prevalent in the district, while consumption is very rare; so rare, indeed, that M. Lizon, during a period of twenty years, had only seen seven cases, of which the two before referred to were cured. On the other hand, a neighbouring practitioner, M. Gambon, reported that in adjacent districts which were not marshy, as at Cosne, and where ague did not prevail, consumption was a common complaint. Similar observations have been recorded by M. Bérenguier of the district of Rabastens, in the department of Tarn,* and by other writers. Facts of this kind, however, do not prove the opposition of consumption and ague, or that the malarious poison is capable of preventing the occurrence of phthisis. For, supposing it to be true that consumptive affections are less prevalent and more curable in marshy districts, it may be, as was supposed by Dr. Harrison, the "soft and moist" character of the air which exercises the beneficial influence.

1. The question of the antagonism of consumption and ague would appear to admit of ready solution by comparing the mortality from phthisis in different districts of a similar character, except that, in some, aguish affections should be prevalent, and, in others, that they should be absent or only rarely seen. Dr. Greenhow, in his able and elaborate report on the sanitary state of the people of England,† has inserted a table giving the proportion of deaths in males and females, calculated on the respective numbers living, from ague, phthisis, and other diseases of the respiratory organs, deduced from the returns to the Registrar-General for the nine years 1846 to 1854 inclusive, in the Wisbeach, Spalding, Whittlesey, North Witchford and Stroud districts, in which ague prevails; and in Richmond in Yorkshire, Leominster, Leighton Buzzard, Wycombe and Liskeard, in which no deaths from ague were reported. From this table it appears that the prevalence of phthisis in the non-malarious districts is less than in the similar aguish districts; thus, he remarks that Liskeard contrasts favourably with Wisbeach, Wycombe, with North Witchford, Leominster with Whittlesey, and Richmond with Spalding, and Dr. Greenhow concludes, that while "it would be a too hasty inference to affirm from data of so limited a character, that the opinion that malarious influence is unfavourable to the development of phthisis, is altogether unfounded. The present facts, at least, afford it no support."

The districts compared by Dr. Greenhow correspond closely as to the amount and density of the population, and the proportion of persons residing in towns and in country situations; but no account is taken of the relative number of persons at different ages, nor of the influence of climate, though these are most important considerations in estimating the relative prevalence of consumption in different localities.

To effect a satisfactory comparison, the districts compared must not only contrast as regards the prevalence of ague, but they must possess similar climates, and must correspond in the density of the popu* Annales d'Hygiène Publique, tome 38, p. 251. 1847,

† Page 109.

lation, the proportion of persons at the ages most prone to consumption, and in the social position and occupations of the inhabitants. The population must be but little affected by immigration, and the mortality must not be modified by the existence of large public hospitals or institutions in which persons are received from other localities.

It will be at once seen that it is not easy to select districts which combine all these requirements. Similarity of climate will best be obtained by adopting adjacent districts, but districts which are adjacent are seldom decidedly opposed as regards the prevalence of ague. Thus the Dartford and Bromley registration districts might at first sight appear very suitable for comparison, but it will be found that the Dartford* district, though generally malarious, embraces portions which are healthy, while that of Bromley, though generally healthy, is in some parts malarious, and thus the death-rate from ague is high in both districts.‡

Of the metropolitan registration division, the Greenwich and Lewisham districts have a high rate of mortality from ague and remittent fever,§ while there are other districts in which these affections very rarely occur,|| yet these different localities do not admit of satisfactory comparison for the purpose of determining the influence of malaria on the prevalence of phthisis. Indeed, the change in the metropolitan population from immigration, the excess of persons at certain ages, the differences in their social position, and the various hospitals, workhouses, barracks, &c., vitiate all calculations of the relative frequency of phthisis and ague in different districts.

It will thus be seen that the selection of the localities to be compared requires careful consideration. For comparison, I have collected from the manuscript tables contained in the RegistrarGeneral's Office, the returns of the deaths from certain causes in some of the districts bordering upon the Wash, and have compared them with similar facts relative to other districts immediately adjacent. For the opportunity of consulting the returns, I am indebted to Dr. Farr and Mr. Hammack, of the Registrar-General's Office. The period over which the comparison extends is the years 1851-52-53-54 and 55, and the districts selected are those

Including the sub-districts of Bexley, Dartford, and Farningham.
Including the sub-districts of Bromley and Chislehurst.

The rate of mortality from ague, estimated on the supposition of the population consisting of 100,000 persons, was respectively 3·8 and 6-8 annually for the 5 years 1851 to

1855.

§ Or 2-4 from ague only, and 7:04 from remittent fever in Greenwich, and 1.7 from ague, and 10-3 from remittent fever in Lewisham.

In all the Southern and Eastern districts of the metropolis, in which the largest proportion of the working population reside, aguish affections are reported as causing death, yet in none of the districts, except the two named above, do such diseases originate at all frequently. I have for long been in the practice of inquiring among the persons who apply at St. Thomas's Hospital, labouring under ague, where the disease has been contracted, and with very few exceptions it turns out that the patients have either had ague in some well-known marshy district, or have come from such locality very shortly before the commencement of the symptoms.

of Wisbeach, Whittlesey, North Witchford (including March and Chatteris in the Isle of Ely), Caxton and Chesterton in Cambridgeshire; Oundle and Thrapston in Northamptonshire; Huntingdon, St. Ives and St. Neots in Huntingdonshire; and Biggleswade in Bedfordshire.* These districts are most of them but slightly elevated above the level of the sea, and must correspond closely in climate. Geologically they are either fenny, or are situated upon the lower greensand formation and upon the upper, middle and lower oolites. They lie within a short distance of the Wash, and between and on either side of the rivers Nene and Ouse. The population is chiefly engaged in agriculture, the only manufactures of any importance carried on in any of the districts being the straw-plait, which prevails in Biggleswade and to a limited extent in Caxton; lace-making, which is somewhat extensively followed in St. Neots and Thrapston, and slightly in Oundle and Caxton; and shoemaking, which is carried on in Thrapston. The density of the population in the different districts is very similar, the towns are all of small size,† the proportion of persons at the ages most prone to consumption does not differ materially, and the population is a moderately stationary one. The districts also one.‡ afford the required contrast in the prevalence of aguish affections. In Caxton no death from these causes was registered during the five years selected for comparison; in Chesterton, St. Ives, and Biggleswade, the mortality from this cause was small; and in St. Neots, Whittlesey, Oundle, Thrapston, Wisbeach, North Witchford and Huntingdon, a large proportion of deaths occurred.

In the annexed table will be found the population of these several districts, as ascertained in the census of 1851, the extent of the districts, the proportion of persons to the square mile in each, and the relative proportion of persons between the ages of fifteen and forty-five inclusive; together with the annual proportion of deaths from ague and remittent fever combined, from ague only, and from phthisis, other diseases of the respiratory organs, and all causes, estimated on the supposition that the population of each district amounts to 100,000 persons of both sexes, and of each sex separately. The districts are arranged according to the relative mortality from aguish affections,

The adjacent Bedford district cannot be included in the calculation, for the town population is much larger than that of the other districts, and a large proportion of the inhabitants are employed in the unhealthy occupation of lace-making, and thus the mortality from phthisis is disproportionately high, being in the two sexes 285 for 100,000 persons living, or 207-7 in males, and 359.3 in females.

The Census Report for 1851 does not give the relative proportion of the population residing in urban and rural situations, and this is only approximatively obtained by comparing the population of the towns with that of the general district. But in the whole of the county of Huntingdon the respective proportions are for the towns 25, and for the country 75. In Cambridge, 31 and 69. In Northampton, 28 and 72. In Bedford, 30 and

70.

The proportion of persons resident out of the population, estimated at 10,000, who were born in the county of Huntingdon at the time of the last census, was 6994; in Northampton, 7586; in Cambridge, 7155; and in Bedford, 7577. In the London districts the proportion is 6167. In Cornwall, where the least change takes place, the proportion is 9322. In the extra metropolitan parts of Middlesex, where the greatest change occurs, the proportion was 4604.

and this is inferred from the number of recorded deaths from both ague and remittent fever, as the former disease very rarely proves fatal but rather terminates in the form of remittent fever. As however the correctness of the returns of deaths under the latter head may be open to question, a column is added, giving the proportion of deaths from ague only, and it will be observed that their number corresponds generally with the results deduced from the two diseases combined.

The comparison here instituted is open to objections, but I believe it to be sufficiently accurate for the purpose. From an inspection of the Table it will be seen that, taking the prevalence of malarious affections as indicated by the deaths in both males and females, the places in which aguish affections were least fatal are those in which the largest number of deaths from phthisis were registered, and vice versa. Thus in Caxton, where no death from malarious causes was registered, and Chesterton and St. Ives, where the deaths only amounted to 1.5 and 1.9 annually per 100,000 persons living, the proportion of deaths from phthisis was 251.2, 309.8, and 287·4; while at Huntingdon and North Witchford, with the deaths from malarious causes amounting to 37.3 and 11, the proportion of cases of phthisis was 225-8 and 217.9. But on looking more closely at the table it will be found that this rule does not apply throughout. Thus Biggleswade and Whittlesey, where malarious affections prevail to the extent of 4.2 and 7-8, lose 245·5 and 243.1 from phthisis. While Oundle, with a large prevalence of ague, 8-9, has the lowest proportion of phthisis, or 200-5.

If the deaths from phthisis in the several districts in males and females separately, be compared with the prevalence of malarious. affections, similar discrepancies will be found to exist. Thus among males the fatality of phthisis is seen to be almost identical in Caxton (181) without any death from malaria; in Oundle (1804), where the deaths were 8.3; in Thrapston (1805), where they were 9.3; and in North Witchford (180-2), where they were 11. So also there is but little difference between Biggleswade (1962), where the malarious deaths were 4.2; St. Neots (191-2), where they were 74; and Huntingdon (202), where they were 373; and between Chesterton, St. Ives, and Whittlesey, where the malarious deaths are 1.5, 1.9, and 7-8, and the phthisical deaths were 256, 240-2, and 248-5.

The deaths from phthisis in females exceeded those in males in all the districts except Whittlesey; but the relative mortality varies equally in different districts, and bears no regular relation to the prevalence of aguish affections. The rate is highest in Chesterton, Caxton, Biggleswade, St. Ives, Thrapston, St. Neots, and Huntingdon, and lowest in Whittlesey, Oundle, North Witchford, and Wisbeach. While therefore, as a general rule, in the districts compared, a large prevalence of aguish affections coincided with a low rate of mortality from consumption, and a small prevalence of ague with a high rate of mortality from consumption, this rule is liable to such marked exceptions that we are not warranted in inferring that 45-XXIII.

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