Part 12

There may be other causes besides the above which tend to assist the propagation of cholera in warm, more than in cold weather. It is not unlikely that insects, especially the common house-flies, aid in spreading the disease. An ingenious friend of mine has informed me that, when infusion of quassia has been placed in the room for the purpose of poisoning flies, he has more than once perceived the taste of it on his bread and butter.

Dr. Farr gives the following very important information respecting the sex of persons who died of cholera at different periods of the epidemic.[32]

“It is worthy of remark, that at the beginning of the epidemic, the deaths of males exceeded the deaths of females very considerably; the numbers in the months of October, November, and December, 1848, were,—males 612, females 493; or in the proportion of 100 to 80....

“As a general rule, when the mortality from cholera attained a very high rate, the number of deaths among females exceeded the deaths among males.

“In London a remarkable change was observed in the proportion of the sexes affected in the course of the epidemic. In four weeks of October 1848, the deaths of 80 males and of 42 females by cholera were registered; in the thirteen last weeks of the year the deaths of 258 males and 210 females were registered; and there was an excess of males at all ages, but particularly in the ten years of age 15–25. In the quarter ending March 1849, the deaths of males amounted to 250, of females to 266: at the age of 25 and upwards the excess of deaths among females was considerable. In June, at the commencement of the great outbreak, the males again furnished the most numerous victims. At the close of July the females died in greater numbers than the males, and continued to do so to the end. In the week that the mortality was highest, the deaths of 895 males and of 1131 females were returned. In the September quarter the deaths of males under the age of 25 exceeded the deaths of females; but after that age the proportions were reversed.”

[Sidenote: PROPORTION OF THE SEXES WHO DIE OF CHOLERA.]

The greater part of the female population remain almost constantly at home, and take their meals at home, whilst a considerable number of the men move about in following their occupations, and take both food and drink at a variety of places; consequently, in the early part of an epidemic, when the disease only exists in a few spots, the male part of the population is most liable to come within the operation of the morbid poison; but at a later period of the epidemic, when the cholera is more generally diffused, it may reach those who stay at home as readily as those who move about; and in addition to the risk which the women share with the men, they have the additional one of being engaged in attending on the sick.

It is a confirmation of this view of the matter that, when the cholera poison is distributed through the pipes of a Water Company, the above rule does not hold good, but a contrary one prevails, owing, probably, to females being less in the habit of drinking beer than men, and being therefore more likely to drink water. Of the 334 deaths detailed in the Appendix to this work (286 of them amongst the customers of the Southwark and Vauxhall Water Company), only 147 were males, whilst 187 were females. The deaths occurred in the first four weeks of the recent epidemic. On the other hand, out of the 229 deaths from cholera which occurred in all the rest of London during this period, 140 were males and only 89 females. When the mortality of the whole of the metropolis during this period is taken together, there is a slight preponderance on the part of the males; the numbers being,—males 287, females 276: total 563.

The deaths from cholera in England in 1849 were 53,293; of those, 14,718, or 27 per cent. of the whole, occurred in children under 15 years of age. Of the 334 deaths which are recorded in the Appendix to this work, 127, or 38 per cent., are those of children under 15, whilst of the remaining 229 which occurred in the rest of London during the first four weeks of the epidemic, only 61, or 26 per cent., took place before the age of 15,—a proportion nearly the same as in the whole of England in 1849. The higher proportion of deaths amongst children in the houses supplied with the impure water from the Thames at Battersea Fields, probably arose from the circumstance that children are very fond of drinking water in warm weather. I often heard such remarks as the following, in making my inquiries in the south districts of London:—“My children like water better than tea or anything else, I cannot keep them away from the water-butt;” or, “the child that is dead used to drink a great deal of that water, she was big enough to reach to the butt herself.”

Dr. Guy, physician to King’s College Hospital, made a table showing the occupations of 4,312 males, of fifteen years of age and upwards, who died of cholera in London in the epidemic of 1848–49; together with the ratio which the deaths bear to the living, as well as it could be ascertained from the census of 1841. I have not room for the whole table, but have selected the occupations which suffered most, and those which suffered least. The following abstract of Dr. Guy’s table contains all the occupations where the deaths from cholera equalled one-fiftieth of the number living, and all those in which the deaths did not exceed one in two hundred and fifty living.

[Sidenote: PROPORTION OF DEATHS IN DIFFERENT OCCUPATIONS.]

In some of the occupations which show a high relative mortality, the number of living is too small to allow of any reliable statistical result, and the relative mortality is probably due to accidental circumstances quite unconnected with the occupation. In other cases, however, the numbers are so considerable as to indicate something more than accident. The 299 sailors, for instance, constituted one twenty-fourth of the whole estimated number in that occupation. The 7 ballast-heavers form just the same proportion of the whole in that occupation, and the 53 coalporters and coalheavers constituted one in 32 of those so employed. Now all those persons lived or were employed on the river, where it is the habit to drink water drawn by pailfuls from the side of the ship. The 67 hawkers are one in 22 of the whole number. These persons are constantly moving about, and are in the habit of living in crowded lodging-houses, and consequently must be extremely liable to contract any communicable disease. Tanners nearly all live in Bermondsey and Lambeth, supplied in 1849 with none but very impure water, as was previously explained. The weavers probably suffered the high rate of mortality from the crowding of their apartments in Spitalfields, and the uncleanness of their habits.

The persons who suffered less from cholera than any other part of the male population, are footmen and men-servants; and it is impossible to conceive a class less exposed to the disease. They live in the best parts of London, and go from home much less than their masters. The low rate of mortality amongst medical men and undertakers is worthy of notice. If cholera were propagated by effluvia given off from the patient, or the dead body, as used to be the opinion of those who believed in its communicability; or, if it depended on effluvia lurking about what are by others called infected localities, in either case medical men and undertakers would be peculiarly liable to the disease; but, according to the principles explained in this treatise, there is no reason why these callings should particularly expose persons to the malady.

=TABLE XIV.=

┌───────────────────────────────────────────────────┬────────┬────────┐ │ │ No. of │ Ratio. │ │ │Deaths. │ │ ├───────────────────────────────────────────────────┼────────┼────────┤ │Agents │ 12│1 in 49 │ │Bricklayers and builders │ 14│1 „ 39 │ │Cowkeepers, dairymen, and milkmen │ 8│1 „ 20 │ │Egg merchants │ 5│1 „ 6 │ │Fishmongers │ 11│1 „ 20 │ │Fruiterers and greengrocers │ 12│1 „ 28 │ │Jobmasters, livery-stable keepers │ 5│1 „ 37 │ │Oilmen │ 13│1 „ 46 │ │Paper-makers │ 2│1 „ 15 │ │Poulterers │ 3│1 „ 32 │ │Sail-makers │ 2│1 „ 30 │ │Turners │ 2│1 „ 50 │ │Ballast-heavers │ 7│1 „ 24 │ │Coal-porters and coalheavers │ 53│1 „ 32 │ │Dustmen and scavengers │ 6│1 „ 39 │ │Founders │ 10│1 „ 12 │ │Hawkers, etc. │ 67│1 „ 22 │ │Lithographers │ 3│1 „ 48 │ │Modellers │ 3│1 „ 41 │ │Polishers │ 4│1 „ 36 │ │Sailors, including Greenwich pensioners │ 299│1 „ 24 │ │Tanners │ 22│1 „ 39 │ │Weavers │ 102│1 „ 36 │ │ │ │ │ │Physicians, surgeons, & general practitioners │ 16│1 „ 265 │ │Magistrates, barristers, conveyancers, and │ 13│1 „ 375 │ │ attorneys │ │ │ │Merchants │ 11│1 „ 348 │ │Auctioneers │ 1│1 „ 266 │ │Saddlers │ 1│1 „ 250 │ │Brass-finishers │ 3│1 „ 318 │ │Coach-makers │ 16│1 „ 262 │ │Cork-cutters │ 2│1 „ 279 │ │Footmen and men-servants │ 25│1 „ 1572│ │Jewellers, goldsmiths, and silversmiths │ 6│1 „ 583 │ │Millwrights │ 2│1 „ 266 │ │Tallow-chandlers │ 2│1 „ 430 │ │Type-founders │ 1│1 „ 390 │ │Undertakers │ 2│1 „ 325 │ │Warehousemen │ 8│1 „ 472 │ │Watchmakers │ 11│1 „ 364 │ │Wheelwrights │ 8│1 „ 294 │ └───────────────────────────────────────────────────┴────────┴────────┘

[Sidenote: ABSENCE OF DRAINAGE INCREASES CHOLERA.]

There is one remarkable circumstance connected with Dr. Guy’s table. One master-brewer died of cholera, being 1 in 160 of the trade; but no brewer’s man or brewer’s servant is mentioned as having died of this malady, although these men must constitute a very numerous body in London. There must be a few thousands of them. I have, indeed, met with the deaths of two or three of these persons, in looking over the returns of some of the most fatal weeks in 1849; but the brewers’ men seem to have suffered very slightly both in that and the more recent epidemics. The reason of this probably is, that they never drink water, and are therefore exempted from imbibing the cholera poison in that vehicle.

The great prevalence of cholera along the course of rivers has been well known for a quarter of a century; and it meets with a satisfactory explanation from the mode of communication of the disease which I am inculcating. Rivers always receive the refuse of those living on the banks, and they nearly always supply, at the same time, the drinking water of the community so situated. It has sometimes been objected to the propagation of the disease by the water of rivers, that the epidemic travels as often against the stream as with it. The reply to this is, that people travel both against the stream and with it, and thus convey the malady from village to village and from town to town on the banks, whilst the water serves as a medium to propagate the disease amongst those living at each spot, and thus prevents it from dying out through not reaching fresh victims.

The principles I have laid down afford a satisfactory explanation of the circumstances, that absence of drainage promotes the prevalence of cholera, and that it flourishes better on a clay soil than on primitive rocks, sandstone, or gravel. Without drainage, the refuse of the population permeates the ground, and gains access to the pump-wells. Merthyr Tydvil, with 52,863 inhabitants, is entirely without drainage, and the people derive their supply of water from pump-wells. This place has suffered severely from cholera in every epidemic. In 1849 there were 1,682 deaths from this disease, being 234 to each 10,000 inhabitants,—a rate of mortality as high as in Hull and certain of the south districts of London, where the morbid poison of cholera was distributed by the steam-engines of the water companies. The primitive rocks, sandstone, and gravel, generally cause the purification of the water by the separation or oxidation of organic matters, whilst clay does not exert this salutary influence to the same extent.

Since the latter part of 1848, when I first arrived at my present conclusions respecting the mode of communication of cholera, I have become more and more convinced that many other diseases are propagated in the same way.

When the plague visited this country, it was most fatal in London, York, Winchester, and certain other towns having a river of fresh water passing through them. It resembled cholera also in being twice as fatal in the districts on the south of the Thames as in those on the north. The following passage from Stow’s “Survey”, published in 1633, shows the way in which Southwark was supplied with water about the time of the great visitations of plague: “Southwark useth chiefly the water of the Thames, that falls into a great pond at St. Mary Overies, that drives a mill called St. Saviour’s Mill, the owner whereof is one Mr. Gulston. The revenue thereof is supposed by some to be worth 1,300_l._ a year.”

[Sidenote: MODE OF PROPAGATION OF THE PLAGUE.]

Although some of the lower parts of the City were supplied with water from the Thames, at the latter part of the sixteenth and throughout the seventeenth century, yet the greater part of London north of the Thames was supplied by fountains and conduits, conveying spring water from a distance. The following quaint but poetic account of the conduits of London cannot fail to be interesting: “As nature, by veins and arteries, some great and some small, placed up and down all parts of the body, ministereth blood to every part thereof; so was that wholesome water, which was necessary for the good of London, as blood is for the good and health of the body, conveyed by pipes, wooden or metalline, as by veins, to every part of this famous city.... They were lovely streams indeed that did refresh that noble city, one of which was always at work pouring out itself when the rest lay still. Methinks these several conduits of London stood like so many little but strong forts, to confront and give check to that great enemy, fire, as occasion should be. There, methinks, the water was intrenched and in-garrisoned. The several pipes and vehicles of water that were within these conduits, all of them charged with water, till by turning of the cock they were discharged again, were as so many soldiers within these forts, with their musketry charged, ready to keep and defend these places. And look how enemies are wont to deal with these castles, which they take to be impregnable, and despair of every getting by them,—that is, by attempting to storm them by a close siege: so went the fire to work with these little castles of stone, which were not easy for it to burn down (witness their standing to this day); spoiled them, or almost spoiled them, it hath for the present, by cutting off those supplies of water which had vent to flow to them, melting those leaden channels by which it had been conveyed, and thereby, as it were, starving those garrisons which it could not take by storm. As if the fire had been angry with the poor old tankard-bearers, both men and women, for propagating that element which was contrary to it, and carrying it upon their shoulders, as it were, in state and triumph, it hath even destroyed their trade, and threatens to make them perish by fire who had wont to live by water.”[33]

Dr. Farr makes the following remarks on the plague, in his report on the cholera of 1848–9: “It is endemic in the Delta of the Nile, and periodically decimates the population of Cairo and Alexandria.... It grows gradually less fatal up the Nile, and is less frequent and destructive in Upper than in Lower Egypt, in the high lands and in the desert, than on the low lands on the shores of the Mediterranean.” Speaking of Cairo, he says: “Through the midst of it passes the Great Canal, into which the sewers are discharged over carrion, excretion, and mud. At the yearly overflow of the Nile, its waters, filling this canal, are distributed over the city, and drunk by its wretched inhabitants.”

The plague resembles cholera in being much promoted by crowding and want of personal cleanliness. The natives of Gurhwal, a province in the north-west of British India, in which the plague has been present for the last thirty years, believe that it may be transmitted from one place to another in articles of diet, such as a jar of ghee.[34]

[Sidenote: MODE OF PROPAGATION OF YELLOW FEVER.]

Yellow fever, which has been clearly proved by Dr. M’William and others to be a communicable disease, resembles cholera and the plague in flourishing best, as a general rule, on low alluvial soil, and also in spreading greatly where there is a want of personal cleanliness. This disease has more than once appeared in ships sailing up the river Plate, before they have had any communication with the shore. The most probable cause of this circumstance is, that the fresh water of this river, taken up from alongside the ship, contained the evacuations of patients with yellow fever in La Plata or other towns.

It was long ago observed, that dysentery was apparently propagated by the drinking of water containing excrementitious matters.[35] The frequent appearance of this disease in Millbank prison, when the Thames water was used, is a confirmation of this; and Dr. Bryson has lately related a number of instances where both dysentery and fever seemed to be occasioned by the water of the Yangtse-Kiang, the Canton river, and other rivers of China.[36] What very much confirms this view of the case, is, that nearly all the patients were afflicted with great numbers of intestinal worms (_lumbrici_); for it cannot be supposed that the worms could proceed from malaria, miasmata, or any of the causes which are frequently believed to occasion dysentery and fever. The eggs of the lumbrici were no doubt contained in great numbers in the water of the densely populated Chinese rivers.

There are many facts which indicate that one at least of the continued fevers—the typhoid fever with ulceration of the small intestines—is also propagated in the same way as cholera. Dr. Jenner called my attention some time ago to an instance occurring at the village of North Boston, Erie County, N.Y., in which typhoid fever was probably communicated to a number of families by the contamination of the water of a well which they used.[37] The epidemic which prevailed so extensively at Croydon two years ago was of this character, as was verified by a Committee of the Epidemiological Society, of which Drs. Sankey, Jenner, and A. P. Stewart were members. Mr. Carpenter, of Croydon, has lately shown very ably that this epidemic was connected with the pollution of the pump-wells of the town, owing to the disturbance of the ground, and of many old cesspools during the drainage operations of the Local Board of Health.[38] The Board had supplied the town with good water from a deep well in the chalk, but the population had a prejudice against it and persisted in resorting to the water of the shallow pump-wells. In the autumn of last year diarrhœa was very prevalent in Croydon, and Mr. Carpenter found that this also was caused by the impure water of the pump-wells. Nine-tenths of the people of Croydon were drinking the new water supplied by the Board of Health, but, out of thirty-two patients with diarrhœa who came under the notice of Mr. Carpenter, twenty-five were drinking well-water entirely, five drank water from both sources, and the other two could not decidedly say that they had not drank well-water.

Intermittent fevers are so fixed to particular places that they have deservedly obtained the name of endemics. They spread occasionally, however, much beyond their ordinary localities, and become epidemic. Intermittent fevers are undoubtedly often connected with a marshy state of the soil; for draining the land frequently causes their disappearance. They sometimes, however, exist as endemics, where there is no marshy land or stagnant water within scores of miles. Towards the end of the seventeenth century, intermittent fevers were, for the first time, attributed by Lancisi to noxious effluvia arising from marshes. These supposed effluvia, or marsh miasmata, as they were afterwards called, were thought to arise from decomposing vegetable and animal matter; but, as intermittent fevers have prevailed in many places where there was no decomposing vegetable or animal matter, this opinion has been given up in a great measure; still the belief in miasmata or malaria of some kind, as a cause of intermittents, is very general. It must be acknowledged, however, that there is no direct proof of the existence of malaria or miasmata, much less of their nature.

[Sidenote: CAUSE OF INTERMITTENT FEVERS.]

That preventive of ague, draining the land, must affect the water of a district quite as much as it affects the air, and there is direct evidence to prove that intermittent fever has, at all events in some cases, been caused by drinking the water of marshes. In the “General Report of the Poor Law Commissioners on the Sanitary Condition of Great Britain,”[39] Mr. Wm. Blower, surgeon, of Bedford, states that typhus and ague, which had long infested the village of Wootton, near Bedford, had been much diminished by digging a few wells, and obtaining good water. He also states that, in the neighbouring parish of Houghton, almost the only family which escaped ague, at one time, was that of a respectable farmer who used well-water, whilst all the other families had only ditch water.

M. Boudin[40] relates a very marked instance in which intermittent, and apparently also remittent, fever were caused by drinking marsh water. It is as follows:—