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 typhus 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 remarkable 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.

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 contagiousness 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 illus tration of this truth the two metropolitan districts of Dulwich and

St. Ann's, Blackfriars-districts probably nearly equal in population-in the former of which there was not a single death from Cholera, while in the latter the deaths from that cause alone were at the rate of 25 to every 1,000 of the population. Mr. Simon adds, "Dulwich is one of the healthiest subdistricts within the bills of mortality. St. Ann's belongs to one of the unhealthiest subdistricts of the city of London; and the Cholera visited them in proportion to their ordinary healthiness." So also of still smaller districts. No one who is aware of the close and unwholesome condition of the streets immediately surrounding Printing House Square; or of the squalid wretchedness of Church Lane, and Carrier Street, St. Giles; or of the still worse condition (if that be possible) of Jacob's Island, Bermondsey, could doubt for a moment that the Cholera would find in those localities a ready reception and a hearty welcome. Again, when the Cholera broke out at the notorious establishment of Mr. Drouet, at Tooting, no one, informed of the over-crowding, defective clothing, and, at least occasionally, unsuitable diet of the children, could be surprised at the fearful ravages which it made; nor could it excite our wonder that Milbank Penitentiary, built in a swamp, and supplied with water from the Thames, the scene in turn of scurvy, dysentery, and fever, should have its 30 deaths from Cholera in the quarter ending September 30th. The recent reports of the Registrar-General abound with cases both in the metropolis and in the rural districts in which the coincidence of filth and Cholera is established beyond the reach of doubt or cavil. We proceed to extract a few instances from the last quarterly return. The registrar of Shoreditch says, "The greater proportion of cases of the epidemic has occurred in the narrow streets, courts and alleys, with which the district abounds, and which for the most part are very badly drained and ill-ventilated." From the registrar of Hackney Road sub-district we learn, that "The principal seat of this calamitous visitation has been a very small portion of the district, which is in a very wretched state from defective sewerage, has suffered much from the want of timely sanitary arrangements, and is still only partially cleansed." From the Trinity sub-district of Newington the report is, "The deaths are about four times the average: 308 deaths were from Cholera, and 30 from diarrhoea. The most important local causes I believe to be the very defective drainage; and the over-populated and ill-ventilated habitations of the poorer class." One of the Lambeth registrars (Kennington 1st part) says, "The parts of my district which have suffered most are Spring Place and the small streets adjoining, near the Wandsworth Road. The neighbourhood is thickly populated and badly drained." The registrar of Greenwich East gives the following comparison:-"North side of the district, chiefly below high-water mark, and (Greenwich Hospital excepted) badly drained, 102 Cholera, 12 diarrhoea. South side of the district, a rising ground and healthy, 28 Cholera, and 21 diarrhoea."

The tenour of the reports from the rural districts is in strict keeping with those from the metropolis. From Mortlake, Surrey,

we learn that 20 cases and upwards of Asiatic Cholera, “have arisen principally from defective drainage, deficient ventilation, overcrowded habitations, and intemperance," and "the drainage is very bad"-and from Gravesend that "Cholera has prevailed in the same and similar localities as those that were severely visited with fever in the September quarter of last year," that there "are no available common sewers," and that "the whole of the surface and underground drainage falls into rudely constructed cesspools." The registrar of Portsea island calls attention to two localities, Fountain Street and Nance's Row. The first has the main sewer of the parish passing under it, which having been "blown," during the wet season of last winter, the whole place was inundated with its contents, so that the poor inhabitants were obliged to wade through 14 inches deep of foul refuse. Here the Cholera first appeared, and here it raged most severely. Nance's Row contains about 20 mean crowded houses, and is situate in an open field. At the end of this Row there is a junction of the four parish water courses about 6 feet deep, where a vast accumulation of foul stagnant water is formed, and here the Cholera appeared in its most fatal form, 22 persons falling victims in the seven northern houses, and not a single case in any of the others. In Windsor, out of 26 deaths from Asiatic Cholera and four from diarrhoea, 14 were in Bier Lane and the courts adjacent. The medical attendant remarks of one of these courts that the houses abut on a black ditch, and are filled with disgusting odours from this source at all times; and other nuisances are in the neighbourhood. There have been within a radius of 25 yards of this part of Bier Lane, 10 deaths from Cholera in the last month, and cases of diarrhoea have occurred

in every one of the houses. At Edmonton the pestilence "broke out in a row of houses to which there are no back yards. The privies are in the wash-house on a level and communicating with the houses where the families live. In this row, of eight houses only, there were 11 fatal cases." Three cases of Cholera at St. Albans are reported to have occurred in houses with an open cesspool close to the back doors. The Cholera prevailed to a very alarming extent in the town of Great Marlow (Bucks), but "the disease was confined to the poor and over-crowded, ill-drained, and ill-ventilated part of the town." One of the registrars of Norwich reports that of 14 cases of Asiatic Cholera, 10 occurred in a small yard, underneath some of the houses of which runs a most abominable sewer.

Such are a few of the cases reported in the last quarterly return of the Registrar-General. It would be easy to increase their number three or fourfold. Sufficient facts have, however, been adduced to prove that though it may not be possible by statistical returns from large districts to establish any broad principle of causation, it is quite possible to show that in small districts, in single buildings and streets, defective drainage, polluted water, and overcrowding, have acted as efficient predisposing causes of the pestilence.

There still remains to be considered, in addition to the local circum·

stances we have detailed, the influence of sex, age, and occupation, on the mortality from Cholera. We are indebted for the following table setting forth the per centage mortality by Cholera and diarrhoea in London in the two sexes, at different ages, to the courtesy of Mr. Farr, of the Registrar-General's office.

Mortality per cent. by Cholera and Diarrhoea at 11 different ages.

From this table it appears that the mortality of males from Cholera and diarrhoea exceeds that of females at all the earlier ages up to 25, after which time the excess is generally on the side of females. With regard to age, the mortality, with the exception of the first 10 years of life, and of aged persons above 75, follows the general rule of progressively increasing fatality.

The influence of occupation on the mortality from Cholera is a subject of interesting inquiry, upon which we have not had time or space to enter so minutely as we could have wished. The following table gives a rough approximation to the ratio of deaths by Cholera among the several classes of males in the metropolis.

We have to acknowledge our obligations to Mr. Farr of the Registrar-General's Office, and to Mr. Austin, the Secretary of the Board of Health, for some of the facts contained in this paper. We have also derived much assistance from an able history of the Cholera of 1831-2, published in the Times Newspaper; from a short summary of the progress of the recent epidemic given by Dr. J. C. Hall, in the first volume of the Journal of Public Health; and from the excellent Cholera map of Dr. Peterman.