collects the watersof 6160 square miles of country, extending from the Cotswold Hills in Gloucestershire to the eastern coast ; and the great body of this water flows and reflows through London in tides ; which carry the matter below London Bridge, a mile and a half above Battersea Bridge twice a day, and ascend as high as Teddmgton. The con- tents of the greater part of the drains, sinks, and water-closets of this vast city and of the 2,360,000 people on its sides, are discharged through the sewers into its waters ; which, scarcely sullied by the primitive inhabitants, have now lost all their clearness uud purity. '1'he dark, turbid, dirty waters Irom half-stagnant sewers are agitated by the tides, but are not purified until they reach the sea. lix The Thames and the Water Supply. The Thames presents a large evaporating surface which must be taken into account, and it gives off vapours day and night in quantities which the phenomena of a “ London fog” reveal. The still air then condenses the matter which at other times enters the atmosphere invisibly, and escapes observation. The mean lowest night temperature of the Tiiames from May 27th to September 15th, 1849, was 64°; the mean lowest night temperature of the air was 52’; so that the wide simmering waters were breathing incessantly into the vast sleeping city tainted vapours, which the temperature of the air at night would not sustain. it is a fact well worthy of attention, that after the temperature of the Thames has risen above 60, diarrhoea, summer cholera, and dysentery become prevalent, and dis- appear as the temperature subsides. The cholera reached London in the new epidemic form about October, 1848 ; it prevailed through the winter, and destroyed 94 lives in the second week of Januarv, when the temperature of the Thames was 37° ; it declined rapidly through April and May ; the night temperature of the Thames then rose to 62° in the week ending June 2nd ; with some fluctuations it went up to 68° in July, and remained above 6o° until the middle of September (week ending September 15th). The deaths from cholera registered during each of the 16 weeks were 9, 22, 42, 49, 124, 152, 339, 678, 783, 926, 823, 1230, 1272,1663,2026,1682. The mean night temperature of the Thames fell to 56°; the deaths from cholera to 839 in the week September 16-22 ; the temperature gradually fell to 38° on the last week of November, when there was only one death from cholera registered. The mortality from cholera increases generally in descending the river on the south side; in Wandsworth it was at the rate of 100 in 10000 inhabitants, in Lambeth 120, St. Saviour 153, St. Olave 1 8 1 , Bermondsey 161, Rotherhithe 205, where the water was perhaps most impure, Greenwich 75, where it had lost some of its impurities. On the north side, commencing at the highest part of the river, the mortality from cholera was, in Kensington 33, Chelsea 46, Belgravia 28, Westminster 68, St. Martin- in-the-Fields 37, Strand 35, West London (on the old Fleet Ditch) 96, London city 38. East London 45, Whitechapel 64, St. George in the East 42, Stepney 47, Poplar 71, The mortality trom cholera in the three sub-districts of Stepney, adjoining the Thames was twice as great as in the two districts away from the river. The result is here disturbed by elevation. No good analysis has been made of the Thames water at different points of its course ; but the matter in suspension is perhaps greatest between London Bridge and Limehouse Reach, against Rotherhithe. The seven districts of London in which the mortality is highest from ordinary causes, are the West London District (between Smithfield and the Thames), St. Saviour, Whitechapel, St. George in-the-East, Chelsea, St. Olave, and Rotherhithe. They all adjoin the Thames. Mr. Glaisher, of the Royal Observatory, Greenwich, was requested to make an estimate of the amount of vapour raised by evaporation from the Thames in London, and favoured the Registrar-General with the subjoined statement: — “ For some years past I have made daily experiments upon the amount of water evaporated from a surface of water, and the amount exceeded 30 inches annually. “ A depth of water of fully 30 inches must evaporate from the surface of the Thames annually ; in- deed the quantity must be larger than this from the circumstance of its relative high night temperature. Take it, however, at 30 inches, and we shall have — 2 ‘5 X 9 X 4840 = 108900 cubic feet evaporated in a year from an area of water of one acre. ~o°^6°5 = ^7®5°5 9att°ns °f water evaporated in one year from an acre of water. 108900 X 2245 = 244,480,500 cubic feet of water evaporated from asurface of 2245 acres of water in one year. = 1 , 5 23 , 242 , 99 1 gallons of water evaporated in one year from a surface of water of 2245 acres in extent, or more than 1523 millions of gallons. The salt water affects the water at Wool- wich: it is usually what is termed brackish there. Lieut. Sanders states that at Greenwich, at high- water spring tides, the water is frequently brackish. “ The dirt and filth in solution must be very large. The ‘ Dreadnought ’ experiments are made under my direction chiefly, and 1 can assure you that to read the instruments is a serious affair, owing to the filth of the waters ; on first pulling them up they are covered with a slimy adhesive mud ; they first have to be wiped, and if the wind is blowing strongly, this muddy water is blown about and over the observer. lx The London Water Companies. A new trunk is now being made, with a perforated copper-bottrm turning d lwnwards upon hinges, so as to get rid of the enormous deposit.” Upon Mr. Glaisher’s estimate, 678505 gallons evaporate from an acre of water in a year, which is at the rate of 1 8 5 7 ' 6 gallons daily. The bed of the Thames in London is estimated approximately at 2245 acres; consequently 4,1 70,000 gallons are raised from the Thames on an average daily through the year. The quantity evaporated at low water is, perhaps, much less than this; on the other hand, the evaporation in summer is more active than in winter; and the proportion of decomposing organic matter in the water, and on the banks exposed to evaporation, is greater at low than at high water. Hence, it is probuble that in summer 4 million gallons, or about 18000 tons of wuter, are raised from the polluted Thames daily and discharged into the atmosphere which is breathed by the inhabitants of London. It remains to determine how much of the organic matter in the water is raised with the vapour at different temperatures. London derives its supply of water for washing, cleansing, cooking, and drinking, to a small extent from wells; 18 districts have supplies from the ri\er Amwell, and from the Lea, a tidal tributary of the Thames; two districts from the Ravensbourne ; and 18 districts from the Thames, at five points of its course. The water is generally pumped by steam-power into water-butts or reservoirs in the houses, at interva's of one, two, or three days. As the water is of very different degrees of impurity, it will now be right to state the fatality of cholera in the several water districts of London, arranged under the companies by which the water is furnished. Grand Junction Company. — The waters of the Thames at Keio chiefly supply the sub-districts of Paddinston, Hanover-square, and May Fair, and the greater part of the district of St. James Westminster. The mortality from cholera was at the rate of 9 in 10000 inhabitants. West Middlesex Company. — The waters of the Thames at Hammersmith supply Marylehone and a small part of Hampstead. The mortality from cholera was at the rate of 17 in roooo inhabitants in Marylebone. In Hampstead the mortality was 8 in 10000. Chelsea Water Company. — The waters of the Thames at Battersea , much below Battersea Bridge and below the Chelsea Hospital, supply the Belgrave sub-district of St. George Hanover-square, and the districts of Chelsea and Westminster. The mor- tality from cholera was at the mean rate of 47 in 10000 inhabitants; in the Belgrave sub-district the deaths from cholera were 28, in Chelsea 46, in Westminster 68 in 10000 inhabitants. Southwark Water Company — The waters of the Thames at Battersea — still lower down the river — supply the districts of Wandsworth, St. Olave, and Bermondsey. The mortality from cholera was at the rate of 147 in 10000. In Wandsworth the mortality was 100, in St. Olave 181, in Bermondsey 161, in 10000. Lambeth Water Company and Southwark Water Company. — The waters of the Thames between Waterloo Bridge and the Hungerford Suspension Bridge , supply parts of the districts of Lambeth, St. Saviour, St. George Southwark, Newington, and Camberwell; the other parts of these districts being supplied from Battersea by the Southwark Company. The mortality from cholera was at the rate of 136 in 10000. In the district of Lambeth the mortality was 120, St. Saviour 153, St. George South- wark 164, Newington 144, Camberwell 97, in 10000. Southwark and East Kent Water Companies. — Rotherhithe is supplied with water partly by the litanies at Battersea and by the Ravensbourne— and partly from ditches and wells, into some of which the drains and cesspools soak. The mortality from cholera was at the rate of 205 in 10000 inhabitants. East London Water Company. — The Lea supplies the districts of Poplar, Stepney, Bethnal Green, St. George-in-the-East, and Whitechapel with water. The mortality from cholera was at the rate of 63 in 10000 inhabitants; and 71, 47, 90, 42 and 64 in each of the 5 districts. New River H ater Company. — The Amwell and the Lea supply Islington, St. Luke, Clerkenwell, London City, West London, East London, Ilolborn. St. Giles, the Strand, St. Martin-in-the-Ficlds. The mwtn mortality from cholera was at the rate of 41 in Elevation. lxi ioooo inhabitants ; the mortality was least in Clerkenwell (19), near the head reservoir ; greatest (96) in West London, on the edge of the Thames. Kent Water Company. — The waters of the Ravensbourne supply Greenwich, where the mortality from cholera was 75 in ioooo inhabitants; and parts of Lewisham, where the cholera was at the rate of 30 in ioooo inhabitants. Two or more companies supply some districts. The district of St. James Westminster is supplied by the Kew and the New River waters : the mortality from cholera was 16 in ioooo inhabitants; Kensington is supplied by the West Middlesex, the Chelsea and the Grand Junction Companies ; -the mortality from cholera was 33 in ioooo. St. Pan- eras is supplied by the New River, Hampstead, and the West Middlesex Companies; the mortality from cholera was 22 in ioooo. Shoreditch and Hackney are supplied by the New River and the East London Companies; the mortality in the two districts from cholera was 76 and 25 in ioooo. Arranging-the groups of districts in the order of mortality, it appears that the mor- tality from cholera was lowest in districts which have their water chiefly from the Thames so high in its course as Hammersmith and Kew. Upon the other hand, the mortality was greatest in the districts which derive their water from the Thames so low down as Battersea and the Hungerford Bridge. The districts of the New River occupy an intermediate station. In the 6 districts -which are supplied with water taken from the Thames at Kew and Hammersmith, 15 in ioooo inhabitants died from cholera; and the mortality ranged from 8 to 33. In the 20 districts which are supplied with water from the Amwell, the Lea, and the Ravensbourne, 48 in ioooo inhabitants died of cholera ; and the mortality ranged from 19 to 96. In the 12 districts which are supplied with water taken from the Thames between Battersea and the Waterloo Bridge, 123 in ioooo inhabitants died of cholera; and the mortality ranged from 28 to 205. In the second group of districts cholera was three times as fatal; in the third, eight times as fatal, as it was in the first: 1, 3 and 8, express the relative virulence of the epidemic in the three conditions. The density of the population was greatest in the central group, and nearly the same in the first and third group ( u ). LONDON.— ELEVATION. The elevation of the soil in London has a more constant relation with the mortality from cholera than any other known element. The mortality from cholera is in the inverse ratio of the elevation. The mortality of the 19 highest districts was at the rate of 33 in ioooo, and of the 19 lowest districts 100 in ioooo. The elevation in the two groups was as 71 to 10 feet above the high-water mark of the Thames, or as 7 do 1 ; while the mortality was as 1 to 3, or in the inverse ratio. In the two groups of the 6 districts, supplied with the waters of the Thames at Kew and Hammersmith, the O) LONDON. Deaths from Density of Elevation in Feet above High Water Mark, (Trinity). Annual Value of Houses (Year ending April 5th, 1 843). Grouf of Districts. Cholera to 10000 Persons Living. (Persons to an Acre). 6 Districts supplied with Water taken 1 from the Thames above Battersea} 15 72 105 £. 82 20 Districts supplied with Water from j the New River, the Lea, and the V Ravensbourne J 48 137 42 44 12 Districts supplied with Water taken 1 from the Thames, between Batter- sea and Waterloo Bridges . .J 123 73 5 31 lxii Elevation. mean elevation was 35 and 175 feet, the mortality from cholera 19 and 11 in 10000. In the two groups of 12 districts, supplied with the Thames water between the Battersea and Waterloo Bridges, the mean elevations were \ foot and 10 feet ; the mortality 168 and 77 in 10000. In the two groups of 20 districts, supplied with the waters of the New River and the Lea, the mean elevation was 24 and 59-$ feet ; the mortality from cholera was 59 and 37. While the effects of the water and of the wealth of the districts are apparent, they do not, in this analysis, conceal the effects of elevation. Cholera was excessively fatal in all the four districts which lie on a level with, or below the Trinity high-water mark; it destroyed 144, 161, 164, and 205, in 10000 inhabitants. In the five districts which lie 2 to 4 feet higher, on an average, the mor- tality from cholera was at the rate of 68, 97, 120, 153, and 181 in 10000. Westminster experienced the lowest mortality (68) in the 9 low districts, and it is supplied with water by the Chelsea Company ; while all the other districts are supplied by the Lambeth and Southwark Companies. In 10 districts, of an elevation of 50 feet and upwards, the mortality from cholera was at the rate only of 8, 8, 17, 19, 22, 22, 25, 35, 35, and 53. The mor- tality from cholera was not higherthan 35, except in the district of St. Giles, which is an exceptional case : its elevation being 68 feet above the Thames, and the mortality from cholera at the rate of 53 in 10000. It is a mixed district, and contains in near proximity the British Museum, Bedford Square, Russell Square, and Great Russell Street, where no death from cholera occurred ; and Church Lane, — a low, damp, dirty lane, generally covered with decaying vegetables, and filled with a wretched population, where thirty deaths from cholera happened, in addition to its quota of 109 patients who from all parts of the district, were sent to, and died from cholera in, the Union workhouse.* Notwithstanding the disturbance produced by the operation of other causes, the mortality from cholera in London bore a certain constant relation to the elevation of the soil, as is evident when the districts are arranged by groups in the order of their altitude. We place the districts together which are not on an average 20 feet above the Thames, and find that on this bottom of the London basin the mortality was at the average rate of 102 in 10000 : in the second group, at 20 and under 40 feet of elevation, or on the second terrace, the mortality from cholera was at the rate of 65 in 10000 ; in the third group, or on the third terrace, 40 to 60 feet high, the mortality from cholera was at the rale of 34 in 10000 ; in the fourth group, 60 to 80 feet high, the mortality from cholera was at the rate of 27 in 10000; in the fifth group, 80 to 100 feet high, the mortality was at the rate of 22 in 10000 ; in a district 100 feet high, the mortality was 17 in 10000 ; in Hampstead, about 350 feet high, the mortality was 8, or deducting a stranger in- fected at Wandsworth, but who died there, 7 in 10000. By ascending from the bottom to the third terrace, the mortality is reduced from 102 to 34 ; by ascending to the sixth terrace it is reduced to 1 7 (tc). It will be observed, that the number representing the mortality on the third terrace is one-third of the number 1 02, representing the mortality on the first, and that the mortality on the sixth terrace is one-sixth part of the mortality on the first. And a series approximating nearly to the * See Report on Church Lane and its vicinage in the Journal (Yol. xi., p. 4, 1848) of the Statistical Society of London. See also in the same volume a valuable paper on St. Giles's district, by Horace Maun, Esq., Uarrister-at-Law. (*) Elevation of Districts, in feet. Number of Terrace from bottom. Deaths from Cholera in 10000 Inhab- itants. Calculated .Series (1.) Feet. 20 — I 102 If = 102 51 20—40 2 65 40 — 60 3 34 if = 34 60 — 80 4 27 If = 26 80 — 100 5 22 lf= 20 100 — 120 6 17 = 17 340 — 360 18 7 W = 6 Elevation. lxiii numbers representing the mortality from cholera, is obtained by dividing 102 succes- sively by 2, 3, 4, 5, 6. A comparison of the numbers of this series with the actual mortality experienced in each district, will serve to indicate roughly as much of the effect as is due to elevation ; and the deviations from the scale are generally explained by the other elements of the problem. The mortality from cholera on the ground under 20 feet high being represented by 1, the relative mortality in each successive terrace is represented by -J-, i, -L, x, -i; or the mortality on each successive elevation is -f, £, -§-, &c. of the mortality on the terrace immediately below it. The elevation of the five terraces may be represented by 10, 30, 50, 70, 90 feet. The elevations of the two higher districts are 100, and 350 feet. It will be observed that the mortality at 100 feet is 17, at 50 feet 34 in 10,000; consequently at half the elevation the mortality is doubled. The half of 50 feet is 25 feet; and the double of the mor- tality, 34, is 68. Now observation gives 65 in 10000 as the mortality at 30 feet of eleva- tion. As the processes of dividing the elevation, and of multiplying the mortality by 2, may be carried on ad infinitum , it is evident that the mortality is not strictly in the in- verse ratio of the heights of the soil; otherwise at the elevations 12*5, 6'25, 3*125 feet, the mortality would be 136, 272, 544. Let e be any elevation within the observed limits o and 350, and c be the average rate of mortality from cholera at that elevation ; also let e' be any higher elevation, and c' the mortality at that higher elevation. Then if the mortality from cholera is inversely as the elevation, we shall have the proportion e> c — - ' e c . By adding a constant element, a, the velocity at which the mortality increases, par- ticularly at the lower elevations, can be retarded to any extent. The equation then 1 a assumes the form (1) . c' = c. The value of a can be most readily obtained 6 d by taking e' = 90, where the mortality was 22 ; and e = o, where in three districts on a level with the Thames at high water the mortality was 177 in 10000 on an average. g c From Eq. 1 the value of a in general terms is found to be a = — . Inserting the above numbers, we have a = 9° X 22 - o X 177 = = i2.8 177—22 • f l x 55 As the series is not perfectly uniform, different values of a are obtained from the for- mula ; and 1 3 is an intermediate value of a, which has been employed in the construc- tion of the annexed Table, by making e successively o, 5, 10, 15, . . . no, 150, 200, 250, 300, 350, in the equation — c = 9° + 13 . 22 = 103 X 22 _ 2266 e + 13 e+ 13 e + 13 Upon comparing the numbers of this series with the mean mortality observed in the districts at eight different elevations, it will be observed that the only considerable discre- pancy is at the mean elevation (20 — 40) assumed to be 30 feet. The excess of mor- tality is in Wandsworth, West London, and Bethnal Green. Mean Elevation of the ground Mean Mortality Calculated above the High- from Cholera. Series. water Mark. O 177 174 IO 102 99 30 65 53 5° 34 34 70 27 27 90 22 22 IOO 17 20 — — — 35° 7 6 lxiv Elevation. The houses necessarily raise the people of London above the ground ; and if their habitat, day and night, is on an average 13 feet above the ground level, it is evident that the mortality within the limits observed, is in the inverse ratio of the elevations at which the people live. The causes of the discrepancies in particular districts are partly explained by differences in the wealth of the people and other causes which may now be noticed ( y ) ( z ). (y) London Districts, arranged according to tlie Elevation of their Soil. Number of Districts. Elevation in Feet above Trinity High-water Mark. OBSERVED AVERAGE. Annual Mortality to 10000 Persons living. Number of Persotis to Average Annual Value of Poor Rate in the £ of House- rent 1842-43. Cholera 0 849). All Causes (1838-44). An Acre. A House. Houses. House and Shop room to each Person. £. £. 16 Uuder 20 ft. 102 251 74 6-8 3i 4-645 •072 7 0 1 o n 65 237 105 7-6 56 7-358 •071 8 40 — 60 34 235 184 8-5 64 7’342 •056 3 60 — 80 27 236 152 8-8 52 6-374 •049 2 80 — 100 22 2 1 1 44 7*7 38 5-183 •036 I IOO 17 227 102 9-8 7i 7-586 •043 I 35° 8 202 5 7'2 40 5-804 * # Mean of 38 Districts. 66 24O 107* 7-6 46 5-985 •064 All Loudon • • 62 252 29* 7 40 5*419 •063 * The difference between the number of peisons to an acre in the mean of 38 districts, and in all London, as separately calculated, arises in consequence of several districts of large area being thrown into the divisor in the latter case, while the effect of taking the mean of 38 districts is to render the population of each district of equal amount. (z) London. — Mean Mortality from Cholera at different Elevations; reduced from the observations to a regular series. Elevation in feet above Trinity High-water mark on the Thames. e + 13 Deaths from Cholera to 10000 Inhabitants. Increase of Mortality in descending five feet. Calculated c. Observed (a\erage.)+ Rate of In- crease =r. Increase per Cent. IOO 113 20 17 1-0463 4-6 95 108 21 1-0485 4-8 90 103 22 22 1*05 IO 5*1 85 98 23 1-0538 5-4 80 93 24 • • 1-0568 5*7 75 88 26 1 • 0602 6*o 70 83 27 27 1 -0641 6 4 65 78 29 1 -0685 6*9 60 73 31 1-0735 7*4 55 68 33 I*°794 7*9 5° 63 36 34 1 -0862 8-6 45 58 39 1-0943 9"4 40 53 43 1 ’ 1042 io#4 35 48 47 1-1163 ir-6 30 43 53 65 1-1316 13-2 25 38 60 1-1515 15-2 20 33 69 1*1786 17-9 15 28 81 1-2174 21*7 10 23 99 102 1-2776 27-8 5 18 126 • . 1-3846 38-5 O 13 174 177 * * f The observed average is obtained by taking the mean height of districts at the elevation 10-40 feet at 30, those at 40 GO at 30, See. Sec. Elevation. lxv DIAGRAM the average mortality from cholera was 22 in roooo inhabitants. The relation discovered between the elevation of the soil, and the mortality from cholera, is so important that it was thought right after the above calculations were made to submit the principle to another test, by comparing the elevation and the mor- 'xvi London : Density , Wealth , and Poverty. (ality from cholera of each sub-district. The population of the sub-districts in 1851 having been enumerated, it became possible to construct the Tables in subsequent pages (pp. clxvi-ix) ; which, although it makes the mortality on the lowest level less, and is de- ranged by the deaths in hospitals and workhouses, entirely confirms the announced law. LONDON.— DENSITY. Density of population within the limits of the London districts is a less important element than elevation of soil. For in the table (1) where the districts are arranged in the order of the mortality from cholera, the density is least on the average in the 1 9 districts where the mortality from cholera is greatest. The wealth of the 19 districts, represented by the rental of the houses, and the elevation of the sod, here completely mask the effects of density ; the mortality in the wealthiest and densest distiicts is less than it should be by the elevation scale (a). The districts in the same table (1) are thrown into three groups, distinguishing the sources of water supply ; and there the density is invariably greatest in the groups of highest mortality from cholera. Again, in table 3, where the districts are arranged in the order of density, the 19 densest districts had 178 inhabitants to an acre, and the mortality from cholera was at the rate of 71 in 10000 inhabitants; while in the 19 least dense districts, where the inhabitants were only 34 to an acre, the mortality was 61 in 10000 inhabitants. A five-fold increase of density (from 34 to 178) was accompanied by an increase of one-sixth in the mortality ; which may however be caused by the difference in the elevation and wealth of the two groups of districts. In the New River districts and the districts supplied with the waters of the Thames below Battersea the mortality from cholera is greatest in the densest districts ; but those districts are also the lowest and the poorest. In all the 6 districts supplied by the water of the Thames, from Kew and Hammersmith, the mortality from cholera is low ; but the mortality is lowest in the three densest districts which happen to be only half as wealthy as the rest. The following table seems to indicate that the mortality from cholera increases to the density of 150 persons to an acre, and then decreases to 250 — 284 to an acre. But it will be seen that the elevation and wealth interfere with the results, the two latter groups being much above the average in both respects. The great drains and ditches are also generally left open until the density of the population becomes considerable ; and this ought to be taken into account; but we have not yet the means of showing the area of uncovered drains left in the different parts of London ( b ) p. lxvii. LONDON.— WEALTH AND POVERTY. Wealth appears to influence the mortality of cholera. Under the income tax a return was made of the annual value of houses which serve indirectly to indicate the wealth of the inhabitants. Shops and some public buildings, returned under this head, disturb the results; but the division of the value of the homes of a district by their number, or by the number of inhabitants, shows the relative wealth of the dis- tricts better than any of the other indirect tests at our disposal. Wealth represents food, lodging, clothing, cleanliness, medical advice in sickness to a certain extent, as large masses of people supply themselves with these necessaries in proportion to their means. (a) Elev.it ion, 1 Mortality from Cholera. Density, or Number of Persons to an Acre. Average Annual Value of Houses in Feet. By Observ- ation. By Elevation Scale. • £. *5 106 81 96 30 1 6s 26 29 117 62 lxvii Wealth and Poverty. If the 19 wealthiest districts are compared with the 19 poorest districts, the mor- tality from cholera is found to be inversely as the wealth, measured by the value of house-room (e). The value of house-room is as 8 ’140 to 3*831 in the two groups, while the cholera was in the inverse ratio of 43 to 90. In the three groups arranged to show the effect of water supply, it will also be found that the poorest population suffered most from cholera as well as from ordinary causes ; but that the influence of wealth on cholera was greatest in the districts which experienced the fewest deaths in ordinary years, and were supplied with Thames water from Kew and Hammersmith. Elevation however interferes considerably with these results. If the 10 districts not differing greatlv in elevation, but all lying on an average under 10 feet, are arranged in the order of wealth, this singular result is obtained — that the five poorest districts ex- perienced the least average loss from cholera. The mortality from cholera in 10000 was 151m the 5 richest, and 122 in the 5 poorest districts. At the higher elevation of 10 to 50 feet there are 18 districts. The average value of houses in the 9 wealthiest, and the 9 poorest districts was io’282 l. and 3*7 37 A ; the mortality from cholera was 47 and 53 in 10000. The rent of house-room was as 3 to 1, and the mortality differed only one-eighth part. The mortality from ordinary causes differed to nearly the same extent; it was at the rate of 223 and 256 in 10000. Ten districts are at elevations of 50 feet and upwards ; the average value of house- room was 7-199/. 'n l'ie 5 richest, and 4-907/. in the 5 poorest districts. The mortality from cholera in the same districts was 21 and 28 in 10000; greatest therefore in the poorest districts. The general mortality was at the rate of 227 and 226 in 10000. Under these circumstances I find it impossible at present to establish any definite relation between the various degrees of wealth and of the mortality of cholera, further than that in districts of some elevation wealth does exert a certain influence on the mortality both of cholera and of ordinary causes. ( b ) Districts of London classed in the order of their Density of Population. Densitv. Average Number of Districts. Persons to an Acre. Elevation in Feet. Annual Value of House and Shop room to each Person. Annual Mortality to 10000 persons Living. Cholera, 1849. All Causes (1838-44.) 12 O — 50 55 £ 5*304 66 215 8 50 — IOO 27 7*142 52 236 6 100 — 150 29 6*730 104 248 4 150 — 200 23 3-641 87 274 6 200 — 250 5r 6*585 42 26l 2 ''d* 00 1 O VA 46 6-099 40 251 (0 Average Value Annual Mortality Of Houses. Of House and Shop room to each Person. From Cholera, 1849. From all Causes, 1838-44. Elevation, in Feet. 19 Wealthiest Districts £. 66 £. 8*140 43 226 61 19 Poorest Districts . 26 3-831 90 254 20 f2 lxviii Coincident Mortality of Cholera and of other Diseases. In the annexed Table the districts of different degrees of wealth are classed in order ; and it will be seen that the differences of mortality maybe in a great measure accounted for by the column of elevation ( d ). LONDON.— MORTALITY FROM ORDINARY CAUSES. The ordinary mortality of the districts of London has been deduced from the returns of 1838-44 and the Census of 1841. There is a certain relation between the degrees of mortality from ordinary causes and the mortality from cholera. The mean mortality of 1 9 districts in which the mortality is the highest from ordinary causes, was at the rate of 268 in 10000; the mean mortality of the other 19 districts was 212 in 10000. The mortality from cholera was at the rate of 84 and 48 in the same two groups of districts ; there was a density of 1 5 5 and 57 persons to an acre ; and the elevation was in the inverse order of 26 and 55 feet. When the districts supplied with the same water are placed together in three groups, the general mortality, the mortality from cholera, and the density of population, are in similar direct ratios; the elevation is in the inverse ratio. There is a very constant relation between the mortality from ordinary causes and the density of population. This has been shown before, and is illustrated in the annexed Table. The value of houses also increases generally with the density; hut it is only within certain limits ; for the densest are here the poorest districts ( e ). (d) London Districts, arranged according to the Annual Value of House and Shop room to each Person. Number of Annual Value of House and Shop room to each Person. Average Elevation Average Density. Average Annual Mortality to 10000 Persons living. Districts. Feet. Persons to an Acre. Cholera (1849). All Causes (1838-44). ! 6 £. 2-5 — 3-5 17 u8 98 259 8 3*5 — 4*5 23 93 83 25 1 10 4*5 — 5 ‘5 30 85 73 234 ! 3 5’5 — 6-5 157 154 32 246 3 6-5 — 7-5 29 160 67 262 1 7-586 100 102 17 227 1 8-875 19 65 28 194 * 9’349 76 32 8 i97 I 11-844 35 81 37 240 I 12-669 43 222 l6 212 I 16-754 49 57 8 179 I 17-676 , 38 129 38 214 (e) London Districts. — Arranged in the order of the Mortality from all Causes. No. of Districts. Annual Deaths from all Caus?s to louoo Inhabitants. (1838 — 44.) Avebaof. Annual Deaths from Cholera to 10000 Inhabitants. (1849.) Elevation in Feet above Thames High-water mark. Density, or Persons to an Acre. Annual Value of House and Shop room to each Person. 7 Und>T 200 42 36 27 i 7*640 ; 5 200—2 25 2 r 120 89 9-303 J I 225—250 63 30 93 5 ’430 7 250 275 86 30 174 4-290 8 275 & upwards 103 ‘7 147 4-703 Why is Cholera Fatal in Low Places ? lxix CONDITIONS IN WHICH CHOLERA IS MOST FATAL. It has been shown in the general analysis of the returns from the whole kingdom, that cholera has not only been most fatal in the low, and least fatal in the high parts of the country, hut that the fatality has diminished proportionally as the dwellings of the population have been raised above the sea level. The epidemic began and was most fatal in the ports on the coast ; and in ascending the rivers step by step, we saw it grow less and less fatal. It became probable that a certain relation existed between elevation and the power of cholera to destroy life. The more exact information which we possess respecting the London districts establishes this connexion beyond doubt. The relation may not be expressed by the same figures in other places, or in London at other times, but it will always be the general rule that the mortality of cholera is inversely as the elevation of the people assailed above the sea level. Mere density of population had not the same direct effect of increasing the mortality in this disease as in others; for in many inland towns, and in high, dense parts of London, the mortality was slight or inconsiderable. Neither does the mortality from cholera vary in the London districts in any ratio of the density. Still density and numbers of people are not to be lost sight of; for the cholera was not fatal to many in- habitants of thinly peopled, though low and marshy parts; while in such localities it was very fatal in nearly all towns. The law is, that the mortality in toivns of some- extent and density is inversely as the elevation. The wealth of different places differs in amount and distribution. The differences in wealth and poverty probably have an effect on the mortality. But abstracting the indirect effect through the seleciion of sites and the supply of water, the great differ- ences in the wealth of the London districts do not enable us to detect a very marked or constant influence of this element on the mortality from cholera. In the country at large there is no reason to believe that the wealth of the iniiabitants increases as we ascend the high grounds which the cholera left unscathed. The reverse is probably the fact. Elevation of the land involves several conditions which have an important effect on life and health. As we ascend, the pressure of the atmosphere diminishes, the tem- perature decreases, the fall of water increases, the vegetation varies, and successive families of plants and animals appear in different zones of elevation. The waters roll along the surface of the rocks, or filter through them and the porous strata of the earth to burst out below — the sources of rivers, or of tributaries which carry disintegrated rocks, with the remains and excretions of vegetables, animals, or men, in every stage of decomposition. The deposits in stagnant places, and at the estuaries, show the kind and quantity of mixed matter which the laden rivers carry down and deposit on the low margins of the sea at the tidal confluences of the fresh and salt waters. If we take a series of towns on a river it is evident that the refuse matter of the first town will pass through the second ; of the first and second through the third ; of the first, second, and third through the fourth ; and so on to the lowest town, which will be traversed by all the unevaporated and unwasted organic matter that has found its way into the waters on their way to the ocean. As the transformation of decaying organic matter into inorganic and innoxious elements is constantly going on, it will be in many cases completely decomposed in its course. What has been said of the refuse of towns will apply to the leaves of the forests, and to vegetable remains of all kinds. As the rivers descend, the fall of their beds often grows less, and the water creeps sluggishly along, or oozes and meanders through the alluvial soil. The drainage of the towns is difficult on the low ground, and the impurities lie on the surface, or filter into the earth. The wells and all the waters are infected. Where the houses are built on hill sides and elevations, as in London, the sewage of each successive terrace flows through the terrace below it, and the stream widens, the ground becomes more charged, every successive step of the descent, until it is completely saturated in the parts lying below the high-water mark. The river, the canals, the docks, and the soil of a port may be viewed as a large basin full of an almost infinite variety of organic matters, undergoing infusion and distillation Lxx Physical Effects of Elevation. at varying temperatures; and as the aqueous vapour which is given off ascends, it will be impregnated with a quantity of the products of the chemical action going on below, variable in amount, but necessarily greatest in the lowest and foulest parts. The emanations, mixing with the superincumbent atmosphere, ascend like smoke ; but at the same time become less and less dense by dilution and by the gradual destructive decomposition. A glass vessel, perforated by small holes, filled with pure water, and dipped into a coloured solution, might give a good idea of the atmosphere of such a town ; the coloured solution flowing down the sides would grow thicker by every accession of colouring matter, as it descended, and at the same time colour the water above with a tint deepening in intensity. Or if the river basins of the country were quite smooth and even, the sides descending rapidly at first and then slowly, the fall over the whole face of the country of rain flowing in thicker and thicker sheets as it descended, would present a good image of the phenomena ; but perhaps not so vivid as the vapour which, when the rain ceased, would arise from the wet and saturated soil in every degree of density, from the thickest fog round the marshy bottom to the thinnest mist upon the hills. From an eminence on summer evenings, when the sun has set, exhalations are often seen rising at the bottoms of valleys, over rivers, wet meadows, or low streets ; the thickness of the fog diminishing and disappearing in upper air. The evaporation is most abundant in the day ; but so long as the temperature of the air is high, it sustains the vapour in an invisible body, which is, according to common observation, less noxious while penetrated by sunlight and heat, than when the watery vapour has lost its elasticity, and floats about surcharged with organic compounds in the chill and darkness of night. The amount of organic matter, then, in the atmosphere we breathe, and in the waters, will differ at different elevations, and the law which regulates its distribu- tion, will bear some resemblance to the law regulating the mortality from cholera at the various elevations. It has been seen how rapidly in London the mortality from cholera diminishes a few feet above the low ground on a level with the Thames, while several feet of elevation in higher regions produces no sensible effect. The same thing holds in drainage. The ground on a level with the outlet cannot be drained at all, while a few feet of elevation make drainage practicable, efficient, and easy. And the law holds that while a few feet of elevation are so important near the outlet, they are of little or of no importance on the higher lands of the country. The diagram at page Ixv represents roughly the facilities of drainage, as well as the mortality from cholera at the several elevations.* It is established by observation that cholera is most fatal in the low towns, and in the low parts of London ; where, from various causes, the greatest quantity of organic matter is in a state of chemical action ; and it may be admitted that cholera, varying in intensity with the quantity, is the result of some chanye in the chemical action of this matter; leaving it open for further inquiry to determine whether, in England, that change is spontaneous, or the result of ti;e introduction of a zymotic matter from beyond the seas; whether the poison enters the human frame in air or water, through the skin, the mucous membrane-;, or the air-cells of the lungs. If the facts are so, it follows, that cholera will not only be fatal on low ground, but on high ground, if, from any concurrence of circumstances, the conditions exist there which are so constantly found in alluvial soils, lying on a level with or below the tidal waters. Now these conditions did exist in nearly every place severely visited by cholera on ground much above the sea level; in Salisbury, Merthyr Tv dvil, Bilston, Newcastle- under-Lyme, and Church-street St. (iiles, London. The atmospheric pressure and the temperature diminish with the elevation; and it is easy to conceive that either may exercise considerable influence when the elevation is considerable. The rarity of the atmosphere, or the perpetual snow on the Himalaya and the Alps, may be alleged as the causes why the epidemic never * See Table relative ati Mouvement <le l’ean dan* le* Canaux et lvivicre* : in Levant de Mceanique Pratique, par A. Morin, J" Partie Hydraidique, p. 71. Estimated Number of Cholera Attacks. lxxi crossed their passes. But the barometric column is depressed little more than i-iothof an inch for an elevation of ioo feet ; the atmospheric pressure therefore is not i-300th part less at that elevation in London than it is at the water level. The difference in mean temperature, produced according to the ordinary computation by that elevation, dojs not exceed 4-ioths of a degree of Fahrenheit’s thermometer.* Both these changes of temperature and pressure affect the organization, and they may be greater in summer than in other seasons ; but when it is found that great and sudden changes of heat and pressure are borne with impunity, and moreover, that cholera has prevailed at different latitudes in different seasons, it does not appear probable that here these physical changes had much effect on the fatality of the disease. Besides this, it has been shown that an elevation of 10 feet above the water level diminishes the mortality from cholera very considerably ; while a difference of ten feet at the higher elevation of a hundred feet, has little effect on the mortality of that disease. The variations of temperature and of pressure follow laws entirely different, and are too slight at elevations differing only ten feet to be the direct cause of the great difference in the mortality of cholera. Certain diseases arise when men are crowded together in close dirty gaols, camps, or hospitals ; when they inhale morbid exhalations, or are placed in contact with others labouring under such zymotic diseases as small-pox ; and when they reside in marshy countries. The explanation of the diffusion of cholera by an organic matter is therefore consonant with what is known of the etiology of other diseases. It has been shown already that when the cholera invades a place, it generally ad- vances slowly at first ; then that great numbers are attacked : and at the same time that many have ail the symptoms of Asiatic cholera, others have cholera of a milder type: a class still more numerous have choleraic diarrhoea; and great numbers have disorder of the bowels, sickness, indigestion, and slight cramps. The stated proportion of deaths from cholera, out of a given number of cases, varies not only with the malignity of the form and with the medical treatment, but with the definition of the disease : some taking as cholera only cases in collapse, others including the mildest forms : the lighter forms of diarrhoea are seldom noticed in medical registers, and rarely come under medical observation. Cholera has rarely been fatal in England to more than 1 in 2 attacked ; and it may be laid down, that for 1 death, not more than 3 persons were attacked »n the severer way uj- The deaths from cholera in the last 3 months of 1848, and in the year 1849, were 54398 ; the deaths from the disease in 1849 were 53293 ; which may be taken to represent the deaths in the two years from the Asiatic type, leaving 1105 as from the common variety. About 160000 persons then may have been attacked by cholera in England. The population was about 17,541 ,000 in the middle of 1849; so that 17,381,000 of the population escaped attack. The deaths from diarrhoea in 1849 were 18887 ; 3887 may be set down as the result of common diarrhoea, leaving 15000; and if there are 100 cases to 1 death, the cases induced by the epidemic must have been 1,500,000. Less than x in 10 of the population were attacked by cholera or diarrhoea. By the table, p. cxxx, it will be seen that in all England 30 died of cholera, 1 1 of diarrhoea to 10000 living ; of whom, by the previous estimate, 90 must have sustained an attack of cholera, and 1100 an attack of diarrhoea. In London, upon the same basis, it may be estimated that 1886 in 10000 inhabitants had an attack either of diarrhoea or cholera. In Hull, the district in which the mortality was highest, 24 r died of cholera, 40 of diarrhoea, in 10000 inhabitants; of whom 4723 must have been attacked either by cholera or diarrhoea. If an exact return of every shade of the disease could be procured, it is probable that it would be found over a great part of the country in one form or other — differing not in nature but in intensity ; never in any place attacking all the * f = j j . 00j e> where e is the elevation in feet, and f the change of temperature in degrees of Fahrenheit. f The cases of cholera reported to the Central Board of Health in England, 1831-2, were 82528, the deaths 31376 ; the mortality was consequently at the rate of 38 deaths to 100 cases. lxxii Indian Origin of the Cholera. inhabitants, and, as we have seen, leaving few districts without one or more deaths to mark its presence. Under any circumstances it is certain that in this, as in other zymotic diseases, great multitudes of the people who in one way or other take an average dose of the poison resist its influence : and it may he admitted that the numbers attacked bear some proportion to the quantity of the specific matter in the air, water, or earth of the place where they dwell. This specific matter is known only by its effects; but it has been shown that the deaths from cholera vary in some proportion to the quantity of organic matter in the state so commonly observed in the low parts of low towns. Our generali- zation then goes to this extent, that the cause of cholera is some chemical modification of organic matter; and here is the great practical fact — that although elevation of habi- tation, with purity of air and privity of water, does not shut out the cause of cholera , it reduces its effects to insignificance. ORIGIN OF THE CHOLERA EPIDEMIC IN THE DELTA OF THE GANGES. Cholera has prevailed in many parts of the civilized world, and has probably not spared unexplored regions of whose barbarous inhabitants little or nothing is known. It appears to have followed everywhere the same general laws; affecting most fatally the low seaports and the cities near the mouths of rivers, and sparing the inhabitants of high grounds around the river sources. The physical circumstances of the country in which cholera first assumed the epidemic form throw great light on the causes of its mortality in other places. India was at the time covered by an intelligent band of army medical officers. They were called upon for returns which were made the basis of official reports, in Bengal by Jameson, a man who like Pringle, kind, Jackson, Blane, and Martin, had the genius of medical topography ; by Scott in Madras, who drew up a judicious and able report on the ravages of the disease in that presidency; by Steuard and Phillips in Bombay. Annesley, Kennedy, and Orton have described and analyzed the disease; Martin has written a medical topography of the country; so that the information respecting the origin is more complete in respect to this than to any other great epidemic. The Indian epidemic began in the Delta of the Ganges. Mr. Orton thus sums up the evidence of the Reports : — “ The epidemic had not one but various local sources in the level and alluvial, the marshy and jungly tract of country which forms the Delta of the Ganges, and extends fjom thence to the Burrampooter. For here we find it as early as June, and the beginning of July, 1817, noticed as prevailing to a serious extent in Nuddea, a province which is stated to he notorious for the disease in its endemic form, and in Dacca.”* “ Jessore, the place in which the disorder first put on a very malignant form, is,” says Jameson, “ a crowded, dirty, ill-ventilated town, surrounded by a thick jungle, and in the rains by an immense quantity of stagnant water. * * In Sylhet the influence of situation was perhaps more remarkable than in any other quarter. * * It appeared that the villages in which it raged most extensively were considered by the natives as comparatively unhealthy and obnoxious to fevers of the intermittent type ; being exposed to the effluvia arising from marshes and extensive lakes, in which the Zila abounds, particularly towards the south-west division, where the greatest number of victims fell. The Sepoy lines, on the contrary, being placed from sixty to a hundred feet above the general level of the country, had scarcely any eases excepting such as occurred in persons on guard at the different outports. “ In Calcutta, again, the disease was, from first to last, most prevalent in the lower parts of the town and suburbs, as the Bura Bazar, Simeleia, Dyahutta, and Suwah Bazar; and in the suburbs, the villages of Khidderpore, Bhuwanipore, Manicktolla, Kurrya, Entally, Chitpore, and Sealdah. “ These dependencies are everywhere intersected by pools, broad ditches, and channels, which, being imperfectly drained, are in the rainy season always full of stagnant water and rank weeds. • Orton on the Epidemic Cholera, 2nd edition, p. 329. lxxiii Theories and Analogies. “ From this plentiful source of corruption, foul air is constantly given forth ; and as all ventilation is obstructed by large groves of trees and vegetation of every description, it is there concentrated until it becomes entirely unfit for the purposes of respiration. “ The miserable condition of the generality of the inhabitants of these villages is hardly to be imagined. Each hamlet is made up of many mud or straw huts, generally from six to twelve feet square, placed so close to each other as to leave scarcely room to pass between. In every one of these wretched hovels a whole family, some- times consisting of six or eight persons, resides ; and not unfrequently cows, pigs, and other domestic animals add to the filth and foul atmosphere in which they abound. The singularity is not that persons so situated should be more than others subject to the influence of a prevailing epidemic, but that they should ever be free from maladies of this description. “The higher classes of natives, and Europeans generally, inhabiting the better raised and more airy parts of the town, suffered proportionably less than the lower ranks.”* * * § Such was the condition of a large part of the dense population in the birthplace of cholera. The returns of the mortality among the natives are very imperfect ; but they show that while many thousands perished in Calcutta and the districts on the Ganges as far as Allahabad, the casualties higher up the river were “ comparatively fewer: in Agra the deaths did not exceed io daily, although the town contained 30000 people. Not 500 in all died in Muttra; and about a like number died in the immense city of Delhi.”f Mr. Jameson and Mr. Scott give other examples of towms and camps on low grounds suffering severely, and of elevated spots escaping with little loss ; they also cite, excep- tionally, instances of camps and cities on high ground suffering attacks of great severity, or of high places escaping for a time and being assailed in after years. The early Indian returns of mortality were imperfect and often incorrect : the relative eleva- tion is rarely stated ; it is impossible therefore to determine how far the law deduced from the English returns regulates the Indian observations. The general result is summed up by Mr. Jameson in words as precise as the observations justified : — “ There is abundant proof that in high , dry , and generally salubrious spots, it was both less frequent in its appearance and less general and jatal in its attacks than in those that were loiv and manifestly unwholesome.” \ THEORIES AND ANALOGIES. A cholera, which, in all its leading symptoms, is the same as the epidemic disease, has existed from time immemorial in Europe and Asia. Cases are related in the earliest medical writings, and occur sporadically every year in England. The disease in the epidemic is a variety, well characterised by the duration of the fatal cases. We call the one variety Summer cholera, the other Asiatic cholera, merely to give them distinctive names. Wiih the facts before us will any theory account for the pheno- mena? What is the cause of Summer cholera? What is the cause of the Asiatic cholera? Why does cholera in one year destroy only a few lives and occur sporadi- cally, in other years spread successively over the whole world, and destroy a million or more of the inhabitants in a short space of time? In what way is the malady pro- pagated ? This pestilence like others has been ascribed to great phenomena in the heavens and the earth, which shake the minds of men, and have sometimes happened at the same epochs, or a few years before or after the ravages. Comets, eclipses, meteors, earth- quakes, “ violent commotions in the earth’s organism, ”§ besides exciting strong allied emotions, have some points of analogy with pestilence in their going and coming. A * Report on Epidemic Cholera Morbus in the Presidency of Bengal, in the years 1817-8-9 (pp. 107- in), try James Jameson, Esq. f Pages 174-5. t I Report on Epidemic Cholera Morbus in the Presidency of Bengal, in the years 1817-8-9 fp, 106) by James Jameson, Esq. § Hecker on Epidemics, translated by B G. Babingtou, M.D. (pp. 1 1-2 1.) lxxiv Volcanic Action. comet as it approaches the earth’s orbit, flames through the firmament, recedes, and disappears, serves to illustrate as well as a diagram, the rise and decline of an epidemic ; but no theorist has ever proved that there is any constant connexion between comets and plagues, much less that there is any coincidence in the succession of their phenomena. The theory of volcanic agency has been ingeniously advocated by a recent writer who has closely studied cholera and other epidemics.* He discovers five points in which the phenomena of volcanoes and o! pestilences agree, and thus summarily lays them down as laws: — I. The effects of volcanic and pestilential action are felt along parti- cular lines of the earth's surface. 2. There is regularity in their progress both chrono- logically and geographically. 3. The effects of subterranean agency are lesson secondary than on tertiary strata, while they are seldom witnessed on primary formations. 4. They are always natch greater and more perceptible near the sea, and oiher collections of waters, as lakes, rivers, [springs ?j. 5. And, finally, the phenomena of volcanic erup- tions and pestilence have, in common, a limited duration, periodical returns, and total cessation in the particular locality after certain definite periods. The theory assumes that the pestilence is caused by “ poisonous elements generated in subterraneous reser- voirs, and diffused in the surrounding atmosphere. ’’I The work of Mr. Parkin must be consulted for the discussion of all the facts which support the theory. The gases and ashes which escape front volcanoes have been analyzed, but the “ poisonous element ” has not been identified or detected in places suffering from cholera. Cholera is appa- rently not more fatal in the immediate neighbourhood of volcanoes thau it is elsewhere, and its successive outbreaks in the district* of England have not, in 1832 or 1849, been preceded, accompanied, or followed by any earthquake or visible volcanic phe- nomena. Tempests, thunder-storms, showers of rain, the formation o^ clouds, evaporation, and combustion, present many analogies with the pestilential outbreak. The gentle wind quickens into a violent tornado, traverses lines of country, prostrates everything in its course, and then quietly dies away like cholera, to reappear again at intervals and in other places. The cloud, no bigger than a man’s hand, lies quietly on the sky, spreads, covers the heavens; a few drops of rain fall, the lightning flashes, the thunders roll, the waters descend in sheets on the earth; then the tempest subsides and the atmosphere is more tranquil than it was before, just as the phenomena succeed each other in tin epidemic. In combustion the fire smoulders for a time, until the whole mass is heated ; then chemical action is accelerated; the flame bursts out, intense heat is evolved, and the fire subsides when the combustible material is consumed. Blights and the sudden development of infusorial and cryptogamic life present so many analogies with epidemics in the r effects on the vegetable kingdom, their diffusion, and their course, that they have been by some regarded as the causes of pestilence. i The growth of grasses also presents a parallel. The cholera in England kept pace in its development with the wheat plant, which took root in October, germinated in the winter, flowered in June, filled in July and August, was cut down by the reaper before the lir*t week in September when cholera was most rife, and would have been dead ripe in October and November when cholera ceased. Many striking processes of the inorganic as well as of the organic kingdom, present series of developments which have analogies with, hut are trot causes of pestilential phenomena. The theorist, however speculative * “On t lie Influence of Vulcanic Action in the production of Epidemic Diseases,” by John Parkin, Fellow of the ltoyal Academy of Madiid, &c. &c., 1845. -'If- Parkin's life presents a rare example of courage and zeal. “ Having,” he says, “ followed the epidemic cholera for some years, and having paid frequent and oft-repeated visits to districts in which malaria abounds, it has generally happened, after I have been residing for any time in other and more healthy localities, that 1 was, on my arrival in an infected district, attacked with the prevailing complaint, no matter whether it was epidemic "or endemic; that is to say, the cholera, fever, or dysentery,” p. 22. Mr. Parkin was in Loudon in 1849, and went to Jamaica on the outbreak of the epidemic there. He is a sanguine advocate of the treatment by carbonic acid gas. t Pages 39-60, 185. £ The hypothesis of insect life as a cause of disease is stated with much ingeuuity by Dr. Holland in liis Medical Notes. Heat, Electricity, Ozone. lxxv he is, may. by tracing these analogies, often open the way to a happy generalization, which admits of practical applications, and is the explanation of the facts. Heat has a great influence on the intensity of the epidemic cholera, which began on the verge of the torrid zone, and in the temperate zone has been unquestionably most fatal in the hot season of the year : there is, however, no constant relation between a high temperature and this variety of cholera: it does not prevail so frequently in other hot climates as it does in the East Indies, and it has in some places raged with the greatest violence in winter, where, however, as in St. Petersburgh, the dwellings are always heated artificially. As eacli place at different latitudes has its harvest season so it appears to have its pestilential season. The hypothesis that Electricity is the cause of cholera has been advanced by recent writers of ability. Mr. Orton has summed up all the facts and arguments in its favour.* He suggests rather than asserts that a “ deficiency of electricity,” or a negative, instead of the more common positive electricity of the at mosphere, is the “ primary remote cause ” of the epidemic. Mr. Orton, with the candour that marks bis writings, adds, that if the condition in question “ is absent in a single instance of a general attack, the theory must fall to the ground.” Many examples of thunder- storms, and of great electrical disturbances, have been noted in the epidemic years. Similar disturbances happen in other yeais, and neither Mr. Orton nor any other writer has succeeded in showing, from observations with the electrometer, that there is any invariable relation between the progress of electrical phenomena and epidemic out- breaks of cholera. No importance can be attached to the stories of the inaction of the electrical machines of certain philosophers, any more than to the isolated observation of Dr. Prout's barometer in 1832. Schonbein, the Professor of Chemistry at Basle, has given a new turn to the elec- trical theory. His experiments and the investigations of De la Bive, Marignac, Ber- zelius, Erdmann, and Marchand, prove that pure or atmospheric oxygen, on being- expose 1 to the action of electrical sparks, is transformed into an odoriferous matter, which he calls ozone ; declared by them to be nothing but an allotropic modification of oxygen. The results of his recent researches incline him to adopt their view, although he had previously considered it to be a peroxide of hydrogen. Be this as it may, ozone is found to be one of the most powerful oxidizing agents yet known. It transforms, in the cold, silver into the peroxide of that metal ; instantly decomposes sulphuretted or phosphoretted hydrogen, and acts upon almost all organic substances. He found that one dose of ozone would disinfect or destroy the smell of 3,240,000 volumes of atmospheric air saturated with the miasms of putrid flesh. Ozone, in variable quantities, is incessantly formed bv electrical discharges continually going on in the atmosphere, and Schonbein’s observations show that its quantity varies in different places, and at the same place at different times. The. miasmatic matters thrown into the atmosphere by the infinite number of plants and animals hourly dying in the earth, water, and air, are, he is disposed to believe, decomposed by ozone, which is simultaneously destroyed. Ozone, like chlorine, irritates the lungs, and produced in Schonbein “ a painful affection of the chest, a sort of asthma, with a violent cough,” which forced him for a time to discontinue his investigations. Ou comparing his ozonometric observations with the lists of the catarrhal patient's of several physicians of Basle, they were struck by the coincidence between the unusual number of catarrhs and his “ blue days,” or days in which ozone existed in excess in the atmosphere. Schonbein does not think the question of causation decided, but strongly recommends ozonometric observations.! Instead of adopting this suggestion, and in the absence of observation, it was argued by some, when cholera was epidemic in 1849, that an excess of ozone was the cause of influenza, and that a deficiency of ozone was the cause of cholera! * Orton on the Epidemic Cholera of India, chap. ix. See, for another hypothesis, Mr. Orton’s chapter viii., on Sol-lunar influence. f “ On some Secondary Physiological Effects produced by Atmospheric Electricity,” by C. F. Schon- bein. Paper communicated to the Royal Medical and Chirurgical Society of London, by M. Faraday, D.C.L. ; Transactions, vol. xxxiv. or second series, vol. xvi., 1851, pp. 205-32. lxxvi Bad Water. That ozone exists in the atmosphere and destroys some miasms is probable ; but the hypothesis itself assumes that a cholera matter exists independently of ozone, by which it is supposed to be destroyed. Schonbein, by experiments on the Jura Mountains, ascertained that at 12-1800 feet above the level of Basle, his ozonometers exhibited higher degrees than they did at the same time in Basle ; whence he infers that the higher contain less miasmatic matter than the lower regions of the atmosphere. Jameson, in the last page of the Supplement to his admirable “Report on Cholera in Bengal,” after noticing that some of the natives placed “great faith in boiled water as a preventive,” and that one of the principal native gentlemen of Calcutta ascribed the “ singular healthiness of his numerous household to his having taken the simple pre- caution of allowing no water to he drank by them until it had been previously boiled,” adds: “ Bad water no doubt sometimes immediately induces the disorder; but we must not suppose it is the sole cause of it.”* * * § This is borne out by some observations in the Indian Reports; where, however, the sources of the water supply are too seldom referred to, although a popular belief prevails in many countries of India that it is the water which produces ague and remittent fever. f Dr. Barnes, who had medical charge of the district of Jessore in Bengal from i8ioto 1822, but who was absent in part of the years 1816 and 1817 when the disease assumed the epidemic character, stated in 1831, that he had there been intimately acquainted with the disease as an endemic. He had considered it from the first as a disease peculiar to that country and previously unknown, which had superseded the periodical remittent fever formerly so prevalent. If the annual storms of violent thunder, lightning, wind, and rain commenced early in March, and recurred at short intervals until the rainy season began, the hot season (April, May, June) was, he says, comparatively healthy, and conversely : if the rains broke up at the ei.d of August, and the waters sank rapidly during September, the cholera commenced its attack at the beginning of October, carrying death and, desolation among the inha- bitants until the midfile of December, when the disease in a short time became apparently extinct. Instead of the usual rainy and dry season, scarcely a week of 1816, in Jessore, was without rain; the^sun was constantly obscured; the atmosphere close, heavy, moist ; the thermometer from March to November, ranging between 70 and 95 . The crowded ill-ventilated native huts are on mounds surrounded with pits, which are the receptacles of stagnant water, and of every kind of filth. Dr. Barnes asserts unhesi- tatingly that in these circumstances the Asiatic epidemic was generated from the ex- halations arising from the decomposition of animal and vegetable mutter and the use of water in which this process was continually going on. “ These,” he emphatically declares, “ were the sole cause of this disease.’ % “ In the autumn of. 1849, Dr. Brittain and Dr. Swayne, of Bristol, considered that they had discovered the cause of cholera in a minute fungus; and Dr. W. Budd, of the same city, met with the supposed fungus in various specimens of water used as drink, in places where the cholera was very prevalent. ”§ Upon further investigation the supposed fungi were, by experienced microscopists, pronounced to be other matters ; and after the able Report of the Committee of the London College of Physicians, the hypo- thesis was genet ally abandoned. Dr. Snow, in a paper dated Aug. 29, 1849, advanced a theory of the pathology of cholera; and it is in many respects the most important theory that has yet been pro- pounded. Dr. Snow, after endeavouring in a subsequent paper to show that the disease is propagated by human intercourse, and that it is a local affection of the alimentary canal, thus states his doctrine: — “ The induction from these data is that the disease must be caused by something * Report on Cholera Morbus in Bengal, by James Jameson, p. 32+, Supplement. ■f See Bishop Heber’s Indian Journal, ed. 1843, chap, xvii., p. 253. In a previous |>age (251) is a good description of the depressing and degrading effects of malaria on man. 4 Letter addressed to Dr. Roupell, Dr. llabington, II. Field, Esq., and J. Ridout, Esq., members of the London Board of Health, dated Nov. 12, 1831, published in M‘Culloch and Maclaren on Cholera, pp. 26-35, l85°- § Dr. Snow on Cholera, paper read at the Epidemiological Society, 1851. lxxvii Dr. Snow's Theory. which passes from the mucous membrane of the alimentary canal of one patient to that of the other, which it can only do by being swallowed; and as the disease grows in a community by what it feeds upon, attacking a few people in a town first, and then becoming more prevalent, it is clear that the cholera poison must multiply itself by a kind of growth, changing surrounding materials to its own nature like any other morbid poison; this increase is the cause of the materies morbi of cholera taking place in the alimentary canal. “ The instances in which minute quantities of the ejections and dejections of cholera patients must be swallowed are sufficiently numerous to account for the spread of the. disease ; and on examination it is found to spread most where the facilities for this mode of communication are greatest. Nothing has been found to favour the extension of cholera more than want of personal cleanliness, whether arising from habit or scarcity of water, although the circumstance hitherto remained unexplained. The bed- linen nearly always becomes wetted by the cholera evacuations, and as these are devoid of the usual colour and odour, the hands of persons waiting on the patient become soiled, and unless these persons are scrupulously cleanly in their habits, and wash their hands upon taking food, they must accidentally swallow some of the excretion, and leave some on the food they handle or prepare, which has to be eaten by the rest of the family, who, amongst the working classes, often have to take their meals in the sick room. Hence the thousands of instances in which, amongst this class of the popula- tion, a case of cholera in one member of the family is followed by other cases: whilst medical men and others who merely visit the patients, generally escape. “ With only the means of communication which we have been considering, the cholera would be constrained to confine itself chiefly to poor and crowded dwellings, and would be continually liable to die out accidentally in a place, for want of the oppor tunity to reach fresh victims ; but there is often a way open for it to extend itself more widely, and that is by the mixture of the cholera evacuations with the water used for drinking and culinary purposes, either by permeating the ground and getting into wells, or by running along channels and sewers into the rivers.”* Dr. Lloyd, on August 30, 1849, at a meeting of the South London Medical Society, adduced instances of the great mortality from cholera, of people living in Silver-street and Charlotte-place, Rotherhithe, who got their water from a well and a ditch into which the privies discharged their contents. The disease was much more fatal in the parts of Rotherhithe where ditch-water was used, than it was in places which had their supply from the water-works. Dr. Snow has collected examples in the South London districts, where the water being derived from deep wells, few cases of cholera occurred ; and other instances of a great fatality among people living in houses, such as those in Wandsworth-road, where the contents of the water-closets found their way into the water. He shows, from a communication by Dr. Shapter, that in 1832 Exeter was supplied with water taken from the streams of the Exe, into which the sewers emptied them- selves ; and that subsequently water- works were established on the river, two miles above the town, and more than twro miles above the tidal range. In three months of 1832 cholera destroyed 347 lives in Exeter; in 1849 it was only fatal to 44 persons, many of them strangers, who died within three days of their arrival. An opposite instance is afforded by Hull, which in 1832 was scantily supplied with water from springs at Anlabv, three miles distant. About seven years since water-works were established on the river Hull, two miles and three-quarters above its confluence with the Humber, and afford the town a plentiful supply. But half the sewage of the town is delivered into the waters of the river Hull, halt into the Humber; the tide flows up the river many miles past the water-works, and carries with it the contaminated liquids of the sewers. In 1832 the cholera was confined almost enclusively to the poor, and the deaths amounted to about 300 ; in 1849 the deaths were 1178, and occurred among all classes of persons. f Negative and positive instances in other towns are cited by Dr. * “ On the Pathology and Mode of Communication of Cholera,” by John Snow, M.D. (Paper reprinted from the London Medical Gazette, pp. 2, 3). f Dr. Snow, pp. 7, 8. The numbers of deaths in 1849 are from the present returns. lxxviii The Unclean Water of London and Paris. Snow; and in their Reports to the Board of Health by Dr. Sutherland and Mr. Grainger. Dr. Snow’s theory of the propagation of Asiatic cholera in London is very simple. The cholera matter was brought to London by patients from Hamburgh ; it was multiplied in the intestines of infected people until the disease spread in this way all over the metropolis. It necessarily implies that the rice-water discharges of the cholera patients may, under the present system of water supply, be distributed unchanged to nearly every house in London, where water is used for drink, ablu- tion, and washing. Dr. Snow is unfortunately able to show that this e.vcremental distribution — almost too revolting and disgusting to write or read — is possible to a very considerable extent.* * * § The sewers of London run into the Thames and the Lea, from which a part of the water supply is derived. The water, which the inhabitants ot London have but the repulsive alternative to discuss in words or to use in fact, is however baled from the ditches only by the wretched inhabitants of such parts as Jacob’s Island. It is in one case before distribution pumped up to a distant reservoir at Brixton ; in other cases it is taken higher up the rivers, largely diluted, or beyond the reach of any but casual contamination ; filtration is employed ; chemical action, as the chemists on behalf of their wealthy clients tell us, is incessantly going on, and converting impurities into simple elements; so that it is only in some places, or in rare circumstances, that the organic waste can reach and injure the people. Still, in this mitigated form, the risk is too tremendous to be incurred by two millions and a half of the people, who require and can obtain an abundance of sweet water. The supply of Paris is from various sources, hut four-fifths of the water is from the Canal de l’Ourque, which, by the decision of Napoleon, was also appropriated to navigation. The water for some years, and in 1832 when the first epidemic was so fatal, was drawn from the duty basin in which the boats and barges of the canals rested ; but is now drawn from the canal before it enters the basin. The water in the Regent’s Canal round London, and in the Cumberland Basin, Regent’s Park, present a pretty faithful image of the waters of the Canal de l’Ourque, which flow from the foun- tains, and supply the wants of the Parisians. The water in the Cumberland Basin is described by l)r. Milroy as “in a most offensive state, and, indeed, no better than that of a stagnant putrid ditch ;” and a great deal of choleraic disease prevailed among the men who were employed in the barges, and most of the families living in the houses on the wharves were more or less affected. ”f The mortality of cholera in Paris was excessive, and in 1832 varied from 80 of xOOOO inhabitants in the elegant Chaussee d’Antin and in Montmartre on the heights, to 530 and 520 in the low Quartiers of the Hotel de Ville and the Cite.J The experience of Paris, then, as well as of many of our own towns, lends some countenance to Dr. Snow’s theory. The general argument in favour of the propagation of cholera by infection has been forcibly stated by Dr. Bryson, who brings facts from the experience of the navy to show that the existing virus may take effect at the distance of one or two miles, if not further; and, in contact with inanimate substances, may be conveyed to the distance of many hundred miles, provided the transit be accomplished within the space of about ten days.§ Dr. Bryson admits that the question of quarantine is surrounded wiih practical difficulties, as instances of cholera occurred in several ships of tire Mediterranean squadron before they had any communication with the shore where the disease was prevailing. Indeed, on the hypothesis of infection, which assumes that “ an atmosphere charged with the specific virus emanating from a population labouring under cholera and choleraic diarrhoea may prove effective at the distance of several miles from an infected locality;” or on the hypothesis of diffusion by water up the tidal streams, it is difficult to understand how the ordinary quarantine can at all exclude the epidemic. * “ On the Communication of Cholera,” by J. Snow, M.D., pp. 23-26. t Report of General Board of Heallli on Cholera, p. 48. J Etudes sur la Ville de Paris, par Horace Say, pp. 384-422, 481, and maps. And Rapport du Cholera dans Paris 1834. § On the Infectious Origin and Propagation of Cholera, by A. Bryson, M.D., Surgeon R.N., 1851, pp. 39, 46, 47- Contagion : Spontaneous Development. lxxix Nothing but the absolute cessation of all intercourse between this island and the rest of the world could be effectual. Instances are cited by writers on contagion of medical officers in attendance on cholera patients, suffering or escaping attacks of the disease; but they are seldom conclusive. In London, for example, one hospital physician and one hospital surgeon died of the disease : the mortality was consequently higher in this class than it was in the rest of the inhabitants of London. The two medical officers resided on the north side of the Thames; but the two hospitals, Guy’s and St. Thomas’s, are in two of the lowest and most fatal districts on the south side of the river, and cholera patients were not apparently admitted at Guy’s hospital, although they were treated at St. Thomas’s. The disease was not fatal on the higher ground, north of the Thames, to any of the medical officers of the hospitals where cholera patients were freely admitted. Whether any of them suffered from premonitory symptoms is unknown ; yet this is an element to be taken into account ; for it maybe assumed that in medical men the disease is more frequently checked in the early stage, when it is amenable to treatment, than it is in the rest of the community. The fact that the first cases of the epidemic appear in the sea-ports is not in itself a decisive proof of the importation of the disease ; for if it is ever indigenous, as it was on the Delta of the Ganges, it will almost certainly break out in such low places and cir- cumstances as are found in the neighbourhood of nearly all sea-ports. The hypothesis of spontaneous development in England has been advanced, and may be supported by arguments of some weight. Thus there can be no doubt that the epidemic cholera is closely allied in all its essential symptoms to sporadic cholera, and the conversion of the one variety into the other in England is not a priori impossible. The march of cholera and diarrhoea since 1838 presents the appearance of a progres- sive development. The deaths from cholera in England were 331 in 1838, 702 in 1840, and 1620 in 1842 ; from diarrhoea 2482 in 1838, 3469 in 1840, and 5241 in 1842. These diseases became much more serious in 1846, and raised the general mortality. In London the deaths in 1839, 1840, 1842, 1846, 1848, 1849, were 3 6, 6q, 118, 228, 652, 14137 from cholera; 376, 452, 7C4, 2152, 1913, 3899 from diarrhoea. The seasons of the year, and the circumstances of the people presented great variations in the twelve years, but on the whole they favoured epidemic develop- ment. The price of wheat rose rapidly from 39 s. a quarter in 1835, to 71s. in 1839, and then declined to 57 s. in 1842. The potato crop failed partially in 1845, in 1846 the failure was general, and the country in 1847 besides commercial distress, suffered some of the consequences of famine. The potato is antiscorbutic, and could not be replaced by other food of a different quality. Scurvy prevailed in many parts of the kingdom; influenza broke out as an epidemic at the close of 1847; the cholera eruption followed at an interval of a year. The spontaneous eruption of cholera has its analogue in the other zymotic diseases : thus small-pox, scarlatina, and typhus are five or ten times as fatal at some times as they are at others in districts of London. An isolated, local epidemic of cholera which broke out in the Coventry workhouse, appears to show that the spontaneous evolution of epidemic cholera is possible in England. The following account has been drawn up exclusively from the Registra- tion Returns, which did not in 1838 contain any statement of the duration of the fatal diseases. The season of the year, however, as well as the fatality of the disease, prove that the cholera had not the common character. The House of Industry at Coventry suffered in the beginning of 1838 a sudden ancl severe outbreak of cholera, when 55 of the inmates, 27 males and 28 females, perished by the epidemic. The first death occurred on the 7th of January, and on that and the four following days, seven cases were fatal; from the 12th to the 16th inclusive, 4 persons died; between the 17th and 21st, 15 ; between the 22nd and 26th, 20; be- tween the 27th and 31st, 7 ; and on the first three days of February, 2. 18 of the fatal cases occurred under 40 years of age, and 8 between that and 60; but the greatest mortality was between 60 and 80 years, when 20 patients sunk under the epidemic ; the remaining 9 died at upwards of 80 years. Fortunately the disease was confined to the house, and did not extend its visit to the town. CVJL lxxx Zymotic Theory. While the facts prove that the population was undergoing a morbid change, which may have issued in a great epidemic, it seems more consonant with the whole history of the disease to admit that while the materials were smouldering in England the flame which threw the mass into combustion was of Asiatic origin. It is not necessary to discuss the zymotic theory here, but I give in a note the substance of a paper on the subject which appeared in the Appendix to the Registrar-General’s Fourth Report. As there restricted, it only expresses certain facts in the history of diseases, and of cholera among the rest, which are shown to be analogous to other facts with which chemistry is conversant. It may, I think, be admitted that the disease Asiatic cholera is induced in man by a certain specific matter, and as it has been proposed to call the matter varioline which causes small-pox, so cholerine may designate the zymotic principle of cholera. A variety of that matter was produced in India in certain unfavourable circumstances ; it had the property of propagating and multiplying itself in air, or water, or food, and of destroying men, by producing in successive attacks the series of phenomena which con- stitute Asiatic cholera. That cholerine is an organic matter, cannot, I think, be doubted by those avho have studied the whole of its phenomena and the general laws of zymotic disease. The great questions remain — Is cholerine produced in the human organization alone and propagated by excreted matter? Is it produced and propagated in dead animal or vege- table matter or mixed infusions of excreta and other matter out of the body ? Is it propagated through water? through air? through contact? or through all these channels? Observations sufficiently exact to decide these questions definitively have yet to be made, and discussed on the principles of probability. The decisive facts cannot be investigated by experiments in which human life may be exposed to risk. They must be carefully looked for and noted by good observers. Conflicting theories serve, among other purposes, to direct the attention of observers to important points which they may otherwise neglect. While fully admitting the importance of theories, I have endeavoured to present, from the Returns, a view of the facts, without reference to any theory; and to show, inde- pendently of the theories, that the conditions in which cholera is or is not fatal, may be determined, and yield important practical deductions. Note. — The zymotic hypothesis, which is strictly applicable to all the known phenomena of cholera, is thus stated in the Appendix to the Fourth Annual Report, 8vo, of the Registrar-General, pp. 199 — 105. “ Miasm, properly so called, causes disease without being itself reproduced. * * * Carbonic acid and sulphuretted hydrogen, which are frequently evolved from the earth in cellars, mines, wells, sewers, and other places, are amongst the most pernicious miasms,’’ (Liebiy). Miasms produce diseases like ague, without being propagated by contagion ; and the poisons — carbonic acid, sulphuretted hydrogen, and other gases, which are given off by organic matter in putrefaction, afford an illustration of their action. The miasm which excites intermittent fever may be designated py retine ; and if it were not probable that modifications of the marsh miasm induce, in certain circumstances, remittent and yellow fever, specific names should be found for their principles. Rheumatic fever is apparently caused by a miasm.* Its changes of scat can scarcely be accounted for on the hypothesis that it is a local inflamma- tion of the fibrous tissue. Certain matters which have not yet been analyzed produce small-pox, glanders, hydrophobia, syphilis, measles, scarlatina, and other diseases ; and as it was before proposed to give names to the well-defined diseases produced by poisons, so, for the purposes of reasoning, it will be equally useful to name these specific matters or transformations of matter by which diseases are propagated either by inoculation and contact (contagion), or by inhalation (infection). The following list exhibits the popular and scientific names of diseases in juxtaposition with the pioposed names of their exciters ; and it may be assumed hypothetically, that in the blood corresponding bodies exist which are destroyed, and by the transformation of which the exciters are generated or reproduced. The names in the second column terminate in a, except a few in s. Lyssa (from \ueea., rabies), the old Greek term, has been lestored by Mason Good; I propose, for the sake of uniformity, to call puerperal fever mctria ; mumps, parotid, reserving parotitis for simple inflam- mation of the parot ids ; croup, truclteia ; and the disease from puncture in dissection, necusia («*»;, the dead body). • The exciting cause of intermittent fevers, rheumatism, anil [rheumatic] neumljjia, is generally admitted (?1 to be malaria; and if viewed abstractedly, and with reference to their spccillc nature, it it probable that malaria it the on/y 1 rcitiny cause of these diseases.— I’rout on Stomach and Urinary Diseases, p. SO. Zymotic Principles. lxxxi Diseases. Zymotic Principles. Small-pox . . variola. varioline. Cow-pox .... . vaccinia. vaccinine. Glanders. . . . . equinia. • equinine. Hydrophobia. . lyssa. lyssine. Syphilis .... . syphilis. syphiline. Infection in dissecting . necusia. necusine. Erysipelas. . erysipelas. erysipeline. Puerperal fever . . . .metria. metrine. Measles .... . rubeola. rubeoline. Scarlet fever . • . scarlatina. scarlatinine. Hooping cough , . pertussis. pertussine. Dysentery . , . dysenteria. ( enterine. Diarrhoea, . . . . diarrhoea. Cholera .... . cholera. ( cholerine. Influenza .... . influenza. influenzine. Typhus .... . typh us. typhine. Plague .... . pesti's. pestine. The existence of gangrenine, ergotine, ophthalmine, tetanine, miliarine, diphtherine, parotine, nphthine, tracheine, may also be admitted. It is maintained by some pathologists, that the same specific poison produces several of these diseases — erysipelas, necusia, and metria, for instance — but while the diseases are described as distinct, it will be most convenient to consider their exciters as distinct, although they may be convertible into each other, and be as nearly related as varioline and vaccinine. The chemical composition of these principles is at present unknown ; but as salts are distinguished from each other by their relations to other bodies, and, though they may have the same appearance in solution, are found to differ by the compounds which they form with other bodies in solution, so the existence is demonstrated by the effect, of the matter here called “ lyssine ,” on animals, although it cannot be detected by the rough analysis of artificial chemistry. The smallest quantity imaginable of lyssine inserted under the skin of a dog produces hydrophobia ; and the bites of the infected dog will throw other dogs, and even human beings, into a state similar to that of the dog from which the charge of lyssine originally came. Varioline in the same manner produces small-pox, if the patient has not previously undergone its influence or the influence of vaccinine — a modification of varioline. The diseases of this class have been frequently spoken of as fermentations ; and Liebig has now opened the way to the explanation of their nature by a reference to the phenomena attending the transformations of organic compounds, excited by the action of other compounds simultaneously undergoing analogous transformations. Thus yeast, which is gluten in a state of transformation, added to wort, which contains gluten and sugar, converts the gluten of the wort into yeast, and at the same time the sugar into alcohol and carbonic acid, the two transformations going on together, and the latter ceasing when the former ends. The yeast reproduces yeast, if gluten, from which it was originally derived, be present : and if the temperature and circum- stances be favourable, fermentation may be spontaneous.* It must be admitted, with respect to all the forms of these diseases, that the body, in the cycle of external circumstances through which it passes, may run into them spontaneously (in this they differ from the class of diseases referred to external causes), for it is impossible to trace them invariably to infectious sources ; it is not a priori more improbable that they, than other diseases, should arise spontaneously, and it is impossible to account for their existence in the world upon any other principle than that of spontaneous origin. Still the property of communicating their action, and affecting analogous transfor- mations in other bodies, is as important as it is characteristic in these diseases, which it is proposed therefore to call in this sense zymotic.f A single word, such as Zymotics, is required to replace in com- position the long periphrasis “ epidemic, endemic, and contagious diseases;” with a new name and a definition of the kind of pathological process, which the name is intended to indicate, persons who have not made themselves acquainted with the researches of modern chemistry can scarcely fall into the gross error of considering this peculiar kind of diseased action and vinous fermentation absolutely identical ; or of considering that others entertain that opinion. Liebig draws a distinction between fermentation and putrefaction: t lie reasons are more urgent, for distinguishing the pathological transformations from fer- mentation or putrefaction, while it is admitted that they are of a chemical nature, and analogous to fermentation ; by which they are moreover to a certain extent explained, although so little is known of the series of chemical changes and products in any single zymotic malady, or of the chemical reactions of the living forces and organs. Small-pox is by hypothesis the transformation of varioline, and certain unknown concomitant chemical changes in the blood and skin; manifesting the important symptoms which fall under direct observation. Some of the morbific principles are fixed ; others are volatile ; but the greater part of them are fixed and volatile in different circumstances. Necusine, pestine, syphiline, lyssine, equinine, and vaccinine, are * See Liebig’s luminous exposition of the doctrines of fermentation, in his Chemistry of Agriculture, Physiology, and Pathology. Two vols. -f- From ^v/ioui, I ferment : zymosis — fermentation, and zyma — ferment, may also be employed in English, not in the sense which they have in Greek, but as general designations of the morbid processes and their exciters. Zymosis, and the verb from which it is derived, occur in Hippocrates. See a good note and quotation from Galen, by Foesius, in the < Economia Hippucratis, appended to the Geneva edition (1602) of the works of Hippocrates. Coction appears to have been used by the father of medicine with the same qualification as ebullition and fermentation by Sydenham. See his Treatise on Ancient Medicine, vol. i. CEuvres Completes d’Hippocrate, par E. Littre, 1839. 9 lxxxii Zyviotics. the most frequently fixed ; they give rise, when placed on the skin, particularly where the epidermis is removed, to their peculiar diseases ; but contagion is not invariably the result of their contact ; indeed, in several of them it is the exception rather than the rule. Either there is no matter in the organization susceptible of transformation, or the specific transformation is overpowered by the vital energies; for in every case, if the morbific principle (zymine) tends to impart its movement to the organization, the organization, animated by the natural forces, has a tendency to continue its own processes, and to impart its conservative movements to all the organic matters which are brought within its sphere. Varioline is converted in the cow (as Mr. Seeley has shown) into vacciniue, and cow-pox affords an interesting illustration of the modifications which diseases undergo, and which may be imparted to them, by changes in their exciters. Vaccinine taken from the cow effects the transformation of the materics morbi in man almost as completely as varioline ; but it reproduces vaccinine ; and in the process is never fatal, never produces the variolous fever, and its vapour is never infectious like that of varioline. The mild form of small-pox which appears in persons modified by previous vaccination, or which follows small-pox inoculation, is an equally good example of the changes induced in diseases by the actual constitution of the individual, and the mode of infection. Syphilis, erysipelas, necusia, metria, rubeola, scarlatina, and the other zymotic diseases, also put on different forms ; which may be referred to the state of the exciter, the mode of its application, the matter on which the exciter acts, or the vitality of the patient. A modification of cholerine, or of enterine, probably produces diarrhoea. Louis considers dothinenteria (his Jievre typhoide) a different disease from the typhus of this country, and points out the ulcerations, particularly of the glands of Peyer, with the correlative phenomena, and the rose-spots disappearing under pressure, as establishing its distinct character.* The differences in certain cases are unquestionable, and may be expressed by dothinenteria and typhus : but the two forms of the disease occur in this country ; the characters are frequently mixed ; and they are not greater than are observed in scarlatina simplex, and scarlatina maligna, with black incrus- tations, and gangrenous inflammation of the throat — in the erythema and phlegmonous erysipelas of Mr. Lawrence, or in the varieties of other diseases. The blood which pervades the whole system is the primary seat of zymotic diseases ; but this does not diminish the importance of the local phenomena with which they commence, proceed, or terminate; for they affect (as poisons do) particular organs more extensively and frequently than others, give rise to specific pathological formations or secretions, and derive their character from the lesions and affected organs. The heat disengaged in these diseases suggested the term fever, derived from ferveo, as fermentum is from fervimentum. Some zymotic diseases recur, others happen only once in life, or if they happen twice, it is the exception: this has been explained on the hypothesis that some but not all kinds of matter (zymin) are reproduced in the organization after they have been destroyed by transformation (zymosis) in attacks of disease. The tendency of zymotic diseases to increase and decline in activity, is one of their most remarkable properties ; and the suddenness of their outbreaks, with the great mortality of which they were the cause, excited at an early period the attention and solicitude of mankind. This tendency is indicated by the terms epidemic and endemic ; the latter serving to designate diseases which are excited by miasmata, and prevail in proportion to the quantity of miasm developed ; the former, epidemic, denoting the diseases transmitted from man to man, independently of locality, or oidy dependent on locality, temperature, and moisture, as adventitious circumstances. For statistical purposes, the epidemic, endemic, and contagious diseases, have been classed under one head, as they may all be excited by organic matter in a state of pathological transformation. Ague is not contagious, and is apt to recur ; it therefore apparently approaches the class of toxical diseases ; but I feel inclined rather to consider it a zymotic disease, in which, to use the language of Liebig, the exciter is destroyed as soon as it is reproduced ; and this view is confirmed by the analogies of remittent fever, or yellow fever, so intimately allied in some respects with ague, in others with plague, and apparently contagious (though this is disputed) in certain circumstances. Scurvy is a transformation induced by the want or inadequate supply of vegetable food. It formerly decimated the English navy, and is now met with in certain prisons. Scabies and porrigo (both con- tagious diseases) are ascribed to an insect ( acarus scabiei) and a low form of independent organization. The mode in which zymotic diseases are propagated has offered the ground of an interesting comparison between their diffusion, blight of vegetables, and the generation of animalcules. Sydenham referred, in the following passage, to zymotic diseases, which were so rife in Loudon, formerly, as to divert attention from pure inttammalions ; and, as they approach nearer than other diseases to the definition of species in natural history, justify the comparison which he has instituted : — “ If the humours are retained in the body beyond the due time, either (1) because nature cannot digest and afterwards expel them, or (2) from their having contracted a morbific taint from a particular consti- tution of the air, or (3) lastly, from their being infected with some poison: by these, 1 say, and the like causes, these humours are worked up into a substantial form or species, that discovers itself by particular symptoms, agreeable to its peculiar essence; and these symptoms, notwithstanding they may, for want of attention, seem to arise either from the nature of the part in which the humour is lrxlged, or from the humour itself before it assumed this species, are in reality disorders that proceed from the essence of the species newly raised to this pitch [zymine] ; so that every specific disease arises from some specific exaltation, or peculiar quality of some humour [zymtn] contained in a living body. Undei this kind may be comprehended most diseases which have a certain form or appearance; nature in fact observing • Louts.— Flevre typhoide. Vol. ii. p. 311. lxxxiii Sydenham, Morton , Willis. i lie same uniform method in producing and bringing diseases to a height or crisis as she does in the pro- duction or growth of plants or animals: for, as every plant or animal is possessed of peculiar properties, so is it likewise in every exaltation of any humour, after its being come to a species or disease. We have a clear proof of this every day, in those kinds of excrescences that grow on trees and shrubs (occasioned by the ill quality of the nutritious juice, or other causes), in the form of moss, mistletoe, mushrooms, and the like ; all which are manifestly different essences or species from the tree or shrub that bears them.” — Sydenham’ s Works, trans. by G. Wallis. Sydenham’s methods of treatment were adopted by him, and recommended as the results of experi- mental investigation. However their use might have been suggested, their efficacy was determined by their apparent influence on the recovery of patients; but, in his exposition of therapeutic principles, he keeps constantly in view his theory of “ commotion” ( commotio ) ; “a general term which he chooses in order to prevent all fruitless dispute about words that might arise from the use of ‘ fermentation,’ or ‘ ebullition’ ( fermentatio vel ebullitio), which, though they may seem harsh and metaphorical to some, are capable of a commodious interpretation.” Thus, in speaking of “continued fever,” he says, “ with regard to this disease, 1 judge that the genuine indications are to keep the commotion of the blood [zymosis] within such bounds as suit the design of nature, so as to prevent its rising too high on one side, whence dangerous symptoms might follow ; or sinking too low on the other, whereby either the exclusion of the morbific matter might be hindered, or the endeavour of the blood affecting a new state be frustrated. The early medical observers have directed attention to the analogies zymotic diseases have with com- bustion, fermentation, putrefaction, and poisoning. These analogies have been, to a certain extent, confirmed by the researches of modem chemistry; and Liebig has been led by the study of organic transformations, — fermentation, putrefaction, decay,— to develop a theory invented by the greatest practical physicians to explain the phenomena of zymotic diseases. Liebig observes, “ that physicians had referred formerly to fermentation merely by way of illustration from which it is evident that he had not had time to consult the English medical classics on this head, or he would have discovered not, indeed, an anticipation of his own generalizations, but a theory very similar to his own, — the basis of their pathology, — founded upon enlarged views, and well calculated to prepare the way for his researches and the researches of other chemists. Morton, in his Pyretologia, calls the principles which it has been proposed in a previous page to designate generally zymine, “ fermentum venenatum and the following definition is printed in italics in the intro- duction, and applied in the subsequent chapters of his work to the explanation of all the “ inorbi univer- sales acuti ” — * * * “ fomitem febriferum ('the ‘ fermentum venenatum’ of a previous sentence) asseramus esse — Deleterium quid in spirituum systemate delitescens, quod fermenti ad instar eos adoriens atque oestro primum exagitans, deinde humoribus secundo quasi momento, varias mutationes atque qualitates morbosas nobis sensibiles impertit.” This, he adds, is his general hypothesis — “ nostram generalem hypothesin.” Here we have (1) the “ deleterium quid ” communicating its action like a ferment to (2) the latent assumed constituents (spirituum systems*), and by a secondary impulse, as it were, producing perceptible transformations ( mutationes ) in the blood, tissue, and secretions. The sentence also recalls a principle in physics, which Liebig has quoted in the words of Laplace and Berthollet, and to which he appears to think all chemical transformations maybe referred: — '“A molecule, set in motion by any power, can impart its own motion to another molecule with which it may be in contact.” The three great cotemporaries, Sydenham, Morton, and Willis, lived in London when plague and epidemic diseases prevailed, and much as they differed or were mistaken, on some points, all announced more or less clearly the zymotic hypothesis. They were not, it must be borne in mind, mere chemiafric theorists ; they had studied diseased action as assiduously and with as much sagacity as modern chemists have studied fermentation; Willis was a great anatomist; Sydenham and Morton have left original pathological delineations which have never been surpassed, and laid down plans of treatment which are still followed. * Morton adopted the hypothesis of animal spirits from Kernel, and though it enabled him to explain many pheno- mena happily, lie did not fail to fall into absurdities, (for so we must now call them,) by employing it to explain every- thing ; still such passages as the following admit of a scientific coustructiou, and are another proof that the exploded theories of ingenious men always contain traces of important truths. Spiritus animales esse to evepyprircov seu primum prineipium activum, et quasi fermentum universale totius corporis a quo sanguis et liumores varie agitantur, etimmutantur, non dubito. T. 2, p. 7, 8. Willis employed the chemical theory and the few chemical facts known in the seventeenth century with still greater rashness in his treatises de fermentaoone and de febribus ; yet he has many felicitous ant cipations of modern deductions, and Liebig will admit that in the following passages the Oxford professor referred to fermentation i'or something more than an illustiation. He is speaking of small-pox, measles, (and scarlatina.) Convenit enim homini umrii , soli , et semel variolis aut morbilis affici. (p. 165.) ***** jsta diathesis, seu naturalis praedispositio, quae genus humanum ad hunc morbum inclinat, videtur esse labes q rued am seu impuritas sanguinis, inter prima feel us rudimenta in utero concepta. ***** Licet autem qenenata hujus morbi semtna ut plurimum semel, et unied cegritudine soleut difflari ; quandoque tamen accidit, ut parte miasmatis adhunc relicta, bis, aut ter aegri in hunc affectum inciderint * * * Causa evident, quae haec semina fermrntutma commovet, et saepissime in actum deducit, triplex assignatur, scilicet, cuntayium aliunde susceptum, disposilio aiiris, ac immudim sanguinis, et humvrum perturbatio. Cuntagio hunc morbum in alios serpere, lateque grassari, quotidiana experientia manifestum est : scilicet a curpnre infecto continue deceduni ejfluvia qua ab aliis curpnribus su.cepta stutim, instnr veneni cum sanguine fermentescunt, et Semina ejusdem uffectus latentia, ipsisque homogenea suscitant, et in hujus morbi ideam disponunt : nec solum contacto, sed ad distans miasma communicator. * * * peculiaris aeris dispositio : hinc saepissime popularis evadit ac per totas regiones, urbes, vicosque passim destEvit, p. 166. He adds that the “ immodica sanguinis, et humorum perturbatio” may arise from immoderate exercise or excesses, — Opera Medica et Physica, 1676. 2 9 lxxxiv Pestilences in Low Places. THE PESTILENCES OF THE PRESENT DAY ARE MOST FATAL IN LOW PLACES. The influence of elevation, if not as obvious in other zymotic diseases as it is in cholera, is equally important, for they are all governed by similar laws. Ague and Remittent Fever. The marsh fever of the intermittent, remittent, and continued form, exists in parts of England, and of almost every kingdom of the world. Instead of investigating its mild forms in the Essex marshes, or the intense varieties of th^ tropics, it will be more convenient to study it in Italy, where it has from an early period attracted the atten- tion of qualified observers. The fever of the Mediterranean appears to be a milder form of the remittent of the tropics. Its type is well seen in the Tuscan Maremme, which have been recently de- scribed by A. Salvagnoli Marchetti, in two Reports published by the Grand Duke of Tuscany.* The fevers are simple interinittents in spring : as the season advances gastric complications supervene, and they then become bilious remittent, continued gastric, typhoid, dysenteric. In the Maremme, from January to June, the diseases peculiar to temperate climates are observed ; during the other months of the year, in proportion as the temperature rises, the fevers put on a severer form, turn gradually from intermittents into remittents, remittents into continuants, and then assume the graver aspect of tropical disease.f The Tuscan Maremme lies along the Mediterranean : commencing at San Vicenzio, it extends to the river Chiarone on the borders of the Papal States. It is chiefly in the province of Grosselo, and comprises a considerable territory of mountain, hill, and beautiful plain. A map accompanies the Reports, and shows, by a yellow colour, the parts in which malaria prevails; by a red colour the parts where the malaria is less pernicious. The yellow colour stretches from io to 1 6 miles into the interior, over the low plains traversed by the waters, and the red colour runs higher up the rivers Cornio, Ombrone, and Albegna. The high land round the river sources, even where it approaches the coast — is white, healthy, untouched — except in a few exceptional cases. The insalubrity is at its maximum in the plains, slight among the hills, inap- preciable in the mountains. To cite the w ords of the Report : Massimo, e la malsania nclle pianure, mediocre nelle colline, affatto insensibile sui monti; quindi quest i abitabile senza alcun rischio, le colline con qualche pericolo, le pianure con g rave e eontinuo. Ten towns and castles are mentioned that are abandoned bv the greater part of the inhabitants every summer. Some are far from the sea, some far from the marshes. Montepescali is 760 feet above the level of the sea, Capalbio is still higher, and Sovana is as high as 1-012 feet. The malaria is felt in some cases as high as 1400 or 2000 feet; it never arrives at Montorsajo, 2500 feet (1217 braccia) above the sea. A remarkable instance is given of the sanification of Massa by Ximenes, who drained the high plain by a subterranean canal ; of the reappearance of malaria when the canal was stopped up, and its disappearance a second time when the water was drawn off by effectual drainage^. Dr. Marchetti notices that the blood of the inhabitants of the Maremme is changed : all the physicians, he says, who have attentively examined it, are struck by the character it presents, which is so constant and striking that by the blood alone you can distinguish the patient living habitually on a malarious soil from a person residing in a healthy country. § A chemical analysis by Professor Cozzi shows a deficiency of fibrine, albumen, fatty matter, and phosphates, and an appre- ciable quantity of cholesierine. Nutrition is feeble, digestion bad, the liver disordered, the spleen swollen, respiration weak; the heart is flaccid and beats fegblv. The countenance is of a palish sallow tint, as in a chlorotic girl, or yellow as in jaundice. The muscular movements are languid, bodily exercise fatiguing. Sensibility is diminished. Strangers in the malaria speedily feel its effects ; they undergo a great * Statistic.! Medica delle Marenime Toscane, 1840-1-2-3-4. Firenze, 1844. ■f Primo Biennio, p. 47. J 2 Biennio, p. 33-35. $ 1 Bien,, p. 65—7. Remittent Fever. lxxxv change, and soon acquire the constitution of the inhabitants of the Maremme.* Nearly all the inhabitants of the neighbouring mountains, who descend to gather in and to thrash the harvest, are attacked on the fields and doors, or shortly after their return home. Their food is poor, the wine and water bad. They work hard in the sun, and sleep often in the open air, or crowded, men and women together, in open cottages (Capannoni) .j The agriculture of the Maremme is in the rudest state, the dwellings are miserable, and there is no industrial manufacture. Such is the effect of the low lands of Italy on the population not only of the Tuscan Maremme, but of the Pontine Marshes, and all the other depressed parts of the Mediterranean coast. The land of the coast of the Adriatic is traversed by rapid rivers, and it is comparatively salubrious, except at Ravenna, where the Apennines retreat from the sea. The temperature of the province of Grosseto, lying between 420 22' and 43° 6' of north latitude, necessarily varies at different elevations. At Grosseto it is at sunrise and midday two degrees higher in spring, and one degree lower in summer than at Florence, by Reaumur’s thermometer. The hygrometer at Grosseto shows an excess of 20 degrees of moisture over (hat at Florence, and in the evening it is from 25 to 30 degrees moister than in the morning. The permanent population of the province of Grosseto was 5 3 1 7 5 *n I^I4’ anr^ 7^*79 in 1843. The number of births in the interval was 84075, of deaths 72954, exclusive of those in hospitals, which the Reporter thinks may be fairly