Medical Times and Gazette

Vol. 15, Oct. 24, 1857, pp. 417-419.
On the Outbreak of Cholera at Abbey-row, West Ham.

John Snow, M.D.

On seeing the notice in the Medical Times and Gazette of the 17th instant of the outbreak of cholera at West Ham, I called on Dr. Elliott, of Stratford, who was kind enough to take me to the place where the outbreak occurred, and to inform me of the various particulars connected with it. I also made some inquiries of the inhabitants, and the proprietor of the greater part of the property was good enough to give me some information respecting the drainage. The row of small houses in which the outbreak has occurred is situated, as was stated in the Medical Times and Gazette, about a hundred yards from the River Lea, and about two miles from the Thames .
The row consists of eighteen dwellings: sixteen of these contain but two rooms, one over the other, and a small back kitchen; at the north-east end of the row, which is the farthest from the River Lea, is a house with four rooms, and at the opposite end of the row is a still larger house, occupied by the proprietor of the large flour-mills, a few paces further on, situated on the banks of the Lea, and partly overhanging it.
The only water which the inhabitants of Abbey-row used for every purpose was that of a pump-well near the middle of the row, and across the road. It is a shallow pump-well of not more than twenty feet deep, in the opinion of the proprietor. A few years ago, before this well was sunk, the inhabitants of the place had no other water than that of the Lea. Besides Abbey-row, the above pump supplied a dwelling in the above-mentioned flour-mill, a small dwelling just beyond the mill, and across the bridge, called the toll-house, and four very small cabins of one room a little way - perhaps thirty yards - from the mill, and situated under the bank of the Lea, and much below its level when the tide is up. When standing on the bank of the Lea, just above the water's edge, one is almost on a level with the roofs of these cabins.
The number of inhabitants in the dwellings having the water supply of the above-mentioned pump was, at the beginning of the epidemic, 115, and they were distributed as follow; 93 in Abbey-row, 7 in the flour-mill, 2 in the small toll-house, and 13 in the four little cabins. The cases of cholera at West Ham have been confined to this population, with one exception to be mentioned afterwards. Out of the above-mentioned 115 persons, 6 died of cholera between the 3rd and 13th of the present month, being rather over 5 per cent. These 6 fatal cases indeed all occurred in Abbey-row, having but 93 inhabitants. Dr. Elliott informed me that there were also 6 or 7 very severe and decided cases of cholera which ended, or were in progress, of recovery. Cases which proceeded no further than diarrhoea, but which form a part of the same outbreak were numerous: by inquiry from house to house I found that, from September 29th, when the first case (not fatal) occurred, till October 16th, there had been 19 cases of illness with bowel complaint, sufficiently severe to require medical treatment, in addition to the fatal cases; so that above one-fifth of the inhabitants were more or less implicated in the epidemic. As some families were from home, or had removed, there might have been slight cases of illness that I did not hear of. I was only informed of one case of illness amongst the 13 inhabitants of the four little cabins mentioned above, so that they seem to have escaped rather better than the other inhabitants having the same drinking water. These cabins are inhabited by the families of labourers. The inhabitants of Abbey-row are clean looking and apparently industrious people. The men are chiefly employed in a large silk factory close by. The single case of cholera which occurred to any one at West Ham, or even near it, so far as is known, happened to the sister of a licensed victualler, living opposite to Abbey-row, and assisting in the business. The public house was supplied by a separate pump-well, on the premises. The public-house is distant from Abbey-row only the width of the road; and I may mention that, except where this public-house obstructs it the view extends from the front of the dwellings in Abbey-row across the marshes to the shipping at Blackwall and Greenwich.
The water of the pump which supplied the houses described above, was very impure, letting fall a copious deposit of dirty organic matter on standing. The nature of this deposit leaves no doubt on any one's mind that it proceeds from the sewer and drains which pass within a few feet of the well: but whether the leakage is by percolation, or by a direct opening, has not yet been determined. There is a ditch or sewer which passes behind the pump-well, and within a few feet of it. The ditch is now covered at this spot, but Mr. Kayess of West Ham Abbey showed me a plan of it. This ditch or sewer flows into the Lea when the tide permits, but at other times the water from the Lea flows back up the ditch, as may be observed; for it is still opened in a great part of its course between the river Lea and the pump. The drains from Abbey-row pass under the road, and pass very near to this pump-well, before entering the above-mentioned tidal ditch. The five houses in Abbey-row nearest to the house of the proprietor of the flour-mill belong to that gentleman; they are each provided with a privy over a cesspool; some, at least, of these privies have an overflow drain, which pass under the house and road to reach the tidal sewer. The remaining twelve houses belong to Mr. Kayess, mentioned above, and the privies of the first eleven of these were converted about a year ago into water-closets, the water being however carried from the pump and thrown down.
These closets communicate, by means of drain pipes, with a large covered cesspool at the back of the row, which receives also all the water used in the cottages; the overflow from the cesspool passes into the tidal sewer, by a drain which passes under the floor of the first house (that adjoining the last of the five belonging to the proprietor of the flour-mill) and then passes under the road and near to the pump-well. The impurity of the water of this pump-well was a chronic affair, and therefore, as mere impurity, would not account for the remarkably sudden and circumscribed outbreak of cholera which has occurred around it. Moreover, mere impurity in the water was never known to cause, or even aggravate, cholera. In all the sudden outbreaks of cholera which I have been able to connect with impure water, and have related in previous volumes of this Journal, and the two Journals from which it sprung, there has always been either absolute proof or strong presumption that the evacuations of a cholera patient had entered the water. In the fearful outbreak of cholera near Golden-square, which I described in the Medical Times and Gazette in Sept. 1854, I could myself only bring forward statistical and other evidence of the effect of the water, not having the power to open the well and adjoining drains; but when this was done by the parish authorities, at the suggestion of the Rev. Henry Whitehead, six months afterwards, the pump-well which caused the outbreak was found to be the recipient of the overflow from a cesspool, into which the evacuations of a child ill of cholera had been emptied within three days before the great irruption of the disease.
At Abbey-row, the contamination of the pump-well, forming the sole water-supply of the place, by the drains and sewer, which carry away the overflow from the water-closets and privies of that row, explains the way in which the cholera was propagated to so great an extent on the spot, when once it was introduced. Many of the persons attacked had had no personal communication with any previous patient. Some cases of illness followed a day or two after a previous case in the same family, and in these instances it is probable that the morbid matter of cholera was swallowed in the more ordinary way, without the medium of the water. I ascertained that a great number of the persons attacked were in the habit of drinking the water cold: but, in addition to the opportunity of taking the disease when it is first introduced into a household without the intervention of the water, it must be acknowledged that water, even before being boiled, enters in so many ways into the preparation of articles of diet, that every one is liable to take it.
Cholera prevailed in Abbey-row in 1832, 1849, and 1854, but not to the same extent as in the present month.
With regard to the introduction of the disease on the present occasion, the explanation I have to offer is somewhat circuitous, but is well supported by what has occurred in previous epidemics. In the Weekly Return of Births and Deaths for September 26 of the present year, the following death is recorded: - "at Horselydown, on board the Lütcken, on 22nd September, a seaman, aged 27 years, Cholera Asiatica (nineteen hours)". The following note is added - "The ship Lütcken arrived at Horselydown on the afternoon of the 21st instant from Hamburgh; she had touched at Glückstadt, and stopped there twenty hours, at which place cholera raged lately, and carried off five per cent, of the inhabitants. The deceased had not been ashore at Horselydown." Glückstadt is on the Elbe, thirty miles below Hamburgh. The evacuations of the seaman who died at Horselydown would, of course, be thrown overboard, according to universal custom. There might also be other cases of cholera in the shipping from the ports on the River Elbe, lying in the Thames; but if not fatal, or occurring beyond the metropolitan boundary we should not hear of them. From what occurred at the pump-well near Golden-square, in 1851, and at many other places in former epidemics, it is evident that the active material contained in the cholera evacuations is not destroyed by being mixed with water. Now, a morbid material which communicates any disease from one person to another, does so by the faculty of reproduction, which takes place during the so-called period of incubation, the disease which ensues being due, not to the matter first introduced, to the resulting crop. But no one will deny that everything which multiplies and reproduces its kind must not only be organic, but organized. Even yeast is organized: and smallpox matter consists chiefly of cells. The morbid material of cholera, therefore, is not dissolved in water so long as it retains its properties, but is only distributed ; and the amount of water in which it is so distributed ought merely to diminish the chances of its reproducing the disease, but not necessarily to prevent its doing so. Now, anything thrown into the Thames at Horselydown which can float goes backwards and forwards with the tide, ultimately, as a general rule, to reach the sea; but, in the meantime, it may pass up the Lea, or other tributaries, and also up any tidal ditches which communicate with these tributaries. If a sack of poppy seeds or mustard-seeds were thrown into the river at Horselydown, there is nothing more probable than that a few of them might find their way up the Lea, and the tidal sewer, and into the very pump-well at Abbey-row. I beg the attention of the reader to the following account of what occurred in previous epidemics. It will be remarked, in the meantime, that the first case of cholera at Abbey-row occurred seven days after the death of the seaman on board-ship at Horselydown.
The first case of Asiatic cholera in London in the autumn of 1848, was, according to an inquiry instituted by the then Board of Health, that of a seaman named John Harnold, who had newly arrived from Hamburg, where the disease was prevailing. The date of his death was the 22nd of September, like that of the seaman who died in the present year, and he died also at Horselydown, not, however, on board ship, but in a lodging near the shore. There was a severe case on September 30, in a man who came to lodge in the room in which Harnold died, but this man recovered. The first twelve fatal cases succeeding that of Harnold took place in the following situations. On September 30, a man was attacked in Lower Fore-street, Lambeth, and died on the following day; at the same time that this man was attacked, the first of a series of cases occurred in White Hart-court, Duke-street, Chelsea, near the river. A day or two afterwards there was a case at 3, Harp-court, Fleet-street; the next case occurred on board the hulk Justitia, lying off Woolwich; and the next to this in Lower Fore-street, Lambeth, three doors from where the previous case occurred. It was not till October 5, that a case was registered, as occurring in any other part of London. The inhabitants of Lower Fore-street, Lambeth, as well as those of White Hart-court, Chelsea, had no means of obtaining water in 1848, except by dipping a pail directly, into the Thames. The inhabitants of Harp-court, Fleet-street, were in the habit, at that time, of fetching water from St. Bride's pump, which was afterwards closed in consequence of its having been found that the well had a communication with the Fleet-ditch sewer, up which the tide flows from the Thames. When the cholera revived again in 1849, the first case in the sub-district of "Lambeth; Church, 1st part," was in Lower Fore-street; and on the commencement of the epidemic of 1854, the first case of cholera, in any part of Lambeth, and one of the earliest in London, occurred at 52, Upper Fore-street, where the people had no water but what they obtained from the Thames with a pail, as I ascertained by calling at the house.
Since 1854 the persons who drink Thames water, obtained within reach of pollution by the shipping and the London sewers, are diminished to a very small number. The water companies supplied from the Thames now obtain their supplies above the reach of the tide, and the river itself in London is become so foul that people are deterred from drinking it. It is chiefly for these reasons that we may hope that cholera will not at present become epidemic in London.