04 Cholera

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THE S O H CHOLERA EPIDEMIC 854by Mr W R Winterton

Cholera IS an infection wh ich has been endem ic i n many par ts o f the w or l d fo rcen tu ri es . In Ind ia there i s a s ta tue o f the t ime o f A lex and er the Great o f a cho le rav i c t~ m u t the f lr s t appearance o f the i n fec t ion i n the Br i ti sh I s l es is compara ti ve lyrecent only 150 years ago.Cho le ra was thou ght to be caused by emanat i ons f r om fou l d ra ins an d tha ts p re a d b y c o n t a g io n d i d n o t o c c u r. C o n s e q u en t ly i t w a s n o t u n d e r s t o o d h o w i tw a s c o n v e y e d f r o m o n e m a jo r t o w n t o a n o t h e r w h i c h w e r e o n l y c o n n e c t e d b yroads . The t r aders w ho t rave l led these roads were no t cons idered poss ib l ecarriers.

There have been four major out-- 1833; 1848 - 1849; 1953 -1866. There has been none

era was in Sunderland in February1. This originated from an

1832. It died down duringof 1833. Naturally it

Observer put the epidemic

ing granted Catholic EmancipationThis was some years before they and nearly fifty

In London the infection spreadmes which

The Middlesex Hospital, to

hospitals refused, sheltering behindtheir laws.The Royal Free Hospital on theother hand opened its doors for thefirst time in order to help with thisepidemic. This hospital began in 1828as a dispensary on the ground floor ofa four story building at 16 GrevilleStreet, Hatton Garden, and was calledthe London General Institution for theGratuitous Cure of MalignantDiseases. In 1832 the tenants of theupper floors at Greville Street weregiven notice to quit and the cholerasufferers became the first in-patients.2A point of particular interest is thatWilliam Stevens treated these casesby the administration orally and intra-venously of up to four pints of ~a l i n e . ~The Royal Free Hospital claims tohave treated in this 1832 epidemic566 patients with only 135 deaths.Stevens' treatment was much inadvance of the accepted treatmenteven in the 1854 outbreak.By some miracle cholera did notappear again until 1848- 1849 and bythis time London was to some extentprepared. Treatment mainly consistedof purging and emetics, in order toeliminate the poisons, astringents andalteratives (calomel). Records of thisoutbreak are more complete. It wasthe most widespread of the four, partlydue to the freer movement of peopleas a result of improved transport.During the summer of 1853 therehad been some diarrhoea and in Julythe reports state that the diarrhoea aswell as the common form of cholerabecame serious and some deaths wererecorded, and beside the river a fewdeaths from cholera of the Asiatic formwere registered. In the autumn the

continued and there were deathroughout the first six months 1854, but during the summer the dearate rose until at the end of August abeginning of September the numbereached a dramatic peak. In Octoband November the numbers fell unin December they dropped t zeroDiarrhoea and cholera are referrt as separate diagnoses, with tformer sometimes progressing to tlatter. Without bacteriological assiance an exact differentiation s impoiible. The definitions used at the timand in the Board of Health report aas follows.DiarrhoeaSimple: Stools faecal. Novomiting, no cramps.Choleraeic: Watery stools, buttinged with bile. Vomiting, nocramps.choleraRice water stools, colourless.Cramps. No urine passed.Temperature lowered. Poorpulse.

, In London generally the 18outbreak was more severe than that1854 apart from the Golden SquarBerwick Street area of Soho. Ttotal deaths in 1849 being 14,600, 6.2 per 1,000 living, whereas in 18the death rate was 11,000 or 4.5 p1,000.The report of the Committee fScientific Eaquiries set up by tGeneral Board of Health4 investigatthe epidemic in relation to density population, Elevation, AtmospheInfluences and Water Supply, bothe chemical content and microspcontent.-There had been a lower inciden

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epidemic of 184 8 1849 , Dr .out an investigation5of the waterSouth London. I n that area

supplies, the Vauxhallpany, which took

by Hungerford Bridge, almost

s an d their mains ran alonge roads which made comp ari-

t heany moved their workswhich is above the tidal part ofr and above the Lond on output

In 1854 South London had 33 4ied by Vauxhall and S outhwark

10,000 . Th at is, there were

Battersea to every case FARAD 4Y GIVING EIIS CARD TO FATHER THAMEAnd we hope the Dirty ellow will consult the learned Rofeseor.

c ~ ~ ~ ~ ~rom Punch

In a letter to The Times 7th July

Even in recent times, A.Phe Tham es:Sweet efluentdear Father DrainWhose generous bosomdoth containA lot of oil a little rainAnd all the muckof Middlesex.

s which becamesible when they reached ad ep th of

Helps asthmaticslead normal active lives.rescr~bi~ ignformat~ons ava~iable n request from F~s on sL~ m~t ed.Pharn~aceut~cal~v~sion2 Derby Road. Loughborough . Le~cestersh~reLEI1 OBB Reg~ sterr d rade Mark.

lntalCompound

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In 1853, a report on the 1849ic was presented to the Roy alollege of Physicians by the disting-ished au thor itie s, Baly and G ~ l l . ~Snow's theorycontamination of watertions but state thathe gives no facts to prove that they

The other source of water wasmostly shallow wells. Then the area is gravel and mostthe clay, so that theell cam e from the gravelportant Broad

elow the bottom o f theool, often old with leaking walls,

Dr. Snow was told by an engineer

us the brick walls of the cessp oolwas used for making tea but forhe coo l water from

hame s bank usually just filledmay seem to be an exaggeration

r John Snow 1813 858)Dr. John Snow was an interestingThe 'son of a Yorkshireborn in 18 13 and died

During the 183 1 epidem ic hee coal mines where he

ies. In 183 6 he decided to walk

did through North and South Wales,calling on an uncle in B ath on the way.He studied at the Little WindmillStreet Scho ol of Anatom y an d did hisclinical training at the WestminsterHospital. At this time he lived offSoho Square, in Bateman buildings.He then went into general practice at5 4 Frith Street, also off Soho Squa re,later moving to Sackville Street. Hebecame a vegetarian and remained sofor eight years. W hen h is health beganto fail, he then decided that it wasinconsistent to be a vegetarian andwear leather boots so he gave it up. Hewas a rigid teetotaler and it is perhapsunfortunate that his best knownmemorial in the area is the JohnSnow , Public Hou se, in Broad S treet.Dr. Snow is remembered for twoentirely separate achievements. Hewas a pioneer anaesthetist, beginningwithin a few weeks of the f m t reportedanaesthetic which was given in BostonU.S.A. in October, 1846. He admin-istered anaesthetics to Q ueen Victoriafor the births of Prince Leopold andPrincess Beatrice. Queen Victoria

thought it was wonderful, but there wasan outcry because the Bible says inpain shalt thou travail.Snow's other great achievementwas to prove that ch olera was a waterborne infection contrary to the thenheld view that it was airborne andtherefore impossible to erad icate.He gave up his general practicein 184 8 in order to investigate thespread of cholera. He argued thatsince cholera began with diarrhoeaand vomiting the poison must be ac tingon the alimentary canal by directcontact. Emanations on the other handwould first enter the lungs, then theblood stream before it could get to thegut, in which case there would begeneral symptoms, temperature, rigors,headache and rapid pulse. From hisown experience during the 1 831 out-break he knew that the m iners workedten hours a day, brought their ownmeals and had no opportunity towash their hands and since there wereno sanitary arrang emen ts there wouldbe every chance that faeces cou ld be

mouth. Added to this there were convincing investigationscomp arisons of the two water supplVauxhall and Southwark, takingpolluted T ham es water from the loreaches, and Lambeth from pTham es Ditton w ater, with the figuof 71 cases of cholera in the formand 5 in the latter, per 10 ,00 0 housThe EpidemicThe outbreak of c holera beganJuly, 1853 in Southampton. Anusual number of cases of diarrhowere admitted to The MiddleHospital from surrounding distriwith an occasional death. In L ondgenerally, there were 600 deathsOctober and Novem ber 1853 . It thsettled down until July 1854, althoudiarrhoea persisted and so anotoutbreak was expected.One of the difficulties is a defition of cholera. In The M iddlesexthis time there were four diagnomadee; diarrhoea, which had a definmortality; choloraeic diarrhoAng lican cholera an d Asian or M alnant cholbra. There is no way sorting these out so that the calabelled dlarrhoea h ave been omitfrom the figures although the Med iCouncil cdnsidered that these caswere niild cholera which had mortality of 8%.During August 1854 there wincreased infection in this area wan average of about seven deathsweek, and then without any preliinary build up cam e the explosioncases on the night of 31 t August1st September. At The MiddlesHospital which had two hundred bea hundred and twenty cases weadm itted in three d ays; eighty per ceof these cases were from St. JameWestminster, of whom two thirds diOthers were admitted to UniversCollege Hospital and Charing CroHospital and the Workho use, but tmajoti died at home. T o read tt descriptive notes of thepatien a hundred and twenty-fiyears ter, fills one with pity ahorror for the terrible sufferings th

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or perhaps even worse, large parts offamilies, were wiped out. The deathrate in the two sub districts was 21 per10 00 hree times that of the rest ofLondon. It was prob ably considerablyhigher than th at as h undreds fled fromthe are a and de aths were registered inthe parish in which they died. Forinstance, those who died in TheMiddlesex Hospital were registeredas Marylebone a nd not Westm inster.The number of admissions toTh e Middlesex Hos pital fell after thefirst week to about sev en a day a nd inthe third week to three a day. Thisrapid falling off in num bers w as partlyue to the fact that three quarters ofhe inhabitants had left the district.Snow estimated that 200 died on1 t12nd September and over 5 fromthese two So ho subdistricts then an dlater.

road Street Pum pSnow visited the place daily,on the 3rd Septemb er. A t first it

ared small white flocculentng. H e had these particlesmicroscopically hey

The Broad Street pump had aater,ther seven pumps ind people came from somet that it wasjudged by the organ ic

ix with sherbetmake fizzy drinks Snow considered

eone living nearby

somewh at unwillingly as it was againstall the accep ted theories, they removedthe handle of the pump on 8thSeptember. The result was not sodramatic as is often stated, as the out-break had already passed its peak. Itwould, however, be unfair to detractfrom the famous story, as later itproved how right Snow's simple butbrilliant deductio ns were. Snow wrotea report on his investigations in whichhe pointed out that many of the inhabi-tants preferred well water generally fordrinking, and the Broad Street well in

particula r, while using the mains wfor teamaking and washing. Work house with 536 inmates had ofive deaths apart from those br oin % alre ady infected, but thad their own well.In the brewery in Broad Streeone d ied, except the proprie tor, thono water was ever drunk. They ahad their ow n deep well. A t the Epercussion cap factory, 38 BrStreet, which employed 200 peop18 died. Their drinking water wbrought from the pump and st

asked perm ission to give his ashing shirts in drinking water as victims taken to the cemeterye begged them to remove the handle

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stored in tubs. Snow als o mentions ama n from Brighton who cam e to visithis brother in Poland Street. Hisrother was dead by the time herrived, and he did not see the body,

case was Mrs. Ele y, widowf the percussion cap factory p r eetor, she livedin H ampstead wherehe never wentd a bottle was brought to hern 3 1st August. S he drank it that day

September.niece who was visiting her also drankto Islington, whereMr. Gould, the famous ornith-ist, had been out of London andHesom e of the well water and h esurprised to find that althoug h itlear it had a n offensive srnell and. H is servant however

There was a number of theoriessation of the outbreakof the

nonths pleviously had disturbedon in the soil. Th e Broadtheoiy was that the old plaguet by Ca rnab y S treet had been dis-This however was ou ts ~d ehe

An extremely important invest-tion was carried out in 1855 by thenry W hiteheade, the curate ofd 2 9 and had been appointedin 185 1. Snow had presentedwith his book on his 1849

was not convinced and

wtiter from the Broad Stree tratio of 80 to 57 had been

affected while among the non-drinkersi t was only 20 to 279. Whiteheadshowed that the greatest pollutionwas on st August an d partial purif-ication had occurred by 3rdSeptem ber. This w as followed by hismost dramatic discovery. On 2ndSeptember an infant of five monthswhose attack of cholera began on28th August had died at 40 BroadStreet. T he i~n porta ncc f this rests onthe fac t tha t t h s house was the nearestto the pump and the d ate of the onset,allowirlg 24 36 hours incubationn~ atc he d the rnajur outbreak. Themother of the dead child had washedits napkins an d emptied the pails intothe cesspool m front of the house a ndthis was less than three feet from thewell. W hitzhoube reported this t o theComrmttee who thereupon orderedan inspection of the cesspool. Thisirispection show ed that the brickworkwas very decayed a ~ ~ dlso showedthat there had undoubtedly beenseepage into the well. The child'sfather contracted cholera on the 8thSeptember. the day that the handle ofthe pump was removed. This mana lso d ~ e d nd could well have startedanother outbreak if the handle hadremained on the pump allowing thewell water to be used. By this timeWhitehead had himself become astrong supporter of Snow.Wh itehead interviewed those whohad recovered, rzlations of the deadand those who never contracted thedisease. H e showed overwhelminglyby statistics that the well water was toblame.nquiriesThe members of the Council ofEnquiry set up by the Board of Healththe year following the epidemic in1855 reportedlo that they still could notur~d erstaiid his sud den rise in theincidence over the two days, 3 1stAugust an d 1st September, al thoughadmitting that the sanita ry conditionswere appal ling. T he report s tates h a tthe atmosphere was offensive w i h

effluvia from ill-conditioned sewers,from defects of drainage and clean-liness in the houses and from unreg-

ulated slaughtering a nd o ther offentrades. T here was some of the wovercrowding, but they asked whshould select particular foci extreme outbreaks. They had the S nand Whitehead reports before thand referred to D r. Snow's theorythe well in Broad Stree t but reporwe do not find it established that water was more contaminated nor tthe inhabitants using the well wparticularly affected. The ir oexplanation was that the troudepende d on other organic impuriparticipated in the atmospheinfection of the district.

The following quotation takfrom the report gives the view of DHassall, one of the members of Scientific Com mittee who carried the microscopic examination of different waters. The examinatiwere carried out at St. ThomaHospital and the following extrgives the views of the time:M an y of the public believethat everything we e at and drinkteams with life, and that evenour bodies aboun d with minuteliving and parasitic productions.This is a vulgar error and thenotion is as disgusting as it iserroneous.The St. James Vestry also hean enquiry headed b y D r. Lancastthree local doctors and W hiteheadThey had Snow's and Whiteheadreports before them, both of whiwere included in the Committeepublished findings. Unlike the Boaof Health E nquiry they accepted thetheories, perhaps not quite wholheartedly. Their recommendatioshow:-1. T ha t there should be flushing of tsewers.2. The wells should be closed aartesian wells dug.3. Cisterns should be abolished.4. There should be stand-pipes water mains.

con t i nued on Page 2

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Hospital areThe Apothecary to TheMiddlesex Hospital wrote a full reportof the outbreak from the hospital pointof view. He stated that he was mostimpressed by the devotion of thenursing staff (at a time when nursingwas not what it is today). He was alsoimpressed by the porters who had tocarry the patients to the wards, (therewere no lifts,) and the hundred or sobodies back to the Dead House.Each patient was given a warmbath by the nurse, rubbed over withmustard, and hot bottles were putalong the sides of the patient in bed.Turpentine fomentations were put onthe abdomen and the limbs were

e of cholera. A purge and

must be remembered that fheo each ward of

rds at night. (Othert night). Neither

to eleven night nurseswas Florence Nightingale whon Harley Street. We know little

peakingreatures staggering

y. This is probably Victorian

also said, three studentsg cigars, had one lookwent away, yet Dr. Sibley gave

staff and students of The MiddlesexHospital in what must have been aterrifying experience. He statesspecifically that no one ran away.Large pans were put in eachward generating chlorine gas as adisinfectant and the windows were allkept open. An interesting part of thepreventative care for the nurses wasto send them by cab to the nearestpiece of country for fresh air andrecreation each day. Every resident inthe hospital was given two chops andthree ounces of brandy extra daily.Only one patient who was alreadyin the hospital when the epidemicbegan developed cholera and sherecovered. One nurse died of choleraand another was affected but sherecovered. A laundry assistant alsodeveloped it and recovered. Whenone thinks of all the handling ofinfected linen by nurses and laundrystaff it is a remarkable achievement.There was another outbreak ofcholera in 866.j3 It was largelyconfined to the East End of Londonand along the banks of the Thames. Itlasted for about 1 5 weeks and

resulted in 7,000 deaths in London, arate of 3.6 deaths per 1,000. Dr.Snow was dead (he died of a stroke in1858), but Henry Whitehead, still acurate, was asked to help. He showedthat it was due to the East LondonWater Company of Lee Bridge Roadusing unfiltered polluted water from

the River Lee. As the epidemic bthe St. James's Committee chosetime to replace the handle onBroad Street pump.Whitehead moved to Carlisl1870 and to his dying day he hpicture of Snow on his desk. Atfarewell banquet before departinthe north he replied to his toast wthree hour after-dinner spedescribing his work in London.onclusionThis is a fascinating but horstory of Dickensian London but an illustration of what two dedicaand intelligent men, John Snow Henry Whitehead, achieved by simobservation and without laborathelp. Though official obstinacy exithen as now, thanks to the workthese two men the whole attitudesanitation and water supply eventuchanged in this country. Unfortunathere are still some parts of the wwhere 1854 conditions still existFinally to quote some downearth Victorian practical sense frLord Palmerston. When asked byPresbyter of Edinburgh for a day

fasting and humiliation to check progress of cholera, he replied: Owhen Edinburgh frees itself of gaseous exhalations arising from ovcrowded dwellings and undispofilth would it e time to ask Maker of the Universe to interfer

References1. Br~ggs,Past and Present . 19 61

2. Royal Free Hosp~tal,Board M~nutes .20 February 1832. Dr Gilchr~stPersonal Commun~cat~ons

3 . W ~ l l ~ a r narsen. Cholera 1848 .2 n d E d ~ t ~ o n ,ondon

4 . Report of Medical Counc~lo Boardof Health

5. John Snow, On Mode of Commun-ication of Cholera . 2 nd Edi t~on

Baly and Gull. Epidem~cCholera .report to Royal College ofPhysic~ans. 853

7 D N 8 and 8 W Richardson.Foreward to John Snow. 18 58

8. Middlesex Hospital. Board Minutes,October 1854

9. Henry Wh~t ehea deport. 1835, toSt James Vestry (see Ref 11)

10. Repon of Medical Committee toBoard of Health, 1856

1 1. St James Vestry repon on Outbreakof Cholera

12. Elizabeth Haldane. Mrs Gaskelland Her Fr~ends , Hodder

Stoughton13. Privy Council Report of Med Off1866. Lancet

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John Snows 1854 map of the area of the Golden Square area of London

Published by C.F. Cheffins, Lith, Southhampton Buildings, London, England, 1854 in Snow,John. On the Mode of Communication of Cholera, 2nd Ed, John Churchill, New

This image is in the public domain due to its age. Author died in 1858, material is public domain.