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"On the pathology and mode of communication of cholera"

London Medical Gazette
(2 November 1849): 745-52
Part 1.

Reasons for considering cholera a local affection of the alimentary canal--proofs of its communicability--difficulties in the way of the ordinary doctrine of contagion. Cholera poison is contained in the evacuations, and communicates the disease by being swallowed: illustrations of this in the houses of the working classes--in mining districts. Cholera communicated by drinking water: cases illustrating this. Difference of elevation in London influences cholera only through the drinking-water. Communication of cholera through the water in York, Exeter, Hull.

Writers on cholera, however much they may have differed in their views concerning the nature of the disease, have generally considered it to be an affection of the whole body, and consequently due to some cause which acts, either on the blood or the nervous system. The following are the reasons which have led me to entertain the opinion that cholera is, in the first instance at least, a local affection of the mucous membrane of the alimentary canal; an opinion which I thought almost peculiar to myself when I was first led to adopt it, but which, as I have since been informed, others were beginning to entertain.

In those diseases in which there is reason to conclude that a morbid poison has entered the blood, there are symptoms of general illness, usually of a febrile character, before any local affection manifests itself; but so far as I have been able to observe or to learn from carefully recorded cases, it is not so in cholera. On the contrary, the disease begins with the affection of the bowels, which often proceeds with so little feeling of general illness, that the patient does not consider himself in danger, or apply for advice till the malady is far advanced. It is true that, in a few cases, there are dizziness and faintness before discharges from the bowels actually take place, but there can be no doubt that these symptoms depend on the exudation from the mucous membrane, which is soon afterwards copiously evacuated. With respect to certain rare cases of cholera without purging, Dr. Watson has remarked in his Lectures, that when the bodies of such patients have been opened, the characteristic fluid was found in the bowels. Another reason for looking on cholera as a local disease is, that the affection of the stomach and bowels is sufficient to explain all the general symptoms. The evacuations, in the cases I have witnessed, have always appeared sufficient to account for the collapse, when the suddenness of the attack is considered, and the circumstance that absorption is probably suspended. The thickened state of the blood arising from the loss of fluid accounts for the symptoms of asphyxia, by the obstruction it must occasion in the pulmonary circulation. The recent analyses of the blood of cholera patients, by Dr. Garrod, afford the strongest confirmation of this view; for he found it to contain a much greater amount of solid materials in proportion to the water, than in health or other diseases. If there has been more purging in some of the less severe cases than in the rapidly fatal ones, it only shows that, in the former, absorption has been still going on, or else that some of the fluids which have been swallowed have passed through the bowels. The drain of fluid into the alimentary canal suspends the urinary secretion, either totally or in great part, and the kidneys become congested from the altered state of the blood: hence any little urine that is secreted is albuminous; and if the kidneys do not soon recover from the congestion, urea accumulates in the blood in those cases in which the patient survives the stage of collapse. Although in a great number of cases the symptoms of cholera manifest themselves suddenly, and are not amenable to any known treatment, yet in other cases the disease commences gradually with diarrhœa, and in this stage there is evidence to show that it can usually be cured by the ordinary remedies for diarrhœa. Now this circumstance is a strong reason for concluding, that the mischief in cholera is at first confined to the mucous membrane; for it is not easy to conceive that chalk, and opium, and catechu, could neutralize or suspend the action of a poison in the blood. [745/746] Indeed, diseases caused by a morbid poison in the blood, such as the eruptive fevers, cannot be cut short, either by local or general means, but run a definite course.

An important part of the pathology of every disease is the knowledge of its cause. To ascertain the cause of cholera, we must consider it not only in individual cases, but also in its more general character as an epidemic. On examining the history of cholera, one feature immediately strikes the inquirer--viz. the evidence of its communication by human intercourse. In its progress from place to place it has nearly always followed the great channels of human intercourse. In spreading along the highways in India, it often spared the villages that were situated at a little distance from the main road, on either side. When a body of troops were attacked with it on their march, it often remained with them through countries having a very different climate and physical character from that in which they contracted the malady; and they often communicated it to towns and villages previously free from it. In extending itself to a fresh island or continent, the cholera has always made its appearance first at a sea-port, and not till ships had arrived from some infected place. Crews of ships approaching a country in which the disease was prevailing, have never been attacked until they have had communication with the shore. The cholera, moreover, in progressing from one place to another, has never travelled faster than the means of human transit, and usually much slower. Such are the general considerations which show that cholera is communicated by human intercourse; and there are besides instances so numerous of persons being attacked with the disease within a day or two after immediate proximity to the sick, that it seems impossible to attribute the circumstance to mere coincidence. On the other hand, there are a number of facts which have been thought to oppose this evidence: numerous persons hold intercourse without becoming affected, and a great number take the disease who have had no apparent connection with other patient. These facts, however, have always been examined with the conviction that cholera, if communicable, must be contagious in the same way that the eruptive fevers are believed to be--viz. by effluvia given off from the patient into the surrounding air, and acting on other persons either directly or through the medium of fomites. But with a fresh pathology of the disease this opposing evidence requires to be reconsidered, and will, in the sequel, be found to afford the strongest confirmation of the communication of the disease.

In the meantime we have arrived at two conclusions--first, that cholera is a local affection of the alimentary canal; and secondly, that it is communicated from one person to another. The induction from these data is that the disease must be caused by something which passes from the mucous membrane of the alimentary canal of one patient to that of the other, which it can only do by being swallowed; and as the disease grows in a community by what it feeds upon, attacking a few people in a town first, and then becoming more prevalent, it is clear that the cholera poison must multiply itself by a kind of growth, changing surrounding materials to its own nature like any other morbid poison; this increase is the case of the materies morbi of cholera taking place in the alimentary canal.

The instances in which minute quantities of the ejections and dejections of cholera patients must be swallowed are sufficiently numerous to account for the spread of the disease; and on examination it is found to spread most where the facilities for this mode of communication are greatest. Nothing has been found to favour the extension of cholera more than want of personal cleanliness, whether arising from habit or scarcity of water, although the circumstance hitherto remained unexplained. The bed linen nearly always becomes wetted by the cholera evacuations, and as these are devoid of the usual colour and odour, the hands of persons waiting on the patient become soiled, and unless these persons are scrupulously cleanly in their habits, and wash their hands upon taking food, they must accidentally swallow some of the excretion, and leave some on the food they handle or prepare, which has to be eaten by the rest of the family, who amongst the working classes often arrive to take their meals in the sick [746/747] room: hence the thousands of instances in which, amongst this class of the population, a case of cholera in one member of the family is followed by other cases; whilst medical men and others, who merely visit the patients, generally escape. The post-mortem inspection of the bodies of cholera patients has hardly ever been followed by the disease that I am aware, this being a duty that is necessarily followed by careful washing of the hands; and it is not the habit of medical men to be taking food on such an occasion. On the other hand, the duties performed about the body, such as laying it out, when done by women of the working class, who make the occasion one of eating and drinking, are often followed by an attack of cholera; and persons who merely attend the funeral, and have no connection with the body, frequently contract the disease; in consequence, apparently, of partaking of food which has been prepared or handled by those having duties about the cholera patient, or his linen and bedding.

It has been found that the mining population of this country has suffered more from cholera than any other, and there is a reason for this. There are no privies in the coal pits,* (*Dr. D. B. Reid, in Second Report of Commissioners for inquiring into the state of large towns and populous districts. Appendix, part ii, p. 122), and I believe that this is true of other mines: as the workmen stay down the pit about eight hours at a time, they take food down with them, which they eat, of course, with unwashed hands, and as soon as one pitman gets the cholera, there must be great liability of others working in the gloomy subterranean passages to get their hands contaminated, and to acquire the malady; and the crowded state in which they often live affords every opportunity for it to spread to other members of their families. There is also another cause which favours the spread of cholera amongst many of the mining populations, to which I shall have to allude shortly, in treating of the water.

With only the means of communication which we have been considering, the cholera would be constrained to confine itself chiefly to poor and crowded dwellings, and would be continually liable to die out accidentally in a place, for want of the opportunity to reach fresh victims; but there is often a way open for it to extend itself more widely, and that is by the mixture of the cholera evacuations with the water used for drinking and culinary purposes, either by permeating the ground and getting into wells, or by running along channels and sewers in to the rivers.* (*See review in Med. Gaz. present volume, p. 466.)

The part of the metropolis most severely visited by cholera in 1832, was the Borough of Southwark, in which 97 persons in each 10,000 of the population were carried off, being nearly three times the proportion of deaths that occurred in the rest of London. Now the population of Southwark at that time (such of them as did not use pump-water), were supplied by the Southwark Water Works with Thames water obtained at London Bridge, and sent direct to their dwellings without the intervention of any reservoir. The Thames has since become more polluted by the gradual abolition of numbers of cesspools in the metropolis, and the Southwark Water Works have been removed to Battersea, a little further from the sewers. I am endeavouring to compile a full account of the recent epidemic in London, in its relation to the water, but as it is not yet complete I must here be content with citing certain instances of severe visitation, or of exemption from its ravages.

There are two courts in Thomas Street, Horsleydown, exactly resembling each other; the small houses which occupy one side of each court being placed back to back, and the privies for both courts being placed in the intervening back areas, and emptied into the same drain which communicated with an open sewer passing the end of both the courts. In Trusscott's Court, as one of them is called, there was but one death from cholera, whilst in the other, named Surrey Buildings, there were eleven deaths. In this latter court the refuse water from the houses got into the well from which the people obtained their water. The succession of the cases illustrates the mode of communication. There were first two cases in Surrey Buildings, the evacuations of these patients being passed into the bed, as I was in-[747/748]formed by Mr. Vinen, of Tooley Street, who attended them; in a few days after, when the water in which the soiled linen had been washed must have become mixed with that in the well, a number of cases commenced nearly together in all parts of the small court. The instance of Albion Terrace, Wandsworth Road, was a still more striking one of the communication of cholera by means of water. As the account of the occurrence was quoted in a Review in the Medical Gazette,* (*Present vol., p. 468)and some further particulars supplied by me in a note† (†Ibid., p. 504), I need not now relate the particulars, but will briefly state that, owing to a storm of rain and thunder, such a connection was established between the drains and water, that, on a case of cholera occurring in any one of seventeen houses, the evacuations might enter the water supplied to all the others. Such a case did occur, and in a short time the prevalence of cholera was such as I believe had not before been known in this country; whilst at the same time there was but little of the disease at the time, or I believe since, in the surrounding streets and houses. I will take this occasion to remark that we have now an explanation of the reason why the cholera has on some occasions increased very much immediately after a thunder storm, and on other occasions has very much diminished. The cause of this lies in the rain, and not in the thunder. In some places drains containing cholera discharges would be made to overflow into a brook or river, or other source from which water was obtained, whilst in other places drinking-water already contaminated would be nearly altogether washed away, and replaced by a fresh supply.

Dr. Lloyd mentioned some instances of the effects of impure water at the South London Medical Society, on August 30th‡ (‡See Report in Med. Gaz., p. 429). In Silver Street, Rotherhithe, there were eighty cases, and thirty-eight deaths, in the course of a fortnight early in July last, at a time when there was very little cholera in any other part of Rotherhithe. The contents of all the privies in this street ran into a drain which had once had a communication with the Thames; and the people got their supply of water from a well situated very near the end of the drain, with the contents of which the water got contaminated. Dr. Lloyd has informed me that the fœtid water from the drain could be seen dribbling through the side of the well, above the surface of the water. Amongst other sanitary measures recommended by Dr. Lloyd was the filling up of the well; and the cholera ceased in Silver Street as soon as the people gave over using the water. Another instance alluded to by Dr. Lloyd was Charlotte Place, in Rotherhithe, consisting of seven houses, the inhabitants of which, excepting those of one house, obtained their water from a ditch communicating with the Thames, and receiving the contents of the privies of all the seven houses. In these houses there were twenty-five cases of cholera, and fourteen deaths; one of the houses had a pump railed off, to which the inhabitants of the other houses had no access, and there was but one case in that house. The people in Rotherhithe, where the mortality from cholera has been greater than in any other part of the metropolis, are supplied with water to a great extent from certain tidal ditches communicating with the Thames, and receiving besides the refuse of the houses in the neighbourhood; and Dr. Lloyd informs me that a line may be drawn between the places where ditch-water is used, and those supplied from the Water Works, and that the cholera has been many times more prevalent in the first mentioned places; although, in my opinion, the water supplied from the water works is itself not free from suspicion of having conveyed cholera poison, being obtained from the Thames. Rotherhithe is less densely populated than many parts of the metropolis which have been comparatively free from cholera, and those ditches, it should be remembered, are not very offensive to the smell; being only Thames water rendered a little richer in manure; being, in short, probably equal to what Thames water would be if certain of our sanitary advisers could succeed in having the contents of all the cesspools washed into the river. In Bermondsey, the district in which next to Rotherhithe the cholera has been most fatal, the people also have to drink ditch water to a great extent. [748/749]

The Registrar-General has very ably pointed out the connection between the higher rate of mortality from cholera on the south side of the Thames, and the lower level of the ground; but when this division of the metropolis is examined in detail, and compared with certain other parts of London, it will be found that the relation is not one simply of level, or of the state of the air in connection with it, but that it depends altogether on the water used by the people. Not because the water carries the poison to every individual case, but because it supplies a number of scattered cases which diffuse the disease more generally. The water works supplying the South of London take water from the Thames mostly at places near which the chief sewers run into it. Moreover, the wells in this part of London are very liable to be contaminated by the contents of cesspools. Mr. Quick, engineer of the Southwark waterworks, in his evidence before the Sanitary Commissioners in 1844, said that in the South side of the Thames the wells are often so contaminated owing to the cesspools and the wells being often about the same depth--viz. from eight to twelve feet, whilst on the north of the Thames the wells require to be from thirty to seventy, or eighty feet deep* (*First Report, p. 396). These, together with the water from the ditches mentioned above, are the chief sources of the high mortality on the south of the Thames, and where they are not in operation there has been comparative immunity from the disease. Bethlem Hospital is very copiously supplied with water from an Artesian well on the premises, and I am informed that there have been but two or three cases of cholera out of a population of about seven hundred. Mr. Morton, Surgeon to the Queen's Prison, informs me that, although there has been a good deal of diarrhea there have been but two cases of cholera in that establishment, containing a population, with the officers and attendants, of 300 and upwards, and one of the cases (the only fatal one) occurred in a patient who had been about a week in the prison, had suffered from an attack of cholera just before he entered, and had lost some members of his family by it. Now, the Queen's Prison is supplied with very good water from various wells within the walls. Bethlem Hospital is situated in Lambeth, where one in every eighty-eight of the population have been carried off by cholera; and the Queen's Prison in Southwark, where one in every sixty persons have died of it: and the latter establishment is closely surrounded by houses, in numbers of which the cholera has been very fatal. In another institution in London, situated at the same elevation as those just mentioned, there has been, together with a difference of water, a difference in the relative prevalence and facility of cholera amongst its inmates and the surrounding population, but here it has been against the institution and in favour of those outside: I allude to the Millbank Prison. The cholera showed itself there soon after its appearance in London last autumn; and during the summer of the present year it became very prevalent, and the greater number of the prisoners were sent away. Dr. Baly stated before the coroner that the cases occurred in different parts of the prison, amongst persons having no connection with each other, and that the strongest and most healthy men were often its victims. The water used in the Millbank Prison is obtained from the Thames at the spot, and is filtered, through sand and charcoal and looks very clear. Before these investigations there could be no objection to such water; but it would appear by the result that the filtration was not an effectual safeguard. I cannot help suggesting that the water used here may have had some connection with the dysentery which has been often prevalent in this prison, for dysentery has apparently been kept up in India by water containing human excrements; and the same circumstance was observed in the old barracks at Cork, by Mr. Bell, surgeon of that town* (*Dr. Cheyne on Dysentery, Dublin Hospital Reports, vol. iii).

The greater part of Westminster abounds in nuisances, and is crowded with very poor and destitute people. The average elevation of it is exactly the same as that of St. Saviour's and St. Olave's, Southwark, but the mortality from cholera in Westminister to the end of September has been but [749/750] 69 in the 10,000; whilst in St. Saviour's it has been 162, and in St. Olave's 152 or 179, according as the deaths in St. Thomas's Hospital are left out or included. The greater part of Pimlico and Chelsea have the same elevation as the Borough, but the mortality in them has been less than one-third as great as in the Borough. Westminster, Chelsea, and Pimlico are supplied with Thames water from the Chelsea water-works; but as the same water is supplied to the Court and a great part of the aristocracy, the Company have large settling reservoirs and very expensive filters, by means of which, probably, the greater part of the cholera poison has been got rid of. The registrar's district of Brixton is situated on rising ground, the elevation of which varies from 12 to 140 feet above Trinity high-water mark, giving an average elevation at least equal to that part of London situated on the north of the Thames; and it is inhabited very much by people in comfortable circumstances, occupying wide and open streets, and scattered rows of houses, or even detached villas; yet in looking over the reports, I find eighty-three deaths from cholera since May last. The population in 1841 was 10,175; this would yield 81 deaths in the 10,000, or twice as many as have occurred on the north of the Thames; but the population of Brixton has probably increased since 1841, by the building of new houses, more than in London generally. Still there can be no doubt that the mortality there from cholera has been much higher than in many of the worst parts to the north of the river; and the reason is not far to seek, for the greater part of the Brixton district is supplied by the Lambeth water-works with water obtained from the Thames near the Hungerford Suspension Bridge.

I will now proceed to narrate some circumstances that have occurred in the provinces. The drainage from the cesspools found its way into the well attached to some houses at Locksbrook, near Bath, and the cholera making its appearance there this present autumn became very fatal. The people complained of the water to the gentleman belonging to the property, who lived at Weston, in Bath, and he sent a surveyor, who reported that nothing was the matter. The tenants still complaining, the owner went himself, and on looking at the water and smelling it, he said that he could perceive nothing the matter with it. He was asked if he would taste it, and he drank a glass of it. This occurred on a Wednesday; he went home, was taken ill with the cholera, and died on the Saturday following, there being no cholera in his own neighbourhood at the time.

When the cholera made its appearance at York, about the middle of July last, it was at first chiefly prevalent in some narrow streets near the river, called the Water Lanes. The inhabitants of this spot had been in the habit from time immemorial of fetching their water from the river at a place near which one of the chief sewers of the town empties itself; and recently a public necessity had been built, the contents of which were washed every morning into the river just above the spot at which they got the water. In a short time from twenty to thirty deaths occurred in this locality; but the medical men considering the impure water injurious, the people were supplied from the water-works, with water obtained from the river at a point some distance above the town, and the cholera soon almost ceased in this part of the city, but continued to spread in some other parts. The cholera having thus abated in the Water Lanes, the gratuitous supply or water was cut off, and the people went to the river as before. There were still cases of cholera in the town, and it soon broke out again in this locality, and in the first few days of September eight deaths occurred among the persons who used water obtained direct from the river. The tap for general use was again opened, and the river water interdicted, and the cholera again ceased, and has not recurred. These circumstances were communicated to me by a friend on whose accuracy I can rely, and an extract from his notes on the subject afterwards appeared in the Yorkshireman Newspaper.

The first cases of cholera in Exeter, in 1832, were three in the same day besides one in St. Thomas's, a suburb of Exeter, in a gentleman just arrived from London, where the disease was prevailing. The other three were a woman and her two children; the former, with one of her children, had [750/751] returned from Plymouth the previous day where she had been nursing a child that had died of the cholera. Within five days from this time, there were seven fresh cases in is many different parts of the town, amongst persons having no intercourse with each other or the first cases. The disease soon became very prevalent, and in three months there were 1,135 cases, and 345 deaths. Exeter is situated on ground which rises from the edge of the river to an elevation of 150 feet. In 1832 the inhabitants were chiefly supplied with river water by water-carriers, who conveyed it in carts and pails. Dr. Shapter, from whose work the above particulars are obtained, has kindly furnished me with information concerning the sewers, and maps of their position. The water-carriers, by whom Exeter was very greatly supplied, obtained their water almost exclusively from certain streams of water, diverted from the river in order to turn watermills; and one of the chief sewers of the town, which receives such sewage as might come from North Street, in which the first cases of cholera occurred, empties itself into the branch from the river which divides into the two mill-streams just mentioned. It must be remarked that the parish of St. Edmund, in which these streams of water were situated, had a lower mortality from cholera than other parts of the town like it densely populated and on low ground near the river. Dr. Shapter attributes this lower rate of mortality, and I believe rightly, to St. Edmund's being freely intersected by running streams of water. The people would probably not drink more of the water than in parts of the town where it was less plentiful, and had to be paid for, but they would have much better opportunities for personal cleanliness: so that whilst they would be exposed to only the same number of scattered cases, they would be less likely to have the malady spreading through families, and by personal intercourse. After the cholera of 1832 measures were taken to afford a better supply of water to Exeter; not, so far as I can find by Dr. Shapter's work, that its impurity was complained of, but because of its scarcity and cost. Water-works were established on the river Exe, two miles above the town, and more than two miles above the influence of the tide. Exeter is now very plentifully supplied with this water, and Dr. Shapter has informed me that this year there have only been about twenty cases of cholera, nearly half of which have occurred in strangers coming into the town, and dying within two or three days after their arrival.

We will now consider the town of Hull, in which, together with other sanitary measures adopted since 1832, there has been a new and more plentiful supply of water, but with a different result to that at Exeter. In 1832 Hull was scantily supplied with water conveyed in pipes from springs at Anlaby, three miles from the town. About five years ago new water-works were established to afford a more plentiful supply. These works are situated on the river Hull, at Stoneferry, two miles and three quarters from the confluence of that river with the Humber. About half the sewage of the town is delivered into the river of the same name, the rest being discharged into the Humber, as appears from information and a map kindly furnished me by Dr. Horner, of Hull, who has been making great efforts to have better water obtained for the town. The tide flows up the river many miles past the water-works, carrying up with it the filth from the sewers. The supply of water is, to be sure, obtained when the tide is down, but as the banks of the river are clothed with sedges in many parts, and its bottom deep with mud, the water can never be free from sewage. Moreover, there are some parts of the river above Stoneferry much deeper than the rest, and where the deeper water is, according to the testimony of boatmen, nearly stagnant; thus allowing the water carried up by the tide to remain and gradually mix with that afterwards flowing down. There are also boats, with families on board, pressing up the river to the extent of 5,000 voyages in the year. The water when taken from the river is allowed to settle in the reservoir for twenty-four hours, and is then said to be filtered before being sent to the town. In 1832 the cholera was confined almost exclusively to the poor, and the deaths amounted to 300.

This year, according to what I have gathered from the weekly reports, they [751/752] have been six times as numerous. Dr. Horner informs me that they have occurred amongst all classes of the community; that he thinks one in every thirty-three of the population has been carried off although 8,000 or 10,000 are said to have left the town to escape the ravages of the pestilence. All this has happened notwithstanding that the town is much better drained now than in 1832, and the drains in Hull proper are flushed frequently with water from the Docks.

[Part 2 appeared in the 30 November issue.]

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