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inuard. state without which the outward was innocuous-it wasthe meeting of the two ; the spark added to the ready preparedtinder. Some had a perfect immunity, whilst old cases allturned up again, although in different houses," &c. Careless-ness in food, want of personal cleanliness, neglect of the dailyhead-to-foot washing with soap and water-on which Mr. EdwinChadwick justly lays so much stress,-the indulgence inspirituous liquors and other irregularities, have a most markedeffect. The lower classes are in the habit of indulging in drinkand dissipation on the last and first days of the week, and thecholera returns are always worst on the subsequent days.Personal predispositions should not by any means be over-looked.

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THE following printed form has been prepared and issuedfor the use of the inspectors in the Hackney District, for thepurpose of carrying out one of the most useful provisions ofthe Diseases Prevention Act. The example might be followedwith convenience and advantage in other districts :-"Whereas, by Order of Council, dated July 21st, 1866, the Dis-

eases Prevention Act has been put in force within the HackneyDistrict, and whereas it is provided that all persons dyingfrom cholera or other epidemic disease shall be speedily buried,You are therefore required to bury within hours from theservice hereof, the body of now lying at .

If this order is not obeyed the body will be removed by theboard, and proceedings will be taken to enforce the heavypenalty which will be incurred by disobedience of this order.

"RICHARD ELLis, Clerk."

A GREAT deal of time may be saved, and a large amount ofuseful information collected which would otherwise be lost, bythe adoption of a well-arranged and complete printed form ofreturn for district medical visitors and inspectors. By far thebest form which we have seen is that in use in Southwark, ofwhich Dr. Rendle has forwarded us a copy. He will no doubtbe happy to send it to any person interested. The medicalofficers of health, who have the general charge of districts,would, we think, render a desirable service by agreeing amongthemselves upon a uniform, full, and complete form of return.This would not only constitute the information obtained fromeach district fuller and more accurate than it now is, but itwould have the great advantage of making the results easilycomparable, a matter which will ultimately prove of very greatimportance indeed.

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DR. JAMES DUNCAN, of Heriot-row, Edinburgh, died fromcholera last week, at Tours, while taking his annual holiday.Dr. Duncan was M.D. of Edinburgh, and Fellow of the RoyalColleges of Surgeons of London and Edinburgh. He was a

favourite and distinguished pupil of Mr. Liston. At the timeof his death Dr. Duncan had the largest general practice inEdinburgh ; and the pre-occupation incidental to his profes-sional labours will probably explain the fact that he has con-tributed little to medical literature. He was of the middle age,and previously in robust health. He was widely known andmuch esteemed in Edinburgh, and his death under these pain-ful circumstances has evoked universal sympathy in society aswell as in the columns of the press.

THE daily papers have contained the account of an unpleasantaccident which befell Dr. Wilks, of Guy’s Hospital, in his so-journ at Scarborough. He was overtaken by the advancingsea, and belated on a rock. He escaped without serious injury,although much exhausted and fatigued. We are happy to hearthat Dr. Wilks is now returning to London, none the worsefor this rather awkward holiday mishap.

WITH reference to the immunity which the fumes of gas-works were alleged to give from attacks of cholera, it will beobserved that Mr. Edmund Pope, one of the medical visitors

of the Centre ward, Mile-end Old-town, reports that choleraand choleraic diarrhoea were specially localised in the imme.diate vicinity of the gas-works.

ReportOF

THE LANCET SANITARY COMMISSIONON THE

EPIDEMIC OF CHOLERA IN THEEAST END OF LONDON.

No. II.

The River Lea above Enfield, and the tributaries of the Lea;sewage received by them. Cobbin’s Brook and Epping. Thecholera ditch. Sewage of Hertford not deodorised. Sewageof Ware. Barges on Lea and Stort as far as Hertford and

, Bishop Stortford. Summary account of the contaminations, of the Lea. Comparison of the cholera nio)-tality in. the dis-

tricts supplied with water by the East London Company withthat in the rest of London.IN our Report on the llth inst., we stated that the East

London Company took their water from the Lea, near Ponder’s-end, above Edmonton, and that a cutting made by them servedto receive the drainage from Edmonton and Tottenham, so asto withhold it from the river until this had passed the last-named place, the river being in this way protected from theentrance of sewage as far up as Enfield. Here, on the east ofthe river, beyond the marshy ground through which it flows,lies the commencement of the hilly border of Epping Forest,coursing off in a north-easterly direction. This watershedforms the Roding on its south-east, distinct from the Lea, anda stream known as Cobbin’s Brook on its north-west, runninginto the’Lea at Waltham Abbey. Cobbin’s Brook, which takesits rise in the country about Epping, is in parts but a narrowstream at present, while in other places it forms half-stagnantpools. It receives the drainage of Epping, and, about fiftyyards from its outlet by an open ditch, that of the town ofWaltham Abbey. The ditch from Waltham Abbey, whichruns at the back of the church, and at least one house wheredeath has been busy, is in such a condition as to occasion greatcomplaint, and to cause it to receive in the neighbourhood thename of the "Cholera Ditch." In its present state the Cobbinis a very undesirable tributary of the Lea.The mention of Epping in connexion with an investigation

of the influence of the river Lea upon the present cholera out-break at once attracts our attention to the fact of the occurrenceof cholera there last autumn. Whether there can be traced

through the Lea and its tributary any connexion between thatoutbreak and the present one, we are not now prepared to say;but we believe that Theydon Bois, where the Groombridgeslived, is on the other side of the watershed, and, if that bethe case, its drainage must contribute, not to Cobbin’s Brook,but to the Roding, which empties into the Thames direct.From our own inquiries, the information received by Dr. Farr,to the effect that the Cobbin has recently been dry, seems tohave been incorrect.The Lea above Waltham Abbey lies in Hertfordshire, close

to and partly coincident with its eastern boundary betweenWaltham Cross and Hoddesdon. In this part of its course itreceives sewage from Waltham Cross, Cheshunt, Wormley,Broxbourne, and Hoddesdon-all on the Cambridge road. AtHoddesdon is the junction of the Stort and the upper part ofthe Lea. The river Stort runs along the border of Hertford-shire from Stansted Montfichet to Hoddesdon. It takes itsrise in Hertfordshire, but runs for some miles through Essextill it reaches Stansted Montfichet, receiving the drainage of

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this town and of a number of villages and hamlets above it.Three miles below this it receives the sewage of Bishop Stort-ford, in Hertfordshire, where it becomes navigable for barges.Lower down comes the drainage of Sawbridgeworth on itsbanks. Below Sawbridgeworth the Pincey brook runs into theStort, bringing with it for some miles the drainage from Hat-field, in Essex. The Stort also receives the sewage fromHarlow and Roydon, in Essex, and Hunsdon, in Hertford-shire.

Passing along the river Lea from Hoddesdon, we come tothe important towns of Ware, about five miles up, and Hert-ford, two miles above this. The sewage of Hertford flows

through the town to a place called the " filtering-bed, inwhich it is professed to be deodorised by the New River Com-pany. From this place it runs in an open cutting about twelvefeet wide to discharge itself a little above Ware. This sewage,2vherz it passes into the river, is highly offensive, and causes muchcomplaint from the inhabitants of Ware. The offensivenessof the river can be appreciated by anyone standing on Ware-bridge. The sewage of Ware itself is conveyed by three sewersto the river near the bridge. Below Ware the Lea receivesthe sewage from St. Margaret’s and Stansted Abbots.Below Hertford the river Rib flows into the Lea. This river

runs for some miles through Hertfordshire in a southerly direc-tion to Hertford, receiving in its course the river Quin. These

streams bring the drainage from Buntingford, and the maintowns and villages in this part of Hertfordshire. Just above

Hertford the Beane and Mimram flow into the Lea. Theformer flows to the Lea in a southerly direction; the latter ina south-easterly direction. The Lea itself rises in Bedford-

shire, south-east of the Chiltern hills ; and, passing throughLuton, runs in a south-easterly direction through Hertford-shire till it approaches Hatfield in this county, when it pur-sues an easterly course to Hertford. It receives the drainageof Luton, Wheathampstead (and its paper-mill), and, we be-lieve, Hatfield in Hertfordshire, and, with the Beane andMimram, that of a number of villages. The Lea is navigableby means of a system of locks as far up as the Mill-bridge inthe town of Hertford. Barges pass up the Lea and the Stort,carrying manure, bricks, timber, &c., into Essex and Hert-

fordshire, returning with malt, corn, wool, &c.To sum up, then, nearly the whole of Hertfordshire, it will

be seen, besides the western border of Essex, drains into theriver Lea, which receives excrementitious matters from 150,000to 200,000 persons before it reaches Enfield, below which istaken the supply of drinking water for the east of London.In Hertfordshire, it is rendered noisome at Hertford and Wareby the sewage of these places, and then has only some twentymiles to flow before its waters are taken up into the water-works above Lea-bridge. If, then, the opinion of such a che-mical philosopher as Sir Benjamin Brodie is worth anything,that the atmosphere does not remove from the water of theThames the noxious qualities imparted to it by the sewage ofOxford, even when it has flowed down to Teddington-lock,surely the action of the atmosphere can still less be dependedon to do so for the Lea during its flow of twenty miles fromWare. After all, however, this is only an opinion, althoughborne out by similar opinions of Professor Way, ProfessorAcland, and others ; so we must not make too much of it.At Waltham Abbey, the Cobbin pours into the Lea the sewage

of this town and of Epping, in its most offensive state, but threemiles above Ponder’s-end; and then, when there are added tothese sources of pollution of the stream the mills out of numberalong its banks, and the barges passing up and down thenavigable river by a system of locks, which go far to give thecharacter of a canal to the river, and to cause comparativestagnation of its waters, we have sufficient cause to wonderthat the inhabitants of East London do not generally suffermore in health.

Such facts as are here noticed, no less than those brought

out by the Royal Commission of Inquiry into the Pollution ofRivers, are surely enough to convince anyone of the urgentneed of some other source of drinking water for London thanthe Lea or the Thames.

Cholera mortality in the districts supplied with water by theEast London Company compared with that of other parts ofLondon.

Attention was called in the first report to the close agree-ment of the boundaries of the cholera field in the east of Lon-don with those of the mains of the East London Waterworks.As the result of calculations made from the weekly returns ofthe Registrar-General, we stated that of the 346 deaths bycholera registered in the London districts for the week endingJuly 21st, 309 occurred in the field of these mains; of the 904cholera deaths registered for the week ending July 28th, 815 ;and of the 1053 registered for the week ending August 4th,930 (or 931) took place in this field. We have now to add thatof the 781 deaths by cholera in London during the week endingAugust llth, 679 happened within the limits of the mains ofthis company ; and of the 451 cholera deaths during the weekending August 18th, 368 happened within these limits. Thenumber of cholera deaths occurring in the East London regis-tration districts represents very closely, sometimes exactly,the number of deaths in that part of London supplied withwater by the East London Water Company. This results fromthe fact that the deaths in the parts of the northern and cen-tral districts supplied with this water are about equal innumber to those in the eastern districts supplied with the NewRiver water.

Let us now, as we did for the deaths up to July 28th,run along the western boundary of these mains—beginning atSt. Katharine’s Docks, and passing afterwards along Shore-ditch and through Hackney,- and see how the deaths havefallen with regard to it from July 29th to Monday, August13th (both days inclusive).In Aldgate, the sub-district crossing the southern termina-

tion of this line, 8 deaths have occurred in this period, ofwhich 7 were east of the line. In the sub-district of St. Botolph,which lies north of Aldgate district and mostly west of the line,we found, it will be remembered, that a number of deaths fromcholera had occurred, although this sub-district receives verylittle of the East London water. During the period which weare now considering 17 deaths have been caused by cholera,of which 2 only have fallen east of the line. On the east of St.Botolph and of the East London water line lies the sub-districtof Goodman’s Fields, in which 28 deaths have been registeredin this period. North of Goodman’s Fields and east of the linelies the Church sub-district of Whitechapel, and above thisthe North sub-district. In the former 36 deaths have occurred,exclusive of those in the London Hospital (which is situatedin this sub-district) not brought in from Whitechapel. In

Whitechapel North sub-district 20 have been registered, allwith the exception of one or two east of the line. In the

Artillery sub-district, which is north of the one last referredto and east of the water boundary line, 11 have occurred,principally in and about Cox’s-square. Most of these deaths

took place in the East London water district, but it is difficultto ascertain what water company supplies the houses in thisneighbourhood, the New River and the East London mainsbordering here upon each other, and the landlord paying thewater-rate, not the tenants. On the west of the line, north ofSt. Botolph, are the Holywell and St. Leonard sub-districts ofShoreditch. In St. Leonard’s, 5 deaths have been registeredas occurring east of this line, and 3 west of it. In Holywell,3 cholera deaths west of the line, and 2 east of it, happened inthe period we are considering. Lastly, in the HaggerstonWest sub-district of Shoreditch, which runs north of these

,

across the line, 7 or 8 of the 10 deaths recorded happened westof the line-that is, out of the East London water district.Next let us see the distribution of cholera deaths with regard

to this line from August 14th to the 21st, both inclusive.In Aldgate, 7 occurred east of this line, and 1 west of it. InSt. Botolph, 1 occurred in the small piece of this sub-districtlving east of the line, and 4 on the west of it. In Goodman’sFields, east of the line, 4 deaths occurred. In White chapelChurch and Whitechapel North sub-districts, also east of theline, 6 deaths occurred. In the Artillery, Whitechapel sub-

. district, and St. Leonards, Shoreditch, no deaths occurred.In the Holywell sub-district, 2 deaths occurred west of theline. Lastly, in Haggerstone West, 2 deaths occurred west ofthe line, and none east of it.

, The difference, therefore, in the degree of mortality on the

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respective sides of the line to some distance from it, althoughstill very great, is not so marked as it was.The fact of this decided difference is not by itself very im-

portant as a means of concluding as to the influence of thewater of East London upon the cholera outbreak, but takenwith other facts it is of much interest. Supposing the watersupplied to the cholera field to have been active for a timeonly in sowing cholera among the inhabitants of the field, andsince then to have lost this power, either from a change inits qualities, or from a cessation of other circumstances in theatmosphere &c. suitable for the development of the disease,we ought to expect the limits of the cholera district and thoseof the water-supply district to become, as they are doing, lessand less nearly coincident.

CHOLERA CORRESPONDENCE.

OuR table is so overladen with correspondence on this sub-ject that we are compelled to present brief abstracts of thegreat bulk of the communications.

Dr. BRUEN, of the army medical staff, in a communicationfor which we have not space, recommends an

" excreting planof treatment. Believing that the poison, exerting its forcefirst and mainly upon the solar plexus, produces an imme-diate derangement of the blood, and a secondary derangementby stopping the action of the great abdominal depuratingorgans, he would direct all his efforts to restoring the latter totheir proper function. He recommends grey powder and rhu-barb until one or two bilious stools are procured, with smalland frequent doses of tannic acid to prevent desquamation ofepithelium, and to lessen the transudation of serum. He hasused those remedies with great success in dysentery and" muco-epithelial" diarrhœa. For pain he applies heat locallyby a hot-water cushion to the abdomen, and immersing thefeet in a pail of hot water. He would encourage the patientto take plenty of hot drink, preferring for this purpose dilutedmilk whey. After the liver had begun to act, he would dry-cup the kidneys, and, if the bladder still remained quiteempty, would give small diuretic doses of turpentine. In pro-found collapse he would inject a hot, weak saline solution, andwould take advantage of the temporary reanimation to ply thecholagogue medicine with vigour, giving the grey powderand rhubarb internally, and forming on the epigastrium aninstantaneous blister, to be dressed with mercurial ointment.If sinking recommenced, he would give sesquicarbonate ofammonia in effervescence; and, if that failed, would injectagain. Whenever vomiting was excessive, he would give smalldoses of hydrocyanic acid with soda in effervescence at thesame time that the cholagogue was administered. He dwellsespecially upon the necessity of a common agreement as tcwhat constitutes collapse, in order to render statistics of somevalue ; and defines as " profound collapse" that state in whichthe pulse is hardly, if at all, perceptible at the wrist, in whichthe patient cannot be roused without difficulty, and cannot b(,at all induced to swallow. He considers opium a poison,alcohol generally unsuitable, and that neither castor oil nor sulphuric acid is indicated. Finally, for prevention, he wouldmake up for the poor a cheap mixture of sulphate of iron, witla small addition of sulphate of soda and chloride of sodiumDr. Bruen believes that by carefully following out this excreting plan cholera will become one of the most manageable oepidemics.

Dr. AnArR. CRAWFORD writes respecting the importance ofhouse-to-house visitation, and quotes at some length, in illus-tration of his views, from a report which he made to theMetropolitan Sanitary Commission in 1848 on the violent out-break of cholera which he witnessed in St. Petersburg in thatyear.Mr. W. WHITEIIEAD (Mansfield, Woodhouse) suggests a

trial in cholera of "the injection into the circulation of eitherchlorate of potash or permanganate of potash. The injectionof medicinal agents," he adds, "in cases of cattle plague was sofar encouraging to me that I believe, had the new regulationspermitted my continuing experiments, I could have broughtthem to a successful conclusion."

Dr. T. M. Lowrrns (Surgeon, Rajpootana Agency) sends thefollowing notes on a means of nutriment in the collapsed stageof cholera :-

" Some six years ago, in consultation with Dr. Ogilvy, ojH.M.’s 33rd Foot, I treated three patients in the collapsedstage of cholera with Liebig’s cold soup (vide Ranking’s Ab.

stract, vol. xxi., p. 357). All those patients did well; andwe considered at the time that marked benefit was derivedfrom the administration of the soup.

" During the past month I had an opportunity of carefullywatching the effects of this soup in three cases of cholera offairly average severity. Two of the cases were not collapsedon admission ; the third was. In one case the collapse super-vened in three hours from the first occurrence of vomiting; inthe other two after about six hours.

" The treatment pursued on admission, if collapse was notpresent, was to give ten or fifteen drops of chloroform, withsix or eight drops of laudanum, in a suitable menstruum; alsofive grains of calomel, and to apply a sinapism to the epigas-trium. To have as a drink-chlorate of potass, one drachm ;dilute nitric acid, a drachm and a half ; strong muriatic acid,eight minims ; water, twenty-four ounces : an ounce to betaken every two or three hours. From one to three ounces ofLiebig’s soup every hour or half hour.

" The first case was admitted about eleven A.M.; and atthree P.M. the pulse was barely perceptible, vomiting frequent,and nothing could be kept down. At five P.M. the same statecontinued; pulse only to be felt as a flutter at intervals. The

soup made from a freshly-killed fowl was then administered,and repeated every half-hour or so. This was retained, andup to half-past seven P.M. there had been no vomiting orpurging; the pulse was then markedly better, and could befelt and counted. Vomiting and purging persisted at inter-vals for two days, the pulse continuing distinct and graduallyimproving. At the end of the second day strong and markedreaction came on. During the night following this he had onebilious stool and two rice-water stools: strange to say, the

rice-water evacuations followed the bilious stool. After this,, his recovery was uninterrupted. _ _ _ - _

"the other cases dittered from this only in there being com-plete suppression of urine for three days, and three and a halfdays, respectively; the vomiting and purging continuing moreor less until the urine was restored. One of these cases was

complicated with distressing hiccough. At no time after thefirst six doses did I feel any doubt that these cases would do

well, as the pulse in each case was rising during the wholecontinuance."Another case was admitted, but died before being seen,

from two to two and a half hours after admission." No spirit, with the exception of a small quantity adminis-

tered to the first patient and immediately vomited, was givenin these cases until reaction was fairly established."It is especially to the fact of the pulse returning veryearly in the collapsed stage, apparently under the use ofLiebig’s soup, that I would draw attention. No medicines,except the chlorate drink, were administered with the soupduring collapse. I should be very sorry to build hopes toostrong upon these cases. It is not from the fact that recoverytook place that I venture to ask a trial of this nutriment, butfrom the very marked assistance afforded to the system, whichappeared to me to enable it to bear up under and carry thepatients through the disease, which was not suddenly checked,but ran its course and gradually subsided.

"In a postscript to some remarks on the Treatment ofCholera published in the Transactions of the Bombay Medical

and Physical Society for 1860, I noted the progress of thethree cases first referred to ; and since the treatment of thelatter three cases I have forwarded fuller notes to the editorof the Indian Medical Gazette for publication. The likelihoodof cholera visiting England induces me to ask the publicationof the few preceding notes.

’’ These cases were treated in tents of the simplest descrip-

tion, and all the excreta were at once removed and buried toleeward. Unglazed earthen pans were the only means athand for this purpose, and each was only used for twenty-fourhours, and then broken and buried. If in the act of vomitingor defecation any portion was spilled on the ground, all theearth contaminated was removed and buried. Not even a caseof diarrhœa occurred among the attendants, and among thesewere the wives of two of the patients, and one of these womenwas accompanied by two children. The tents were kept openat each end, and were pitched on the side of a hill to the

’ north of the station, away from all public roads, and at rightangles to the prevailing wind.

i "It must be remembered that these cases occurred at a hillstation where cholera had not heretofore been known epidemi-cally ; but three Bheels just arrived from the plains were all at-

r tacked, and two succumbed before it was known that choleral was present; the third recovered. On the day that the last of. these deaths occurred, three persons were attacked in the