Chapter 9: Epilogue

by R. J. Morris

in Cholera 1832 -- The Social Response to An Epidemic, 1976.

The Partial Solution

The summer of 1849 marked the high noon of miasmatic theory. By the end of the year confidence in the theory had been weakened by its failure, and by the scientific work of John Snow; and a group of doctors in Bristol.

The work of Budd, Swayne and Brittain in Bristol was made possible by the improvement of the microscope and by the development of the provincial medical societies. Bristol had an active medical community centered on its general hospital, the medical school and the Bristol Medico-Chirugical Society, which set up a sub-committee '...for the microscopic investigation of choleraic evacuations'. In the course of this research Swayne and Brittain found distinctive annular bodies which grew progressively in size. Specimens were sent to Quekett at the Royal College of Surgeons who agreed that they were 'of a fungoid nature'. William Budd, a leading local physician already known for his work on typhus and typhoid, was prepared to take his inferences much further than the other two men. He found the same objects in the drinking water of places infected with cholera, and concluded that the cause of cholera was 'a living organism of a distinct species, which was taken by the act of swallowing it, which multiplied in the intestine by self propagation...' The disruption thus caused derived from the 'enormous chemical power which plants possess to supply themselves with material for their growth'. Baly and Gull, the leading members of the Cholera Committee of the Royal College of Physicians, immediately investigated these claims but found that the particles described were not always present in cholera-infected water, and identified them as partially digested food. The rapid rise and fall of the fungus theory of the origin of cholera showed how well-organized the medical community had become since 1832. The theory was immediately published and immediate notice was taken by the London leadership of the profession. These empirically tested and logically consistent predictions were subjected to mutual evaluation and in this case found wanting, not for reasons of prestige or social pressure but by those same scientific rules of observation and logic.[26] The fall of the fungus theory was unfortunate for it discredited other 'water-borne' theories like that of John Snow, but the investigations had shown that particles from intestines could turn up in drinking water. There were now good scientific reasons for suspecting sewage-tainted water apart from the smell. The 1850s saw a sustained parliamentary campaign to improve the water supply of London which brought slow results.[27]

Of the two routes to the understanding of cholera which had been blocked in 1832, the Bristol men had chosen microscopic studies. John Snow linked his prestige as an influential London surgeon [actually an anesthesiologist, general practitioner and epidemiologist] to the analytical power of descriptive statistics. The early papers he wrote in 1853 showed that his inferences had begun with observations on the pathology and clinical history of the disease in the traditional manner. Cholera, he wrote, 'always commences with disturbances of the functions of the alimentary canal; all the early symptoms are connected with this canal, and the effects which follow are only the results of what have occurred.'[28] Thus he looked for some poison, which he believed came from the excreta of cholera patients and was swallowed by the new victims. His attention was drawn to a number of instances in which water supplies polluted with sewage had been the common factor in an explosive outbreak of cholera. He was especially impressed by the deaths in middle-class Albion Terrace in Wandsworth where a stockbroker and a surgeon's daughter had been amongst those who had died after the overflow pipe from a sewer had poured water into the water supply system from a nearby spring.[29] When Snow published the first edition of On the mode of communication of cholera it aroused considerable interest, but few were convinced by this rather slight volume of scattered examples which illustrated, as events subsequently proved, a brilliant intuition. Snow admitted that the evidence was imperfect but he published so that he might lay claim to that prestige which science grants to those who first publish an original and successful idea.

When cholera returned to London in 1854 Snow was ready. Events presented him with two massive experiments which demonstrated his theory with convincing clarity. He directed his attention to the districts of Kennington, Waterloo, Lambeth, St George Southwark and St Peter Walworth which were supplied by the Vauxhall Water Company which drew water from the sewage-laden Thames at Battersea Fields, and by the Lambeth Company, which had been one of the first to respond to the pressure for purer supplies, and drew water from a new position at Thames Ditton.

No fewer than three hundred thousand people of both sexes, of every age and occupation, and of every rank and station from gentlefolks down to the very poor, were divided into two groups without their choice, and, in most cases without their knowledge; one group being supplied with water containing the sewage of London, and, amongst it, whatever might have come from the cholera patients, and the other group having water quite free from such impurity.[30]

The cholera cases he identified through information given him by the Registrar-General [i.e., William Farr]. The water company of the victim he identified by a silver nitrate test which showed up the high quantity of common salt in the Vauxhall Company product. As Snow said coolly, it was 'part of that which has passed through the kidneys and bowels of two millions and a quarter of the inhabitants of London' [31] The results of the experiment were striking (Table 13).

Table 13: Cholera Deaths and Water Supplies in London [32]


Pop. 1851

Cholera deaths

in 14 weeks

ending 14 Oct

Deaths per

10,000 living

Houses supplied 

by Southwark and Vauxhall

266,516

4,093

153

Houses supplied by 

Lambeth Co.

173,748

461

26

If this were not enough he had his Broad Street experience to quote. He had investigated an explosive outbreak in this area of Soho and found that the Broad Street pump was a factor common to most cases. He persuaded the parish authorities to remove the handle of the pump and the epidemic faded. It was only with the help of the church that he found the source of infection. Rev. Henry Whitehead, curate of St Luke's, had recently graduated from Oxford and was one of an increasing number of clergy who sought to serve God by social reform as well as saving souls. He knew the affairs of the parish better than any visiting surgeon and found that just before the epidemic a child had died in No. 40 Broad Street from exhaustion following diarrhea, but that the symptoms were those of cholera. The child's nappies had been steeped and the water thrown down a sink and into a cesspool which seeped into the pump well.[33] The second edition was a convincing and compelling statement of his case. Snow realized that the argument still had its social and political dimension and assured his readers that accepting the water-borne theory of cholera implied prevention by 'simple measures that will not interfere with social and commercial intercourse'. Snow had reconciled the needs of industrial laissez-faire society with contagionist theory.[34]

The immediate impact of Snow's theory has disappointed many historians who find that he made no sweeping conversion of the profession and received little mention in medical textbooks or subsequent works on cholera. In 1854, the Scientific Committee of the re-formed General Board of Health attacked the theory at its weakest point. Neither Snow nor the committee could identify the nature of the 'cholera poison' in the water. This had to wait for the work of Robert Koch in Alexandria in l883.[35] Snow's impact was greater than this neglect and criticism suggests. He was careful to present his theory as a partial solution. Water was not the only means by which cholera was transmitted. He also linked his inferences to the prestigious activities of pathology and collecting case histories. Men like John Simon, medical officer of the City of London, rejected the theory at the start but by 1856 he was publishing, unacknowledged, very similar views. Thomas Acland, leader of the medical profession in Oxford, wrote a powerful miasmatic account of the 1854 epidemic there, but the measures he adopted included shutting off the water supply of the prison, a policy straight from Snow.  ln 1849, Acland had done no more than recommend an improved diet for the prison.[36]  Snow's real triumph came in 1866 after his death. William Farr at the Registrar-General's office had been convinced by Snow's theory; 'I was thus prepared in 1866 to closely scrutinize the water supply.' When an explosive epidemic hit East London in July he did just this, and, despite the denials of company officials he rapidly traced the source of the epidemic to the Old Ford works of the East London Water Company, where open ponds of water tainted by sewage from the nearby River Lea were being used as an emergency reserve of water by the Company. As soon as this practice was stopped, the epidemic died.[37]

This was the last of the great 'experiments' from which the Registrar-General's office gathered data which demonstrated Snow's theory. Cholera was defeated in a grim game of scientific inference and political resistance. British society finally outwitted the cholera with a technology of sewers, water pipes and artesian wells, a network of information with the Registrar-General at its center, and an administration almost as confused, overlapping and ill-coordinated as it had been in 1832, but a little less powerless. Cholera had been blindly admitted to Britain in 1832. The men who curbed its spread in 1866 were a little less blind though their understanding was by no means complete. God the scientist emerged slowly from the mists of miasma and the fires of vengeance which had obscured the workings of natural law in 1832.

 

THE END

 

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