Extracts from

ON THE MODE OF COMMUNICATIONOF CHOLERA.

(Pamphlet, August/September 1849)_____

It is not the intention of the writer to go overthe much debated question of the contagionof cholera. An examination of the history ofthat malady, from its first appearance, or atleast recognition, in India in 1817, hasconvinced him, in common with a greatportion of the medical profession, that it ispropagated by human intercourse. Itsprogress along the great channels of thatintercourse, and the very numerous instances,both in this country and abroad, in whichcholera dates its commencement in a town orvillage previously free from it to the arrivaland illness of a person coming from a place inwhich the disease was prevalent, seem toleave no room for doubting itscommunicability.

Extracts from

ON THE PATHOLOGY AND MODE OFCOMMUNICATION OF CHOLERA.

London Medical Gazette 44 (1849): 745-52,923-29)

If there really be such a disease as Asiaticcholera, distinct from the ordinary Englishcholera which prevails in autumn, with whichit is confounded by the Registrar-General, . . .

On examining the history of cholera, onefeature immediately strikes the inquirer –viz.the evidence of its communication by humanintercourse. In its progress from place toplace it has nearly always followed the greatchannels of human intercourse. In spreadingalong the highways in India, it often sparedthe villages that were situated at a littledistance from the main road, on either side. When a body of troops were attacked with iton their march, it often remained with themthrough countries having a very differentclimate and physical character from that inwhich they contacted the malady; and theyoften communicated it to towns and villagespreviously free from it. In extending itself to afresh island or continent, the cholera hasalways made its appearance first at a sea-port,and not till ships had arrived from someinfected place. Crews of ships approaching acountry in which the disease was prevailing,have never been attacked until they have hadcommunication with the shore. The cholera,moreover, in progressing from one place toanother, has never travelled faster than themeans of human transit, and usually muchslower. Such are the general considerations

ON THE MODE OF PROPAGATION OFCHOLERA.

Medical Times 3 (29 November 1851): 559-62.

Although the more severe cases of commonEnglish cholera cannot always bedistinguished from the malady called Asiaticcholera, yet hardly any one doubts the distinctnature of these diseases, or that the latter wasa stranger to Europe prior to the year 1830. Acareful consideration of Asiatic cholerashows clearly enough that it is propagatedby human intercourse. It has proceeded invarious directions along the great channels ofintercommunication, never progressing fasterthan people travel, and generally much moreslowly. In attending to an island or a freshcontinent, it always makes its first appearanceat a seaport, and it never attacks the crew of aship from a healthy port that is approachingan infected country, till their actual arrival.Many instances have occurred in whichquarantine or cordons sanitaires haveprotected places from the cholera, eitheraltogether, or for a time; and the mostconclusive part of the evidence, is the numberof instances in which the malady has beenintroduced into healthy localities by personswho have been taken ill after their arrivalfrom places where cholera prevailed.

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which show that cholera is communicated byhuman intercourse; and there are besidesinstances so numerous of persons beingattacked with the disease within a day or twoafter immediate proximity to the sick, that itseems impossible to attribute the circumstanceto mere coincidence.

The duration of cholera in a place is usually ina direct proportion to the number of thepopulation. The disease remains but two orthree weeks in a village, two or three monthsin a good-sized town, but in a great metropolisit often remains a whole year or longer. I findfrom an analysis of the valuable table of Dr.Wm. Merriman, of the cholera in England in1832,*

(*Trans. of Roy. Med. and Chir. Soc.1844.)

that 52 places are enumerated in which thedisease continued less than 50 days, and thatthe average population of these places is6,624. 43 places are likewise down in which

Dr. Bryson related several instances of thiskind in the paper that he read before thisSociety, and a number more might be nowrelated did the time permit: indeed, the casesin which the progress of cholera can be tracedin this manner are the rule rather than theexception, and are, at all events far toonumerous to be set down as merecoincidences. It may be remarked, also, thatcoincidences of this sort are not found toobtain in rheumatism, ague, or indeed in anybut epidemic diseases, the whole of which Ilook upon as communicable from one patientto another, this communication beingprobably the real feature of distinctionbetween epidemic and other diseases.

Another circumstance stronglyconfirmatory of the communication ofcholera, is the direct relation which existsbetween the number of the population and theduration of the disease in different towns andvillages. The accompanying figures werecompiled by me from Dr. W. Merriman’svaluable table of cholera in England in 1832 :-- (b)

(b) Transactions of Royal Medicaland Chirurgical Society, 1849 [?? –date is illegible on copy][559a/559b]

Number Duration in Averageof Places. Days. Population. 52 0 to 50 6,624

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It is quite true that a great deal of argumenthas been employed on the opposite side, and

the cholera lasted 50 days, but less than 100;the average population of these is 12,624. And these are, without including London, 33places in which the epidemic continued 100days and upwards, the average population ofwhich 123; or if London be included, 34places, with an average of 78,823. Thefollowing short table will show these figuresin a more convenient form: –

No. of Duration in AveragePlaces. days. population

.52 0 to 50 6,624

43 50 to 100 12,624

33 100 and 38,123or upwards or34 78,823

This difference in the duration ofcholera points clearly to its propagation frompatient to patient. If each case were notconnected with a previous one, but dependedon some unknown atmospheric or telluricstate, why should not the twenty cases thathappen in a village be distributed over as longa period as the twenty hundred cases whichoccur in a large town? The views propoundedin this paper offer a more ready explanation ofthe decline of the disease for want of freshvictims, than the usual theory of contagion orinfection; for all the members of thecommunity are not liable to be reached by apoison which must be swallowed, as theywould be by one in the form of an effluvium.

43 50 to 100 12,624

33 100 and 38,123oror 34 upwards 78,823

It will be seen, that 52 places areenumerated in which the cholera continuedless than 50 days, and that the averagepopulation of these places was 6,624; thatthere are 43 places specified in which thedisease lasted 50 days, but less than 100, theaverage population of these places beingnearly twice as great as that of the former;while in the remaining 34 towns, in which thecholera continued for 100 days and upwards,the average population was very much greaterstill, being 38,000 or 78,000, according asLondon is omitted from or included in thelist. I believe that the same rule has obtainedduring the recent epidemic, but I have noprecise information on the point. It is hardlynecessary to remark, that if the cholera caseswere not connected one with another, therewould be no reason why the few cases whichhappen in a village should not be scatteredover as long a period as the thousands whichoccur in a great metropolis.

I shall perhaps be thought singular inasserting, that there is no evidence opposed tothe propagation of cholera by itscommunication from individual to individual,or in favour of any other origin of the disease.

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that many eminent men hold an oppositeopinion; but, besides the objection thatnegative evidence ought not to overthrow thatof a positive kind, . . .

the instances that are believed to oppose theproofs of communication are reasoned uponin the opinion that cholera, if conveyed byhuman intercourse, must be contagious in thesame way that the eruptive fevers areconsidered to be, viz., by emanations from thesick person into the surrounding air, whichenter the system of others by being inhaled,and absorbed by the blood passing throughthe lungs. There is, however, no reason toconclude à priori, that this must be the modeof communication of cholera; and it must beconfessed that it is difficult to imagine thatthere can be such a difference in thepredisposition to be affected or not by aninhaled poison, as would enable a greatnumber to breathe it without injury in a prettyconcentrated form (the immunity not havingbeen earned by a previous attack, as in thecase of measles, &c.), whilst others should bekilled by it when millions of times diluted.The difficulties that beset this view are of thesame kind, but not so great, as those whichsurround the hypothesis of a cholera poisongenerally diffused in the air, and notemanating from the sick.

On the other hand, there are a number of factswhich have been thought to oppose thisevidence: numerous persons hold intercoursewithout becoming affected, and a greatnumber take the disease who have had noapparent connection with other patient. Thesefacts, however, have always been examinedwith the conviction that cholera, ifcommunicable, must be contagious in thesame way that the eruptive fevers are believedto be –viz. by effluvia given off from thepatient into the surrounding air, and acting onother persons either directly or through themedium of fomites.

The chief facts which are believed to beopposed to the extension of cholera bycommunication are the following: That manypersons are placed in close relation with thesick, nurse them, and wait upon them, andsometimes even sleep in the same bed,without becoming infected with the malady;that quarantine and cordons sanitaires oftenfail to arrest its progress; and that persons areoften attacked with it who have had nointercourse with the sick or their friends.

These facts are thought to beopposed to the communication of cholera,because it is assumed, that this disease, to becommunicated, must extend itself, as theeruptive fevers are believed to do, by meansof some emanation given off from the patientinto the air; or, if not in that way, then bycontact with the patient, or articles ofclothing, etc., which have been near him. But,without assuming such hypotheses, thecircumstances above mentioned would not inany way oppose the evidence of thecommunication of cholera. Nearly every oneof these facts is equally true of syphilis as ofcholera. Persons nurse and wait on syphiliticpatients and might even sleep in the same bedwith them without contracting the malady;and it is very doubtful, whether quarantineregulations, however strict, would prevent itscommunication, as they would be evaded.These circumstances are not considered tointerfere with the proofs of thecontagiousness of syphilis, only because wehappen to know the way in which it iscommunicated and when we shall knowequally well the way in which cholera iscommunicated, I do not doubt that we shallfind them equally in applicable to thatdisease.

A consideration of the pathology ofcholera is capable of indicating to us the

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Reasoning by analogy from what is known ofother diseases, we ought not to conclude thatcholera is propagated by an effluvium. In allknown diseases in which the blood ispoisoned in the first instance, generalsymptoms, such as rigors, headaches, andquickened pulse, precede the local symptoms;but it has always appeared, from what thewriter could observe, that in cholera thealimentary canal is first affected, and that allthe symptoms not referable to that part areconsecutive, and apparently the result of thelocal affection. In those cases in whichvertigo, lassitude, and depression precede theevacuations from the bowels, there is noreason to doubt that exudation of the waterypart of the blood, which is soon copiouslydischarged, is already taking place from themucous membrane; whilst in the cases inwhich the purging comes on more gradually,there is often so little feeling of illness thatthe patient cannot persuade himself that hehas the cholera, or apply for remedies untilthe disease is far advanced,--this being acircumstance which increases the mortality.The quantity of fluid lost by purging andvomiting, taking into consideration theprevious state of the patient, the suddennessof the attack, and the circumstance that theloss is not replaced by absorption, has seemedsufficient, in all the cases witnessed by thewriter, to account, by the change it mustoccasion in the quantity and composition ofthe blood,* for the collapse, difficulty ofbreathing, and, in short for all the symptoms,without assuming that the blood is poisoned,until it become so by the retention of matterswhich ought to pass off through the kidneys,the functions of which are, however,suspended by the thickened state of the blood,which will scarcely allow it to pass throughthe capillaries.

In those diseases in which there is reason toconclude that a morbid poison has enteredthe blood, there are symptoms of generalillness, usually of a febrile character, beforeany local affection manifests itself; but so faras I have been able to observe or to learn fromcarefully recorded cases, it is not so incholera. On the contrary, the disease beginswith the affection of the bowels, which oftenproceeds with so little feeling of generalillness, that the patient does not considerhimself in danger, or apply for advice till themalady is far advanced. It is true that, in afew cases, there are dizziness and faintnessbefore discharges from the bowels actuallytake place, but there can be no doubt thatthese symptoms depend on the exudation fromthe mucous membrane, which is soonafterwards copiously evacuated. With respectto certain rare cases of cholera, withoutpurging, Dr. Watson has remarked in hisLectures, that when the bodies of suchpatients have been opened, the characteristicfluid was found in the bowels. Anotherreason for looking on cholera as a localdisease is, that the affection of the stomachand bowels is sufficient to explain all thegeneral symptoms. The evacuations, in thecases I have witnessed, have always appearedsufficient to account for the collapse, when thesuddenness of the attack is considered, and thecircumstance that absorption is probablysuspended. The thickened state of the bloodarising from the loss of fluid accounts for thesymptoms of asphyxia, by the obstruction itmust occasion in the pulmonary circulation. The recent analyses of the blood of cholerapatients, by Dr. Garrod, afford the strongestconfirmation of this view; for he found it tocontain a much greater amount of solidmaterials in proportion to the water, than inhealth or other diseases. If there has been

manner in which the disease iscommunicated. If it were ushered in by feveror any other general constitutional disorder,then we should be furnished with no clue tothe way in which the morbid poison entersthe system; but if it commences by a localaffection of any particular part, and thesystem at large only suffers in consequence ofthe local affection, then it is pretty evident,that the material cause of the disease musthave been applied to the part first affected.From all that I have been able to learn ofcholera, either by my own observation or thatof others, it has appeared, that the illnessalways commences with the affection of thealimentary canal; and in all the cases that Ihave seen, the loss of fluid from the stomachand bowels has been sufficient to account forthe collapse, when the previous condition ofthe patient was taken into account, togetherwith the suddenness of the loss, and thecircumstance that the process of absorptionappears to be suspended. Certain fatal casesof cholera without evacuations have occurred;but, whenever there has been an examination,of the body in such cases, the excretionspeculiar to cholera have been found in thebowels. It appears, indeed, that the cholerapoison never enters the circulation, and thatthe blood does not become contaminated inthis disease, except when congestion of thekidneys follows as a secondary affection. Theirritation of the bowels accounts for thecramps; and the loss of the water and salineconstituents of the blood is the cause of thecollapse and the symptoms of [559b/560a]asphyxia. The careful analyses of the bloodby Dr. Garrod have confirmed the fact, thatits solid constituents are relatively muchincreased by the loss of water. On thisaccount, it becomes so thick that it circulateswith difficulty through the capillaries of the

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*The valuable analyses of Dr.Garrod have recently fullyconfirmed what had been stated inthe former visitation of Europe bythe cholera, viz., that the solidcontents of the blood of patientslabouring under this disease aregreatly increased in proportion to thewater–a state of the blood that is notmet wit in any other malady.

It is generally assumed that theblood becomes so altered by the cholerapoison, that its watery and saline parts beginto exude by the mucous membrane of thealimentary canal; but it is more consonantwith experience, both therapeutical andpathological, to attribute the exudation tosome local irritant of the mucous membrane;no instance suggesting itself to the writer inwhich a poison in the blood causes irritationof, and exudation from, a single surface, as incholera; for the sweating, as the patientapproaches to collapse, is only what takesplace in other cases from loss of blood,during fainting, and in any state in which theforce of circulation is greatly reduced.

more purging in some of the less severe casesthan in the rapidly fatal ones, it only showsthat, in the former, absorption has been stillgoing on, or else that some of the fluids whichhave been swallowed have passed through thebowels. The drain of fluid into the alimentarycanal suspends the urinary secretion, eithertotally or in great part, and the kidneysbecome congested from the altered state of theblood: hence any little urine that is secreted isalbuminous; and if the kidneys do not soonrecover from the congestion, urea accumulatesin the blood in those cases in which the patientsurvives the stage of collapse. Although in agreat number of cases the symptoms ofcholera manifest themselves suddenly, and arenot amenable to any known treatment, yet inother cases the disease commences graduallywith diarrhoea, and in this stage there isevidence to show that it can usually be curedby the ordinary remedies for diarrhoea. Nowthis circumstance is a strong reason forconcluding, that the mischief in cholera is atfirst confined to the mucous membrane; for itis not easy to conceive that chalk, and opium,and catechu, could neutralize or suspend theaction of a poison in the blood. [745/746] Indeed, diseases caused by a morbid poison inthe blood, such as the cruptive fevers, cannotbe cut short, either by local or general means,but run a definite course.

lungs, while the diminished quantity of saltsrenders it still further unfitted to undergo theusual changes in respiration.

The injection of a weak saline solution intothe veins of cholera patients in the state ofcollapse has often been attended with themost surprising effects of a temporary nature,at once restoring the patent, who the minutebefore was nearly dead, to a state of apparenthealth and strength. It was justly remarked byDr. Budd, in a clinical lecture delivered atKing’s College Hospital, that, if the patient’ssymptoms depended on a poison circulatingin the blood, they could not be removed by

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Having rejected effluvia and thepoisoning of the blood in the first instance,and being led to the conclusion that thedisease is communicated by something thatacts directly on the alimentary canal, theexcretions of the sick at once suggestthemselves as containing some materialwhich, being accidentally swallowed, mightattach itself to the mucous membrane of thesmall intestines, and there multiply itself bythe appropriation of surrounding matter, invirtue of molecular changes going on withinit, or capable of going on, as soon as it isplaced in congenial circumstances. Such amode of communication of disease is notwithout precedent. The ova of the intestinalworms are undoubtedly introduced in thisway. . . .

That a portion of the ejections ordejections must often be swallowed byhealthy persons is, however, a matter ofnecessity. The latter even are voided withsuch suddeness and force that the clothes andbedding scarcely fail to become soiled, andbeing almost devoid of colour and odour, thepresence of the evacuations is not alwaysrecognized; hence they become attachedunobserved to the hands of the person nursingthe patient, and are unconsciously swallowed,unless care be taken to wash the hands beforepartaking of food: or if the person waiting onthe sick have to prepare food for the rest ofthe family, as often happens, the material ofcommunication here suggested has a widerfield in which to operate; and where the

In the meantime we have arrived attwo conclusions – first, that cholera is a localaffection of the alimentary canal; andsecondly, that it is communicated from oneperson to another. The induction from thesedata is that the disease must be caused bysomething which passes from the mucousmembrane of the alimentary canal of onepatient to that of the other, which it can onlydo by being swallowed; and as the diseasegrows in a community by what it feeds upon,attacking a few people in a town first, andthen becoming more prevalent, it is clear thatthe cholera poison must multiply itself by akind of growth, changing surroundingmaterials to its own nature like any othermorbid poison; this increase is the case of themateries morbi of cholera taking place in thealimentary canal.

The instances in which minutequantities of the ejections and dejections ofcholera patients must be swallowed aresufficiently numerous to account for thespread of the disease; and on examination it isfound to spread most where the facilities forthis mode of communication are greatest. Nothing has been found to favour theextension of cholera more than want ofpersonal cleanliness, whether arising fromhabit or scarcity of water, although thecircumstance hitherto remained unexplained. The bed linen nearly always becomes wettedby the cholera evacuations, and as these aredevoid of the usual colour and odour, thehands of persons waiting on the patientbecome soiled, and unless these persons arescrupulously cleanly in their habits, and wash

the injection of a simple saline solution. Thesaline solution merely restores the waterwhich has become deficient, and suppliessalts analogous to those which have been lost.

If the poison which communicatescholera from person to person does not enterthe blood, it is evident that it must multiplyitself on the surface of the alimentary canal,and must be contained in the evacuationsfrom the stomach and bowels. The proofs thatthe cholera poison is contained in thesedischarges and that the disease iscommunicated by their being accidentallyswallowed, are of a general as well as aparticular kind.

It has been constantly observed, thatthe want of personal cleanliness aided verymuch the propagation of cholera, although noexplanation could be given of thecircumstance; it is very evident, however, thatwithout habits of strict cleanliness personswaiting on the sick must get their handssoiled with the cholera discharges, and mustunknowingly contaminate the provisions theyhandle, in eating their own food or preparingthat of others. The sudden discharge of theevacuations, which often soil the clothing orbed linen, and the little colour or odour theypossess, very much increase the liability totheir being swallowed in this way, and under

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patient, or those waiting on him, are occupiedin the preparation or vending of provisions,the disease may be conveyed to a distance,and into quarters having apparently nocommunication with the sick.

All the observers who have recordedtheir opinions on the subject, agree inattributing a great influence to want ofpersonal cleanliness in increasing theprevalence and fatality of cholera. Dr.Lichtenstädt, in a work on Cholera publishedin 1831, states, “that at Berditscher, inVolhynia, a place of a few thousandinhabitants, no less than 900 were attacked inthirty-one days. Amongst 764 of these were658 Jews, and only 106 Christians althoughthe Jewish population is far from beingproportionally so great; and among theChristians the deaths were 61.3 per cent.,while among the Jews they were 90.7 percent. The only reason assigned by the reporterfor these extraordinary differences is theexcessive disregard of cleanliness among theJewish inhabitants.”*

*Edin. Med. And Surg. Journal, vol.xxxvii.

The first appearance of cholera in many of thetowns of this country in 1832 was in thecourts and alleys to which vagrants resort fora night’s lodging, where it often lingered forsome time before spreading to the morecleanly part of the people.

their hands upon taking food, they mustaccidentally swallow some of the excretion,and leave some on the food they handle orprepare, which has to be eaten by the rest ofthe family, who amongst the working classesoften arrive to take their meals in the sick[746/747] room: hence the thousands ofinstances in which, amongst this class of thepopulation, a case of cholera in one memberof the family is followed by other cases;whilst medical men and others, who merelyvisit the patients, generally escape. Thepost-mortem inspection of the bodies ofcholera patients has hardly ever been followedby the disease that I am aware, this being aduty that is necessarily followed by carefulwashing of the hands; and it is not the habit ofmedical men to be taking food on such anoccasion. On the other hand, the dutiesperformed about the body, such as laying itout, when done by women of the workingclass, who make the occasion one of eatingand drinking, are often followed by an attackof cholera; and persons who merely attend thefuneral, and have no connection with thebody, frequently contract the disease; inconsequence, apparently, of partaking of foodwhich has been prepared or handled by thosehaving duties about the cholera patient, or hislinen and bedding.

some circumstances render it almost certain.For instance, when a large family, or morethan one family are crowded into a singleroom, and when the same persons have toattend to the patient, and also to prepare andserve the meals for the rest of the inmates,without the materials for washing the hands,even if the inclination should exist, it is nextto impossible that the provisions should beeaten without being contaminated with thepeculiar discharges of the patient; and theseare the circumstances under which the diseaseis found most frequently to spread among theinmates of a room.

Mr. Baker, of Staines, who attended 260cases of cholera and diarrhœa in the lateepidemic, chiefly among the poor, informedme in a letter, with which he favoured me inDecember, 1849, that “where the patientspassed their stools involuntarily the diseaseevidently spread.” Deficiency of light is agreat obstacle to cleanliness, as it preventsdirt from being seen, and it must aid verymuch the contamination of the food with thecholera evacuations.

The assistance which crowdinglends to the spread of cholera could beexplained on the hypothesis of effluvia or

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It has been found that the miningpopulation of this country has suffered morefrom cholera than any other, and there is areason for this. There are no privies in thecoal pits,*

(*Dr. D. B. Reid, in Second Reportof Commissioners for inquiring intothe state of large towns and populousdistricts. Appendix, Part ii. p. 122.)

and I believe that this is true of other mines:as the workmen stay down the pit about eighthours at a time, they take food down withthem, which they eat, of course, withunwashed hands, and as soon as one pitman

miasmata given off from the patient into thesurrounding air; but the extension of thedisease from want of cleanliness, deficiencyof water, and deficiency of light, cannot beexplained on such a hypothesis. Thenon-communication of cholera in cleanlyfamilies, where the hand-basin and the towelare in constant use and where the apartmentsfor cooking and eating are distinct from thesick-room; and also its non-communication,as a general rule, to medical men and othervisitors of the sick belonging to the educatedclasses of society, are fully explained on thedoctrine here laid down, although thesecircumstances are inexplicable on thesupposition of its spread by means ofeffluvia. Its fearful extension in certainpauper asylums for children and lunatics isalso clearly accounted for, together with itsnon-liability to spread in more commodiousand better regulated establishments.

The great fatality of cholera amongall the mining populations of this kingdomhas been very remarkable in both theepidemics of that disease. The chief reasonsof this are as follow: -- The miners generallyremain eight hours in the pits, and take foodwith them, which they eat whilst at work.There are neither privies, hand-basins, nortowels in the mines; and when a case ofcholera occurs in a pit, the hands of theworkmen, in the dark subterranean passages,can hardly fail to become soiled with thedischarges. Should [560a/560b] we have areturn of the cholera, I believe that manythousands of lives might be saved by dividingthe time of labour into two periods of fourhours, dissuading the workmen from takingfood into the mines and enjoining them towash their hands on going home beforetaking any food. There are other causes to beafterwards mentioned which contribute to the

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gets the cholera, there must be great liabilityof others working in the gloomy subterraneanpassages to get their hands contaminated, andto acquire the malady; and the crowded statein which they often live affords everyopportunity for it to spread to other membersof their families. There is also another causewhich favours the spread of cholera amongstmany of the mining populations, to which Ishall have to allude shortly, in treating of thewater.

When the cholera makes its appearance in amining district it would be advisable that themen should work during two “shifts” in thetwenty-four hours, of four hours each, insteadof one “shift" of eight hours; and should bedissuaded from taking food to their work, andrecommended to wash themselves on goinghome, as I believe they usually do.

extension of cholera in several of the miningdistricts, viz., the contamination of the wellsand brooks with the evacuations of thepeople.

It can hardly be anticipated, from thenature of the subject, that we should be ableto obtain distinct evidence of the choleraevacuations having been taken with the food.The following cases, perhaps, afford asdecisive proof of this variety ofcommunication of cholera as can be expected.In the beginning of last year, a letter appearedin the Provincial Medical and SurgicalJournal, from Mr. John C. Bloxam, in the Isleof Wight, being an answer to the inquiry oncholera by Mr. Hunt. Among other interestinginformation, Mr. Bloxam stated, that the onlycases of cholera that occurred in the village ofCarisbrook, happened in persons who ate ofsome stale cow-heels, which had been theproperty of a man who died in Newport, aftera short and violent attack of cholera. Mr.Bloxam kindly made additional personal inquiries into the case, in consequence ofquestions I put to him, and the following is asummary of the information contained in hisletter: –

The man from whose house thecow-heels were sent for sale died on Monday,the 20th of August. It was the custom in thehouse to boil these articles on Monday,Wednesday, and Friday; and the cow-heelsunder consideration were taken toCarisbrook, which is a mile from Newportready boiled, on Tuesday, the 21st. Elevenpersons in all partook of this food, seven ofwhom ate it without any additional cooking.Six of these were taken ill within twenty- fourhours after eating it, five of whom died, andone recovered. The seventh individual, achild, who ate but a small quantity of thecow-heels, was unaffected by it. Four persons

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The views here explained open up toconsideration a most important way in whichthe cholera may be widely disseminated, viz.,

With only the means ofcommunication which we have been

partook of the food after additional cooking.In one case the cow-heels were fried, and theperson who ate them was taken ill of cholerawithin twenty-four ours afterwards, and died.Some of the food was made into broth, ofwhich three persons partook while it waswarm; two of then remained well, but thethird person partook again of the broth nextday, when cold, and, within twenty-foursafter this latter meal, she was taken ill withcholera of which she died. It may be proper tomention, although it is no unusualcircumstance for animal food to be eaten inhot weather when not quite fresh, that someof the persons perceived the cow-heels to benot so fresh as they ought to have been at thetime they were eaten, and part of them had tobe thrown away a day or two afterwards, inconsequence of being quite putrid.

A man living in West-street, Soho,who kept a horse and cart, was employed, inthe beginning of September, 1849, to removesome furniture from a house in Lambeth. Thefurniture had been the property of a womanwho died of cholera, and had just beenburied. The bedding and night-chair were leftjust as they were when the patient died. Thisman was taken with cholera during the night,within thirty-six hours after removing thefurniture and other effects and he died of theattack. I saw him with Mr. Marshall, ofGreek-street, and we both remarked that hishands were very dirty, and had apparently notbeen washed for some days.

If the views here explained becorrect it is evident that the cholera poisonmay often be conveyed to a distance withprovisions, as in the instance of the cow-heelsabove-mentioned, when there is no evidenceof personal intercourse. There is also anothervery important medium for transmitting thecholera poison from the sick to the healthy

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by the emptying of sewers into the drinkingwater of the community; and, as far as thewriter’s inquires have extended, he has foundthat in most towns in which the malady hasprevailed to an unusual extent this means ofits communication has existed.

[two point-source epidemics discussed inreverse order from 1851 article]

In Albion Terrace, Wandsworth Road, therehas been an extraordinary mortality fromcholera, which was the more striking, as therewere no other cases at the time in theimmediate neighbourhood; the housesopposite to, behind, and in the same line, ateach end of those in which the diseaseprevailed, having been free from it. The rowof houses in which the cholera prevailed to anextent probably altogether unprecedented in

considering, the cholera would be constrainedto confine itself chiefly to poor and crowdeddwellings, and would be continually liable todie out accidentally in a place, for want of theopportunity to reach fresh victims; but there isoften a way open for it to extend itself morewidely, and that is by the mixture of thecholera evacuations with the water used fordrinking and culinary purposes, either bypermeating the ground and getting into wells,or by running along channels and sewers in tothe rivers.*

(*See review in Med. Gaz. presentvol. p. 466.)

[two point-source epidemics discussed inreverse order from 1851 article]

The instance of Albion Terrace, WandsworthRoad, was a still more striking one of thecommunication of cholera by means of water. As the account of the occurrence was quotedin a Review in the Medical Gazette,*

(*Present vol. p. 468)

and some further particulars supplied by me ina note,*

without immediate intercourse. It is the waterwhich people drink and in this case the proofsare often of a more direct and decisive nature.

The deficiency of water had oftenbeen spoken of, but the quality of the waterhad hardly ever been publicly mentioned ascontributing to the increase of cholera tillAugust 1849, when Dr. Lloyd related to theSouth London Medical Society someoccurrences that had taken place inRotherhithe, and a pamphlet of mine,containing other instances, and somereasoning on the subject, appeared as thesame time. Mr. John Grant, Surveyor to theCommissioners of Sewers for Surrey andKent, also drew up a report in the samemonth, respecting the contamination of awell, in a [560b/561a] court in Thomas-street,Horsleydown; and attention having beenstrongly directed to the matter, several otherinstances of the connexion between violentoutbreaks of cholera and the contamination ofthe drinking water were related.

One of the most fatal instances ofcommunication of cholera by means of water,is that which occurred at Albion- terrace,Wandsworth-road -- a row of seventeenhouses, most of them detached a few feetfrom each other, and constituting the genteelsuburban dwellings of a number ofprofessional and tradespeople. All the houseswere supplied with water on a uniform plan,from a spring in the neighbourhood, the waterbeing conducted into a tank placed behindeach house, from which it was pumped intothe kitchen when required. The tanks were allconnected together by pipes, and the surpluswater flowed away into a drain, whichreceived the contents of the house drains andcesspools. The various drains and pipes wereso constructed that the water was liable tobecome tainted, and it had been occasionally

12

this country, constituted the genteel suburbandwellings of a number of professional andtradespeople, and are most of them detached afew feet from each other. They are suppliedwith water on the same plan. In this instancethe water got contaminated by the contents ofthe house-drains and cesspools; the choleraextended to nearly all the houses in which thewater was thus tainted, and to no others. . . .

Various substances have been found in itwhich escape digestion, as the stones andhusks of currants and grapes, and portions ofthe thin epidermis of other fruits andvegetables. Little bits of paper were likewisefound. Some of the water removed from thistank continued to ferment till a day or twoago, but is now quite clear and transparent;and although there are some portions of thefibrous structures of vegetables lying at thebottom of the bottle in which it is contained,the water itself has neither taste nor smell,and cannot, by either physical or chemicalexamination, be distinguished from that of thespring whence it originally proceeded.

The first case of cholera occurred atNo. 13, on July 28th (two days after thebursting of the drain), in a lady who had hadpremonitory symptoms for three or four days.It was fatal in fourteen hours. There was anaccumulation of rubbish in the cellar of thishouse, which was said to be offensive by theperson who removed it; but the proprietor ofthe house denied this. A lady at No. 8 wasattacked with choleraic diarrhœa on July 30th:she recovered. On August 1st, a lady, age 81,

(*Ibid, p. 504.)

I need not now relate the particulars, but willbriefly state that, owing to a storm of rain andthunder, such a connection was establishedbetween the drains and water, that, on a caseof cholera occurring in any one of seventeenhouses, the evacuations might enter the watersupplied to all the others. Such a case didoccur, and in a short time the prevalence ofcholera was such as I believe had not beforebeen known in this country; whilst at the sametime there was but little of the disease at thetime, or I believe since, in the surroundingstreets and houses. I will take this occasion toremark that we have now an explanation ofthe reason why the cholera has on someoccasions increased very much immediatelyafter a thunder storm, and on other occasionshas very much diminished. The cause of thislies in the rain, and not in the thunder. Insome places drains containing choleradischarges would be made to overflow into abrook or river, or other source from whichwater was obtained, whilst in other placesdrinking-water already contaminated would benearly altogether washed away, and replacedby a fresh supply.

complained of previously; but during a stormof rain on July 26th, the chief drain burst, andits contents became mixed with the water inthe tanks. I had an opportunity of findingafterwards in the water, the stones and husksof currants and grapes and various othersubstances which had gone through thealimentary canal. The more gross materials,however, settled to the bottom of the tanks,and the water pumped up was not so bad as toexcite suspicion or attract much attentionexcept in two or three of the houses.

“The first case of cholera occurredat No. 13, on July 28, (two days after thebursting of the drain,) in a lady who had hadpremonitory symptoms for three or four days.It was fatal in fourteen hours. There was anaccumulation of rubbish in the cellar of thishouse, which was said to be offensive by theperson who removed it; but the proprietor ofthe house denied this. A lady at No. 8 wasattacked with choleraic diarrhœa on July 30;she recovered. On August 1, a lady, aged 81,at No. 6, who had had some diarrhœa eight orten days before, which had yielded to her owntreatment, was attacked with cholera ; shedied on the 4th, with congestion of the brain.Diarrhœa commenced on August 1, in a lady,aged 60, at No. 3; collapse took place on the5th, and death on the 6th. On August 3 therewere three or four cases in different parts ofthe row of houses, and two of themterminated fatally on the same day. The

13

at No. 6, who had had some diarrhœa eight orten days before, which had yielded to her owntreatment, was attacked with cholera; she diedon the 4th with congested brain. Diarrhœacommenced on August 1st, in a lady aged 60,at No. 3; collapse took place on the 5th, anddeath on the 6th. On August 3rd, there werethree or four cases in different parts of therow of houses, and two of them terminatedfatally on the same day. The attacks werenumerous during the following three or fourdays, and after that time they diminished innumber. More than half the inhabitants of thepart of the terrace in which the choleraprevailed were attacked with it, and upwardsto half the cases were fatal. The deathsoccurred as follows; but as some of thepatients lingered a few days, and died in theconsecutive fever, the deaths are less closelygrouped than the seizures. There was onedeath on July 28th, two on August 3rd, four onthe 4th, two on the 6th, two on the 7th, four onthe 8th, three on the 9th, one on the 11th, andone on the 13th. These make twenty fatalcases; and there were four or five deathsbesides amongst those who were attackedafter flying from the place.

The fatal cases were distributed overten out of the seventeen houses, and Mr.Mimpriss, of Wandsworth Road, whoattended many of the cases, and to whosekindness the writer is indebted for several ofthese particulars, states that cases occurred inthe other seven houses, with the exception ofone or two that were empty, or nearly so.There were five deaths in the house No. 6,and one of a gentleman the day after he left it,and went to Hampstead Heath. The entirehousehold, consisting of seven individuals,had the cholera, and six of them died.

There are no data for showing howthe disease was probably communicated to

attacks were numerous during the followingthree or four days, and after that time theydiminished in number. More than half theinhabitants of the part of the terrace in whichthe cholera prevailed were attacked with it,and upwards of half the cases were fatal. Thedeaths occurred as follow; but as some of thepatients lingered a few days, and died in theconsecutive fever, the deaths were lessclosely grouped than the seizures. There was1 death on July 28, 2 on August 3, 4 on the4th, 2 on the 6th , 2 on the 7th, 4on the 8th, 3 onthe 9th, 1 on the 11th, and 1 on the 13th. Thesemake 20 fatal cases; and there were 4 or 5deaths besides amongst those who wereattacked after flying from the place.”

The fatal cases were distributed overten of the seventeen houses, and casesoccurred also in the other seven houses, withthe exception of one or two that were empty,or nearly so. In short, the cholera extended toall the houses supplied by the contaminatedwater, and to no others; for there were hardlyany cases in the immediate neighbourhood atthe time.

There are no data for showing howthe disease was communicated to the firstpatient, at No. 13, on July28; but it was twoor three days afterwards, when theevacuations from this patient must haveentered the drains having a communicationwith the water supplied to all the houses, thatother persons were attacked, and in two daysmore the disease prevailed to an alarmingextent.

14

the first patient, at No. 13, on July 28th; but itwas two or three days afterwards, when theevacuations from this patient must haveentered the drains, having a communicationwith the water supplied to all the houses, thatother persons were attacked, and in two daysmore the disease prevailed to an alarmingextent.

[. . . several more paras on thisoutbreak]

In Thomas Street, Horsleydown,there are two courts close together, consistingof a number of small houses or cottages,inhabited by poor people. The houses occupyone side of each court or alley--the south sideof Trusscott’s Court, and north side of theother, which is called Surrey Buildings, beingplaced back to back, with an interveningspace, divided into small back areas, in whichare situated the privies of both the courts,communicating with the same drain, andthere is an open sewer which passes thefurther end of both courts. Now, in SurreyBuildings the cholera has committed fearfuldevastation, whilst in the adjoining courtthere has been but one fatal case, and anothercase that ended in recovery. In the formercourt the slops of dirty water poured down bythe inhabitants into a channel in front of thehouses got into the well from which theyobtained their water, this being the onlydifference that Mr. Grant, the Assistant-Surveyor for the Commissioners of Sewers,could find between the circumstances of thetwo courts, as he stated in his report to theCommissioners. The well in question wassupplied from the pipes of the South LondonWater Works, and was covered in on a levelwith the adjoining ground; and the inhabitantsobtained the water by a pump placed over the

There are two courts in Thomas Street,Horsleydown, exactly resembling each other;the small houses which occupy one side ofeach court being placed back to back, and theprivies for both courts being placed in theintervening back areas, and emptied into thesame drain which communicated with an opensewer passing the end of both the courts. InTrusscott’s Court, as one of them is called,there was but one death from cholera, whilstin the other, named Surrey Buildings, therewere eleven deaths. In this latter court therefuse water from the houses got into the wellfrom which the people obtained their water. The succession of the cases illustrates themode of communication. There were first twocases in Surrey Buildings, the evacuations ofthese patients being passed into the bed, as Iwas in-[474/748] formed by Mr. Vinen, ofTooley Street, who attended them; in a fewdays after, when the water in which the soiledlinen had been washed must have becomemixed with that in the well, a number of casescommenced nearly together in all parts of thesmall court.

A similar instance of communication ofcholera through the water occurred nearly atthe same time “in Thomas-street,Horsleydown, where there are two courtsclose together, consisting of a number ofsmall houses or cottages inhabited by poorpeople. The houses occupy one side of eachcourt or alley, the south side of Trusscott’s-court, and the north side of the other, which iscalled Surrey-buildings, being placed back toback, with an intervening space, divided intosmall back areas, in which are situated theprivies of both the courts, communicatingwith the same drain; and there is an opensewer which passes the further end of boththe courts. Now, in Surrey-buildings, thecholera committed fearful devastation, whilstin the ad- [561a/561b] joining court there wasbut one fatal case, and another that ended inrecovery. In the former court the slops ofdirty water, poured down by the inhabitantsinto a channel in front of the houses, got intothe well from which they obtained theirwater, this being the only difference that Mr.Grant, the Assistant-Surveyor for theCommissioners of Sewers, could findbetween the circumstances of the two courts,as he stated in his report to theCommissioners. The well in question wassupplied from the pipes of the South LondonWater Works, and was covered in on a levelwith the adjoining ground; and the inhabitantsobtained the water by a pump placed over thewell. The channel mentioned abovecommenced close by the pump. Owing tosomething being out of order, the water forsome time past occasionally burst out at thetop of the well, and overflowed into the gutteror channel, afterwards flowing back againmixed with the impurities; and crevices wereleft in the ground or pavement, allowing part

15

well. The channel mentioned abovecommenced close by the pump. Owing tosomething being out of order, the water forsome time past occasionally burst out at thetop of the well, and overflowed into the gutteror channel, afterwards flowing back againmixed with the impurities; and crevices wereleft in the ground or pavement, allowing partof the contents of the gutter to flow at alltimes into the well, and when it wasafterwards emptied a large quantity of blackand highly offensive deposit was found in it.

The first case of cholera in thiscourt occurred on July 20th, in a little girl,who had been labouring under diarrhoea forfour days. This case ended favourably. On the21st of July, the next day, an elderly femalewas attacked with the disease, and was in astate of collapse at ten o’clock the same night.This patient partially recovered, but died ofsome consecutive affection on August 1. Mr.Vinen, of Tooley Street, who attended thesecases, states that the evacuations were passedinto the beds, and that the water in which thefoul linen would be washed would inevitablybe emptied into the channel mentioned above.Mr. Russell, of Thornton Street,Horsleydown, who attended many of thesubsequent cases in the court, and who, alongwith another medical gentlemen, was the firstto call the attention of the authorities to thestate of the well, says that such water wasinvariably emptied there, and the peopleadmit the circumstance. About a week afterthe above two cases commenced, a number ofpatients were taken ill nearly together: four onSaturday, July 28th, seven or eight on the 29th,and several on the day following. The deathsin the cases that were fatal took place asfollows:--One on the 29th, four on the 30th,

of the contents of the gutter to flow at alltimes into the well, and when it wasafterwards emptied, a large quantity of blackand highly offensive deposit was found it.

“The first case of cholera in thiscourt occurred on July 20th, in a little girl,who had been labouring under diarrhœa forfour days. This case ended favourably. On the21st July, the next day, an elderly female wasattacked with the disease, and was in a stateof collapse at ten o’clock the same night. Mr.Vinen, of Tooley-street, who attended thesecases, states that the evacuations were passedinto the beds, and that the water in which thefoul linen would be washed would inevitablyhe emptied into the channel mentioned above.Mr. Russell, of Thornton-street,Horsleydown, who attended many of thesubsequent cases in the court, and who, alongwith another medical gentleman, was the firstto call the attention of the authorities to thestate of the well, says that such water wasinvariably emptied there, and the peopleadmit the circumstance. About a week afterthe above two cases commenced, a number ofpatients were taken ill nearly together: fouron Saturday, July 28th, seven or eight on the29th, and several on the following day. Elevenof the cases were fatal. The deaths occurredin seven out of the fourteen small houses inthe court.

“The two first cases on the 20th and21st may be considered to represent about theaverage amount of cases for theneighbourhood, there having been just thatnumber in the adjoining court about the same

16

and one on the 31st July; two on August 1st,and one on August the 2nd , 5th, and 10th

respectively, making eleven in all. Theyoccurred in seven out of the fourteen smallhouses situated in the court.

The two first cases on the 20th and21st may be considered to represent about theaverage amount of cases for theneighbourhood, there having been just thatnumber in the adjoining court, about the sametime. But in a few days, when the dejectionsof these patients must have become mixedwith the water the people drank, a number ofadditional cases commenced nearly together.The patients were all women and children, themen living in the court not having beenattacked; but there has been no opportunityhitherto of examining into the cause ofexemption, as the surviving inhabitants hadnearly all left the place when the writer’sattention was called to this circumstance.

Dr. Lloyd mentioned some instancesof the effects of impure water at the SouthLondon Medical Society, on August 30th.*

(*See Report in Med. Gaz. p. 429.)

In Silver Street, Rotherhithe, there were eightycases, and thirty-eight deaths, in the course ofa fortnight early in July list, at a time whenthere was very little cholera in any other partof Rotherhithe. The contents of all the priviesin this street ran into a drain which had oncehad a communication with the Thames; andthe people got their supply of water from awell situated very near the end of the drain,with the contents of which the water gotcontaminated. Dr. Lloyd has informed methat the foetid water from the drain could beseen dribbling through the side of the well,above the surface of the water. Amongstother sanitary measures recommended by Dr.

time. But, in a few days, when the dejectionsof these patients must have become mixedwith the water the people drank, a number ofadditional cases commenced nearly together.”(a)

(a) The passages in the aboveaccount. Included within invertedcommas, are quoted from apamphlet, by the Author, “On theCommunication of Cholera.”

The following instances were madeknown by Dr. Lloyd: –

In Silver-street, Rotherhithe, there were 80cases and 38 deaths in the course of afortnight, early in July, 1849, at a time whenthere was very little cholera in any other partof Rotherhithe. The contents of all the priviesin this street ran into a drain which had oncehad a communication with the Thames; andthe people got their supply of water from awell situated very near the end of the drain,with the contents of which the water gotcontaminated. Dr. Lloyd informed me that thefetid water from the drain could be seendribbling through the side of the well, abovethe surface of the water. Among othersanitary measures recommended by Dr.Lloyd, was the filling up of the well; and thecholera ceased in Silver-street as soon as thepeople gave over using the water. Anotherinstance alluded to by Dr. Lloyd wasCharlotte-place, in Rotherhithe, consisting ofseven houses, the inhabitants of which,excepting those of one house, obtained theirwater from a ditch communicating with theThames, and receiving the contents of the

17

Lloyd was the filling up of the well; and thecholera ceased in Silver Street as soon as thepeople gave over using the water. Anotherinstance alluded to by Dr. Lloyd was CharlottePlace, in Rotherhithe, consisting of sevenhouses, the inhabitants of which, exceptingthose of one house, obtained their water froma ditch communicating with the Thames, andreceiving the contents of the privies of all theseven houses. In these houses there weretwenty-five cases of cholera, and fourteendeaths; one of the houses had a pump railedoff, to which the inhabitants of the otherhouses had no access, and there was but onecase in that house. The people in Rotherhithe,where the mortality from cholera has beengreater than in any other part of themetropolis, are supplied with water to a greatextent from certain tidal ditchescommunicating with the Thames, andreceiving besides the refuse of the houses inthe neighbourhood; and Dr. Lloyd informs methat a line may be drawn between the placeswhere ditch-water is used, and those suppliedfrom the Water Works, and that the cholerahas been many times more prevalent in thefirst mentioned places; although, in myopinion, the water supplied from the waterworks is itself not free from suspicion ofhaving conveyed cholera poison, beingobtained from the Thames. Rotherhithe is lessdensely populated than many parts of themetropolis which have been comparativelyfree from cholera, and those ditches, it shouldbe remembered, are not very offensive to thesmell; being only Thames water rendered alittle richer in manure; being, in short,probably equal to what Thames water wouldbe if certain of our sanitary advisers couldsucceed in having the contents of all thecesspools washed into the river. InBermondsey, the district in which next to

privies of all the seven houses. In thesehouses there were 25 cases of cholera, and 14deaths; one of the houses had a pump railedoff to which the inhabitants of the otherhouses had no access and there was but onecase in that house. (b)

(b) See Med. Gaz., 1849, Vol. II., p.429.

The following instance, as well assome others of a similar kind, is related in theReport on Cholera by the General Board ofHealth: –

“In Manchester, a sudden and

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Rotherhithe the cholera has been most fatal,the people also have to drink ditch water to agreat extent. [748/749]

violent outbreak of cholera occurred inHope-street, Salford. The inhabitants usedwater from a particular pump-well. This wellhad been repaired, and a sewer which passeswithin nine inches of the [561b/562a] edge ofit became accidentally stopped up, and leakedinto the well. The inhabitants. of 30 housesused the water from this well; among themthere occurred 19 cases of diarrhœa, 26 casesof cholera, and 25 deaths. The inhabitants of60 houses in the same immediateneighbourhood used other water; among thesethere occurred 11 cases of diarrrhœa, but nota single case of cholera, nor one death. It isremarkable, that, in this instance, out of the26 persons attacked with cholera, the wholeperished except one.” – P. 62.

Dr. Thomas King Chambersinformed me, that at Ilford, in Essex, in thesummer of 1849, the cholera prevailed veryseverely in a row of houses a little way fromthe main part of the town. It had visited everyhouse in the row but one. The refuse whichoverflowed from the privies and a pigstycould he seen running into the well over thesurface of the ground, and the water was veryfetid; yet it was used by the people in all thehouses except that which had escapedcholera. That house was inhabited by awoman who took linen to wash, and she,finding that the water gave the linen anoffensive smell, paid a person to fetch waterfor her from the pump in the town, and thiswater she used for culinary purposes, as wellas for washing.

The time does not permit of myrelating any more of the numerous instancesin which severe outbreaks of cholera havebeen connected with adulteration of the waterwith the contents of drains and cesspools; andthis is the less to be regretted, as the influenceof this kind of water over the increase of

19

Many medical men to whom theabove circumstances respecting the waterhave been mentioned, admit the influence ofthe water, without admitting the special effectof the new element introduced into it – viz.,the cholera evacuations in communicating, thedisease. They look upon the bad water asonly a predisposing cause, making the diseasemore prevalent amongst those who use it – aview which, in a hygienic sense, is calculatedto be to some extent as useful as the admissionof what I believe to be the real truth, butwhich, I think, will be found to be untenable,when the circumstances are closely examined. If the bad water merely predisposed persons tobe acted on by some occult cause of cholera towhich it is supposed that all are exposed,those using such water ought to become moresubject to the disease from the time it enters atown or neighbourhood; instead of which ithas been shown in many of the aboveinstances that no particular effect wasobserved amongst those using the water, untilby the occurrence of a case or two of cholera,the evacuations entered the water, when, aftera short period of incubation, there wereseveral persons attacked nearly together.

cholera is now generally admitted.In the seventh notification of the

General Board of Health, on September 18,1849, soon after attention had been firstprominently drawn to this matter, thefollowing passage occurs: – “The ascertainedfact, that the use of vitiated water acts as apoison on the stomach and bowels, producingsickness, diarrhœa, and other symptomsresembling those of cholera, has recentlyreceived melancholy confirmation innumerous instances.”

Now, in these instances, the diseaseinduced is admitted to have been actualcholera in the same notification, and in thesubsequent report of the Board, and there isno evidence to show that vitiated watergenerally acts as a poison; on the contrary, inmany of the instances in which theseoutbreaks of cholera occurred, the people hadbeen drinking the same vitiated water sincethe cholera of 1832. However repulsive to thefeelings the swallowing of human excrementmay be, it does not appear to be veryinjurious so long as it comes from healthypersons, but when it proceeds from cholerapatients, and probably patients with someother maladies, it is a means ofcommunicating disease. [562b]

[continued in Medical Times 3 (6 December1851): 610-12]

Although, as I have observed, the influence ofvitiated water in aiding the spread of cholerais now generally admitted, it must be statedthat it is not usually understood to act in theway I have explained; but the contaminatedwater is thought by many to predisposepersons, so that an unknown cause of choleramay act upon them in some inexplicable way.The manner in which these outbreaks occur,

20

when caused by the contamination of a localsupply of water shows however, that it doesnot act by merely inducing a predisposition.The water in many of the instances had beencontaminated for months or even years, whena case or two of cholera occurring amongstthe people on the spot, whose evacuationsentered the water through the drains orotherwise, in a day or two afterwards therewas a simultaneous outbreak of the maladyamongst a number of the persons using thewater; whereas, if the water had merelycaused a predisposition, and was not acting asthe exciting cause, the cases of cholera,however numerous in the locality, might beexpected to be distributed over the period thatthe disease prevailed in the town or district inwhich the locality was situated. In a review inthe Medical Gazette, in 1849, the remark wasmade, that as the communication of cholerato the first case in Albion-terrace could not betraced, and was of course not attributable tothe water, which did not yet contain thecholera evacuations, the same cause whichwould produce that case would produceothers in the immediate vicinity. This must beadmitted to be possible; and in the same way,if a fire had taken place from some unknowncause in No. 13, and the whole row had beenburned down, it must also be admitted that afire might possibly have originated from thesame unknown cause in all the other housesabout the same time, and that the burning ofthe one had no connexion with that of theothers. No one, however, would believe thisto have been the case.

Besides the local outbreaks alreadyalluded to, it can be shown, that the cholerawas often communicated through the water,on a more extensive scale, by means of thesewers which empty themselves into variousrivers, from which the population of many

21

The first cases of cholera in Exeter,in 1832, were three in the same day besidesone in St. Thomas's, a suburb of Exeter, in agentleman just arrived from London, wherethe disease was prevailing. The other three

towns derive their supply of water. In severaltowns of this country, among which areBirmingham, Leicester, Bath, andCheltenham, there were only a few cases ofcholera, either in 1832 or 1849 and thosechiefly In persons who had arrived from otherplaces in which the cholera was prevailing, oramong the immediate attendants of thesepatients. Now, all these towns were suppliedwith water from sources quiteuncontaminated with the contents of sewers.In some towns so circumstanced, there hasbeen a good deal of cholera, but then it wasconfined to the poor, and to particularlocalities in the towns; but on the other hand,in all those towns in which the maladyextended generally, and was not confined tothe poor and dirty, this connexion betweenthe sewers and drinking-water existed. Agreat part of London was in this condition inboth epidemics; Exeter was so in 1832, andHull in 1849. The difference between the twoepidemics in Exeter and Hull, in connexionwith an altered supply of water, is veryremarkable. In 1832, the people of Exeterwere supplied with water by water-carriers,who obtained it from two mill-streamsdiverted from the river; and one of the chiefsewers of the town emptied into a branch ofthe river which divided into the twomill-streams. Cholera commenced with awoman and child who had just arrived fromPlymouth, where the former had been nursinganother child that had died of [610a/610b] thesame disease. It soon became very prevalentand severe for the size of the town. Therewere 1135 eases, and 343 deaths. (a)

(a) See “History of the Cholera InExeter in 1832.” by Dr. Shapter, towhose kindness the writer isindebted for additional information.

22

were a woman and her two children; theformer, with one of her children, had[750/751] returned from Plymouth theprevious day where she had been nursing achild that had died of the cholera. Within fivedays from this time, there were seven freshcases in is many different parts of the town,amongst persons having no intercourse witheach other or the first cases. The disease soonbecame very prevalent, and in three monthsthere were 1,135 cases, and 345 deaths. Exeter is situated on ground which rises fromthe edge of the river to an elevation of 150feet. In 1832 the inhabitants were chieflysupplied with river water by water-carriers,who conveyed it in carts and pails. Dr.Shapter, from whose work the aboveparticulars are obtained, has kindly furnishedme with information concerning the sewers,and maps of their position. Thewater-carriers, by whom Exeter was verygreatly supplied, obtained their water almostexclusively from certain streams of water,diverted from the river in order to turnwatermills; and one of the chief sewers of thetown, which receives such sewage as mightcome from North Street, in which the firstcases of cholera occurred, empties itself intothe branch from the river which divides intothe two mill-streams just mentioned. It mustbe remarked that the parish of St. Edmund, inwhich these streams of water were situated,had a lower mortality from cholera than otherparts of the town like it densely populated andon low ground near the river. Dr. Shapterattributes this lower rate of mortality, and Ibelieve rightly, to St. Edmund's being freelyintersected by running streams of water. Thepeople would probably not drink more of thewater than in parts of the town where it wasless plentiful, and had to be paid for, but theywould have much better opportunities for

Subsequently to 1832, Exeter has beensupplied by waterworks, with water derivedfrom the river Exe, at a point two miles abovethe town and more than that distance abovethe influence the tide. In 1849, there wereonly about 20 cases of cholera in Exeter,nearly half of which occurred in strangerscoming into the town, and dying within twoor three days after their arrival.

23

personal cleanliness: so that whilst they wouldbe exposed to only the same number ofscattered cases, they would be less likely tohave the malady spreading through families,and by personal intercourse. After the choleraof 1832 measures were taken to afford a bettersupply of water to Exeter; not, so far as I canfind by Dr. Shapter's work, that its impuritywas complained of, but because of its scarcityand cost. Water-works were established onthe river Exe, two miles above the town, andmore than two miles above the influence ofthe tide. Exeter is now very plentifullysupplied with this water, and Dr. Shapter hasinformed me that this year there have onlybeen about twenty cases of cholera, nearlyhalf of which have occurred in strangerscoming into the town, and dying within two orthree days after their arrival.

We will now consider the town ofHull, in which, together with other sanitarymeasures adopted since 1832, there has been anew and more plentiful supply of water, butwith a different result to that at Exeter. In1832 Hull was scantily supplied with waterconveyed in pipes from springs at Anlaby,three miles from the town. About five yearsago new water-works were established toafford a more plentiful supply. These worksare situated on the river Hull, at Stoneferry,two miles and three quarters from theconfluence of that river with the Humber. About half the sewage of the town is deliveredinto the river of the same name, the rest beingdischarged into the Humber, as appears frominformation and a map kindly furnished me byDr. Horner, of Hull, who has been makinggreat efforts to have better water obtained forthe town. The tide flows up the river manymiles past the water-works, carrying up with itthe filth from the sewers. The supply of wateris, to be sure, obtained when the tide is down,

In 1832 Hull was scantily suppliedwith water, conveyed in pipes from somesprings situated three miles from the town; inthe epidemic of that year the cholera wasconfined almost exclusively to the poor, andthe deaths amounted to 300. Between thattime and 1849, Hull, besides an improvedsystem of drainage, obtained a more abundantsupply of water. The water-works, however,are situated on the river Hull two miles andthree quarters from its confluence with theHumber. About half the sewage of the town isdelivered into the river Hull, and the tideflows up this river for many miles past thewaterworks, carrying with it the filth from thesewers. In the late epidemic the deaths fromcholera and diarrhœa in Hull amounted tonearly 3000, and occurred among all classesof the community.

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Although there are a great number of pumps,supplied by wells, in this metropolis, yet byfar the greater part of the water used fordrinking and for culinary purposes isfurnished by the various Water Companies.On the south side of the Thames the waterworks all obtain their supply from that river,at parts where it is much polluted by thesewers; none of them obtaining their waterhigher up the stream than Vauxhall Bridge,–the position of the South London WaterWorks. Now as soon as the cholera began toprevail in London, part of the water whichhad been contained in the evacuations of thepatients would begin to enter the mains of theWater Works: whether the materies morbi of

but as the banks of the river are clothed withsedges in many parts, and its bottom deepwith mud, the water can never be free fromsewage. Moreover, there are some parts ofthe river above Stoneferry much deeper thanthe rest, and where the deeper water is,according to the testimony of boatmen, nearlystagnant; thus allowing the water carried upby the tide to remain and gradually mix withthat afterwards flowing down. There are alsoboats, with families on board, pressing up theriver to the extent of 5,000 voyages in theyear. The water when taken from the river isallowed to settle in the reservoir fortwenty-four hours, and is then said to befiltered before being sent to the town. In 1832the cholera was confined almost exclusively tothe poor, and the deaths amounted to 300.

This year, according to what I havegathered from the weekly reports, they[751/752] have been six times as numerous. Dr. Horner informs me that they haveoccurred amongst all classes of thecommunity; that he thinks one in every thirty-three of the population has been carried offalthough 8,000 or 10,000 are said to have leftthe town to escape the ravages of thepestilence. All this has happenednotwithstanding that the town is much betterdrained now than in 1832, and the drains inHull proper are flushed frequently with waterfrom the Docks.

The Registrar-General has very ablypointed out the connection between the higherrate of mortality from cholera on the southside of the Thames, and the lower level of theground; but when this division of themetropolis is examined in detail, andcompared with certain other parts of London,it will be found that the relation is not onesimply of level, or of the state or the air in

In London the cholera was mostprevalent during both epidemics in thosedistricts supplied with water vitiated by thecontents of sewers and cesspools, and indeedit generally bore an exact relation to theamount of vitiation.

The map from the second Report on theHealth of Towns, which is suspended in theroom, shows the districts of the metropolissupplied by the different Water Companies;and the other map, from Mr. Grainger’sAppendix to the Report of the Board ofHealth on Cholera, is coloured to show therelative prevalence of the late epidemic in

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cholera, –which, it has been shewn, there isgood reason for believing is contained in theevacuations, –would be sent round to theinhabitants, would depend on whether thewater were kept in the reservoirs till thismateries morbi settled down or wasdestroyed; or whether it could be separated bythe filtration through gravel and sand, whichthe water is stated to undergo.Notwithstanding this filtration, the water inthis part of town is not always quite clear, andsometimes it has an offensive smell whenclear. The deaths from cholera in this district,which contains a very little more than aquarter of the population, have been morenumerous than in all the other districts puttogether; as will be seen by the followingtable, taken from the reports of the Registrar-General. Out of the 7466 deaths in themetropolis, 4001 have occurred on the southside of the Thames, being nearly eight to eachthousand of the inhabitants.

Deaths from Cholera in London, registeredfrom

September 23rd, 1848, to August 25th, 1849.

[table not included]

That division of London called the EastDistrict in the registration reports, is suppliedwith water entirely by the East London WaterCompany. In the Cholera of 1832 and 1833the reservoirs of the company at Old Fordwere entirely filled from the river Lea whenthe water flowed up with the rising tide fromthe Thames, in the neighbourhood ofBlackwall; and the river Lea itself receivessome large sewers. The Company have sinceobtained water from near Lea Bridge, above

connection with it, but that it dependsaltogether on the water used by the people. Not because the water carries the poison toevery individual case, but because it suppliesa number of scattered cases which diffuse thedisease more generally.

different parts of London. A large district onthe north of the Thames is supplied with theNew River water, which is not contaminatedby the sewers; another district on the sameside of the river is supplied by the EastLondon Water Works Company, with waterobtained from the Lea, above the influence ofthe tide, and nearly, if not altogether, freefrom contamination. These districts are notmuch tinted with the blue of cholera in Mr.Grainger’s map, except in particular spots inwhich there was generally a local supply ofcontaminated water, as, for instance, in theneighbourhood of Bridge-street, Blackfriars,where many of the inhabitants obtained waterfor drinking from St. Bride’s pump, whichwas afterwards closed in consequence of itsbeing ascertained that the well had acommunication with a sewer which emptiedinto the Fleet ditch; and in the vicinity ofShoreditch and at Hackney, where Dr. Gavinfound the contents of the privies overflowingor percolating into the wells in certain courtsand allies. The north-west districts of themetropolis are supplied with water by theWest Middlesex and Grand Junction WaterCompanies, who obtain the water from theThames, near Hammersmith and Brentford,where the river is in a great measure freefrom sewage at particular times of the tide,and the water is also purified by subsidencein large reservoirs. The districts so suppliedwere not severely visited by cholera.

The district supplied by the Chelseawater-works, was not severely visited bycholera during the late epidemic, as appearsby the cholera map, except in particular spotswhere contaminated water was used, as in theneighbourhood of Duke-street, Chelsea,where many of the people obtained water bydipping a pail into the Thames. Now, theChelsea Company derive their supply of

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the reach of the tide; but whether they stillsupply themselves in part from the river atOld Ford, where their chief works andreservoirs are still situated, and if so, to whatparts of their district the water so obtained issent, cannot be here stated, for want of exactinformation.

The cholera has prevailed to aconsiderable extent in the East districts, aswill be seen by the Table, though not so muchas on the south of the Thames.

The North districts have sufferedvery little from cholera as yet. St. Pancras andIslington, which comprise a great portion ofthis division, are supplied with the New Riverwater, which is brought from Hertfordshire.Hackney is supplied by the East LondonWater Works; Hampstead by sources of itsown; and Marylebone, which will again bealluded to, chiefly by the West MiddlesexWater Works.

The whole of the Central Districtsare likewise supplied from the New River,and this part of the town has suffered muchless from cholera, hitherto, than the south andeast divisions; although many portions of itare quite on a par with the worst parts on thesouth of the Thames as regards overcrowdingand bad smells.

The West Districts, together withMarylebone, are supplied with Thames waterby the West Middlesex, Grand Junction, andChelsea Water Works. The West MiddlesexCompany obtain their water aboveHammersmith, and the Grand Junction atBrentford; both these places, and especiallythe latter, are, by the meandering course ofthe river, several miles above London; andunless, perhaps, at certain parts of the tide,are free from sewage water, except that ofcertain towns, –as Richmond, Barnes,&c.–inwhich the cholera has not yet been prevalent.

Westminster, Chelsea, and Pimlico aresupplied with Thames water from the Chelseawater-works; but as the same water is suppliedto the Court and a great part of the aristocracy,the Company have large settling reservoirsand very expensive filters, by means of which,probably, the greater part of the cholerapoison has been got rid of.

The registrar's district of Brixton is situated onrising ground, the elevation of which variesfrom 12 to 140 feet above Trinity high-watermark, giving an average elevation at leastequal to that part of London situated on thenorth of the Thames; and it is inhabited verymuch by people in comfortable circumstances,occupying wide and open streets, andscattered rows of houses, or even detachedvillas; yet in looking over the reports, I findeighty-three deaths from cholera since Maylast. The population in 1841 was 10,175; thiswould yield 81 deaths in the 10,000, or twiceas many as have occurred on the north of theThames; but the population of Brixton hasprobably increased since 1841, by the buildingof new houses, more than in Londongenerally. Still there can be no doubt that themortality there from cholera has been muchhigher than in many of the worst parts to thenorth of the river; and the reason is not far toseek, for the greater part of the Brixtondristrict is supplied by the Lambethwater-works with water obtained from theThames near the Hungerford SuspensionBridge.

water from the Thames at Chelsea, where it isvery foul; but having till lately to supply theCourt and a great part of the nobility, theyhave large and expensive filters, and alsovery capacious settling reservoirs, in whichthe water is kept for a considerable timebefore its distribution. Dr. Hassall found theChelsea Company’s water to contain muchless organic matter than that of theCompanies supplying the districts on thesouth of the Thames; and he found it to befree from the hairs of the down of wheat,yellow ochreous substance, (believed to bepartially digested muscular fibre,) and othersubstances which had passed through thealimentary canal, and were found in theVauxhall and Lambeth Companies’ water.(b)

(b) A Microscopic Examination ofthe Water supplied to the Inhabitantsof London.

The districts of London, on the southside of the river, are [610b/611a] suppliedwith water obtained from the Thames near theHungerford Suspension Bridge, and atVauxhall, by the Lambeth, the Vauxhall, andthe South London Companies. The water isvery imperfectly filtered and has little or noopportunity to subside; and according to theevidence of Dr. Hassall, mentioned above, itcontains a great deal of excrementitousmatter. The cholera war very much moresevere on the south side of the Thames thanon the north, as appears by the map. Therewere other causes for this besides the watersupplied by the Companies. The wells in thispart of the town are very shallow, and areoften vitiated by the contents of thecesspools, which percolate through theground; and a yet more important cause of thegreat prevalence and fatality of cholera was

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The Chelsea Company, which supplyChelsea, Pimlico, Westminster, and part ofBrompton, get their water at Chelsea, onlyone or two miles above Vauxhall; but theytake great pains to filter it carefully. It willperhaps be remarked that the dilution of thecholera poison in the Thames would mostlikely render it innocuous; but as far as can bejudged from analogy, the poison consistsprobably of organized particles, extremelysmall no doubt, but not capable of indefinitedivision, so long as they retain theirproperties.

The water works supplying the South ofLondon take water from the Thames mostly atplaces near which the chief sewers run into it. Moreover, the wells in this part of London arevery liable to be contaminated by the contentsof cesspools. Mr. Quick, engineer of theSouthwark waterworks, in his evidence beforethe Sanitary Commissioners in 1844, said*

(*First Report, p. 396.)

that in the South side of the Thames the wellsare often so contaminated owing to thecesspools and the wells being often about thesame depth –viz. from eight to twelve feet,whilst on the north of the Thames the wellsrequire to be from thirty to seventy, or eightyfeet deep. These, together with the water fromthe ditches mentioned above, are the chiefsources of the high mortality on the south ofthe Thames, and where they are not inoperation there has been comparativeimmunity from the disease.

The part of the metropolis most severelyvisited by cholera in 1832, was the Boroughof Southwark, in which 97 persons in each10,000 of the population were carried off,being nearly three times the proportion ofdeaths 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 Workswith Thames water obtained at LondonBridge, and sent direct to their dwellings

the existence of certain tidal ditches inBermondsey and Rotherhite, the places inwhich the mortality was greater than in anyother part of the Metropolis in the lateepidemic. These ditches were the directreceptacles of the excrementitious matters ofa large population, and furnished at the sametime the only supply of water that could beobtained by a great number of the inhabitants.I was furnished by Mr. Grant with the resultof a house to house visitation in Jacob’sIsland, which is surrounded by one of theseditches, and it shows that the mortality fromcholera was much higher among the peoplewho had no supply of water except from theditches, than among those who had access tothe pipe-water of the Company.

In the epidemic of 1832, the part ofthis Metropolis most severely visited bycholera was the Borough of Southwark, inwhich ninety-seven persons in each 10,000 ofthe population were carried off, being nearlythree times the proportion of those that diedin the rest of London. Now, the Borough atthat time was supplied by the SouthwarkWater Works with Thames water obtained atLondon-bridge, and sent direct to the houseswithout the intervention of any reservoir.

The communication of cholera bymeans of the Water is well illustrated by the

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without the intervention of any reservoir. TheThames has since become more polluted bythe gradual abolition of numbers of cesspoolsin the metropolis, and the Southwark WaterWorks have been removed to Battersea, alittle further from the sewers. I amendeavouring to compile a full account of therecent epidemic in London, in its relation tothe water, but as it is not yet complete I musthere be content with citing certain instances ofsevere visitation, or of exemption from itsravages.

instance of Moscow, which was severelyvisited by that disease in 1830, but much lessseverely in the second epidemic.Subsequently to 1830 the greater part of thetown, which is situated to the north of theMoscow river, obtained a supply of excellentwater conducted in pipes from springs at adistance; and the cholera in 1847 was chieflyconfined to those parts of the town which lieto the south of the river, to which the newsupply of water did not extend, and where thepeople had still only impure river water todrink. (a)

(a) Report of SwedishCommissioners, quoted in theSecond Report of the MetropolitanSanitary Commission. 1848.

The Table [copied. and suspended inthe room] from the Weekly Report of theRegistrar-General of January 12, 1850, showsthe mortality from cholera in the differentdistricts of London supplied by the variousWater Companies; and if the purification ofthe Chelsea water, and certain localcontaminations of the water before mentionedbe taken into account, the mortality will befound to bear a very close relation to theabsence or presence of connexion betweenthe sewers and the water supplied. It alsoappears from the same table that the averagemortality from all causes in a series of yearsbears a relation to the quality of the drinkingwater. There is great reason to believe thattyphoid fever and some other epidemicdiseases are communicated occasionallythrough the drinking water; and there are agreat number of facts in the history of thePlague that have led me to believe that it iscommunicated in exactly the same way ascholera. There are also many circumstances

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which render it probable that the cause of onedisease not epidemic and communicable fromperson to person, but endemic viz., ague --often exists in the water of marshy districts,and is acquired by drinking the water; butthere is not space to enter on these subjects atpresent. (b)

(b) Mr. Wm. Blower, surgeon ofBedford. speaking of Woot, . nearBedford, says, “A few wells havebeen dug lately, and good water hasbeen obtained, and there is everyprobability, that if the water pitswere filled up, and more wells-dug,and the draining completed, thatsporadic typhus and ague whichhave so long infested this village,and occasioned so much distress andexpense, might be entirelyeradicated. A respectable farmerinformed me that, in theneighbourhood of Houghton, a fewyears ago, his was the only familythat used well water, and almost theonly one that escaped ague.” --General Report of Poor-lawCommissioners on the SanitaryCondition of Great Britain, 8vo.1842. P. 66.

Mr. Grainger also quotes someinstances, at page 94 of his recentAppendix to the Cholera Report, inwhich a number of personscontracted intermittent fever bydrinking marsh water, while others,exposed no the same atmosphere,who did not drink the water,altogether escaped.

The large public institutions of

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Bethlem Hospital is very copiously suppliedwith water from, an Artesian well on thepremises, and I am informed that there havebeen but two or three cases of cholera out of apopulation of about seven hundred. Mr. Morton, Surgeon to the Queen’s Prison,informs me that, although there has been agood deal of diarrhoea there have been buttwo cases of cholera in that establishment,containing a population, with the officers andattendants, of 300 and upwards, and one of thecases (the only fatal one) occurred in a patientwho had been about a week in the prison, hadsuffered from an attack of cholera just beforehe entered, and had lost some members of hisfamily by it. Now, the Queen's Prison issupplied with very good water from variouswells within the walls. Bethlem Hospital issituated in Lambeth, where one in everyeighty-eight of the population have beencarried off by cholera; and the Queen's Prisonin Southwark, where one in every sixtypersons have died of it: and the latterestablishment is closely surrounded byhouses, in numbers of which the cholera hasbeen very fatal. In another institution in

London, in which the [611a/611b] inmatesare shut up from the rest of the community,showed the influence of the water, or theabsence of that influence, in a remarkablemanner during the late epidemic of cholera.Bethlem Hospital and the Queen’s Prisonare both supplied with water from deep wellson the premises, and, although situated on thesouth of the Thames, in a district in which thecholera was very fatal, there was not a deathfrom that disease in Bethlem Hospital, with apopulation of more than 400, and only onedeath in the Queen’s Prison, with apopulation of 300 and upwards. In MilbankPrison, on the contrary the cholera was veryprevalent until the greater number of theprisoners were sent away. It was considerablyworse, in fact, than among the populationoutside in the same neighbourhood. Therewere 113 cases and 48 deaths; the deathsamounting to 4.3 per cent. of the averagenumber of prisoners. The water used in theMilbank Prison was obtained from theThames at the spot: it was filtered, indeed,through sand and charcoal, but not kept for awhile in large reservoirs like that sent fromthe Chelsea Water-works to the rest ofPimlico and Westminster. In TothillfieldsPrison, supplied by the waterworks justmentioned, there were 13 deaths from choleraamong 800 prisoners, but in all the otherprisons on the north of the Thames which aresupplied with water into which the sewagecannot enter, there was but one death. fromcholera; that death took place in Newgate.

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Mr. Russell, of Horsleydown, who attended

London, situated at the same elevation asthose just mentioned, there has been, togetherwith a difference of water, a difference in therelative prevalence and facility of choleraamongst its inmates and the surroundingpopulation, but here it has been against theinstitution and in favour of those outside: Iallude to the Millbank Prison. The cholerashowed itself there soon after its appearancein London last autumn; and during thesummer of the present year it became veryprevalent, and the greater number of theprisoners were sent away. Dr. Baly statedbefore the coroner that the cases occurred indifferent parts of the prison, amongst personshaving no connection with each other, and thatthe strongest and most healthy men were oftenits victims. The water used in the MillbankPrison is obtained from the Thames at thespot, and is filtered, through sand and charcoaland looks very clear. Before theseinvestigations there could be no objection tosuch water; but it would appear, by the resultthat the filtration was not an effectualsafeguard. I cannot help suggesting that thewater used here may have had someconnection with the dysentery which has beenoften prevalent in this prison, for dysenteryhas apparently been kept up in India by watercontaining human excrements; and the samecircumstance was observed in the old barracksat Cork, by Mr. Bell, surgeon of that town.

(*Dr. Cheyne on Dysentery, DublinHospital Reports, vol. iii.)

The first cases of cholera whichoccurred in London in the autumn of 1848 areparticularly interesting with reference to theinfluence of the water of the Thames.According to the valuable Report of Dr.Parkes on the subject, subsequently correctedby him in one or two particulars, inconsequence of some information which Ireceived from Mr. Russell, surgeon, ofHorsleydown, the first case of cholera inLondon (when the disease was introducedinto this country from Hamburg, the greatestcommercial town on the continent of Europe,as it had been just seventeen years before)occurred on September 22nd, in a seamannamed John Harnold, newly arrived by theElbe steamer. It is, indeed, said that cases ofcholera occurred in London prior to this; andDr. Copland mentioned one in the MedicalGazette as having happened on July 11th, in aman who had been employed on board of a

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the two first cases of the disease occurring inLondon last autumn–that of John Harnold, aseaman just arrived from Hamburgh, wherethe disease was prevailing, and that of a mannamed Blenkinsopp, who came, after thedeath of the former, to lodge and sleep in thesame room, and had the cholera eight daysafter him*–states, that the next cases inHorsleydown, which commenced three orfour days after wards, were in a situation alittle way removed from that of the twopreceding, and having no apparent connectionwith it, except that an open sewer, up whichthe tide flows, runs past both places, and thesewage from the houses in the firstneighbourhood is, when the tide rises, carriedpast those in the second.

*some serious mistakes respectingthese cases have crept into thedocuments furnished to Dr. Parkesby the General Board of Health, assubject matter for his inquiry into thebearing of the earliest cases ofcholera on the question of contagion;as will be evident from a comparisonof the following quotations from Dr.Parkes’s paper, with theaccompanying statement of the realcircumstances:--

“The Elbe steamer leftHamburgh on the 22d September,and arrived in the river on the 25th. Aseaman, named John Harnold, leftthe vessel, and went to live at No.8,New Lane, Gainsford Street,Horsleydown. On the 28th ofSeptember he was seized withsymptoms of cholera, and died in afew hours. It is stated in a letter tothe General Board of Health, fromMr. Russell, who attended the

steam-vessel from St. Petersburgh, where thepestilence was then prevailing. But, lookingon the case of John Harnold as the first, thenthe next case occurred in the same room, onSeptember 30th – eight days afterwards – inthe person of a workman, namedBlenkinsopp. These cases occurred inNew-lane, Gainsford-street, Horsleydown,close to the Thames. In the evening of the dayon which the second case occurred inHorsleydown, a man was taken ill in LowerFore-street, Lambeth, and died on thefollowing morning. At the same time that thiscase occurred in Lambeth, the first of a seriesof cases occurred in White Hart-court,Duke-street, Chelsea, near the river. A day ortwo afterwards, there was a case at 3,Harp-court, Fleet-street. The next caseoccurred on October 2nd, on board the hulkJustitia, lying off Woolwich; and the next tothis in Lower Fore-street, Lambeth, threedoors from where a previous case hadoccurred. The first thirteen cases were allsituated in the localities just mentioned; andon October 5th there were two cases inSpitalfields.

Now, the people in LowerFore-street Lambeth, obtained their water bydipping a pail into the Thames, there being noother supply in the street. In WhiteHart-court, Chelsea, the inhabitants obtainedwater for all purposes in a similar way. Awell was afterwards sunk in the court; but atthe time these cases occurred the people hadno other means of obtaining water, as Iascertained by inquiry on the spot. Theinhabitants of Harp-court, Fleet-street, werein the habit, at that time of procuring waterfrom St. Bride’s pump, which was afterwardsclosed on the representation of Mr.Hutchinson, surgeon, of Farringdon-street inconsequence of its having been found that the

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patient, that all the characteristicsymptoms of cholera were present.Mr. Bowie, who inquired on behalfof the Board into the particulars ofthe case, corroborated this statement.This may, then, be considered as anundoubted case of Cholera.”

“If the disease wasimported thus from Hamburgh, it didnot spread in Horsleydown. Twodays subsequently, indeed, Mr.Russell was sent for to a patient inthe same house, who fancied he hadcholera; but, on examining intoparticulars, it turned out that theindividual in question had beengreatly alarmed at the death of theseaman, and was suffering morefrom the effects of fear thananything else. He was quite well in afew hours. No other person wastaken ill in the house or immediateneighbourhood, although, if thesecond case had not been inquiredinto, a vague story of communicateddisease might have arisen in theneighbourhood.”

Now, the illness and deathof John Harnold took place on the22nd of September, and not on the28th, and Mr. Russell attended thenext case in the same room onSeptember 30th. There were, in thislatter case, rice-water evacuations,and, amongst other decidedsymptoms of cholera, completesuppression of urine from Saturdayto Tuesday morning, and the patientvomited incessantly for twenty-fourhours after this, and after wards hadconsecutive fever. Mr. Russell hadseen a great deal of cholera in 1832,

well had a communication with theFleet-ditch sewer, up which the tide flowsfrom the Thames. I was informed by Dr.Dabbs, that the hulk Justitia was suppliedwith spring water from the WoolwichArsenal; but it is not improbable that waterwas occasionally taken from the Thamesalongside, as was constantly the practice insome of the other hulks, and amongst theshipping generally.

It must no doubt seem very unlikelyto many that the materies morbi of a diseaseshould pass for a distance of two or threemiles through the water; but the propagationof [611b/612a] plants and the lower forms of

34

and had no doubt of this being agenuine case; and he has seen a greatdeal of the disease lately, and stillcontinues of the same conviction.

The mistake in the datealone at which the first caseoccurred, alters the bearing of all thefacts submitted to Dr. Parkes, evenshould the particulars of all the othercases be correct. The writeraccidentally detected the errorspointed out in this note by having tocall on Mr. Russell in his inquiriesrespecting Surrey Buildings.

The writer, however, does not wish to bemisunderstood as making this comparison soclosely as to imply that cholera depends onveritable animals, or even animalcules, butrather to appeal to that general tendency tothe continuity of molecular changes, bywhich combustion, putrefaction,fermentation, and the various processes inorganized beings, are kept up.

the cholera poison must multiply itself by akind of growth, changing surroundingmaterials to its own nature like any othermorbid poison;

animals by seeds and ova which can betransported to a distance would appearequally improbable, were it propounded forthe first time. Analogy leads to the belief that,however minute the particles which propagatecholera, they must yet have a definitestructure, (probably that of a microscopiccell), and must therefore not be capable ofdilution, so as to be rendered inert. In the autumn of 1849, Drs. Brittanand Swayne, of Bristol, considered that theyhad discovered the cause of cholera in aminute fungus; and Dr. Wm. Budd, of thesame city, met with the supposed fungus invarious specimens of water used as drink, inplaces where the cholera was very prevalent.It was, perhaps, too much to expect, that weshould obtain a knowledge of cholera moreexact than that which we possess of syphilis,small-pox, and other better known diseases;and the supposed fungi were resolved intoother things. As many of these, however,were particles of bran and other matterswhich had passed through human intestines,the labours of these gentlemen confirm thefact of the water in various places being amedium of communication between thealimentary canals of cholera patients andthose of other people.

In one of the Registration Reports, inthe beginning of last year, Mr. Farr pointedout a remarkable connexion between theprevalence of the cholera of 1849 and thetemperature of the Thames. The probablereason of this connexion is, that the cholerapoison does not so well retain its propertiesunimpaired in water below 60° Fahr. as atwarmer temperatures. Mr. Farr appeared toattribute the influence of temperature to theincreased amount of vapour and effluviagiven off from the surface of the river; butthis would not explain the influence of the

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The recognized physical conditions of theseason do undoubtedly influence cholera. Although it can flourish in every temperature,warm weather is usually most congenial to itsprogress. In September last the number ofcases began to decrease both in London andmany parts of the provinces immediately aftera considerable diminution in the temperatureof the weather. This circumstance, however,is quite compatible with almost every theoryof the cause of cholera. It certainly does notoppose the view of the communication of thedisease; for whilst temperature modifies thehabits as well as the constitution of man, itmight also be expected materially to influencethe cholera poison, when it has to remain anytime out of the body between quitting onepatient and entering another, for the lowerforms of organisms to which the specialanimal poisons bear a marked analogy, aregreatly influenced by heat and cold.

Assuming the views here entertainedto be correct, it is not to be expected that weshould be able to trace the communication ofevery case of cholera. The very nature of themode of propagation of disease aboveexplained must render it obscure and difficultof detection. And the difficulty is probablyincreased by the poison being conveyed bypersons in whom the disease proceeds nofurther than diarrhoea. The communication ofintestinal worms from one patient to anotherhas never been detected, and yet we areobliged to conclude that their minute ova areswallowed, unless we not only adopt thehypothesis of spontaneous generation, butapply it to creatures much higher in the scaleof development than do the usual advocates ofthe doctrine.

water on those who drink it.

It may be here remarked, that itwould be unreasonable to expect to traceevery case of cholera, either through thewater, or by contamination of the food; moreespecially as it is sufficiently probable thatthe disease may he communicated by caseswhich proceed no further than preliminarydiarrhœa. If the view here given be found toexplain more of the progress of cholera themore it is inquired into, it must be held toaccount for the cases which cannot be traced,in the same way that generation accounts forthe existence of plants and animals undercircumstances in which we cannot alwaystrace their parentage.With regard to preventive measures, I entirelyagree with the Registrar-General, that“internal sanitary arrangements, and notquarantine or sanitary lines, are the safe-guards of nations.” For I believe thatquarantine would often be evaded, and isaltogether unnecessary. The presumedsanitary measures however, should have aparticular reference to the mode ofcommunication of cholera, otherwise theymay sometimes be prejudicial instead ofadvantageous. I have given one instance inthe case of Hull, where the malady wasnearly ten times as fatal in the late as in theformer epidemic, on account of a moreplentiful supply of water having beenobtained without reference to its quality. InLondon, the late epidemic was three times as

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fatal as that of 1832. This was, in my opinion,partly owing to the manifestoes of theGeneral Board of health, which wereunderstood to imply that the cholera was notcommunicable or catching in any way; andthese documents had an immense circulation,by being copied into the newspapers. Theeffect was also due to presumed sanitarymeasures employed both in the interval of thetwo epidemics and during the late one. In theinterval a great number of cesspools had beenabolished, and a much larger amount of fæcesbecame daily sent into the Thames, whilst agreat portion of the people had still to drinkthe water; and during the epidemic itself, theflushing of the sewers increased the mischiefin two ways: first, by driving the choleraevacuations into the river before there wastime for the poison to be rendered inert bydecomposition; and second, by makingincreased calls on the various companies forwater to flush the sewers with, so that thewater which they sent to their customersremained for a shorter time in the reservoirsbefore being distributed. It should beremarked also, that the contents of the sewerswere driven into the Thames by the flushing,at low water, and remained flowing up thestream for four or five hours afterwards.

The sanitary measures required forthe prevention of cholera, according to theviews here explained, suggest themselves atonce. They are as follow: –

1. The entire disuse of water intowhich sewers flow, or [612a/612b] which isnavigated by persons living in boats, or whichis in any other way contaminated by thecontents of drains or cesspools.

2. An extended use of hand-basinsand towels among the poor, together withsufficient water always in readiness.

3. Strict cleanliness in every one

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If the writer’s opinions be correct, choleramight be checked and kept at bay by simplemeasures that would not interfere with socialor commercial intercourse; and the enemywould be shorn of his chief terrors. It wouldonly be necessary for all persons attending orwaiting on the patient to wash their handscarefully and frequently, never omitting to doso before touching food, and for everybody toavoid drinking, or using for culinarypurposes, water into which drains and sewersempty themselves; or, if that cannot beaccomplished, to have the water filtered andwell boiled before it is used. The sanitarymeasure most required in the metropolis is asupply of water for the south and east districtsof it from some source quite removed fromthe sewers.

It should be observed, that the modeof contracting the malady here indicated doesnot altogether preclude the possibility of itsbeing transmitted a short distance through theair; for the organic part of the fæces, whendry, might be wafted as a fine dust, in thesame way as the spores of cryptogamicplants, or the germs of animalcules, andentering the mouth, might be swallowed. Inthis manner, open sewers, as their contents

about the patient, or the dead body; andespecial care in all such persons to wash theirhands before touching food.

4. The separation of the healthy fromthe sick, and their removal to another abode,when they have no place but the sick room inwhich to prepare and take their meals.

5. The immersion of all soiled linenin water, until it can be scalded and washed;for if it should become dry, the fæces mightbe wafted about in the form of dust and so beswallowed by any one who should come nearthe linen.

In the way just indicated, it isprobable that cholera may be occasionallycommunicated for a short distance throughthe air; and when small-pox and otherdiseases are communicated through the air, itis most likely by organised particles, whichare wafted like the seeds of plants and the ovaof some animals, and not by anything in theform of gas or vapour. Indeed there areneither facts nor analogy to show that anykind of epidemic disease whatever can becaused by the air, or even influenced by it,otherwise than indirectly. Epidemics havebeen attributed to the state of the atmospheresince the time of Hippocrates, and theantiquity of the belief causes it to be receivedas an indisputable axiom, although our betterknowledge of the nature of the air, and ofgaseous bodies in general, is capable ofentirely disproving it. But the facts whichdisprove the atmospheric theory of diseasesare often pressed into its service, and sohandled as to lend it apparent support.

It is a curious circumstance that themedical men who are most active inadvocating the sanitary measures whish, as ageneral rule, would prevent thecommunication of cholera, for the most partdisbelieve in its communicability, probably

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are continually becoming dry on the sides,might be means of conveying cholera,independently of their mixing with water usedfor drinking.

because the question had never suggesteditself to them, except in the form of infectionby means of effluvia, or of contagion bycontact. What is still more remarkable is thatthese gentlemen generally look on thepresence of all those circumstances which aidin the communication of cholera, when foundin situations where the pestilence prevails, asproofs that it is not communicable. Theyspeak of these circumstances as somethingwhich can explain the increased prevalence ofthe disease without its being communicable,although it has never been explained in thisway, even by a hypothesis. One or twohypotheses have indeed been attempted, buthave signally failed. One of the most able andexperienced authors on cholera writes, forinstance, as follows . – “If we could supposethat certain organic impurities existing in theatmosphere of unhealthy neighbourhoods,passed into the blood through the lungs, so asto follow the circulation and that similarimpurities taken into the stomach witharticies of food or drink, were likewiseabsorbed into the blood; if we could,moreover, suppose that the epidemicinfluence possessed the power of assimilatingsuch organic matter to its own poisonousnature, we should be enabled to include anumber of complex phenomena under ahypothesis which would indicate the requisitemeasures of prevention.” The abovequotation is from Dr. Sutherland’s Appendixto the Report on Cholera; but the latter part ofthe supposition is quite incapable of beingentertained for various reasons, one of whichis, that the assumed epidemic influence, inorder to he capable of acting in this way,must consist of some material mixed with theatmosphere, and if so, it would diffuse itselfthrough the air, and would also pass alongwith the air. It could not travel against the

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wind, or remain in a spot for weeks, withoutextending to the next parish when the air ismoving at the rate of one or two hundredmiles a day.

There is much evidence on thesubject of this paper which I had not room tobring forward, and many important pointsconnected with it that have not been ableeven to allude to; but I trust that I havesucceeded in drawing the attention of theSociety to the views I have endeavoured toexplain, in such a way that they will beinduced to consider the question carefully forthemselves. (a)

54, Frith-street, Soho-square.

(a) This paper was originally readbefore the Epidemiological Society.