a Published by HMSO, London, 1850.
Section 1
Localizing causes of cholera
Before proceeding to describe the various measures of a medical preventive nature carried out under the regulations of the General Board of Health, it is necessary that I should enter shortly into the reasons for their adoption, by describing those special conditions attending the epidemic seizure which they were intended to meet. Sufficient evidence will presently be advanced to show that cholera is by no means so capricious in its attacks as has been generally supposed, but that on the contrary it is propagated according to certain fixed laws, although the limits of these have not as yet been precisely defined. Whether or not there be sufficient proof that the epidemic influence progresses from point to point, and that it is not always universally diffused over the whole face of a countrywhether or not there be also evidence to show that the intensity of that influence is not necessarily equal throughout the area within which it operatesand whether or not human means have any control over these properties of the epidemic; it is nevertheless of extreme importance to know that there are other laws, the modifying conditions of which can be to a great extent influenced. By far the most important of these laws is that which will frequently be referred to under the term localization, or, in other words, that property which is possessed by certain states of the constitution, or by certain well-marked characteristics of special localities, by virtue of which the epidemic obtains such power over the resisting vital forces of individuals, as to produce that class of phenomena usually ranked under the general designation of cholera.
During the late epidemic the following were among the more frequent indications of the prevalence of an epidemic constitution:
Such symptoms have very frequently prevailed over considerable epidemic areas, without leading to any more serious disease. It has happened, however, that in certain constitutions, predisposed by irregular and dissipated habits, these slight premonitions have been followed by rapid and fatal attacks of cholera. It appeared as if the weakened vital stamina, after resisting to a certain point, suddenly gave way, while the natural powers of other individuals, which had not been put to so severe a test, were sufficient to preserve life.
Under similar circumstances specific acts of intemperance in food or drink, over-fatigue, or perhaps sudden alarm, have destroyed the resisting power. I have likewise known a number of instances in which individuals, living in comparatively healthy situations, have been suddenly destroyed by the use of purgative medicine, and that in very moderate quantity. Saline purgatives, which under ordinary circumstances may be used with advantage, are invested with poisonous properties in relation to the altered constitutional state produced by the epidemic influence. A similar fact has been observed in regard to almost every form of aperient. A case came under my own knowledge, in which an ordinary dose of rhubarb and magnesia with mint-water produced a rapid and fatal attack of cholera in a healthy young woman who had taken the medicine as an aperient.
Improper articles of food have not unfrequently produced a like result; a remarkable illustration of which will be found in the case of the Prussian sailors on board the barque Pallas.
The influence of such causes in producing attacks of cholera has not been uniformly great. In some epidemic attacks imprudences have been committed with impunity, which in others have been attended with fatal results, while under neither of the circumstances alluded to did the disease distinctly localize itself. It appears reasonable, therefore, to conclude, that it is possible for the population of one locality to become more pre-disposed than that of another similarly circumstanced, simply from the greater intensity of the epidemic influence.
It is of great importance to keep in mind this distinction, because, in issuing instructions for the guidance of the population, as to diet, regimen, etc., it would be manifestly insufficient to take the previous experience of any one locality as a foundation on which to rest those precautionary measures to be recommended for every other. I have met with instances in which eminent members of the medical profession objected to certain of the recommendations of the General Board of Health, in regard to the points under discussion, from their not being entirely borne out by their own experience. It would certainly be more satisfactory were it practicable to advise those measures which would be precisely adapted to every given condition, but, as such is not the case, general recommendations founded on the broadest basis of experience must obviously be the best.
It is possible to conceive that an epidemic constitution might be so intense as to destroy every human being exposed to its influence, although living under the best possible sanitary conditions, just as if the atmosphere were to become suddenly converted into carbonic acid gas. Such, however, does not appear to be the function of epidemics. They are corrective rather than destructive, and one of their special objects seems that of arousing mankind, by signs which cannot be mistaken, to a sense of the necessity of recognising and obeying the laws of his physical existence. They have an indirect bearing also on his moral state, by exciting to action the dormant powers of observation, intelligence, and sympathy; while on the other hand, those very sanitary evils which tend to propagate epidemics have a direct influence in degrading the human race, and in leading to ignorance, vice, and crime.
Under such circumstances men are most readily affected by the passion of fear, and the instinct of self-preservation leads them to inquiries and physical reforms which remove those material causes from which originated a debased state of health both of body and mind.
Epidemics invariably haunt the same localities. A few scattered drops of the storm may fall elsewhere, but its violence is spent where its purifying influence is most required. I shall presently describe and illustrate those conditions which cholera finds most congenial. It is under these that a new class of phenomena is developed. We find certain appearances among the people, which, when once observed, can hardly be forgotten. The countenance has a peculiar aspect, half anxious, half apathetic. The eyes are suffused, and often surrounded by a faint areola. The skin has a dusky reddish hue, as if from impeded circulation. I have found such persons averse to exertion, and indisposed to take any steps for their safety. They have usually denied being ill, and refused to leave the locality; and I have not unfrequently been able to predict the deaths of individuals from their positively objecting to being interfered with. Existing cases of fever, or other epidemics, change their aspect and fall rapidly into hopeless collapse. A very fatal disease suddenly breaks out, marked by the following symptoms:
The development of these diseased states has occupied very different periods of time in different localities and constitutions. Sometimes their course has extended over a period of several days, and at others death has ensued within two or three hours of the moment of seizure. A state of hopeless collapse has sometimes been produced in a few minutes, by the passing of a single large watery evacuation, in persons who had risen from bed apparently in their usual health. Instances have also occurred of persons dropping down in the street and dying shortly after.
It has been generally observed that the larger proportion of attacks have taken place through the night, a point in the history of the epidemic which is well illustrated by the following table supplied to me by Dr. Alex M. Adams, Glasgow (see Table 1).
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The most important practical point which it behoves us to know is, that the severe manifestation of the presence of cholera described above does not take place over the whole district covered by the epidemic influence. Were this the case, a large proportion of the people in affected countries must necessarily perish. All experience has, however, proved that a certain portion escape, while another portion are destroyed, and the fatal outbreaks of the disease are invariably connected with one or more of the following local defects:
It will be observed that the diseased conditions likely to arise from the influence of such causes are those connected with atmospheric impurity, a deranged state of the digestive functions, and depression of the vital powers. In all localities where they exist there is a great preponderance of disease and mortality; but I am inclined to consider the epidemic susceptibility, properly so called, as distinct from the ordinary diseased states. It is not always the most sickly who suffer from epidemics; on the contrary, a large number of victims from fever and cholera are taken from amongst persons in the prime of life; and it has been often remarked, that the wards of cholera hospitals have shown a considerable proportion of robust men and women amongst their occupants.
The following table of the ages of 2322 cholera cases, and 1058 deaths from cholera, occurring in Glasgow, will prove how heavily the epidemic fell on the productive periods of life (see Table 2).
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All the facts which I have observed have appeared to point to a solution of the following kind: namely, that under the unhealthy conditions above mentioned the epidemic has the power of intensifying itself, or, in other words, multiplying its force of attack, until at last it produces results closely approximating to those of aerial poisons. It appears as if some peculiar organic matter, which constitutes the essence of the epidemic, when brought in contact with other organic matter proceeding from living bodies, or from decomposition, has the power of so changing the condition of the latter as to impress it with poisonous qualities of a peculiar kind similar to its own.
If we could suppose that certain organic impurities, existing in the atmosphere of unhealthy neighbourhoods, passed into the blood through the lungs, so as to follow the circulation, and that similar impurities taken into the stomach with articles of food or drink were likewise absorbed into the blood; if we could moreover suppose that the epidemic influence possessed the power of assimilating such organic matter to its own poisonous nature, we should be enabled to include a number of complex phenomena under a hypothesis which would indicate the requisite measure of prevention.
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Illustrations of localising causes of cholera
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Unwholesome Water
I have frequently had occasion to refer to the very injurious effects resulting from the use of impure water during the late epidemic. In nearly every city or town affected this element has been more or less prominent, and a number of most severe and fatal outbursts of cholera were referable to no other cause except the state of the water-supply. Such has especially been the case when the water was obtained from wells into which the contents of sewers or privies, or the drainage of graveyards, had escaped. The predisposition occasioned by the continued use of such water is perhaps the most fatal of all; and the proportion of deaths to attacks has generally been much greater in epidemic seizures resulting from it than from any other predisposing cause ().
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I select the following illustration out of a number, because it is accompanied with statistical data (see Table 3).
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The following are specimens of the complaints made against the water by the people in the neighbourhood:
The water looks rather muddy, and has not been clean since the pump was mended.Dreadful heavy dirty water-settlings from a canfull.
Has seen the sludge boil like barm at top, and it left something on the pan like soapsuds. The week we began to use the pump-water the man died.
John Holding states that he was stopped from using a pure well-water, and was obliged to use the pump-water. On Saturday, Sept. 29, he Got two cans of water from Pump-court. A lodger was seized with cholera on Monday, and died next day.
Another complainant states:
That he was afraid of using the pump-water, on account of the water in which the bedding of two persons who had died of cholera had been washed having been thrown into the gutter, and he thought it ran into the well.
It appears that the well had been repaired, and, from some cause or other, a sewer which passes within 9 inches of the edge of it had become obstructed and leaked into the well.
The statistical evidence given in the preceding page affords a melancholy and convincing proof of the enormous destruction of human life which may ensue from a very slight degree of negligence or accident.
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7 Defective Sanitary Alterations, etc.
The first outburst of cholera in the city of Bristol took place in three courts in Red Cross-Street, known by the names of Wellington-Court, Wellington-Buildings, and Gloucester-Court, which cover a piece of land 56 yards in length by 37 in breadth (see Figure 1). This measurement includes the houses in Red Cross-street, so that the actual area covered by the courts is about 1850 square yards. On this oblong piece of land are 6 rows of houses built back to back, making in all 66 dwellings. An overcrowded graveyard extends along two sides of the ground, and on the other two sides it is shut in by buildings, and two out of the three courts are entered from Red Cross-Street by narrow covered passages about 10 yards in length, the third court being open. Were there no other unfavourable circumstances than the position which these courts occupy, it would be sufficient to account for their unhealthiness, the only ventilation they receive being from the adjacent burial-ground, the drainage from which no doubt also exercises a most injurious influence on the neighbourhood. The houses are very small, and when the disease broke out they were crowded with people. The supply of water was deficient and impure, and was derived for all the three courts from one pump in Wellington-Court, into which there had been an escape of drainage, either from the sewer of the court, which passed close to it, or from the burial-ground. A sewer runs through Red Cross-Street, which is connected with two drains in Wellington-Court and Gloucester-Court; but there being no fall to carry off the drainage, the court drains were constantly full of the refuse of the privies. These drains are in fact the cesspools of all the houses, and they communicate directly with the surface of the courts by a large number of ill-trapped gully-grates, the effluvia from which are at times most horrible. The people were obliged to cover the gratings with canvas pressed down by a weight.
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