Chapter IX · (continued 2)

In the treatment of cholera in 1832 many things were tried. The view taken of the pathology naturally determined the means of cure. To check the premonitory diarrhoea was seen to be of the first importance, and to that end laudanum or other form of opium was the familiar means. Lawrie, at Glasgow, found it most satisfactory, at a time when the profession in London were, as he says, denouncing it as a pernicious error. Towards the end of the epidemic in Dublin, Graves combined with the opium acetate of lead in large doses (a scruple of acetate of lead with a grain of opium, divided into twelve pills, one to be given every half-hour until the rice-water evacuations from the stomach and bowels began to diminish)[1538]. Some professed to find great benefit from blood-letting at a sufficiently early stage in the attack[1539]. The enormous drain of the fluids, leaving the blood thick or tarry, suggested to some that saline substances would be beneficial. The saline treatment was indeed the principal subject of writing during the year 1832. One way was to give saline drugs by the mouth; another way was to inject into a vein a large quantity of distilled water with some common salt and bicarbonate of soda dissolved in it, the vein at the bend of the elbow being usually chosen to operate on. Some were confident that they had saved lives in this manner, others were equally clear that salines were useless. One writer had abandoned salines by the mouth as a “most useless remedy,” while he had not lost faith in their intravenous injection, four having recovered out of twenty-three in which he had tried it. At length, however, the intravenous use of salines was abandoned also[1540].

It is well known that the greatest of all the lessons taught by cholera was the need of sanitary reform. The disease in its successive visitations so obviously sought out the spots of ground most befouled with excremental and other filth as to bring home to everyone the dangers of the casual disposal of town refuse. It was not until some years after the first visit of cholera that much was done in the way of extending the main drainage of towns, connecting the house-drainage systematically therewith, getting rid of open nuisances in back yards, and protecting the water-supplies from contamination. The Report of the Health of Towns Commission, 1844, was “the great magazine from which sanitary reformers drew their weapons[1541].” In the next few years an active school of sanitarians arose, including Sutherland of Liverpool, Grainger of London, and others. In 1848 was passed the first Public Health Act, administered by a Board of Health, of which Lord Shaftesbury was chairman, Chadwick and Southwood Smith members. London was excepted from the scope of the Act; but the City had a most vigorous medical officer in the person of John Simon, whose reports dealt with public sanitation on broad principles applicable to the capital and the whole kingdom. The movement in favour of sanitation, thus begun, received an irresistible impulse from the cholera of 1849, the lessons of which were as obvious as those of 1832.

The cholera which reached Orenburg in 1829 and Astrakhan in 1830 lingered in one part of Europe or another until 1837, Portugal and Spain having been its chief theatre in 1833, the south of France in 1834, Italy in 1835 and 1836, Austria, the Tyrol, Bavaria and (for the second time) Poland and the Baltic ports in 1837. In England, there was some revival of the seeds of it in 1833, as many as 1454 deaths being put down to Asiatic cholera in London from the 1st of August to the 7th of September. There was an undoubted epidemic of it at the fishing village of Ferryden, near Montrose, in June, 1833 (27 deaths during four weeks in a population of 700), the infection having been brought by one or more of the crew of the smack ‘Eagle’ from the Thames[1542]. In Glasgow a case occurred in Boar Head Close, High Street, on 30 May, 1833, which had the blueness, pinched face, whispering voice and cold clammy skin of Asiatic cholera[1543]. In Ireland there were a good many outbreaks in 1833, especially in villages or hamlets, and it is believed that these were renewed in 1834. But the most singular reappearance of cholera in the British Isles was in the month of December, 1837, some two months after it is believed to have ceased elsewhere in Europe. Outbreaks of true cholera in that month were observed at several places in the south of Ireland-around Bere Haven[1544], at Youghal, at Waterford, and at Dungarvan, where they went so far as to form a board of health[1545]. It was suspected to have been in Limehouse, on the Thames, in November. The most remarkable explosion of it was in the month of January following (1838) among the inmates of the Coventry House of Industry, of whom no fewer than 55 died in the course of four weeks—a mortality from choleraic disease that could hardly be explained on the hypothesis of cholera nostras even if the season had been the proper one[1546].

The Cholera of 1848-49 in Scotland.

The invasion of cholera from India, which reached Britain in the autumn of 1848, had progressed as far as Peshawur and Cabul from 1842 to 1844, and thereafter step by step continuously through Herat, Samarkand, Bokhara, Astrabad and Teheran by the caravan routes. In the beginning of 1847 it entered Russia by the two great interior waterways of the Volga and the Don. Next year, 1848, it reached the German shores of the Baltic and North Seas, and within a few weeks of its appearance at Hamburg, it was found established on British soil at Edinburgh and Leith in the beginning of October. The severe outburst which followed in the south of Scotland was purely a winter epidemic, like that of Durham, Northumberland and East Lothian on the last occasion in the winter of 1831-32. It will not be necessary to give the details of the cholera of 1848-49 so fully as has been done for 1831-32, but merely to notice special points.

The cholera of 1848 broke out almost simultaneously at Newhaven and Edinburgh, on the 1st and 2nd of October, and at Leith on the 9th. At Newhaven nearly the whole population was suffering from diarrhoea, in the midst of which epidemic the true cholera raged for four weeks only, to the 28th October, attacking 30, of whom 20 died. In Leith the deaths were 185 (males 75, females 110). The Edinburgh outbreak lasted until the 18th of January, 1849, causing 801 attacks, with 448 deaths (or 478 deaths, of which 196 were males and 282 females). A cholera hospital was opened in Surgeons’ Square on the 28th of October, the admissions and fatalities to 14th December being as follows:

Females Males Total

Admitted 152 96 248

Died 90 64 154

Of the whole 248 cases, the Grassmarket sent 42, the Cowgate 37, the Canongate 33, College Wynd 16, High Street 14, and numerous scattered localities of the New and Old towns one or more cases each. Severe outbreaks took place also at Niddry, Restalrig and Loanhead, villages close to Edinburgh[1547]. While this limited epidemic was proceeding in and around the capital, the infection appeared in the mining region of Carron at the head of the Firth of Forth, where there were some 400 cases after the 6th of December, and in some other mining villages of the Scotch midlands.

Glasgow was infected on the night of the 11th November, in the suburban district of Springburn, on the north-west of the city close to the Forth and Clyde Canal. The choice of this spot to begin upon was intelligible enough in one way, but singular in another. Springburn had come into existence as a poor village of weavers about the year 1820; before the cholera year of 1832 it had grown to a population of 600, and was thought a likely spot for cholera inasmuch as it was one of the most wretched communities in Scotland. It occupied the site of a half-drained bog below the level of the canal, from which the water percolated into its subsoil; its houses were low, always damp, and full of filth. During all the cholera in Glasgow in 1832 there had not been a case in Springburn until the 6th of September, when a girl of the village came home with it and died; during her brief illness she was visited by the greater part of the villagers, but no other case occurred until six weeks after, on the 15th of October[1548]. At this spot, where the cholera of 1832 may be said to have left off, it began in 1848 with a sudden explosion of numerous attacks scattered all over the locality; a doctor attended twenty-one cases before he found two together in the same house or even in the same lane. There had been forty cases there in November, before any case was discovered in Glasgow; at length it seemed to spread from Springburn all round as if from a centre, while it also lingered there longer than anywhere else in the city and suburbs[1549]. On the 5th of December a case was reported on the south bank of the Clyde, and another on the 9th in the west end. Within a few days the disease fell upon all parts of the city with the suddenness of a thunder shower; it reached a height in the Christmas week, one day, the 30th December, having 158 burials from cholera. After the orgies of the New Year there was a fresh outburst, 235 cases having been reported on the 5th of January. The proportion of fatalities was as high as 60 per cent. at the beginning of the epidemic, 50 per cent. about Christmas and the New Year, and thereafter from 30 to 40 per cent. The epidemic was short and sharp, declining irregularly after the first or second week of January, and ceasing, but for a few dropping cases, about the 8th of March.

The deaths in Glasgow, which included many among the wealthier class and made the festival season of 1848-49 to be long remembered, were about 3800, or 1·06 per cent. of the population (355,800), a higher total but a lower ratio than in 1832, when the deaths, distributed over many more weeks of the year and largely due to two revivals in August and October, were 1·4 per cent. of the population. At Paisley there were 68 deaths from 26 December to 24 February, and at Charlestown 115 deaths all in some five weeks from 15 January to 19 February.

It was in the same season of midwinter that the cholera burst suddenly upon many mining villages of Lanarkshire and Ayrshire.

In that unlikely season there was an almost universal prevalence of diarrhoea. At the mining village of Carnbroe, near Coatbridge, there were five sudden attacks on the last night of the old year, one of them fatal. On New Year’s day there were forty attacks, thirteen of them fatal in a few hours. Terror seized the whole place: one man cut his throat in sheer fright. Diarrhoea attacked 1100 of the 1200 inhabitants, and turned to spasmodic or rice-water cholera in 240 of them, of whom 94 died, the rate of fatality being excessive only in the first few days. By the end of February the epidemic was over.

In the town of Coatbridge, with a population of 4000, the various grades of sickness were classified as follows:

Diarrhoea Vomiting, purging and cramp Rice-water purging Cholera Deaths by Cholera

2659 480 175 107 61

In the town of Hamilton, population 9000, the infection was most malignant, 440 cases yielding 251 deaths from the 24th of December to the 7th of March. The same ravages of winter cholera occurred at some of the Ayrshire ironworks, such as Glengarnock, among a very rough and drunken class, who were made more than ordinarily reckless and drunken by this unaccountable visitation. It was also severe in Riccarton and other mining villages round Kilmarnock, but less prevalent in that town itself. Dumfries and Maxwelltown, which had been among the last places visited by the cholera of 1832, were infected in the middle of November, 1848, about the same time as Springburn near Glasgow. One of the Dumfries doctors died of rapid cholera on the 10th December, the parochial board fell into disputes with the faculty, and the infection proceeded amidst great confusion in the poorest parts of the town, causing about 250 deaths before Christmas. After that it subsided quickly[1550].

The other centres in the south of Scotland were Selkirk (13 deaths), Kelso (Dec. to end of Jan., maximum of 12 attacks in a day) and Jedburgh, which last had escaped in 1832 but had now a very rapid and extensive epidemic in its lower parts among drunken people especially. A few cases occurred at Moffat, in December; a man who was seized in crossing the hills died in a shepherd’s hut eight miles from Moffat after twenty-one hours illness[1551].

The only recorded epidemic in the north of Scotland in the proper cholera season, the summer of 1849, was at Dundee. But there was a small outbreak in March and April at Campbelton (41 cases, 14 deaths) and Inverness (23 cases, 12 deaths)[1552].

The infection began in Dundee on the 29th of May, 1849, in Fish Street, the filthiest part of the town. It prevailed in high and low situations, but usually in the old localities of typhus fever. One group of houses, said to have had a population of 100, had 40 deaths. Dudhope Crescent, consisting of seventeen large five-storied tenement houses occupied by clean and respectable people, had 57 deaths. In about a fourth part of all the fatalities, death was from sudden collapse; this was a feature of the 1849 cholera also in Ireland; but in Dundee, as elsewhere, there was usually premonitory diarrhoea, and a very general prevalence of diarrhoea which never came to true cholera[1553].

The Cholera of 1849 in Ireland.

The cholera of 1849 found Ireland in a state of exhaustion and confusion. The fever and dysentery that followed the great potato famines of 1845 and 1846 were still far from extinct; the workhouses, which had not existed in 1832, were full of paupers. The mortality of nearly half a million in the famine years, and the emigration of perhaps three times as many, had reduced greatly the population of the scattered cabins, hamlets and villages; but the towns were more populous than ever from the immense number of destitute persons that had gravitated to them. In these circumstances it was not surprising that the cholera of 1849 should have been more disastrous than that of 1832. The infection appeared first in Belfast in November, 1848, in a man who had come with his family from Edinburgh and had been admitted into the workhouse. Some thirty cases of cholera among the inmates followed his death, and at length the infection was started at large in the town, probably by a man who had been discharged from the workhouse[1554]. The cholera of 1849 in the capital of Ulster was more fatal than that of 1832, causing 969 deaths in 2705 attacks. Over Ireland generally its great season appears to have been, as in England, the summer, and in part also the spring. Excepting Belfast, the principal cities and towns had fewer deaths than in 1832; Dublin having only 1664 as compared with 5632, Cork 1329, or nearly the same number as in 1832, Limerick 746, which was about a fourth less, Galway less, Waterford about the same as in 1832 and 1833 together, and Drogheda as severe an epidemic as last time. But the smaller towns and the rural districts generally suffered more. The deaths for all Ireland returned to the Board of Health were 19,325, nearly the same total as in 1832; but there were no returns included from Wicklow, Cavan, Fermanagh and Donegal, and it is probable that the returns were otherwise incomplete, the census taken in 1851 giving 30,156 cholera deaths under the year 1849, and 35,989 in the whole decennial period from 1841. The larger total was distributed as follows:

Urban Rural In hospitals In workhouses

10,653 10,656 7964 6716

The number of rural deaths is much larger than in 1832. There were only a few towns with over 2000 inhabitants that escaped—one in Connaught, six in Munster, one out of forty-one in Leinster, while seventeen towns were visited in Ulster. The counties of Dublin, Carlow, Clare and Galway suffered most; of the smaller towns, Tralee and Dingle lost heavily, both among the poor and the rich. The town of Ballinasloe, near the confluence of the Suck with the Shannon, had 756 deaths from 23 April to 19 August, a great part of them in the workhouse. In clinical characters, the cholera of 1849 was noted in Ireland, as in Scotland and England, for the high proportion of sudden fatalities, about one-third, without the warnings of diarrhoea or the usual choleraic symptoms. It was remarked also that many children under the age of seven died of cholera, about one in ten of all ages. There was a second season in 1850, with 1768 deaths (according to the census), but hardly comparable to the return of cholera in 1833 in the country districts more particularly.

The Cholera of 1849 in England.

The brief but very severe epidemic of cholera in the south of Scotland in midwinter was all over and done with for good before the disease really began in England. Hull, which had a few cases on board ship in the end of 1848, about the same time as the infection began to rage in Edinburgh and Leith, was spared its great visitation, the greatest in all England, until the late summer and autumn[1555]. The progress of the infection in London also was strangely different from that in Scotland. There were undoubted cases in Bethnal Green and other out-parishes in the autumn of 1848, and there seemed no reason why the infection should not run through the population and exhaust itself at once, as in Glasgow. But it will appear from the following table of the deaths in London that the real outburst was delayed until the summer and autumn of 1849:

Cholera deaths

1848

Sept. 11

Oct. 122

Nov. 215

Dec. 131

1849

Jan. 262

Feb. 181

March 73

April 9

May 13

June 246

July 1952

Aug. 4251

Sept. 6644

Oct. 464

Nov. 27

Although a certain number of deaths were returned in October and November, 1848, they came in twos or threes from many parishes of the metropolis and made no great impression upon any one locality. It was not until the beginning of December that the presence of cholera was fully realized, owing to an extraordinary explosion of the disease in a huge pauper institution at Tooting. The school contained about a thousand children, of whom some three hundred took Asiatic cholera, with one hundred and eighty deaths, in the course of three or four weeks: this was the whole cholera mortality that the parish of Streatham had from first to last. In the spring months the cases declined all over London in a very remarkable way, so that it looked for a time as if the infection were extinct, just as in 1832. But in June there was a revival, and thereafter a steady increase to the maximum of 6644 deaths in September. The table given under the year 1866 shows upon what parishes the mortality fell most—those of Southwark, Bermondsey, Rotherhithe, Greenwich, Newington, Lambeth and Battersea on the south side, of Westminster, the City and Liberties, Shoreditch, Bethnal Green and Whitechapel on the north side of the Thames. It was a more severe visitation per head of the inhabitants than that of 1832, cutting off many beyond the limits of the destitute and reckless class who were its most usual victims on the first occasion. Many of the respectable class of workmen and small shopkeepers were among the victims. Several medical men died of it, including one well-known surgeon, Mr Aston Key, at his house in St Helen’s Place, Bishopsgate, on 23 August, after a few hours’ illness. As in Ireland, and at Dundee, an unusually large proportion of the London deaths, perhaps a fourth part, were from sudden collapse and blueness, without premonitory diarrhoea or predominant intestinal symptoms. Opinion was strongly against contagiousness in this epidemic. There were 478 cases treated in St Bartholomew’s Hospital, but not one of the nurses took cholera.

The infection seemed to find out the insanitary spots and to act miasmatically upon the residents. The common remark in all parts of England, Scotland and Ireland was that the localities that suffered most from the typhus fever of 1847-48 suffered most also from cholera. The one black spot in Kensington was a poor district on the north side of the parish known as the Potteries, where an immense number of pigs were kept.

One of the most remarkable features of the cholera-seasons of 1848-49 was the extensive prevalence of common bowel-complaints. Evidence of this has been given for the south of Scotland just before or during the cholera of midwinter, a season when diarrhoea is not usual. It was equally remarked in England in the course of 1849. In the Taunton workhouse, where true Asiatic cholera broke out in November, there had been many cases of bowel-complaint, as well as of fever, in the spring (7 deaths from dysentery and diarrhoea, 5 from fever). In the Exeter workhouse there were eighteen deaths from dysentery in the end of the year, although there is nothing said of cholera, which caused only 44 deaths in the whole city. The efforts of the inspectors sent by the Board of Health were in great part directed to finding out the cases of “premonitory” diarrhoea, by house-to-house visitation, and insisting upon the importance of checking it before it could turn to true cholera. Leeds will serve as an example of English towns. In an incomplete survey after the month of July there were found 5129 cases of simple diarrhoea, 1484 cases of dysentery, 1273 cases of choleraic diarrhoea, and 1090 cases of true cholera[1556]. It was something of a paradox that, with such excessive prevalence of ordinary bowel-complaints, an unusual proportion of the cases of true cholera proved quickly fatal with symptoms of collapse and asphyxia only.

Just as the first startling indication of the presence of Asiatic cholera in London was the enormous fatality in the pauper school at Tooting in the winter, so in some other towns the infection seemed to pick out workhouses or prisons to begin upon. At Belfast there were forty cases in the workhouse before there was one in the town. At Liverpool there were 28 cholera deaths in the first quarter of 1849, of which 8 were in the workhouse. At Wakefield, 19 died of cholera in January, 16 of these in the House of Correction. Among the people at large the infection made little progress until the summer. In the first and second quarters of the year it is heard of, but to a moderate extent, in the towns and colliery districts of Durham and Northumberland, which were the scene of its earliest outbreak in the winter of 1831-32. It was also beginning in the poorest and filthiest parts of Liverpool, Bristol and Plymouth. Its great season all over England was July, August and September, the incidence of the disease according to counties being shown in the table. The right-hand column, showing the number of deaths at the principal centres in each county, must serve for a conspectus of the epidemic.

Cholera Mortality in England and Wales in 1849.

Deaths Death-rate per 1000 inhab. Principal centres in each county

England and Wales 53293 3·0

London 14137 6·2 Lambeth 1618, Newington 907, Bermondsey 734, Southwark 1704

Surrey, part of 255 1·3

Kent, part of 1208 2·5 Gravesend, Milton, Rochester, Chatham, Margate, Ramsgate, Maidstone

Sussex 346 1·1 Hastings

Hampshire 1245 3·2 Portsmouth 568, Southampton 240

Berkshire 148 ·8

Middlesex 406 2·7 Edmonton, Barnet

Hertfordshire 323 1·9 Hitchin 127, Hertford 81, Watford 45

Buckinghamshire 175 1·2 Marlow, Wycombe 100

Oxfordshire 117 ·7 Oxford 44, Witney 33

Northamptonshire 141 ·7 Northampton 49, Peterborough 49

Huntingdonshire 14 ·2

Bedfordshire 72 ·6 Bedford 37, Biggleswade 28

Cambridgeshire 269 1·4 Wisbech 138, North Witchford 85

Essex 580 1·7 West Ham 134, Romford 163, Rochford 105, Harwich

Suffolk 79 ·2 Ipswich 18, Mutford 27

Norfolk 223 ·5 Yarmouth 87, Norwich 38

Wiltshire 320 1·3 Salisbury 165, Devizes 67

Dorset 122 ·7 Weymouth 59, Poole 31

Devon 2366 4·2 Plymouth 830, Stonehouse 171, Stoke Damerel 721, Plympton St Mary 151, Tavistock 140, Totnes 107

Cornwall 835 2·4 St Germans 236, Liskeard 132, St Austell 135, Redruth 133

Somerset 923 2 Bridgewater 235, Keynsham 77, Bath 90, Bedminster 281

Gloucestershire 1465 3·5 Bristol 591, Tewkesbury 59, Gloucester 119, Clifton 563, Dursley 58

Herefordshire 1 ·01

Shropshire 316 1·3 Bridgnorth 75, Shrewsbury 116

Staffordshire 2672 4·4 Newcastle-under-Lyme 241, Wolverhampton (incl. Bilston, Tipton, Sedgley) 1365, Stoke 103, W. Bromwich 250, Dudley 412, Walsall 186

Worcestershire 432 1·7 Stourbridge 314

Warwickshire 293 ·6 Coventry 202, Birmingham 29, Warwick 20

Leicestershire 8 ·08 Loughborough 7, Leicester 2

Rutlandshire 7 ·4

Lincolnshire 372 ·9 Gainsborough 246, Boston 35, Grimsby 29

Nottinghamshire 137 ·5 East Retford 21, Basford 42, Nottingham 18

Derbyshire 50 ·06 Derby 18

Cheshire 653 1·6 Nantwich 181, Runcorn 82, Stockport 72, Birkenhead 139

Lancashire 8184 4·1 Liverpool and W. Derby 5308, Wigan 503, Manchester 878, Chorlton 280, Salford 237

West Riding 4151 3·2 Huddersfield 52, Bradford 426, Hunslet 884, Dewsbury 224, Wakefield 241, Pontefract &c. 238, Leeds 1439

East Riding 2140 8·7 Hull and Sculcoates 1834, York 174, Pocklington 37, Howden 58

North Riding 47 ·2 Whitby 10

Durham 1642 4·2 Darlington 4, Stockton 248, Durham 192, Hartlepool, Chester-le-Street 134, Sunderland 363, Gateshead 257, S. Shields 201

Northumberland 1417 4·8 Newcastle 295, Tynemouth 815, Alnwick 142

Cumberland 419 2·2 Carlisle 51, Cockermouth 282, Whitehaven 79

Westmoreland 1 ·02

Monmouth 775 4·1 Newport 246, Pontypool 69, Abergavenny 438

S. Wales 3544 6·1 Merthyr Tydvil 1682, Cardiff 396, Neath 738, Llanelly 45, Swansea 262, Carmarthen 142, Crickhowell 95

N. Wales 245 ·6 Holywell 86, Montgomery 37, Carnarvon 21

The highest rates in the table are for the East Riding, owing to Hull (24·1), for South Wales, owing to Merthyr Tydvil (23·4), for Northumberland and Durham, for Staffordshire, owing to the iron district round Wolverhampton, for Devonshire, owing to Plymouth, for Lancashire, owing to Liverpool, and for Monmouth, owing to a few mining places. The miners suffered most, the lower class in the seaports next most severely. The Black Country in the south of Staffordshire, which had been the worst centre of the 1832 cholera, was again one of its chief centres in 1849, the mortality falling most, as before, upon the town of Bilston, and next to it upon Willenhall and Wolverhampton. But a great rival to the Staffordshire coal and iron mining had sprung up since 1832 in Glamorgan; and it was in this comparatively new region of miners that cholera in 1849 reproduced the Black Country horrors of 1832 and, indeed, surpassed them.

Merthyr Tydvil had sprung up more like a vast miners’ camp than like a well-ordered municipality. Along the eastern side of the Taff valley, on the slopes and in bottoms of the hills, but everywhere at an elevation of some four or five hundred feet above the level of Cardiff docks, were numerous groups of mean-looking miners’ cottages, with their attendant ale-houses, small retail shops, schools and meeting-houses. This peculiar township had drawn to itself the special notice of the Health of Towns Commission in 1844: “From the poorer inhabitants (who constitute the mass of the population) throwing all slops and refuse into the nearest open gutter before their houses, from the impeded course of such channels, and the scarcity of privies, some parts of the town are complete networks of filth emitting noxious exhalations.... During the rapid increase of the town no attention seems to have been paid to its drainage.”

In this district the registrar had returned 162 deaths from “cholera” in the year 1841, which must have been from an unusually severe type of cholera nostras or British cholera. A first case of Asiatic cholera occurred at Cardiff in a sailor on the 13th of May, 1849, a week after there was a case at Lower Merthyr, and a week after that another at Upper Merthyr. In the course of the summer the ravages of the disease were enormous in the hilly mining regions of the interior of Glamorgan and Monmouth, as well as severe in the seaports:

Merthyr Tydvil 1682

Cardiff 396

Neath 738

Swansea 262

Abergavenny district 438

Pontypool 69

Newport 246

The peculiar selection of the mining townships was well shown in the district of Abergavenny: of 378 deaths from cholera in the third quarter of 1849, only 9 occurred in Abergavenny town, while 157 were at the iron-works of Tredegar and 210 at those of Aberystruth, just as, in the winter preceding, the villages of the iron-works all round Kilmarnock had been ravaged by cholera while there was little of it in that town itself.

Another chief centre of cholera in 1849 was the port of Hull. Including the district of Sculcoates, it had the following enormous mortalities from cholera in four weeks of September: 398, 507, 524 and 171, the whole epidemic from July to the 18th of October producing 2534 deaths[1557]. Its neglect of scavenging became a classical instance of the favouring conditions of cholera. An open space at Witham called the “muckgarths,” from the refuse deposited upon it, was one of the worst centres, just as the town moor of Sunderland, used for the same purpose, had been in 1831[1558]. In the other ports, Liverpool, with West Derby, Bristol with Clifton, and Plymouth with East Stonehouse and Devonport, the infection was most severe (see Table), and was observed to choose the poorest streets, lanes and houses, where there had been most typhus for a year or two before[1559]. On the Tyne, the greatest centre on this occasion was not Newcastle, but Tynemouth. The city of Durham, which escaped the cholera of 1832, had a severe visitation. The chief inland centres, besides the mining districts of Staffordshire and Glamorgan, were Manchester and the cloth-making towns of Airedale,—Leeds, Hunslet, Bradford, Dewsbury, and some others in the West Riding. Most of the Lancashire towns occupied with the cotton industry again escaped with little cholera—Preston, Clitheroe, Oldham, Bury, Rochdale, Bolton, Blackburn, Ashton and Chorley. Wigan had nearly twenty times as many deaths as in 1832; on the other hand Sheffield had only a quarter of its former cholera mortality, while Nottingham and Norwich had this time very little. Birmingham, Leicester, Cheltenham, Hereford, Stafford, Ipswich, Cambridge and Colchester were again almost or altogether free from infection. The agricultural counties, notably the Eastern counties, escaped once more with few centres of infection, and these unimportant. Cumberland as a whole had fewer deaths than in 1832, while Cockermouth had more. Exeter, which was severely visited on the former occasion, escaped almost wholly, while Totnes and Tavistock, with the surrounding Dartmoor country and other towns in Devon, had epidemics of the first degree for their size. In England as a whole the cholera of 1849 was more severe relatively to the numbers living than that of 1832, its great centres having been the same, or of the same kind, on both occasions[1560].

The cholera of 1849 reproduced very closely the former characteristics. The attacks were often in the night, especially in persons who had supped heartily on the coarser kinds of savoury meat. With the same undoubted preference for the poorer and more filthy quarters of towns, the infection showed also a certain apparent caprice in fixing on some places and avoiding others.

Thus at Leeds it was most malignant in the locality of York Street and Marsh Lane (an old centre of plague and typhus), which had lately been drained at a cost of some thousands of pounds, “whilst in the adjoining district, which lies nearly level with the river, and will scarcely admit of any sewerage, I have not heard,” writes the registrar, “of a single case of cholera”—an experience similar to that of a low-lying district of Bristol in 1832. At Liverpool, where much had been undertaken for sanitation since the disastrous Irish fever of 1847-48, the cholera appeared to Dr Duncan, the medical officer of health, to attack sewered and unsewered streets impartially. Another singular thing, which used to be noticed in the plague and is observed in the malarial fevers of towns abroad, was the choice of one side of a street only: thus, at Rotherhithe, in a street where numerous deaths occurred, they were nearly all one side of the street, in houses occupied by respectable private families, only one house having been infected on the other side; at Bedford, two streets showed the same thing.

In London, the least elevated parishes on both sides of the Thames were again its chief seats. Dr Farr, the superintendent of statistics, deduced the law that the death-rate from cholera in London was inversely as the altitude of the parish, and he showed, by a somewhat rough grouping of the cholera deaths, that the law applied to all England[1561]. An empirical generality such as that may have some value; but it is the exceptions to it that show the inward meaning of the fact.

Merthyr Tydvil, which was the worst cholera-spot in England with the possible exception of Hull, was five hundred feet above the level of Cardiff, its seaport, where the death-rate was much lower. Neath, also, had much more cholera than Swansea. Newcastle-under-Lyme, situated near the source of the Trent, and the highest town in the course of that river, had a far more severe visitation of cholera than any other town upon it all the way to its mouth. At Tavistock among the Dartmoor hills, cholera “sat for many a week,” as Kingsley says, “amid the dull brown haze, and sunburnt bents and dried-up watercourses, of white dusty granite.” But the poorer and more populous part of Tavistock was a somewhat peculiarly shut-in basin, which was “very often involved in fog during the night.” The town had escaped cholera in 1832, but one of its physicians, writing in 1841, and recalling its dreadful plague of 1626, did not feel sure that it would escape if cholera came back[1562]. Again, one thinks of Salisbury as standing among high downs; but it had a wet subsoil, bad sewerage, and bad water supply, and in 1849 it had 200 deaths from cholera among all classes in two months[1563].

In the not very extensive outbreak at Sheffield, one of its chosen seats was an elevated district called the Park, inhabited by colliers. At Bedlington colliery, near Morpeth, the cholera deaths in November were in the miners’ houses on the hill side. The elevated, airy and clean village of Loanhead, near Edinburgh, had 46 deaths in its population of 1200, during a few weeks of midwinter. In Dundee, built upon a steep slope at the waterside, there were bad centres of cholera in the higher parts as well as in the lower.

The determining thing appears to have been not so much the elevation as the configuration of the ground; any basin, or cup, or shelving terrace, any natural collecting-ground of moisture and organic refuse in the soil, may become a seat of cholera, whether it be at the sea-level or several hundred feet above it, provided it have a sufficient number of human occupants and a mode of drainage inadequate to its peculiar needs. Such was the situation of Merthyr Tydvil, of Neath, of Newcastle-under-Lyme, of Tavistock, of some colliery villages, and of certain localities in towns such as Dundee. Such, of course, was also the situation of the London parishes next the river on the south and east, of Hull, of Plymouth, of Liverpool, and of other seaports on estuaries. Neither altitude nor configuration means anything for cholera unless the ground itself be full of rotting filth. In all England and Scotland the cholera chose, as if by an unerring instinct, those not very extensive mining parts of the counties of Stafford, Glamorgan, Durham, Lanark and Ayr, which had as many hundreds of inhabitants to the square mile, and as little provision for the safe disposal of their excrements, as those village communities of Lower Bengal in which the infection had become established since 1817 as if it were an annual product of the soil.

The Report of the Board of Health brought to light many instances in which it seemed probable that cholera had been favoured, if not induced, by the water of wells contaminated with organic filth soaking through the ground or entering with the surface water. This was especially the case at Merthyr Tydvil. It was during the next cholera, that of 1854, that the question of contaminated water came into great prominence, in connexion both with wells and with the vast volumes of water supplied through the mains of water companies.

The Cholera of 1853 at Newcastle and Gateshead.

The third visitation of Great Britain and Ireland by Asiatic Cholera was in 1853-54. There had been none of it in any part of the kingdom since 1850; but it is not so clear that all other European countries, especially Poland, were equally free from it. Whether due to a new approach from Asia, or to a rekindling of smouldering fires, cholera appeared in the Baltic ports in the summer of 1853, and soon after reached the Tyne. For the third time a severe but localized epidemic was the prelude—this time at Newcastle and Gateshead, just as in 1848 at Edinburgh, Glasgow and the south of Scotland, and in 1831 at Sunderland and Newcastle.

In the cholera of 1849, which was the most general and the most severe visitation that England has had, Newcastle escaped with a light visitation and Gateshead with a moderate or average one, while Tynemouth (with North Shields) had about twice as many deaths as Newcastle and Gateshead together (12·9 deaths per 1000 inhabitants). In 1853 it was the turn of Newcastle—for no better reason, perhaps, than its escape last time. The very thorough and masterly inquiry by Messrs Simon, Bateman and Hume did, indeed, reveal a most unwholesome state of things; but the town was no worse or only a little worse than in 1849, when the cholera had dealt lightly with it, and it was probably an average sample of the insanitary condition of the greater English industrial towns in the time of their rapid growth and before the period of well-ordered local government had arrived. In some parts, such as Sandgate, the dwellings of the labouring class were “not fit to live in”; in the newer mean suburbs, it was found, as in Glasgow twenty years before, that cellars had become the dwelling-places of a class who in former times lived above ground. Those who had been dispossessed by the railways and other public structures had not been provided for elsewhere; so that, with more trade and better wages, the working class were worse housed than before. Overcrowding, for which the ports on the Tyne and Wear are still pre-eminent, was then most excessive. Only the better-class houses had the water laid on. Excremental offences to sight and smell were everywhere. There was a system of main sewers, passably good; but house-drainage or connexions with the main drains were quite casual. The scavenging of the town was greatly neglected. Piggeries, slaughter-houses and other such nuisances, were uncontrolled. The burial-grounds were over-full. With all this the death-rate of Newcastle could be low enough in a good year, such as 1844, when it was 20·9 per 1000; in the year of the Irish fever, 1847, it rose to 32·8; and in other years it fluctuated between those extremes, according to the nature of the seasons[1564].

The cholera of 1853 was a sudden explosion in the heavy stagnant atmosphere of the month of September. No one knew where the infection came from; there were, of course, ships arriving from the Baltic, but no particular source was ever traced. On the 30th or 31st of August, a case occurred of the rapidly fatal kind; before a week there were about a hundred attacks daily all over the town. From the 13th of September the deaths in Newcastle mounted up rapidly as follows:

Cholera deaths

Sept. 13 59

14 90

15 106

16 114

17 103

18 103

19 111

20 85

21 68

22 82

23 60

24 56

In the thirty days of September there were 1371 deaths, and some one or two hundreds more in the first part of October, when the infection ceased almost abruptly, the total of deaths to the 4th of November having been 1533. During the same time Gateshead with a population of 26,000, had 433 deaths, or in a ratio nearly equal to that of Newcastle. On the other hand Tynemouth, with a population of 30,000, had only twelve deaths, several of them in vagrants or other arrivals from Newcastle, the rest in a cluster of pitmen’s cottages on the outskirts of North Shields.

It was freely rumoured at the time, and was even repeated with much unction in so dry and deliberate a work as the report of the Registrar-General, that the cholera at Newcastle and Gateshead in September, 1853, was owing to the sudden contamination of the town’s water with sewage. The facts about the water-supply are as follows: Previous to 1848, Newcastle was supplied with Tyne water pumped up at Elswick, and passed through the settling tanks and filtering beds. In 1848 the Whittle Dean Water Company, incorporated in 1845, had their new supply ready, and the old company, with its pumping station at Elswick, was superseded. The new supply was collected from landward sources, and was apt to be peaty. There was a great demand upon it, especially for public works (it was supplied to comparatively few houses), so that the distribution in 1853 had increased 2½ times since the company began in 1848. They had extended their collecting area to meet this demand; but, owing probably to the drought, they found it necessary on the 6th of July, 1853, to resort to the old pumping-station at Elswick for about a third part of all the water that flowed daily through the mains. This had gone on for eight weeks before the epidemic began, and was promptly discontinued on 15 September, as soon as the possible danger from Tyne water was realized. The pumping-station was higher up the river than the only one of the Newcastle sewers that discharged in its vicinity. There were complaints about the water, but these appear to have been chiefly of the peaty colour or flavour, which came from the Whittle Dean part of the mixture. The water from the mains was not equally bad at all points, as if the suspected contamination might have occurred in its transit through the town. Also the water of some wells was complained of as offensive at the same time, which was the season of the year when the springs are lowest. Gateshead was also supplied by the mains of the Whittle Dean Company. It is clear from the report of the Commissioners that they considered the water of Newcastle and Gateshead to have been a very subordinate factor, if a factor at all, in the epidemic of cholera.

The Cholera of 1854 in England.

The great epidemic at Newcastle and Gateshead was over by November, 1853, those towns having no share in the general epidemic in England in 1854, although it visited their near neighbour Tynemouth. The interest of the cholera of 1854 centres chiefly in London[1565]. Few of the great foci of infection in 1849 were visited severely. Liverpool, which never escaped, had a moderate epidemic, Merthyr Tydvil also had about a fourth part of its 1849 mortality, Dudley had the disease somewhat severely, while some towns, such as Norwich, Wisbech and Sheffield, had more than usual. But Plymouth, Hull, Bristol, Manchester, Leeds, the towns of the Black Country and nearly all the populous places that had suffered heavily either in 1832 or in 1849, or on both occasions, escaped in 1854 with little cholera or none[1566]. The table shows the incidence of the epidemic (as well as that of 1866) according to counties.

Cholera Mortality in England and Wales in 1854 and 1866.

1854 1866

Rate per 1000 Rate per 1000 Principal centres in each county

Deaths Deaths 1854 1866

England and Wales 20097 14378

London 10738 4·3 5596 1·9 South of Thames, Eastern parishes Eastern parishes 3691

Surrey, part of 252 1·2 82

Kent, part of 1056 2·1 284

Sussex 94 ·3 79

Hampshire 130 ·3 417 ·9 Portsea Island 20, Southampton 48 Portsea Island 129, Southampton 41

Berkshire 49 ·2 3

Middlesex, part of 380 2·4 51 Brentford 196

Hertfordshire 97 ·5 9

Buckinghamshire 68 ·5 10

Oxfordshire 183 1·0 4

Northamptonshire 152 ·7 7 Towcester 86

Huntingdonshire 18 ·3 1

Bedfordshire 61 ·4 22

Cambridgeshire 270 1·3 7 Wisbech 176, Ely 46

Essex 513 1·4 471 1·0 West Ham 124, Romford 113, Maldon 102 West Ham 389

Suffolk 67 ·2 15

Norfolk 381 ·8 15 Norwich 193, Yarmouth 41

Wiltshire 60 ·2 11

Dorset 45 ·2 6

Devon 188 ·3 525 ·9 Plymouth 59, Stonehouse 15, Devonport 2, Bideford 46 Exeter and St Thomas 247, Newton Abbot 57, Totnes 146

Cornwall 24 ·06 21

Somerset 21 ·04 68

Gloucestershire 260 ·6 39 Bristol 76, Clifton 92, Gloucester 48

Herefordshire 1 ·01 2

Shropshire 13 ·05 17

Staffordshire 426 ·6 30 Dudley 256, Wolverhampton 80

Worcestershire 103 ·4 36 Worcester 45

Warwickshire 89 ·2 15

Leicestershire 14 ·06 3

Rutlandshire 9 ·08 —

Lincolnshire 134 ·3 48 Great Grimsby 68

Nottinghamshire 80 ·3 12 Worksop 27, Nottingham 16

Derbyshire 17 ·06 20

Cheshire 141 ·3 391 Chester

Lancashire 1775 ·8 2600 1·0 Liverpool 1084, W. Derby 206, Wigan 158 Liverpool and W. Derby 2122, Wigan 137

West Riding 470 ·3 283 Sheffield 126, Dewsbury 66, Leeds 48

East Riding 70 ·3 54 Hull 27

North Riding 84 ·4 21 Whitby 33, Guisboro’ 30

Durham[1567] 2·9 352 ·6 Stockton, Auckland, Durham

Northumberland[1568] 5·7 224 Newcastle 1431, Gateshead 525, Tynemouth 203

Cumberland 35 ·2 32

Westmoreland 1 ·02 1

Monmouth 18 ·1 204

South Wales 887 1·4 2033 2·9 Merthyr Tydvil 455, Cardiff 255, Neath 54, Brecon 54 Swansea 521, Neath 520, Llanelly 232, Merthyr Tydvil 229

North Wales 34 ·08 256

The London cholera of 1854, like that of 1832 and of 1849, fell most upon the southern (Southwark etc.), eastern and southeastern parishes (Table, p. 858). But it fell somewhat unequally upon these; and for Southwark and Lambeth the water supply was seized upon as the thing that made the difference. There were two water companies in South London, the Lambeth company and the Southwark and Vauxhall company. The parish of Christ Church, Lambeth, chiefly supplied by the Lambeth company, had a death-rate from cholera in 1854 of only 0·43 per 1000 inhabitants; whereas the parish of St Saviour, supplied by the Southwark and Vauxhall company, had a death-rate of 2·27 per 1000. In 1849 there had been no such disparity between them, the death-rate of Christ Church being if anything the higher of the two. Now it happened that in the interval of the two epidemics of cholera the Lambeth company had removed their intake works from opposite Hungerford Market to Thames Ditton, whilst the Southwark and Vauxhall company still continued to draw their supply from the Thames near Vauxhall. Here was a fine instance of the logical method of difference. Farther, within the parish of Christ Church itself, it was sought to show that the cholera followed the lines of old water supplies, and did not follow the mains from Thames Ditton. After 1854 the Southwark and Vauxhall company also made their intake at Thames Ditton. According to the water-hypothesis of cholera, it is not surprising, as we shall duly find, that the whole of the South London parishes, which had been the chief seats of the cholera in 1832, 1849, and 1854, escaped in 1866 with a very slight visitation. Newcastle was another chosen instance of cholera distributed by the water mains; but, as we have seen, that was improbable. Another instance was Exeter: its water supply in 1832, when part of it had a disastrous epidemic of cholera, was taken from the Exe, and was impure; in 1849, when it had only a tenth part of its last cholera mortality, its water supply had been greatly improved; in 1854 it had 10 deaths; but in 1866, Exeter with the registration district of St Thomas had 247 deaths, and Totnes had 146,—for their size about the most severely visited towns in England.

In the London cholera of 1854 a very sudden and simultaneous explosion in the district of Soho attracted much notice[1569]. The district stands high, which did not save it from being the scene of the first outbreak in the great plague of 1665. In the subdistricts of St Anne, Golden Square and Berwick Street, with a population of 42,000, many of them well-to-do families, there were 537 deaths from cholera, a rate of 12·8 per 1000, contrasting with the rate of 6 per 1000 for all London. The attacks and fatalities were remarkably numerous for one or two days, falling at once thereafter to about a half. There was a pump in Broad Street, in the centre of this district, which was supposed to have dispersed cholera broadcast in its contaminated water; a death had occurred in Swain’s Lane, at the foot of Highgate Hill, of a person who had drank the water of the Broad Street pump. The whole incident was seized upon and worked up by Dr Snow, who had written a speculative essay in 1849 upon the probability of cholera being conveyed by water, according to the similar theory of Parkin in 1832[1570]. The Board of Health, having very full data before them of the Soho outbreak in all its aspects (including a whole biological treatise upon the organisms found in water), did not adopt Snow’s conclusion, although he had enthusiastic followers at the time, and has probably more now[1571]:

“In explanation of the remarkable intensity of this outbreak within very definite limits, it has been suggested by Dr Snow that the real cause of whatever was peculiar in the case lay in the general use of one particular well, situate at Broad Street in the middle of the district, and having (it was imagined) its waters contaminated by the rice-water evacuations of cholera patients. After careful inquiry we see no reason to adopt this belief. We do not find it established that the water was contaminated in the manner alleged; nor is there before us any sufficient evidence to show whether inhabitants of the district, drinking from that well, suffered in proportion more than other inhabitants of the district who drank from other sources.”

The Cholera of 1853-54 in Scotland and Ireland.

The cholera of 1853-54 in Scotland has not been so fully recorded as either of the two preceding epidemics. It is said to have caused about six thousand deaths, of which 3892 were in Glasgow alone, and a considerable part of the remainder in Edinburgh and Dundee. The infection began to appear in the end of September, having been derived probably from the dreadful explosion at Newcastle. A few early cases occurred at Dunse, in Berwickshire. On the 16th September, 1853, the old Cholera Hospital at Edinburgh, in Surgeons’ Square, was opened, but received only 45 cases until the beginning of June, 1854, when it was closed. In the autumn of 1854 the real epidemic began, the hospital being re-opened on 24th August, from which date until the 30th November the admissions were 198. These hospital figures indicate for Edinburgh a milder epidemic than that of the winter of 1848, which was itself milder than that of 1832. The cases came mostly from the very same localities of the old town as in 1848. There were 145 females to 97 males; the deaths were 117 in 243 cases admitted[1572].

The epidemic at Dundee was a late autumnal or winter one, in the end of 1853, and of great severity, the mortality having probably exceeded 500. The Glasgow epidemic had a course very nearly parallel to that of 1832, and quite unlike the extraordinary winter explosion of 1848-9. It began, indeed, in winter—about the 15th of December, 1853, and had caused 849 deaths to the 27th of February; there was a sharp rise of the mortality from the 13th to the 24th of March, the total deaths to that date being 1306. As in 1832, the infection appeared to die out in the late spring and early summer; but in June it revived and increased in virulence until August, after which it subsided gradually until November, the whole mortality having been 3892, or ·98 per cent. of the population, nearly the same ratio as in 1848-9, (1·06) and a lower ratio than in 1832 (1·4). The first part of the epidemic fell chiefly on the north and east of the city, the second part, in summer and autumn, was all over the city, as in 1832, and among all classes, as in the winter of 1848-49, but perhaps less disastrously in the best quarters of the city than the last had been. The cholera hospital received a comparatively small part of all the cases—600 of cholera, 253 of diarrhoea, the deaths being 306, or less than a tenth part of the whole mortality[1573].

It is probable that the mortalities in Scotland on this occasion, besides those in Glasgow, Edinburgh and Dundee, were neither so general nor so great as in 1832. One remarkable outbreak happened at the village of Symington, in Ayrshire: in a population of 240 there were 110 attacks and 30 deaths; nearly all the cases were in houses on one side of the village street, which got their water from a public well; the houses on the other side, having private wells (and differing, doubtless, in other respects), were notably free from the infection[1574].

The cholera of 1854 was unimportant in Ireland. Cases appeared among emigrants on board ships in Belfast Lough and at Queenstown in the end of 1853, but no diffusion took place until 1854, and then only to a moderate extent. It is supposed that some 1706 persons died of it in Ireland in that year, according to the retrospective figures of the census of 1861; but a good many deaths from “cholera” were returned for every year of the decennium, so that it is improbable that the whole 1706 in 1854 were of the true Asiatic type. Ulster had 895 of these, Leinster 453, Munster 324, and the whole of Connaught only 34[1575].

The Cholera of 1865-66.

Asiatic cholera reached Europe by a new route in 1865—by the way of Egypt with the pilgrims returning from the Hâj at Mecca. In the course of the autumn it appeared at Southampton and caused 35 deaths from 24 September to 4 November. A strange extension from Southampton (or from Weymouth) took place to the village of Theydon Bois in Epping Forest, where nine deaths were traced to one house from 28 September to 31 October, unhappily including the death of a most estimable medical gentleman who tasted the water of a well into which the evacuations of the sick had probably percolated.

The cholera having become established on the continent of Europe in the end of 1865, was brought into England by emigrants passing from Hull and Grimsby to Liverpool on their way to America. On board one of the emigrant steamships, the ‘England,’ a very severe epidemic arose in mid-Atlantic in April. Liverpool had once more a severe epidemic (2122 deaths); but the only other important centres in England, besides London, were Swansea, Neath, Llanelly and Merthyr Tydvil, Chester and Northwich, a group of towns on the Exe in Devonshire, and Portsmouth with other places in Hampshire. Still, the deaths in all England made the large total of 14,378, no county excepting Rutland being absolutely free. That means that the infection, although widely diffused, now wanted the conditions favourable to its development and effectiveness; and that, again, seems to mean that a vast improvement had been made in the sewering of towns, in scavenging, and in all other matters of municipal police by which the soil of inhabited spots is preserved from saturation with excremental and other filth.

The interest of the cholera of 1866 centres in London, and chiefly in the fact that three-fourths of the deaths, to the number of 3696, took place in the eastern parishes, Whitechapel, Bethnal Green, Poplar, Stepney, Mile End, St George’s in the East, and Greenwich. These had in former epidemics a fair share; but hitherto they had been surpassed by the Southwark parishes and others on the south of the Thames from Battersea to Rotherhithe, and nearly equalled by Shoreditch and the Liberties of the City. The comparative table of the four great choleras of London shows how remarkably the infection in 1866 had left its old principal seats, remaining, as if a residue, only in the East End, with death-rates comparable to those of 1849.

Comparative view of the Four Epidemics of Cholera in the several parishes of London[1576].

1832 1849 1854 (17 wks. end. 4 Nov.) 1866

Rate per 10,000 Deaths Rate per 10,000 Deaths Rate per 10,000 Deaths Rate per 10,000 Deaths

Kensington 10 52 24 260 35 490 3·7 85

Chelsea 80 272 46 247 47 300 3·3 22

St George, Hanover Sq. 10 74 18 131 38 295 1·7 18

Westminster 50 450 68 437 60 423 6·2 43

St Martin in the Fields — — 37 91 24 58 4·2 10

St James, Westminster — — 16 57 152 485 3·5 13

Marylebone 30 355 17 261 16 347 3·0 54

Hampstead — — 8 9 11 14 ·8 2

Pancras 20 230 22 360 13 248 6·0 138

Islington 10 39 22 187 8 97 4·3 120

Hackney 2 8 25 139 11 73 10·6 103

St Giles 50 280 53 285 21 115 9·2 49

Strand 1 26 35 156 24 111 6·6 29

Holborn 10 46 35 161 5 25 5·2 22

Clerkenwell 10 65 19 121 9 59 7·0 45

St Luke 30 118 34 183 9 52 8·1 46

East City } } 50 605 45 182 23 85 15·7 59

West City 96 429 10 126 18·8 60

City 38 207 14 71 5·0 20

Shoreditch 10 57 76 789 20 237 10·7 139

Bethnal Green 50 345 90 789 20 192 60·4 611

Whitechapel 110 736 64 506 40 330 84·2 909

St George in the East 30 123 42 199 30 154 87·9 385

Stepney 50 358 47 501 32 388 107·6 559

Mile End Old Town — — — — — — 67·7 501

Poplar 40 101 71 313 38 208 90·8 837

St Saviour } 120 1128 153 539 134 495 7·4 32

St Olave 181 349 162 315 8·5 21

Bermondsey 70 210 161 734 158 845 5·3 35

St George, Southwark — — 164 836 101 546 6·6 38

Newington 40 200 144 907 101 696 2·8 26

Lambeth 40 337 120 1618 63 941 6·5 114

Wandsworth 10 46 100 484 77 422 4·8 40

Camberwell 30 107 97 504 91 553 5·6 46

Rotherhithe 10 19 205 352 147 285 8·7 25

Greenwich 20 149 75 718 53 576 19·5 284

Lewisham — — 30 96 20 81 6·1 56

Stratford — — — — — — 77·6 —

West Ham — — — — — — 49·3 —

Leyton — — — — — — 13·1 —

There was one significant thing associated with the peculiar incidence of the cholera of 1866 upon the East End. The main drainage of London, consisting of a high level and a low level sewer on each side of the Thames, was commenced in 1859, and was formally opened on 4 April, 1865. The two levels on each side of the river made together a length of eighty-two miles; the cost, with pumping station, was £4,200,000. When the cholera of 1866 broke out, only one part of the system was incomplete and not yet in working, namely, the low level main drainage on the northern side, which served the whole of the cholera-stricken parishes from Aldgate to Bow. However, the official mind in this country has somehow become prejudiced against the well-known and usually accepted generalities of von Pettenkofer, which make more of a foul soil in the causation of miasmatic infections, than of contaminated surface water or contaminated water from reservoirs. Accordingly, the somewhat remarkable fact that the East End of London alone retained its old proclivity for choleraic infection was not joined to the fact of its being the only great division of the capital still unsewered, but to the fact that it was supplied by water taken in from the river Lea in Hertfordshire and (it was alleged) insufficiently filtered or otherwise purified at the Old Ford waterworks[1577].

The extension to Scotland in 1866 was late in the season and insignificant compared with former epidemics. It was heard of about the end of summer in Fraserburgh and one or two other ports or fishing places on the East Coast, but it was not until October and November that it attracted notice in the eight principal towns, the whole mortality from it in Glasgow being 53, in Edinburgh 154, in Dundee 105, in Aberdeen 62, in Paisley 2, in Greenock 14, in Leith 95, and in Perth 15. Besides these deaths there were 435 more in smaller towns or villages. The year was a very healthy one, the death-rates of Glasgow, Greenock and Perth having been below the mean of the previous ten years.

In Ireland the cholera of 1866 was even slighter than in Scotland, the only considerable epidemic having been at Belfast.

Cholera has never obtained a footing in London since the epidemic of 1866. In 1873, while the disease was unusually active in some parts of Europe, a few cases occurred in Wapping among Scandinavian emigrants on their way to America, who had been landed for a few days. But the infection did not spread. In 1884, when cholera came from Cochin China to Toulon and Marseilles, two or three cases occurred on board steamships arriving at Cardiff and Liverpool. In 1893, when the disease raged in Hamburg, a number of choleraic cases occurred at Grimsby in August, which were considered certainly Asiatic owing to their high degree of fatality. In August-October, the deaths from cholera, whether cholera nostras or the Asiatic type, or both together, were about thirty in Grimsby, eighteen in Hull, and about fifty more in various other places, chiefly in the south of Yorkshire. The autumn of that year was favourable to bowel-complaints and to enteric fever.

The Antecedents of Epidemic Cholera in India.

The antecedents and circumstances that made the year 1817 so critical for cholera in India, and for its diffusiveness far beyond India, constitute one of the greatest problems in epidemiology. A full and minute examination of them cannot be attempted here; but the chapter would be incomplete without some statement on the subject, which, if summary, need not be dogmatic. Cholera with the same symptoms and a similar degree of fatality was certainly not new to India about the year 1817; it can be traced from the earliest records of the Portuguese and other Europeans in India, if not also in other countries in ancient times[1578]. The mortalities among troops during the military operations in the Northern Circars in 1781 and 1790, and the deaths of some 20,000 pilgrims in eight days during the Hurdwar festival of 1783, were undoubtedly from the same epidemic infective cholera that was seen fifty years after in Europe. But these were occasional great explosions, which arose suddenly and ceased abruptly; whereas from about 1817 onwards the infection became, as it were, a seasonal product of the soil of Lower Bengal year after year, and at the same time began to range widely beyond its “endemic area” to other provinces of India, beyond the North-Western frontier to Central Asia and to Europe, and across the ocean to America. It was not by any sudden change in the year 1817, we may be sure, that cholera began to be endemic at various places far apart in the valley of the Ganges. Things must have been tending towards that manifestation for some time before, and those things must have been of the same kind that made the great explosion at Hurdwar in 1783 and have made many other great explosions at the Indian religious festivals in later times. Briefly the opinion may be hazarded, that it was the permeation with excremental matters of the soil at large in and around Bengali villages that gave rise to the endemic miasmatic infection of cholera. The odor stercoreus of those innumerable village communities is, or used to be, a familiar fact, just as it is well known to be the custom there to dispense with latrines or other systematic provision for the disposal of faecal matters. But it may seem improbable that personal habits of the peasantry, not unknown in other countries, and immemorial in Lower Bengal itself, should have led to a definite disease-effect in a certain year of the 19th century and perennially thereafter. As to the special risk of engendering such a soil-poison in the valley of the Ganges, it has to be said that the region is peculiar in its alternations from extreme saturation to extreme dryness, within a stratum of alluvial or other porous soil which has a bed of impervious blue clay beneath it at a depth seldom more than 10 feet. It is just where such extreme fluctuations of the ground-water within a limited range occur from season to season, that organic matters in the soil are most apt to develop a miasmatic infective property. But why should the year 1817 have been, by the general consent of Anglo-Indian observers, the beginning of a new era in the history of cholera? The guiding principle in all such cases is, that things must have been moving that way before, and that in the particular season there had been reached at length such a degree of aggravation as to make a specific result manifest or the cumulative causes effective. Two things may be indicated as relevant to this assumed aggravation, or integration of accumulating causes. One was a certain gradual change in the beds of rivers, especially in the province of Behar, which entirely altered the relative amount of water flowing above ground and under ground, and must have made a difference in kind and in degree to the decomposition-processes in the soil. (In Burdwan these changes in the ground-water have caused much miasmatic fever since about thirty years ago.) The other thing was the increase of the number of cultivators per square mile under British rule. The latter cannot be stated with even approximate exactness for periods before the census of 1872; but there can be no reasonable doubt that the increase was great and progressive from the end of last century, owing to the cessation of intertribal wars, and of famines which were chiefly caused by the overflow of rivers now no longer subject to floods, and of wilful and barbarous checks to population. Among the cholera localities of 1817 were some that have now the greatest pressure of inhabitants on the soil, not in cities, but in uniformly dispersed rural communities—such as the division of Patna with 637 inhabitants per square mile, the district of Jessore with 693, and of Dacca with 756. This is of course a very general account of the matter, which a minute study of localities and seasons might show to be highly inadequate; but in seeking for some circumstances of aggravation at the particular juncture, the two things that have been mentioned, both of them coincident historical matters of fact, will appear to be not irrelevant according to the received teaching on the favouring conditions of cholera.

Note on Cerebro-spinal Fever.

British experience, or the records of it, afford so little material for the history of epidemic cerebro-spinal fever (very abundant for France, Germany and the United States of America, see Hirsch, III. 547) that it has not seemed desirable to interpolate the subject in the chapter on Typhus and other Continued Fevers. Although our experience of it has fallen perhaps wholly within the period of exact statistics of the causes of death (saving some doubtful identifications in the 18th century), yet the registration tables contain so few deaths from it that it hardly seems as if a new and remarkable type of fever of the typhus kind had really been in our midst. There are, however, two periods when a good many papers were written upon it in Ireland and England, the years 1865-67 and the year 1876. When the first cases were seen in London in 1865 Murchison pronounced the new fever to be closely allied to typhus (Lancet, 1865, p. 1417). At the same time in Ireland it was sometimes called “the black death,” from the dark or livid vibices of the skin, or purpura maligna, or purpuric fever (J. T. Banks, Dubl. Quart. Journ. Med. Sc. XLIII. 98; E. W. Collins, ibid. XLVI. 170; Cogan, ibid. XLIV. 172; Gordon, ibid. XLIV. 408; H. Wilson, ibid. XLIII.; Haverty, ibid.; T. W. Belcher, Med. Press, N. S. III. 167; J. H. Benson, ibid. III. 387; editor, ibid. 506. For England, S. Wilks, Lancet, 1865, I. 388, Brit. Med. Journ. 1868, I. 427; F. J. Brown, Trans. Epid. Soc. II. (1865), 391; J. N. Radcliffe in Reynolds’ System of Medicine, 1st ed. II. 676; H. Day, Lancet, 1867, I. 731). In the second period, 1876, there were many cases in England, especially in the Midlands, but it is said that they were usually diagnosed as typhoid fever (Sir Walter Foster, Brit. Med. Journ. 1892, II. 278, and Lancet, 1876, I. 849; Neville Hart (for Birmingham), St Barth. Hosp. Rep. XII. (1876), 105; H. Thompson, Lancet, 1876, I. 849. The Irish papers in the second period are by T. W. Grimshaw, Dub. Journ. Med. Sc. LXI. 520, and LVII. 375; E. H. Bennett, ibid. LIX.; Brabazon, Brit. Med. Journ. 1876, I. 509). An epidemic of cerebro-spinal fever, resembling typhoid, was described for a Shropshire village in May, 1891 (Monk, Brit. Med. Journ. 1892, II. 278). A case which came under my notice on 19 March, 1894, in an eastern parish of London, has led me to doubt whether the half-dozen or so of deaths annually certified in London as from cerebro-spinal fever (contrasting with as many hundreds in New York), are of the slightest statistical value.

A young woman, aged 16, an artificial flower maker, became ill with pains in the limbs and was taken as an out-patient to a hospital. Thereafter she became light-headed. A private practitioner (M.R.C.S.) was called in, who found her with a temperature of 103°, excited, and inclined to clutch spasmodically at his arms; her coarse black hair was full of pediculi and nits. She died next day, having had sent her by the practitioner a draught of chlorodyne on account of her extreme restlessness. An inquest was appointed, and the practitioner ordered to make a post-mortem examination. He attended the inquest and gave evidence that death was due to “congestion of the brain.” The jury were dissatisfied, and the coroner adjourned the inquest for a second examination by a skilled pathologist. After spending two hours looking for the cause of death (there was no congestion of the brain), I discovered that the base of the brain had been left in the skull intact, the hemispheres having been sliced off by a horizontal section in the plane of the saw-draught round the cranium. On raising the frontal lobes I saw green flaky lymph lying on the orbital plates and on the corresponding surfaces of the arachnoid; the same was found on the optic commissure, the surface of the pons, the medulla and over a small area of the under convexities of the lateral lobes of the cerebellum, where it amounted to little more than whitish opacity. The lymph was purely basal, solely on the arachnoid, not in the fissures or sulci. The examination having already lasted over two hours, it was found impracticable to expose the spinal cord. The facts previously found were: an extensive blood-shot state of the left conjunctiva with oedema of the upper lid (there was no obvious intra-orbital disease); round dusky-red spots on the outer sides of the thighs and on the shoulders; both lungs in a state of solid purple congestion at the bases, crepitant at the apices, the costal pleura dark red or livid; the tongue large and flabby, congested around the broad papillae; the stomach at the cardiac end, exactly corresponding to the pressure of a mass of hard undigested food, dotted with numerous small round ecchymoses under the serosa; six inches of the lower end of the jejunum, corresponding to a mass of hard impacted faeces, dotted with the same subserous ecchymoses; a narrow belt of deep congestion round the broad ends of the kidney pyramids; the mucosa of the fundus uteri haemorrhagic. There was no herpetic eruption. At the adjourned inquest the cause of death was found to be cerebro-spinal fever, and was so certified by the coroner to the Registrar-General. The practitioner who attended the deceased was unable to say whether the most distinctive of all the symptoms, the violent retraction of the occiput upon the shoulders, was present or absent. It is improbable that this was a solitary case of epidemic cerebro-spinal meningitis in the East End of London in the spring of 1894, (the early spring being the distinctive season of the infection). Even if it were the only case, it narrowly missed being returned as a death from “congestion of the brain,” and that, too, after post-mortem inquisition. The practitioner’s statutory fees were three guineas. There has lately been collected much evidence upon certificates of death, and upon diagnosis under the Notification Act, which makes it doubtful whether our mortality statistics are as correct in substance as they are methodical and exhaustive in form.