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"On the pathology and mode of communication of cholera"

London Medical Gazette
(30 November 1849): 923-29
Part 2.

Communication of Cholera through the water at Dumfries--at Newburn-on-the-Tyne--at Bilston--Exemption of Birmingham and other towns from cholera--Propagation of cholera by means of water in India--The materies morbi probably sometimes destroyed by the digestive powers--Proof of communication of cholera derived from the period of its duration--Its decline explained--Measures for preventing the propagation of cholera by means of either food or water.

The former part of this paper concluded with the instances of Exeter and Hull, in both of which towns there had been, amongst other sanitary measures, a new and increased supply of water between 1832 and the present year; and in connection with this change was an immense difference in the prevalence of cholera for the better or the worse, according as the evacuations or the patients were shut out from, or admitted to, the water. In the next town I have to mention the drinking-water has remained the same and the two epidemics have been almost equally fatal.

The inhabitants of Dumfries drink the water of the river Nith, which flows through the town, and into which the sewers discharge their contents, which float afterwards to and fro with the tide. In 1832 there were 418 deaths from cholera out of a population of 11,606, being at the rate of 360 in 10,000, or 1 in every 28 of the inhabitants. The present epidemic visited Dumfries at the close of last year, and carried off 431 persons, or 1 in every 32, out of a population now numbering 14,000; so that the mortality his been excessive on both occasions.

There is no spot in this country in which the cholera was more fatal during the epidemic of 1832 than the village of Newburn, near Newcastle-upon-Tyne. We are informed, in an excellent paper on the subject by Dr. David Craigie,* that exactly one-tenth of the population died. (*Edin. Med. and Sur. Jour., vol. xxxvii) The number of the inhabitants was 550; of these, 320 suffered from the epidemic, either in the form of diarrhœa or the more confirmed disease, and the deaths amounted to 55. Being aware of this mortality, I wrote, about the beginning of the present year, to a friend in Newcastle--Dr Embleton--to make inquiries respecting the water used at Newburn, and he kindly procured me some information from the Rev. John Reed, of Newburn Vicarage, which I received in February, as well as an answer from Mr. Davison, surgeon, of Newburn, to whom I had written in the meantime. I learnt from these communications that the people were supplied with water in 1832, as at present, from three wells, two of which were very little used, and that the water in the third well is derived from the workings of an old coal mine near the village. The water of this well, as I was informed, although generally good when first drawn, becomes putrid after being kept two days. It was considered that the evacuations of the people could not get into any of the wells; but the vicar thought that the water of a little brook which runs past the village, and falls into the Tyne immediately afterwards, might find its way into that well which is chiefly resorted to. Putrefaction, on being kept a day or two, is so much the character of water containing animal matter, that after receiving confirmation of my views respecting the communication of cholera by water from many other places, I recently wrote to Mr. Davison again on the subject, and he has kindly taken a great deal of trouble to investigate the matter further. He informs me that the brook is principally formed by water which is constantly pumped from coal pits in the neighbourhood. About half a mile before reaching Newburn it receives the refuse of a small village, and between that village and Newburn it runs through a privy used by the workmen of a steel factory. In Newburn this brook receives the contents of the open drains or gutters from the houses. The drain which conveys water from [923/924] a coal mine or drift not worked for a great number of years, to the well mentioned above, passes underneath the brook at one part of its course, and from that point runs alongside of the brook to the well, a distance of about 300 yards. Mr. Davison says that it is disputed whether there is any communication between the drain and the brook, but that it is highly probable that there may be, and that an occurrence which took place a few months ago seems to prove that there is. Some gas-water from the steel manufactory mentioned above got by accident into the brook, and some of the people affirm that the water in the well was strongly impregnated with it.

The first case of cholera in Newburn was that of a young man living close to the brook, about 100 yards above the place at which it passes the well. He was taken ill on the 29th December, 1831, and died, in the stage of consecutive fever, on Jan. 4th, 1832. There were some cases of diarrhœa in the village, but no new cases of cholera till the night of January the 9th, during which night and the following morning thirteen persons were taken ill. During the night of the 12th four persons were attacked; by the 15th there were fourteen new cases, and on this day the late vicar died--the Rev. John Edmonston. By the next day at noon there were it least fifty new cases. A few days after this the disease began to subside, and by the 2d of February had almost disappeared. As several days elapsed between the first case of cholera and the great outbreak, it is probable that the water in which the soiled linen must have been washed, and which would necessarily run into the brook, was the means of communicating the disease to the thirteen persons taken ill on the night between the 9th and 10th of January; unless, indeed, the intermediate cases of diarrhœa could transmit the disease. There have been a few cases of cholera at Newburn the present year, and five deaths, but I have not yet ascertained whether any of them occurred in houses the gutters from which enter the brook above the well; if so, probably some accidental circumstance has intervened to prevent a catastrophe like that which took place in the former epidemic.

The state of the water is often a means of the spread of cholera in mining districts, in addition to the more constant cause pointed out in the former part of this paper. In some places the mines divert the springs, and cause a great scarcity of water, thus limiting the means of personal cleanliness; in other places the people have to use water pumped out of the pits, which of course is liable to be contaminated by the fæces of the miners: this is the case to some extent in the neighbourhood of Bilston, in Staffordshire, as I learn from Dr. Ogier Ward, and also from the Health of Towns Report.* (*Appendix. Part 1, p. 35.)(1) In other districts, again, the ground is so saturated with the refuse of a large population congregated in spots which have neither sewers nor drainage of any kind, and often not even privies, that the impurities get into the wells. This is the state of Merthyr Tydvil, as we are informed by Sir H. T. de la Beche.* (*Ibid., p. 145.)

When the cholera was at Kendal in 1832, the only place in which it was particularly prevalent was a spot called Robinson's Yard, in which there were 20 cases and 6 deaths, out of a population of 96. "From the dunghill and privies" in this yard, "there is every reason to believe that moisture percolated the earth and vitiated the water in the well, as they were more elevated, and consequently the moisture, except by evaporation, could escape in no other direction. The water, moreover, seemed impure, and it was nauseous to the taste."‡ (‡Dr. Proudfoot on the Epidemic Cholera of Kendal, Edin. Med. and Surg. Journ., vol. xxxix, p. 79)

In a court, also, in Windsor, in which the cholera was lately prevailing, it was found that the contents of the drains had got into the well from which the people obtained their water.

There are several large and populous towns which nearly altogether escaped the cholera in 1832, and have had a like exemption from the epide-[924/925]mic that is now subsiding. There have been a few cases in these towns, it is true, and this makes the evidence to be derived from them more instructive; for as these cases were chiefly those of persons newly arrived from places where the disease was prevailing, and of a few individuals who were in close proximity with them after their arrival and illness, we learn that though the cholera was imported to these places and capable of affecting others, yet some means of communication necessary for its diffusion was wanting, or failed to operate. We shall find that in all these towns there was no connection between the sewers and drinking water by which the cholera could be propagated. Birmingham being a very large town, its freedom from cholera has attracted a great deal of attention, and not a few attempts have been made to solve what was thought to be a singularity, though, as we shall find, it is not really so. Birmingham possesses an advantage in point of salubrity in its elevated position, but Walsall, in the neighbourhood, which is as much elevated above the level of the sea, suffered rather severely from cholera both recently and in 1832; and Dowlais, in South Wales, at twice the elevation, was severely visited with cholera during the epidemic of 17 years ago. Birmingham is drained into the River Rea and its tributaries. "The state of the river Rea, which may be regarded as the cloaca or main sewer of the town, is very bad. The stream is sluggish, and the quantity of water which it supplies is not sufficient to dilute and wash away the refuse which it receives in its passage through the town. In hot weather it is consequently often very offensive, and in some situations it is at these seasons covered with a thick scum of decomposing matters."* (*Local Reports on the Sanitary Condition of the Labouring Population of England. 8vo. 1842, p. 194.) From this quotation it appears that if effluvia from sewers caused the prevalence of cholera, Birmingham ought not to have escaped. The state of the river may, indeed, have since been altered, but the description would, at all events, apply to 1832. There is one good property about the river which has escaped the observation of the reporters--viz., that the water is rendered too impure for any one to think of drinking it. The inhabitants are supplied with water from springs and wells, and by water-works, from the river Taine, which is quite uncontaminated by the sewers. In Birmingham, consequently, there is no opportunity for the communication of cholera through the water, and the activity of the local Board of Health, in paying attention to every case amongst the poor, has no doubt been the means of preventing the spread of the disease from one individual to another by contamination of the hands and the food.

Bath has enjoyed an almost total exemption from cholera both recently and in 1832, although Bristol has on both occasions suffered rather severely, and this year the epidemic has prevailed in some villages still nearer than Bristol. Bath is supplied with water conveyed in pipes from the hills surrounding the town, whilst the sewers empty themselves into the river Avon, from which but a very few of the poor people ever obtain water. Cheltenham has enjoyed a like immunity from cholera, with Bath, and the drinking-water there is quite free from connection with the sewers.

The above-mentioned three towns possess some physical advantages, in addition to the purity of the water, over some of the places in which cholera has been prevalent; but such is not the state of Leicester. It is situated in a low elevation, and entire quarters of the town are liable, after heavy rains, to be covered with offensive water from the overflowing of the open sewers and badly constructed drains; and it contains a large population of underfed operatives; yet there has been scarcely any cholera there either in 1832 or the present year. Leicester is supplied with water from springs and pumps, and partly by spring water conveyed in pipes; and the river which flows through the town and receives the sewage, is so much altered by the refuse of dye works, that the water is quite undrinkable.

Preston and Oldham, in Lancashire, are supplied with water from surface drainage on the neighbouring hills, and there has been scarcely any cholera at either of these places. The greater part of the town of Paisley is supplied in a similar way; and I am informed that the cases of cholera which have occurred there in the recent epidemic [925/926] were confined to a quarter of the town to which this supply of water does not extend. Nottingham is supplied with filtered water obtained from the river Trent, some distance above the town. In 1832 this supply did not extend to all the inhabitants, and the cholera was somewhat prevalent amongst the poor, of whom it carried off 289; the population of the town being 53,000. Since that time the water has been extended copiously to all the inhabitants, and there have been but six deaths from the epidemic in the present year. The local Sanitary Committee place the supply of water amongst the chief causes of this immunity from cholera,* and I believe justly. (*See Med. Gaz., p. 672.)

However injurious impure water must be to the health, there is no reason to suppose that it can assist in the spreading of cholera unless it contain the excretions of the patients. Stafford is an illustration of this. In that town, as I learn through the kindness of Dr. Harland, there is not a single sewer, and the liquid refuse from the houses runs down the channels on each side of the streets. It is common at the poorer houses to have holes dug in the ground to allow the waste and refuse water to run into. The town is built on a bed of sand, and water is everywhere found at 8 or 10 feet below the surface, and the whole of the inhabitants have pumps convenient to their dwellings. Dr. Harland, from whom I have these particulars, says he has no doubt that in many cases the refuse liquid must percolate through the sand and get into the pump water; and he has known some instances in which the filthy surface water was allowed to get into the wells. There has been scarcely a case of cholera at Stafford at any time, although the disease has been very prevalent it Bilston, and many other places in Staffordshire, both recently and seventeen years ago. As almost every house has its own well, it is evident that the water does not afford the means of disseminating the cholera in Stafford; but if the disease had been introduced to any extent by other means, the pollution of the wells would no doubt have rendered it more prevalent amongst the limited number of people using the water of such wells.

There are several towns in which the cholera has prevailed to a considerable extent, although the water cannot be blamed, so far as I have been able to learn. But under those circumstances it appears that the malady has been confined almost exclusively to the poor, and has spread chiefly by personal communication. So far as my inquiries have extended respecting the more considerable provincial towns, the results of them has been as follows:--In those towns supplied with water from a river where it contains the sewage of the town, the disease on making its appearance has become very prevalent. All those towns that have enjoyed a comparative immunity from cholera are supplied with water that is uncontaminated; and lastly, the cholera has prevailed to a considerable extent in some towns in which the water can have had no share in the extension of it. The profession may expect to receive a considerable amount of information on this subject shortly, from the replies that will be made to the questions lately issued by the cholera Committee of the College of Physicians.

As we are never informed in works on cholera what water the people drink, I have scarcely been able to collect any information on this point, respecting foreign countries. There are, however, one or two circumstances that I may mention. In 1831, when the cholera had extended itself across Poland, the Hungarians placed a strong cordon of military posts to guard all the passes and defiles of the Carpathian mountains. The epidemic, however, soon showed itself on the south-west side of the chain of mountains; it first appeared in the town of Eperies, situated on one of the streams issuing from the Carpathian mountains, and two days afterwards it appeared at Tockay, a town situated about 70 miles farther south at the junction of this stream, named the Bodrod, with the Theiss.* (*Dr. Craigie in Edin. Med. and Surg. Journ., Supplement, Feb. 1832, p. 150.)

Dr. Parkes informs us in his valuable work on cholera, that in the epidemic at Moulmein, in 1842-3, this disease was confined for many months almost entirely to the houses situated on or over the river; and that "one side of the main street runs close to the river, and the great majority of [926/927] cases occurred on this side; comparatively few on the other." Dr. Parkes has informed me that he has no doubt that the people living near the river drank the water obtained from it; and the river of course received the refuse of the houses near to it. The circumstances detailed in the following passage from the same page (161) of his work, seem to illustrate very well the communication of cholera through the drinking-water, and are at all events better explained by this view of their cause than any other. "The only Europeans attacked at the commencement of the epidemic were the sailors belonging to the ships in the river: the ships nearest the shore suffered most. Thus nine cases occurred on board H. M. brig Britomarte, lying close in shore; she was moved about a mile away, into the centre of the river, and no more cases occurred. Three cases occurred on board H. M. brig Syren, also lying in shore: she was also moved into the centre of the river, and the cholera immediately ceased. The 63d regiment sailed in September and October, 1842, for Madras. One transport being accidentally detained three days in the river, had fourteen cases of cholera during the voyage; the other transports, four in number, got to sea at once, and had no cholera. A few cases occurred during this time among the Europeans on shore, but these consisted only of those who lived close to the river."

On some occasions in India the cholera has increased in prevalence with such rapidity that it has been thought that contagion would not account for the immense number of new cases: if, however, any of the discharges from the patients accidentally found admission to a limited source of water, we can perceive how that circumstance might account for these sudden outbreaks of the malady, in a warm climate where the drinking of water must be frequent and universal. Whether they have been really due to this cause can only be determined by persons resident in the country.

Many medical men to whom the above circumstances respecting the water have been mentioned, admit the influence of the water, without admitting the special effect of the new element introduced into it--viz., the cholera evacuations in communicating, the disease. They look upon the bad water as only a predisposing cause, making the disease more prevalent amongst those who use it--a view which, in a hygienic sense, is calculated to be to some extent as useful as the admission of what I believe to be the real truth, but which, I think, will be found to be untenable, when the circumstances are closely examined. If the bad water merely predisposed persons to be acted on by some occult cause of cholera to which it is supposed that all are exposed, those using such water ought to become more subject to the disease from the time it enters a town or neighbourhood; instead of which it has been shown in many of the above instances that no particular effect was observed amongst those using the water, until by the occurrence of a case or two of cholera, the evacuations entered the water, when, after a short period of incubation, there were several persons attacked nearly together.

The above evidence of the communication of cholera through drinking-water, confirms the view of the disease being propagated by the swallowing of the materies morbi in the cases resulting from personal intercourse; for if the evacuations can produce the disease when largely diluted, à fortiori must they be capable of causing it when undiluted.

The only circumstance of which I am aware that offers any material opposition to the views on the communication of cholera here explained, is that two or three members of a medical commission in Berlin, in 1831, are related to have swallowed a portion of the cholera evacuations experimentally. The reply that must be made to this is that the stomach has most likely the power of sometimes destroying the poison. There are many reasons for concluding that this is the case. Persons are more liable to the disease in proportion as they advance in age, as is shown by comparing the attacks at different ages with the numbers living of those ages,* and as people advance in life the powers of digestion diminish.(*See Dr. Budd's Lecture, Med. Times, Oct. 20, p. 315.) Whatever has a tendency to produce indigestion, increases the liability to an attack; as fear, anxiety and excesses in eating or drinking. To that part of [927/928] the subject which refers to the communication of cholera through the water of a river, two objections naturally arise--1st, that the large dilution might be expected to render the poison innocuous; and 2d, that the whole, or nearly so, of the people using the water ought to be affected by it. One answer applies to both the objections: it is, that a poison capable of multiplying in the body must, one would conclude, be organized, and therefore consist of particles, however minute, any one of which happening to reach its suitable habitation without being destroyed, might induce the diseases. Or if the poison be really a chemical compound, capable of complete solution without losing its properties, it might yet be imbibed by minute cells, such as mucous globules or epithelial cells,* and be thus conveyed without being much diluted.(*I am indebted for the idea of epithelium cells conveying the poison, to Dr. Lankester, who indeed thought that I had suggested it.)

It has been asked how these views explain the cessation or decline of the disease; and whilst it must be at once admitted that we cannot actually tell why the cholera begins to decline in a place just when it does, it will appear on sufficient examination that the period of prevalence and declension of the malady are such as afford strong evidence of its communication--evidence even of this being its sole cause. The duration of cholera in a place is usually in a direct proportion to the number of the population. The disease remains but two or three weeks in a village, two or three months in a good-sized town, but in a great metropolis it often remains a whole year or longer. I find from an analysis of the valuable table of Dr. Wm. Merriman, of the cholera in England in 1832,* that 52 places are enumerated in which the disease continued less than 50 days, and that the average population of these places is 6,624. 43 places are likewise down in which the cholera lasted 50 days, but less than 100; the average population of these is 12,624. And there are, without including London, 33 places in which the epidemic continued 100 days and upwards, the average population of which 38,123; or if London be included, 34 places, with an average of 78,823.(*Trans. of Roy. Med. and Chir. Soc., 1844. The following short table will show these figures in a more convenient form:--

No. of Places Duration of Days Average Population
52 0 to 50 6,624
43 50 to 100 12,624
33 or 34 100 and upwards 38,123 or 78,823

This difference in the duration of cholera points clearly to its propagation from patient to patient. If each case were not connected with a previous one, but depended on some unknown atmospheric or telluric state, why should not the twenty cases that happen in a village be distributed over as long a period as the twenty hundred cases which occur in a large town? The views propounded in this paper offer a more ready explanation of the decline of the disease for want of fresh victims, than the usual theory of contagion or infection; for all the members of the community are not liable to be reached by a poison which must be swallowed, as they would be by one in the form of an effluvium.

The recognized physical conditions of the season do undoubtedly influence cholera. Although it can flourish in every temperature, warm weather is usually most congenial to its progress. In September last the number of cases began to decrease both in London and many parts of the provinces immediately after a considerable diminution in the temperature of the weather. This circumstance, however, is quite compatible with almost every theory of the cause of cholera. It certainly does not oppose the view of the communication of the disease; for whilst temperature modifies the habits as well as the constitution of man, it might also be expected materially to influence the cholera poison, when it has to remain any time out of the body between quitting one patient and entering another, for the lower forms of organisms to which the special animal poisons bear a marked analogy, are greatly influenced by heat and cold.

The fact of cholera having spread from India over the greater part of the world, and then having retired within its former bounds to extend again after a number of years, is thought by many to have no kind of analogy amongst the more familiar diseases; but it is only a more marked instance of what occurs constantly on a smaller scale, [928/929] in all diseases in which each case owes its origin to a previous one. It is only in a great metropolis that the eruptive fevers are all constantly present; in a village or small town they each disappear, and remain absent for a longer or shorter period either till they be re-introduced from some distant place, or by poison accidentally preserved. Small islands often remain free from some of these diseases for very long periods at a time.

Assuming the views here entertained to be correct, it is not to be expected that we should be able to trace the communication of every case of cholera. The very nature of the mode of propagation of disease above explained must render it obscure and difficult of detection. And the difficulty is probably increased by the poison being conveyed by persons in whom the disease proceeds no further than diarrhœa. The communication of intestinal worms from one patient to another has never been detected, and yet we are obliged to conclude that their minute ova are swallowed, unless we not only adopt the hypothesis of spontaneous generation, but apply it to creatures much higher in the scale of development than do the usual advocates of the doctrine. If there really be such a disease as Asiatic cholera, distinct from the ordinary English cholera which prevails in autumn, with which it is confounded by the Registrar-General, who says that the deaths from cholera are now approaching the average,--a disease imported from Hamburgh after being absent fifteen years, and evidently spreading by communication in very numerous instances; we ought not to conclude that part of the cases must depend on some other occult cause, but rather, first to examine the one sufficient cause we have found, to ascertain whether it will not explain more and more of the facts the further they are inquired into; and to search whether the localities which are favourable to cholera do not promote it through physical conditions which favour its communication.

In concluding this paper it is necessary to point out the measures which, according to the opinions and evidence above detailed, might be expected to prevent the communication, and thus stay the ravages of cholera. They are fortunately of a kind that would not interfere with commercial intercourse, and which medical men would probably be willing to make trial of, whether they do or do not entirely concur in the absolute necessity of them. The most scrupulous attention to cleanliness should be inculcated on those waiting on the sick who ought especially to be careful to wash their hands before touching food. When cholera shews itself in a family having but one room, the patient should either be removed, or the other members of the family, except those required as nurses, should be provided with an asylum elsewhere, especially for cooking and eating their meals. As the evacuations might fly about as a fine dust whenever linen should be disturbed on which they had been allowed to become dry, it is desirable that the soiled linen and blankets should be immersed in water as soon as removed, and afterwards exposed to a boiling heat. The fruit that is hawked about the streets is kept at night in the rooms (and generally under the bed, if there be a bedstead) in which a crowd of people sleep, and in those courts and alleys into which contagious diseases are often first introduced by vagrants: hence people should be dissuaded from buying such fruit. When the cholera makes its appearance in a mining district it would be advisable that the men should work during two "shifts" in the twenty-four hours, of four hours each, instead of one "shift" of eight hours; and should be dissuaded from taking food to their work, and recommended to wash themselves on going home, as I believe they usually do. And, lastly, whilst cholera remains in the country, people should avoid using water which receives the contents of drains or sewers, or the refuse of persons navigating the water. Since anything touched by the hands may enter the mouth, it would be desirable to avoid even washing with such water; and all events, when no other water can be obtained, so much of it as is used for drinking and culinary purposes should be filtered and well-boiled.

I take the opportunity of expressing the obligation I am under to several medical gentlemen, to some of whom I was previously unknown, for the trouble they have kindly taken in answering my enquiries.

1. Since the above was written I have received, through the Rev. J. Win. Owen, a note from Mr. Wm. M. Hancox, surgeon of Bilston, from which I likewise learn that the cholera first made its appearance there this year in a street parallel with the course of a brook which receives the refuse of the whole town; and that "in a small square of buildings consisting of about ten houses, ten persons died of the disease. Most of the inhabitants of this range of houses were in the habit of using water that filtered itself into wells from this stream."


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