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This table exhibits, for the several sub-districts, similar results to those just obtained for the five principal groups. There is only a general correspondence between the localities in which the two epidemics have proved most and least fatal, and in which the mortality from all causes is highest and lowest. The districts least and most severely visited by Cholera are, with few exceptions, gronped towards the two extremities of the table; but the mortality from all causes refuses to be brought into subjection to the rule of the prevalence of Cholera, the most and least healthy districts being blended in every part of the table with great irregularity.
In searching for a local explanation of the variable fatality of Cholera in different parts of London, that which appears most feasible, is elevation. The outbreak of Cholera in the low swamps of India in 1817; and its marked preference, as a general rule, for sea and river ports, for towns, like Salisbury, situated amidst marshes, and for low-lying situations on the borders of rivers or water-courses, point strongly in this direction. The great fatality of the Cholera on the south side of the river, and the especial severity with which it visited Rotherhithe and Bermondsey, so notorious for their filthy ditches, and equally filthy habitations, go far to confirm this explanation. A table given by the registrar-general, showing the deaths from Cholera for every 10,000 inhabitants in each aistrict in London, in the 52 weeks ending September 29, 1849, supplies the means of testing this probability. From it we have compiled the following table :
Elevation in feet
above Trinity Deaths from Cholera High Water in 1,000 inhabitants.
Max. Min. Mean.
Rotherhithe, Bermondsey, St. George, From 2 feet 263
below to 0. St. Saviour, St. Olave, Lambeth, Cam. 0 to 10 feet
162 berwell, Greenwich, Westminster, and
above. Poplar Chelsea, Stepney, and St. George-in- 10 to 20 feet
above. Wandsworth, West London, White-20 to 30 feet 108* chapel, and Lewisham
above. Bethnal-green, City, St. Martin-in- 30 to 40 feet
91 the-Fields, and St. George, Hanover
above. Square... St. Luke, Shoreditch, St. James, East 40 to 50 feet
71 London, Strand, Kensington..
50 to 60 feet 35 Hackney and Holborn
60 to 70 feet 51 St. Giles and Clerkenwell....
above. St. Pancras, Islington, Marylebone, and Upwards of 70
25 Hampstead ...
* District of Wandsworth, comprising Mr. Drouet's establishment at Tooting.
These comparisons certainly favour the conclusion, that the most fatal Cholera is in low situations; but it is obvious that the influence of elevation is modified by many concurrent predisposing and exciting causes. Thus, if we select three districts, Rotherhithe, Bermondsey, and St. George's, Southwark, each of which has the same mean elevation as the river itself at high water, we find the mortality to be respectively 263, 189, and 164, in the 10,000 ; but that which constitutes the main difference between these three districts, namely, the proximity to the Thames, and the consequent easy access of sailors from infected ships, probably offers a sufficient explanation of the different rates of mortality Rotberhithe, which is most accessible, and a common resort of seafaring men, suffers the greatest.mortality, while St. George's, Southwark, which is least liable to the intrusion of this class of the population, exhibits the lowest rate. Bermondsey is intermediate in both respects. To take another instance :-Wandsworth and Lewisham, both on the south side of the river, have an elevation, the one of 22 feet, the other of 28 feet, above high-water mark; but Wandsworth lost 108 in the 10,000, while Lewisham lost only 35 in the 10,000; but a great part of the excess in the Wandsworth district is at once accounted for by the awful loss of life in Mr. Drouet's establishment at Tooting, a loss evidently due to causes existing within the establishment itself. Allowance being made for this accidental circumstance, the mortality is at once reduced to 76 in the 10,000, which would doubtless be still further diminished by the omission of the frightful mortality in Albion Terrace, due also to causes unconnected with mere elevation. The advantage of six feet of elevation added to that of less density of population, will probably go far to account for the disparity still existing. Density of population will perhaps be found to account, at least in part, for the difference of mortality in other districts, having the same degree of elevation. Three such districts are Whitechapel and West London on the north, and Lewisham on the sonth side of the river, all of which are twenty-eight feet above the Thames at high water. The mortality of Whitechapel is 67 per 10,000, and that of West London 79 per 10,000, while that of Lewisham is only 35 per 10,000, or less than half the average of the other two districts. This difference coincides with, if it do not depend upon, the great density of the population in the first-named districts, when compared with the last. On the other hand, there are districts of equal elevation which differ comparatively little in density of population, and which, nevertheless, have suffered in a very different degree from the ravages of Cholera. The adjoining districts of St. Luke and Shoreditch, for instance, have each the same elevation of 48 feet above the Thames at high water, and yet St. Luke's has lost by Cholera 48 in the 10,000, while Shoreditch has lost 71. St. Luke's, which suffered least, has a density of population represented by 23 square yards to each person, while Shoreditch has a density represented by 36 square yards to each person. A still greater difference in the mortality from ChoJera in two districts having nearly the same elevation, exists
in the case of St. Giles-in-the-Fields and Clerkenwell, of which the first has an average elevation of 68 feet, and the last of 63 feet. The mortality from Cholera in St. Giles was 51 in the 10,000, while in Clerkenwell it was only 18 in the 10,000, and yet the density of the population differs but little in the two cases, the parish of St. Ġiles giving 22 square yards to each person, and that of Clerkenwell 27.
As it is natural to suppose that density of population is one of the elements which regulates the mortality from Cholera, let us now inquire in what degree this influential cause of disease has influenced the spread of the pestilence.
The district which has suffered most severely by Cholera is Rotherhithe, which lost 263 in the 10,000, and yet the density of its population is represented by the favourable figure of 240 square yards to each person. Again, the Strand and Holborn presents the very favourable rate of mortality of 35 in the 10,000, and yet the population in the one has a density represented by 18 square yards, and in the other by 20 square yards to each person.
Another way of testing the influence of density of population on the mortality from Cholera, will be to compare districts having the same density of population.
We find two such districts in St. Martin's-in-the-Fields and Bethnal Green. Each has a density of population represented by 50 square yards to each person, and yet the mortality from Cholera in the one has been 33, and in the other 91 in the 10,000.
We may bring the question to one other test; the density of population in Shoreditch is just double that in Westminster, and yet the mortality of the former was 71, and of the latter 69 in the 10,000.
From all the comparisons which we have just instituted, the conclusion seems justified that elevation exercises a greater influence upon Cholera than density of population. Perhaps few facts are better established in reference to the Cholera than its fatality in low-lying districts upon the banks of rivers ; but no argument is necessary to prove that that increased mortality is not dependent on the mere elevation, but on the defective drainage, and consequent dampness and impurity of the air, which, in the present condition of our towns, are apt to prevail in such low situations. The dreadful ravages committed by Cholera in the elevated but filthy districts of Bilston and Merthyr Tydvil, are strongly confirmatory of this view of the case. Merthyr, which is 500 feet above the level of the sea, and, according to Sir H. T. de la Beche, in an open, airy, and well-exposed situation, shares with Sculcoates, on the level of the Humber, a mortality (mainly due to Cholera) at the rate of upwards of 10 per cent. per annum.
Having examined the influence of elevation and density of population, separately, on the mortality from Cholera, it will be interesting to inquire into the relation of the two causes combined to the prevalence and mortality of that disease. This may be best done by taking two districts having the same, or nearly the same, density, and the same, or nearly the same, elevation. The two districts of
St. Martin's-in-the-Fields and Bethnal Green fulfil these conditions. The former has an elevation of 35, the latter of 36 feet, and both have a density of population represented by 50 square yards to each inhabitant; nevertheless, while St. Martin's lost only 33 inhabitants in every 10,000, Bethnal Green lost 91. So far, then, as one instance may be allowed to test a principle, there seems no ground for supposing that the two combined circumstances of elevation and density of population exercise any marked or invariable influence on the spread of Cholera.
Much has been said on the coincidence of the track of typlus fever, with that of Cholera. It has been alleged that the same places are favourable to the prevalence of both diseases, and that the fact of typhus fever having been very fatal in any particular district, affords good ground for anticipating a similar fatality of the Cholera in the same place. If in alleging the coincidence of the fever track and the Cholera track it be meant to assert that in spots remarkablė for the neglect of all sanitary precautions, the two diseases are both pretty sure to prevail to a greater or less extent, the allegation may certainly be received as a truth; but if we were to affirm that the mortality of the two diseases in any two or more districts has so close and intimate a relation that the district which suffers most from Cholera shall also suffer most from typhus fever, we should find our facts refusing to bear us out. The same may be said of scarlet fever, and probably of all other contagious disorders. This question also is brought to the test of figures in the following table, in which the deaths from Cholera are taken from the returns of the Registrar-General for the week ending September 29, 1849, and the mortality from typhus and scarlatina from the third annual report of the Registrar-General, which gives the deaths from these two diseases for the last half-year of 1837, and the two complete years 1838 and 1839. For convenience sake, this mortality is compared with the estimated population of the middle of the year 1849, which is sufficient for the general purposes of comparison.
Elevation above high water mark.
from Fever in 10,000.
from Scarlet Fever in 10,000.
29 22 St. George, Southwark
29 St. Luke
29 26 Clerkenwell.
22 St. Giles,
51 69 Clerkenwell
71 24 22 Thus, then, we glean from statistical data that neither elevation alone, nor density of population alone, nor even the two combined, nor the predisposing causes, whatever they may be, of typhus and scarlet fever, exercise such an influence on the spread of Cholera as to determine its prevalence, or otherwise, over the larger districts of our town populations. The want of coincidence between
the mortality of Cholera and that of typhus fever and scarlatina, may probably be explained by the highly contagious nature of the two latter, when compared to the comparatively feeble contagious. ness of the former ; and it is not improbable that, in spite of the utter failure of the fungoid theory, the spread of the Cholera may, at least in certain instances, be dependent on the use of water contaminated by the contents of sewers and cesspools. This theory has been put forward and justified by Dr. Snow in his pamphlet « On the Mode of Communication of Cholera.' In support of this view he instances the joint towns of Dumfries and Maxwell-town, which, though not usually unhealthy, have been severely visited by Cholera, both in 1832 and in 1848. The inhabitants drink the waters of the Nith, into which the sewers of the town empty themselves. He also instances the city of Glasgow, similarly supplied from the Clyde, and the south and east districts of London, which are supplied with water from the Thames and the Lea, where those rivers are much contaminated by the sewers. Dr. Snow also enters into a minute examination of one or two special cases of high mortality, in which he traces the existence of the same cause. The first case is that of Thomas Street, Horsleydown, where two adjoining courts suffered with very unequal severity, the comparative immunity being probably due to the use of good water, and the high mortality to the drinking of water contaminated by the drainage. Another case quoted by the same author is that of Albion Terrace, Wandsworth Road, where also the mortality was frightful, and the water found to be greatly polluted by the drainage. The Cholera, as it is well known, was also extremely fatal at Jacob's Island, Bermondsey, where the water used for drinking purposes was notoriously polluted by the excreta of a large population,
Our space is too limited to allow us to enter further into the examination of this very interesting question; but we think it not unlikely that this peculiar cause of disease, combined with the very feebly contagious nature of Cholera, may account for the difference already pointed out between the prevalence of Cholera on the one hand, and of typhus and scarlet fever on the other, in the large registration districts of the metropolis.
But though the conclusions at which we have just arrived are at variance with the popular expositions which represent the fatality of Cholera as directly proportioned to density of population, or lowness of situation, and the track of Typhus and Cholera as minutely coincident, they do by no means invalidate the great practical truth, that where the sanitary laws are most wantonly outraged and set at defiance, Cholera, in common with other epidemics, is almost certain to prevail with greater or less severity. And it is even probable that where sufficiently small districts are compared with each other, the general mortality from all causes, and the special mortality from epidemics inclusive of Cholera, will be found to coincide.
Mr. Simon, for instance, in his able sanitary report, cites in illuetration of this truth the two metropolitan districts of Dulwich and