So notoriously are outbreaks of fever connected with deficient sanitary arrangement,-typhoid with impure water and air, typhus more generally with overcrowding and putrefying emanations from the living body, that it is unnecessary to enlarge upon the subject further than to state the significant fact that typhus, the old genuine typhus of Edinburgh and other large towns, will die out, in cases which may succeed, if any do, a case imported into a perfectly healthy situation. The best defined special fact which Dr. Greenhow seems to have elicited in his fever investigations is, that although generally

"The differences in fever death-rates in males and females are very considerable and very irregular, the places in which the female death loss is proportionally highest, and most largely exceeds the male death loss, are counties in which the proportion of females engaged in manufactures is very much greater than that of the males." (Dr. Greenhow's 'Papers,' p. 100.)

The same fact we find elicited with respect to erysipelas, the female death loss from that disease being

"Proportionally higher than the male in Bedfordshire, where the men are chiefly employed in agriculture, but thirty-three per cent. of the women are employed in manufactures; and likewise in Leicestershire and Nottinghamshire, where the women are largely employed in the manufacture of lace." (Papers,' p. 105.)

Although fever causes a larger proportion of deaths in unhealthy than in healthy places, it yet holds a subordinate position to several other causes of death in the production of a high death-rate; moreover, the death-rate seems to have no definite relation either to the density or the amount of population. Thus:

"The mortality from fever in the large and densely-peopled cities of Manchester and Liverpool is rather less in proportion to their population than the mortality in the much less thicklypeopled towns of Blackburn and Wolverhampton; lower in Blackburn and Wolverhampton than in the smaller and much less dense population of Leighton Buzzard, Merthyr-Tydfil, and Abergavenny." ('Papers,' p. 192.)

Again :

"Although the 'general death-rates are lower,' the mortality from fever is larger in proportion to the population, in the South Midland counties and in Monmouthshire and Wales, than in either London or the South-Western counties." (Ibid. p. 100.)

These facts are quite at variance with the commonly received idea that the zymotic diseases, and fever especially, are more prevalent and more fatal in proportion to the density of population. Equally erroneous proves to be the opinion "that fever is especially a disease of mature life." Of 10,995 deaths that occurred "during the Septennial period in twenty of the districts comprised in that investigation, with a population of 1,297,832, the deaths of persons under twenty amounted to 4700." Although fever will doubtless spread more widely amid a crowded population, and find more force for its origin, it does not require large aggregations of impurity for its development; a neglected sewer, ash-pit, or cesspool, an unsound soil-pipe,* it matters not whether in town or country, may be all that is required. The farm-house or labourer's cottage, nay, the mansion of the squire, though situated in the most healthy district, if putrefying animal and vegetable refuse is permitted to taint its immediate atmosphere, is as liable to be invaded by fever as the town-dwelling in the close alley. The taint of the atmosphere in the vicinity of fermenting and decaying matter proceeds chiefly from the gases, but partly also from organic matter "in a state of active decomposition." Dr. Letheby tells us that he cannot speak with certainty "as to the properties and effects of the organic vapour which is contained in sewer gases," but both he and

Dr. Herbert Barker* most thoroughly demonstrate, not only how certainly sewage gas affects both health and life, but how small a proportion of the gases are capable of extinguishing life, or of giving rise to the phenomena of febrile disease according to the intensity and period of their administration. The demonstrations of Dr. Barker are chiefly in the way of experiment. Exposure, by means of a suit. able and ingenious contrivancé, to the gas of a large cesspool, proved fatal to a mouse, and produced in larger animals, such as dogs, a series of symptoms analogous to those of febrile disease. Sulphuretted hydrogen, carbonic acid, and ammonia, the principal and most deleterious components of sewage gas, were experimented with separately. Of the first, less than two per cent. in the air killed a puppy in two minutes and a half, and so small a proportion as 0.428 killed a second within the hour. A dog exposed to an atmosphere containing 0-206 per cent. of the gas died in nine hours and a half, but another, in the same description of atmosphere, suffered at first, but soon recovered; others were more violently affected in a less contaminated air. Ammonia and its salts produce "what may be unhesitatingly considered typhoid symptoms," and prostration and diarrhoea followed the inhalation of carbonic acid in small proportions. In short, as Dr. Barker concludes :

"The symptoms which have thus been noticed as resulting from the inhalation of sulphuretted hydrogen, sulphate of ammonia, and carbonic acid, are sufficient to account for the effects arising from cesspool effluvia, without seeking for any further product from such emanations." (p. 19.)

The most important result of these experiments is the demonstration of the minute quantity of the deleterious gas which is sufficient to produce disease, a fact, moreover, evinced practically by the researches of Dr. Letheby. In the cutting of the Thames Tunnel the men" suffered severely" from the gas, "although the proportion of it in the air was hardly to be discovered by lead paper, and could not therefore have exceeded one part in 100,000." (p. 33.) Emaciation, low fever, and death were the results in several cases.

“Another remarkable instance of the same kind of poisoning occurred last summer at Clayton Moor, near Whitehaven, where there is a row of small cottages built on the refuse slag of some neighbouring iron-furnaces. The houses are occupied by the workmen and their families, who for some time had been annoyed by a bad odour, which pervaded the lower rooms. Suddenly, however, in the month of June of last year, the smell became unusually offensive; and in the course of two days thirty of the inhabitants were made seriously ill by it. The attack was remarkably sudden, as if a poison had been at work. In one of the houses there was a family of seven persons, consisting of the husband and wife, and five children. They retired to rest in their usual health, but in the morning two of them were dead, and the others were in a state of profound insensibility. Before the day was over another of them died, and in the course of a week a fourth. In a second case, a strong, healthy man came home from his night-work and went to bed; but an hour had hardly elapsed, when he also was found dead. And in a sixth instance, a child was taken ill in the morning and was a corpse at night. An inquiry was instituted for the purpose of discovering the cause of the mischief, and Dr. Taylor came to the conclusion that it was sulphuretted hydrogen, generated by the action of water on the refuse slag upon which the houses were built. If so, it is a remarkable instance of the poisonous action of this gas; for those who examined the air of the rooms declare that the test of lead paper failed to show the presence of the poison, except in mere traces-that is, in quantities which could not have been greater than one part in 100,000 of air, for such a proportion would have been easily recognised if it had been present."§

Clear as may be the connexion between impurity and zymotic disease, small as may be the amount of impurity requisite to work the mischief, the question yet remains

to be solved, why the outbreaks of disease are only occasional in most instances, often few and far between, but yet the pollutions are constant? As Dr. Ackland says of Horwood,*"there are doubtless many sanitary errors, but scarce any that may not be found in hundreds of other rural parishes." The same might be said of a village which, under our observation, has suffered from a severe visitation of typhoid fever during the last two months-a village, moreover, in which fever cannot be remembered to have occurred before, and in which the sanitary conditions, or perhaps deficiencies, have been the same throughout. The materies morbi, the miasma of fever, if such exists, has as yet eluded the test of the chemist, and the microscope of the physician; but whether it be discoverable or not, of this we may be certain, that it cannot act, perhaps cannot be developed, in the absence of impurity. This is our fact-a fact so important, so simple, so well ascertained, that we can only marvel how little has yet been its practical application. Death-rates may show where that application is needed most; they cannot show more plainly than we know it, the necessity for its immediate and universal application throughout the length and breadth of Britain.

It has usually been thought, not only popularly, but medically, that croup is more prevalent and fatal "in damp places, by the sides of rivers and marshes, than in drier and more elevated situations." The tables in Dr. Greenhow's work disprove the idea. The Eastern and South-eastern counties, with their fens and abundant moisture, have a lower death-rate from croup than Monmouthshire and Wales, the North-western, or the West-midland counties. Cambridgeshire, Lincolnshire, and Durham, suffer less than Staffordshire, Cheshire, and Lancashire. It must, however, he remembered, when considering the mortality from croup, especially in connexion with such districts as those last named, that probably many cases of spasmodic croup are recorded under the present head, and that we have then one of the nervous diseases of children in which "the chief manufacturing towns sustain the highest mortality, and the more purely agricultural counties the lowest." (p. 115.) The tables confirm the generally received opinion that males suffer more from croup than females.

Influenza, which is included by Dr. Greenhow in the same division as croup, is not remarkable for a high death-rate; but where the death-loss from the epidemic is heaviest, there do we find the most unhealthy conditions of a town or district, people debilitated from any other cause most readily succumbing to the attack of a disease not characterized by any necessary fatality. In this we have an unique example. A purely epidemic malady, mild in character, affects the whole community, but only severely and fatally where the causes and fosterers of zymotic diseases generally exist in strength.

A singular fact with regard to scrofula becomes apparent from the investigations. "It is found to be, upon the whole, more fatal in healthy than in unhealthy districts?" "The agricultural counties of Cambridge and Buckingham sustain a higher proportionate mortality from scrofula than the counties of Lancashire, Staffordshire, and the West Riding of Yorkshire." ("Papers," p. 111.) Why this should be, scarcely appears. It may be, as Dr. Greenhow suggests, that deaths from scrofula take place in early life, while children are yet under their parents' roof, and before the age when they depart to the crowded industrial districts; we would, however, suggest two causes which may account still more readily for the apparent anomaly. Some of the diseases of childhood, such as tabes, hydrocephalus, and some forms of convulsion, are of undoubted scrofulous origin, and it is not at all improbable that scrofulous children die, and are registered as dying, of these diseases in crowded situations, who in more healthy districts would have survived till a later period, and succumbed to their scrofulous taint in another form, their deaths being registered under the head of scrofula. A second cause we would suggest, is the intermarriage which frequently takes place in country places, where the same name occurring over and over again among the present inhabitants, can be traced back perhaps for centuries.

Fever in Agricultural Districts.

The mortality caused in childhood by disease of the nervous system, forms one of the most important heads of the present inquiry, approaching in this respect pulmonary disease and alvine flux. There may be some doubt, however, whether convulsions, hydrocephalus, and teething, the division of the subject adopted, is likely to lead to perfectly sound conclusions, considering how loosely certificates of death are often filled up. A large proportion of deaths from hydrocephalus and teething are accompanied with convulsions, and often, probably, the death return is made in accordance with the most prominent symptom, thus leaving a large margin for indefinite conclusions.

The anomalies exhibited by the death-rates of the nervous diseases of children are numerous, and Dr. Greenhow tells us that "the mortuary statistics of the infantine population" seem marked by an absence of any uniform relation "between the proportion of deaths from all causes and from particular diseases." (p. 118.) Males die in a much larger proportion than females from these diseases, but why we cannot tell. The male rate for England being considered as 100, the female is but 75; in some places, such as Nottingham, Leicester, Derby, falling as low as 67 or 68; in others, such as Newcastle-upon-Tyne, approximating the 100 as nearly as 91. Carnarvon, which has almost acquired notoriety from the circumstance, has greatly the largest death-rate from nervous disease in children, and yet it is by no means an unhealthy place, being very far in advance of such a place as Liverpool in general salubrity; as much indeed as in the proportion of two to one in the value of young life generally, and "yet for every hundred of the males of Liverpool that die from these children's diseases, more than one hundred and forty perish in Carnarvon." (p. 117.) This fact, and others of a similar kind, is at present inexplicable. As a general rule, however, "the mortality is lowest among the thinly scattered population of rural districts, highest in the large towns" (p. 116); highest of all where female labour is most in request, and especially, as in factories, away from their own homes. In other words, the young children die off most rapidly where, as we have already seen, the lives of the mothers are shortened by their industrial employments, where the temptation, if not often the necessity, exists for early weaning; where infants are left in the hands of strangers; where irregular and improper feeding causes fretfulness and disquiet; and where last, not least, drugging, chiefly with opiates, given to subdue the effects of the mismanagement, completes the catalogue of evils by which the infant constitution is irretrievably ruined, and those diseases of the nervous system developed which form so large an item in the death-rate of the country. Taking a retrospective view of our subject, as we find it brought out in the researches and reports we have passed in review, the results seem to arrange themselves under the following heads :

The confirmation of facts which have either been tolerably well established already, or which, though received, have been so on indefinite grounds, or which, if not entirely new, are nearly so ;—

The reversal of facts which have hitherto been accepted as established ;

The eduction of anomalous facts which are perfectly inexplicable in the present state of our sanitary knowledge.

Of the first of these, we would cite the excess of the female death-rate from pulmonary disease where much in-door female industry is required; the greater liability to cholera, diarrhoea, and fever where impure water is drunk, and especially the valuable fact connected with the surface wells of London; the difference in the female pulmonary death-loss traceable apparently to work at home and work in the factory, the probable connexion of pauperism with high death-rates, both pulmonary and zymotic, and the important results of the experiments of Drs. Barker and Letheby.

Under the second of these heads, we would call to mind the Paper of Mr. Neison respecting the causes of pulmonary disease in the army, the disproof of fever being either, in large proportion, a disease of mature life, or of very crowded localities, as compared with others; and the fact that croup is not found to have

the highest death-rate in damp and cold situations. Moreover, that consumption is more fatal in the comparatively mild climate of the southern English counties, than in the northern.

Lastly, as regards anomalies, we have them abundantly enough. Cambridgeshire has a high pulmonary death-rate without palpable reason. Stock and Walstanton show no cause for giving different mortalities from lung disease, nor can we tell why the Welsh coal-mining districts should differ in this respect from their English neighbours. Birmingham, Nottingham, and Leicester, if liable to diarrheal outbreaks, have an exemption from cholera, apparently from no merit of their own; and when we come to the differences in the male and female deathrate from the nervous diseases of children, as well as the differences in the general death-rate itself, we are completely at fault; neither is our perplexity lightened by finding that scrofula is a more fatal disease in the generally healthy than in the unhealthy districts.

To these anomalies we may add another not yet alluded to, the fact that the waterguard" and the waterside officers of Her Majesty's Customs, although exposed to much vicissitude of weather, and to the constant influence of Thames emanations, do not suffer from a high rate of mortality.*

Perhaps sufficient has been said to show that although many and valuable are the facts which we have acquired, especially were they practically used, we are as yet but on the threshold of the science of hygiène, and that, as Dr. Greenhow remarks, "the entire subject is barely opened by the present inquiry."

In addition to investigations respecting crowding, occupation, drainage, &c., climate, domestic habits, the structure of the houses, the food, the topography and geology of the districts, must be examined, as well as every circumstance which can affect health, before we shall be in a position to ascertain correctly the causes and the practical bearings of the death-rates of England.

Such minute and local investigations are evidently beyond the power of one man, and the necessity is at once apparent that local "medical officers of health" should be appointed throughout the entire kingdom, from whose reports, rendered in a systematic, and above all in an independent form, deductions might be drawn, not simply of the broad features of the sanitary question, but of the varied local circumstances which not only occasion preventable mortality, but which tend to impair health and constitution. Till this is done, there will be no real sanitary science. Individual labours may bring out new facts, and confirm old ones, but they will want much of that minuteness which would make them truly valuable in practical application.

REVIEW II.

1. A Manual of Obstetrics, Theoretical and Practical. By W. TYLER SMITH, M.D., Member of the College of Physicians, Physician-Accoucheur to, and Lecturer. on Midwifery at, St. Mary's Hospital.-London, 1858. pp. 628.

2. Lehrbuch der Geburtshülfe. Von Dr. OTTO SPIEGELBERG, Privat-docenten an der Universität zu Göttingen.-Lahr, 1858. pp. 372.

Manual of Midwifery. By Dr. OTTO SPIEGELBERG.

3. Illustrations of Difficult Parturition. By JOHN HALL DAVIS, M.D., &c. &c.— London, 1858. pp. 284.

SOME One has called this the "Age of Manuals," and there is so much truth in it,

*Second Report on the Customs, by J. O. McWilliams, M.D.