flows through the town, and into which the sewers discharge their
contents, which float afterwards to and fro with the tide. In 1832 there
were 418 deaths from cholera out of a population of 11,606, being at the
rate of 360 in 10,000, or 1 in every 28 of the inhabitants. The cholera
again visited Dumfries at the close of 1848, and carried off 431
persons, or 1 in every 32, out of a population now numbering 14,000; so
that the mortality was excessive on both occasions.
Preston and Oldham, in Lancashire, are supplied with water from surface
drainage on the neighbouring hills, and there was scarcely any cholera
at either of these places in 1849. The greater part of the town of
Paisley is supplied in a similar way; and I was informed that the cases
of cholera which occurred there in 1849 were confined to a quarter of
the town to which this supply of water does not extend. Nottingham is
supplied with filtered water obtained from the river Trent, some
distance above the town. In 1832 this supply did not extend to all the
inhabitants, and the cholera was somewhat prevalent amongst the poor, of
whom it carried off 289; the population of the town being 53,000. After
that time the water was extended copiously to all the inhabitants, and
there were but thirteen deaths from the epidemic in 1849. The local
Sanitary Committee placed the supply of water amongst the chief causes
of this immunity from cholera, and I believe justly. There were but
seven deaths from cholera in Nottingham last summer.
[Sidenote: CHOLERA IN GLASGOW.]
Glasgow has been supplied, since the early part of the present century,
with the water of the Clyde, obtained a little way above the town, but
within the influence of the tide, and consequently mixed with the
contents of the sewers. It is imperfectly filtered through sand. In
1847, however, the parish of Gorbals, which forms the south part of
Glasgow, was furnished with a supply of water collected on the
neighbouring hills; and Dr. Leech, of Glasgow, speaks as follows
respecting the influence of this water on the prevalence of cholera:
“During the late cholera there was a remarkable circumstance, which
deserves notice as compared with the epidemic of 1832. Since the former
period, the population of Glasgow, south of the Clyde, has nearly
doubled; and with this exception, and the introduction of the soft-water
supply, the circumstances might be considered as the same at both
periods. In one district, the parish of Gorbals, the attack in 1832 was
fearful; while Glasgow, north of the Clyde, also suffered severely.
During the late epidemic [that of 1848–49], Gorbals parish furnished
comparatively a small number of cases; while the epidemic in other parts
of Glasgow was very severe. The unanimous opinion of the Medical Society
was, that this comparative immunity was to be attributed to the
soft-water supply.”[22]
[Sidenote: CHOLERA IN NEWCASTLE.]
I was informed that when the cholera was prevalent in Glasgow last
winter, the parish of Gorbals again enjoyed a similar immunity from the
disease.
The following passage respecting the water supply of Paris is from Dr.
Farr’s “Report to the Registrar-General on the Cholera of 1848–49”:—“The
supply of Paris is from various sources, but four-fifths of the water is
from the Canal de l’Ourque, which, by the decision of Napoleon, was also
appropriated to navigation. The water for some years, and in 1832, when
the epidemic was so fatal, was drawn from the dirty basin in which the
boats and barges of the canals rested; but is now drawn from the canal
before it enters the basin.... The mortality of cholera in Paris was
excessive, and in 1832 varied from 80, of 10,000 inhabitants, in the
elegant Chaussée d’Antin and in Montmartre on the heights, to 530 and
520 in the low quartiers of the Hôtel de Ville and the Cité.” (p.
lxxviii.)
The town of Newcastle-upon-Tyne affords a remarkable instance of the
influence of the water supply on the prevalence of cholera. In 1831–32
there were no waterworks at Newcastle; it was supplied, in an
insufficient manner, with spring water, which generally had to be
carried some distance to the houses from “pants” in the streets. The
epidemic was pretty severe at this time. From November 1831 to November
1832 there were 801 deaths from cholera out of a population of 42,760.
The disease prevailed chiefly amongst the poor, and was worst in the
least elevated parts of the town, near the river. Subsequently to 1832,
waterworks were established on the river Tyne, a little above the town;
but these were abandoned, in 1848, in favour of a supply from a rivulet
and springs at Whittle Dean, about ten miles distant. In 1849, there
were but 295 deaths from cholera in a population then increased to
71,847. In the beginning of July 1853, two months before the
reappearance of cholera in England, the Whittle Dean Water Company found
their proper sources insufficient for the demands of the population and
the various factories, and they made use of the former waterworks,
mentioned above, to obtain water from the Tyne. The point at which they
obtained water from the river, is scarcely a mile above Newcastle, and
the tide flows for six miles above the town, carrying the contents of
the sewers with it. There are also villages, containing several
thousands of colliers and ironfounders, on the banks of the Tyne, above
the waterworks. The water from the Tyne was mixed, without filtration,
with that from Whittle Dean, to the extent of one-third; and the mixed
water, so supplied, was discoloured, and contained the large quantity of
7·1 grains of organic matter per gallon.
In the autumn of 1853, the cholera was prevailing extensively at
Hamburgh, and in nearly all the ports of the Baltic, whence a number of
ships were arriving every day in the Tyne. The first cases of cholera
commenced, with diarrhœa, on the 27th and 28th August, at Bell Quay, on
the banks of the Tyne, three miles below Newcastle. One of the patients
from Bell Quay was taken worse whilst on a visit to her mother at
Newcastle: she died on 2nd September. Her mother was taken ill the same
evening, and died on the following day. Other cases occurred in
Newcastle on the 1st and 2nd of September, having no connexion with
these. A ship from Bremen was lying at Bell Quay, opposite the house
where the first cases occurred; but there had been no illness on board
this ship, and the precise way in which the cholera was introduced on
this occasion, is not known.
The disease soon spread to an extent almost unprecedented in this
country: by the 15th of September the deaths exceeded a hundred a day.
In nine weeks there were 1,533 deaths from cholera in a population of
86,114, being 178 to each 10,000 inhabitants; but the greater number of
these deaths occurred in a few days, as 1001 took place from the 13th to
the 23rd Sept. inclusive.[23]
Gateshead, which is situated opposite to Newcastle, on the other side of
the Tyne, is supplied with the same water; and in 1849 it shared with
that town a comparative immunity from cholera, whilst in the autumn of
1853, 433 persons died of that disease out of a population of 26,000, or
thereabouts, being 166 to each 10,000 inhabitants.
The lowest streets in Newcastle and Gateshead are about five feet above
high-water mark; and only a few streets are situated at this level, for
the banks rise very abruptly, at a little distance from the river, on
both sides. A great portion of each town is elevated nearly 200 feet
above the river, and some parts are nearly 300 feet high; yet the Water
Company supplies all these districts, and all were severely visited by
the cholera, which on this occasion spared no class of the community. In
the districts which are most crowded, the mortality was greatest, the
deaths being much more numerous in the parishes which contained a great
number of tenements consisting of a single room, than in those which
consisted chiefly of houses occupied by one family.[24] This, however,
is quite in accordance with the principles which I am throughout
endeavouring to explain. A great deal of stress is laid, very properly,
by the Commissioners who have reported respecting this outbreak, on the
ill-arranged buildings, the defective drainage, and want of privy
accommodation, in Newcastle; but it must be remembered that all these
evils existed in 1849, when Newcastle escaped with less cholera than
most towns,—to a greater extent than they did in 1853, for many
improvements had taken place in the meantime.
In consequence of a great outcry on the part of the public, who
naturally connected the great fatality of cholera in some measure with
the turbidity and offensive smell of the drinking water, the Company
entirely ceased to draw water from the Tyne on the 15th September; and
although the Tyne water was not entirely out of the pipes for a day or
two, the deaths, which had been rapidly increasing, began to diminish on
the 17th, and were lessened considerably by the 20th. The following is
the course of the mortality in Newcastle, in the most fatal part of the
epidemic; and it began to decline at exactly the same time in Gateshead:
September 12 13 14 15 16 17 18 19 20 21 22 23
DEATHS 38 59 90 106 114 103 103 111 85 68 82 60.
The late General Board of Health directed one of their medical
inspectors, Dr. Waller Lewis, to make minute inquiry as to the relative
effects produced by the use of pure spring water, and that of the Water
Company, during the epidemic of cholera in Newcastle; and it is much to
be regretted that the inquiry was not carried out. To have conducted the
inquiry through the whole of Newcastle and Gateshead would not have
entailed a quarter as much labour as my investigations in Lambeth,
Newington, and the Borough. Dr. Lewis called on Mr. Main, the secretary
of the Water Company, and they made an inquiry in certain houses, taken
at random, through three streets, and also in Greenhow Terrace, where a
severe outbreak of cholera had occurred, although it was not supplied by
the Company, but had what was reported to be good spring water. Dr.
Lewis gave up the inquiry because he could not find two places exactly
alike in all their physical conditions,—one place supplied with spring
water, the other by the Company. He made no report of what he had done;
but Mr. Main sent a paper on the subject of this commenced inquiry to
the Pathological Society of Newcastle, an abstract of which appeared in
the “Medical Times and Gazette”.
By adding Greenhow Terrace to the streets partly supplied by the
Company, and by including cases of cholera, fatal or otherwise, with
those of mere diarrhœa, Mr. Main was able to show a result apparently in
favour of the Company’s water. He was good enough, however, to send me a
copy of his paper, which contains the details of the inquiry as far as
it extended; and I found, on perusing it, that, leaving out Greenhow
Terrace, which is not supplied by the Company at all, there was no case
of cholera, either fatal or otherwise, and no case, even of approaching
cholera, in any house which was not supplied with the Company’s water.
All the deaths and all the cholera occurred in the houses having this
water, whilst in the houses having only pump-water, there was simply
diarrhœa. In the workhouse, supplied by the Water Company, and having
five hundred and forty inmates, there were twelve cases of cholera, or
approaching cholera, and seven deaths; whilst in the military barracks,
supplied from wells on the premises, and having five hundred and
nineteen inmates, although there was a good deal of harmless diarrhæa,
there was no cholera, nor any case of approaching cholera.
[Sidenote: CHOLERA AT MOSCOW.]
The communication of cholera by means of the water is well illustrated
by the instance of Moscow, which was severely visited by that disease in
1830; but much less severely in the second epidemic. Subsequently to
1830 the greater part of the town, which is situated to the north of the
Moscow river, obtained a supply of excellent water, conducted in pipes
from springs at a distance; and the cholera in 1847 was chiefly confined
to those parts of the town which lie to the south of the river, to which
the new supply of water did not extend, and where the people had still
only impure river water to drink.[25]
The above instances are probably sufficient to illustrate the
widely-spread influence which the pollution of the drinking water exerts
in the propagation of cholera.
[Sidenote: DIFFUSION OF THE CHOLERA POISON IN WATER.]
After the Registrar-General alluded, in the “Weekly Return” of 14th
October last, to the very conclusive investigation of the effects of
polluted water in the south districts of London, there was a leading
article, in nearly all the medical periodicals,[26] fully admitting the
influence of the water on the mortality from cholera. It may therefore
be safely concluded that this influence is pretty generally admitted by
the profession. It must not be disguised, however, that medical men are
not yet generally convinced that the disease is actually communicated
from person to person by the morbid matter being swallowed in the
drinking water, or otherwise. It used to be the custom of medical
authors to speak of three kinds of causes of a disease, viz.
predisposing, exciting, and proximate causes. The proximate causes have
been given up, as being the diseases themselves; but authors still
divide causes into predisposing and exciting ones. It may be remarked,
however, that in treating of certain communicable diseases, the cause of
which is thoroughly understood, as syphilis and the itch, predisposing
causes are never mentioned; and that they are rarely alluded to in
treating of small-pox, measles, and scarlet fever, whilst they continue
to be appealed to in explanation of the various continued fevers.[27]
Now many medical men, whilst they admit the influence of polluted water
on the prevalence of cholera, believe that it acts by predisposing or
preparing the system to be acted on by some unknown cause of the disease
existing in the atmosphere or elsewhere. The following amongst other
reasons prove, however, that opinion cannot long halt here, and that, if
the effect of contaminated water be admitted, it must lead to the
conclusion that it acts by containing the true and specific cause of the
malady.
In my inquiries in the south districts of London I met with several
instances in which persons, especially maidservants and young men, died
of cholera within a few days after coming from the country to a house
supplied with water by the Southwark and Vauxhall Company. The Registrar
of Waterloo Road (2nd) remarked as follows on this point, on 26th August
last:—“This is the third successive case of fatal cholera, where the
patients have recently come from the country. Similar instances have
frequently attracted the Registrar’s notice.” I found that the houses in
which these cases occurred were supplied by the above-named Company. The
outbreak of cholera in the Baltic fleet, related at page 36, occurred
within forty-eight hours after the polluted water had been taken on
board. And lastly, if the contaminated water merely acted by
predisposing or preparing the system to be affected by some other cause,
it would be impossible to explain why nearly all the persons drinking it
should be attacked together, in cases where a pump-well or some other
limited supply is polluted, while the population around experience no
increase of the malady.
All the evidence proving the communication of cholera through the medium
of water, confirms that with which I set out, of its communication in
the crowded habitations of the poor, in coal-mines and other places, by
the hands getting soiled with the evacuations of the patients, and by
small quantities of these evacuations being swallowed with the food, as
paint is swallowed by house painters of uncleanly habits, who contract
lead-colic in this way.
There are one or two objections to the mode of communication of cholera
which I am endeavouring to establish, that deserve to be noticed.
Messrs. Pearse and Marston state, in their account of the cases of
cholera treated at the Newcastle Dispensary in 1853, that one of the
dispensers drank by mistake some rice-water evacuation without any
effect whatever.[28] In rejoinder to this negative incident, it may be
remarked, that several conditions may be requisite to the communication
of cholera with which we are as yet unacquainted. Certain conditions we
know to be requisite to the communication of other diseases. Syphilis we
know is only communicable in its primary stage, and vaccine lymph must
be removed at a particular time to produce its proper effects. In the
incident above mentioned, the large quantity of the evacuation taken
might even prevent its action. It must be remembered that the effects of
a morbid poison are never due to what first enters the system, but to
the crop or progeny produced from this during a period of reproduction,
termed the period of incubation; and if a whole sack of grain, or seed
of any kind, were put into a hole in the ground, it is very doubtful
whether any crop whatever would be produced.
[Sidenote: EXPERIMENTS OF DR. THIERSCH ANSWERS TO CERTAIN OBJECTIONS.]
Dr. Thiersch is of opinion, as appears by a discussion which has
recently taken place at Munich, that the cholera evacuations are not at
first capable of generating the disease; but that a decomposition takes
place in them, and that in from six to nine days they become in a state
to induce cholera. He founds this opinion on experiments which he
performed by giving small quantities of the cholera evacuations to white
mice. Although it is not contrary to all analogy that some change or
development should take place in the cholera poison in the interval
between its leaving one person and entering another, it is most probable
that the fatal bowel complaint produced in white mice by Dr. Thiersch
was not a specific disease, but the ordinary effect of putrifying
ingesta. Many of the best attested instances of the communication of
cholera are those, such as were related at the commencement of this
work, where the patient is attacked in from twenty-four to forty-eight
hours after first being near another patient, and although an interval
of a week or so, often elapses between one case of the disease and those
which follow, it is extremely probable that, in these instances, the
evacuations remain the greater part of this time in a dry state on the
soiled linen, without undergoing any change.
An objection that has repeatedly been made to the propagation of cholera
through the medium of water, is, that every one who drinks of the water
ought to have the disease at once. This objection arises from mistaking
the department of science to which the communication of cholera belongs,
and looking on it as a question of chemistry, instead of one of natural
history, as it undoubtedly is. It cannot be supposed that a morbid
poison, which has the property, under suitable circumstances, of
reproducing its kind, should be capable of being diluted indefinitely in
water, like a chemical salt; and therefore it is not to be presumed that
the cholera poison would be equally diffused through every particle of
the water. The eggs of the tape-worm must undoubtedly pass down the
sewers into the Thames, but it by no means follows that everybody who
drinks a glass of the water should swallow one of the eggs. As regards
the morbid matter of cholera, many other circumstances, besides the
quantity of it which is present in a river at different periods of the
epidemic, must influence the chances of its being swallowed, such as its
remaining in a butt or other vessel till it is decomposed or devoured by
animalcules, or its merely settling to the bottom and remaining there.
In the case of the pump-well in Broad Street, Golden Square, if the
cholera poison was contained in the minute whitish flocculi, visible on
close inspection to the naked eye, some persons might drink of the water
without taking any, as they soon settled to the bottom of the vessel.
[Sidenote: THEORIES OF THE CAUSE OF CHOLERA.]
It is not necessary to oppose any other theories in order to establish
the principles I am endeavouring to explain, for the field I have
entered on was almost unoccupied. The best attempt at explaining the
phenomena of cholera, which previously existed, was probably that which
supposed that the disease was communicated by effluvia given off from
the patient into the surrounding air, and inhaled by others into the
lungs; but this view required its advocates to draw very largely on what
is called predisposition, in order to account for the numbers who
approach near to the patient without being affected, whilst others
acquire the disease without any near approach. It also failed entirely
to account for the sudden and violent outbreaks of the disease, such as
that which occurred in the neighbourhood of Golden Square.
Another view having a certain number of advocates is, that cholera
depends on an unknown something in the atmosphere which becomes
localized, and has its effects increased by the gases given off from
decomposing animal and vegetable matters. This hypothesis is, however,
rendered impossible by the motion of the atmosphere, and, even in the
absence of wind, by the laws which govern the diffusion of aeriform
bodies; moreover, the connection between cholera and offensive effluvia
is by no means such as to indicate cause and effect; even in London, as
was before mentioned, many places where offensive effluvia are very
abundant have been visited very lightly by cholera, whilst the
comparatively open and cleanly districts of Kennington and Clapham have
suffered severely. If inquiry were made, a far closer connection would
be found to exist between offensive effluvia and the itch, than between
these effluvia and cholera; yet as the cause of itch is well known, we
are quite aware that this connection is not one of cause and effect.
Mr. John Lea, of Cincinnati, has advanced what he calls a geological
theory of cholera.[29] He supposes that the cholera poison, which he
believes to exist in the air about the sick, requires the existence of
calcareous or magnesian salts in the drinking water to give it effect.
This view is not consistent with what we know of cholera, but there are
certain circumstances related by Mr. Lea which deserve attention. He
says that, in the western districts of the United States, the cholera
passed round the arenacious, and spent its fury on the calcareous
regions; and that it attacked with deadly effect those who used the
calcareous water, while it passed by those who used sandstone or soft
water. He gives many instances of towns suffering severely when river
water was used, whilst others, having only soft spring water or rain
water, escaped almost entirely; and he states that there has been
scarcely a case of cholera in families who used only rain water. The
rivers, it is evident, might be contaminated with the evacuations,
whilst it is equally evident that the rain water could not be so
polluted. As regards sand and all sandstone formations, they are well
known to have the effect of oxidizing and thus destroying organic
matters; whilst the limestone might not have that effect, although I
have no experience on that point. The connection which Mr. Lea has
observed between cholera and the water is highly interesting, although
it probably admits of a very different explanation from the one he has
given.
[Sidenote: DURATION OF CHOLERA IN DIFFERENT PLACES.]