P)ARD OF WORKS, WHITECHAPEIj DISTRICT. REPORT ON THE EPIDEMIC OF CHOLERA in isee, JOHN LIDDLE, gle&ial <§ta jof $t a% PRESENTED TO THE BOAKD 21& T JANUARY, 1867. LONDON 1867. BOARD OF WORKS, WHITECHAPEL DISTRICT. REPORT ON THE EPIDEMIC OF CHOLERA in isee, JOHN LIDDLE, Ptol®faof|^l% PKBSENTED TO THE BOARD 21st JANUAEY, 1867. LONDON. 1867. LONDON PEINTED BY T. PENNY, 121, LEMAN STREET, WHITECHAPEL. CONTENTS. Pag« Preliminary Remarks... ... ... ... ... ... ••• 5 Precautions taken in 1865 ... ... ... ••• ... ••• ••• 5 Address to the inhabitants of the Whitechapel District ... ... ... 6 Orders of the Privy Council ... ... ... ... ... ««• 7 Extract from Memorandum of the Medical Officer of Privy Council ... ... 10 First Meeting of the Board ... ... ... ... ••• ••• H Instructions to Medical Visitors ' ... ... ... •« ••« 13 Proceedings of the Board ... ... ... ... ... - ••• •¦• 1^ First case of .Cholera in the Whitechapel District ... ... ... ••• 17 Return of Cholera and Diarrhoea Cases ... ... ... ••• ••• 18 Form of Daily Return sent in by Private Medical Practitioners ... ... 19 Form of Daily Return sent in by Medical Visitors ... ... ... ...20 Staff of Inspectors of Nuisances ... ... ... ... ... 21 Report of Inspectors of Nuisances ... ... ... ... ... ... 21 Works executed in Surveyor's Department ... ... ... ... 21 Inspection of the Shipping in the River ... ... •• ••• ... 21 Water Supply to the Shipping in the River and in the Docks .. ... 21 Proceedings in cases of Death ... ... ... ... ... ... 22 Mode of Disinfecting Rooms ... .. ... ... ... ••• 22 Dr. Lbtheby's Letter to the Registrar General on the use of Disinfectants ... 23 Dr. Stephen Duke's Report on the result of disinfecting rooms, &c... ... 24 Disinfectants ... ... ... ... ... ... ••• ••• 25 Necessity of using Disinfectants ... ... ... ... ... 26 Burial of the Dead ... ... ... ... ... ... ... 26 Theories respecting the Cause and Mode of Propagation of Cholera ... ... 27 Practical bearing on some of the above Theories ... ... ... ... 30 Water Supply ... ... ... ... ... ... ... 30 Localities chiefly affected in the Whitechapel District ... ... ... ... 89 Table showing the Mortality from Cholera in the District supplied by the New- River Company ... ... ... ... ... ... ... 40 Comparison of the rate of Mortality in the South Districts of London ... ... 41 Comparison of the rate of Mortality in some of the principal Cities of Europe ... 41 Jewish Inhabitants and the Cholera ... ... ... ... ... 42 Intervals of Cholera ... ... ... ... ... ... ... 43 Mortality from Cholera in the Whitechapel District ... ... ... ... 44 Of the Points of Similarity and of Difference in the several Epidemics ... 44 Weekly Returns of Deaths from Cholera in 1833, 1849, 1854, 1857, and 1866 ... 45 Temperature ... ... ... ... ... ... ... 46 Elevation ... ... ... ... ... ... ... ... 47 Rate of Mortality per 10,000 in the Sub-districts of Whitechapel ... ... 47 Deaths from Cholera in the Sub-districts of the Whitechapel District ... ... 48 CONTENTS— cojnmnnro. Cholera in the Whitechapel Union in 1849 and 1854 ... ... ... ...48 Letter of the Eev. W. W. Champneys .. ... ... ... ... 49 Cholera in the Whitechapel Uuion in 1853-4... ... ... ... ...50 Voluntary Associations ... ... ... ... ... ... 51 Letter of the Eev. James Cohen ... ... ... ... ... ... 51 „ „ Eev. # John Patteson ... ... ... ... ... 52 „ „ Eev. Brooke Lambebt ... ... ... ... ... 53 „ „ Eev. John Stbiokland ... ... ... ... ... 55 London Hospital... ... ... ... ... ... ... ... 56 Compulsory Eemoval of Patients ... ... ... ... ... 58 Temporary Cholera Hospital in Commercial Street ... ... ... ...68 Workhouse ... ... ... ... ... ... ... ... 59 Expenses. ... ... ... ... ... ... ... ... 59 Concluding observations ... ... ... ... ... ... 61 Appendix ... ... ... ... ... ... ... ... 63 §mxh d Wmfa--Wfyiikrfpipl REPORT ON THE EPIDEMIC OF CHOLERA In 1866. Gentlemen, Preliminary Remarks. Before entering upon the consideration of the recent Cholera Epidemic, and of the proceedings adopted by the Board during the prevalence of the disease, it may be desirable that I should mention that, so far back as July, 1865, steps were taken to cause a fuller investigation to be made into the sanitary condition of the District, and for this purpose a third Inspector of Nuisances was appointed. Precautions taken in 1865. In my Eeport for July, 1865, I brought under the notice of the Board the overcrowded state of the District, and the number and condition of the houses that required a regular and systematic inspection. I directed your attention to the annual increase of pauperism since 1861, also to the great augmentation in the number of the sick-poor who applied for assistance to the Medical Officers of the Union. I likewise stated that cases of Diarrhoea had increased in number, and that I had made use of the services of the additional inspector to visit every house where Diarrhoea had occurred, and to report to me upon its sanitary condition. In my next Quarterly Eeport (September 1865) I brought under your notice the fact, that Cholera, although it had not approached these shores, as on former occasions, through Eussia and the cities and towns on the Baltic, had travelled from the East along the shores of the Mediterranean, and attacked the inhabitants of Marseilles and Toulon, and that it then made its appearance in Paris. Cases of the disease occurred about the beginning of September in Southampton and Woolwich, which induced me to believe, that the disease might at any time break out in an epidemic form in London. The additional inspector, which the Board had kindly placed at my disposal, enabled me to be tolerably well informed of the sanitary condition of some of the worst localities, and to carry into effect the necessary proceedings to compel a removal of the nuisances therein. The result was a greatly improved sanitary condition of the District. At the same time about 2,500 6 tants of the District, but more especially among the poorer classes, informing them, among other things, of the sanitary appliances they had a right to receive from their landlord, and pointing out to them the duties which -were required to be performed by the scavengers and dustmen as regards the regular cleansing of the streets and the removal of dust and house refuse :—: — BOAED OF WORKS for the WHITEOHAPEL DISTRICT. To the Inhabitants of the Whitechapel District. The Parishes in the Whitechapel District are Whitechapel, Spitalfields, Aldgate Without, Minories, St. Katherine, Mile End New Town, Norton Folgate, Old Artillery Ground, and Tower Without. It is required that every house in each of these Parishes shall haye — " Sufficient Water for the use of the Tenants ; " " A proper Water-closet ; " " A proper Dust-bin." The water for the use of the Tenants should be kept in a proper butt or cistern, having a cover and a tap, and should be large enough to hold as much water as all the Tenants of the house may reasonably require. The water-closet should be made to communicate with the sewer. It should be properly inclosed with a door, and should be kept clean and free from stoppage. No cesspool should be allowed. Yards to houses should be paved and drained, so as to prevent water standing in'pools. The accumulation of manure, bones, rags, and other offensive matter will not be allowed. No pigs should be kept upon any premises in the District. The pavement of streets, both roadway and carriageway, should always be kept in good condition. The gullies of the streets should always be free from stoppage. No carts or other carriages are allowed to stand in the public streets longer than necessary for loading or unloading. If any persons place goods, canks, packages, or anything else, so as to obstruct the public way, they will be liable to a fine. If any persons wheel trucks or barrows upon any footway, they will be liable to a fine. EEMOVAL OF BUST, ETC. The Dustmen are bound to remove the dust from houses twice at] least in every week. Public dust-bins must be emptied every day. The Dustmen are bound to clear away the dust without payment, as the Board contracts to pay the cost of the removal of all dust. All persons throwing ashes, dirt, shop-sweepings, or refuse of any kind, upon any public way, are liable to a fine of Forty Shillings. CLEANSING STREETS. All the streets and courts in the district are to be swept all over three times in every week. The mud is to be carted away within one hour after the street has been swept. The information contained in this paper is given that the Inhabitants of the Whitechapel District may communicate to the Board of Works any cause of complaint that may exist in the neighbourhood in which they reside. All complaints will be investigated by the Board upon receipt of information, which may be given either by letter or by the attendance of the person having cause of complaint. When persons desire to make a complaint in person, they should attend at the Office of the Board between the hours of 10 and 11 o'Clock in "the Morning, or between 4 and 5 o' Clock in the Afternoon. Office oftlie Board of Works, By order of the Board, Whitechapel District, ALFRED TURNER, Clerk. 15, Great AUe Street, Whitechapel, E, 7 In addition to the distribution of copies of this address, a printed notice was affixed upon each court in the District, informing the inhabitants that the scavengers were bound to cleanse the place tliree times in every week, and to empty the public dust-bin daily. The importance to health of having the house refuse removed frequently (say twice a week in summer, and at least once a week in winter) before decomposition has taken place, cannot be overrated. The foul smells given off from the dust-bins when placed in some of the confined areas in private houses, are frequently perceptible to passers by, and render the air poisonous to the public generally, and particularly to the inhabitants of that house where this nuisance exists. As the danger of retaining any refuse near to dwelling houses is greatly increased during the prevalence of any epidemic disease, stringent measures should at that time be adopted by the local Boards to enforce its daily removal. Having, therefore, endeavoured to make preparations for the safety of the inhabitants of this District in case the pestilence, which was then prevailing in foreign parts, should make its appearance among us, we were more readily enabled to act immediately upon the advice of the Privy Council. Now that the Cholera has disappeared from the Metropolis, it may perhaps, be deemed interesting by some Members of the Board, if I briefly record the proceedings which have been adopted to limit the ravages of the disease and to mitigate the sufferings of those attacked. Proceedings of the Board. Before entering upon the details of the proceedings of the Board, I may state, that at its first meeting it resolved itself into a Committee of the whole Board, and to meet daily for the purpose of carrying out the Provisions of the Privy Council, which are here subjoined: AT THE COUNCIL CHAMBEK, WHITEHALL, The 2\st day of July, 1866. BY THE LOEDS OF HER MAJESTY'S MOST HONOBABLE PEIVY COUNCIL. Peesent : LOED CHANCELLOR LOED PRESIDENT. LOED PEIVY SEAL. MR. SECEETARY WALPOLE. GENERAL PEEL. MR. CORRY. WHEREAS the Lords of Her Majesty's Most Honorable Privy Council, by an Order made the 14th day of July instant, in exercise of the powers given by " The Diseases Prevention Act, 1855," and the Amending M Act of the twentythird and twenty-fourth years of Her Majesty, chapter seventy-seven, did order and direct that the provisions contained in the said Acts for the prevention of diseases should, from and after the date of that Order, be put in force within the whole and every part of England. And whereas the Lords of Her Majesty's Privy Council have thought fit, under the authority conferred upon them by the said first cited Act and all other Acts in such behalf, to issue certain directions and regulations, to be in force within the Metropolis so long as the provisions aforesaid shall be in force uader the said Order : Now, therefore, in exercise of the powers conferred upon them by the above named Acts, the Lords of the Council order, and it is hereby ordered, as follows, that is to say : 8 I. — Preliminary. Preliminary Forthwith on the issuing of the present Regulations, the Clerk of every arrangements, y egtr y or District Board (as the case may be) under the Act of the Session holden in the eighteenth and nineteenth years of Her Majesty, chapter one hundred and twenty, shall summon a special meeting of the Vestry or Board, in order that the present regulations may be brought before them, and that the Vestry or Board may make, as they are hereby required to do, such preliminary arrangements as will enable them, if sudden need shall arise, to carry the following regulations into immediate effect ; and the Vestry or Board at such meeting shall direct the Clerk, by circular letters of request addressed to all legally qualified Medical Practitioners in the Parish or District, and in such other ways as the Vestry or Board may think necessary, to take measures for causing the Vestry or Board to be made acquainted with any presence of Cholera or unusual amount or severity of Diarrhoea in the Parish or District, or any part of it, if such be existing or should thereafter exist : and the Vestry or Board if apprised of any such presence of Cholera or Diarrhoea shall thereupon forthwith, so far as the circumstances require, do the several things hereinafter ordered : II. — When Cholera is in a Parish or District. Meetings j # Every Vestry or Board shall make arrangements for meeting, where the disease is actually prevailing, daily, either in a body or in one or more Committees, according to the exigencies of the Parish or District, for the purpose of exercising the powers conferred upon them by the Act. Place of Meet- 2. The meetinga may be held at the ordinary Board-room, and where necessary, at such other places as shall appear to be most convenient for dealing with the disease, and the Vestry or Board shall cause proper minutes of all proceedings to be made and duly recorded. Medteaiofflcer 3. The Medical Officer of Health shall, as far as practicable, attend the meetings of the "Vestry or Board, and of its Committees, to render his advice thereat, and shall superintend all the medical arrangements for preventing and treating the disease. Appointment 4 j n eac jj p ar ; s h or District in which Cholera is present, or, if the Visitors and quantity of work to be done renders it desirable to subdivide the Parish or Assistants. District, then in each of such subdivisions, a legally qualified Medical Practitioner shall be put in charge, of the Parish or District or subdivision for the medical purposes of these Regulations ; and to each such Medical Practitioner (hereinafter named the Medical Visitor) shall be allotted such Assistants as the Vestry or Board see fit. Such Medical Visitor, where practicable, or, in other cases, one of his Assistants, shall at least once daily visit those places assigned to him which are inhabited by the poorer classes and wherein the disease is, and shall there inquire at every house as to the existence of Diarrhoea or Cholera, and shall enter in a book to be kept for the purpose the facts as to all cases he may meet with, and shall without delay give, or take the proper steps for causing to be given all necessary medical assistance to the sick. And the Medical Visitor or Assistant shall, when visiting the places assigned to him, be provided with medicines for immediate administration in urgent cases, and shall be held to be in medical charge of all cases of Diarrhoea or Cholera with which he may meet until he i 3 relieved by such other provision for their medical attendance as may be made or sanctioned by the Vestry or Board. Their report. 5. Such Medical Visitor shall, by transmitting his above required book, ' or otherwise, report daily to the Medical Officer of Health the result of his own and his Assistants' inquiries, and shall report any nuisances which he or they find existing in any premises visited by him or them, and shall make such suggestions as to the state of the Parish or District as he shall deem advisable. re B ortc!ases Visitors shall, where they find it expedient, communicate to the of destitution Relieving Officer of the District any case of destitution requiring relief, which is ine'oiflcen 7 ' not entered in his relief list ; and such Officer shall forthwith visit the same and give such relief as in his judgment the case shall require. dispensary ?• ne Ve&try or Board shall provide a sufficient number of Dispensaries, stations'. to bp open night and day, at convenient places within their Parish or District, with' an adequate supply of such medicines, medical appliances and disinfectants, as their Medical Officer of Health shall recommend, and with a legally qualified Medical Practitione.r or skilled Assistant always in attendance at each ; and such medicines, medical appliances and disinfectants, shall be dispensed without charge by such Medical Practitioner or Assistant to persons bringing orders 9 for the same from the Medical Visitors, and to other persons who apply for immediate medical treatment. And the names and addresses of all such applicants shall be sent to the Medical "Visitor of the place in which they reside. To supply 8. In every case of Cholera or Diarrhoea, where the patient is not under poor cholera medical care and treatment, the Vestry or Board shall cause medical assistance patients. to be rendered with the utmost expedition, and such aid and comfort, nourishment and accommodation, as the circumstances of the case will admit, with the object of restoring health. To provide 9. The Vestry or Board shall provide competent Nurses to aid every nurses. Medical Visitor in his attendance upon the patients suffering from the disease. To provide 10- When the Medical Officer of Health recommends, the Vestry or hospitals m Board shall, with as much dispatch as practicable, provide fit and proper certaincascs. »/. « .. ? * o i ,• i_ i_ r f accommodation for the reception of such patients as have no home, or cannot properly te treated at home, and may with advantage to themselves be removed, and shall cause the same to be provided with all appliances, medicines, furniture, and other things necessary for the emergency, and shall appoint a legally qualified Medical Practitioner, with or without Assistant, as the case may require, to attend to the same. To procure H. If Cholera or Choleraic Diarrhoea exist in any dwelling whereof the fn pUce'of Medical Officer of Health reports that the sick and healthy cannot therein be poUuted ich " properly separated, the Vestry or Board shall forthwith cause adequate accommodation to be procured for the reception of the healthy ; and when the Medical Officer of Health recommends that the sick person shall not be removed, but that the healthy shall be removed from the same room in which the sick person is lying, the Vestry or Board shall cause the other inmates of such room to be removed to some convenient place of reception. To provide for 12. The Vestry or Board shall, in dwellings where Cholera or Diarrhoea of e the P s!ck tion exists, cause proper disinfectants to be used in sufficient quantities for the pur- from the heal p Ose o f disinfecting the discharges from the sick, and the bedding, clothing, and dwelling! same other things thereby infected, and the utensils and privies in which such discharges may have been received. To provide 13. The Vestry or Board shall cause every article of clothing, bedding, or anTtocause 8 furniture which shall have been infected with any such discharge, and which places to"be *h ey sna^ nn(^ incapable of being speedily disinfected, to be forthwith destroyed, disinfected, the Vestry or Board within a reasonable time replacing all such articles, or paying the reasonable value to the owner. ftcted U |oo I ds to If it be shown to the Vestry or Board that any drinking-water used destroyed. ju their Parish or District is polluted, they shall take measures, with as much expedition as possible, for procuring wholesome water to be supplied in its stead, so far as the case requires, to the inmates of the houses in their Parish or District, and for preventing, as far as possible, the further use of the polluted water. And every Vestry or Board owning or having possession of any waterworks for the supply of water shall cause the reservoirs, cistern, pipes, pumps, and other apparatus belonging thereto, to be carefully examined, cleansed and purified, and other necessary measures to be taken, to that the water may be supplied without impurity. Provision for 15. The Vestry or Board shall make due arrangements with undertakers, burials. an( j y/jfa the proper authorities of the churchyards, burialgrounds, and Cemeteries of their Parish or District, so that coffins may be ready to be supplied immediately on demand, and interments speedily take place in the cases of deaths arising from Cholera or Diarrhoea ; and the Vestry or Board shall, when informed of any such death, cause the corpse to be buried with the earliest possible dispatch. peSs l^ 6 ° f 16. Where any death shall occur from Cholera or Choleraic Diarrhoea, no wakiug the collection of persons shall assemble in the room where the corpse is, and no dead prohibl- ,< waking ? of the dead sball be a U owe d. Corpses to be 17. The Vestry or Board shall cause the immediate removal, from any fromtiSYiv- 6 room which living persons inhabit, of the corpse of every person dying ins. from Cholera or Choleraic Diarrhoea, until the time of its interment, and shall cause such means to be adopted for preventing the spread of infection from the corpse as their Medical Officer of Health shall recommend. To take pie- 18. If the Vestry or Board shall be informed that Cholera or Choleraic C h" t s C a"id'v 8 es < ? Diarrhoea exists, or within three days previously has existed, in any Ship or seiTiying Vessel which may be lying within their Parish or District, they shall cause the ParUhor sa me to be forthwith visited, inspected, and otherwise dealt with, according to district. the circumstances of the case, in like manner as if it were an inhabited house 10 on thore, and shall give all such medical and' other directions in reference to the persons in such Vessel or Ship, as shall be requisite for preventing the spread of the disease, and for the disinfection or disposal of any things which may be infected or may have been exposed to infection, subject always to the provisions of any Order of Council issued under the Quarantine Laws for -the time being in force in such Parish or District. tu?nB Sto°£e re" obtained. *9. The Clerk of the Vestry or Board shall, every Monday, send by post to the Medical Officer of the Privy Council a return of the number of new cases of Diarrhoea or Cholera which have during the week ended on Saturday midnight last come under the cognisance of the Vestry or Board, and of the number of recoveries, and the number of deaths, with such other particulars as such Medical Officer shall from time to time require. The return shall be in the following form, or to the like effect : — Parish or District. Weekly Return of Cases of Cholera or Diarrhoea for the Week ending on Saturday last. New Attacks during the Week Deaths during the Week Recovered during the Week Total number of Cases now under treatment Date 1866. (Signed) Clerh to J he % estr y \ c / , or Board, TopnbUsh 20. The Vestry or Board shall, from time to time as they shall find expedient, issue, publish, and distribute in placards, hand-bills or other communications, such admonitory notices to the owners and occupiers of property within their parish or District as to the provisions of the Acts for the .Removal of Nuisances as shall appear to be requisite, and in a like manner publish all such medical advice and such directions and instructions as in their judgment shall be necessary to afford aid to persons attacked with Cholera or Diarrhoea, or for the carrying of these Regulations into execution, and inform the public what special arrangements have been made for affording medical or other assistance in the Parish or District. General Order and exhortation for aid to the Vestry or Board. 21. All Officers, Assistants, and Servants of the Vestry or Board are ordered, and all Medical Practitioners and other persona inhabiting within the Parish or District of the Vestry or x Board are requested, to supply information and to give their aid to the utmost of their ability to the Vestry or Board in the execution of these regulations and directions. ARTHUR HELPS. Accompanying the Orders of the Privy Council, a Memorandum by the Medical Officer, Mr. Simon, on the Precautions to be taken against Cholera was forwarded to the Board, which contains the following important observations upon The Mode of Propagation of Cholera. Happily for mankind, Cholera is so little contagious, in the sense in which small-pox and typhus are commonly called contagious, that, if proper precautions are taken where it is present, there is scarcely any risk that the disease will spread to persons who nurse and otherwise closely attend upon the sick. But cholera has a certain peculiar contagiousness of its own, now to be explained ; which, where sanitary circumstances are bad, can operate with terrible force, and at considerable distances from the sick. It appears to be characteristic of Cholera — not only of the disease in its developed and alarming form, but equally of the slightest diarrhoea which the epidemic influence can produce, that all matters which the patient discharges from his stomach and bowels are infective ; that the patient's power of infecting other persons is represented almost or quite exclusively by those discharges ; that they, however, are comparatively non-infective at the moment when they are discharged, but afterwards, while undergoing decomposition, acquire their maximum of infective power ; that, if they be cast away without previous disinfection, they impart their own infective quality to the excremental matters with which they mingle, in filth- Bodden earth or in depositaries and conduits of filth, and to the effluvia which those excremental matters evolve ; that if the infective material, by leakage or 11 soakage from drains or cesspools, or otherwise, gets access, even in the Binallest quantity, directly or through porous soil, to wells or other sources of drinkingwater, it can infect, in the moat dangerous manner, very large volumes of the water ; that the infective influence of choleraic discharges attaches to whatever bedding, clothing, towels, and like things, have been imbued with them, and renders these things, if not disinfected, capable as (the cholera-patient himself would be capable, under the same conditions) of spreading the disease in places whither they are sent for washing or other purposes ; that, in the above described ways, even a single case of disease, perhaps of the slightest degree, and perhaps quite unsuspected in its neighbourhood, may, if local circumstances co-operate, exert a terrible infective power on considerable masses of population. "If local "circumstances co-operate," however, is the stated condition for that possibility ; and it will be observed that the essence of the sanitary precautions, which have been recommended to Nuisance- Authorities and others, is to annihilate those "local circumstances." The choleraic infection does not seem able largely to injure any population unless a filthy state of things be pre- Bupposed. It is pre-supposed that the atmosphere or the drinking-water of the population is impure with the most loathsome of impurities, — that the infective material has had opportunities of action which decent cleanliness would not have afforded it, — that, in inefficient drains or cesspools or other like depositaries, it has had time to develop its own infective power, and to render other stagnating filth equally infective with itself, — and that, from such foci of infection, the disgusting leaven of the disease has spread, in air or water, to be breathed or swallowed by the population. In this view of the case, it will be understood that works of sewerage, house-drainage and water-supply, properly executed and properly used, give to town-populations an almost absolute security that Cholera, if introduced among them, can have no means of spreading its infection. And equally it will be understood that, in the absence of those permanent safeguards, no approach to such security can be got without incessant cleansings and disinfections, or without extreme vigilance against every possible contamination of drinking-water. First Meeting of the Board. On Thursday, July 26th, a meeting of the Board was specially convened to consider the orders of Her Majesty's Privy Council upon the subject of the Prevalence of Cholera in the Metropolis, which orders, although dated July 21st, were not received until July 24th. But previous to the holding of this meeting, Mr. Turner, Clerk to the Board, in anticipation of the duties which would he required of the Board, had given an invitation to the whole of the legally qualified Medical Practitioners residing within the District to attend this meeting of the Board. It was deemed convenient that the Medical Officer of Health should confer with the several Medical Gentlemen who attended upon the invitation and report the result of the conference to the Board. At this meeting the Medical Officer of Health retired in order to ascertain the opinion of the Medical Practitioners present on that occasion, and having obtained their views, ho informed the Board, that it was a matter beyond dispute, that Diarrhoea and Cholera existed to a very considerable extent in this District. In order, therefore, to carry into effect the orders of the Privy Council, the District was divided into eleven sub-districts, and a qualified Medical Practitioner was appointed to take chargg of each of the sub-divisions. He was furnished with a plan of the District, and his name was legibly written on that division which was allotted to him; and he was required to perform a house to house visitation in the poorer localities of his division, to administer to the relief of all persons suffering from Diarrhoea or from Cholera, and to perform such duties as were enjoined by the Order of the Privy Council. An additional Medical Practitioner was appointed, whose special duty it was to render assistance in the office of the Medical Officer of Health. The names of the medical gentlemen appointed were Mr. Chahpnevs, Mr. Kichardson, Dr. Swier, Mr. Seqt/iera, Mr. Betts, Mr. Cohley, Mr. "Wells, Dr. Loane, Mr. Stirling, Dr. Allinson, Dr. Dujkes, and Dr. Stephen Duke. 12 The services rendered by Dr. Stephen Duke were attended with very good effect. This gentleman gave assistance under my direction in any portion of the District when necessity arose, and in case of emergency was ready to assist any of the Medical "Visitors who had more to do than it was possible for them to perform in a satisfactory manner. All persons who died were seen by him, and he gave directions for the immediate removal and burial of the body, superintended the disinfecting of the room, saw to the removal of the bedding and clothes of the deceased, and superintended the burning of them in a furnace erected for the purpose in the Stone Yard belonging to the District. On the 31st of July a letter was received from Mr. Simon, the Medical Officer of the Privy Council, in which was expressed the satisfaction of the Lords of Her Majesty's Privy Council at learning that the Board is taking active measures to carry out the Order of Council of the 21st July. Each of the twelve Medical Gentlemen who were appointed received £7 7s. per week, and it was agreed that the drugs were to be paid for by the Board, at the cost price. The staff of Medical Visitors was subsequently increased by the addition of nine advanced medical students, at a salary of £3 13s. 6d. each per week. The entire staff of the Medical Visitors was 21. The London Hospital authorities had intimated that they would receive patients to the extent of their accommodation, but as such accommodation necessarily depended upon the demands made upon it by the several districts, it was recommended that inquiries be instituted for obtaining a suitable building for a temporary Cholera Hospital. The Keverend Jas. Cohen, Rector of Whitechapel, expressed his willingness to co-operate with the Committee. Articles of nourishment, &c, were supplied by the Guardians upon orders of the Medical Visitors. Coffins were also provided by the Workhouse authorities. The Guardians further proposed to set apart the new wing of the Workhouse for the reception of Cholera patients. A letter prepared by the Clerk, to be addressed to Clergymen and others in the. District, was approved and ordered to be printed. The letter intimated that the Board had sub-divided the District and appointed Medical Visitors to attend the sick, and dispense medicines, free of charge ; and it informed the party to whom it was addressed, that a plan could be obtained showing the sub-divisions of each district for the purposes of Medical Visitation, and the residence of the Medical Gentleman appointed to each sub-division. It was stated in the letter that " effectual aid is only to be rendered by searching out the existence of disease in its incipient stage, and then obtaining medical advice and assistance, and any assistance to forward that object will be most valuable and must be productive of beneficial results." It was further intimated, that if nuisances existed upon any premises that were visited, and complaint made to the Office of the Board, it should receive immediate attention. The Clerk and Medical Officer attended a meeting of the Board of Guardians, and the result of that interview was reported to the Committee on the 2nd August. The report was to the following effect : — That the destitute cases could be reported to the Eelieving Officers by sending a notice to them, in writing, addressed to the Workhouse. That nourishment, &c., would be given on such order, and that the cost of the articles supplied by the Guardians would be debited to the Board of Works. That the Guardians had provided accommodation in the Workhouse for the reception of 40 male and 40 female Cholera patients, and that at the present time, August 1 st, there were about 20 of such patient s in the Workhouse; but the Guardians urged that district hospital accommodation should be prosby 13 the Board of Works. That in the event of the Board fitting up a ra Hospital, the Guardians would supply some articles of furniture, for the removal of Cholera patients, the cot belonging to the Guardians be used on the order of the Medical Visitor. That the Guardians were willing to place at the disposal of the Board eight houses in Thomas Street, in default of better arrangements, for a temporary Cholera Hospital. The following code of instructions were approved and ordered to be printed, and a copy to be sent to each district Medical Visitor :—: — BOARD OP WORKS— WHITECHAPEL DISTRICT. Instructions to the Medical Visitors appointed by the Board within the WJiitechapel District. To Sir, The Sub-division of the Whitechapel District to which you have been appointed by this Board, and of which you are now in charge, is defined by the coloured portion of the plan with which you have already been supplied ; and the duties which devolve upon you, consequent upon such appointment, are defined by the copy of the Orders by Her Majesty's most honourable Privy Council, dated the 21st of July instant, with which you have also been supplied. Notices have been prepared and will be supplied to you for distribution on the occasion of your visits within your Sub-division, that the inhabitants may know to whom to apply for medical attendance and medicine. The separate forms already supplied to you, upon which to make your returns, are to be filled up from cases which have occurred in your Sub-division within the period of 24 hours, terminating at midnight, and will have to be sent to the Medical Officer of the District, at the Offices of the Board, before eleven o'clock on the following morning. The Medical Officer of Health of the District will be happy to see you at^this office any morning between ten and twelve o'clock. It will be convenient if you will in your return, mention the number of houses visited by you, or under your direction, during the 24 hours, and the number of recoveries. You will be pleased to report the existence of all nuisances that may come under your observation during your visitations. Medicine, medical appliances and disinfectants will be supplied by you as directed by the 7th of the Orders, the cost price of which will be repaid by the Board ; and you will be pleased to render a weekly account of the total quantities of each article so dispensed, with the cost price thereof. For the purposes of the 6th Order, the Relieving Officers of the Whitechapel Union can be readily communicated with at the Workhouse. For the purpose of the Bth Order an application should be made to the Master of the Union Workhouse, Charles Street, Mile End New Town, for such articles as may be requisite. Cholera Patients will be received at the London Eospital, and also at the Union Workhouse, and if the accommodation at those establishments should prove insufficient, other arrangements Jwill be made by the Board to meet the demand. At the Union Workhouse there is a cot on wheels for the removal of patients, and the Guardians have kindly placed it at the disposal of the Board, and it will be forwarded for patients upon your order in writing. If it be necessary in your judgment to remove healthy persons from the sick, you are requested to communicate forthwith, by writing or otherwise, to the Medical Officer of the Board. McDougall's Disinfecting Fluid and Disinfecting Powder are recommended by the Medical Officer of the Board, and they are kept in Store at the Office of the Board; you can, upon request, be supplied with them for disinfecting purposes. In the event of your recommending infected Articles to be destroyed, you will be pleased to coaimuuicate with the Medical Officer of the District on the subject. 14 The necessity for the speedy interment of persons dying of Cholera or Diarrhoea should be strongly represented to the friends of the deceased, and if any delay is likely to occur in the burial, or if the friends have not sufficient funds for the purpose, you are requested to report the case forthwith to the Medical Officer of the District. Order of the Board, ALFRED TURNEE, Clerk, Office of the Board of Works, 15, Great Alib Street, "Whitechapel, July, 1866. It was resolved that the Medical Officer of Health should arrange with an undertaker for the supply of coffins and the burial of bodies. On the recommendation of the Medical Officer it was resolved that in cases of emergency, the premises where Cholera existed should be immediately limewashed and disinfected at the expense of the Board. It was further resolved that a notice be prepared by the Clerk and printed, advising the friends of deceased persons that corpses must be buried forthwith, or that they would be removed by the Board. August Ist. The Medical Officer reported, that in accordance with the discretion vested in him at the previous meeting of the Committee, two men had been employed as labourers for the purpose of carrying into effect arrangements for disinfecting premises and limewhiting rooms as necessity might arise. August 2nd. At a meeting of the Committee of Works, it was recommended to the Board that as a temporary arrangement, Goulston Street, Middlesex Street, Bear's Head Yard, Wentworth Street West of Commercial Street, Bell Lane, Eoyal Mint Street, Glass House Street, and Blue Anchor Yard, be cleansed every day. August 3rd. At the meeting of the Committee held on the 3rd August, it was stated by a deputation of the Medical Visitors that the distribution of the Bills informing all persons afflicted with Diarrhoea that they could obtain medical advice and medicines free of charge, had been a considerable daily loss to each of them, for numbers of respectable persons took advantage of the notice, who were well capable of paying the usual fee for medical advice. August 4th. It was resolved upon the recommendation of the Medical Officer of Health that a communication be made to the Water Companies supplying the District, requesting that water should be supplied on Sundays, and. a larger supply allowed on the other days of the week. August 6th. It was reported to the Committee that the Poor Law Board had intimated that no patients after this date would be permitted to be received into the Workhouse. This prohibiting order on the part of the Poor Law Board appeared to the Medical Officer of Health to be arbitrary in the extreme, and altogether unnecessary, the same being entirely at variance with the opinion expressed in the report of the Epidemiological Society, by the most eminent members of the medical profession in the Kingdom, viz., "That with proper precautions, Cholera patients may be admitted into separate wards in general hospitals or infirmaries without undue risk of the extension of the malady to the other inmates of the institution." The precautions above referred to are these : 1. Ample space to each patient; not less than 15Q0 or 2000 cubic feet. 2. Thorough ventilation of the wards at all times, both night and day. 3. Immediate disinfection and removal of the excreta, soiled linen, &c. 4. A separate staff of nurses. 15 L August 7th. It was stated by a member of the Committee that the verend F. Geevis, the Eeverend William Hobbins, the Curates of Spitalfields, and the Eeverend A. B. Suteb, the Incumbent of Mile End New Town, were making a house to house visitation in their respective Districts. August Bth. Dr. Loane ? one of the Medical Visitors, attended the Committee and explained that in some instances which had come under his notice, the nourishment which had been supplied on his order had been consumed by other persons. He, therefore, suggested that as Mrs. Dunn, at the Parsonage of St. Paul's, Dock. Street, and Miss Black, of Mill Yard, had expressed their readiness to have beef tea made for the patients, and to take steps to insure the proper delivery of the articles to the patients, he desired to know if the Committee would assent to his ordering the necessary beef to be supplied. Dr. Loane mentioned that in some cases patients had been neglected by their relatives, and suggested that nurses should be appointed. The Committee informed Dr. Loane that he was at liberty to adopt any measure that the emergency might demand. August 9th. The Medical Officer of Health reported that he and the Clerk had inspected the building in Commercial Street, then in the course of being fitted up as a Cholera Hospital, under the supervision of the Sisters of Mercy, and that Miss Sellon, the Lady Superior, had stated that it would be opened in a few days. August 1 3th. The Reverend Beooke Lambeet, Incumbent of St. Mark's, Tenter Ground, Goodman's Fields, attended the Committee, and suggested that for articles of Clothing, &c, destroyed by order of the Medical Visitors, compensation in kind should be given instead of in money. Lists of nuisances found on a house to house visitation by the Eeverend B. Lambebt, the Eeverend James Cohen, and Mr. Turner of Spitalfields, were given in. These Lists were referred to the Medical Officer of Health. The Committee were informed that the effluvium which arose from the Bone Boiling premises in the neighbourhood of Buck's Eow, affected the neighbourhood most prejudicially, as the whole area appeared to be impregnated with the offensive smell. The abatement of this nuisance had however been anticipated, by proceedings recently taken against Mr. Cambden and Mr. Quantrall, in consequence of which the former had resolved to discontinue his business during the prevalence of Cholera, and as regards the latter, it was stated that the Magistrate had, on Saturday, the 11th August, on the assent of Mr. Quanteall, ordered that the whole of the bones on his premises should be removed within four days, and that for the period of two months the bones were to be removed every day during the prevalence of the Epidemic of Cholera. It was ordered that the Medical Visitors be supplied with printed forms for the supply of nourishment, &c, ordered by them for the relief of the sick and destitute. August 21st. A letter of Mr. AY. Finch Edwards, of the Medical Department of the Privy Council, was read, in which letter the attention of the Board was directed to the 29th, 30th, and 32nd sections of the 29th and 30th Viet., c. 90, known as the Sanitary Act of 1866, relating to the inspection of ships in the Thames. It was resolved on the personal application of two members of a Committee in Spitalfields, appointed to administer funds for the relief of a portion of that Parish, to supply disinfectants, which they undertook should be properly used, 16 August 23rd. The Medical Officer of Health stated to the Committee, that in some districts little or no Diarrhoea existed, and that he was now in a position to suggest that the staff of Medical Visitors might be decreased, and that a redistribution of the District for the purpose of medical visitation might be made. A letter fromT Miss Sellon was read, informing the Medical Officer of Health that the temporary Cholera Hospital in Commercial Street was open for the admission of any cases which he may wish to be taken in. August 24th. A list of nuisances discovered on a house to house visitation was sent in by the Reverend James Patteson, also one by Mr. Hodsoht, a member of the Committee, another by Mr. Tttbnek, likewise a member of the Committee, and one by the Curate of Spitalfields. These lists were referred to the Medical Officer of Health. The Medical Officer of Health was empowered to effect an arrangement for the purchase and supply of articles of clothing and bedding, for the purpose of compensation in kind in all cases where similar articles had been destroyed by order of the Medical Visitors. The Medical Officer of Health laid before the Committee a letter that he had received from the Engineer of the Liverpool Local Authority, in reply to a communication made to Dr. Trench by the Medical Officer of Health, asking for information respecting the mode adopted in that Town for disinfecting articles of clothing, &c. The letter was accompanied by a plan of the Building and the Apparatus. The object of laying Dr. Teench's letter before the Committee was with the view of inducing them to recommend to the Board the erection of a disinfecting apparatus in a suitable locality, where all the soiled or otherwise infected clothes and bedding might be removed, and there submitted to a dry heat, sufficient to destroy the contagious matter in them. The Medical Officer of Health reported that an arrangement had been made in Dr. Loane's District to remove healthy persons from infected houses to a lodging-house hired for that purpose. The Medical Officer of Health also reported that he had appointed Mr. Semple to visit from ship to ship in the River Thames, abutting upon the District. August 28th. The Medical Staff, upon the recommendation of the Medical Officer of Health, was still further reduced. Up to the 31st August, the meetings of the Committee had been held daily, Sundays excepted, in conformity with the resolution passed at the first meeting of the Board, and at each meeting the Medical Officer read a report of the new cases of Diarrhoea and Cholera which the Medical Visitors had discovered and attended on the preceding day. On the 1 3th September, when in consequence of the great diminution of the number of cases of Diarrhoea and Cholera, the Medical Visitors were reduced to three, and on the 27th September the services of the Medical Visitors were altogether discontinued. Having in the foregoing pages briefly mentioned the proceedings of the Board during the active progress of the Cholera, I shall now attempt to give a short history of the disease as it affected this District. 17 Cholera in the Whitechapel District. Cholera first made its appearance in Bromley, Middlesex, on the 27th June, but did not mainfest itself in this District until the 10th July, when the first case came under my notice. This patient was a female who had accompanied a family in the capacity of a servant from Holland, where they had been residing, and had only been four days in London when she was attacked with the disease in a severe form. She was removed to the London Hospital, where she died within fourteen hours of her admission. The family occupied one of the most respectable houses in Great Prescot Street, which, so soon as I heard of the case, was inspected by myself and an Inspector. The only complaint that was made by the lady of the house was, that of a disagreeable smell from a large stable situated at the rear of the premises, and within a few feet of the back parlour and back kitchen. No other inmate of this family was attacked with the disease. Within a day or two from the occurrence of this case, information was given to me of another severe case in Mansell Street, a street abutting upon great Prescot Street, and running at right angles with it. This case was that of a working man, who went to bed in perfect health on the night preceding the attack, after having partaken of a hearty supper. About three o'clock in the morning he was seized with Cholera, and died in the course of seven hours. On examination of the house, it was found to be dirty, the drain in the yard was untrapped, and the water-butt was without a cover. Cases then occurred in rapid succession. The Table on the next page is a copy of the daily returns made by the Medical Visitors. The returns were made up from midnight to midnight, and were presented to the Board on the following morning. The first return was up to midnight of Saturday the 28th July and was dated on that day. This Table gives but a very imperfect account of the number of cases of Diarrhoea and of Cholera which occurred in this District during the prevalence of the recent epidemic ; for it makes no mention of the cases that were prescribed for at the residences of the Medical Visitors, nor of those attended by the Medical Ofiicers of the Union, nor of those treated by private Medical Practitioners, nor of those prescribed for at the London Hospital, the Eastern and London Dispensaries, nor of those treated by the Surgeons to the Jewish Board of Guardians. The record of the cases prescribed for by the Medical visitors at their own residences could not be accurately kept, in consequence of the overwhelming amount of work which devolved upon them in visiting the sick, but the number may be estimated at about 9,000. The Medical Ofiicers of the Union attended 4,100 cases of Diarrhoea and 58 of Cholera ; and from the returns kindly made to me by the private practitioners in the District it appears that they had attended 2,322 cases of Diarrhoea, 183 of Choleraic Diarrhoea, 126 of Cholera, and 41 of Diarrhoea which passed into Cholera. The Diarrhoea cases at the London Hospital were, up to August 31st, nearly 10,000 ; of these about a fifth part or 2,000 may be estimated as belonging to this District. The returns from the Eastern and London Dispensaries show that about 1,100 cases were attended at these institutions, and the number attended by the Surgeons to the Jewish Board of Guardians, may be estimated at the same amount. Thus the total number of cases of Diarrhoea that came under treatment in this District containing a population of about 78,000 was about 27,251, which is nearly 35 per cent, of the entire population. This number does not include those relieved at the Eectory, Whitechapel, and at other places which were opened for the relief of persons suffering from Diarrhoea. (B) 18 t RETURN OP CHOLERA AND DIARRHOEA CASES For the WMtechapel District. DEATHS. - No of Houses 2 H 2 S^ fi 2 0) l_ _£!_ _l I l_ I 6I 6 July 28 40 8 9 2 ... 102 29 133 24 27 11 .., 3 70 30 226 20 18 4 ... 7 897 31 230 17 24 15 ... 4 634 Aug. 1 306 34 20 10 ... 3 1511 2 226 25 24 10 ... 8 1231 3 222 24 14 9 ... 2 1087 4 m 12 15 9 ... 3 1109 5 140 23 20 7 ... 1 445 6 263 19 28 12 ... 6 1268 7 224 24 21 8 ... 1 986 8 249 18 20 17 ... 1 1017 9 232 20 15 5 ... 833 10 233 13 11 2 ... "{ 875 11 169 20 16 4 ... 1 1057 12 135 18 8 9 ... 1 628 13 273 26 22 13 ... 1 1644 14 245 14 10 4 ... 1 1473 15 191 30 12 5 ... 1486 16 213 31 9 2 ... 1 1323 17 222 38 11 3 1 1577 18 197 26 18 7 ... ... 1354 19 197 19 11 3 ... 1 912 20 246 20 11 3 ... 1 1266 21 181 16 11 5 ... ... 1434 22 180 19 9 5 ... 1337 23 220 17 10 1 ... ... ]301 24 150 15 3 1 ... 1122 25 135 15 3 ... ... " 1024 26 93 15 3 2 ... 631 27 193 17 8 4 ... ... 1018 28 123 19 8 ... ... 1 963 29 141 16 6 4 ... . 766 30 121 8 3 3 ... 572 31 68 9 5 ... ... ... 490 Sept. 1 66 7 2 ... 1 1 322 2 64 7 3 ... ... ... 134 3 84 6 3 ... ... ... 274 4 51 5 6 1 ... 1 247 5 57 8 5 2 ... ... 223 6 57 5 3 1 ... ... 208 7 54 9 ... 1 ... ... 235 8 53 4 1 ... ... . 203 9 43 6 1 ... ... ... 103 10 57 1 5 1 ... ... 164 11 51 6 4 1 ... ... 177 | 7226 751 496 206 2 50 37233 19 Return of Cholera and Diarrhoea Cases for the Whitechapel District—Continued. I —~T 1 T^ 1 4 DEATHS. Date. -a o ~ No. ofHousai « A - i .1 2 Visited. * *" iJ-f —' 3 *S "3 "3 a ffi =3 fl 0 S 0 l_ _l^ Brought over 7226 751 496 206 2 50 37233 Sept. 12 53 5 2 ... .. 175 13 53 1 5 1 196 14 33 1 ... 1 149 15 26 3 1 139 16 24 2 1 69 17 26 2 1 149 18 29 ... 1 ... 123 19 22 3 4 1 ... ... 125 20 24 3 1 ... ... ... 114 21 11 3 1 96 22 17 1 1 ... ... ... 94 23 16 ... ... 1 ... ... 91 24 18 53 25 20 ... ... ... ... ... 60 26 15 2 ... 57 27 16 58 7629 777 514 I 210 2 50 88981 Weekly Summary of the above- Aug. 2 1555 164 151 70 ... 30 6141 11 1510 137 131 55 ... 11 6481 18 1476 183 90 43 1 4 9415 .25 1309 121 58 18 ... 2 8396 Sept. 1 805 91 35 13 1 2 4762 8 420 44 21 5 ... 1 1524 15 316 21 18 4 ... ... 1103 22 153 14 9 1 ... . ... 770 27 85 2 1 1 ... ... 319 7629 [ 777 I 514 210 2 1 50 | 38981 The returns of the Private Medical Practitioners in the District were sent to me in the following form: — BOARD OF WORKS—WHITECHAPEL DISTRICT. Date 186 Return of Cases of Diarrhoea, Choleraic Diarrhoea, Cases which have passed from Diarrhoea into Cholera, and Cholera, WHICH OCCURKED IN MY PRIVATE PRACTICE DURING THE PRECEDING DAY. r.. , Choleraic Passed into r,, , Diarrhoea. Diarrhoea> Cholera> Cholera. New att&cka Becovered Died Total number of Cases now 1 under treatment f Remarks. Name Address 20 I am happy to be able to state that with one exception all the Medical Practitioners in the District complied with my request, in sending me dailyreturns, and I take this opportunity of cordially thanking them for their trouble in doing so. Nuisances. In accordance with the instructions issued to *the Medical Visitors a return of all nuisances was made by them to me daily. These returns were immediately given to the Inspectors, who, with as little delay as possible, served a notice upon the landlord in each case forthwith to abate the nuisance. If, however, the nuisance was of such a character as admitted of no delay, such as a choked drain or an overflowing privy, the case was immediately attended to by labourers employed by the Board, who had directions to remove the nuisance at once, and also to apply freely the disinfectants which were kept in large quantities on the premises of the Board. The following is a copy of the daily return paper which was filled up by the Medical Visitors : — BOARD OF WORKS— WHITECHAPEL DISTRICT. Late 186 Pbemonitoby Cases and Choleba discovebed on Visitation. „ , Cases discovered on Visitation. Diarrhoea LOOALXTY. <« .X ? T,, * ** SSS£ habitants. Diarrhea, ing to Cholera. « . Cholera. tholera< Total Recovered Died J Number of ) Total number under Houses raited) Treatment Medical Visitor. Staff of Inspectors of Nuisances. For the carrying into effect the removal of nuisances, the staff of inspectors was increased from three to seven, and I gave instruction that the Office should not at any time be left during the day without one of the inspectors being present, so that in case of a notice of the existence of any nuisance requiring immediate action to be taken, the same might be promptly attended to. This large staff was most actively employed during the whole day, at the time when the disease was at its height, and their services were frequently required on Sundays. The duties of the Inspectors were performed in a most praiseworthy manner, and the result of their labours may be seen on referring to my last quarterly report. When it is borne in mind that all the complaints of nuisances were attended to which were reported not only by 21 medical visitors, but by the Inspectors employed at the expense of the Board of Guardians of the Jewish Poor, by district visitors, by scripture readers, by Committees of voluntary 21 1,600, some estimate may be formed of the amount of work performed by the sanitary officers of the Board. As might have been excepted, from the reports of so many persons, not having much experience in the matter, complaints were made of nuisances which the Board had no power to remedy, but nevertheless they all had the attention of the Inspectors. To all those gentlemen who so freely gave their time to visit the houses of the poor to relieve their wants, and make known their unfavorable surroundings, I respectfully offer my best thanks. The following report is made by the Inspectors of Nuisances :—: — Ninety-three public privies were limewashed. About 150 ditto disinfected at least twice every week. About 60 privies belonging to private houses were disinfected at least twice every week. A house, No. 34, Phoenix Street, which was in a filthy condition, was limewhited throughout. Also several rooms where deaths from Cholera had taken place were limewashed. All the above work was done by men engaged expressly for the purpose. Rather more than half a pint of Carbolic Acid was mixed with the water in each watering cart, thereby diffusing the disinfectant over the entire district. SURVEYOR'S DEPARTMENT. Statement of Works executed during the prevalence of Cholera, 1866. Eightyone privies were unstopped and cleansed. Eighty-nine drains were complained of as being offensive, and the nuisance in each case was abated. Fifty bags (each containing about 71bs) of McDougall's Disinfecting Powder were suspended in the ventilating shafts of the sewers in the narrowest thoroughfares by means of strong wire hooks hanging upon the ventilating gratings. The complaints of smells arising in these thoroughfares became less numerous after this plan of deodorizing the gases from the sewers was adopted. The whole of the gullies in the District were disinfected with McDougall's Disinfecting Powder, and the courts flushed by means of hose pipes twice in each week. The public privies and courts were all limewashed and disinfected. An average of 10 men per day were in constant employment during the period of the epidemic in executing the above works. There was also a large amount of sanitary work done which has not been taken account of, the same having been for the most part ordered by the Inspectors verbally. Inspection of the Shipping in the River. Immediately upon the appointment of Mr. Semple, on the 27th August, that gentleman entered upon his duties and visited daily a certain number of the ships in that part of the river abutting upon this District. On the termination of his duties he presented the following report : — September 20th, 1866. I have been engaged by the Board of 'Works for the Whitechapel District during the last three weeks, as Medical Inspector of the Vessels fronting that District. During the term of my office I have met with the greatest civility and courtesy from the Captains and Mates of the several vessels, the utmost willingness being shown by those officers in conducting me over the vessels. • I have encountered very little disease of any kind, only four or five cases of Diarrhoea having come under my notice. Many of the vessels were well supplied with medicine chesla ; and I found, on inquiry, that medicine had been supplied to those of the crew who had suffered from any illness. 22 many as from 9 to 13, and even 18 men were found to be occupying very close and ill ventilated quarters. The forecastle of one of the ships visited was about 6 feet high, 5 feet wide, and 8 feet long, and in this small space 13 men slept ; thus affording for each man only about 19 cubic feet. I have inspected more than 150 vessels, and I can state that the general health of the persons on board is satisfactory. (Signed) CHAELES SEMPLE. Upon inquiry I have learnt that the vessels in the Docks and in the River are supplied with water from three different sources, viz., from the East London Company, the New Eiver Company, and another Company that takes water from the Thames at Blackwall, which, after filtration, is supplied to the ships. The water supplied by this Company is said to be preferred. The crowded condition of the sleeping berths in some of the vessels inspected by Mr. Semple demands the serious attention of the public, and of those in authority. Not only is it of importance to the health of the sailors that their berths should be duly inspected, and that more spacious and better ventilated quarters should be assigned to them ; but it is likewise necessary that a competent officer should examine the provisions supplied to the crew, and to ascertain that a sufficient quantity of lime juice of the best quality is provided for their use. The inspection, however, of the shipping in the Thames should be performed under the direction of the Conservancy Board, and should not be intrusted to local Boards whose Districts abut upon the Biver. If a similar inspection of ships to that recently adopted with reference to Cholera were hereafter duly carried out by properly qualified Medical Officers, and power given to enforce all that was deemed necessary for the health of the crews, the most important results might be anticipated. During the recent epidemic, the authorities of the Dreadnought Hospital ship caused a large number of the vessels in the River to be inspected, so that any case of Diarrhoea that was discovered might be promptly relieved. This was attended with the most beneficial results, as shown by the cases of Cholera on the River being considerably less in number than in either of the Epidemics of 1849 and 1854. Proceedings in eases of Death. In all cases when a death from Cholera occurred, the house was inspected by a qualified Medical Practitioner, who superintended the disinfecting of the room, and the removal of the clothes and bedding which had been soiled by the discharges of the patient, to the Stone Yard where they were burnt under his inspection. A list of the articles so destroyed was made by that gentleman, and the nearest relative of the patient was directed to apply immediately at the Office of the Board, where an order was given to a respectable tradesman in the District to supply the parties with new articles for those that had been destroyed. The room was also immediately limewhited at the expense of the Board. Mode of Disinfecting Rooms. The plan adopted in this District to disinfect rooms was as follows : — Ehe clothes and bedding of the patient were first well sprinkled with ie of lime, and were then conveyed ma truck covered with canvas, to the Yard. A large iron pot (provided with.a cover to be applied in case of the boiling over of the tar) containing about half a pound of Stockholm tar, was placed upon the floor of the room, and into it was thrust a red hot poker or a live coal, the door and windows of the room having been previously closed. The smoke, which issues from the burning tar is speedily 23 carefully watched, and if any danger to the room from the boiling over of the tar, is likely to arise, the pot is immediately covered and the fire extinguished. This is undoubtedly a very prompt and effective mode of applying the disinfecting properties of tar. In addition, however, McDottgall's Disinfecting Powder was sprinkled over the room. Dr. Lethebt suggests, in a letter addeessed to the Registrar General, on the practice of disinfection, the use of the following disinfectants, which he says he has largely tested and has found them most effective : — 1 Chlorine gas, 2 chloride of lime, 3 carbolate of lime, 4 carbolic acid, 5 chloride of zinc, 6 chloride of iron, 7 permanganate of potash (Condy's Fluid), 8 animal charcoal. Dr. Lethebt says " I have found that chlorine gas is best suited for the disinfection of rooms, where, as is the case generally, the occupant cannot be removed for a thorough cleansing. The process which I adopt is the following : about a tea spoonful of the black oxyde of manganese is put into a tea cup, and there is poured over it, little by little, about half a tea-cupful of strong muriatic acid. In this manner chlorine is gradually evolved.* As chlorine is heavier than atmospheric air, it is best diffused through the room upon putting the mixtnre upon a high shelf." " Chloride of lime," Dr. Lethebt states, "was used to the amount of about seven tons, and about 2000 of the worst class of houses were disinfected by it every week. A staff of 45 men was employed for this purpose. Carbolate of lime was also used; "but as the disinfecting power of this substance is destroyed by chloride of lime, it is of great importance that they should.not be used tegether. The advantage of the carbolate of lime is its continuous action, for the carbonic acid of the air slowly lets lpose the carbolic acid, which diffuses itself through the atmosphere in sufficient quantity to act as a disinfectant, and it does not destroy fche colour of the clothing." Carbolic acid has been used in the City of London in its concentrated form for disinfecting privies and drains. Diluted with 2000 times its bulk of water it was distributed by means of the water carts over the public ways. About 1000 gallons of this fluid were used. The effect of carbolic acid in the sewers was to arrest the decomposition of the sewage. " Chloride of zinc (Sir William Burnett's Fluid) is well suited for the disinfection of the discharges from sick persons. A table- spoonful of this liquid is sufficient to disinfect each discharge from the body." " Chloride of iron it applicable in exactly the same manner as chloride of zinc." " Permanganate of potash (Condy's Fluid) is only suited for the disinfection of drinking water. It would take more than a pint of this liquid to disinfect a pint of rice-water discharge from a cholera patient, and even then the disinfection is very uncertain." Animal charcoal is used for the removal of dangerous organic impurity from water. * The following mode of preparing Chlorine Gas was recommended by a Committee of the Royal College of Edinburgh. " Chlorine may be prepared by mixing two table-spoonfuls of oommon salt, two teaspoonfuls of red lead, half a wine-glassful of Sulphurio Acid, and a pint of water." fA bottle, wide-mouthed, in which the following ingredients are mixed will give off Chlorine for a long time, if kept corked when not in use : — Chlorate of Potash 2 drachms, strong Muriatic Acid and pure water of each two ounces. " Sulphurous Acid destroys organic matter, and it is said to have a powerful effect on miasma. This acid is easily obtained by burning Sulphur." 24 Dr. Lethebt concludes his valuable remarks upon the subject of disinfection in the following words : — " I refrain from entering into any explanation of the mode of action of these several disinfectants ; for whether the agent of the disease is a living germ, capable of reproducing- itself in the human body under certain conditions, as most likely it is, or whether it is an unorganised, or even as Dr. Eichaedson supposes, a crystalline compound, the practical results are the same and are unquestionable ; and in conclusion, I would say, by way of summary that for the disinfection of sick rooms, chlorine and chloride of lime are the best agents; for the disinfection of drains, middens and sewers, carbolate of lime and carbolic acid are the best ; for the discharges from the body carbolic acid, chloride of zinc, or chloride of iron are the best ; for clothing the best disinfectant is heat above 260° if a dry heat, and 212° if a wet heat ; and for drinking water filtration through animal charcoal." Result of Disinfecting Rooms and Destruction of Soiled Clothing and Bedding of Cholera Patients. Dr. Stephen Duke, who had the exclusive management of the details in the destruction of clothing, &c, makes the following report upon this subject : — DE. STEPHEN DUKE'S REPORT. Dear Sib, Under your direction I visited every house where a death was recorded, and I superintended the destruction of the clothes and bedding of every person who died of Cholera, and inquired into and minutely inspected the sanitary condition of the house and locality, and ascertained the existence or otherwise of Diarrhoea. I also visited every house where Cholera appeared, immediately I received information of the same. In many cases I received the information as soon as the person was attacked, for I made a daily visit to the Temporary Cholera Hospital, Commercial Street, where I ascertained the number and situation of the house from which a Cholera patient had been removed. On my arrival at the infected house, I ordered the beds and bedding, if soiled, to be immediately removed to the Stone Yard, where they were burnt at night in a furnace erected for that purpose. Before the Board had resolved to have the operation of the burning of the clothes performed at night, I superintended the process myself. Before removing the beds and bedding, I freely sprinkled them with chloride of lime, and I saw that the same disinfectant was used freely about the room and passages of the house ; and it was also thrown into the privy and drains, and the room was disinfected by means of the vapour from heated tar. I inspected most minutely all the inmates, to ascertain whether any cases of Diarrhoea existed among them, and it was only by the most searching investigation that I sometimes discovered cases of that disease, especially amongst children. I observed that there was very little fear among the inhabitants where Cholera appeared, and not a single instance of opposition came under my notice to the carrying out of the directions given by me for their safety. The beds and bedding, with only three exceptions, were of little value, and the removal of the same, I have no doubt, greatly tended to arrest the spread of the disease ; for immediately after the means as above- described were used, the mortality decreased quickly. My principal reason for considering, that it was the free use of disinfectants, and the destruction of the soiled bedding, &c, that lessened the number of cases, is, that many of the cases which occurred towards the end of the epidemic visitation were as severe in character as they were at the commencement of it, or in other words that the poison had not become less virulent. The greatest sanitary defect that I observed in the Whitechapel District, and which was very prejudicial to health, was the filthy state of almost all the water butts, and the leaky condition of many of them, thereby causing constant dampness. This dampness was not confined to the yards, but the water made its way into the cellars ; and worst of all, in many cases, into the dust bins, thereby causing a more speedy decomposition of the vegetable and animal matter therein. The effluvia arising from this cause, I believe tended to spread the disease. 25 Cholera is the most fatal disease known in the annals of medicine. The mortality in the Cholera Wards in the London Hospital, and in those of the Temporary Cholera Hospital, Commercial Street, being respectively as high as 54"9 and 54*7 per cent. The sudden falling off in the number attacked, during the late epidemic, may be ascribed to some important cause, and I gave it as my opinion from observation, that it was due to the close and great attention paid to the sanitary state of the East End of London ; and that as we lessen destitution, remove filth, foul air, and the causes of disease generally, so we destroy the agencies through which this formidable disease operates. STEPHEN DUKE, M.D., To John Liddle, Esq. December 27th, 1866. The concurrent testimony of those Medical Practitioners who gave much time to the investigation of the causes and treatment of Cholera during its recent visitation, is similar to that arrived at by Dr. Stephen Duke, as regards the benefits derived from the use of disinfectants in preventing the spreading of the disease. Carbolic acid was extensively used in this District, both in the streets and in the houses where death ocxmrred. Carbolic acid was also very extensively used in the streets of the City of London, and as the City was but slightly attacked it may be fairly assumed that this was attended with benefit. Disinfectants.* Tar was used as a disinfectant in the manner described upon the theory that the poison of Cholera depended upon the emission of living organisms being given off from patients suffering from that disease, and that tar vapour, whether given off by the burning of tar, by carbolic acid, or by carbolate of lime, is proved to be fatal to these germinal growths, whether they consist of animal or of vegetable matter, of minute animals, or of the cells of cryptogamous plants. If the tar acids were useful in destroying the germs or living particles of these animal or vegetable organisms, constituting the contagious matter of the disease, then the plan adopted appeared to me to be one of the most efficacious modes of applying them. But if we were certain of the precise nature of the poison it might not perhaps be difficult to find a perfect disinfectant or destroying agent of this organic matter, the the proper application of which would at once put a stop to the disease by killing these organized germs. Deodorizers, disinfectants, and antiseptics, must not be confounded the one with the other; they are not convertible terms, the first term merely relates to the removal of smell, such as the removing of the offensive odour of putrefaction, and the use of deodorizers forms no security against infection. The second applies to the destruction of the poisonous matter or contagiumi t This word is applied by Mr. Simon to the contagious property of the matter which is supposed to pass from one body to another. The third or antiseptics is applied to those agents which prevent chemical change by destroying the tendency to putrefaction. The materies morbi, or contagium has not however been as yet identified, but the reasoning upon this mode of the spread of the contagion is entirely founded upon analogy. This is not however a sufficient reason why this theory should be rejected, for ifc appears to be the opinion of the most celebrated microscopists and pathologists that the contagium " consists of very minute particles of matter in a living state, each capable of growing and multiplying rapidly when placed under favorable conditions." This theory may explain the spread of Epidemic diseases, but it does not explain their origin. • For further particulars respecting the use of disinfectants, see the valuable Reports of Dr. Angus Smith and Mr. Cbooks on the Cattle Plague. 26 by actually destroying infecting substances, antiseptics by destroying tbeir activity. The former act more energetically upon dead than living organic matter. Antiseptics destroy vitality and act with intense energy on the inodorous germs of infection. If the theory that living germs are the materials of infection, then antiseptics are the proper agents to use. If the con tagium consist of a chemical compound then such an agent must be used which will combine with that substance so as to convert it into an inert body. Carbolic acid has the power of arresting and preventiug decomposition ; it checks the evolution of offensive odours, and stops the development of minute animal organisms" Mr. Crooks, in the concluding paragraph of his most valuable paper on the use of disinfectants, says, " Although foul sewage and putrefying animal matter are probably insufficient to generate the first septic germ of zymotic disease, there can be no question that when such diseases do attack a population they spread with the greatest virulence whenever such materials abound." The science of disinfection, is at present, like all other part of sanitary science, still in its infancy. Dr. Angus Smith says " many substances prevent the decay of organic matter. These are antiseptics, and they have also been called disinfectants. Charcoal condenses the oxygen within the pores, aud assists the destruction of the animal matter. Permanganate of potash gives out oxygen, and hastens the formation of carbonic acid. Chloride of lime gives out oxygen. Sulphurous acid acts by taking oxygen from the substance to be disinfected. Charcoal is destructive of animal matter ; it not only absorbs the gases which arise from decomposition, but it also destroys the organic compounds and forms more simple compounds in their places. Not being volatile, charcoal has no influence upon the air at a distance from the place where it is laid." The necessity of using Disinfectants. To illustrate the necessity for disinfecting or destroying the clothes, &c, of those who perish from Cholera, it is right to mention the following : " A woman residing in Underwood Street, in the Whitechapel District, last week got the clothes of a person who died from Cholera in Bethnal Green, and she brought them home and washed them. She was immediately seized with the disease and died on Saturday ; a man living in the same house was attacked and died on Monday ; a man living in the next house was seized with Cholera. No case of Cholera had occurred in Underwood Street until the fatal clothes had been brought from Bethnal Green." If it were necessary I might adduce other cases of a similar nature to Bhow that there is considerable danger from the washing of infected articles of bedding and clothing of Cholera patients. As it is not known how long the excretions of patients suffering from Cholera, when received on articles of clothing, retain their power of propagating, the disease, it is absolutely necessary for the public health that all clothes soiled with such discharges should be at once destroyed or properly disinfected in suitable places to be provided for that purpose, in accordance with the 23rd Section of the Sanitary Act, 1866. Burial of the Dead. In accordance with the 15th Section of the Orders of the Privy Council an arrangement was made with an undertaker to remove the bodies of all persons who had died of Cholera, and upon every occasion when persons were either unable or unwilling to bury their dead, I gave written 27 authority to the undertaker so engaged to remove and bury forthwith the bodies, and I am happy to be able to report that comparatively little difficulty occurred in removing and burying the dead. It is true that in some few instances a delay occurred in getting the body removed from the room in which the patient died. This delay was sometimes caused by the neglect of the friends of the deceased in not registering the death until a period of two or three days had elapsed ; and thus it occasionally happened, that although I was indebted to the kindness of the Registrar Oeneral in transmitting to me daily the returns of the local Registrars, in which were specified the houses where Cholera occurred, I was not made acquainted with a death until several days after the event. On a future occasion, the danger arising from the prolonged retention of the dead may be obviated by making arrangements with the Registrars of deaths to transmit immediately to the Medical Officer of Health the name of the deceased, the number of the house, and the name of the street where the death occurred. During an epidemic period, in order to preserve the public health, it should be incumbent upon all Medical Practitioners to inform the Health Officer of the District of every dfeath from Cholera which shall occur in his practice. In two or three instances only was the aid of the police required to effect the prompt removal of a corpse, and these occurred among the Irish, who are anxious to perform the "religious ceremony" over the corpse, called II waking the dead." During the recent Epidemic no case of this kind came under my notice in this District, although it was on several occasions attempted, whereas during the Epidemic of 1848-9 some disgraceful scenes were enacted. For example, Dr. Bowie reported (December 13th, 1848) to the General Board of Health that Mr. Liddle had informed him that within the last eight days he had attended 16 cases of Cholera in Rosemary Lane and the immediate neighbourhood, and he gives the following description of a visit he made with me in Hairbrain Court " when I attempted," says Dr. Bowie, "to enter a house in this Court, the smell was so dreadful as actually to make me stagger back. At the bottom of the stairs there was a privy contaminating the whole atmosphere of the dwelling. On reaching the top of the stairs a most extraordinary scene presented itself; a room crowded with people smoking and drinking, two dead bodies dressed up and surrounded by blazing candles, and on the left hand side of the bed there was a child rallying from collapse. This place suffered from Cholera in 1832." Dr. Bowie further states " that by ordering the bodies to be removed, the Medical Officer was in danger of personal violence from the Irish when the order interfered with the custom of ' waking the dead." I may add that almost immediately after the scene above described, the father and mother of the children, who had been present at the wake, were seized with Cholera of a severe form, though they fortunately recovered j but another person who had also been present was attacked and died. Theories respecting the Cause, and Mode of Propagation, of Cholera. Having briefly described the use of disinfectants it may not be deemed out of place if I now briefly state a few of the various theories upon the origin and mode of propagation of the recent epidemic of Cholera, so that the members of the Board may be made acquainted with the reasons why any particular plan to check the progress of the disease was adopted. It must be confessed that our information upon the subject of Epidemic diseases is very limited, still, however, very valuable facts relating to the mode of propagation of Cholera have been brought to light by the labours of the numerous scientific inquirers, who have not only devoted much time 28 lv tllC lnVOSulfTTlblOll 01 T/U0 SllDlGCu DUu WDO lldVO IIKoWIBv IIIaHLULLiU, LlllllltJrUUo experiments with a view of further elucidating several points in connexion with it. 1. The first theory that has been propounded upon the subject is, that the disease is caused by certain conditions of the atmosphere, and that it, spreads by, what is called, "atmospheric influence or epidemic constitution. As facts are not given to show the nature of the atmospheric influence or epidemic constitution," our information is not advanced by these fine Bounding words. 2. The telluric theory is that which supposes that poisonous emanations are given off from the earth, but this theory is altogether destitute of proof, and as the disease has prevailed more or less in every climate, this hypothesis appears to be untenable. 3. The third is the electric and ozonic theories. This, I suppose, must be included in the first, but as it appears from the experiments made by scientific men that Cholera prevails whether there is an excess or deficiency of electricity in the atmosphere, and also when ozone is more or less present, this theory is not satisfactory. 4. The emanations from putrid animal matter are considered by some theorists to be the cause of Cholera and of some other epidemic diseases ; but as these emanations are always more or less abundant in populous places, it is not sufficient to account for the origin of the disease ; they may, however, predispose the body for its reception. 5. The yeast, or zymotic, or fermenting theory assumes that the Cholera matter is a poison which is increased by a species of fermentation when taken into the system, and that it may be diffused over the whole earth by means of human intercourse. This theory does not in my opinion sufficiently explain the rapidity of its deadly action; it having been frequently observed that death has taken place within a few hours after a person has been attacked. This rapid action of the poison is especially observed at the commencement of the Epidemic. 6. The animalcule theory attributes the spread of the Cholera to the Structive agency of minute insects in a similar manner to their effects producing blight in fruit trees and in vegetables. The fact however t Cholera sometimes spreads in a direction opposite to the current of the air would seem to militate against this theory. 7. It is asserted that each Cholera patient gives off a specific poison like the small-pox virus, and that it attacks only those who are predisposed to the infection. The poison is said to have a period of incubation or latency which varies from two to four days. 8. Dr. Beittan maintains the theory that Cholera is spread by the emanations from the fluids passed from the stomach and bowels of persons attacked with the disease, which fluids, he says, exhibit characters such as naturalists attribute to cryptogamic plants belonging to the order of fungi. It is however said, that all decomposing vegetable and animal matter furnish fungi in great abundance. 9. The late Dr. Snow, to whom the public are greatly indebted for the pains he took to investigate the effects of impure water upon the spread of Cholera, supposes that the poison of Cholera is swallowed, and acts directly on the mucous membrane of the bowels. It may at the same time be reproduced in the intestinal canal, and may pass out much increased in quantity with the discharges ; and these discharges in various ways, but chiefly by becoming mixed with the drinking water in rivers or wells, may reach the alimentary canal of other persons, and produce the like disease in them, 29 Ei cause of malignant Cholera is a living organism of a distinct species his organism, which seems to be of the fungus tribe, is taken by the swallowing into the intestinal canal, and there becomes infinitely tied t ied by self propagation — that the presence and propagation of these organisms in the intestinal canal, and the action they there exert is the cause of the peculiar flux which is characteristic of malignant Cholera — that these organisms are disseminated through society ; " Ist. In the air in the form of impalpable particles ; " 2nd. In the contact with articles of food ; and " 3rd. In the drinking water of infected places." Dr. Budd adds " that by acting upon this knowledge, although we may not be able to ' stay the plague,' we may yet much abridge its sojourn among us." The means by which this mitigation may be accomplished are obvious. First, to destroy all the poison which continues to be generated in the bodies of infected persons, and second, to prevent as far as possible the poison which has already escaped from taking effect. " The discharges of the sick should therefore be received into some chemical fluid such as, chloride of zinc, which is known to be fatal •to beings of the fungus tribe. "As water is the principal channel through which this poison finds its way into the human body, so, the procuring of pure water for drink is the first and most effectual means of preventing its action." Dr. Fuller states that in his opinion " the existence of a distinct materies morbi — a cholera germ — probably of the fungoid origin, which can be conveyed from one place to another, and which possesses the power of reproduction in each locality, under certain atmospheric and other conditions, is alone capable of explaining many of the facts which have been observed with regard to the disease." The theory of contagion as accounting for the spread of the disease has always held a prominent place in the minds of many members of the Medical Profession ; that the disease is diffused by human intercourse; and that it ceases in a district when there are no more persons living therein susceptible of its poisonous influence. This theory does not explain all the phenomena of the disease in relation to its attacks at the same time upon different localities which are situated at a considerable distance from each other, and leaving unscathed large intervening districts. Similar facts were noticed in the attacks of the Cattle Plague. Such are the principle theories by which it is sought to explain the phenomena of Cholera. Dr. Jennee, in a paper recently read before the Epidemiological Society, says, " that for the spread of contagious diseases generally four things are essential. " Ist. The contagious or zymotic substance, be this germ or seed, animalcule or vegetable, or a merely chemical compound. "2nd. A, condition of the atmosphere or surroundings permitting the life or stability of the chemical constitution of the contagious or zymotic substance. "3rd. A vehicle for the conveyance of the contagious or zymotic \ rinciple to the individual or rather the part of the individual from which it can. enter his system, 30 " 4th. An individual to receive the contagious or zymotic substance, whose body is in such a condition, that in it the contagious substance or germ, seed, animalcule, or mere chemical compound can multiply itself." As to the possibility, degree, and modes of prevention of the zymotic diseases, Dr. Jenner states " that the great objects are to exclude or destroy the zymotic element. "To improve the surroundings, so that the conditions may be less favorable for its development, and that fewer individuals who suffer may die. " To watch carefully the vehicles by which experience has shown the zymotic element may be conveyed to others. " To render individuals less susceptible to the influence of the zymotic elements." Practical hearing of some of the above Theories. These remarks of Dr. Jenner require our most attentive consideration, for upon the carrying of these suggestions into effect will depend our success, not only in limiting the ravages of the disease should it re-appear, but may even be the means of preventing its return. The carrying out of sanitary measures in an efficient manner, will however, involve an interference with what are called " vested rights," and these are held to be so sacred that, constituted as society is at present, it will be a long time before any great improvement is effected in the public health. The " vested rights " in property must therefore be vigorously attacked, so far as the preventing of the further building of houses in unsuitable localities, and where proper sanitary arrangements are not provided for the health of the tenants. The public health is now suffering from the selfishness, neglect, and ignorance of our forefathers. They have erected numerous houses totally unfitted for human habitation, without any interference on the part of the legislature: but if the Parliament and the local authorities will now practise the lessons which the late epidemic has taught, laws may be enacted so that, the poor may be provided with more healthy dwellings. It is amongst the poorer class of the community that epidemic diseases find the greatest number of victims ; but when once an epidemic disease has prevailed for any length of time among the poor, the rich to some extent always suffer from the same disease. All classes are therefore interested in endeavouring to prevent disease among the poor. The question of public health will most probably be considered in Parliament during the present Session, and if the same amount of time be devoted to its consideration as was given during the last Session to the discussion of the Cattle Plague, in which was involved only a question of )roperty,much goodmaybe expected to result. The able report of Dr. Hunter lpon the condition of the houses of the labouring classes in agricultural villages and country towns deserves the greatest attention, for it informs the mblic that the labourers in many parts of the country are even worse housed ;han the same class in London. Water Supply. In a supplement to the return of the Registrar General for the week ending August 4th, the attention of the public was drawn to the water-supply of the East districts of the Metropolis. In a letter of Dr. Fkankland, an eminent chemist, it is stated that the water supplied by the East London Company, when examined by him on the Ist July, contained a larger amount 31 of organic matter than it ordinarily did, the average amount being 1*62 in 1 00, 000 parts, while on that day it contained 1 -94. On the Ist August it was again better j theamount of organic matter being only 1-44 in 100,000 parts. In the supplement to the return for the week ending August 18th, it is stated "that the whole of the Districts where the mortality from Cholera was from thirty to forty fold higher than it was either in the "West or the Central, in the North or the South of London, were supplied with water from Old Ford. London is divided into 37 districts, six are supplied from Old Ford, and every one has been ravaged by the epidemic ; the other 31 districts have for six weeks in succession suffered slightly." The Registrar General adds, " the persistence of the Epidemic in the East London Districts is no proof that the supply of the Company is now worse than that of the other Companies, as its effects on the place, and on the population only subside slowly." " This great lesson," the Registrar Qeneral further says, "should be taken to heart by every "Water Company and every community in the Kingdom. Unclean water cannot be consumed with impunity ; its consumption is the sin of which Cholera is the punishment." Although I am unwilling, dogmatically, to assert that the Cholera in the Eastern Districts was caused by the use of the water supplied from the Old Ford reservoirs, which, it is alleged, and from the evidence of Mr. Gbeaves admitted,* did receive, " during certain days of June and July, the waters * The following important evidence of Mr. Gbeaves, the Chief Engineer of the East London Water Company, ia transcribed from the Morning Star. It was taken by Mr. Rawlinson, the Chairman of the Royal Commission, appointed to inquire into the water supply of London. From which evidence it appears that at, or about, the time when Dr. Fbankland examined the'water at Old Ford, and found it to be more impure than usual, an open reservoir bad been drawn upon by the Company and supplied to the inhabitants. " Mr. John Gebaves, the Engineer-in-chief of the East London Waterworks Company, was then examined. He said the highest point at which the company had the absolute control of the channels was called Hyme-hill, which was at the London side of Enfield, measuring along the valley about three miles, and measuring along the course of the river about four miles. The other works which have been erected for the diversion of foul water are further from London. They had influence over the purity of the river from Enfield mill downwards, as their jurisdiction did not extend beyond the latter place. The valley of the Lea is subject to very great floods. They have reservoirs enough now to enable them to shut the river for several days. He shut out the water four days last week, and he thought he could do so for six or seven days, and still leave water in store. He could not say that they had land room enough for the erection of a sufficient number of reservoirs to keep the flood out effectually. The passing of the bill they have now before Parliament would give them an additional area of 100 acres, which if turned into reservoirs would give them an additional volume of water. " Mr. Rawlinson asked the witness if it was not a fact that the sewage of Luton, Hertford, and Norford got into water which was afterwards used for domestic purposes. " The witness said it was so ; and speaking for himself, he considered it of the utmost importance that jurisdiction should be exercised at the earliest possible period for the prevention of the discharge of sewage into water wherever such discharges took place or were likely to take place. The filter-beds at present in use had twelve acres of sand surface, and they were all continually in use, with the exception of such as might be under the process of cleaning. The sectional area of the conduit bringing the water from the River Lea to the filtering beds was 100 square feet. The filtering-beds were cleaned once in five weeks, or whenever tha water was turbid, or there was a tendency to vegetate. " Mr. Rawlinson asked if there was a possibility of dead cats or dead dogs floating into the conduit. " The witness said that dead animals might possibly float in at the upper part, but he had never seen any, and he thought if the occurrence were common he should have known it. It was impossible to stop the drowning of cats and dogs at all points. He had still reservoirs in existence which were originally made as depositing reservoirs for water as it came from the river. They were capable of being filled by a sluice connected with the disused caml, which was the company's conduit before 1852. The water from one of these open reservoirs was drawn upon last spring. " Mr, Rawlinson asked, was it before the outbreak of cholera they were drawn upon ? "The witness replied he could not fix the date — but it was probably in June. 32 of the two open, almost stagnant reservoirs, one filled by soakage in part from the Lea,"* and which water was supplied to the inhabitants in the neighbourhood ; yet I cannot ignore the fact that Cholera is generated at particular times by the use of contaminated water as the following cases indisputably prove. 1. In 1849, in a Court called Surrey Buildings, Horseley Down, containing 1 3 houses, nine or ten persons died from Cholera in a few days, and in an adjoining Court (Truscott Court), not one. In Surrey Court, the people drank polluted water from a well, while in Truscott Court the inhabitants were supplied with purer water, and not one died. The only point in which these Courts differed was in the nature of the water supply. 2. In Albion Terrace, "Wandsworth Eoad, were 17 houses of a superior class, and the inhabitants thereof were supplied with water from a well in close proximity to cesspools and drains. The water got contaminated after a shower of rain, and about 30 of the inhabitants died of Cholera in the course of ten days. The frightful mortality occurred among persons in easy circumstances, while the population east and west of this Terrace was not attacked. The houses attacked, Nos. Ito 17 inclusive, were all supplied with water from the same source, and these were the exact limits of the ravages of the disease. 3. Dr. Suthebland, in his report on the Cholera, (1849) says that in Hope Street, Salford, containing 90 houses, 26 persons were attacked by Cholera, of which 25 died and 19 were attacked by Diarrhoea among the inhabitants of 30 of these houses, who used water from a well into which a sewer had leaked; while among the inhabitants of. the remaining 60 houses which derived their water supply from a purer source there was not a single case of Cholera, and only 1 1 cases of Diarrhsea, none of which proved fatal. 4. The injurious effects of drinking impure water were clearly pointed out by Dr. Donald Fbazeb, one of the Medical Inspectors appointed by the Board of Health in 1854, in his Eeport to that Board. In this report the following facts are recorded. MY. Ely, a percussion cap manufacturer, whose premises are at 38, Broad Street, but who lives with his mother at West-end Hampstead j this lady being partial to the water from Broad Street pump, used to have a supply " Mr. E.AWLINSON inquired if he did not think it worth his while to inquire into the matter when the charge of supplying impure water was brought against the company. - " The witness said the foreman had opened the reservoir in question on a kind of quasi-sanction from him (witness), because he thought it would be wanted. At present it was impossible to draw upon it. The level of the pure water basin was almost equal to that of the open reservoir. The river intervened, and he thought there could not be a sub-soil communication. The pure water basin was brick paved to the bottom slopes, the bottom being ordinary gravel. " Mr. Rawlinson asked whether it would be difficult to get the date of the communication with the open reservoir, together with the quantity pumped and the length of time during which it was used. " The witness said it would be difficult to get the information desired. " Mr. Rawlinson said the witness must see the importance of this matter. He wished to know whether the disused conduit with which the open reservoir was connected, was capable of taking water from the River Lea at a point lower than the new filtered beds, and lower than the junction of the works that separate the sewage from the upper conduit. " The witness said the water could have been let in at the place referred to, but he had no suspicion that had been." • It was ascertained on an inspection made the 22nd February, by Captain Ttlbb and other gentlemen, that one of the covered reservoirs was very leaky to the extent of 300 or 400 feet. As the leak was on the side nearest to the River, it it most probable that the water from the Lea, which at this spot is very foul, percolated into this reservoir. 33 sent to her, and on Thursday, 31st August, had some sent to her as usual. Of thisjshe partook freely, as did also a niece who "was on a visit to her ;. a servant in the house partook of it sparingly. On the following day Mrs. Ely was seized with Cholera, and died within twenty four hours. On Sunday the 3rd of September, the niece returned to her own residence at Islington, and on the next day was attacked with Cholera and died. The servant had a. slight attack of Diarrhoea. There had been no case of Cholera previously, neither in the "West-end nor in that part of Islington where the niece resided. Mr. Ely had frequently remarked, that after the water had been drawn from this pump it soon acquired an unpleasant taste and smell. This gentleman rarely partook of the water. Again, Mr. Wickwab of Brighton, had been summoned to see his brother who had been attacked by Cholera at No. 6, Poland Street. On arriving there, and finding his brother dead, he declined to see the body, but he remained about twenty minutes in the house, and partook of some refreshment and a little cold brandy and water. The water which was used for mixing with the brandy was from the Broad Street pump. He then went to Holford Square, Pentonville, was seized with Cholera the same night, and died. At 10, Cross Street, where eight deaths from Cholera had taken place, one of the survivors stated that all the sufferers had been in the habit of drinking water from another pump till within a day or two of the outbreak, but finding it unpleasant, they sent for some from Broad Street. Upon examination it was found that, although there was no defect discovered in the brick work of the well, yet it was in close proximity to several cesspools, from which it was quite possible that the sewage might make its way into the well and contaminate the water. A Committee of the Vestry of St. James's Parish also inquired into the matter, and they reported that in their opinion the water from the pump in Broad Street was the cause of the Cholera in the neighbourhood. 5. The following Table, prepared by Mr. Simon, giving a synopsis of results of the effects of the use of comparatively pure water, and that greatly contaminated by sewage, is at the present time interesting. SYNOPSIS OF EESULTS. In Houses enumerated in 1854, as Death-Rates per 1,000 of living receiving their water supply- Population in . Two Epidemic Periods, From the Lam- beth Company. p. „,„„ f 1848-9. 12.5 11.8 Cholera * | 1853-4, 3.7 13.0 -p.. , ( 1848-9. 2.9 2.7 Diarrhoea j 1853-4. 2.1 3.3 KB.—Between the two Epidemic periods, the Lambeth Water Company has changed its source of supply. The following table, copied from the Annual Report of the Registrar General, (1854), illustrates the same subject: — (C) 34 Estimated Mortality Mortality Water Comp,n y So«ce of Supply. ,*-- »» »«•£. »? supplied, habitants. Houses. Southwark Com. Thames at Battersea. 40,046 266,516 857 57 Lambeth Comp. Thames at Thames Ditton. 26,107 173,748 109 11 Kent Company Rarensbonrne. 14,594 97,127 194 IS ¦"The population drinking dirty water suffered 3£ times as much mor¦ as the population drinking water from purer sources. ¦" A decrease in the mortality from Cholera occurred in 1854 as compared that in 1849 in the districts supplied by the East London Company 1 drew its supply in 1854 three miles higher up the Biver Lea than it did in 1849." In 1849 the deaths in the East-districts of London were 3097, and in the South-districts 7,137. In 1854 the deaths in the East-districts were 1509, and in the South-districts 5755. In 1849 the deaths in London from Cholera were at the rate of 62 per 10,000 living, in 1854-43, and in 1866 only 18. The deaths in 10,000 living in the West-districts in the three Epidemics were 34, 51 and 4, respectively. In the North-districts 20, 15 and 6 ; in the Central-districts 44, 16 and 9 ; in the East-districts 66, 29, 64 ; and in the South-districts 120, 87 and 8. The greatest mortality in the recent Epidemic being in those sub-districts supplied by the East London Water Company. Epon this subject the Registrar General remarks that "on "Wednesday g, August Ist, the complete coincidence of the Cholera-field with the of the East London "Water Company, was pointed out, in the hope that the state of its water might be immediately looked to. On the same day viz. August Ist, the Engineer of the Company called at the General Register Office, and on the following day he published a letter in the daily journals showing that he fully appreciated the importance of the crisis. On the Ist day of August, when Dr. Franhxand made an analysis of the water, it was found to contain much less organic matter when compared with the analysis made on the first day of July. The disease then, began to decline, but it must be borne in mind that the deaths are registered three or four days after they occur, and that Cholera matter would remain in the mains and butts some time after the supply of purer water had commenced." 6. In 1857, when the deaths in London from 6th June to the 21st November were from Diarrhoea 2759 and from Cholera 204, an outbreak of the latter disease occurred at Abbey Row, "West Ham, which consists of 16 small houses of 4 rooms each, and provided with a back kitchen and yard, there were in this small locality from the 29th September to the 13th October inclusive, thirteen cases of Cholera of which seven were fatal. The sole supply of water to these houses was from a pump situated in such close proximity to a sewer, that the contents of it could readily soak through the loose gravelly soil into the well from which the water was drawn, and from analysis it was ascertained to hold in solution a considerable quantity of organic matter. On the 12th October, after 12 cases of Cholera had occurred, the pump handle was removed upon the order of Dr. Elliot, the Medical Officer of Health for that district. After this, only one other case occurred here, and that was on the following day, the 13th. Dr. Elliott says that all those who were attacked did drink of the water from this pump, and no attack occurred in any person who did not drink that water. Further, a boy died of undoubted Cholera after 24 hours illness at Pelton Place, Bromley, on Friday, 7th October. This boy took a long walk, and on his return he 35 drank the water from this pump, and on the 9th, after an interval of 40 hours, the usual period of the incubation of the Choleraic poison, was attacked with the disease and died. • 7. Dr. Bain's remarks upon the effects of drinking impure water are instructive. Hesaysthat "in 1849 one side of an entire street called Cold Harbour, was free from Cholera, with the exception of one house, while all the houses on the other side, with two exceptions, were attacked in a very fatal manner. In the former the inhabitants were supplied with filtered water from the Thames, which was supplied from a barge from which the water was pumped twice a week into these houses, while in the latter they drank water from a well into which, it was afterwards found, that the leakage of several cesspools had flowed." 8. At Theydonßois, near Epping, within 14 days from the 30th September to the 11th October, 1865, a severe outbreak of Cholera occurred in a highly respectable family, and " within that fortnight, in one little circle, eleven persons had been attacked with Cholera, — mother, father, grandmother, two daughters, son, doctor, serving-lad, servant-maid, labourer, and countrywoman ; and of these eleven only three survived. Later, in the countrywoman's family there was another fatal case. The parents had been staying at "Weymouth, where they were attacked with Diarrhoea, and returned home with the complaint upon them. "Upon an investigation of the water supply to the residence of this family, it was found that it was derived from a well into which there was habitual soakage from the water closet. The discharges from the bowels of the first persons attacked still further tainted the impure water which was used by the household. The use of the pump was discontinued on the 4th October, and this proceeding most probably preserved the lives of the other members of the household." 9. In the report of cases treated by Dr. "Woodman-, in the Cholera Hospital at Wapping, it is recorded that in a house in the vicinity three persons died of Cholera. " Upon inquiry it was ascertained that a family in which a death occurred were in the habit of emptying their excreta into a rain water pipe, which becoming blocked up, allowed the filth to leak through a crack, and drop into the water butt, which, was used in common by all the inmates of the house, among whom occurred cases of Cholera or severe Diarrhoea, undoubtedly caused by the use of the contaminated water." 10. Again, from the supplement to the weekly return of the Eegistrar General for the week ending November 24th, a statement is made by a visitor at Margate, of the most melancholy effects of the drinking of impure water. From this statement it appears that in one house, in which were 20 people, four deaths occurred from Cholera, in the course of a few days, and two of the inmates who immediately after returned to London died at their own residences. The narrator further informs the Registrar General that on the morning of the 27th August, after a heavy thunder storm on the preceding evening, the water which was supplied to the house had an unpleasant taste. Upon inquiry it was ascertained that the well from which the water was drawn was contaminated by the leakage of a cesspool, and upon analysis it was found to contain no less than 7 - 36 parts of organic matter in 100,000. It further appears that the persons who were attacked with Cholera in this house had drunk of the water from this well. On a subsequent examination of the water drawn for the purpose of analysis, it was found to contain only I*l3 part of organic and other volatile matter in 100,000 parts. 11. Dr. Acland, in his report upon Cholera in the City of Oxford in 1854, says that there are two jails in Oxford, one is called the City Jail, the other the County Jail. The Doctor states that neither in 1832 nor in 1849 were there any cases of Diarrhoea or of Cholera in the City Jail, but in the County Jail there were in 1832 three cases of Cholera, and in 1849 fourteen 36 cases. In 1854 there were 4 cases, of these 3 died. Diarrhoea was also very prevalent. In the City Jail in neither of these periods was there a single case of Diarrhoea or of Cholera. In the one Jail (the County) the water was drawn from a contaminated source, while in the other the water was pure. 12. Again, in September last a large number of the poor inhabitants in Ivinghoe, in Buckinghamshire, whose only supply of water was from a well which became contaminated by sewage, was attacked with Cholera of a very fatal character. The well was closed, and the ravages of the disease were stopped. 13. I shall conclude this part of the subject by recording the facts recently communicated to the public by Mr. Ely, of Chatham. This gentleman states that several cases of Cholera occurred on the north side of a brook where the water from a pump was highly charged with organic impurities ; while on the other side of the brook the people did not suffer from the disease until they were obliged to obtain the water from the north side, in consequence of there being an accidental stoppage of the pump on the south, side, when two deaths occurred among them. After reading the above cases, it may be asked — "Was the Cholera Epidemic of 1866 in the East of London caused by the use of impure water ? ¦ • The fact that the ravages of the disease have been principally confined to that district which was supplied with water from the Old Ford reservoirs is undeniable. That the disease first made its appearance in the district which was supplied with water from these receptacles is also undisputed. That the water at Old Ford was proved, upon the analysis made by Dr. Feankland on the Ist July, to contain more organic matter than the usual average, viz., 1"94 against 1*62 in 100,000 parts. The fact is also admitted that in the month of June, just previous to the outbreak of Cholera, unfiltered water from the Lea, which was contaminated with sewage, was received into the reservoirs at Old Ford, from which the district was supplied. "It is a remarkable phenomenon that the sudden outbreak of the disease was over that particular district which was supplied with water from these reservoirs, and that the contiguous districts which received their supply from another source escaped with a death rate from Cholera of only 6 per 10,000, while the districts supplied from Old Ford had a death-rate of 60 per 10,000." The sub-district of Stratford suffered at the rate of 79-1 per 10,000, and that neighbourhood was supplied from the same source. The positive assertion on the one hand that the explosion of the disease was caused by the use of the water supplied from these particular reservoirs, and the bold denial on the other hand that the outbreak had any connection with the use of such water, but that it was caused by something else, are of little or no value. Everyone can form his own opinion upon this subject from the facts above recorded. As regards the outbreak of Cholera in the City "Workhouse, in the Bow Eoad, which is supplied with water from an artesian well, the disease did not appear therein until the 24th July, which was a period of four weeks after it first appeared in Bromley Parish on the 27th June, and when there had occurred in the districts of Limehouse, Mile End Old Town, and Poplar, in the two weeks ending on the 21st July, 222 deaths ; and in the week ending July 28th 509 deaths. We may, therefore, add, for the period from the 21st to the 24th July to the 222 deaths 200 more, thus making a total of 422 deaths in the neighbouring districts, before it attacked i inmate of this building. In this institution 42 inmates were attacked . Cholera of whom 27 died. The disease continued for two weeks only, the oase having occurred on the 4th August. It appears that the majority 37 of those attacked were very aged, and who were at the time of seizure suffering from some malady. The attack was principally confined to the female side of the Infirmary which is situated on the south-east extremity of the building, and which faces the district where the disease was most severe. In the week ending 28th July, there were 36 cases, of these 26 were attacked on the 24th and 25th July, and 20 died. During the night preceding the outbreak of the disease in this institution, there was a most offensive smell within the building. This smell probably arose from some defect in the drains. Had the Cholera appeared in this institution during the first week of its outbreak, the argument against the water theory in causing Cholera would have been important, but as the disease had been fatal to upwards of 400 persons in the neighbourhood before it appeared in this Workhouse, the seeds of the disease might have been carried into the building, and so readily found victims among the aged and infirm inmates. Some stress has been laid upon the absence of Cholera in the East London Workhouse at Homerton, which is supplied by the water of the East London Company, but it appears that this institution is not supplied from the reservoirs at Old "Ford. It appears from the returns of the Registrar General, that the deaths during the 23 weeks of the Cholera period in the districts of the west, north, centre, and south of London, were 1369 by Cholera, and 1867 by Diarrhoea, among 2,430,046 people. Whereas 3909 deaths by Cholera, and 825 by Diarrhoea occurred in the East London district, among 407,945 people supplied with water chiefly from the Old Pord reservoirs. From the weekly returns of the Registrar General it also appears that not a single death from Cholera has been registered either in the Tower of London, the Trinity Minories, or in the Old Tower Without, or in St. Katherine by the Tower ; all of which localities are supplied by the New River Company. The population of these places, according to the census of 1861, was 2037, viz., in the Tower 783, in the Trinity Minories 420, in the Old Tower Without 626, and in St. Katherine by the Tower 208. It is a curious fact that while during the recent Epidemic no deaths from Cholera occurred in the Tower, yet in 1849 in the Tower alone, out of a population of 1107, including the garrison, the deaths were 15, which is at the rate of 135-5 per 10,000 living. The total deaths from Cholera which have occurred in that portion of the district supplied with water by the New Eiver Company, in a population of about 9,224 have been 30, (including one death which occurred in the Workhouse, and one in the temporary Cholera Hospital, of persons who had been removed from this district) which is at the rate of 32 5 per 10,000 ; while in the remainder of the Whitechapel district, which is supplied by the East London Company, the total deaths, including those in the London Hospital* and in the Cholera Hospital f of persons who had been residents within the district, were 536, which, in a population estimated at 68,732 is at the rate of 77*7 per 10,000 living. • The deaths in the London Hospital from the 21st July to the 18th August, of persona belonging to the district, but whose particular residences in the district are not stated, were 67. After the 18th August the residences of persons dying in the Hospital were particularized, and the number belonging to this district was 17. + From the 21st August to the Bth September, the deaths in the Cholera Hospital w«re 30, during which time the residences of the patients dying therein were not specified. After the Bth September the total deaths were 103- 38 Sic only Courts in Petticoat Lane where deaths from Cholera have d are Boar's Head Yard (3), Sandy's Row (1), Cobb's Court (1), Yard (1), Fisher's Alley (1), Tribe's Yard (1), and Hebrew Place (1). — Total deaths 9, which, in a population of about 2103, is at the rate of 42*7 per 10,000. The comparative immunity of this district from the ravages of the recent Epidemic is still further shown in a return made by one of the qualified medical visitors who, on the 14th August, instituted at my request, Kse to house visitation of 193 houses in the Courts of Petticoat Lane, which it appeared that in these houses there were only 4 cases of hoea and not one of Cholera, while in the other parts of the Whitechapel district there were returned on the same day 245 cases of Diarrhoea, 14 of Choleraic Diarrhoea, and 10 of Cholera.* But this is not all that can be said upon the subject ; for if we eliminate the 14 deaths which occurred in the Courts of Blue Anchor Yard from the total deaths and the population of these places from the total population supplied by the New Eiver Company, the rate of mortality will be reduced from 32-5 per 10,000 to 19*3 per 10,000. As no death from Cholera occurred in this locality until the 16th July, which wa3 six days after the disease first appeared in the Whitechapel District, it is not necessary to account for its mortality here by supposing the water supply to be contaminated. The population of these Courts numbers about 966, who live in a parallelogram comprising only about 1644 square yards, and who for the most part are of the poorest class earning a precarious living in the docks and wharves of the river, and amongst whom Epidemic diseases are rarely absent. The mortality in these Courts alone from cholera was at the rate of 144-9 per 10,000. !N"ow, I would again ask (after all the evidence which I have brought together in this report respecting the poisonous effects of drinking water contaminated with sewage has been read), can the recent outbreak of Cholera in the Eastern Districts of London be attributed to the effects of the impure water supplied by the East London Company ? or is the sudden outbreak of the disease and the supply of impure water a mere coincidence ? If it be merely a coincidence that the Cholera should have occurred soon after it was ascertained that the water in the Old Ford Eeserviors was more impure than usual, it is certainly a most remarkable one. But rather may not the outbreak of the disease, and its continuance mainly in the district supplied by the East London Company to be looked upon as cause and effect ? Rlt has been alleged by some writers on the recent visitation of Epidemic olera that out of several hundreds of teetotalers residing in the Tower Hamlets only three (one man and two women) have died from Cholera during the progress of the Epidemic. And again, that out of another body of teetotalers numbering 1,400 members, only five deaths have occurred. This is not a very small proportion, it being at the rate of nearly 36 in 10,000. As the addresses of the teetotalers have not been given, except so far as the statement is made that they resided within the limits of the East London "Water Company, this really proves nothing ; for it is only that district supplied by the water from the reservoirs at Old Ford which suffered from the " explosion" of the disease. But even supposing that this class of persons did suffer less than similar c living in the immediate neighbourhood, it would be of little imporunless it could be shown that they were equally destitute, and in dwellings equally unhealthy as those who suffered in greater proportion. The teetotalers, from their temperate habits, are generally better clothed and fed, and consequently enjoy better health ; they are, therefore, more capable of resisting the action of the poison of Cholera than those who spend a large portion of their earnings in intoxicating drinks. * For further particulars on this subject, see Table, page 40. 39 supplied with water, receives the sewage of several of the towns and villages situated on its banks has been made known to us in a report prepared by a Commmittee appointed by the Poplar Board of .Works, in September last, who personally inspected the River from its source to the Works at Old Ford. The report states that at Bishop Stortford, the Eiver Stort, which falls into the Lea, forms itself into a small bay, and on two sides of it are overhanging privies, and several drains from houses, all emptying into this portion of the River ; the drainage from Malt-houses and Gas Works is also received into the River. Lower down at Ware, the filth from piggeries drains into the River; there are also on its banks several overhanging privies which empty into the stream. Broxbourne and Waltham Abbey further contaminate the water. At the latter place human excrement was to be plainly seen falling into the water, and numerous privies are built over the water courses. The Committee conclude their report in the following words, "From personal inspection your Committee find that the water before it reaches the filtering beds is polluted in a most disgusting and abominable manner, by drainage from land, overflow from cesspools, privies, factories, piggeries, &c, from the towns and places before mentioned." If the recent visitation of Cholera should lead to the inhabitants in the Eastern Districts of London obtaining water from a purer source, the mortality which they have suffered will not have been without some beneficial result. It is obvious that all rivers are more or less contaminated with foeculent matter, for even if it were possible to entirely intercept the sewage of towns and places situated on their banks, yet the drainage from manured land would make its way into the stream and so pollute it. Another source of supply must, therefore, be obtained. Dk. Acland, the Regius Professor of Medicine in Oxford says "that it is a standing marvel why the Londoners do not rise up against us provincials for remorselessly pouring our sewage down upon some of the Water Companies." The Doctor says " that we may now assume that the elements of disease are carried in water." Although the evidence is conclusive as to the fact that the drinking of water contaminated with foeculent matter will at certain times cause attacks of Cholera, and perhaps other epidemic diseases ; yet as impure water is frequently drank with impunity, so far at least as its not causing such diseases, we are compelled to look elsewhere for the exciting cause of Cholera which has now for the fourth time visited London as an Epidemic. Cases more or less numerous have annually occurred in England since it first made its appearance in Sunderland in 1831. The poison appears to act v after the manner of a ferment, and to take effect only amid congenial circumstances." Air and water abounding in organic impurities are the chief means by which the poison is disseminated. A^hen the water in water-butts is exposed to light and air, organic life is quickly generated therein, and is thus soon rendered unfit for drinking purposes, and if the receptacle for the water be not frequently cleansed, the danger of drinking water so exposed is greatly increased. In poor localities all butts and cisterns should be discontinued, and the water required for domestic use should be drawn direct from the main. Localities chiefly affected. The localities chiefly affected in the Whitechapel District, were Grey Eagle Street, in which 16 deaths occurred ; Great Pearl Street, 10 ; Dorset Street, 8 ; Whitechapel Road, 7 ; Dunk Street, 9 ; Fashion Street, 8 ; Freemam Street, 7 ; Pelham Street, 8 ; Well's Place, 6 ; Mansell Street, 7 ; Back Church Lane, 5 ; .Newnham Street, 4 ; Charlotte Court, 4 ; Crown Court, Blue Anchor Yard, 8 ; Shorter's Rents, 3 j and Swan Court, 3. 40 TABLE.—Showing the number of Houses, number of Inhabitants, and the Deaths* from Cholera in the District supplied by the New River Company. vr v c -vt t. *¦ Number of » Number of Number of Jm)li. fmm Names of Streets, &c. Houses. Persons. Swan-court, Middlesex-street 21 126 Boar's Head-yard 26 156 3 % Tripes-yard ... .* 4 20 1 Sandys-row 44 396 1 "3 Middlesex-street 46 414 ••• Jj Hebrew-place 16 89 1 g Little Middlesex-street 8 60 ... Love-court... 37 270 ... $ Love-court, (little) ... 5 56 ••• £ Marlbro'-court 7 82 ... w Horse Shoe-alley 7 35 ... -g, Fisher's alley 8 40 1 g Frying Pan-alley •... 7 63 ... «,_ Tuson's-court 9 45 Bull-court, (part) H 66 Cobb's-court 2 18 1 ° Cobb's-yard, (part) 18 49 1 « Artillery-passage 6 54 ... Elizabeth-court 3 15 ••• Eosctta-placc 7 49 ... ¦ Hollo way-court 6 94 1 Russell-court 8 101 Crown -court, Blue Anchor Yard ... 24 282 8 Parson's-courfc ?. 3 22 ••• Royal Mint-street 140 1400 1 Kittleby-court 8 74 Slaters-court 10 107 » 1 Bracey's-buildings 12 116 Coopers-court 12 95 Hairbrain-court & Searl's-buildings 9 80 3 Darby-street 14 140 ... "3 Peters-court & Wells-yard 31 250 1 Walton's court 10 62 ... 1j Cartwright-street & Square 45 435 1 « Alma place 5 28 Providence-place & Row 19 128 ... *\ Prescot-street, (Little) 12 108 ... tS Butlers-buildings ' 16 112 Norwich-court 10 73 ... <« Becks-rents 7 42 ... -g, Tnrner-street 14 84 ... Q Christopher-court 6 62 ... Baker's Arms-alley 7 64 Enochs-court 6 42 Griggs-court 1° 94 ... o Sugar Loaf-court 10 43 ... ra Swan-street H 88 Goodman's-yard ... 6 42 ... Mansell-passage ... 4 28 ... Queen-street, Aldgate ... [23 276 King-street, Aldgate 30 300 1 Loat's-buildings ••• 2 12 Upper Fast Smithfield 20 180 Saint Katherine by the Tower a ... 9 208 Old Tower Without a 41 626 Tower of London» 44 783 Holy Trinity Minories a 83 420 1 Total 920 9224 30 (a) As enumerated in the census return of 1861. 41 Comparison oftlte rate of Mortality in some of the South Districts of London in the Cholera Epidemics o/"1849, 1854, and 1866. It is certainly a very curious fact, that in 1849 and 1854, the rate of -mortality in the South- districts of London should have exceeded to such a great extent that of the East-districts, while in 1866, the mortality in the East-districts has so greatly exceeded that of the South-districts. The deaths in the South-districts in 1849 being at the rate of 120 per 10,000, while in the East- districts they were at the rate of 66 per 10,000, and 1854, the deaths in the South-districts were at the rate of 87 per 10,000, and in the Eastdistricts 29 per 10,000, while in the recent Epidemic the rate in the South-districts was 8, and in the East-districts 64 per 10,000. The contrast in the rate of mortality in some of the South districts is better shown in the following Table. Rate of Mortality in 10,000. Districts. — ¦ — 1849. 1854. 1866. St. Saviour, Southwark 165 208 74 St. Olive, Southwark 182 163 B's Bermondsey 227 167 S - 6 St. George, Southwark 187 142 70 Newington 162 120 26 Lambeth 137 64 65 Rotherhithe 270 171 9'o The only cause that I can assign to this most remarkable difference in the rate of mortality in the several districts, is the water supply. "In 1849, the Lambeth Company began to make arrangements to improve its water supply. In 1854, the other Companies had not completed their works for nn improved water supply when the Cholera re-appeared and destroyed 10,738 lives in London, viz. : — 2,051 in the West districts, 779 in the North districts, 644 in the Central-districts, 1509 in the East-districts, and 5,755 in the Southdistricts. In 1866, the effect of a pure supply of water became evident, the deaths from Cholera in London to 10,000 inhabitants being 62 in 1849, 43 in 1854, and 18 in 1866. The deaths to 10,000 living in the West-districts in each of the three Epidemics was 31, 51, and 4 ; in the North-districts 20, 15, and 6 ; in the Central-districts 44, 16, and 9 ; in the East-districts 66, 29, and 64 ; and in the South-districts 120, 87, and 8 : the mortality being greatly in excess in 1866 in the district supplied by the East London Water Company from the Old Ford reservoirs." While the whole of London has suffered to the extent of less than the half of the mortality during the Epidemic of 1866, viz., 5,548 as against 14,137 in 1849, and 10,738 in 1854 ; yet in the Eastern districts, the mortality has been above the half of the mortality in the whole metropolis, viz., 3,909. The mortality in the Eastern districts in 1849, was 3,097 ; and in 1854, 1,509. The Epidemic has also been much more severe in the Eastern districts while it lasted than in either of the previous visitations ; for in the two former, the calculations in the rate of mortality was made in a period embracing 52 weeks, while in that of 1866, the period embraced is only 23 weeks. The population of the Eastern districts, however, has increased since 1849 from 469,159 to about 607,945. In 1854, the population of these districts was 514,860, consequently the rate of mortality is not so great as would be inferred by merely reading the total deaths. Comparision of the Hate of Mortality from the recent Epidemic of Cholera in some of the principal Cities in Europe. The following Table, as prepared by the Registrar General, shows the proportion of deaths by Cholera to population in European Cities, 42 Deaths ' Deaths I Cities. Epidemic Period. Population, from to 10,000 I Cholera. * living. | London 23 Weeks 3,037,991 5,548 (a) 183 ¦p . ( 12 Months, 1865 ... , RQR 14l (6,653 w j 392 Pans 7 Months, 1866 \ 1>69 1 > 696 ' Ul j 1,812 j 107 Naples 1865 446,931 2,301 61-5 Vienna j "^August to 10th Nov. J MMOO 2m 51 .g Liverpool | SOW^eeks ending 24th Nov. | mm 1j754 86 . 2 15 Dutch Cities and ( ) Towns, (including] June to October, 1866 > 826,464 8,872 107*3 Amsterdam) ( ) Amsterdam June to October, 1866 262,691 1,104 42 0 7 Belgian Towns (in- j Ist May to 15th October, ) „„ i qaa ij 771 1856 eluding Brussels)... ( 1866 J ' ' Brussels Ist May to 15th Oct., 1866... 184,932 3,028 1637 (a) Epidemic ended. (b) Epidemic going on. Prom the perusal of the above table, we learn that the people in London have suffered from the effects of Cholera in a much less degree than the inhabitants of some of the principal cities on the continent. Thus, while in London the mortality was at the rate of IS in every 10,000, it was in Brussels as high as 163. If therefore, the mortality in London had been in the same proportion to that in Brussels, the deaths in London instead of being 5,548, would have been nearly 50,000. Jewish Inhabitants and the Cholera. In my Eeport to the General Board of Health on the Cholera in 1849, I stated that the Jews, although they did not entirely escape the ravages of the pestilence, suffered far less in proportion than their Christian brethren. To a certain extent a similar, immunity has been observed among them during the Epidemic of 1866, for very few cases of Cholera have occurred among the Jewish inhabitants in Petticoat Lane and its adjacent courts, nearly all of which places are entirely inhabited by Jews. In 1849, the Hebrew Community in London only lost about 1 in 2,000 as compared with 6 in 1000 of the general population of Whitechapel, and with 29 in 1000 of the Christians in Rotherhithe. On the occasion of the recent Epidemic, the Jews, however, and especially those living in the quadrangle formed by the four streets known as the Tenter Ground, Spitalfields, have not escaped its ravages in a less degree than their Christian brethren. This locality is chiefly inhabited by Dutch, Polish, and German Jews. " The habits of these people, as described by Mr. Dyte, are filthy in the extreme, and among these the pestilence has been doing its deadly work, and threatens to do it yet more decisively, unless further precautions are taken. It is only fair to state, however, that the Jewish Board of Guardians have bestirred themselves most earnestly to bring about sanitary reform where it is so much needed. A sanitary inspector has been appointed to report to the board all cases demanding attention. "As the result of an inspection of the sanitary condition of the houses o* the Jewish poor made some time ago, it was reported that of 311 houses visited promiscuously, 245 exhibited sanitary defects of some kind or another. The defects principally complained of were defective drainage, deficient water supply, untrapped gullies, accumulation of dust, overcrowding, filthy ceilings and walls, decayed floors, and deficient means of ventilation. 43 "In regard to the difficulty of inducing landlords to cleanse the interior of dwellings, the Jewish Board of Guardians, in addition to the disinfectants which their poor can obtain gratuitously, make a point of limewhiting every house recommended by the sanatory inspector. Those suffering from diarrhoea or choleraic attacks have been well supplied with rice, linseed, brandy, clothing, blankets, &c. The number of applicants at Mr. Dyte's surgery have been between 50 and 60 per day. "It is pleasing to add that the wealthier members of the Jewish community have during the past week sent about £1000 to the board for the relief of their poorer brethren, in addition to presents of necessaries and delicacies for the suffering. It should also be said that in all cases the sick and dying have received the most assiduous attention from the Chief Rabbi, the Rev. Dr. Adler, Mr. Marcus Adler, his eldest son, the Rev. Mr. Ascher, and other members of the Jewish clergy." During the Cholera Epidemic of last year, the Jews proved themselves to be the best practical philanthropists ; for, in addition to their labours above recorded, they erected, at their own cost, several stand posts, from which the inhabitants could obtain an unlimited supply of water direct from the main, without the intervention of any butt or cistern. This boon was greatly prized by the poor, and in one or two instances where these stand pipes were erected in private courts, and which have been subsequently removed, I have induced the landlords to substitute a "Water Waste Preventer. These stand pipes were supplied with water gratuitously by the Water Companies. This liberal act on the part of the Companies ought not to be forgotten by the public in their present agitation for a better supply of water to the metropolis. The fault that the poor have not a sufficient supply, lies more with the landlords and Local Boards than with the Companies. Intervals of Cholera. Epidemic diseases appear at intervals, and the period of each visitation varies in the recurrence of each epidemic. Thus, the first epidemic of Cholera in the Metropolis appeared in the first week in February 1832, about four months after it had broken out in Sunderland in the month of October in the preceding year. After a period of 17 years, viz., in 1849, it re-appeared in London, and in 1854, after a lapse of only five years it came again ; and once more in 1866, after an interval of twelve years ; but of 17 years from the very severe Epidemic in 1849. In every year since 1837, when the causes of death were first registered, a certain number of deaths from Cholera have been registered in England. Thus in 1850, the deaths in England from Cholera were 887 ; in 1851, 1132 ;in 1852, 1381 ; in 1853, 4419 ; in 1854, 20,097 ; in 1855, 837 ; in 1856, 762 ; in 1857, 1150 ; in 1858, 673 ; in 1859, 887 ; in 1860, 327 ; in 1861, 837 ;in 1862, 517 ;in 1863, 807 ; and in 1864, 934. In each of the above-named years several deaths from Cholera occurred in the Metropolis. So general has been the visitation of the Epidemic of Cholera in England in 1866 that only in two Counties, viz., Rutlandshire and Herefordshire have no deaths been registered. In 1865, from the 22nd September to the 4th November 60 cases of Cholera occurred in Southampton, and 13 cases in a village in Essex, also a few more in other parts of the kingdom. As Cholera is annually occurring in this country it is not necessary that we allege the importation in order to account for its epidemic influence. We may as well say that fever and other diseases of this class are imported ; for, like Cholera, they are always to some extent present, but it is only at particular times that they spread among the whole community, or in other words become epidemic. 44 It is not at all improbable that isolated cases of Cattle Plague have occasionally occurred in this country before the year 1865, but the cases of the disease having been few m number did not excite attention until the disease assumed the epizootic form, when, from the severity of the outbreak in 1865, it became necessary for the legislature to interfere with a view of preventing the spread of the contagion. Words having no definite meaning are used to explain the cause of the rapid diffusion of certain diseases. Thus, there is said to be present an Epidemic condition of the atmosphere, and a predispositic n of the bodies of certain persons to receive the poison ; but the use of such terms is merely a cloak to our ignorance. To use a metaphor, it would appear that in many of our cities, towns, and villages, there is a train constantly laid, and it only requires the application of a match to cause the " explosion/ but of what the lurking poison consists, and the nature of the agent in producing its activity, we know nothing — they are still to be discovered. It is however, probable that Cholera and other epidemic diseases follow definite, and it is to be hoped, ascertainable laws, but hitherto those laws have not been discovered. We have therefore no positive data from which we can dogmatise upon the subject, and say that epidemic diseases are caused by bad drainage, by overcrowding, by the drinking of impure water, by damp, by heat, by want of proper food or sufficient clothing, or by the abuse of intoxicating drinks, &c, or even by all these causes combined. The best way to improve our knowledge upon the subject is to collect such facts which come before us at each visitation of the disease as are likely to elucidate the subject ; but not to collect them with the view of merely supporting a preconceived theory — only so to gather and arrange them that we may arrive at correct conclusions. The cause of epidemic diseases may be found in the violation or neglect of the natural laws of life, the proper observance of which will tend to promote the happiness of mankind. Our duty is therefore to study these laws — to insist upon their being taught in schools, and to act in accordance with them ; for "by so doing we may find that these returns of pestilence will be of less frequent occurrence. In unfavorable circumstances, where many are immersed in an atmosphere of decaying organic matter, some zymotic disease is invariably produced." Mortality in the Whitechapel District. The total number of deaths by Cholera in the Whitechapel District have been 904, including those of non-residents (235) in the London Hospital, and those in the temporary Cholera Hospital 103. The deaths from Cholera in this District have therefore been 566. [See Table on opposite page.] Of the Points of similarity and of difference in the several Epidemics of Cholera in London. The table on the opposte page shows the weekly return of deaths from Cholera in 1832, 1848-9, 1858-4, 1857, and 1 866. From it we learn that Cholera made its first appearance in London in 1848 and 1853 in September, and that in each of those years it prevailed with more or less severity, until December. So far the Epidemic of 1848 resembled that of 1853. But in the year 1849, the disease continued during the months of January, February, and March, when the deaths in London during that period were 478, while during the corresponding mouths of 1854, the deaths were only 7. In June, however, of 1849 and of 1854, the disease again broke out in London, and here again these two Epidemics presented a great similarity in their rise, culminating point, and decline. In the first week of September in each of the above named years, the deaths in London were respectively 2026 and 2050, and from that time the weekly mortality gradually declined until the latter end of November or the beginning of December, when it ceased, the Whitechapel District. London. Whitechapei,. . De ?;ths Date. from Cholera 1848-9 1853-4 1865-6 1848-9 1853-4 1865-6 *" J? n *° n ' 1057, 1002 Sept. 23rd 0 29 0 0 2 0 and 1833. » 30th 6 47 0 0 1 0 IR)iy 1832 _ 3 Oct. 7th 13 66 0 2 0 0 1857 > 6 „ 14th 30 45 0 3 1 0 • „ 21st 45 83 0 2 10 0 „ 28th 34 99 O 1 14 0 Nov. 4th 65 102 0 0 9 0 ... '... „ 11th 62 98 0 0 8 0 „ 18th 54 72 0 1 8 0 „ 25th 34 46 0 5 8 0 Dec. 2nd 20 28 0 4 3 0 „ 9th 21 13 0 4 2 0 „ 16th 29 11 0 7 2 0 „ 23rd 31 7 0 6 3 0 „ 30th 30 10 0 5 1 0 Jan 6th 61 2 0 3 0 0 ... '..'. „ 13th „ 94 2 0 2 0 0 „ 20th 62 1 0 4 0 0 „ 27th 45 0 0 2 0 0 Feb. 3rd 37 1 0 1 0 0 „ 10th 55 1 0 3 0 0 „ 17th 49 0 0 2 0 0 „ 24th 40 0 0 3 0 0 0 14 March 3rd 35 O 0 3 0 0 0 57 „ 10th 15 0 0 0 0 0 0 139 „ 17th 9 0 O 0 0 0 0 195 „ 24th 10 0 0 3 0 0 0 225 „ 31st 4 0 0 1 0 0 0 277 April 7th g 0 0 0 0 0 0 198 „ 14th 2 2 0 1 0 0 0 94 „ 21st. 1201000 34 „ 28th 1001000 27 May sth 4000000 20 „ 12th 3 0 0 0 0 0 0 12 „ 19th 1200000 16 „ 26th 5000004 7 June 2nd......... 9 2 2 0 1 0 1 17 „ 9th 22 1 3 3 O 0 0 13 „ 16th 42 1 3 2 0 0 3 15 „ 23rd 49 1 1 3 0 0 5 24 „ 30th 124 0 6 4 0 0 9 116 July 7th 152 1 41 2 0 0 14 99 „ 14th 339 5 32 7 0 2 28 239 „ 2lst 678 26 346 14 2 25 24 394 „ 28th 783 133 904 20 3 131 30 445 Aug. 4th 926 399 1053 30 4 184 2l 299 „- 11th..; • 823 644 781 28 7 178 12 190 „ 18th 1230 729 455 45 26 91 15 234 ? 25th 1272 847 265 55 28 50 4 325 Sept. Ist 1663 1277 198 74 24 41 9 350 „ Bth 2026 2050 157 58 49 34 3 309 ? 15th 1682 1549 182 48 45 30 3 144 „ 22nd 839 1284 150 39 50 23 2 147 „ 29th 434 754 177 17 42 22 1 43 Oct. 6th 288 411 182 20 26 27 4 81 „ 13th 110 249 207 4 19 27 6 150 „ 20th 41 103 144 2 5 12 0 37 „ 27th 25 66 122 2 3 11 3 61 Nov. 3rd 11 31 73 1 1 6 2 48 „ 10th 6 23 67 0 0 7 0 9 „ 17th 8 12 32 0 2 2 1 3 „ 24th 2880010 1 46 In 1832, the disease commenced in the last week of February, and continued until the end of November, inflicting a mortality on the population of London of 5275. In 1833, the disease returned in July, about a month later than was the case in 1849 and 1854, and continued until the second week in September. During this period the mortality was 1,454, making a total for the two years 1832-3 of 6,729. In 1866, the Epidemic of Cholera commenced on the 27th June, and continued until the latter end of November. It acquired its culminating point in the week ending August 4th, when the deaths were 1 053. While the deaths in London in 1832-3, in a population of 1,681,641, were 6,729, the deaths in the Whitechapel District, in a population of 64,141, were 736, which gives a death-rate of 114 per 10,000. But as the Registrar General's office was not established until 1837 the statement of the returns of Cholera cannot be depended upon. It is most probable that in the returns of death from Cholera are included every death from Diarrhoea and from Temperature. From the fact that Cholera is always more severe in hot climates than in temperate ones, it has been supposed that the disease is caused by excessive heat, and this opinion would seem to be confirmed by the absence of the disease in Upper India during the cold weather. There are, however, many exceptions to this opinion, although it is admitted, that unless a high temperature prevails, the disease, except under certain conditions, will not be severe or of long duration. In all the countries of Europe and America, with few exceptions, when Cholera has been epidemic, the greatest number of deaths has been in the months of July, August and September, when the themometer usually indicates the highest temperature. Among the exceptions to this rule may be mentioned the following instances. In 1832 the disease first made its appearance in London in the month of February, when 57 deaths were recorded, and in March they rose to 880, when the mean temperature of the air was 410°. .In 1848 the disease prevailed in the cold months, viz. from October to March, and # was then very fatal in the Whitechapel District, particularly in the courts abutting upon Rosemary Lane. In Petersburg ill 1852 the greatest number of deaths, viz. 666, took place in November, when the mean temperature was 30 # 40°. In Paris in 1832, the greatest mortality occurred in April when in that month 12,7^3 deaths were recorded, the mean temperature being 51*24°. In Glasgow, in 1848 the greatest mortality took place in January, when 681 deaths occurred, while in the month of March, when the temperature rose, only 5 deaths were recorded. The disease in the same year reached its height in Paisley in the middle of winter. In the recent Epidemic, a severe outbreak occurred at Port Glasgow in the beginning of January, 1867. From the above records it is manifest that temperature alone does not determine the severity of the Epidemic, although during a hot summer there is a more rapid decomposition of organic matter, whereby a more impure atmosphere is generated, which in dense populations where hygeinic measures are disregarded, renders the inhabitants more prone to become victims of the disease. In order to account for the greater prevalence of Cholera in Petersburg during the winter, it has been remarked that all classes heat their rooms by close stoves and carefully exclude the cold air from penetrating by various contrivances, economical or otherwise, suited to their respective conditions of life. Rooms artificially heated and overcrowded, as is usually the case in winter in the houses occupied by the poor, may engender such a pestilential 47 atmosphere as will act in a similar manner to that produced during a hot summer, when the atmosphere is charged with particles of organic matter in a state of decomposition. Elevation. It appears from the mortality from Cholera, as shown by the returns of the Registrar General, that, persons living in low situations are more subject to its deadly influence than those living in higher situations, the rate of mortality being apparently graduated by elevation. In all the previous Epidemics of Cholera, this fact has been observed. There are, however, a few exceptions to this rule ; but when the disease has prevailed in high situations, there great sanitary defects have always been found to exist. In the four lowest districts in London, viz. : — Newington, Eotherhithe, St. George's, Southwark, and Bermondsey, the rate of mortality from Cholera in the Epidemic of 1854, was respectively 112, 165, 121, and 179 in 10,000 of the population; and in 1849, it was 144, 205, 164, and 161, while in four terraced-districts at an average elevation respectively of 350, 94, 87, and 73 feet above Trinity high-watermark the mortality by Cholera in these higher districts was at the rate of 12, 11, 17 and 10 in 1854, and of 8, 22, 17, and 22 in 10,000 in 1849. The mortality from Cholera, however, is not always to be found in each sub-district inversely as the elevation ; but by taking groups of districts it has been found to be in proportion to their low position as regards the level of the Thames at high-water-mark. The Registrar General says, " that if the area of London be divided into fourteen stages or terraces, the mean mortality in the two Epidemics, (1849 and 1854), is, if we commence at the lowest ground, 145, 108, 95, 88, 55, 44, 51, 32, 29, 31, 22, 16, ]4, 13, in every 10,000 inhabitants. Cholerine, or any other organic matters, says the Registrar General, mechanically suspended either in the air or in the waters of London, necessarily accumulate in the lower strata." This is certainly a feasible explanation of the difference in rate of mortality between high and low elevations. The elevation of the several sub-divisions of the Whitechapel district, and the deaths from Cholera therein, are shown in the following Table. Deaths from Cholera. Population in -Elevation in ieet Districts. 1848 1853 above Trinand and 1866. 1841. 1851. 1861. ity high 1849. 1854. water mark Artillery 17 24 21 6221 6,769 6,657 40 Spitalfields 93 46 240 15,121 15,33(3 15,700 36 Mile End New Town 95 100 152 12,141 14,543 15,392 36 Whitechapel, North 117 52 43 12,296 12,530 12,109 36 Whitechapel Church 71 78 353 6,990 7,818 8,060 32 Goodman's Fields 42 37 .57 9,848 12,069 11,166 28 Aldgate 117 90 38 9-,148 10,694 9,980 19 Total Deaths 548 427 904 71,765 79,659 78,964 Totals. The following Table shows the rate of mortality from Cholera in the same üb-districts in 10,000 living in the years 1848-9, 1853-4, and in 1866, ncluding the deaths of non-residents in the hospital ; also the rate of mortality from Cholera in the whole district of Whitechapel in 1832-3, and the rate of mortality from the same disease in the metropolis in the four Epidemics of Cholera. 48 Mortality in 10,000. Sub-distriots. 1848 efc 1849, 1853