Cholera Comes to the Asylum: “An awfully interesting disease”
On Monday September 17th 1849 Elizabeth Fenton was removed from Gomersal Workhouse not far from Leeds, and taken to the nearby West Riding Lunatic Asylum. The unfortunate Elizabeth had been deserted by her husband, a stone mason, a long time previously and she had lived in local workhouses for eleven years prior to going into the asylum. Her two children were in the care of the local parish. Elizabeth suffered from epileptic fits which, during their onset, rendered her violent and unmanageable. She would be controlled by means of being forced to wear a straight-jacket and sit in a restraint chair. This meant that her hands, her feet and, if necessary her chest, were bound by leather straps. This might last for three or four nights until she was calm. The Commissioners in Lunacy had visited the asylum some weeks earlier and recommended that she be transferred, which was done by the local Poor Law Relieving officer. Shortly after she arrived at the asylum Elizabeth developed symptoms of vomiting and diarrhoea, in view of which she was isolated and watched over, the door to her room locked. Elizabeth recovered from these symptoms. But in the following weeks cholera was confirmed as present in the asylum. Elizabeth was identified as being the source of the outbreak. She was, apparently, “the unconscious messenger of death” in the asylum.
The first outbreak of cholera in England in 1832 had prompted the medical fraternity into serious action to combat the disease, hitherto unknown in England other than by report, as it spread across Europe, justifiably frightening in the trail of deaths it caused (it was estimated by some that perhaps as many as 50 million across the globe had died from the disease). It challenged existing ideas about treatments and, later on, resulted in a revision of the theory as to its transmission. It had impacts on public and private cleanliness. The disease was also an opportunity for the advancement of statistical methods in the identification of disease patterns which was something of a new discipline at this point. But as well as death and academic development the condition also spread fear around the country. By the end of the outbreak some 52,000 people had died. Even though tuberculosis may have been a more serious threat overall, anxiety about further outbreaks of cholera gripped many.
In the asylums death was routinely expected by the medical superintendents. Regular reviews of the operations of the asylum accounted for the numbers who died, and the annual average appears to have been between 9 and 14 per cent of all those resident. Where these were younger rather than aged and “exhausted” individuals there would be specific comment and, as appropriate, an inquest. However, the death of an individual arising from an epileptic fit — perhaps occurring at night time, might not be deemed worthy of investigation.
Alerted to the increase in deaths in their asylum, the visiting board of magistrates at West Riding asylum took investigative action. The chairman of the board was The Reverend James Armitage Rhodes — a man of significant public responsibilities in the area who gained a reputation for the care and wellbeing of the criminal and the lunatic. The visiting medical superintendent commissioned to investigate was Dr Thomas Giordano Wright. Wright was well-practiced in general medicine and with an evident interest in understanding the origins and investigating the treatments of the cholera outbreak at the asylum. In 1833 Wright had submitted an article to The Lancet in which he reviewed what had then been learned and understood about cholera; he was one of many who was exercised about the causes and possible cures for the condition. The investigation at the West Riding asylum provided him with an unparalleled opportunity: to use an essentially statistical approach to understanding the way in which the disease spread through the asylum, and hence perhaps shed light on its nature and the most effective means of combating it. The very nature of the asylum meant that it was, in effect, a kind of laboratory. If Wright could discover some insights about cholera from this research it might place him at the forefront of medical expertise on the subject. The records of admissions, the available information about all aspects of life in the asylum, who resided there and in which wards, and who had contact with whom, was a golden opportunity. Such conditions were not available to anyone seeking to make similar enquiry of outbreaks in local communities, with their transactional activities and absence of detailed information.
To begin with Wright based much of his investigation on a ground plan of the asylum layout. This enabled him to plot which wards had individuals who contracted the disease, and where they were transferred to when its presence was confirmed. The logic of this approach was that it drew on the prevailing theory as to the transmission of the condition: miasma. This theory held that putrefied organic matter would generate poisonous vapours — miasmas, which, being inhaled, would result in the development of disease. Of course, the breathe of a sufferer — “pestiferous exhalations” — would themselves be assumed to add miasmas to the air and hence could account for contagion amongst those who were nearby unless the ventilation was good. The miasma theory actually dated back some hundreds of years and explained a wide range of illnesses; (The term “malaria”, for example, conjoins Italian words for “bad” and “air” to explain what was believed to be its cause). Thus, by tracking the movement of those first identified Wright hoped to be able to show how cholera had entered and then circulated through the asylum. He was able to identify the first few sufferers, and to chart the incubation period between their entry to the asylum, or their contact with Elizabeth Fenton. Such data should thereby demonstrate the evidence of disease transmission.
It was nine days after her admission to the asylum that Elizabeth first evidenced the unpleasant symptoms that alerted the medical staff to the possibility of cholera. Wright identified the next four individuals from the asylum ward to which Elizabeth was first admitted, and who subsequently suffered from the disease. Wright examined their diet, their age, their length of time of residence in the asylum, and failed to find any common factors associated with the five individuals that might account for the spread of infection. In view of this Wright pursued his enquiries to the workhouse at Gomersal where Elizabeth had resided until her transfer. Wright ascertained that there had been cases of cholera identified there, concurrent with Elizabeths’ stay. So, if Elizabeth had not been admitted, the asylum, in Wrights’ view “would have escaped further or more fatal disease”.
This was a careful conclusion reached by Wright. As the outbreak had progressed through the asylum there were wards that were affected and others that were not. Some of asylum wards were classed as “dirty” — by which Wright meant that the occupants were “inattentive to the calls of nature”. It might have been anticipated, Wright reasoned, that the dirty wards would be the more susceptible. That was not the case. Elizabeth was admitted onto a clean ward “where the bedding is pure and comfortable, and where filthy habits and personal uncleanliness are almost unknown”.
Another way in which miasma might have been responsible for cholera was poor drainage. If the theory held then it might be the case that poor drainage allowed the vapour to circulate in the asylum leading to the outbreak. To that end the engineers examined the drains with some care. They reported that, on the whole, all was well and there were no nearby stagnant or filthy pools in the vicinity. No reason to consider that the structure of the building was in any way responsible for the outbreak. This added weight to Wrights’ conviction that a person was the source.
In an effort to further build his case Wright quoted from another medical case that took place in Scotland. An elderly lady went to visit her daughter, near Dundee. On her way home she stayed with her daughter but died after a few hours. A number of family members who had been identified as in contact with her also contracted cholera and died. These included a family member who was in the street when the funeral cortege passed; she had demanded that the cortege be stopped and the coffin opened, to take a last look at the distressing sight. Such contact could be sufficient for the disease to spread. It was said that nobody else had had direct contact with the deceased lady.
Given the theory Wright was now proposing, objections to it had to be addressed. For example, how to explain the fact that some people who had been in contact with diagnosed cholera sufferers did not contract the disease? Might the diet or the ventilation and cleanliness of the wards be implicated in that? For each question Wright carefully constructed statistical tables to isolate the proportions of patients and of sufferers within each category. In an era without computing power each statistical table had to be manually compiled. Thus, for example, differential mortality rates could be accounted for by the pre-morbid health status of the sufferer. Those who were feeble and exhausted were more likely to die than the previously strong and healthy.
By the 1840’s there was considerable debate amongst the medical fraternity about the most effective ways to treat cholera. It was still considered that calomel was appropriate. This was, in essence, treatment with small or large doses of mercury. In actual fact there had been objections to the use of mercury from as early as 1832, for example in a passionately written paper, based on observations in Belfast, by W.M. Wilson. Not least among the objections to mercurial treatment was that if the choleric patient overcame the disease they were nevertheless left in an enfeebled and exhausted state. Wilson’s paper may have been correct, but his passionate argument was based on personal observations and hence may not have been persuasive. So the lack of convincing evidence about calomel did not exclude its continued use at this time. Other options being practiced included bleeding, hot baths or wet blankets, the use of opium and brandy, mainly for pain relief. Alternatively Wright examined the beneficial effects of special diets, which meant restricting the intake of vegetables and increasing the amount of meat. Wright admitted that his investigations at the asylum offered no firm hopes of identifying a reliable treatment.
The investigation and report compiled by Wright offers real insights into the world within the asylum at this time. The stench of many of the dirty wards on being unlocked in the morning. Crowding. Effluvium. The washing and cleaning of patients and bedding and clothing. The copious whitewash for the floors. The medical roll-call of the numbers with diarrhoea, with vomiting, in agony of gastric pain in addition to their mental infirmities. The chilling atmosphere resulting from the requirement to have plenty of ventilation. The controlled diets and the noxious treatments available. The dedication of staff to the well-being of their charges, alongside the awful conditions that had to be endured. The sense of fear that must have been spread around the enclosed world of the asylum, leaving staff anxious about how far away from patients they would need to be, wondering if they too had contracted the disease and would die — as indeed two of them did. And, all the time, an absence of any real knowledge of the reasons for which the terror disease was being spread and the potential simplicity of its eradication.
It was in fact a close contemporary of Wrights who was able to answer the need to identify the cause of cholera. There is no record of Wright and John Snow having met, even though they grew up and initially practiced medicine in close proximity to each other and might be assumed to have met. Snow used a different approach in his research — topographical analysis — to identify the source of cholera in East London. He plotted the location of the sufferers and the presence of a water supply they all relied on. Persuading the authorities to remove the handle to the water pump meant that they had to go elsewhere. The local outbreak ended. Even so it took some 20 years for Snow’s medical colleagues to accept his arguments. His ideas had been around before and Wright was definitely aware of them. In his investigation he ruled this out as a possible source. If only he had looked into the idea more carefully.
In due course the outbreak of cholera — which Wright referred to as “this awfully interesting disease” — came to an end. It showed the asylum at its best and at its worst. It made a contribution, of sorts, to the growth of medical research, theory and knowledge. It impacted other asylums across the country who were more alert than ever to the spread of the condition around their own establishments. But for another thirty or more years the dread fear of cholera continued to haunt the world of the asylum.