Part 5

The loss of water from the blood causes it to assume the thick tarry appearance, so well known to all who have opened a vein in cholera. The diminished volume of the blood causes many of the symptoms of a true hæmorrhage, as debility, faintness, and coldness; while these effects are much increased by its thick and tenacious condition, which impedes its passage through the pulmonary capillaries, thereby reducing the contents of the arteries throughout the system to the smallest possible amount, as indicated by the small thready pulse. The interruption to the pulmonary circulation occasioned by the want of fluidity of the blood, is the cause of the distressing feeling of want of breath. Proofs of the obstructed circulation through the lungs generally remain after death, in the distended state of the pulmonary arteries and right cavities of the heart. The deficient supply of blood to the various organs, and its unfitness to pass through the capillaries, are the cause of the suppression of the renal, biliary, and other secretions. The cramps appear to consist chiefly of reflex action, caused by the irritation, and probably the distension, of the bowels.

If any further proof were wanting than those above stated, that all the symptoms attending cholera, except those connected with the alimentary canal, depend simply on the physical alteration of the blood, and not on any cholera poison circulating in the system, it would only be necessary to allude to the effects of a weak saline solution injected into the veins in the stage of collapse. The shrunken skin becomes filled out, and loses its coldness and lividity; the countenance assumes a natural aspect; the patient is able to sit up, and for a time seems well. If the symptoms were caused by a poison circulating in the blood, and depressing the action of the heart, it is impossible that they should thus be suspended by an injection of warm water, holding a little carbonate of soda in solution.

It has often been contended that the collapse of cholera cannot be the mere result of the purging and vomiting, because, in some of the most rapid and malignant cases, the amount of the stools and vomited fluid is less than in milder and more protracted ones, or even in some cases in which the patients recover. But, in the most rapid and malignant cases, there is sufficient loss of aqueous fluid by the alimentary canal to alter the blood into the thick tenacious state peculiar to this disease; and the fact of more purging occurring in other cases which are more protracted, only proves that, in these latter, absorption from the stomach and intestines has not been altogether arrested, or that the stools have been diluted with fluids drank by the patient. The loss of fluid in every case of fully developed cholera must be sufficient to cause the thickened state of the blood, which is the cause of the algide symptoms; and the amount of malignancy of the case must depend chiefly on the extent to which the function of absorption is impaired.

If absorption were altogether arrested in every case of cholera from the beginning, the amount of discharge from the alimentary canal would not equal that of a fatal hæmorrhage, for the thickened blood which remains is certainly not able to maintain life so well as the same quantity of healthy blood. Indeed, it is easy to calculate the amount of fluid separated from the blood, by means of the analyses previously quoted, and others which have been made of the cholera stools. In some analyses of these evacuations made by Dr. Parkes, the average composition in 1,000 parts was found to be 982.4 water and 17.6 solids; consequently, the problem is merely to find how much of such a fluid requires to be subtracted from blood consisting of water 785 and solids 215, in 1000 parts, in order to reduce it to blood consisting of water 733 and solids 267. The answer to this problem is that 208.5 parts would require to be subtracted from 1000 parts of blood. M. Valentin has estimated the average amount of blood in the human adult at thirty pounds; and, therefore, the whole quantity of fluid that requires to be effused into the stomach and bowels, in order to reduce the blood of a healthy adult individual to the condition in which it is met with in the collapse of cholera is, on the average, 100 ounces, or five imperial pints. This calculation may be useful as indicating the amount of fluid which ought not to be exceeded in the injection of the blood vessels.

Diseases which are communicated from person to person are caused by some material which passes from the sick to the healthy, and which has the property of increasing and multiplying in the systems of the persons it attacks. In syphilis, small-pox, and vaccinia, we have physical proof of the increase of the morbid material, and in other communicable diseases the evidence of this increase, derived from the fact of their extension, is equally conclusive. As cholera commences with an affection of the alimentary canal, and as we have seen that the blood is not under the influence of any poison in the early stages of this disease, it follows that the morbid material producing cholera must be introduced into the alimentary canal—must, in fact, be swallowed accidentally, for persons would not take it intentionally; and the increase of the morbid material, or cholera poison, must take place in the interior of the stomach and bowels. It would seem that the cholera poison, when reproduced in sufficient quantity, acts as an irritant on the surface of the stomach and intestines, or, what is still more probable, it withdraws fluid from the blood circulating in the capillaries, by a power analogous to that by which the epithelial cells of the various organs abstract the different secretions in the healthy body. For the morbid matter of cholera having the property of reproducing its own kind, must necessarily have some sort of structure, most likely that of a cell. It is no objection to this view that the structure of the cholera poison cannot be recognised by the microscope, for the matter of small-pox and of chancre can only be recognised by their effects, and not by their physical properties.

The period which intervenes between the time when a morbid poison enters the system, and the commencement of the illness which follows, is called the period of incubation. It is, in reality, a period of reproduction, as regards the morbid matter; and the disease is due to the crop or progeny resulting from the small quantity of poison first introduced. In cholera, this period of incubation or reproduction is much shorter than in most other epidemic or communicable diseases. From the cases previously detailed, it is shown to be in general only from twenty-four to forty-eight hours. It is owing to this shortness of the period of incubation, and to the quantity of the morbid poison thrown off in the evacuations, that cholera sometimes spreads with a rapidity unknown in other diseases.

The mode of communication of cholera might have been the same as it is, even if it had been a disease of the blood; for there is a good deal of evidence to show that plague, typhoid fever, and yellow fever, diseases in which the blood is affected, are propagated in the same way as cholera. There is sufficient evidence also, I believe, in the following pages, to prove the mode of communication of cholera here explained, independently of the pathology of the disease; but it was from considerations of its pathology that the mode of communication was first explained, and, if the views here propounded are correct, we had a knowledge of cholera, before it had been twenty years in Europe, more correct than that of most of the older epidemics; a knowledge which, indeed, promises to throw much light on the mode of propagation of many diseases which have been present here for centuries.

The instances in which minute quantities of the ejections and dejections of cholera patients must be swallowed are sufficiently numerous to account for the spread of the disease; and on examination it is found to spread most where the facilities for this mode of communication are greatest. Nothing has been found to favour the extension of cholera more than want of personal cleanliness, whether arising from habit or scarcity of water, although the circumstance till lately remained unexplained. The bed linen nearly always becomes wetted by the cholera evacuations, and as these are devoid of the usual colour and odour, the hands of persons waiting on the patient become soiled without their knowing it; and unless these persons are scrupulously cleanly in their habits, and wash their hands before taking food, they must accidentally swallow some of the excretion, and leave some on the food they handle or prepare, which has to be eaten by the rest of the family, who, amongst the working classes, often have to take their meals in the sick room: hence the thousands of instances in which, amongst this class of the population, a case of cholera in one member of the family is followed by other cases; whilst medical men and others, who merely visit the patients, generally escape. The post mortem inspection of the bodies of cholera patients has hardly ever been followed by the disease that I am aware, this being a duty that is necessarily followed by careful washing of the hands; and it is not the habit of medical men to be taking food on such an occasion. On the other hand, the duties performed about the body, such as laying it out, when done by women of the working class, who make the occasion one of eating and drinking, are often followed by an attack of cholera; and persons who merely attend the funeral, and have no connexion with the body, frequently contract the disease, in consequence, apparently, of partaking of food which has been prepared or handled by those having duties about the cholera patient, or his linen and bedding.

Deficiency of light is a great obstacle to cleanliness, as it prevents dirt from being seen, and it must aid very much the contamination of the food with the cholera evacuations. Now the want of light, in some of the dwellings of the poor, in large towns, is one of the circumstances that has often been commented on as increasing the prevalence of cholera.

The involuntary passage of the evacuations in most bad cases of cholera, must also aid in spreading the disease. Mr. Baker, of Staines, who attended two hundred and sixty cases of cholera and diarrhœa in 1849, chiefly among the poor, informed me, in a letter with which he favoured me in December of that year, that “when the patients passed their stools involuntarily the disease evidently spread.” It is amongst the poor, where a whole family live, sleep, cook, eat, and wash in a single room, that cholera has been found to spread when once introduced, and still more in those places termed common lodging-houses, in which several families were crowded into a single room. It was amongst the vagrant class, who lived in this crowded state, that cholera was most fatal in 1832; but the Act of Parliament for the regulation of common lodging-houses, has caused the disease to be much less fatal amongst these people in the late epidemics. When, on the other hand, cholera is introduced into the better kind of houses, as it often is, by means that will be afterwards pointed out, it hardly ever spreads from one member of the family to another. The constant use of the hand-basin and towel, and the fact of the apartments for cooking and eating being distinct from the sick room, are the cause of this.

The great prevalence of cholera in institutions for pauper children and pauper lunatics, whenever it has gained access to these buildings, meets with a satisfactory explanation according to the principles here laid down. In the asylum for pauper children at Tooting, one hundred and forty deaths from cholera occurred amongst a thousand inmates, and the disease did not cease till the remaining children had been removed. The children were placed two or three in a bed, and vomited over each other when they had the cholera. Under these circumstances, and when it is remembered that children get their hands into everything, and are constantly putting their fingers in their mouths, it is not surprising that the malady spread in this manner, although I believe as much attention was paid to cleanliness as is possible in a building crowded with children. Pauper lunatics are generally a good deal crowded together, especially in their sleeping wards, and as the greater number of them are in a state of imbecility, they are no more careful than children in the use of their hands. It is with the greatest difficulty that they can be kept even moderately clean. As might be expected, according to the views here explained, the lunatic patients generally suffered in a much greater proportion than the keepers and other attendants.

The mining population of Great Britain has suffered more from cholera than persons in any other occupation,—a circumstance which I believe can only be explained by the mode of communication of the malady above pointed out. Pitmen are differently situated from every other class of workmen in many important particulars. There are no privies in the coal-pits, or, as I believe, in other mines. The workmen stay so long in the mines that they are obliged to take a supply of food with them, which they eat invariably with unwashed hands, and without knife and fork. The following is a reply which I received from a relative of mine connected with a colliery near Leeds, in answer to an inquiry I made:—

“Our colliers descend at five o’clock in the morning, to be ready for work at six, and leave the pit from one to half-past three. The average time spent in the pit is eight to nine hours. The pitmen all take down with them a supply of food, which consists of cake, with the addition, in some cases, of meat; and all have a bottle, containing about a quart of ‘drink’. I fear that our colliers are no better than others as regards cleanliness. The pit is one huge privy, and of course the men always take their victuals with unwashed hands.”

It is very evident that, when a pitman is attacked with cholera whilst at work, the disease has facilities for spreading among his fellow-labourers such as occur in no other occupation. That the men are occasionally attacked whilst at work I know, from having seen them brought up from some of the coal-pits in Northumberland, in the winter of 1831–2, after having had profuse discharges from the stomach and bowels, and when fast approaching to a state of collapse.

Dr. Baly, who has done me the honour of giving a very full and impartial account of my views in his “Report on Cholera to the College of Physicians”, makes the objection to what I have said about the colliers, that the women and children who do not work in the mines, were attacked in as large numbers as the men. I believe, however, that this is only what ought to occur from the propagation of the cholera in the crowded dwellings of the pitmen, in the manner previously explained. The only effect of its communication in the pits would be, that the men and boys in a family would have the cholera a day or two earlier than the women and children; and if a special inquiry were made on this point, this would probably be found to be the case. It has often been said that, if cholera were a communicable disease, women ought to suffer in much greater numbers than the men, as they are employed in nursing the sick. I leave this objection and Dr. Baly’s to combat each other.

It is very probable that, when cholera occurs amongst people who are employed in the preparation or vending of provisions, the disease may be spread by this means, although from the nature of the subject it is hardly to be expected that the fact would be discovered. The following cases, perhaps, afford as decisive proof of this variety of communication of cholera as can be expected. In the beginning of 1850, a letter appeared in the Provincial Medical and Surgical Journal, from Mr. John C. Bloxam, in the Isle of Wight, being an answer to the inquiry on cholera by Mr. Hunt. Among other interesting information, Mr. Bloxam stated, that the only cases of cholera that occurred in the village of Carisbrook, happened in persons who ate of some stale cow-heels, which had been the property of a man who died in Newport, after a short and violent attack of cholera. Mr. Bloxam kindly made additional personal inquiries into the case, in consequence of questions I put to him, and the following is a summary of the information contained in his letter:—

The man from whose house the cow-heels were sent for sale died on Monday, the 20th of August. It was the custom in the house to boil these articles on Monday, Wednesday, and Friday; and the cow-heels under consideration were taken to Carisbrook, which is a mile from Newport, ready boiled, on Tuesday the 21st. Eleven persons in all partook of this food, seven of whom ate it without any additional cooking. Six of these were taken ill within twenty-four hours after eating it, five of whom died, and one recovered. The seventh individual, a child, who ate but a small quantity of the cow-heels, was unaffected by it. Four persons partook of the food after additional cooking. In one case the cow-heels were fried, and the person who ate them was taken ill of cholera within twenty-four hours afterwards, and died. Some of the food was made into broth, of which three persons partook while it was warm; two of them remained well, but the third person partook again of the broth next day, when cold, and, within twenty-four hours after this latter meal, she was taken ill with cholera, of which she died. It may be proper to mention, although it is no unusual circumstance for animal food to be eaten in hot weather when not quite fresh, that some of the persons perceived the cow-heels to be not so fresh as they ought to have been at the time they were eaten, and part of them had to be thrown away a day or two afterwards, in consequence of being quite putrid.

It is not unlikely that some of the cases of cholera which spring up without any apparent connection with previous cases, may be communicated through articles of diet. It is the practice of the poor people, who gain a living by selling fruit and other articles in the streets, to keep their stock in the very crowded rooms in which they live, and, when visiting the out-patients of a medical charity a few years ago, I often saw baskets of fruit pushed under the beds of sick patients, in close proximity with the chamber utensils. I need hardly say that if cases of disease were propagated in this way, it would be quite impossible to trace them.

If the cholera had no other means of communication than those which we have been considering, it would be constrained to confine itself chiefly to the crowded dwellings of the poor, and would be continually liable to die out accidentally in a place, for want of the opportunity to reach fresh victims; but there is often a way open for it to extend itself more widely, and to reach the well-to-do classes of the community; I allude to the mixture of the cholera evacuations with the water used for drinking and culinary purposes, either by permeating the ground, and getting into wells, or by running along channels and sewers into the rivers from which entire towns are sometimes supplied with water.

In 1849 there were in Thomas Street, Horsleydown, two courts close together, consisting of a number of small houses or cottages, inhabited by poor people. The houses occupied one side of each court or alley—the south side of Trusscott’s Court, and the north side of the other, which was called Surrey Buildings, being placed back to back, with an intervening space, divided into small back areas, in which were situated the privies of both the courts, communicating with the same drain, and there was an open sewer which passed the further end of both courts. Now, in Surrey Buildings the cholera committed fearful devastation, whilst in the adjoining court there was but one fatal case, and another case that ended in recovery. In the former court, the slops of dirty water, poured down by the inhabitants into a channel in front of the houses, got into the well from which they obtained their water; this being the only difference that Mr. Grant, the Assistant-Surveyor for the Commissioners of Sewers, could find between the circumstances of the two courts, as he stated in a report that he made to the Commissioners. The well in question was supplied from the pipes of the Southwark and Vauxhall Waterworks, and was covered in on a level with the adjoining ground; and the inhabitants obtained the water by a pump placed over the well. The channel mentioned above commenced close by the pump. Owing to something being out of order, the water had for some time occasionally burst out at the top of the well, and overflowed into the gutter or channel, afterwards flowing back again mixed with the impurities; and crevices were left in the ground or pavement, allowing part of the contents of the gutter to flow at all times into the well; and when it was afterwards emptied, a large quantity of black and highly offensive deposit was found.

The first case of cholera in this court occurred on July 20th, in a little girl, who had been labouring under diarrhœa for four days. This case ended favourably. On the 21st July, the next day, an elderly female was attacked with the disease, and was in a state of collapse at ten o’clock the same night. This patient partially recovered, but died of some consecutive affection on August 1. Mr. Vinen, of Tooley Street, who attended these cases, states that the evacuations were passed into the beds, and that the water in which the foul linen was washed would inevitably be emptied into the channel mentioned above. Mr. Russell, of Thornton Street, Horsleydown, who attended many of the subsequent cases in the court, and who, along with another medical gentleman, was the first to call the attention of the authorities to the state of the well, says that such water was invariably emptied there, and the people admit the circumstance. About a week after the above two cases commenced, a number of patients were taken ill nearly together: four on Saturday, July 28th, seven or eight on the 29th, and several on the day following. The deaths in the cases that were fatal took place as follows:—one on the 29th, four on the 30th, and one on the 31st July; two on August 1st, and one on August the 2nd, 5th, and 10th respectively, making eleven in all. They occurred in seven out of the fourteen small houses situated in the court.

The two first cases on the 20th and 21st were probably caused by the cholera evacuations contained in the Thames water, as it came from the waterworks, and they may be considered to represent about the average amount of cases for the neighbourhood, there having been just that number in the adjoining court, about the same time. But in a few days, when the dejections of these patients must have become mixed with the water the people drank, a number of additional cases commenced nearly together. The patients were all women and children, the men living in the court not having been attacked; they may have been out at work all day and not have drank the water, but as the surviving inhabitants nearly all left the place immediately after the above mortality occurred, I was not able to ascertain whether this was so or not.

In Albion Terrace, Wandsworth Road, there was an extraordinary mortality from cholera in 1849, which was the more striking as there were no other cases at the time in the immediate neighbourhood; the houses opposite to, behind, and in the same line, at each end of those in which the disease prevailed, having been free from it. The row of houses in which the cholera prevailed to an extent probably at that time quite unprecedented in this country, constituted the genteel suburban dwellings of a number of professional and tradespeople, and are most of them detached a few feet from each other. They were supplied with water on the same plan. In this instance the water got contaminated by the contents of the house-drains and cesspools. The cholera extended to nearly all the houses in which the water was thus tainted, and to no others.

These houses were numbered from 1 to 17, in Albion Terrace, and were supplied with water from a copious spring in the road in front of the terrace, the water of which was conducted, by a brick barrel-drain between Nos. 7 and 8, to the back of the houses, and then flowed right and left, to supply tanks in the ground behind each house, the tanks being made of brickwork and cement, covered with a flat stone, and connected with each other by stoneware pipes six inches in diameter. A leaden pipe conveyed water from each tank to a pump situated in the back kitchen. There was a cesspool behind each house, under the privy, and situated four feet from the water-tank. The ground was opened behind the houses No. 1 and No. 7, and the drains examined under the superintendence of Mr. Grant, the Assistant-Surveyor to the Commissioners of Sewers. The cesspools at both these places were quite full, and the overflow-drain from that at No. 1 choked up. At this house the respective levels of the cesspool and the water-tank were measured, and the top of the overflow-drain from the cesspool was found to be fifteen inches above the top of the tank, and the intervening ground was very wet. The overflow-drain mentioned above had no bottom, or one so soft that it could be penetrated with a stick; and it crossed, at right angles, above the earthenware pipe of the water-tank, the joints of which were leaky, and allowed the water to escape. Behind No. 7, Mr. Grant found a pipe for bringing surplus water from the tanks, communicating with a drain from the cesspool; and he found a flat brick drain laid over the barrel-drain before mentioned, which brought the water from the spring. It appears, from a plan of the property, that this drain, which was continued in a direction towards the sewer in Battersea Fields, brought surface-drainage from the road, and received the drains from the cesspools, the house-drains from the sinks in the back kitchens, and the surplus water, or some of it, from the tanks. There was every reason to believe that this drain was stopped up, but that was not ascertained: at all events it was unable to convey the water flowing into it during the storm on July 26th, as it burst near the house No. 8, and inundated the lower premises of that and the adjoining house, No. 9, with fœtid water; and it was from this time that the water, which had occasionally been complained of before, was found by most of the people in these seventeen houses to be more or less impure or disagreeable. The water broke out of the drain again at No. 8, and overflowed the kitchens, during a heavy rain on August 2nd. It should be particularly remarked, that the tanks were placed on the same level, so that pumping from one would draw water from the others, and that any impurity getting into one tank would consequently be imparted to the rest.

The first case of cholera occurred at No. 13, on July 28th (two days after the bursting of the drain), in a lady who had had premonitory symptoms for three or four days. It was fatal in fourteen hours. There was an accumulation of rubbish in the cellar of this house, which was said to be offensive by the person who removed it; but the proprietor of the house denied this. A lady at No. 8 was attacked with choleraic diarrhœa on July 30th: she recovered. On August 1st, a lady, aged eighty-one, at No. 6, who had had some diarrhœa eight or ten days before, which had yielded to her own treatment, was attacked with cholera: she died on the 4th with congested brain. Diarrhœa commenced on August 1st in a lady aged 60, at No. 3; collapse took place on the 5th, and death on the 6th. On August 3rd, there were three or four cases, in different parts of the row of houses, and two of them terminated fatally on the same day. The attacks were numerous during the following three or four days, and after that time they diminished in number. More than half the inhabitants of the part of the terrace in which the cholera prevailed, were attacked with it, and upwards of half the cases were fatal. The deaths occurred as follows; but as some of the patients lingered a few days, and died in the consecutive fever, the deaths are less closely grouped than the seizures. There was one death on July 28th, two on August 3rd, four on the 4th, two on the 6th, two on the 7th, four on the 8th, three on the 9th, one on the 11th, and one on the 13th. These make twenty fatal cases; and there were four or five deaths besides amongst those who were attacked after flying from the place.

The fatal cases were distributed over ten out of the seventeen houses; and Mr. Mimpriss of Wandsworth Road, who attended many of the cases, and to whose kindness I am indebted for several of these particulars, stated that cases occurred in the other seven houses, with the exception of one 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 entire household, consisting of seven individuals, had the cholera, and six of them died.

There is no data for showing how the disease was communicated to the first patient, at No. 13, on July 28th; but it was two or three days afterwards, when the evacuations from this patient must have entered the drains having a communication with the water supplied to all the houses, that other persons were attacked, and in two days more the disease prevailed to an alarming extent.

I had an opportunity of examining some of the water removed by Mr. Grant from the tanks behind the houses No. 1 and No. 7, and also some of the deposit which lay in the tanks to the depth of from six to nine inches. The water was offensive, and the deposit possessed the odour of privy soil very distinctly. I found in it various substances which had passed through the alimentary canal, having escaped digestion, as the stones and husks of currants and grapes, and portions of the thin epidermis of other fruits and vegetables.