Britain watched in shock and disbelief as a previously unknown deadly disease made its way steadily westwards from the other side of the world. Any early hopes that escape might be possible were quickly acknowledged to be wishful thinking. The scientists, meanwhile, were trying to understand the nature of the pathogen responsible: how it had emerged, how it was spreading, and how to treat it. It is a tragic story, all too familiar to us in 2024. In this case, however, the year was 1831.
Cholera is thought to have been endemic to the swamplands of India’s Ganges Delta for hundreds of years. During the early nineteenth century it began to travel, first across the Indian subcontinent, and then across the world via three great pandemics. Eventually, it hit the Middle East, Russia, the USA, and most of Europe, killing untold millions.[1]
On 22 October 1831, after months of speculation, rumour, and fear, the famous medical journal, The Lancet, made a dramatic announcement: “cholera, that fierce and unsparing scourge . . . is now but six-and-thirty hours passage from our shores.”[2] As is so often the case, however, the disease was one step ahead. By the time this edition of The Lancet was published, cholera had already broken out in the port of Sunderland on the river Wear in north east England. The prominent physician, Dr William O'Shaughnessy, travelled up from London to see it for himself. In a letter he wrote to a friend he described how on
the floor before the fireplace extended on a palliasse, covered with a solitary blanket and surrounded by a group of female friends, lay a girl of slender make and juvenile height but with the face of a superannuated hag . . . She uttered no moan but languidly flung herself from side to side and from the supine to the prone position. The colour of her countenance was that of lead—a silver blue, ghastly tint; her eyes were sunk deep in their sockets as though they had been driven in an inch behind their natural position; her mouth was squared; her eyelids black; her fingers shrunk. bent and inky in their hue. All pulse was gone at the wrist and a tenacious sweat moistened her bosom. In short Sir, that face and form I can never forget were I to live beyond the period of a man's natural age.[3]
During the nineteenth century people lived in fear of a host of diseases, including typhoid, typhus, smallpox, and scarlet fever. But cholera was new, foreign, and very different. “Our other plagues were home-grown”, as one doctor explained, “and part of ourselves as it were.”
We had a habit of looking at them with fatal indifference . . . But cholera was something outlandish, unknown, monstrous . . . its insidious march over whole continents, its apparent defiance of all the known precautions against the spread of epidemic diseases invested it with a mystery and terror . . . [that] seemed to recall the memory of the great epidemics of the Middle Ages.
Cholera is one of the fastest killers known and can kill within two or three hours of the symptoms first coming on. It sometimes strikes so fast that its victims are described as collapsing as though they had been hit with a club. Those symptoms—violent vomiting, litres of fluid pouring from the bowels, followed by excruciating muscle cramps with the blood thickening like tar—are horrendous enough, as Dr O'Shaughnessy described. What frightened people most, however, was the disease’s habit of exploding without warning, felling hundreds or even thousands of people simultaneously. It also jumped about in the most bizarre manner, striking one place without warning only to disappear just as quickly, then breaking out somewhere else many miles away. No other known disease behaved like that. And because no one could work out how it was spreading, prevention proved impossible. Was it contagious; that is, passed on from person to person? Its long trek out of India, across Asia, and into Europe, following the travel and trade routes, seemed to indicate that it was, but then there were countless cases where people caring for the sick emerged unscathed.
Perhaps, people wondered, the “cholera poison”, as it was called, was coming from beneath the earth. Or was it the result of an electrical disturbance, possibly caused by the new railways? Or did its victims succumb because they had too much carbon in their bodies? There were countless theories, but many doctors believed that the main culprit was miasma, or foul air. This idea had been around since at least the Middle Ages. It held that epidemic disease stemmed from filth, in particular from the stench or “miasma” given off by excrement, rotting flesh, and vegetable matter. There was plenty of all of it around in the 1800s. This bad air, the miasmatists believed, contained the toxins that made people ill, and the extent to which one particular disease prevailed depended upon some additional factor, such as the weather. When cholera reached London in 1832, a surgeon called Thomas Calley recommended setting off bags of gunpowder from canons around the capital. This, he believed, would result in “the complete purification of the city’s atmosphere”, and thus would stop cholera in its tracks.[4]
The miasma theory had persisted for so long because there was so much circumstantial evidence to back it up. There is indeed a link between dirt and disease, but in the days before Louis Pasteur’s germ theory, a vital piece of information, namely the role that bacteria have to play, was missing. Thus, in the sixteenth century King Henry VIII advised Cardinal Wolsey to “fly to clene air incontinently” if he wanted to avoid the sweating sickness, while Florence Nightingale was a convinced miasmatist. “The very first cannon of nursing, the first and last thing upon which a nurse’s attention must be fixed,” as she asserted in her Notes on Nursing, “is this: to keep the air he breathes as pure as the external air without chilling him”.[5] “Of the fatal effects of the effluvia from excreta”, she added, “it would seem unnecessary to speak”.[6]
One of the first British victims of cholera was 12-year-old Isabella Hazard, whose parents kept a pub on the Sunderland quayside. On Sunday 16 October, Isabella went to bed seemingly in perfect health. At midnight she was suddenly struck down with vomiting, diarrhoea, and an unquenchable thirst. Her eyes were sunk in their sockets, her features unrecognisable, her legs seized with terrible spasms, her pulse scarcely perceptible, and her whole body freezing. Most alarming of all, her skin turned a terrible dark blue. “What makes the child so black?”, as her mother was compelled to ask Dr Cook.[7] By four in the morning, Cook realised that he was out of his depth and sent for William Clanny, the consultant at the local infirmary. Clanny ordered a warm bath, brandy, hot water, the application of mustard poultices to the legs, and an hourly dose of opium, ammonia, and peppermint. Three hours later Clanny returned to find the child no better. He told Cook to continue with the treatment, but when he saw Isabella again later that morning it was clear that the case was hopeless. Despite the doctors’ best efforts, Isabella died at four o’clock that afternoon.[8] Thirty-two thousand would die before the outbreak was over.
In case the contagionists were right, the government imposed a fifteen-day quarantine on all ships leaving the Wear that were bound for domestic ports. They enforced this with a warship stationed just off shore. The measure had no noticeable effect, however. The disease spread fast, fanning out first across the region and then the whole country. Then, strangely and typically, in the autumn of 1832, exactly a year after the epidemic began, it petered out.
When cholera struck again in 1848 there had been 17 years of argument about how it was spreading, as well as about treatments. Yet there was still as much confusion as ever. This time, the first case was diagnosed in London. John Harnold, a sailor who had arrived on a ship from Hamburg and rented a bed for the night in a filthy rooming house in the slums of the south London docks, was seized with cholera and died. The following week the man who had taken his room was also attacked and he too died.[9] This would turn out to be the country’s worst epidemic, killing 52,000 people over the next eighteen months. A large swathe of south London, including Wandsworth and Vauxhall, was especially badly hit.
By then the miasmatists were winning the argument. The government statistician William Farr, a friend of Florence Nightingale, wrote of a “disease mist” that hovered in the air “like an angel of death”.[10] “All smell is disease”, as the sanitary campaigner, Edwin Chadwick, informed a committee of MPs.[11] Chadwick played a key role in the introduction of the first of a series of Public Health Acts in 1848. It marked the start of the British state taking responsibility for the health and wellbeing of its citizens. One of the provisions was the establishment of a Board of Health which Chadwick was appointed to lead, much to the fury of the medical profession. The Lancet thought that three dogs might as well have been sent to bark at the disease for all the good that the “paper braying” of Edwin Chadwick and his two colleagues would do.[12]
In fact, Chadwick’s commitment to miasmatism led him to call for some vital reforms, including the construction of efficient drains and sewers, the provision of clean drinking water, and the removal of refuse. Yet he also made matters worse in London. In an attempt to stop the capital’s poor from floundering in their own excrement, he ordered the contents of the cesspits to be flushed down the crumbling sewers into the Thames. The outlet was at Hungerford Bridge, next to the spot where the Southwark and Vauxhall Water Company was taking its supplies directly from the river and pumping it unfiltered into people’s homes. The scientist Michael Faraday wrote to The Times to complain about a stomach-churning trip he took down the river one hot July day in the 1850s.[13] “I traversed this day by steam-boat the space between London and Hungerford Bridges”, he wrote, adding that the “appearance and smell of the water forced themselves at once upon my attention. The whole of the river was an opaque brown fluid . . . Near the bridges the feculence rolled up in clouds.”[14]
Since cholera had first arrived on British soil a reclusive doctor called John Snow had been thinking about how it was spreading. In 1849, he published a short paper on the issue. He apologised that he had not yet collected the evidence to prove his theory but, he said, with the second epidemic raging and thousands of people dying, he felt it was his duty to put his ideas forward, and he asked his colleagues for their views. He was answered with a profound silence. They ignored him.[15]
When cholera returned for a third time in 1854, after a much shorter interval, the British government determined to come up with a definitive answer to the questions about how the disease acted on the body, which treatments were effective, and how it was transmitted. They brought together a team of leading doctors and scientists, including meteorologists and chemists, with the brief to investigate every possibility. It was the first time that a British government had set up a scientific inquiry and paid for it out of the public purse.[16]
While the inquiry was underway, Snow was carrying out some investigations of his own. Unlike the government experts, however, he had a clear idea of what he was looking for. His theory was that the “cholera poison” was spread through ingesting excreta from the victims of the disease. If that excreta were to get into the drinking water, then cholera’s habit of felling large numbers of people at the same time was explained. Drinking polluted water was almost inevitable when cesspits and sewers dating back hundreds of years were steadily leaking their contents into the water supply.
What is now known as Snow’s “Grand Experiment” involved him first comparing the death rates in south London during the 1848–1849 epidemic among the customers of the Southwark and Vauxhall Water with those of the Lambeth Water Company, and then doing the same for the latest 1854–1855 outbreak.[17] While in 1848–1849 the death rates were the same, regardless of which water company the householder used, during 1854–1855 customers of the Southwark and Vauxhall Water Company were between eight and nine times more likely to die than those of the Lambeth Water Company. By then Lambeth had moved its works to Seething Wells near Kingston upon Thames, out of the reach of the filth of London. Yet Southwark and Vauxhall stayed where they were.[18]
Snow paused his research in south London in order to investigate a small but particularly virulent outbreak of cholera in Soho, close to where he lived. Here, he identified the pump well in Broad Street as the cause by mapping the disease, showing the great cluster of deaths among those living immediately around the pump.[19]
In its investigation, the government was understandably keen to explore every avenue. Yet by setting the terms so broadly, it proved impossible to analyse the results in any meaningful way. The government’s team published four separate reports running to over 300 pages, with a 350-page appendix complete with tables, figures, and charts. Their final conclusion was that cholera was caused by a “wandering ferment” in the atmosphere—in other words, miasma.[20]
When Snow published his results, he also gave some advice. Preventing cholera was easy, he said. All an individual had to do was to boil and/or filter their drinking water and to wash their hands frequently when preparing food or nursing a patient. Sadly, however, the idea that a disease could be water-borne was just too revolutionary for its time. Snow was derided and dismissed.
As well as the sheer strangeness of Snow’s theory, another problem was that the miasmatists had lost sight of the fact that their creed was still only a hypothesis, not a proven fact. So when more evidence began to emerge to suggest that Snow might be right, they tweaked their theory accordingly in order to accommodate the new information without having to let go of their core belief. In Soho, for example, Snow uncovered what became known as the case of the Hampstead widow. When Susannah Eley moved from Soho to Hampstead she had a bottle of water from Broad Street delivered to her every day. Ironically, the Broad Street water was known for its fresh, sweet taste. During the Soho epidemic Susannah fell sick and died, the only case in Hampstead. No one could explain this without admitting that the water must have had a part to play, but the government scientists still clung to miasmatism:
. . . if the Broad Street pump did actually become a source of disease to persons dwelling at some distance . . . this . . . may have arisen not in its choleraic excrements but simply in the fact of its impure waters having participated in the atmospheric infection of the district.[21]
There was no eureka moment that proved Snow right. He died in 1858, still largely written off as a crank with an obsession. During the second half of the nineteenth century, however, as the evidence piled up, his theory became increasingly hard to ignore. In London, where in the hot summer of 1858 the insufferable smell from the river, the so-called “Great Stink”, forced parliament to shut down, the government commissioned the engineer Joseph Bazalgette to install a state-of-the art sewerage system across the capital. Aimed at stopping the bad smells, it was prompted by a widespread belief in miasmatism. Yet the measure nevertheless ensured that sewage would no longer leak into the drinking water. The government was doing the right thing, albeit for the wrong reasons. Edwin Chadwick went to his grave holding fast to miasmatism. As late as 1890, he was advocating pumping down fresh air from tall structures like the Eiffel Tower in order to dispel disease.[22]
In 1892, cholera broke out once more in the port of Hamburg, where the drinking water was still as filthy as it had been during the first epidemic 60 years earlier. Britain braced itself, quarantining people and goods entering the country, and setting up floating hospitals. Yet the expected outbreak never came. By the end of the century the British government had classified cholera as a rare and exotic disease.
[1] See Sandra Hempel, The Atlas of Disease (London: White Lion, 2018).
[2] The Lancet 17, Oct 22, 1831.
[3] The Lancet 17, Dec 17, 1831.
[4] The Lancet 18, Sept 1, 1832.
[5] Florence Nightingale, Notes on Nursing (London: Harrison, 1859), 8.
[6] Ibid., 13.
[7] William Reid Claney, Hyperanthraxis or the Cholera of Sunderland (London: Whittaker, 1832).
[8] Ibid.
[9] John Snow, On the Mode of Communication of Cholera, 2nd ed. (London: John Churchill, 1855).
[10] Tenth Annual Report of the Registrar-General (1847), xvii.
[11] Metropolitan Sewage Committee proceedings, Parliamentary Papers, 1846, 1, 651.
[12] The Lancet 54, July 7, 1849.
[13] The Times, July 17, 1855.
[14] Ibid.
[15] John Snow, On the Mode of Communication of Cholera (London: John Churchill 1849).
[16] University of Southampton, Palmerston Papers, Correspondence: Sir Benjamin Hall and Lord Palmerston, August 1854.
[17] Snow, On the Mode of Communication of Cholera, 2nd ed.
[18] Ibid.
[19] Ibid.
[20] General Board of Health, Report of the Committee for Scientific Inquiries in Relation to the Cholera Epidemic of 1854 (London: HMSO, 1855).
[21] Ibid.
[22] S. E. Finer, The Life and Times of Sir Edwin Chadwick (London: Methuen, 1980).