STUDENT OVERVIEW

London 1854: Cesspits, Cholera and Conflict over the Broad Street Pump
A Chapter-length RTTP Science Game for Biology and General Science Courses

Marshall L. Hayes (mlh66@cornell.edu) and Eric B. Nelson (ebn1@cornell.edu)

Dept. of Plant Pathology and Plant-Microbe Biology
Cornell University

‘The first victim to die of cholera in Sunderland’

reproduced in Snow (2002) Int J Epidemiol 31: 908

Cesspits, Cholera and Conflict takes place on the evening of September 7, 1854 at Vestry Hall in
Soho, Greater London. You are a member of a special emergency response committee of the
local Board of Governors and Directors of the Poor of St. James Parish, who have convened to
respond to the deadly outbreak of Cholera that has claimed the lives of more than 500 parish
residents over the preceding eight days. Historically, the outcome of this meeting was the
decision to remove the pump handle from a contaminated neighborhood pump on Broad Street.
This decision and the events leading up to it are considered a defining moment in the
development of modern approaches to public health, epidemiology and municipal waste
management. This role play is designed to highlight various aspects of the historical debate.

In your role as a Board member, you and your colleagues will debate three central questions:

• What is the source of this disease outbreak?

• How is cholera communicated from person to person?
• What steps should be taken to contain the outbreak?

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You are asked to complete the following four tasks over the course of the role play:

1. Introduce your character to the group and discuss your specific perspective on Cholera.

2. Debate and vote on the issue of removing the pump handle from the Broad Street pump.

3. Revise and/or amend the language of a precautionary handbill given to parish residents.

4. Achieve a “secret objective” related to making a particular contribution to the debate.

This Reacting to the Past (RTTP) game will be played over two class sessions with two additional
class sessions devoted to introductory set-up and post-mortem discussion. In the first of the two
role-playing sessions, you will deliver an opening statement on the nature and origins of this
disease outbreak from the specific standpoint of your assigned character. You and your
colleagues will then engage in active debate, and the second of the two sessions will conclude with
a vote on specific action(s) that St. James Parish can take to deal with the outbreak.

This game will immerse you in the scientific debates and methodologies that led to the founding
of the modern fields of microbiology and epidemiology in the mid-to-late 1800’s. It places
particular emphasis on the dichotomy and tension between believers of miasma theory (the
prevailing idea at the time that disease was caused by miasma or unhealthy odors) and advocates
of germ theory (that later attributed a specific disease to being caused by a specific organism).
Central characters in this debate included Dr. John Snow (resident physician in St. James Parish
and believer that cholera was a contagious and waterborne disease), the Rev. Henry Whitehead
(curate of the local Church of St. Luke’s and a staunch supporter of miasma theory) and Dr.
William Farr (vital records statistician for the General Register Office). While Dr. Snow, Rev.
Whitehead and Dr. Farr are not represented as figures in this game, their ideas are channeled
through the perspectives of various other roles. This activity will also introduce you the
importance of sanitation in modern society and the eventual implementation of municipal water-
treatment systems in urban planning.

You are encouraged to engage in as much independent and team research as you deem
appropriate in order to play your role effectively. You will find extensive information is available
online and in print format. In addition, there may be laboratory activities for this game that will
allow you to visualize “microbes” in liquids using period-specific microscopes. You will also be
given the opportunity to work with original morbidity and mortality data on the outbreak, so that
you may generate your own figures and disease maps of London neighborhoods at the time.
This parallels the approaches that Drs. Snow and Farr used in their pioneering efforts to
understand the spatial and temporal aspects of Cholera epidemics.

Your student packet of game materials includes:

1. Your initial instructions, detailing relevant resources and offering general insights about how
the game may be played.

2. An introductory narrative intended to orient you to the mindset of a Board member on the
night of September 7, 1854.

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3. An 1853 Handbill from the Parish of St. James, Westminster providing residents with
resources and advice for avoiding Cholera. Use the specific language in this handbill as
helpful discussion material you and your colleagues begin your debate.

4. Two data figures that will be central to your debate and discussion: a) John Snow’s map of
Cholera mortalities in St. James Parish (Snow, J. 1855. On the Mode of Communication of Cholera.
London: Churchill) and b) William Farr’s correlation of elevation and Cholera mortalities
(Farr, W. 1852. Report on the Mortality of Cholera in England, 1848-1849. London: Clowes). You
are expected to examine these figures closely and formulate any arguments about the origins
and transmission of Cholera that are consistent with the viewpoints of your character.

5. A separate Microsoft Excel spreadsheet containing raw data relating to 1) mortalities in St.
James Parish from 26 July to 7 September, 1854 and 2) Farr’s 1852 study on elevation and
Cholera fatalities (Farr, W. 1852. Influence of Elevation on the Fatality of Cholera. J.
Statistical Society London 15: 155-183). Again, you are encouraged to examine these data closely
and formulate convincing arguments about the origins and transmission of Cholera.

A few final words of encouragement: if you have any concerns about role playing, please do not
hesitate to discuss them with your instructor and fellow classmates. For example, you may feel
intimidated at the idea of researching your character, or you may have reservations about
debating in public. Most importantly, this RTTP experience is a very unique approach to
teaching and learning, and a highly effective one if you invest the time and energy. Have fun,
and good luck!

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 GENERAL INSTRUCTIONS FOR STUDENTS

1. Brief Introductions to Reacting Pedagogy and to Victorian England

For general context on role-playing, please visit the Reacting to the Past site at Barnard College.
http://reacting.barnard.edu/

As needed, please consult the online Victorian Dictionary: A Social History of Victorian London.
http://www.victorianlondon.org

2. Required Readings

Chapter One – “Monday, August 28: The Night-Soil Men” In Johnson, SJ (2006).
The Ghost Map: The Story of London's Most Terrifying Epidemic - and How It Changed, Science,
Cities, and the Modern World. New York: Riverhead Books.

Chapters Two and Ten – “Mapping Symptoms, Making Disease” and “Choleric
Broad Street: The Neighborhood Disease” In Koch, T (2011). Disease Maps: Epidemics
on the Ground. Chicago: University of Chicago Press.

Ackerknecht, EH (1948). Anticontagionism between 1821 and 1867. Reprinted in

Int J Epidemiol 38: 7-21 (2009).

OPTIONAL Chapter Five – “Downhill All the Way” In Summers, J (1989). Soho: A
History of London's Most Colourful Neighbourhood. London: Bloomsbury Publishing.

PLUS specific online resources mentioned on your individual role sheet.

These suggested resources represent a useful starting point for
developing the motivations and viewpoints of your character. If you
have enough time, you should feel free to do additional reading and
research beyond these suggestions.

**SPECIAL NOTE**

In your own research, you may also find it helpful to pay particular attention to the
following specific reference by Dr. John Snow:

Snow, J. (1855). On the mode of communication of cholera (Second Edition, Much

Enlarged). London: J. Churchill.

Available as an E-book at:

http://books.google.co.uk/books/about/On_the_Mode_of_Communic
ation_of_Cholera.html?id=-N0_AAAAcAAJ

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3. Sites on Cholera, John Snow and the 1854 Epidemic in London

Cholera Online: A Modern Pandemic in Texts and Images

U.S. National Library of Medicine.
http://www.nlm.nih.gov/exhibition/cholera/index.html

Harvard University’s Collection on Contagion: Historical Views of Diseases and Epidemics

http://ocp.hul.harvard.edu/contagion/cholera.html

The John Snow Site at UCLA

http://www.ph.ucla.edu/epi/snow.html

The John Snow Archive and Research Companion at MSU

http://johnsnow.matrix.msu.edu/index.php

The John Snow Case Study site at UNC

http://courses.sph.unc.edu/john_snow/

The City of Westminster Archives: Cholera and the Thames Online Resource
http://www.choleraandthethames.co.uk/

4. Additional Sites that May be Useful for Character Research

Association Medical Journal (1853-56).

PubMed Central, National Library of Medicine.
http://www.ncbi.nlm.nih.gov/pmc/journals/3/

British Medical Journal (1857-).

PubMed Central, National Library of Medicine.
http://www.ncbi.nlm.nih.gov/pmc/journals/3/

London Journal of Medicine (1849-52).

PubMed Central. National Library of Medicine.
http://www.ncbi.nlm.nih.gov/pmc/journals/3/

The Lancet Archive (1820-present)

http://www.thelancet.com/journals/lancet/issue/current?tab=past

5. Parliamentary Procedures and Rules of Order

The discussion and debates that will unfold over your two class meetings will take place in a
structured fashion. All role players will be expected to follow a standard procedure for
introducing motions and subsequent voting:

A) There will be a motion on the floor, an issue that is raised by one of the Board members
(i.e. the Chair or other committee members) and proposed for a vote.
B) The Chair will open the floor for discussion on the issue.
  5    
 C) The Chair will then ask committee members if someone will second the motion.
D) If the motion is seconded, then the Chair will put the motion to a vote with no further
debate. Otherwise, the motion is declined and debate continues.
E) If the motion is brought to a vote, there will be a three-step procedure:
a. The Chair will first ask for all voting 'yea' or 'in favor' to raise their hands. The
Clerk will record the numbers of these votes, as well as all subsequent votes.
b. Next, the Chair and Clerk will ask for all voting 'no' or 'opposed'.
c. Finally, the Chair and Clerk will do the same for abstentions.
F) Based on the vote numbers the Clerk and the Chair will then announce whether the
motion passes (is accepted) or fails (is rejected).

This outline is a simplified excerpt of Parliamentary Procedure as detailed in Robert's Rules of

Order, and a useful summary is available online at http://www.robertsrules.org/

6. Historical Consistency and the “Rules” of Gameplay

For the purposes of remaining true to the notion and “rules” of historical gameplay, we are
limited to the knowledge, ideas and resources that were available in 1854. In certain
circumstances, you may justify taking certain liberties. For example, Dr. John Snow’s seminal
work On the Mode of Communication of Cholera was published as a second edition in 1855. You may
assume that characters had access to an advance draft; given that Dr. Snow did publish an earlier
version of this treatise in 1849, his arguments were known throughout the medical community of
the day. Similarly, any weather information prior to September 7, 1854 is considered playable.

Also, as you develop your character’s own arguments, it may be useful for you to consult the
online version of the report by the Cholera Inquiry Committee for relevant supporting material
(http://johnsnow.matrix.msu.edu/work.php?id=15-78-AA). It will simply be necessary to
disregard any data or events that occurred after September 7, 1854.

7. Cholera Data Manager

You may be given Dr. Snow's graphical map (showing the locations of individual Cholera
mortalities and pump locations on London streets) and original data (as an Excel spreadsheet).
There is also an interactive online visualization tool that allows students to manipulate morbidity
and mortality data for the neighborhood and the rest of London:

http://www.ppath.cornell.edu/Courses/PLPA2950/PLPA2950_cholera.html

FINAL WORDS

The RTTP approach is designed to be an engaging and challenging means to explore complex issues. It is also
creative and unpredictable. You are encouraged to embrace the nature of role-playing as enthusiastically
as you wish. The role sheets provide the overall context for your individual character and his intentions. Beyond
these details, you may take the liberty of expanding on any aspect of your
character’s personality and backstory. For example, you may adopt any
mannerisms, wear any clothing, or develop any backstory that you feel will add to
the appeal and/or presence of your character.

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 Thursday 7 September 1854
 
Evening is setting in as you turn down Marshall Street and make your way toward the Vestry of
St. James Piccadilly. There is no haste in your step. Your route is less than a half a mile long,
and it is an easy ten-minute walk even under the worst of conditions. In fact, these may just be the
worst of conditions.

According to unofficial reports, the dreaded Asiatic cholera has claimed the lives of nearly 400 of
your fellow parishioners over the past four and a half weeks. You shudder at the thought that
this number may give a very inadequate idea of the entire loss inflicted by the epidemic thus far,
particularly considering that most fatal cases have been reported within a few city blocks. An
estimated 400 fatalities would not include at least 150 local residents that you know to have died
in the Middlesex, University College, Royal Free, St. George's and King's College Hospitals,
outside of the parish, whose deaths would therefore have been registered elsewhere. You also
suppose that many deaths must have escaped registration altogether, and possibly more than 40
non-residents, who came to work or visit the parish on a daily basis, also perished.

These unfortunate souls were your co-workers, your clients, your neighbors, and the schoolmates
of your children. And, as the sand and gravel grind beneath each step you take, you cannot help
but feel even more haunted by the reality that surrounds you: death and disease have cast a dark shroud
over your beloved parish of St. James Westminster.

One might have almost even felt the shroud descending over the past two weeks - the sky has
been almost continually cloudless and the air temperatures unseasonably warm, as high as 85°F
in the afternoon shade. Even tonight, the temperature must be hovering around 80°F, and there
is no apparent relief in sight, given that London hasn’t experienced rain since August 25. As you
traverse Golden Square, you wonder to yourself as to the relationship between the weather and
the cholera outbreak. Certainly, the events of past several weeks might simply be explained by
atmospheric conditions that favor noxious, cholera-causing odors, might they not?

Ahead of you, you hear the bells of St. James’s Church begin to chime 6:00 pm, a reminder that
you should start focusing on this evening’s business. You are headed to a special meeting of the
Sanitary Committee of the parish’s Board of Governors and Directors of the Poor. It has been
nearly a month since you and your fellow Board members voted to abandon the usual meeting
protocol and form yourselves into a special emergency response committee to deal with the
epidemic. Sadly, your and your colleagues’ worst fears began to come true last Saturday,
September 2. While five-month-old Frances Lewis was taking her final breaths that morning,
cholera began to strike scores of others with little warning, taking those in normal health to
complete collapse within a matter of hours.

It is painfully clear that you and the Board have a daunting task ahead of you: orchestrate a
response to this epidemic that will not only calm the fears of those parishioners who remain in
the neighborhood, but also quiet your harshest critics, who feel that the parish administrators
have been too slow in giving residents access to medical specialists. Certainly, there are many
issues that you will debate this evening, whether how to assuage residents who were fleeing
because of press reports and pressure from employers, or how to aid businesses that were
faltering as the parish streets became more and more deserted. Above all, the Board has to agree
on a decisive action to stop the raging epidemic. These are desperate and urgent times.

As you reach the Vestry on Piccadilly Place, you whisper a solemn prayer to yourself - for
strength and courage to act in the best interests of the parish – and then reach for the door…
 ____________

4.

ALSO BY STEVEN JOHNSON

The
GHOST MAP
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We Create and Communicate
and How It Cltan,ed Science, Cities,
EMERGENCE: and the Modern World
The Connected Lives of Ants, Brains,
Cities, and Software

MIND WIDE OPEN:

Your Brain and the Neuroscience
of Everyday Lf STEVEN JOHNSON
EVERYTHING BAD IS GOOD FOR YOU:
How Today’s Popular Culture Is Actually Making Us Smarter

RIVERI-IEAD BOOKS

New Yo,k

-S
.
 Monday, August 28

THE NIGHT-SOIL MEN

I T IS AUGUST 1854, AND LONDON IS A CITY OF SCAVENGERS.

Just the names alone read now like some kind of exotic zoologi
cal catalogue: bone—pickers, rag—gatherers, pure-finders, dredgermen,
mud-larks, sewer-hunters, dustmen, night-soil men, bunters, toshers,
shoremen. These were the London underciasses, at least a hundred
thousand strong. So immense were their numbers that had the scav
engers broken off and formed their own city, it would have been the
fifth-largest in all of England. But the diversity and precision of their
routines were more remarkable than their sheer number. Early risers
stroffing along the Thames would see the toshers wading through the
muck of low tide, dressed almost comically in flowing velveteen
coats, their oversized pockets filled with stray bits of copper recovered
from the water’s edge. The toshers walked with a lantern strapped to
their chest to help them see in the predawn gloom, and carried an
 2 MONDAY, AUGUST 28
eight—foot—long pole that they used to test the ground in front of them,
and to pull themselves out when they stumbled into a quagmire. The
pole and the eerie glow of the lantern through the robes gave them the
look of ragged wizards, scouring the foul river’s edge for magic coins.
Beside them fluttered the mud—larks, often children, dressed in tatters
and content to scavenge all the waste that the toshers rejected as below
their standards: lumps of coal, old wood, scraps of rope.
Above the river, in the streets of the city, the pure-finders eked
out a living by collecting dog shit (colloquially called “pure”) while
the bone-pickers foraged for carcasses of any stripe. Below ground,
in the cramped but growing network of tunnels beneath London’s
streets, the sewer—hunters slogged through the flowing waste of the
metropolis. Every few months, an unusually dense pocket of methane
gas would be ignited by one of their kerosene lamps and the hapless
soul would be incinerated twenty feet below ground, in a river of
raw sewage.
The scavengers, in other words, lived in a world of excrement
and death. Dickens began his last great novel, Our Mutual Friend,
with a father-daughter team of toshers stumbling across a corpse
floating in the Thames, whose coins they solemnly pocket. “What
world does a dead man belong to?” the father asks rhetorically, when
chided by a fellow tosher for stealing from a corpse. “Tother world.
What world does money belong to? This world.” Dickens’ unspoken
point is that the two worlds, the dead and the living, have begun to
coexist in these marginal spaces. The bustling commerce of the great
city has conjured up its opposite, a ghost class that somehow mimics
the status markers and value calculations of the material world. Con
sider the haunting precision of the bone—pickers’ daily routine, as
captured in Henry Mayhew’s pioneering 1844 work, London Labour
and the London Poor:
THE NIGHT-SOIL MEN 3
It usually takes the bone-picker from seven to nine hours to go over
his rounds, during which time he travels from 20 to 3() miles with a
quarter to a half hundredweight on his back. In the summer he usu
ally reaches home about eleven of the day, and in the winter about
one or two. On his return home he proceeds to sort the contents of
his bag. He separates the rags from the bones, and these again from
the old metal (if he be luckly enough to have found any). He divides
the rags into various lots, according as they are white or coloured;
and if he have picked up any pieces of canvas or sacking, he makes
these also into a separate parcel. When he has finished the sorting he
takes his several lots to the ragshop or the marine—store dealer, and
realizes upon them whatever they may be worth. For the white rags
he gets from 2d. to 3d. per pound. according as they are clean or
soiled. The white rags are very difficult to be found; they are mostly
very dirty, and are therefore sold with the coloured ones at the rate
of about 5 lbs. for 2d.
The homeless continue to haunt today’s postindustrial cities, but
they rarely display the professional clarity of the bone-picker’s im
promptu trade, for two primary reasons. First, minimum wages and
government assistance are now substantial enough that it no longer
makes economic sense to eke out a living as a scavenger. (Where
wages remain depressed, scavenging remains a vital occupation; wit
ness the perpendadores of Mexico City.) The bone collector’s trade
has also declined because most modern cities possess elaborate sys
tems for managing the waste generated by their inhabitants. (In
fact, the closest American equivalent to the Victorian scavengers—
the aluminum-can collectors you sometimes see hovering outside
supermarkets—rely on precisely those waste—management systems
for their paycheck.) But London in 1854 was a Victorian metropolis
4 MONDAY, AUGUST 28
trying to make do with an Elizabethan public infrastructure. The
city was vast even by today’s standards, with two and a half million
people crammed inside a thirty—mile circumference. But most of the
techniques for managing that kind of population density that we
now take for granted—recycling centers, public—health departments,
safe sewage removal—hadn’t been invented yet.
And so the city itself improvised a response—an unplanned, or
ganic response, to be sure, but at the same time a response that was
precisely contoured to the community’s waste-removal needs. As the
garbage and excrement grew, an underground market for refuse de
veloped, with hooks into established trades. Specialists emerged,
each dutifully carting goods to the appropriate site in the official
market: the bone collectors selling their goods to the bone-boilers,
the pure-finders selling their dog shit to tanners, who used the
“pure” to rid their leather goods of the lime they had soaked in for
weeks to remove animal hair. (A process widely considered to be,
as one tanner put it, “the most disagreeable in the whole range of
manufacture.”)
We’re naturally inclined to consider these scavengers tragic fig
ures, and to fulminate against a system that allowed so many thou
sands to eke out a living by foraging through human waste. In many
ways, this is the correct response. (It was, to be sure, the response of
the great crusaders of the age, among them Dickens and Mayhew.)
But such social outrage should be accompanied by a measure of
wonder and respect: without any central planner coordinating their
actions, without any education at all, this itinerant underclass man
aged to conjure up an entire system for processing and sorting the
waste generated by two million people. The great contribution usu
ally ascribed to Mayhew’s London Labour is simply his willingness to
see and record the details of these impoverished lives. But just as
THE NIGHT-SOIL MEN 5
valuable was the insight that came out of that bookkeeping, once he
had run the numbers: far from being unproductive vagabonds, May-
hew discovered, these people were actually performing an essential
function for their community. “The removal of the refuse of a large
town,” he wrote, “is, perhaps. one of the most important of social
operations.” And the scavengers of Victorian London weren’t just
getting rid of that refuse—they were recycling it.
WASTE RECYCLING IS USUALLY ASSUMED TO BE AN INVEN
tion of the environmental movement, as modern as the blue plastic
bags we now fill with detergent bottles and soda cans, But it is an an
cient art. Composting pits were used by the citizens of Knossos in
Crete four thousand years ago. Much of medieval Rome was built
out of materials pilfered from the crumbling ruins of the imperial
city. (Before it was a tourist landmark, the Colosseum served as a de
facto quarry.) Waste recycling—in the form of composting and ma
nure spreading—played a crucial role in the explosive growth of me
dieval European towns. High-density collections of human beings,
by definition, require significant energy inputs to be sustainable, start
ing with reliable supplies of food. The towns of the Middle Ages
lacked highways and container ships to bring them sustenance, and so
their population sizes were limited by the fecundity of the land
around them. If the land could grow only enough food to sustain five
thousand people, then five thousand people became the ceiling. But
by plowing their organic waste back into the earth, the early medieval
towns increased the productivity of the soil, thus raising the popu
lation ceiling, thereby creating more waste—and increasingly fertile
soil. This feedback loop transformed the boggy expanses of the Low
Countries, which had historically been incapable of sustaining
6 MONDAY, AUGUST 28
anything more complex than isolated bands of fishermen, into some
of the most productive soils in all of Europe. To this day, the Nether
lands has the highest population density of any country in the world.
Waste recycling turns out to be a hallmark of almost all complex
systems, whether the man-made ecosystems of urban life, or the mi
croscopic economies of the cell. Our bones are themselves the result
of a recycling scheme pioneered by natural selection billions of years
ago. All nucleated organisms generate excess calcium as a waste prod
uct. Since at least the Cambrian times, organisms have accumulated
those calcium reserves, and put them to good use: building shells, teeth,
skeletons. Your ability to walk upright is due to evolution’s knack for
recycling its toxic waste.
Waste recycling is a crucial attribute of the earth’s most diverse
ecosystems. We value tropical rain forests because they squander so
little of the energy supplied by the sun, thanks to their vast, inter
locked system of organisms exploiting every tiny niche of the nutri
ent cycle. The cherished diversity of the rain—forest ecosystem is not
just a quaint case of biological multiculturalism. The diversity of the
system is precisely why rain forests do such a brilliant job of captur
ing the energy that flows through them; one organism captures a cer
tain amount of energy, but in processing that energy, it generates
waste. In an efficient system, that waste becomes a new source of en
ergy for another creature in the chain. (That efficiency is one of the
reasons why clearing the rain forests is such a shortsighted move: the
nutrient cycles in their ecosystems are so tight that the soil is usually
very poor for farming: all the available energy has been captured on
its way down to the forest floor.)
Coral reefs display a comparable knack for waste management.
Corals live in a symbiotic alliance with tiny algae called zooxanthellae.
I
THE NIGHT-SOIL MEN 7
Thanks to photosynthesis, the algae capture sunlight and use it to turn
carbon dioxide into organic carbon, with oxygen as a waste product
of the process. The coral then uses the oxygen in its own metabolic
cycle. Because we’re aerobic creatures ourselves, we tend not to think
of oxygen as a waste product, but from the point of view of the algae,
that’s precisely what it is: a useless substance discharged as part of its
metabolic cycle. The coral itself produces waste in the form of carbon
dioxide, nitrates, and phosphates, all of which help the algae to grow
That tight waste—recycling chain is one of the primary reasons coral
reefs are able to support such a dense and diverse population of crea
tures, despite residing in tropical waters, which are generally nutrient—
poor. They are the cities of the sea.
There can be many causes behind extreme population density—
whether the population is made up of angelfish or spider monkeys or
humans—but without efficient forms of waste recycling, those dense
concentrations of life can’t survive for long. Most of that recycling
work, in both remote tropical rain forests and urban centers, takes
place at the microbial level. Without the bacteria—driven processes of
decomposition, the earth would have been overrun by offal and car
casses eons ago, and the life—sustaining envelope of the earth’s atmo
sphere would be closer to the uninhabitable, acidic surface of Venus.
If some rogue virus wiped out every single mammal on the planet,
life on earth would proceed, largely unaffected by the loss. But if the
bacteria disappeared overnight, all life on the planet would be extin
guished within a matter of years.
You couldn’t see those microbial scavengers at work in Victo
rian London, and the great majority of scientists—not to mention
laypeople—had no idea that the world was in fact teeming with
tiny organisms that made their lives possible. But you could detect

8 MONDAY, AUGUST 28
them through another sensory channel: smell. No extended descrip
tion of London from that period failed to mention the stench of the
city. Some of that stench came from the burning of industrial fuels,
but the most objectionable smells—the ones that ultimately helped
prod an entire public—health infrastructure into place—came from
the steady, relentless work of bacteria decomposing organic matter.
Those deadly pockets of methane in the sewers were themselves pro
duced by the millions of microorganisms diligently recycling human
dung into a microbial biomass, with a variety of gases released as
waste products. You can think of those fiery, underground explosions
as a kind of skirmish between two different kinds of scavenger:
sewer—hunter versus bacterium—living on different scales but none
theless battling for the same territory.
But in that late summer of 1854, as the toshers and the mud—larks
and the bone collectors made their rounds, London was headed
toward another, even more terrifying, battle between microbe and
man. By the time it was over, it would prove as deadly as any in the
city’s history.
LONDON’S UNDERGROUND MARKET OF SCAVENGING HAD ITS
own system of rank and privilege, and near the top were the night-
soil men. Like the beloved chimney sweeps of Mary Poppins, the
night—soil men worked as independent contractors at the very edge of
the legitimate economy, though their labor was significantly more re
volting than the foraging of the mud-larks and toshers. City landlords
hired the men to remove the “night soil” from the overflowing
cesspools of their buildings. The collecting of human excrement was
a venerable occupation; in medieval times they were called “rakers”
and “gong-fermors,” and they played an indispensable role in the
THE NIGHT-SOIL MEN 9
waste-recycling system that helped London grow into a true metrop
olis, by selling the waste to farmers outside the city walls. (Later en
trepreneurs hit upon a technique for extracting nitrogen from the
ordure that could be reused in the manufacture of gunpowder.)
While the rakers and their descendants made a good wage, the work
conditions could be deadly: in 1326, an ill—fated laborer by the name
of Richard the Raker fell into a cesspool and literally drowned in hu
man shit.
By the nineteenth century, the night-soil men had evolved a pre
cise choreography for their labors. They worked the graveyard shift,
between midnight and five am., in teams of four: a “ropeman,” a
“holeman,” and two “tubmen.” The team would affix lanterns at the
edge of the cesspit, then remove the floorboards or stone covering
it, sometimes with a pickax. If the waste had accumulated high
enough, the ropeman and holeman would begin by scooping it out
with the tub. Eventually, as more night soil was removed, the men
would lower a ladder down and the holeman would descend into the
pit and scoop waste into his tub. The ropeman would help pull up
each full tub, and pass it along to the tubmen who emptied the waste
into their carts. It was standard practice for the night—soil men to be
offered a bottle of gin for their labors. As one reported to Mayhew:
“I should say that there’s been a bottle of gin drunk at the clearing of
every two, ay, and more than every two, out of three cesspools emp
tied in London; and now that I come to think on it, I should say that’s
been the case with three out of every four.”
The work was foul, but the pay was good. Too good, as it turned
out. Thanks to its geographic protection from invasion, London had
become the most sprawling of European cities, expanding far be
yond its Roman walls. (The other great metropolis of the nineteenth
century, Paris, had almost the same population squeezed into half
 10 MONDAY, AUGUST 28
the geographic area.) For the night—soil men, that sprawl meant
longer transport times—open farmland was now often ten miles
away—which drove the price of their removing waste upward. By
the Victorian era, the night-soil men were charging a shilling a
cesspool, wages that were at least twice that of the average skilled la
borer. For many Londoners, the financial cost of removing waste
exceeded the environmental cost of just letting it accumulate—
particularly for landlords, who often didn’t live on top of these over
flowing cesspools. Sights like this one, reported by a civil engineer
hired to survey two houses under repair in the I 840s, became com
monplace: “I found whole areas of the cellars of both houses were
full of nightsoil to the depth of three feet, which had been permitted
for years to accumulate from the overflow of the cesspools. Upon . .
passing through the passage of the first house I found the yard cov
ered in nightsoil, from the overflowing of the privy to the depth of
nearly six inches and bricks were placed to enable the inmates to get
across dryshod.” Another account describes a dustheap in Spitalfields,
in the heart of the East End: “a heap of dung the size of a tolerably
large house, and an artificial pond into which the content of cesspits
are thrown. The contents are allowed to desiccate in the open air, and
they are fi-equently stirred for that purpose.” Mayhew described this
grotesque scene in an article published in the London Morning Chron
icle in 1849 that surveyed the ground zero of that year’s cholera out
break:
We then journeyed on to London-street. . . In No. 1 of this street
. water closet heightened the crisis. A water—flushing device had been
the cholera first appeared seventeen years ago, and spread up it with
fearful virulence; but this year it appeared at the opposite end, and ran
down with like severity. As we passed along the reeking banks of
it
the sewer, the sun shone upon a narrow slip of the water. In the
THE NIGHT-SOIL MEN Ii
bright light appeared the colour of strong green tea, and positively
it
looked as solid as black marble in the shadow—indeed, it was more
like watery mud than muddy water; and yet we were assured this was
the only water the wretched inhabitants had to drink. As we gazed in
horror at it, we saw drains and sewers emptying their filthy contents
into we saw a whole tier of doorless privies in the open road, com
it;
mon to men and women, built over it; we heard bucket after bucket
of filth splash into it; and the limbs of the vagrant boys bathing in it
seemed by pure force of contrast, white as Parian marble. And yet, as
we stood doubting the fearful statement, we saw a little child, from
one of the galleries opposite, lower a tin can with a rope to fill a large
bucket that stood beside her. In each of the balconies that hung over
.
the stream the self—same tub was to be seen in which the inhabitants
put the mucky liquid to stand, so that they may, after it has rested for
a day or two, skim the fluid from the solid particles of filth, pollution,
and disease. As the little thing dangled her tin cup as gently ac possi
ble into the stream, a bucket of night-soil was poured down from the
next gallery.
Victorian London had its postcard wonders, to be sure—the Crystal
Palace, Trafalgar Square, the new additions to Westminster Palace.
But it also had wonders of a different order, no less remarkable: arti
ficial ponds of raw sewage, dung heaps the size of houses.
The elevated wage of the night—soil men wasn’t the only culprit
behind this rising tide of excrement. The runaway popularity of the
invented in the late sixteenth century by SirJohn Harington, who ac
tually installed a functioning version for his godmother, Queen Eliz
abeth, at Richmond Palace. But the device didn’t take off until the
late 1700s, when a watchmaker named Alexander Cummings and a
I
12 MONDAY, AUGUST 28
cabinetmaker named Joseph Bramah filed for two separate patents
on an improved version of Harington’s design. Bramah went on to
build a profitable business instaffing water closets in the homes of the
well-to-do. According to one survey, water-closet installations had in
creased tenfold in the period between 1824 and 1844. Another spike
happened after a manufacturer named George Jennings installed water
closets for public use in Hyde Park during the Great Exhibition of
1851. An estimated 827,000 visitors used them. The visitors no doubt
marveled at the Exhibition’s spectacular display of global culture and
modern engineering, but for many the most astonishing experience
was just sitting on a working toilet for the first time.
Water closets were a tremendous breakthrough as far as quality of
life was concerned, but they had a disastrous effect on the city’s
sewage problem. Without a functioning sewer system to connect to,
most WCs simply flushed their contents into existing cesspools,
greatly increasing their tendency to overflow According to one esti
mate, the average London household used 160 gallons of water a day
in 1850. By 1856, thanks to the runaway success of the water closet,
they were using 244 gallons.
But the single most important factor driving London’s waste-
removal crisis was a matter of simple demography: the number of peo
ple generating waste had almost tripled in the space of fifty years. In
the 1851 census, London had a population of 2.4 million people,
making it the most populous city on the planet, up from around a
million at the turn of the century. Even with a modern civic infia
structure, that kind of explosive growth is difficult to manage. But
without infrastructure, two million people suddenly forced to share
ninety square miles of space wasn’t just a disaster waiting to happen—
it was a kind of permanent, rolling disaster, a vast organism destroy-
THE NIGHT-SOIL MEN 13
ing itself by laying waste to its habitat. Five hundred years after the fact,
London was slowly re-creating the horrific demise of Richard the
Raker: it was drowning in its own filth.
ALL OF THOSE HUMAN LIVES CROWDED TOGETHER HAD AN
inevitable repercussion: a surge in corpses. In the early 1840s, a
twenty-three-year-old Prussian named Friedrich Engels embarked on
a scouting mission for his industrialist father that inspired both a clas
sic text of urban sociology and the modern Socialist movement. Of
his experiences in London, Engels wrote:
The corpses [of the pnorj have no better fate than the carcasses of an—
imnals. The pauper burial ground at St Bride’s is a piece of open
marshland which has been used since Charles IT’s day and there are
heaps of bones all over the place. Wednesday the remains of
dead paupers are thrown in to a hole which is 14 feet deep. A clergy
man gabbles through the burial service and then the grave is filled
with loose soil. On the following Wednesday the ground is opened
again and this goes on until it is completely full. The whole neigh
borhood is infected from the dreadful stench.
One privately run burial ground in Islington had packed 80,000
corpses into an area designed to hold roughly three thousand. A
gravedigger there reported to the Times of London that he had been
“up to my knees in human flesh, jumping on the bodies, so as to cram
them in the least possible space at the bottom of the graves, in which
fresh bodies were afterwards placed.”
Dickens buries the mysterious opium—addicted law—writer who
14 MONDAY. AUGUST 28
overdoses near the beginning of Bleak House in a comparably grim
setting, inspiring one of the book’s most famous, and famously im
passioned, outbursts:
a hemmed-in churchyard, pestiferous and obscene, whence malignant
diseases are communicated to the bodies of our dear brothers and sis
ters who have not departed. With houses looking on, on every
. . .
side, save where a reeking little tunnel of a court gives access to the
iron gate—with every villainy of life in action close on death, and
every poisonous element of death in action close on life—here, they
lower our dear brother down a foot or two: here, sow him in cor
ruption, to be raised in corruption: an avenging ghost at many a sick-
bedside: a shameful testimony to future ages, how civilization and
barbarism walked this boastful island together.
To read those last sentences is to experience the birth of what would
become a dominant rhetorical mode of twentieth-century thought, a
way of making sense of the high-tech carnage of the Great War, or
the Taylorite efficiencies of the concentration camps. The social the
orist Walter Benjamin reworked Dickens’ original slogan in his enig
matic masterpiece “Theses on the Philosophy of History,” written as
the scourge of fascism was enveloping Europe: “There is no docu
ment of civilization that is not also a document of barbarism.”
The opposition between civilization and barbarism was practi
cally as old as the walled city itself. (As soon as there were gates, there
were barbarians ready to storm them.) But Engels and Dickens sug
gested a new twist: that the advance of civilization produced barbar
ity as an unavoidable waste product, as essential to its metabolism
as the gleaming spires and cultivated thought of polite society The
barbarians weren’t storming the gates. They were being bred from
THE NIGHT-SOIL MEN 15
within. Marx took that insight, wrapped it in Hegel’s dialectics, and
transformed the twentieth century. But the idea itself sprang out of
a certain kind of lived experience—on the ground, as the activists
still like to say. It came, in part, from seeing human beings buried in
conditions that defiled both the dead and the living.
But in one crucial sense Dickens and Engels had it wrong. How
ever gruesome the sight of the burial ground was, the corpses them
selves were not likely spreading “malignant diseases.” The stench was
offensive enough, but it was not “infecting” anyone. A mass grave of
decomposing bodies was an affront to both the senses and to personal
dignity; but the smell it emitted was not a public-health risk. No one
died of stench in Victorian London. But tens of thousands died be
cause the fear of stench blinded them to the true perils of the city,
and drove them to implement a series of wrongheaded reforms that
only made the crisis worse. Dickens and Engels were not alone; prac
tically the entire medical and political establishment fell into the same
deadly error: everyone from Florence Nightingale to the pioneering
reformer Edwin Chadwick to the editors of The Lancer to Queen
Victoria herself. The history of knowledge conventionally focuses on
breakthrough ideas and conceptual leaps. But the blind spots on the
map, the dark continents of error and prejudice, carry their own Inys
tery as well. How could so many intelligent people be so grievously
wrong for such an extended period of time? How could they ignore
so much overwhelming evidence that contradicted their most basic
theories? These questions, too, deserve their own discipline—the so
ciology of error.
The fear of death’s contamination can sometimes last for cen
turies. In the middle of the Great Plague of 1665, the Earl of Craven
purchased a block of land in a semirural area to the west of central
London called Soho Field. He built thirty-six small houses “for the
 16 MONDAY, AUGUST 28
reception of poor and miserable objects” suffering from plague. The
rest of the land was used as a mass grave. Each night, the death carts
would empty dozens of corpses into the earth. By some estimates,
over four thousand plague-infected bodies were buried there in a mat
ter of months. Nearby residents gave it the appropriately macabre—
sounding name of “Earl of Craven’s pest—field,” or “Craven’s field” for
short. For two generations, no one dared erect a foundation in the
land for fear of infection. Eventually, the city’s inexorable drive for
shelter won out over its fear of disease, and the pesthouse fields
became the fashionable district of Golden Square, populated largely
by aristocrats and Huguenot immigrants. For another century, the
skeletons lay undisturbed beneath the churn of city commerce, until
late summer of 1854, when another outbreak came to Golden Square
and brought those grim souls back to haunt their final resting grounds
once more.
CRAVEN’S FIELD ASIDE, SOHO IN THE DECADES AFTER THE
plague quickly became one of London’s most fashionable neighbor
hoods. Almost a hundred titled families lived there in the 1690s. In
1717, the Prince and Princess of Wales set up residence in Leicester
House in Soho. Golden Square itself had been built out with elegant
Georgian townhouses, a haven from the tumult of Piccadilly Circus
several blocks to the south. But by the middle of the eighteenth cen
tury, the elites continued their inexorable march westward, building
even grander estates and townhouses in the burgeoning new neigh
borhood of Mayfair. By 1740, there were only twenty titled residents
left. A new kind of Soho native began to appear, best embodied by the
son of a hosier who was born at 28 Broad in 1757, a talented and trou
bled child by the name of William Blake, who would go on to be
THE NIGHT-SOIL MEN 17
one of England’s greatest poets and artists. In his late twenties, he re
turned to Soho and opened a printing shop next door to his late fa
ther’s shop, now run by his brother. Another Blake brother opened a
bakery across the road at 29 Broad shortly thereafter, and so for a few
years, the Blake family had a mini-empire growing on Broad Street,
with three separate businesses on the same block.
The mix of artistic vision and entrepreneurial spirit would define
the area for several generations. As the city grew increasingly indus
trial, and as the old money emptied out, the neighborhood became
grittier; landlords invariably broke up the old townhouses into sepa
rate flats; courtyards between buildings filled up with impromptu
junkyards, stables, jury—rigged extensions. Dickens described it best in
Nicholas Nickleby:
In that quarter of London in which Golden Square is situated, there
is a bygone, faded, tumble—down street. with two irregular rows of
tall meagre houses, which seem to have stared each other out of
countenance years ago. The very chimneys appear to have grown dis
mal and melancholy from having had nothing better to look at than
the chimneys over the way. . To judge from the size of the houses,
.
they have been, at one time, tenanted by persons of better condition
than their present occupants; but they are now let off, by the week,
in floors or rooms, and every door has almost as many plates or bell-
handles as there are apartments within. The windows are, for the
same reason, sufficiently diversified in appearance, being ornamented
with every variety of common blind and curtain that can easily be
imagined; which every doorway is blocked up, and rendered nearly
impassable. by a motley collection of children and porter pots of all
sizes, from the baby in arms and the half-pint pot, to the full-grown
girl and half-gallon can.
 18 MONDAY, AUGUST 28
THE NIGHT-SOfl MEN 19

By 1851, the subdistrict of Berwick Street on the west side of

good, solid furniture in the entire flat. Everything is broken, tattered
Soho was the most densely populated of all 135 subdistricts that made
and torn, finger—thick dust everywhere, and everything in the great
up Greater London, with 432 people to the acre. (Even with its sky
est disorder. .When you enter the. flat, your sight is dimmed
. . . .

scrapers, Manhattan today only houses around 100 per acre.) The
by tobacco and coal smoke so that you grope around at first as if you
parish of St. Luke’s in Soho had thirty houses per acre. In Kensington,
were in a cave, until your eyes get used to the fumes and, as in a fog,
by contrast, the number per acre was two.
you gradually notice a few objects. Everything is dirty; everything
But despite—or perhaps because of—the increasingly crowded
covered with dust; it is dangerous to sit down.
and unsanitary conditions, the neighborhood was a hotbed of cre
ativity. The list of poets and musicians and sculptors and philosophers
Living in this two—room attic were seven individuals: a Prussian im
who lived in Soho during this period reads like an index to a text
migrant couple, their four children, and a maid. (Apparently a maid
book on Enlightenment-era British culture. Edmund Burke, Fanny
with an aversion to dusting.) Yet somehow these cramped, tattered
Burney, Percy Shelley, William Hogarth—all were Soho residents at
quarters did not noticeably hinder the husband’s productivity, though
various points in their lives. Leopold Mozart leased a flat on Frith
one can easily see why he developed such a fondness for the Reading
Street while visiting with his son, the eight-year-old prodigy Wolf
Room at the British Museum. The husband, you see, was a thirty-
gang, in 1764. Franz Liszt and Richard Wagner also stayed in the
something radical by the name of Karl Marx.
neighborhood when visiting London in 1839—1840.
By the time Marx got to Soho, the neighborhood had turned it
“New ideas need old buildings,” Jane Jacobs once wrote, and the
self into the kind of classic mixed-use, economically diverse neigh
maxim applies perfectly to Soho around the dawn of the Industrial
borhood that today’s “new urbanists” celebrate as the bedrock of
Age: a class of visionaries and eccentrics and radicals living in the dis
successful cities: two—to-four-story residential buildings with store
integrating shells that had been abandoned a century ago by the well-
fronts at nearly every address, interlaced with the occasional larger
to-do. The trope is familiar to us by now—artists and renegades
commercial space. (Unlike the typical new urbanist environment,
appropriate a decaying neighborhood, even relish the decay—but it
however, Soho also had its share of industry: slaughterhouses, manu
was a new pattern of urban settlement when Blake and Hogarth and
facturing plants, tripe boilers.) The neighborhood’s residents were
Shelley first made their homes along the crowded streets of Soho.
poor, almost destitute, by the standards of today’s industrialized na
They seem to have been energized by the squalor, not appalled by it.
tions, though by Victorian standards they were a mix of the working
Here is a description of one typical residence on Dean Street, penned
poor and the entrepreneurial middle class. (By mud—lark standards, of
in the early 1850s:
course, they were loaded.) But Soho was something of an anomaly in
the otherwise prosperous West End of the city: an island of working
[The fiatj has two rooms, the one with the view of the street being poverty and foul-smelling industry surrounded by the opulent town
the drawing-room, behind it the bedroom. There is not one piece of houses of Mayfair and Kensington.
20 MONDAY. AUGUST 28 THE NIGHT-SOIL MEN 21

This economic discontinuity is still encoded in the physical layout Poverty and depravity and low breeding created an environment
of the streets around Soho. The western border of the neighborhood where disease prospered, as anyone of good social standing would tell
is defined by the wide avenue of Regcnt Street, with its gleaming you. That’s why they’d built barricades in the first place.
white commercial façades. West of Regent Street you enter the tony But on the wrong side of Regent Street, behind the barricade, the
enclave of Mayfair, posh to this day. But somehow the nonstop traf tradesmen and the mechanics managed to get by in the mean houses
fic and bustle of Regent Street is almost imperceptible from the
of Soho. The neighborhood was a veritable engine of local com
smaller lanes and alleys of western Soho, largely because there are merce, with almost every residence housing some kind of small busi
very few conduits that open directly onto Regent Street. Walking
ness. The assortment of storefronts generally sounds quaint to the
around the neighborhood, it feels almost as if a barricade has been
modern ear. There were the grocers and bakeries that wouldn’t be
erected, keeping you from reaching the prominent avenue that you
out of place in an urban center today; but there were also the ma
know is only a few feet away. And indeed, the street layout was ex
chinists and mineral teeth manufacturers doing business beside them.
plicitly designed to serve as a barricade. When John Nash designed
In August of 1854, walking down Broad Street, a block north of
Regent Street to connect Marylebone Park with the Prince Regent’s
Golden Square, one would have encountered, in progression: a gro
new home at Carlton House, he planned the thoroughfare as a kind
cer, a bonnet maker, a baker, a grocer, a saddle-tree manufacturer, an
of cordon sanitaire separating the well—to—do of Mayfair from the
engraver, and ironmonger, a trimming seller, a percussion-cap manu
growing working-class community of Soho. Nash’s explicit intention
facturer, a wardrobe dealer, a boot-tree manufacturer, and a pub, The
was to create “a complete separation between the streets occupied by Newcastle-on-Tyne. In terms of professions, tailors outnumbered any
the Nobility and Gentry, and the narrower Streets and meaner houses
other trade by a relatively wide margin. After the tailors, at roughly
occupied by mechanics and the trading part of the community....
the same numbcr, were the shoemakers, domestic servants, masons,
My purpose was that the new street should cross the eastern entrance
shopkeepers, and dressmakers.
to all the streets occupied by the higher classes and to leave out to the
Sometime in the late 1840s, a London policeman named Thomas
east all the bad streets.”
Lewis and his wife moved into 40 Broad Street, one door up from the
This social topography would play a pivotal role in the events that
pub. It was an eleven-room house that had originally been designed
unfolded in the late summer of 1854, when a terrible scourge struck
to hold a single family and a handful of servants. Now it contained
Soho but left the surrounding neighborhoods utterly unharmed.
twenty inhabitants. These were spacious accommodations for a part
That selective attack appeared to confirm every elitist cliché in the
of the city where most houses averaged five occupants per room.
book: the plague attacking the debauched and the destitute, while Thomas and Sarah Lewis lived in the parlor at 40 Broad, first with
passing over the better sort that lived only blocks away. Of course the
their little boy; a sickly child who died at ten months. In March of
plague had devastated the “meaner houses” and “bad streets”; anyone
1854, Sarah Lewis gave birth to a girl, who possessed, from the be
who had visited those squalid blocks would have seen it coming. ginning, a more promising constitution than her late brother. Sarah

I
 22 MONDAY, AUGUST 28

Lewis had been unable to breast—feed the infant on account of health

problems of her own, but she had fed her daughter ground rice and
.\ -

milk from a bottle. The little girl had suffered a few bouts of illness in ‘5
her second month, but was relatively healthy for most of the summer.
A few mysteries remain about this second Lewis infant, details
scattered by the chance winds of history. We do not know her name, ‘ri.

for instance. We do not know what series of events led to her con
tracting cholera in late August of 1854, at not even six months old.
—

For almost twenty months, the disease had been flaring up in certain —3..-—
.— —
quarters of London, having last appeared during the revolutionary
years of 1848—1849. (Plagues and political unrest have a long history
of following the same cycles.) But most of the cholera outbreaks in
1854 were located south of the Thames. The Golden Square area had
been largely spared.
On the twenty-eighth of August, all that changed. At around
six am., while the rest of the city struggled for a few final minutes of
sleep at the end of an oppressively hot summer night, the Lewis
in
fant began vomiting and emitting watery, green stools that carried a
pungent smell. Sarah Lewis sent for a local doctor, William Rogers,
who maintained a practice a few blocks away, on Berncrs Street. As
she waited for the doctor’s arrival, Sarah soaked the soiled cloth dia
pers in a bucket of tepid water. In the rare moments when her little
girl caught a few minutes of sleep, Sarah Lewis crept down to the cel
lar at 40 Broad and tossed the fouled water in the cesspool that
lay at
the front of the house.
That is how it began.
.

L
 .
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•
••. •
e
. • . •. .
•
• •%.

DISEASE
MAPS • •.•
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• . . . •.• 0
• •.• • •._I
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••. •. .1 •.• 43• S

• • •
• •. •
• • •

•
•
•. : ••
• • • •0•
•
•
• I
EPIDEMICS ON THE GROUND

TOM KOCH
THE UNIVERSITY OF CHICAGO PRESS / CHICAGO AND LONDON
 CHAPTER 2
MAPPING SYMPTOMS,
MAKING DISEASE

Nobody knows how many disease maps are produced each year. There are neighbor
hood, city, state, national, and international maps of epidemic and endemic conditions
produced by agencies ranging from neighborhood activist groups and local public
health departments to state and federal health agencies. The UN, Pan-American Health
Organization, and the World Health Organization each produce annually hundreds of
disease maps. We know this because many are published in academic journals, daily
newspapers (from the Akron, Ohio, Beacon Journa/to the Times of London), general
periodicals, and of course, across the Internet. Typically these maps are based upon
the work of medical researchers, but others bring forward conditions at the fine scale
of very local health concerns, mapped realities advanced by citizens that officials
have overlooked or rejected.
1 Maps of disease and health are collected in atlases and
produced in books whose job it is to unravel the skeins of often conflicting research
conclusions about this or that health threat. Together, all these maps emphasize this
rIGURE 2.1 Peter Gould’s famous map series describes the spread of AIDS in the United States at the county level as
part of the work toward a model that could accurately predict future diffusion in U.S. communities.
to maps of patient infection in local and regional communities (Verghese, Berk, and
Sarubbi 1989). Famously, in the 1980s geographer Peter Gould and coworkers not
only mapped AIDS at the county level in the United States (fig. 2.1) but did so in a
to
manner generating the first accurate predictive model (mapped) of its spread, iden bi
U,
tifying contiguous and hierarchical elements to its pattern of diffusion (Gould 1993).
0
HIV is a retrovirus, mutating rapidly to maximize its circumstances. We didn’t know z

conclusion: what we know is dwarfed by what we have yet to learn. In that learning, retroviruses existed prior to thel97Os.
maps are, and for centuries have been, a critical medium of our studies. By contrast, West Nile virus (WNV) is almost a relief. In at least a general way we LI,

There are maps of bovine spongiform encephalopathy, for example. Bad as it is think we understand this emergent virus and its principal vector, infected mosquitoes 0
F
0
for Bossy and her bovine friends, it is worse for us in its human variant, Creutzfeldt noshing on birds and mammals. Once confined to a small area of Uganda, WNV >-
(0
Jakob disease. Its agent is a proteinaceous infectious particle, the prion, unknown migrated from Africa to North America via Romania and Israel (CDC 2001). From the 0
z
until recently (Pattison 1998), and we have little idea about how these nonnucle first U.S. case reported in New York State in 1999 (Nasci et al. 1999) through the a
U
ated, self-reproducing, crystal-like proteins propagate or work (Rhodes 1997). We end of 2007, federal Web sites posted myriad maps of WNV by state and county
do know that in 2003, a cow from Washington State discovered to have BSE was both for each year and in each year for five major species groups (birds, humans,
8 9
likely infected in Canada (CDC 2004). We know this because commercial herd mosquitoes, veterinary mammals, and sentinel chickens) (USGS 2006). Also avail N
movements have been mapped as possible disease vectors.
2 able are national maps with county data of cognate viral conditions, including St. a
F
There have been hundreds, perhaps thousands of maps of HIV/AIDS since its first Louis encephalitis, eastern and western equine encephalitis variants, La Crosse en a
Zr
reported case in North America. These range from global maps of disease diffusion cephalitis and Powassan virus (USGS 2007). C-)
 We see the virus in its host populations in the map. This is West Nile virus, the
map says. In figure 2.2 we see its progression from the 1999 index cases in New
York State. There is a slow southwest spread of the disease in mosquitoes and both
a northerly and easterly spread in infected birds. Human infections remained centered
in the area around New York but among veterinary mammals the spread is more dif
fuse. Overtime, map-to-map, we can trace the progress of the virus in its hosts and in
that tracing seek patterns of explanation. Is WNV promoted by certain climates favor
ing specific species of mosquitoes? Do specific avian migration patters explain the
virus’s spread? What is the relation of the infection in humans and veterinary mam
mals to that of the other species (Koch and Denike 2007a)? Each question generates
more work, more maps of the spatial foundations of viral interactions and spread.
For centuries maps have served in this manner, collecting and then projecting data
FIGURE 2.2 West Nile
in a manner that permits this or that disease event to be seen and then considered
Virus infects a range of
carefully. With each new disease we look more closely, map more carefully the data different species. Intro
that are also reviewed in other ways (genetically at one level, statistically at another). duced into the United
States in 1999, it spread
Emerging diseases like WNV are not all newfound threats, however. Since 1983 continuously in birds and
more than twenty-three variants of long-established conditions have emerged, mutat mosquitoes in the year
ing old familiars into new and real threats (Callahan 2006, 135). The history of their 2000. Human incidence
seems to be simple out
mapping is also a history of how we have learned to think about these conditions, come of these infections.
about how we see disease.
Cholera, for example, has been consistently mapped since 1819, a history of dis
ease construction and investigation detailed in the middle chapters of this book. The
seventh international pandemic, whose bacterial agent was a new variant, the El Tor
serotype, was first identified in 1961 and spread into this century, traveling the world
in cargo ships and with airline travelers (Salim et al. 2005).
Influenza in its many, ever-mutating forms is mapped annually. There are maps
of past epidemics and maps of current disease excursions. Practically, some map
imbalances in flu vaccine supplies—the distance between where they are stored and
where they will be most needed—to assure the maximum level of protection for a
population (Davenhill 2005). The 1918 influenza pandemic with its devastating death
toll remains for many the very definition of a potentially devastating epidemic occur
rence. For this reason, some have used it as a model on which to build predictive
maps of the effect of another, similarly severe epidemic. Figure 2.3 is one of a series
of maps that modeled the effect today of a 1918-style, killer outbreak in the Canadian
province of New Brunswick and the U.S. state of Maine. By day eighty of a pandemic
the surface of the map is largely uniform. The virus has diffused, and while there are
some spots of activity, the greatest mortality has occurred. Across the series the early
10
hot spots signaling the viruses incursion spread across the region, slowly fading un
til, at the end of the epidemic, the pattern of continuing mortality is a series of small FIGURE 2.3 Working with historical data from the 1918 influenza pandemic, New Brunswick researchers
modeled the possible effects, day by day, of a similarly severe occurrence. On day 80, shown in the map,
hillocks against the greater geography of the health of the state.
the outbreak has subsided and only minor eruptions can be seen.
Similarly, new maps proliferate of tuberculosis in all its variants: classic presenta
 tion, multidrug-resistant tuberculosis and extremely drug resistant tuberculosis. What
was a single pulmonary condition is now a family of related diseases whose members
are separately considered and distinctly named.
3 The variants share similar symptoms,
but each is caused by a different if related bacterial agent and each requires a distinct
I to be understood. Put another way, mapping is a method of assemblage within which
treatment. Current estimates are that perhaps a third of the planet’s population is in
fected with at least a latent form of one or another tuberculosis and that in the United
States alone ten to fifteen million people are affected (Markel 2004, 16).
The list goes on but the message is clear: if it is a disease we map it at every stage
of our knowing, from the first collection of symptoms across decades of investigation.
What are we doing when we map these problems and what do we learn from the
exercise? More importantly, perhaps, what is it that really we map?
MAPS AND MAPPING
Maps make arguments about disease, their pattern of incidence, and their method of
diffusion. They are workbenches on which we craft our theories about the things that
cause health to fail, imaging data collected in this or that disease outbreak. They are
not, as some argue, either mere representations of the world or simple illustrations
of work completed in other media (Miller and Wentz 2003). It is true but insufficient
to say that “disease maps provide a rapid visual summary of complex geographic
information and may identify subtle patterns in the data that are missed in tabular pre
sentations” (Elliott and Wartenberg 2004, 999). Certainly, mapping permits a visual
statement of spatially grounded data accumulated on the basis of theories whose
exposition—and mode of analysis—is lodged in the map itself. More fundamentally,
however, maps are cognitive instruments whose mode of argument and not the tech
niques of imaging is their raison d’être.
As Franco Moretti put it more generally: “Mapping it—is not the conclusion of
geographical work; it’s the beginning. After which begins in fact the most challenging
part of the whole enterprise: one looks at the map, and thinks. You look at a specific
configuration—those roads that run towards Toledo and Sevilla; those mountains,
such a long way from London; those men and women that live on opposite banks of
the Seine—you look at these patterns and try to understand:’ (Moretti 1998, 7—8;
original emphasis).
It is this visual thinking, grounded and spatial, that the map promotes. To map the
incidence of a thing is to create a shared range of experience in a manner that i not
merely descriptive but more importantly “constative’ bringing forth a meaning acces
sible to analytic address (Austin 1975). Descriptive statements report and reflect a
12
“simple” reality, while “constative” statements indicate “the circumstances in which
the statement is made or reservations to which it is subject or the way in which it is to
be taken and the like” (p. 3). This constative essence enables the map’s performative
ability to argue how a subject, in this case a recurring class of disease symptoms, is
ideas are constituted and then argued about specific experiences.
In its method of assemblage the map changes the individual and particular, trans
forms discrete rows in tables of occurrence into a common experience, an event
class whose members are assumed to be related somehow, one to another, through
the evidence of disease symptoms. In this way the individual rows of morbidity and
mortality tables are transformed in the two-dimensional plane of the map into a uni
tary thing, a single reality composed of multiple occurrences of similar attributes. By
making a map—any map—relationships are asserted between sets of phenomena
in a manner that is inherently both analytic and experimental. “The former is about
specifying the content of the ‘known the latter about putting together elements and
controlling them to create new phenomena (or old phenomena in new ways)” (Pick-
stone 2000, 12).
The map’s intellectual service lies in this conjunction of analytic presentation and
experimental argumentation in a visual exposition. The elments assumed to define
this or that disease state, and this or that place of occurrence, are spatially arranged
in an assemblage proposing that a congress of symptoms (cramps, dehydration, diar
rhea) is one thing (amoebic dysentery) or another (cholera) whose reality we seek to
document as a single condition. We do this in the hope that we can limit, or better,
eliminate, its presence in our communities. By including in the map environmental ele
ments that may be related causally (air temperature, food outlets, sewer lines, water
sources, and the like) we create a medium in which their likely relation to this or that
illness is asserted in a manner inviting systematic assessment.
In this the map is both the subject, an evidentiary statement in its own right, and
an object on which ideas are played out in the two-dimensional plane of the map. In
this way mapping produces a type of knowledge, one rooted in a relational space,
UI)
which has been critical to disease studies for centuries. This is not a characteristic U
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unique to disease mapping but an attribute of mapping generally. As David Turnbull
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argues, “Maps are the paradigmatic examples of the kind of spatial knowledge that z
is produced in the knowledge space we inhabit. Not only do we create spaces
by linking people, practices and places, thus enabling knowledge to be produced, UI)
we also assemble the diverse elements of knowledge by spatial means” (Turnbull 0
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2000, 89). >-
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All this is to say mapping is an experimental system that is at once graphic, nu (3
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merical, spatial, and theoretical. “Experimental systems are the units within which
the signifiers of science are generated. They display their meanings within spaces of
representation, in which graphemes, that is, material traces such as fraction patterns
13
or arrays of counts are produced, articulated, and placed, displaced, replaced .
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scientists create spaces of representation through graphemic concatenations that U
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represent their epistemic traces as engravings, that is, generalized forms of ‘writing”
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(Rheinberger 1997, 2). U
 This particular experimental system employs the map surface as a type of inscrip
Toronto
tion device, a technology that embeds in the map page a set of arrangements for Los Angeles
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performative, concrete, and visible. “It is a set of arrangements for converting rela
tions from non-trace-like into trace-like forms:’ things we can see as specific types of
relations between elements in the map are assessed (Law 2004, 23—29).
Mapping does this by fusing signs upon the map surface under the control of a
series of codes that structure the graphic surface and thus order the data presented.
These codes have a logic that permits a coherent argument to be articulated across
the map (Wood and Fels 1986). Map symbols organized by these codes create at a
concrete level a “geographical matrix” in which a set of events is considered on the
basis of relevant, subject-specific data accumulated to advance an argument or test
a hypothesis based upon it (Chrisman 1997, 24—26). It is this matrix that is constan FIGURE 2.4 The map of travel from Mexico City to other world
cities was used in a project attempting to determine the number
tive, asserting potential linkages among mapped attributes located on the page in of travelers required to spread Hi Ni influenza in 2009.
relation to each other. Maps thus carve specific territories from the blank space of
an empty page, creating ranges of related elements at a specific scale (international,
national, regional, and local). On the map page the rows of data, the elements of the the map proposes that this world city space is linked by air travel carrying people from
matrix, take visual form as a single reality (this is. cholera, cancer, influenza, WNV,
. . one city (Mexico City) to many others.
and so forth) in a manner that permits questions to be asked and theories first to be Fourth, the numbers of travelers included at each point in the map insist we can
generated and then tested. precisely calculate the astonishing degree of traveler between one city, Mexico, City,
and other cities around the globe. Totaled in the map are 2.3 million passengers who
flew in early 2009 from Mexico City to 1,918 cities in 164 cities as far flung as San
H1N1 INFLUENZA: THE PANDEMIC tiago, Chile, Shanghai, China, and Johannesburg, South Africa. We trust the numbers
The 2009 H1N1 influenza pandemic is an example of the service of mapping in in the map to the extent that we trust its source, IATA. We trust the researchers in part bi
U,
the address of public diseases. In an article on the diffusion of the disease from its on the basis of their vehicle of publication, the prestigious New England Journal of
U,
Mexican index case, a group of Canadian researchers published a map in the New Medicine. The creation of a bureaucracy capable of this type of record keeping, and
0
England Journal of Medicine describing its relation to air travel volumes (fig. 2.4). the method by which bureaucratic data are considered and reported, is the subject z

Using International Air Transport Association (IATA) data, the goal was to identify the of the middle chapters of this book.
threshold of travelers (the threshold of travel) required to spread the disease from The point of the map is not IATA’s record-keeping ability or even the vast human LI)

one city to another (Khan et al. 2009). In the map major cities around the world are migrations it chronicles. They are the backcloth that supports the mapped image 0
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identified by name, and with bars calculated to present the number of travelers arriv and the research it presents. The map is about a new version of influenza, a disease >-
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ing from Mexico, the origin of the new outbreak. Implicit in each bar is the assumption we have known for millennia, and its diffusion from Mexico City to everywhere. . . .
0
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that cities receiving Mexican air travelers also were cities where Hi Ni influenza could In reading the map we reflexively translate air travel into a map of influenza diffusion. a
a
or would soon be found. We do this because the map is in an article on this new variant of a well-known virus
Embedded in the map are a series of ideas. First, the map asserts a single space, a and because the article, the “paratext” (Wood and Fels 2008, 4) in which the map
14 15
shared world. We take this for granted but its construction was an enormous achieve is embedded, tells us to. We see the map this way because we think of influenza as
rtJ
ment of the sixteenth and seventeenth centuries (as chapter 3 will argue). Within this a disease transported by humans. Finally, with all this behind it, the map makes this ‘4
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space the map creates an urban sphere, a collection of cities among which travel proposition: if this virus travels along human pathways then it should be possible to a

occurs. Again, we take for granted this fact, another boon of those centuries. Third, calculate the amount of travelers required to transmit this virus from city to city. U
 Each virus has its own level of intensity. Some require more exposure than others 2.5B

before its introduction takes hold in a community. In this case, in 2009, this virus re
quired 1,400 air passengers to transplant the virus from one city to another (Khan et
al. 2009). The map of travel volumes is the basis for work that can be done modeling .2

diffusion over time (add dates of first cases in each city) and of the relation between
diffusion first to larger rather than smaller cities (the gravity” of large bodies, it’s
called). The H1N1 map raises the potential for studies using these ideas, showing us
the data in a way that invites further exploration.

WEST NILE VIRUS: THE U.S. EXPERIENCE

I
What is mapped is not this or that thing, the discrete datum, but things together. These
things-together, lodged in data sets, create factual statements that are propositional
in nature. There is nothing surprising in this. Propositions are statements affirmed 2000 2001
4 All evidence is propositional, its validity accepted or
or denied by their predicates.
rejected on the basis of prior assumptions that are the backcloth out of which the
fabric of an argument is constructed (Neta 2008, Williamson 2000). This means the
data we use in our deliberations are conditional, “IF this is true and accurate then.
Consider figure 2.5, a set of maps of humans infected with West Nile virus in the
United States from 2000 to 2004. Each map separately asserts the presence of a
viral condition in citizens resident in a specific geography during a specific time pe
riod. Residence is defined not by home, street, or city, but by county. The rationale
for this jurisdictional frame is simple: the data are derived from reports submiffed by
county health officials reporting WNV incidence to Centers for Disease Control and
Prevention agents collecting data on this virus (Hayes et al. 2005). The maps are not WNVnbn,n2002
WNV!nhurna202002 WN h(,,,.a,,,. 2003

of WNV but of reports of WNV that were collected by local and state officials and w
On
reported to national officials who brought the data together. 2002 2003 U
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First, the maps each propose a geographic thesis: that is, (a) there is a distinct
region, the continental United States, in which (b) the presence of this virus can be z
2.5E Canada
appropriately studied. This area is divided into counties that are the reservoirs of data
to be considered. Were this untrue the maps would have a different shape. A second On
0
class of propositions asserts a class of events, viral infections, that can be definitively I—
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categorized at the resolution of counties and which occurred during a specific time
U)
period. Each map then insists that all events within a class of occurrence (viral infec 3.)
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tion) located in the map can be considered a single entity, creating an event c/ass 0
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FIGURE 2.5A-E These maps show the yearly NwO,Ie..,o
out of tens, hundreds, or thousands of things. The argument that results is this: if this
-

½
progress of West Nile Virus in humans after Mexico
thing (WNV) in this county is the same as that thing (WNV) in that county, then both its 1999 introduction in the United States. 17
16
are the same thing, together. Through identical symbolization and consistent lettering All are based on data collected and by the
(3/
Centers for Disease Control and published
the map asserts the consistent presence of this thing, WNV as a single event occur in table and map form on federal websites. U
WNV,3h[3,1, 2004 I
ring across continental U.S. counties. a
I
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2004
 The repetition of these propositions, map by map, gives to each (and to the map
set) added weight. We see in the maps the progress of the virus. In the seeing, the
maps propose a way of thinking about events (in this case, WNV in humans) occur
ring in jurisdictional boundaries assumed to be the appropriate scale at which disease
data can be collected, posted in the map (and its database), and trusted. In these
maps, that scale is that of the United States, its resolution that of U.S. counties in
which cases were reported. Individually and together the maps and their data assert
the broad geography of the continental United States and its local political entities as
both existential realities and as appropriate vehicles for WNV study. We accept this
as real and relevant geography even though northern and southern boundaries are
wholly porous political fictions that exist without a physical geographic referent.
These borders are not relevant landforms (not like the oceans to west and east,
for example) and not necessarily relevant to any study of bacterial or viral incidence.
Insects, birds, humans, and trade goods all constantly travel across them, carrying
the bacteria and viruses that become disease. And yet the map insists its geography
is sufficient; on the basis of that posting we assume the appropriateness of U.S.
county, state, and national borders—bureaucratic artifacts with little natural rationale.
The map says the borders are as real as mountains and .we accept that. The map
. .
says “we’ll see WNV in this frame at this resolution” and we accept that, too, without
reflection. Were it otherwise, it would be mapped differently. We might then include
Canadian and Mexican WNV to transform the American epidemic into a North Ameri
can pandemic.
Each dot in the map posts not a case of WNV but a U.S. county in which West
Nile virus was reported to local health officials. It does not say how many cases
occurred or the percentage of the population that were infected, only that one or
more persons were diagnosed with this condition in a certain time period. We could
use graduated symbols to show the number of cases, grouping them in classes
(1—50, 51—150, 151 —300, more than 300, for example). And we could calculate the
incidence per, say, one million persons. These statistical refinements, which have
become standard, were part of a revolution in medical mapping and statistics in the
nineteenth century (and will be described in later chapters).
The map of WNV activity in 2000—the virus was first introduced to the United
States in late summer of 1999—shows a very limited number of cases in the New York
City area. In 2001 the virus progressed contiguously, spreading out down the eastern
seaboard to Washington, D.C., and then jumped—there is no better word—to Florida.
There is little activity in the Carolinas or Georgia where one on the simple basis of
proximity one might have expected it. By 2002 WNV was rampant across the Midwest
18
ern states as well as the eastern seaboard. In 2003 the virus spread more slowly and
contiguously, from the Midwest to the Southwest and into California. Its travel north,
to either Washington State or Maine, seems to have been inhibited by something. By
2004 incidence was declining and the level of activity seemed diminished.
We trust these maps not because we trust the data collectors in this or that U.S.
county (we know nothing about them), or because we trust the anonymous mapmak
ers. Assumptions of validity rest upon our trust in the CDC and its system of data
collection. We believe in the maps to the degree we believe in the CDC and its com
petence. We also believe in the integrity of the continental United States, a political
reality defined by borders drawn on the map but not the land. Similarly, we believe in
the integrity of U.S. counties as catchments for bureaucratic data. Simply, the geogra
phy posted in the map is appropriate because the CDC (and scores of other federal
agency and maps) says it is so. For the purpose of American disease studies it ap
pears irrelevant that WNV also attacked thousands of people in Canadian provinces
and Mexican estados. After all, if it were important it would be in the map.
There is nothing magical in this. It is simply to say that maps aggregate facts
in a manner that creates evidentiary classes in service of an idea. The evidentiary
value of any one datum, any single row in a table of incidence by U.S. county is as
sumed to be the same as any other. Data from Cerro Gordo County, Idaho, Sonoma
County, Washington, Worcester County, Massachusetts, and Yonkers, New York, are
assumed to hold an equal truth value; contributing to the whole. If this were not true, if
points of mapped fact are disputed or plain fiction, the mapped class dissipates into
conjecture. It is not that ‘all maps are wrong:’ as the saying goes, but that all maps
are as right or wrong as the data collected on the basis of the assumptions made
about its importance and validity.
The utility of all data is bounded by our confidence in it and the assumptions we
seek to argue on its basis. What makes mapping unique, and a uniquely valuable tool,
is that it anchors the isolated, evidentiary fact—an entry in a table of incidence—in an
event class at a location. The map then builds from its fields of common incidence to
assert their relation. If this was WNV in continental U.S. counties in 2000 and this bJ
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was WNV in U.S. counties in 2004, then the epicenter of the viral attack expanded U
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westward from New York in those years. The central argument of the map space as
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serts both the validity of data classes and the importance of their juxtaposition. z
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A LOCAL EXAMPLE 0
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West Nile virus was a national concern and one heavily studied (and continuously
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mapped) by entomologists, epidemiologists, public health experts, and veterinarians. 0
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It may be easier to see how disease mapping works—intellectually and practically— 0
0
in a larger scale, more common example of a simple, local disease outbreak. Con
sider an outbreak of severe diarrhea that occurred in metropolitan Vancouver, British
19
Columbia, in 2000. As an example it serves admirably because there was nothing
N
unusual about it. It was one of scores—probably hundreds—of similar outbreaks in Si
I-.
that year in North America. If it is special it is only because data about this outbreak
I
were made accessible.
5 U
 West Vancouver North Vancouver Went Vancouver North Vancouver Welt Vancouver North Vancouver
West Vancouver
North Vancouver
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Vancouver . .
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Vancouver Burnaby Coquitlain .i
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Richmond Surrey
Richmond
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: Richmond
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Delta Delta
Delta

• laolated diarrhea case. • r• • suspected sources

FIGURE 2.6A-D Maps of Greater Vancouver and the elements of a local diarrhea outbreak in 2000. A,
Greater Vancouver; B, isolated cases; C, hospital-reported cases in the Greater Vancouver area; D, sus
pected sources. Severe diarrhea, often but not necessarily from food poisoning. is one of the most frequent
type of outbreaks faced by local public health departments.
Figure 2.6A is a map of Greater Vancouver, an area containing about 2.3 million
persons in Canada’s westernmost province. The map is an arrangement of lines
symbolizing streets within the political boundaries of a region bounded by the sea
and its intrusions upon the land, the creeks, inlets and rivers that are also mapped. It
prior to treatment. Each dot symbolizes an individual case, asserting, “a person with
these symptoms reported living here’ Their shared mapping transforms the individual
cases into a single disease event constructed of a range of cases whose commonal
ity is assumed to outweigh any differences that might exist between members of the
class of mapped patient homes.
The map implies accuracy and a completeness it cannot deliver. To protect patient
confidentiality, all addresses in the official database were randomized to within two
blocks of their actual location, creating a set of cases each of whose members is bi
U,

was created using a computerized mapping program, ArcGIS 9.2. With the program inscribed near to but not at the precise coordinates of a patient’s home. Nor is the UI
U,

came prepared files of geographical data we accept as real (the boundaries of na
tions and local jurisdictions, of mountains, and rivers, and the like).
We projected elements of this data set onto the map page as Greater Vancouver.
Different mapping would create a different city, perhaps one of sewer and power lines
completeness of the map guaranteed. Each dot is a case reported to local health of
0
ficials but, almost certainly, there were additional but unreported cases. Some people z
experiencing only moderately severe diarrhea may not have sought hospital treatment
but self-medicated in their homes. Others may have consulted a family physician U,

but without political boundaries. While the buildings and homes we know exist on the whose treatment program was not reported to officials. Even in a small database like 0
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streets are absent in this map they could be added if we thought them important to this at least one or two cases were probably misreported, entered incorrectly into the >-
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this project. We could populate the map with economic data, elevation contours, or database with a keystroke error. And even if all were reported without error, there were 0
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population housing density.. whatever seemed relevant to the problem at hand. So likely patients treated at a hospital whose location was not reported because they were 0
0

this Vancouver, created for the problem of understanding a set of cases (persons re
porting severe diarrhea to hospital officials) is different from, say, the Vancouver pro
20
duced in a Google map created for a tourist seeking local restaurants or museums.
visitors without a local address or homeless persons with no fixed address.
A single case, or two, or even three in dispersed areas of the region would create
a set of cases that we would not care about. In figure 2.6B, for example, two cases of
21

nj
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During the outbreak health officials registered sixty-one cases of hospital-treated persons hospitalized for severe diarrhea are imagined. One is in the suburb of Rich UI
I
diarrhea for which home addresses were reported. In figure 2.6C, each of these mond, the other in Surrey. They are widely separated in the space of the map and, we 0

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cases is located in the map near the home address the person gave to hospital staff assume, therefore in the Greater Vancouver regional district that the map presents. L)
 Hospitals frequently see patients presenting with severe diarrhea, typically from food
poisoning, and no epidemiologist would worry about two cases so dispersed within
a single time frame.
But in figure 2.6C we have a lot of cases and there seems to be a clustering of Noflh, Vancouver

them. In fact, there are several clusters. Nothing in this figure says anything about
what caused the patients’ distress, only that it was reported at hospital. A range of
agents can cause severe diarrhea, some of them inhaled (classes of airborne poi
sons, for example) but many more of them ingested. Since Robert Koch identified
the cholera bacillus Vibrio cholerae in 1883, and Theobold Smith named the salmo
nella bacillus Salmonella choleraesuis in 1885,6 we have come to assume diarrheic
outbreaks most commonly result from ingesting tainted food or water contaminated
•
with one or another family of bacteria. On the basis of this assumption, two theories .
Surrey

of this particular set of cases were discussed in the summer of 2000. First, it was
feared that local sewer lines under construction in the Vancouver suburb of Richmond Defta Delta
might somehow have contaminated local drinking water. Second, it was thought that . •uu_•
• .sepu,5.d .055.
• suspect food sources 1260 bun.,.
contaminated food products sold by one or more local food outlets might be the • hospitareported diantrea cases
5—”

source of the agent causing the class of diarrhea symptoms. Both these ideas have
histories grounded in nineteenth-century disease studies and are discussed in later
chapters of this book.
Sewer line construction was localized in Richmond while in the map the diarrhea
outbreak extended north into Vancouver, south into Delta, and east into Burnaby
and Surrey (fig. 2.6A). But were sewers the sole source of the problem, experience
suggests more people in Richmond likely would have been affected and fewer peo
ple elsewhere. We know this because we’ve seen it before. The mapped argument,
based on a simple visual examination, did not support the idea of a sewer contamina
tion as likely and is not included here. To consider tainted food as a source meant bJ
LI)
considering products from all the food outlets where the sixty-one hospital-treated 4
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patients had eaten in the eight to twelve hours prior to the onset of their symptoms.
0
Local health officials gathered that data, critical if these were, indeed, cases of food z
poisoning. As a group, diarrhea suffers reported eating or ordering food from one 4

of twenty-one food outlets, restaurants, and stores offering a variety of cuisines and FIGURE 2.7A-C Combining maps of both U)
reported cases of severe diarrhea and food
sale products. These are mapped separately in fig. 2.6D. In the map, their common outlets where patients had eaten (A) permit
0
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symbolization—a blue square—made of all a single class: suspect food outlets pa ted the idea of a food source as the origin of >-
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tronized by one or more of the diarrhea patients during the outbreak. the outbreak to be tested using buffers (B)
0
and surface analytics (C). z
By merging the maps of diarrhea patients and of where at least one member of 0
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the patient class had eaten or purchased food (figure 2.7A) we advanced a set of 4

assumptions. First, that one can describe an area called Greater Vancouver within Third, the map proposed that food outlets patronized by these persons could be
22 23
which this outbreak occurred (if it is accurate and complete, then it is the area within identified and similarly located (if a diarrhea patient ate or purchased food at a place,
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which, and only within which, these related events occurred). Second, that a class of then it was a place in this set). U
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diarrhea patients reporting to hospital could be considered members of a single dis Accepting these propositions for the purpose of testing, we then made a meta 0
4
ease class (/f these cases are the same thing, then we can consider them together). argument based on them (Wood and Fels 2008): if these reported diarrhea cases U
 (red dots) have a similar source in a contaminated food product (blue squares), then
r whose product was sold by local suppliers to a number of area restaurants. It was
proximity between members of the two sets will reveal a causal relation between
them. The idea that geographic proximity might imply causality is itself a proposition,
a “thing” whose validity is based on prior assumptions and whose history in medicine
is told later in this book.
Sometimes (although rarely) mappings like these reveal one and only one possible
source. You can look at the map and say, “This is itl More commonly the result is a
map like figure 2.7A in which no single, suspected source (or collection of sources) is
clearly indicted. A coworker, Ken Denike, and I later carried out two types of analysis
to demonstrate how a relationship that was not immediately evident in the map could
be uncovered (Koch and Denike 2007b). First, we drew overlapping buffers (circles)
around individual food outlets in a way that allowed their combination, building suc
cessive circles until we had two “superbuffers’ each with its own epicenter (figure
2.7C). We counted the cases in each and found the southern buffer was the one with
by far the most cases and that a small number of food outlets were at its center. In
this way we identified a subset of suspected sources that, on the basis of proximity,
became “prime suspects” as the origin of the outbreak.
In another, more sophisticated test, we used an analytic combining surface density
(kerneling) and a measure of proximity between cases and nearby food outlets (near
est neighbor analysis). In the first case the goal was to identify areas with the highest
density of cases. The assumption was that the source of the outbreak would likely be
centered in the area where disease incidence is greatest. Using the “nearest neighbor
analysis:’ we calculated the distance between each reported diarrhea case and the
nearest food source on the assumption that the source would be near the most cases
that were closest to a food outlet. Combining these sets created a new space in which
the density of cases was simultaneously mapped in a metric that relates food outlets to
nearby diarrhea cases. In this manner the incidence of disease was generalized across
the surface of the map and the dots of individual incidence became irrelevant except as
data permitting a precise argument about intensity and density to be inscribed in the
map. The second approach (figure 2.7C, which shows the density gradient) identified
a very small set of suspect food outlets in the southern buffer.
In this map we noticed a north-south bias to the data (it’s pretty obvious) and
upon testing, there was indeed a narrowly oval, north-south, elliptical pattern to both
data sets, but especially to the location of suspected food sources. This “deviational
ellipse” suggested—because we had seen it before—not a single stable origin point
but one that traveled, something or someone moving across the range of food out-
lets. Because Vancouver is the most densely populated municipality in the region we
24
were not surprised to see a spike in the central part of the city where the northern
buffer’s epicenter had been. Inserting into the map the highway and road system for
metropolitan Vancouver showed the food outlets were almost all clustered along
a very few north-south arterial roads. One of the suspected sources was a bakery
later discovered that the bakery used raw eggs in its custard products. Richmond of
ficials tentatively identified that bakery as the origin of the outbreak, and its products
the source of the hospital-reported diarrhea cases.
7
A provisional report on the outbreak by British Columbia Centre for Disease Con
trol researchers was published in the Canada Communicable Disease Report in
October 2000; a final, definitive report was published several years later (Strauss
and Fyfe, 2005). Those reports took so long to produce because they required bacte
riological testing of patient stool samples and of foods from suspected sources. The
result identified the bacterium Salmonella enteritidis as the agent whose source was
the pastry product sold by truck across the lower mainland. Just as the map promised
completeness it did not deliver; so did the bacteriology. Samples for all sixty-one per
sons were not tested, only enough were to assert with statistical confidence that the
majority of the cases were caused by this single agent. Nor was every possible food
product tested, only those that seemed most likely. That one or another of the sixty-
one diarrhea suffers may have eaten another, contaminated food product elsewhere
was possible but, in light of the general report, inconsequential. Like the map, the
bacteriological work proceeded on assumptions of commonality and completeness
that was necessarily limited.
This type of mapping goes on all the time. Often, there is no bacteriology or virology,
no handy laboratory to identify the specific agent and its source. In those cases the
mapped study is the only way an outbreak can be quickly investigated. A recent survey
of CDC reports of suspected food-related diarrhea outbreaks in the United States
found that “in 64 percent of all food-related outbreaks in the U.S. state and local health
departments failed to isolate the specific bacterium or virus responsible; the cause
was officially listed as unknown” (Hargrove 2007, 30). Without such testing, one only Cdi
C,,
has mapping that may point to the origin of an outbreak but cannot clearly identify its Cdi
U,
agent. Bacteriology, where available, may identify the agent of an outbreak and thus
(7
confirm (or disprove) a theory of the disease’s likely source identified in the map. z
These maps of food poisoning and those of West Nile virus seem to be of a
similar nature. They use points and the mapped geography of the space in which U)
disease has occurred. In this case the purpose was to apply a well-accepted theory 0
I—
2
of a disease, one whose conclusions could be tested through bacteriology. For this >-
U,
we did not need population denominators or more sophisticated statistics. The maps C-:,
z
of West Nile virus began in a similar manner and revealed what appeared to be a 0
a
more complex pattern of multispecies incidence that proposed a new idea about the
spread of that virus. While the diarrhea outbreak maps were hypothesis confirming,
testing an idea based on experience, the West Nile virus maps were hypothesis
25
r’J
II
generating, using patterns of spatial incidence to propose a human vector based on Cdi
I
travel and trade. For West Nile virus and its finer resolution data, the mapping was a
I
theory applying, and thus required different types of proof in its application. C--)
I
 THREE QUESTIONS
Where is it?
These are commonplace, mundane examples. But things that are mundane and com
mon are not necessarily simple. A series of complex things were required before •1:ILr1I TRANSMISSION
these cases of severe diarrhea could be transformed into a bacterial disease whose
BODY4----” WORLD BODY 4----f WORLD BODY 4----t WORLD
source was traced to a local bakery. In the map and in the laboratory the study of • Internal • House • Ingested • Food • Organ • Place
(headache) • City • Inhaled • Water to organ to place
these cases rested upon the application of a scientific ideal about the nature and • External • Region • Contact • Air • Body
construction of truth that came into being in the seventeenth century in the con (gunshot) • Every Soil, to body
where other
tested worlds of Robert Boyle and Thomas Hobbes (Shapin and Schaffer 1985).
Boyle’s construction of truth as a testable proposition whose results are replicable
and judged by an informed jury of the knowledgeable underpins the assumptions of What is it?
commonality, completeness, range, and testability that were critical to the diarrhea
study (Shapin 1994). DESCRIBE
In our mundane case the enterprise rested upon an idea of disease as a test
BODY±-WORLD BODY ‘*--- WORLD CLASSIFY-NAME
able thing (1) for which accepted protocols (2) of data accumulation (3) and ar • Fever • Static • Cardiology • Atmospheric • Animalcule
gumentation, (4) have been established and are accepted. The analysis required a • Humors (local) • Gastro- (Miamatic) • Bacteria
• Pain • Dynamic intestinal • Climatic • Miasmatic odor
method of visualization with which the disease outbreak might be imaged in relation • Tumor (portable) • Humoral • Geological • Virus
• Wound • Orthopedic • Other
to suspected food sources. In the process of “seeing” part and whole, the diarrhea • Etc. • Pulmonary
• Etc.
cases became a single range of spatially located incidence set in relation to the food
sources that class of persons patronized prior to their severe diarrhea. In the end, the
FIGURE 2.8 Asking where a thing is and what it might be are intimately related attempts to define the nature
map becomes a thing of its own, at once a statement of occurrence, a theory of what
of a condition and its means of address.
caused it, and a testing field for that theory.
So many things had to be in place before three basic questions could be asked
about the diarrheic symptoms of patients in Greater Vancouver in the summer of
We often name disease after the location where it first manifested. We have, for
2000. These are the questions always asked of symptoms that affect the bodies we
example, the nineteenth-century “Asiatic cholera” that had to be distinguished from
inhabit, the means by which those symptoms become things that can be named and
“English cholera:’ the former originating in India while the latter was common in the L,J
treated: “Where is it?” “What is it?” and “Who is responsible for it?” All three are U,
summer months in Great Britain. There is West Nile virus, born in Uganda but found U
related, one to the other, part of the assemblage with which we structure our thinking U)
as well in Romania and Israel; and the Hong Kong flu variant, first identified in, of
about illness and its investigation. In a very real way, these questions become the 0
course, Hong Kong. Sometimes the origin is a kind of flag of convenience in which z
cognitive landscape, the “mental space” within which disease is produced from the
politics overrides geography. Spanish flu, for example, was born in a U.S. military
symptoms of sufferers. At the least, they provide a convenient structure within which
camp at Fort Riley, Kansas, before being exported to the European war theater in U,

the often-messy realities of disease study can be made clearer.

World War 1.8 If a condition is epidemic or pandemic a critical element of its knowing 0
I—
0
is its origin as well as the specific local source. Separating origin and source has
U,
taken us several hundred years of thinking. 0
z
What and Where To understand this or that disease the question becomes where it might be in the 0
0
“To name a state is indeed to put it in legible order, to interpret it according to visible body. Is it an internal complaint (such as breathing problems, headache, or stomach
symptoms—and often, naming a condition is a way of establishing a diagnosis (Arikha pains) or the result of external injury (like a gunshot, knife wound, or penetrating ar
26

I
2007, 277). Naming requires both a “what” and a “where:’ To think about location row)? If it is an internal problem what is the organ most effected? Did it begin in the
is to consider three related elements: origin, source, and the mode of transmission home, the neighborhood, the city, the region, or is it somehow everywhere at once?
from here to there. Thinking about geographic and internal origins influences our thinking about sources
 of the symptoms that affect us: was it inhaled (pneumonia), ingested (diarrhea), in
troduced through contact (poison ivy rash) or perhaps always there, latent in the
person’s genome, or in classical medicine, his or her humoural makeup? If inhaled,
what in the air made us ill and if it is ingested what in the food or water caused this
complaint? And perhaps most importantly, is it a static and unchanging agent unique
to one place (or one family) or is it mobile and dynamic, moving from place to place,
infecting populations as it moves?
“What” and “where” are collaborating elements of the same question. “What”
describes the symptoms that result from its influence on the body, wherever it origi
nates. Is it a fever, a humour (the pus of yellow bile, the darkened stool of black bile),
the pain of a ruptured appendix, or the hard nodule of a cancerous lymph node? Is
its source local or imported, unique to a few or a complaint common among many?
Its description determines how we categorize it, seeking an agent that may be ad
dressed experimentally and therapeutically. If it is in the heart it is cardiology; the gut
it may lie with the patient and not the physician or society. But if the disease is perva
sive and many are affected, then individual responsibilities rarely serve as a sufficient
explanation. Treatment and ultimate prevention become a communal affair, a task for
society at large. In the Vancouver example the patients were blameless and responsi
bility assignable in part to the local bakery whose cream custards were the apparent
source of the outbreak. But the local baker bought supplies from wholesalers and
they carried a predicate responsibility. Ultimately, the final responsibility rested with
the hospitals that treated the patients and the health agencies that in theory but not
always in practice assure restaurants and food producer practices are safe.
THAT CURIOUS THING
These questions are an integral part of a process of knowing slowly constructed over
centuries to permit the study of the conditions that affect our populations . a way
. .

gastrointestinal, a broken bone is orthopedic, and onwards. All this ultimately permits
the symptoms to be named and a disease constructed in a manner that permits the
practical question: what do we do about it?
The “what” and “where” influence our thinking toward the condition and responsi
bility for it. If the origin lies in individual lifestyle (gluttony, for example), the answer to
What to do about it?
of thinking that was neither inevitable nor intuitive. One may construct this history in
a variety of ways, taking any of several points in time as a beginning. The question I
began with is: when did we first begin to see disease in a certain way, to visualize its
reality in populations as well as individuals? The answer to that question is the sub
ject of the next chapter’s brief review of the sixteenth-century marriage of intellectual
and technological advances. It was in this time that Western societies first presented
body and world as spatial, visual realities amenable to a type of critical study. Seeing
changed everything, contributing to the backcloth of medicine and science in a way
that was fundamental.

RESPONSIBILITY
bJ
INDIVIDUAL 4 CLINICAL - - SOCIAL U)

• Lifestyle • Drugs • For environment LJ

U)
• Diet • Hospitalization • For health resources
• Excercize • Rehabilitation • For travel restrictions 0
z
• Hygiene • Surgery • For trade restrictions
• Profession
U)

0
I
0

>-
TREATMENT PREVENTION (I)

• Free clinics 0
z
MEDICAL • Food SOCIAL a
Social inspections • Medical
0

• Hospitals
• Vaccinations
28 29

FIGURE 2.9 Knowing where it is and what its symptoms are permits a response—medical and public—to
UI
a disease event. I—
a

L)

CHAPTER 10
CHOLERIC BROAD STREET:
THE NEIGHBORHOOD DISEASE
“The most terrible outbreak of cholera which ever occurred in this kingdom:’ Snow
wrote in the second edition of On the Mode of Communication of Cholera, “is prob
ably that which took place in Broad Street, Golden Square, and the adjoining streets:’
“Within two hundred and fifty yards of the spot where Cambridge Street joins Broad
Street, there were upwards of five hundred fatal attacks of cholera in ten days’ (Snow
1855a, 38). While struggling to complete his South London study, and with a side
trip to Deptford to investigate a local outbreak reported there, in the late summer and
early fall of 1854 Snow would simultaneously seek to use this outbreak to prove his
theory.
As a young apothecary Snow lived on Firth Street, a few brief minutes by foot from
the intersection of Broad and Cambridge streets. It was there he cared for patients
while studying for his medical degree, there that he wrote his first professional pa
pers. It was on Firth Street in the 1840s that Snow carried out his seminal work on
anesthesia. In the early 1850s, as his income rose with his fame as an anesthesiolo
gist, Snow moved to more fashionable quarters on Stanwick Street at the southern
end of Regent Street near Piccadilly. That a cholera outbreak of such fierceness
would occur in Snow’s old neighborhood must have seemed to him a personal chal
lenge, if not a cosmic insult.
ST. JAMES, WESTMINSTER
192
Once one of London’s fashionable neighborhoods, St. James was a haven for those
who abjured the busy world of Piccadilly Circus. In the mid-eighteenth century, it had
been home of the family of young William Blake, the future poet, who returned there
in his late twenties to open a printing shop (Johnson 2006, 16—17). Old money disap
peared in the early nineteenth century as the stately townhouses were broken up into
apartments to accommodate the rising population of immigrant workers from Ireland
and from the British countryside. By the time of Charles Dickens, Golden Square it
self was sufficiently diminished to serve as the shabby setting in Nicholas Nickleby.
The beginnings of this transformation can be seen in figures lOlA and 10.1B,
maps of St. James in 1720 and 1750 from the British Library’s Crace Collection.
In the 1720 map are the “pest-house fields,” lands acquired in 1665 by the Earl of
Craven to provide a place where those suspected of plague, or in whom symptoms
were manifest, could be housed. On the land were “thirty-six small Houses, for the
Reception of poor and miserable Objects afflicted with a direful Pestilence)
. . .
(Porter 1999, 129). The creation of pest-houses was seen by Lord Craven and
more generally the Privy Council as one way to isolate and thus contain the dis
ease. Because of the approximately 30 percent mortality there was also a burying
ground for plague victims whose interment was often barred from otherwise ap
propriate cemeteries.
By 1750 the land on which the pest-houses stood had been reclaimed by mer
chants who plied their wares at the Carnaby Market. In the nineteenth century the
market lands were transformed into housing, and the Poland Street workhouse was
erected on the burying place of the 1665 plague epidemic victims.
As population grew, income levels fell until, by 1851, St. James, once a refuge
of the upper class, had become a working class neighborhood with 432 people per
acre, the most densely populated of all the 135 registration subdistricts in Greater
London (Johnson 2006, 18). While in Kensington there were an average of 2 houses
per acre, in the heart of St. James the density was 30 houses per acre with, accord
ing to the 1851 census, an average of 10 persons per house (fig. 9.6A). To accom
modate this social transformation the area was physically reformed as well. Regent
Street was constructed at the district’s western border to separate the streets of the
working population from the upscale homes of Mayfair. New buildings, commercial
and residential, populated the old pest-field. It was in this area that the 1854 cholera
I—
outbreak began. bi
LI
“I requested permission, therefore, to take a list, at the General Register Office, I—
of the deaths from cholera, registered during the week ending 2nd September, in the
0
subdistricts of Golden Square, Berwick Street, and St. Ann’s Soho, which was kindly
granted . .Eighty-nine deaths from cholera were registered, during the week, in the
.
U
LI
three subdistricts .on proceeding to the spot I found that nearly all the deaths had
. .
0
taken place within a short distance of the pump” (Snow 1855a, 39). “The pump:’ I
LI
, was located at the intersection of Broad
one of more than fifteen in the study area
1
193
and Poland streets. Here, Snow would argue, was the origin of the outbreak and a 0
proof that his theory of cholera as solely waterborne. The pump was a block from the LI
I—
southeast corner of Lord Craven’s pest-fields. a
I
U
I
lOlA
biB
FIGURE IO.1A This 1720 engraving by cartog
rapher Richard Blame presents St. James as
a well-to-do parish. In the 1800s its population
would grow with a vastly increased emigrant
population.
FIGURE lo.1B In 1720 the seventeenth-century
plague burial site remained undeveloped land
in St. James, Westminster, a block from Broad
Street. By the mid-nineteenth century the former
pest-fields would be overbuilt with housing.
REVEREND HENRY WHITEHEAD
Snow was not alone in investigating this local outbreak. The Board of Health carried
out its own investigation. So, too, did the Metropolitan Commission of Sewers in
194
hopes of countering a popular belief that bad airs traveling through new sewer lines
caused the outbreak. The first published study, however, was by Reverend Henry
Whitehead, a young curate assigned to St. Luke’s Church in the heart of the Broad
Street district. Today we might call Whitehead an outreach worker. He came ‘to live
the life of human friendship in this world of friendlessness, want and woe” and stayed
at St. Luke’s for five years, serving three successive vicars (Rawnsley 1898, 29). A
graduate first of Chatman and then of Lincoln College, Oxford, Whitehead’s primary
mission was in the streets. When the outbreak began it consumed his days as he
traveled to give comfort to the dying, and later, to the family members who survived.
In 1854 Whitehead published his seventeen-page pamphlet “The Cholera in Ber
wick Street” in part to correct the popular impression that the neighborhood was
wholly devastated by the outbreak. “It was very mortifying to persons interested in
the welfare of the neighborhood, to see the papers teeming with letters describing
whole streets as having hundreds lying dead in them, at a time when the deaths in
each street were really no more than one or two each day; and equally unsatisfactory
was it to hear of employers refusing work to the inhabitants, long after the disease
had disappeared—as if, too, a coat or a pair of boots would carry it [cholera] into a
shop” (Whitehead 1854, 17).
Over the course of several months Whitehead interviewed every family resident
in his parish, sometimes returning to one house four or five times until he could find
a respondent (Chave 1958, 95). As Whitehead put it, writing about himself in the
third person: “The writer does not choose to rest this statement on mere loose asser
tion. His previous acquaintance with the people and their houses, added to personal
observation, and the observation of his colleagues, of the progress of the pestilence,
has enabled him to ascertain—what probably, for obvious reasons, no one else could
or can ascertain—the name of each deceased person, and the room in which he or
she died, or in the case of removal or departure, the room hitherto occupied by the
deceased” (Whitehead 1854, 8—9).
In this first study Whitehead focused on what he knew best: “It is the writer’s
intention to confine his observations to the district of St. Luke’s Berwick Street, with
the houses and people of which he has long been acquainted” (Whitehead 1854,
1). For those who did not know the parish, Whitehead included a map that served
first to define the area of his authority and second as an index to the locations he
I
described in his report (fig. 10.2). Where were the inhabitants of the “model lodging LJ
LJ
houses now building:’ a site of sanitary pride in the parish, so devastated by cholera I— liii
if mere cleanliness and sanitation were causative factors? How far was this model ci
0
lodging from the Poland Street workhouse whose poor and dispossessed inhabit 51
ants were almost untouched by the outbreak? The map presented the geography 0
w
of Whitehead’s parish in which cholera’s occurrence was to be seen, its pattern of -J
0
incidence questioned. C-)
Whitehead’s short pamphlet was an inventory and analysis of 373 cholera deaths,
195
“nearly all of which took place in the first fortnight, and 189, at least, in the first four 0
days” (Whitehead 1854, 3). He listed these August and early-September deaths w
street by street, providing for each street the number of houses, the total popula
I
a
tion, and the total number of deaths. Whitehead filled his short report with a series
ZIZ
C-)
 T
of tables breaking down mortality by house population, age, and deaths over time. It
DJsTcT PIRW SLUKE aw1cx was Whitehead who first noted that “there were only four deaths among the regular
inmates of the workhouse” in a district where hundreds of deaths were elsewhere
occurring (Whitehead 1854, 6). Because newspapers had reported that, “the vast
0 X F 0 R D ST R £ E I
majority of the deaths occurred in the upper rooms” of multiple family homes, pre
sumably because bad airs wafted upward, Whitehead created a table of mortality by
house floor and found the theory mistaken (Whitehead 1854, 8—9).
E_ At least at the beginning, the problem cholera presented for Whitehead was as
CRF.ATMERLBOROUGHSTREETIW STR EEl
much theological as scientific. “At an average distance of 15 yards from St. Luke’s
Church stand four houses, which collectively lost 32 persons” (Whitehead 1854, 6).
The intensity of the outbreak in his (and thus God’s) domain was almost insulting to
PORT LA N D STREET ‘‘

H::sEr
the young curate. In his studies he found “the very old and the very poor have not
supplied nearly so many victims as might have been anticipated:’ populations in which
medicine and common sense said deaths should be especially severe. Might it be, he
BENTINCI(STR wondered, the regular church attendance of these seniors—his daily congregants—
that saved them? Might cholera be an act of God, a testing of faith, rather than simply
the effect of some unseen animalcule or miasmatic force?
While Whitehead’s investigations focused on his parish he was well aware that
BROAD EDWARD STREET; “the streets and parts of streets throughout which the disease may be said to have
literally performed a house-to-house visitation” extended beyond the parish boundaries
C
x
(Whitehead 1854, 2; original emphasis). He described the precise boundaries of this
a’
greater visitation in which his parish was embedded: “Take a point on the east side of
SILVER STREET Poland Street, half-way between Portland Street and the level of Great Marlborough
-

‘1._I Street; draw from thence two straight lines, one to the north-west corner of King Street,
Regent Street, and the other to the east end of St. Anne’s Court’ Joined they formed
I
a four-sided figure “enclosing with singular exactness the area within which only a few
a::
z
w —
houses escaped, and outside of which comparatively few suffered” (Whitehead 1854,
I— Z
-J a 2). While he did not add this description to a map—he assumed the reader’s familiarity
a. Z
I with the area—he did draw the polygon shape in his report to aide in visualization. In
I
figure 10.3, Whitehead’s polygon of the intense area of cholera occurrence is overlaid
Ui

___j on the mapped boundaries of the parish described in figure 10.2. I-

LI)
LI FILE PULTEN EY STREET
BREWER STREET In this manner, Whitehead created two cholera zones: the first was that of the
—----—
0
parish to which he was assigned, in which 218 cholera deaths occurred; and the a.

second was that of the greater area of intense mortality in which an additional 0
a.
Li
165 deaths were recorded. Those zones have been mapped on a simplified ver -J
0
sion of John Snow’s cholera map (fig. 10.3). Absent from Whitehead’s report was I
0
-
Z(W/fVy
any mention of the Broad Street pump that would later figure so prominently in
-

z- (ot,.7’ .5’/ 197

Snow’s study. In the late summer and early autumn of 1854 Whitehead did not 0

consider cholera a waterborne disease. Rather, he assumed, with most of his a.

FIGURE 10.2 The Reverend Henry Whitehead included this map of his parish in his 1854 report, “The Li
I-
Cholera in Berwick Street:’ where St. Luke’s Church was located. contemporaries (ecclesiastic, medical, and secular), that cholera was miasmatic a.
I
in its diffusion and natural in origin: “It may be, as one writer has philosophically 0

. /
FIGURE 10.3 In 1854 Whitehead
described cholera mortality in
his parish (the red rectangular
area) within the general area of
greatest cholera activity. This
St Luke s Ch - map was made by the author
BroadSt. - -
based on Whiteheads textual
Pump Parish boundaries 35
these cases the families of the deceased persons informed me that they always sent
to the pump in Broad Street, as they preferred the water to that of the pump which
was nearer” (Snow 1855a, 39—40).
After requesting pertinent mortality reports from the GRO. Snow almost immedi
ately suspended his investigation. Still a practicing anesthesiologist, Snow was also
engaged in his study of the South London epidemic. Were that not enough, in early
September he also traveled to Deptford to investigate an “equally violent irruption”
where he suspected “a leakage had taken place into the pipes supplying the places
where the outbreak occurred” (Snow 1855a, 55). Snow later acknowledged the ef
fect on the Broad Street study of these other initiatives: “I should have been glad to
inquire respecting the use of water from Broad Street pump in all these instances [of
deaths] but was engaged at the time in an inquiry in the south districts of London
• . and when I began to make fresh inquiries in the neighborhood of Golden Square,
after two or three weeks had elapsed, I found that there had been such a distribution
of the remaining population that it would be impossible to arrive at a complete ac
count of the circumstances” (Snow 1855a, 41).
For Snow, no longer a resident of St. Luke Parish, the outbreak was one he some
times described as located near Golden Square. But for those like Whitehead, who
were more intimately involved, it was the Broad Street or Berwick Street outbreak.
Snow did what might be called an institutional survey in the area nearest the Broad
Street pump. He interviewed “the keeper of a coffee-shop in the neighborhood” who
on September 6 told him she knew of nine customers who drank from the local pump

Cholera description of cholera in his par and were already dead of cholera. Snow learned the Poland Street Workhouse, which
deaths j Cholera area ish and its surrounding area.
Whitehead had noted was surprisingly free of cholera, had its own well. Similarly,
Snow was informed that no deaths occurred among workers at the brewery located
on Whitehead’s map where employees either drank their own product or drew water
and reverently suggested, that great and universal atmospheric changes periodi
directly from the brewery’s private well (Snow 1855a, 42).
cally occur, fraught with ultimate benefit to the whole human race, compared to
For the type of circumstantial, case-based evidence that Snow’s inferential ap
which the premature death of thousands, nay millions, is but as a grain of dust in
proach required, he needed the help of others closer to the community and its pa
the balance” (Whitehead 1854, 14). I
tients. Those who shared their case notes with Snow included the Greek Street w
bi

surgeon, Mr. Marshall, who also was a member of a Board of Health inquiry; a Dr. I
U,

THE BROAD STREET PUMP Fraser of Oakley Square; and of course Henry Whitehead. Their support gave Snow
0
the luxury of being able to focus his attention, and very limited time, on apparently
0
When the outbreak “commenced in the night between 31st August and the 1st Sep
anomalous outriders, deaths occurring at a distance from the epicenter of the out Li

tember’ Snow later wrote, “I suspected some contamination of the water of the
break. “In some of the instances, where the deaths are scattered a little further from _1
much-frequented street-pump in Broad Street, near the end of Cambridge Street” 0
the rest of the map, the malady was probably contracted at a nearer point to the U
(Snow 1855a, 38—39). The pump was the closest public water source to the homes
198 pump;’ Snow hypothesized. As proof, he identified children who lived on Angel Court,
of the neighborhood’s first cholera victims and therefore, Snow reasoned, the likely 199
Noel Street, Ham Yard, and Naylor’s Yard who walked by the pump on their way to 0
origin of the outbreak. “On proceeding to the spot, I found that nearly all the deaths
school; a cabinet-maker who died in Middlesex hospital but lived at Phillips Court, Lu
Ui
had taken place within a short distance of the pump;’ Snow continued. “There were I
Noel Street. All, Snow or his collegial informants were told, regularly drank water from Lu
only ten deaths in houses situated decidedly nearer to another street pump. In view of
the Broad Street pump (Snow 1855a, 41—44). U
 While suggestive, these cases could not be considered definitive. Others used
extensive case histories to argue wholly different conclusions. Seaman had used brief
case reports in his study of yellow fever in New York to argue its miasmatic nature.
In 1855, Dr. George Johnson, an assistant physician at King’s College Hospital in
London, published a 294-page treatise on cholera based on 54 case histories. All
were of hospital patients whose autopsy reports he used to demonstrate that cholera
must be pulmonary and therefore inhaled (Johnson 1855). An anonymous reviewer
praised the study for the thoroughness of its case presentation if not for its treatment
protocols promoting the “eliminative plan of treatment”: castor oil (Anonymous 1855,
148). In many ways, one saw what one was looking for in both the dissection theater
and in the map. To be definitive, Snow needed something more.
In the second edition of On the Mode of Communication of Cholera, Snow’s
strongest evidence implicating the Broad Street well and pump as the source of the
outbreak was presented in “a diagram of the topography of the outbreak:’ Made for
Snow by C. F. Cheffins, the prominent London engraver and mapmaker who drew the
South London map, this was a street map of the study area in which he embedded,
first, public wells and pumps and second, the street location of 596 cholera deaths
reported to the GRO.
2 The map was centered on the Broad Street pump, “the spot
where Cambridge Street joins Broad Street’ the epicenter of the outbreak as Snow
defined it (Snow 1855a, 38). Snow cast a wide evidentiary net for his study. It’s of
ficial boundaries, marked in the map by a dot-and-dash line “surrounds the sub-dis
tricts of Golden Square, St. James, and Berwick Street, St. James, together with the
adjoining portion of the sub-district of St. Anne, Soho, extending from Wardour Street
to Dean Street, and a small part of the sub-district of St. James Square enclosed by
Marylebone Street, Tichfield Street, Great Windmill Street, and Brewer Street” (Snow
1855a, 46). Outside that area were water sources and cases to the west of Regent
Street and north of Oxford Street. FIGURE 10.4 In this map of the Broad Street outbreak, Snow attempted to show the centrality of the Broad
Street pump to the incidence of disease.
Snow’s mapped argument was similar structurally to that of Seaman in his maps
of yellow fever in New York City (figs. 5.6—5.7). First, Snow proposed a study area
composed of city streets and important structures like the Poland Street Workhouse. ticed that the deaths are most numerous near to the pump where the water could be
I
bi
bi
He defined this area through reference to registration subdistrict boundaries that by more readily obtained” (Snow 1855a, 47). I—
U,
then were generally accepted administrative regions. Second, Snow brought forth a Some today dismiss Snow’s now iconic map as nothing but an illustration without
set of possible sources, local wells and pumps. Third, Snow added to the map a set intellectual or scientific force: “Snow’s map of the epidemic area was simply the visual
0
ix
5i
of choleric deaths reported to the GRO, those for which he had street addresses. representation of a deduction from a theory of transmission developed earlier, which 0
ix
Whether the diagnosis was English cholera or premonitory diarrhea, mapping the in turn was grounded in a theory of the pathology of cholera” (Brody et al. 2000, 66). Ui
-J
0
cases together asserted all were part of a single range of occurrence whose mem Mark Monmonier, for his part, dismisses entirely the idea that Snow’s map “or those I
0
bers were to be treated as equal. Snow then made this connection: if cholera is Wa of his rivals were of any value in generating insightful hypotheses. Snow’s was pure
200
201
terborne in nature, then its incidence should be closest to a complicit water source. propaganda.. and copycat propaganda at that” (Monmonier 2002, 155).
.
0
And so it appeared: “It will be observed’ Snow wrote, “that the deaths either very These and similar critics miss the point. Snow developed a spatial theory that ix
Ui
much diminished, or ceased altogether, at every point where it becomes decidedly was tested in the map. This was not propaganda but an attempt at science. The map
I
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.5
nearer to send to another pump than to the one in Broad Street. It may also be no- was the embodiment of Snow’s proposition that if cholera was waterborne then its
I
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 source had to be water, in this case, the Broad Street pump at the epicenter of the
outbreak. The map was perhaps the critical statement of Snow’s argument based on
the available data. In it the cases of Snow’s (and Whitehead’s) circumstantial report
age became members of a class of cholera cases whose location to the maps was
transformed into truthful conclusion. “It may be noticed was all the proof Snow
. . .“
offered (1855a, 47; 1855b, 109). The argument was the map. If one agreed that
proximity implied causality, then the map’s evidentiary value would be overwhelming,
assuming no other confounding sources resided at the epicenter of the outbreak.
In a second version of the Broad Street map (fig. 10.5) included with Snow’s
report to a St. James Parish committee inquiry into the outbreak, Snow added an ad
ditional seventeen deaths for which addresses had earlier been unavailable; he also
rectified minor topographic errors.
3 To this second map Snow added a wandering,
dotted line creating an irregular area nearer to the Broad Street pump than to other
pumps in the study area (Snow 1855b). Snow did not describe how this area was
constructed but it is almost certainly based on walking time between local pumps, a
kind of “Manhattan metric” based on pedestrian rather than shortest distance path
ways. What today would be called a nearest neighbor boundary
4 bolstered Snow’s
argument. Because more deaths appeared nearer to the Broad Street pump than any
other, logically, for Snow, the pump was necessarily the origin of the outbreak.
202
FIGURE 10.5 In a second map of the Broad Street outbreak, Snow included a dotted line to create an ir
regular polygon enclosing the area closer to the Broad Street pump than to other pumps.
Perhaps the most interesting thing about Snow’s mapping was its omissions. He
did not calculate the number of deaths in his walking area compared to the rest of the
study area. He did not create a similar area for, say, the Rupert Street pump in a man
ner permitting him to say that two-thirds of all deaths were in the Broad Street pump
vicinity and less than 12 percent in the second pump’s vicinity. Nor did Snow attempt
to calculate mortality ratios based on the population of the areas he constructed. He
assumed others would see in the map what he saw and that they would draw the
same conclusions. But without even basic quantification of the mapped incidence
Snow could not translate the obvious concentration of deaths near the Broad Street
pump into a meaningfully rigorous argument. Nor in his mapping did Snow attempt
to consider with any rigor other possible sources of contagion, for example the old,
seventeenth-century plague burial pit (Fig. 10.18) many—laypersons and profession
als alike—believed to be a likely source of disease generation. On September 7, for
example, “An Old Subscriber” wrote to Bell’s New Weekly Messenger, quoting Har
rison’s History of London on the location of the old pest-field from the 1665 plague
5 To some, the old plague burial site over which new homes had been built
epidemic.
and under which new sewer lines had been laid (all agreed the smell from these
sewer lines was noxious, and therefore potentially disease generating) was as obvi
ously complicit as the Broad Street pump was to Snow. On September 24, Bell’s
ran a story based on the report of a Dr. J. Rogers, the medical officer of health on
6 Rogers, who visited many of the
Dean Street at the edge of the Broad Street area.
ill, condemned the “sickening and nauseous odours” emanating from the Berwick
Street sewers. “Life destroyed by exhalations from sewers’ the headline insisted,
condemning the “infamous gully-holes in the street:’
7
In his updated monograph Snow dismissed this and other alternate theories in
passing, making no serious attempt to investigate their involvement himself. “The situ
ation of the supposed [plague] pit is, however, said to be Little Marlborough Street,
just out of the area in which the chief mortality occurred. With regard to effluvia from
the sewers passing into the streets and houses, that is a fault common to most parts
I
of London and other towns. There is nothing peculiar in the sewers or drainage of the bJ
limited spot in which this outbreak occurred” (Snow 1855a, 55). As proof he cited I—
U,
a report by the sewer commissioners that had exonerated its sewer lines laid in the
0
1850s. A more complete treatment of these other theories was needed, however,
if Snow was to convince others not simply that the local pump was a source of the CJ
bJ
Broad Street outbreak but the only possible source. -J
0
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203
CA U SAT I 0 N 0
Others with an interest in the cholera outbreak in St. James were able to draw differ In
I
ent conclusions based on the same data Snow drew upon, mortality reported by the
I
GRO. In September 1854 Farr’s office published an interim report on cholera and di- U
i JI
 arrhea deaths occurring between August 19 and September 9 in the districts of Ber
wick Street, Golden Square, St. James; St Anne, Soho; and All Souls, Marylebone, I -.— u
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“to assist in the investigation of the epidemic outbreak’ That report was republished 8

September 13 in both the Daily News and the weekly Bell’s Life in London, which
five days earlier had reported that, “owing to the favourable change in the weather, 1
L -1 ---
. I
I-i
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the pestilence which has raged with such frightful severity in this district has abated, 1118 8j 8

and it may be hoped that the inhabitants have seen the worst of the visitation:’
T- i
I

:
—
.I
8 The :1 /r
i
temperatures had dropped, in other words, at the same time that deaths were dimin ‘1 I
ishing. To others, the relationship of declining temperatures and declining mortality -
“‘

seemed obvious proof of cholera’s climatic origins, and thus of a miasmatic distribu :1
I —

tion. Where Farr had been at pains to note climatic variables, including temperature,
rain and wind, incorporating them in his argument, Snow simply ignored them. •
_—-
FIGURE 10.6 Edmund Cooper, engi
/ithe Broad Street pump was complicit, what was the source of its contamina
neer for the Metropolitan Commis
tion? In neither of his reports on the Broad Street outbreak did Snow identify the index sion of Sewers, mapped a partial set
case from which the contamination spread in the manner of Seaman, who in his study -. IIIII•I
I’ of cholera deaths (black bars) and

of yellow fever in New York City had identified the sailor from the ship Polly. Without
an understanding of the local source of the outbreak—it would be Whitehead who — I’,, 1..
1 sewer lines in the Broad Street area.
The location of the former plague
burial area is incorrectly located and
sized.
identified the index case—Snow’s analysis was open to interpretation. “This certainly
,.-‘-L.. ..m.i -,-‘—

looks more like the effect of an atmospheric cause than any other’ Parkes wrote of
the Broad Street study in his review of Snow’s second edition. “If it were owing to
the water, why should not the cholera have prevailed equally everywhere where the
water was drunk? Dr Snow anticipates this by supposing that those nearest the
pump made most use of it; but persons who lived at a greater distance, though they
came farther for the water, would still take as much of it ...
There are, indeed, so
many pumps in this district, that wherever the outbreak had taken place, it would most
probably have had one pump or another in its vicinity” (Parkes 1855a, 458).
REVEREND WHITEHEAD’S SECOND MAP
Some of these concerns were answered in an extraordinary map (fig. 10.7A) included
common suspicion that new sewer lines might be the source of the Broad Street out
break. Cooper mapped 351 cholera deaths reported to the GRO in the first fortnight
of the outbreak against an inventory of sewer lines, noting the year in which they were
laid. Included as well were the locations of sewer grates from which foul sewer airs
might be expelled. A thick black bar symbolized homes of cholera victims; thinner bars
were stacked under those symbols to show the number of deaths occurring in each
house. Half the homes surveyed were not connected to the new sewer lines, Cooper
reported; instead they used cesspools to store household waste. Looking at the map—
he used no other analytic—Cooper reported no obvious correspondence between the
cholera cases he mapped and the location of sewer lines in the study area.
Cooper mapped an oval to symbolize the old Craven Hill plague pit that he shrank I

Li
in the parish inquiry committee report made in collaboration with the Board of Health. and incorrectly located on Little Marlborough Street, northwest of the epicenter of I—

“Unlike Snow’s better known version, this map included all streets and news, updated the outbreak (fig. 10.1). This was one apparent source of Snow’s easy dismissal of
the number of cholera deaths in the area by tracing people who left the neighborhood the old plague site on the basis of its distance from the outbreak’s epicenter. While
0

for hospitalization, and tallied deaths of nonresidents who worked in or visited Golden “non-medical people” thought the old pest-field more central, Snow wrote, “The situ C-)

Square” (Paneth, Vinten-Johansen, and Brody 1998, 1547). To the map Whitehead ation of the supposed pit is, however, said to be Little Marlborough Street, just out lii
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204
added, for his parish inquiry committee report, a large circle centered on Broad Street
to show the area of cholera activity in his parish and its environs.
9 This circle served as a
I of the area in which the chief mortality occurred” (Snow 1855a, 54). He had this on
the authority of a sewer commissioner, who had it on the authority of Cooper’s map.
I
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205
visual analytic, drawing attention to the epicenter of the outbreak in St. Luke Parish. Unfortunately, Cooper was wrong. 0
Produced by the lithographers Day and Son, the map simultaneously borrowed Whitehead included in his map Cooper’s oval as well as the correct size and bJ
from and improved upon a map by Edmund Cooper, an engineer for the Metropolitan location of the former plague burial site on which houses had been built. The bound
I—
a
Commission of Sewers (fig. 10.6). In 1854 Cooper was ordered to investigate the then ary of that area, far greater than Cooper’s mapped oval, was a block from the Broad
I
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I
 Street pump. In his map Whitehead had included the sewer lines and grates from
/ Cooper’s study, as well as fifteen public pumps and wells in his study area. To all this
Whitehead mapped 684 deaths, symbolized by the now-familiar black bars, reported
by the GRO from August through October. As on Cooper’s map, these deaths could
I ••--:
be located both by street and house number (and unlike Snow’s map by Cheffins,
which did not include house numbers on the individual streets).
I The map that resulted presented a broadly ecumenical meta-argument: if cholera
is influenced by environmental attributes, then the pattern of disease occurrence

S
should reveal a correlation with one or more of those attributes (water, sewer lines,
5 =
plague burial site, or the like). Each of these might be individually tested in the map.
!:Th If the airs from the old plague pit were the source of the outbreak, then deaths would
be clustered near that site. If the source of cholera was in sewer lines built since
- /
1850, then cholera cases would be seen to cluster along those lines in the map. But if
cholera resulted from contamination of water, then perhaps one or more of the fifteen
water pumps inscribed in the map would be shown to be complicit in the outbreak.
Each separate proposition assumed proximity of clusters of deaths to a suspected
source might argue one or another association. Whitehead’s principal analytic was a
circle, encompassing almost all the reported cases of cholera, whose center was almost
precisely at the location of the Broad Street pump. In effect, by using his dividers to

,,*l,:!Z
1 create a cholera field (today we would call the circle a “buffer”), Whitehead located the
epicenter of the outbreak at the Broad Street pump. This, and his close association with
Snow during the months of their mutual investigations, convinced Whitehead of the
pump’s complicity in the outbreak. As he would write in 1865 in a MacMillan’s magazine
article, Whitehead became convinced, “slowly and I may add reluctantly that the use of
this water was connected with the commencement and continuance of the outburst’

-
4: The old ladies who seemed immune to cholera contracted it less frequently because
their homes did not have children to run to the pump and bring them water. They thus
drank from it less frequently (Chave 1958, 95). It was not God’s presence but the stair
climbing limits of age that had protected Whitehead’s elderly parishioners.
N-
In almost every way, Whitehead’s map—and the report it supported—was more
complete than either Cooper’s or Snow’s. The total numbers of deaths and water
P I. ‘/ sources were greater and the location of deaths more precisely mapped. And while,
SKEWING TUE ASCERTAINED DEATHS FROM CHOLERA I
0
A0(h,. .
like Cooper’s and Snow’s, Whitehead’s data set was based on GRO mortality re
‘JAJ’AJ.t. ‘OY!.n,JJ1J51zn. ports, his local knowledge gave his report an unparalleled ethnographic depth. “The
ST .NNE. 50110. ordinary course of my duties taking me almost daily in the street, I was under no ne
EflOFKIIMME.A.EERRKK
: cessity to be either hasty or intrusive, but asked my questions just when and where
opportunity occurred, making a point of letting scarcely a day pass without acquiring
207

FIGURE 10.7.4 Reverend Henry Whitehead mapped 684 deaths that occurred during the Broad Street
outbreak and considered their location in relation to a range of potential environmental contaminants,
including water sources.
S
some information and not caring how often I had to verify it” (quoted in Chave, 1958,
96). What Snow had believed impossible—I found that there had been such a distri
. S . . . S

bution of the remaining population that it would be impossible to arrive at a complete

account of the circumstances” (Snow 1 855a, 41 )—Whitehead accomplished.
 F

higher than that of the well, whose walls were surrounded by soil contaminated by
the cesspool.
Here was both the index case and a likely source of the well’s contamination.
Because only the Lewis household had easy access to the cesspool at their house
the chain of infection stopped when Sarah Lewis died even though other residents of
40 Broad Street would later become ill (Chave 1958, 96). Not surprisingly, perhaps,
Snow was enormously pleased with Whitehead’s argument, and with engineer York’s
physical support of it.
° Unfortunately, that supporting material was discovered only
1
after Snow finished writing both On the Mode of Communication of Cholera and his
report for the parish inquiry.

I
THE LIMITS OF BROAD STREET
Famously, Snow had petitioned to have the handle of the pump removed to prevent
local citizens from drinking its water. “I had an interview with the Board of Guardians
of St. James’s parish, on the evening of Thursday, 7th September.. In consequence
.

FIGURE 1O.7B Whitehead correctly located the Craven Estate plague pit,
incorrectly located In Coooper’s map, that of what I said, the handle of the pump was removed on the following day” (Snow
many believed comphcrt in the Broad Street outbreak. Dotted
and solid lines symbolize different sewer lines.
1855a, 40). But by then, Snow acknowledged, “the attacks had so far diminished
before the use of the water was stopped, that it is impossible to decide whether the
It was not simply that Snow did not have the time and that
Whitehead did. Snow, well still contained the cholera poison in an active state, or whether, from some cause,
never the most garrulous of men, was less suited to the business
of visits to the home the water had become free from it” (Snow 1855a, 51—52).
of the bereaved local worker than was the young curate.
Snow was no longer the When the second edition of On the Mode of Communication of Cholera went
young apothecary with a local practice on Firth Street. By
the 1 850s Snow was a fa to the printers Snow had not yet received the news of Whitehead’s discovery of the
mous anesthesiologist, a specialist whose practice was
not bound by the community index case near the pump. Nor did he have in hand York’s report on the physical
in which he lived. Whitehead’s mission was to serve the
troubled of the neighbor state of the Broad Street well. All Snow knew was that a cursory external examination
hood: they knew him and he knew them in a way that Snow
could not. showed “no hole or crevice in the brickwork of the well, by which any impurity might
Not surprisingly, therefore, it was Whitehead who identified
the index case of enter; consequently in this respect the contamination of the water is not made out
the outbreak and the method by which the Broad Street
pump was contaminated. by the kind of physical evidence detailed in some of the instances previously stated”
London constable Thomas Lewis and his wife had moved
to 40 Broad Street in the (Snow 1855a, 52).
1840s, living with their growing family through the 1850s
in a former single-family To this negative evidence was added the acknowledged quality, and broadly as I—
building that had been cut into flats. Their daughter Sarah w
was born in March of 1854 sumed purity, of the Broad Street well water. England’s first great authority on mi
and in August first became ill with “promontory diarrhea” She I—
died on September 2. croscopy, Arthur Hill Hassall, who examined the water from the Broad Street pump
U,

As the CR0 weekly mortality reports put it: “At 40, Broad
Street, 2d September, a for the Board of Health inquiry, declared it “relatively bereft of microscopic animal life” C
daughter, aged five months: exhaustion, after an attack
of diarrhoea four days previ that might be identified as a contaminant (Paneth, Vinten-Johansen, and Brody 1998, L)
ous to death” (Johnson 2006, 178).
1547). Snow admitted that the absence of observable contaminants—he carried out
Mrs. Lewis told Reverend Whitehead the diarrhea had begun -J
on August 28, five his own microscopic examination—forced him to “hesitate to come to a conclusion”
0
I
days before Sarah’s demise. Mrs. Lewis soaked her daughter’s (J
208 soiled diapers in pails on the pump water’s complicity in the outbreak (Snow 1855a, 39). He could dem
of water and then tossed the wastewater into the 209
cesspool at the front of the house. onstrate the centrality of the well and pump but only assert, deductively, its pollution:
While lined with bricks, the cesspool, less than a yard from 0
the edge of the Broad “Whether the impurities of the water were derived from the sewers, the drains, or 0:
Street well, later was found to leak when examined by local
engineer Jeremiah York the cesspools, of which latter there are a number in the neighborhood, I cannot tell” I—
0.
for the parish inquiry committee (York 1855). The water
line of the cesspool was (Snow 1855a, 53). I
 r
Snow therefore could argue, on the basis of his mapping, the centrality of the
Broad Street well and its apparently pure waters; he could also argue inductively its
complicity in the outbreak. That, however, was not the definitive proof he had hoped
to achieve and, apparently, believed he had produced.
Nor, of course, could Snow prove beyond any reasonable doubt his assertion
that “each epidemic of cholera in London has borne a strict relation to the nature
of the water-supply of its different districts, being modified only by poverty, and the
crowding and want of cleanliness which always attend it” (Snow 1855a, 56—57). In
its separate report, the Board of Health’s Cholera Inquiry Committee came to a very
different conclusion: “We do not find it established:’ they wrote, “that the water was
contaminated in the manner alleged, nor is there before us any sufficient evidence to
show whether inhabitants of that district, drinking from the well, suffered in propor
tion more than other inhabitants of the district who drank from other wells” (General
Board of Health 1855, 52).
It was not that evidence was lacking but that the evidence was insufficient to prove
that the Broad Street pump was solely responsible for that neighborhood outbreak.
There was room for doubt in this local case, and therefore skepticism toward Snow’s
broader theory in which cholera exemplified a class of waterborne disease. The Board
of Health committee members wondered about those who drank from the well and
did not get sick, and those who appeared to have become sick even though they lived
far from the Broad Street pump and were not all known to prefer its waters.
Snow mapped the problem, but that mapping did not guarantee a solution. Too
many potentially confounding variables had yet to be ruled out. As John Simon said of
another map in his report on the 1854 epidemic: “When the 211 deaths are mapped
upon a house plan of the city (as may conveniently be done by stamping a black ink
mark at each place where one of these occurred) the broad features of the epidemic
will be visible at a glance . [T]heir distribution may be noticed especially in two
. .
directions: many, dotted about in confined and crowded courts, where domestic
cleanliness is rare, and atmospheric purity impossible; many, on the southern slope of
the city, where it is a habitual complaint that stenches arose from the sewer” (Simon
1856, 27). In the map the epidemic was “visible at a glance,” but in the mapped
environment others saw a range of potentially explanatory conditions, each related
to a different theory of disease. Simon saw in the map the close quarters of the poor
and the unsanitary conditions that resulted as disease inducing. In South London he
saw areas of “atmospheric impurity” that on the basis of Farr’s 1852 study and the
medicine handed down from Hippocrates through Sydenham to the mid-nineteenth
century seemed to suggest a miasmatic correlation. Snow only saw water, and in his
210
refusal to consider the other possibilities in his map, as Whitehead had in his, the jury
of his contemporaries remained unconvinced.
Equally limiting was the scale of the study itself. Neighborhood-level studies did
not easily translate into definitive general proofs of the nature of the disease. There
was nothing obvious about the Broad Street pump and its water. “Bad as was the
produce of the Broad Street well,—containing the results of organic decomposition
filtered through but scanty thickness of surrounding soil:’ Dr. Simon wrote, “this qual
ity of water was not peculiar to it’ This was the general state of the wells of London:
“Everywhere filtering from a dangerous proximity to cesspools and sewers; every
where loaded with nitrates or ammonia; everywhere containing evidence that they
represent the drainage of a great manure-bed; and everywhere liable at any moment
to contain excremental matter only imperfectly oxidized” (Simon 1856, 12). At the
scale of the particular one could agree with Lea or Snow arguing the likelihood of a
local outbreak’s source but it was impossible, Simon argued, to generalize from the
eccentrically local to the universal.
It did not help that in the second edition of On the Mode of Communication of
Cholera Snow proposed waterborne disease as a general category that included
with cholera other diseases, including plague, typhoid fever, and yellow fever. “I have
become more and more convinced that many other diseases are propagated in the
same way” (Snow 1 855a, 125). The evidence here was at best anecdotal and specu
lative: “The natives of Gurhwal, a province in the north-west of British India, in which
the plague has been present for the last thirty years, believe that it may be transmitted
from one person to another in articles of diet, such as a jar of ghee” Snow noted. And
yellow fever, he continued, resembled cholera and the plague by flourishing in “low
alluvial soil, and also in spreading greatly where there is a want of personal cleanli
ness” (Snow 1855a, 127). From there to the fact that communicable diseases might
generally share a solely waterborne source was a simple step only for Snow.
Columbia, Pennsylvania: 1854
Other researchers using similar techniques worked with equal diligence and at least
equally complete mortality reports in other countries. Most of these concluded, in
the 1 850s, that the data supported a cholera that was principally miasmatic and air
borne. Unlike Snow, most considered the subject of the nature and origin of the dis
F
w
ease an open question and not one that easily could be definitively settled. In 1855, I
for example, Dr. T. Heber Jackson published an extraordinarily thorough study of an
0
1854 cholera outbreak in Columbia, Pennsylvania. Jackson’s goal was to consider
“all such conditions as might reasonably be supposed to have exerted an influence 0
upon the development and propagation of the epidemic” (Jackson 1855, 123_31).12
0
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0
This included the local geography, which meant the waters of the Susquehanna River
ZIZ
0
and the terminus of two canals. Was it the water, impurities transferred to the local
reservoirs? Some thought so: “It was well known to all the physicians that very many
211
C
ml’
who confined themselves, from habit, to the use of pump-water, were attacked with 0
I
fatal effect” (Jackson [1855] 1958, 126). This ruled out the reservoirs because as
Jackson had noted, pump waters drew from local wells. 0
I
 r
Like Jackson’s argument, the map placed the theories in the space of the city,
suggested and rejected alternatives, and supported in the end a tentative rather
than definitive conclusion: it’s in the environment, somehow. Unsatisfactory, perhaps,
I. S
from Snow’s perspective and that of other strident advocates of this or that theory,
? Jill 1 ‘H’ 3
but honest in its assessments and knowledgeable about the limits with which mid-
nineteenth-century science could argue definitively the etiology of an invisible disease
lLiu%(raiiic at jr ihiirru if-iiei,iic
,ir,lI,i
1
‘, i$.4. whose symptoms were glaringly evident in the patient.

FIGURE 10.8 In this 1855 map of the 1854 cholera outbreak in Columbia, Pennsylvania, the location of
individual deaths, listed to the left, did not argue a single source or origin. For Dr. T. Heber Jackson, the
conclusion was that cholera was environmental, and likely miasmatic.
CONCLUSION
Neither the Broad Street nor the South London study settled the cholera question.
Snow’s arguments did not, as he hoped they might, rewrite the idea of disease itself.
“Intellectually and rationally” theories of airborne and waterborne disease, each with
its evidenced geographies, were too evenly balanced for a determination between
them (Ackerknecht 1948b, 566). Balancing Snow’s arguments were other studies,
in England and elsewhere, which argued on the basis of reams of data that cholera
was a miasmatic or at least a multifactorial disease. Notable in England was Dr. H. W.
Acland’s Memoir on the Cholera at Oxford, an extraordinarily careful and detailed
study of cholera in that city. The conclusion was, a Ia Farr, that altitude above water
and therefore air quality was the strongest correlation with cholera deaths. For each

But was it the well water that was the origin of the disease? The path of conta
gion was not clear and the number of deaths seemed to argue a different origin and MAP OF OXFORD.

spread. For the origin, many looked at local immigrants, who were among the first to
be attacked in the epidemic. It spread . . . from them, many believed. “Contagious
disease[s] do not seize upon great numbers at once:’ Jackson explained, “but prog
ress from case to cas&’ But why did it take hold, there, among the immigrants and
others? “It would appear that the cause of the appearance and spread of malignant
:
cholera in Columbia, was manifestly connected with the air and locality; that it was ,
I—
U
!‘‘ U
0:
endemico-epidemic” (Jackson [1855] 1958, 128). F
- / U,
The nice thing about Jackson’s report is the ecumenical manner in which he care
XE
0
fully considered each theory—popular and scientific—and attempted to work his way 0:

through the data using this or that thesis—air, immigrants, environment, or water (river L)
0:
or well) —to come to his conclusion. The progression of ideas stated, considered, and U
-J
0
tentatively rejected made of his article a review of the contending ideas that for him 0

argued an environmental, and probably miasmatic disease. With his study Jackson /
212 213
included a simple schematic of Columbia, the bare geography instantiating the city 0

with its streets, rail lines, and the river itself. Embedded in the map were the locations 0:
U

of 27 of the 127 deaths that occurred across the epidemic. For 13 cases there was FIGURE 10.9 Acland’s map of cholera in Oxford argued the airborne nature of the disease, using contour F—
0
lines to show altitude as a correlate to disease intensity in the city. XE
I
no locational data and presumably he saw no reason to map the other 87 deaths. 0
 of the 290 cases occurring in 1854 (128 of them fatal), Acland published tables of
the age, date of onset, diagnosis, outcome (death or recovery), location, occupation,
r .L

residence by street, and the sex of the patient. Beautifully mapped, Acland included
contour lines to construct an argument that altitude was inversely correlated to chol
era mortality.
Even if Snow did not convince his contemporaries, they did listen. In 1852 Farr
acknowledged the likelihood of the fecal-oral route of interpersonal transmission. In
the 1850s critics like Simon rejected Snow’s thesis as definitive but accepted water
as a possible source and vehicle of transmission. When cholera returned to South
London in the 1860s, Whitehead wrote popular articles on the 1854 Broad Street
outbreak for MacMillan’s, as well as a more technical article in 1867 for the Transac
tions of the Epidemio/ogical Society of London. In these retellings Snow was very
much the hero.
Farr, still at the GRO, was “prepared in 1865 to closely scrutinize the water sup
ply” (Morris 1976, 210). It was not simply the accumulated weight of Snow’s argu
ments, which he had always been willing to entertain. It had been Farr who had first
introduced the idea of the South London registration district water supply as a field
of study. In the 1865 outbreak Farr traced the likely source to an East London Water
Company emergency reservoir where open ponds of water appeared to be tainted by
FIGURE 10.10 A young priest at the
sewage. The company objected, arguing that Farr’s analysis was based on obsolete time of the Broad Street outbreak,
maps whose accuracy it questioned. The Medical Times and Gazette defended Farr, this photograph shows Whitehead
his methodology, and his focus on the East London Water Company reservoir, calling at the age of fifty-eight years.

the company’s objections “puerile’ and insisting that its culpability was proven (East
London Water Company 1866, 254).
It would not be until 1883, when bacteriologist Robert Koch definitively identified
Vibrio cholerae as the previously invisible, waterborne agent, that the nature of chol
era would be settled. Others had previously seen the bacterium, but it was Koch’s
rigorous methodology that made his study conclusive. Still, as late as 1874, mem
bers of the International Sanitary Conference in Vienna “unanimously affirmed” the
concept of cholera as a portable disease whose source might be “excremental pol
the high degree of probability attaching to it’ wrote one of Whitehead’s biographers
(Rawnsley 1898, 40). After all, it was Whitehead who discovered the index case and
in his tireless, repeated visits to the homes of the victims in his parish was the master
of the “shoe leather epidemiology” which Snow used to eloquently and passionately
argue his thesis.
Quoting an 1871 valedictory of Whitehead, Rawnsley wrote, “In the Broad Street
I—
outbreak of cholera not only did Mr. Whitehead faithfully discharge the duties of a bi

lution, excremental sodden earth, excrement-reeking air, or excrement-tainted water” parish priest, but by a subsequent inquiry, unique in character and extending over four F
LI,
(Woodworth 1875, 47). Any or all of them might be complicit. Without a method of months, during which time he sat up night after night till 4 am. arranging the evidence
a
seeing the disease agent the multifactoral, the idea of environmental cholera contin he had steadily collected during the day in the course of his laborious duties in that La

ued to dominate. With the fact secured and the bacterium identifiable, Snow’s work densely populated parish, he laid the first solid groundwork of the doctrine that chol (-L

was at least temporarily forgotten, one more relic of an older, science replaced by a era may be propagated through the medium of drinking water, polluted with the in
bJ
-J
0
new methodology. testinal discharges of persons suffering from that disease” (Rawnsley 1898, 40). For Li

214
In England some would argue that while Snow proposed the thesis that cholera those few still concerned with cholera’s history, or medical history generally, it was the 215
was a waterborne disease it was Whitehead who truly made the case in his study ‘Snow-Whitehead” theory, one in which the disciplinary matrix of local investigation, 0

of the Broad Street outbreak. “This doctrine, now fully accepted in medicine, was spatial mapping, and temporal analysis of public health data came together. Li
F
originally advanced by the late Dr. Snow, but to Mr. Whitehead unquestionably be 0

longs the honour of having first shown with anything approaching to conclusiveness Li

I
Published by Oxford University Press on behalf of the International Epidemiological Association
ß The Author 2009; all rights reserved.
REPRINTS AND REFLECTIONS
Anticontagionism between 1821 and 1867¨*
The Fielding H. Garrison Lecture
Erwin H Ackerknecht
Accepted
Nothing might perhaps orient us quicker in our
subject matter than perusal of what Hippolyte Marie
Bernheim (1840-1919) (who was a contagionist
himself and an authority on epidemic diseases
before he became famous as a psychotherapist) had
to say in 1877 concerning Jacob Henle, the teacher of
Robert Koch.1 Henle lives in our minds and textbooks
as the man who ‘‘produced the first clear statement of
the idea of a contagium animatum,’’ who fought a
bold vanguard action. To Bernheim the situation
appeared as follows:
‘‘The serious observers recognized the emptiness of
these fantastic concepts. Towards the middle of the
century the doctrine of the contagium animatum was
generally abandoned as a product of the imagination,
lacking scientific foundations. Among medical leaders
Henle was perhaps the last who defended in 1853
with strong determination the doctrine of the
contagium vivum which he had defended already in
1840 with great logical vigor. Yet the parasitary
doctrine has during the last 10 years regained con-
siderable credit in public opinion as the result of new
research and more positive findings.’’
It becomes thus obvious that what to us appears a
vanguard action, impressed Henle’s contemporaries
rather as a rearguard action, the last gallant defense
of a dead hypothesis. That the theories of contagion
and the contagium animatum appeared old and
obsolete to many in the first half of the 19th century
is easily seen from the following examples:
Trotter speaks contemptuously in 1804 of the
‘‘relicts of the old animalcular hypothesis of con-
tagion.’’2 ‘‘Alpha’’ states in the Lancet in 1832 that
certainly not within the last fifty years have any
diseases been added to the list of the contagious
ones.3 Ozanam writes in 1835: ‘‘Nous connaissons un
* 1821 is the date of the famous Barcelona yellow fever
outbreak and 1867 of the last great European cholera
epidemic. In preparation of this paper the Library of the
College of Physicians in Philadelphia and Dr. W.B. McDaniel
II have been most helpful through liberal book loans.
International Journal of Epidemiology 2009;38:7–21
doi:10.1093/ije/dyn254
30 October 2008
grand nombre d’auteurs qui ont écrit sur l’animal-
isation des contages . . . nous ne perdrons pas de temps
à confuter ces hypothèses absurdes.’’4 [‘‘We know a
Downloaded from ije.oxfordjournals.org at Cornell University Library on October 4, 2011
great number of authors who wrote about the trans-
mission of contagion by microscopic organisms . . . we
will not waste time in refuting these absurd hypoth-
eses.’’] Wunderlich speaks in 1843 of the ‘‘remnants
of childish ideas.’’5 J.K. Mitchell, one of the inventors
of the fungus miasma, regrets in 1848 that ‘‘Morgan
and Holland reverted to the exploded animalcular
theory of Kircher and Linnaeus,’’6 ‘‘which has hith-
erto been so feebly sustained by proofs, as to have at
no time received general favor from the profession,
although supported by some eminent men in almost
every period of medical history.’’7 E.A. Parkes states
in 1849: ‘‘During the last sixty years, however, the
study of several diseases imperfectly known to the
older physicians has added so many new facts to our
knowledge of the several specific epidemic diseases,
that the strict contagion theory has been insensibly
undergoing alteration, until in the present day it
tends to become merged in a higher generalization.’’8
C.F. Riecke states in 1859 that the contagious doctrine
has made no progress in centuries, and recent res-
earch has reversed the whole old authoritarian
building of the contagion doctrine.9 Even a modern
author, Major Greenwood, feels that Henle’s essay ‘‘is
worth reading, but not better worth reading than a
book published in 1546 and written by a Veronese
physician, Hieronymus Fracastorius.’’10 And Charles
Singer, who has been a most indulgent and sympa-
thetic historian of animate contagionism, states that,
except for a small school at the beginning of the 18th
century, no real progress was achieved between
Fracastorius and Pasteur.11
As a matter of fact, contagion and the contagium
animatum were rather old theories around 1800. The
youthful appearance they enjoy in our mind today is
¨
Ackerknecht EH. Anticontagionism between 1821 and 1867.
Bulletin of the History of Medicine 1948; 22, 562-593. Abridged
and with portions translated. Reprinted with permission.
7
8 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
exclusively due to the very thorough rejuvenation they
underwent in the 1870’s and 80’s. Once we realize the
oldness of both theories we can hardly be surprized in
finding that their development was by no means uni-
linear, but a continuous series of ups and downs, of
acceptance and refutation. The notion of contagion,
almost unknown to classic antiquity, had become firmly
entrenched in Western culture after the acceptance of
the (contagionist) Jewish Old Testament as a holy book
in Christianity. After the introduction of quarantines in
most Christian countries in the 15th and following
centuries the notion of contagion had in addition the
official backing of the state, the worldly authority.
The idea of the contagium animatum had been
formulated first in the 16th century by Cardanus,
Paracelsus, and above all, by Fracastorius (1546). It
had been further developed by V. de Bonagens, Fallo-
pius, Mattioli and many others. It had not fared too
well under the hands of Montanus, Valeriola, Sanctor-
ius, and particularly Facio. But it had victoriously
returned in the 17th century with the microscopic
‘‘worms’’ of A. Hauptmann, Father Kircher (1659),
Chr. Lange, etc. Around the turn of the 17th century it
had reached perhaps its highest elaboration with
Lancisi, Andry, Vallisnieri, and after the Marseilles
plague of 1721 with Bradley, Goiffon, and Lebègue. The
satirical Syste`me d’un Me´decin Anglois (by M.A.C.D. Paris,
1726) had almost ruined it through ridicule. But
though now undergoing progressive degeneration,
according to Singer,12 it had still inspired a Linné
(1757), Plenciz, Lorry, etc., and in the 19th century
Rasori, H. Holland, and Henle. With Ag. Bassi (1838),
Davaine (1850), Villemin it started on a new experi-
mental basis; but how was one to differentiate at that
moment solid acquisitions from the uncritical produc-
tions of Donné or Hallier? The day belonged to Woehler
and Liebig’s cruel anticontagionist jokes (1839), fash-
ioned after the Parisian ‘‘M.A.C.D.’’ of 1726.13
It was, curiously enough, in the first half of the 19th
century, that is shortly before their final and over-
whelming victory, that the theories of contagion and
the contagium vivum experienced the deepest depres-
sion and devaluation in their long and stormy career,
and it was shortly before its disappearance that
‘‘anticontagionism’’ reached its highest peak of ela-
boration, acceptance, and scientific respectability. It
might contribute to our understanding of the phe-
nomenon when we realize that what happened to
medicine in the first half of the 19th century and what
looks now to us only like normal birth pains or vigorous
growth, might just as well be regarded as a deep
crisis.14 René la Roche called it downright a revolution,
an event which is know to produce new things in the
midst of a maximum of confusion and disorder. It is by
no means incidental that the medical revolution
paralleled everywhere so many political revolutions,
and that the ‘‘anticontagionist revolution’’ in France
was preceded, just like her political sister, by an
American anticontagionist revolution.
The men who brought about this last victory of
anticontagionism worked with unprecedented energy.
The fact that such outstanding leaders of modern
‘‘contagionism’’ and thoroughly unromantic characters
as William H. Welch and C.-E. A. Winslow have found
understanding words for anticontagionism, seems to
justify closer occupation with this movement.
‘‘The official opinion, as expressed by sanitary
authorities at that time (1848) was definitely hostile
to the germ theory of disease. I attach, however, no
great importance to this circumstance, for it is not
clear what practical use sanitarians would have made
of this theory with the knowledge existing at that
time. Hypotheses born before their time are often
sterile. They must have some relation to the state of
knowledge existing at the time, and history affords
many instances of the useful purpose served for a
time by inadequate and even erroneous theories. It is
doubtful whether any more useful working hypoth-
esis concerning the sources of epidemics would have
been framed in 1848 than that which guided most of
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the sanitary activities at that period and for many
subsequent years, erroneous as it was, and tenaciously
as it was held after it had served its primary purpose.
This doctrine, as is well known, was the so-called filth
theory of the generation of epidemic diseases.’’15
‘‘We cannot dismiss the resistance of the medical
profession to the doctrine of contagion as merely an
evidence of hidebound conservatism. There were sound
reasons for this attitude. The layman perceived the
broad truth of contagion as he watched the plague
spread from country to country and from seaport to
seaport; but the physician knowing the facts more
intimately realized that no existing theory of contagion
taken by itself could possibly explain those facts.
Contagion, before the germ theory, was visualized as
the direct passage of some chemical or physical
influence from a sick person to a susceptible victim
by contact or fomites or, for a relatively short distance,
through the atmosphere. The physician knew that such
a theory was clearly inadequate. Cases occurred with-
out any possibility of such a direct influence. Cases
failed to occur when such a direct influence was
present. Epidemics broke out without the introduction
into the locality of any recognizable cases from with-
out; and within the city or country they raged in a
particular section and failed completely to spread
beyond the border of that area. Outbreaks began and
outbreaks ceased without any causes that would be
directly related to the presence or the absence of the
sick. Until the theory of inanimate contagion was
replaced by a theory of living germs, and until to that
theory were added the concepts of long-distance
transmission by water and food supplies and, above
all, of human and animal carriers – the hypothesis of
contagion simply would not work.’’16
The anticontagionists were motivated by the
new critical scientific spirit of their time. (Griesinger
calls it somewhat sourly ‘‘Zweifelsucht’’17).

Contagionism was so old that it seemed never to have
been submitted to rational examination. So they did
submit it. It is no accident that so many leading
anticontagionists were outstanding scientists. To them
this was a fight for science, against outdated
authorities and medieval mysticism; for observation
and research against systems and speculation.
Chervin’s battle cry was ‘‘non verbis, sed factis.’’
[‘‘not words, but actions’’] J.A. Rouchoux stated that
experience of the typhus and yellow fever epidemics
of the Napoleonic wars had more than anything else
undermined the belief in contagion,18 and coldly
declared in the Academy of Medicine in 1832 that the
experience with cholera ‘‘va achever le discredit des
mésures sanitaires (quarantines)’’.19 [‘‘will discredit
the use of quarantine as a sanitary measure’’.]
Still, the vigor of our movement would remain
largely unexplained, did we not realize the powerful
social and political factors that animated this see-
mingly scientific discussion. Contagionism was not a
mere theoretical or even medical problem. Contagion-
ism had found its material expression in the quaran-
tines and their bureaucracy, and the whole discussion
was thus never a discussion on contagion alone, but
always on contagion and quarantines. Quarantines meant,
to the rapidly growing class of merchants and indus-
trialists, a source of losses, a limitation to expansion,
a weapon of bureaucratic control that it was no longer
willing to tolerate, and this class was quite naturally
with its press and deputies, its material, moral, and
political resources behind those who showed that the
scientific foundations of quarantine were naught, and
who anyhow were usually sons of this class. Con-
tagionism would, through its associations with the
old bureaucratic powers, be suspect to all liberals,
trying to reduce state interference to a minimum.
Anticontagionists were thus not simply scientists,
they were reformers, fighting for the freedom of the
individual and commerce against the shackles of
despotism and reaction. This second aspect of antic-
ontagionism contributed probably no less than its
scientific aspects to its gaining over the majority of
those parts of the medical profession that were
independent of the state.
That the anticontagionists were usually honest men
and in deadly earnest is shown, among other things,
by the numerous self-experiments to which they sub-
mitted themselves to prove their contentions. Between
the plague auto-inoculation of Desgenettes in 1798
and Pettenkofer’s swallowing of a cholera culture in
1892, (both men, by the way, were rather ‘‘contingent
contagionists’’ than pure anticontagionists), a verita-
ble epidemic of self-experimentation seems to have
shaken the medical profession. Yellow fever self-
experiments are reported e.g. from Pfirth v. Salun,
Lavallée, Musgrave, Potter, Chervin,20 Prost, Dorsey,
O’Connor, Govin,21 Ffirth, Cathrall,22 Guyon,23 and
Puhlschneider. Famous are the plague self-experiments
of Clot-Bey, the offers for plague self-experiment by
ANTICONTAGIONISM BETWEEN 1821 AND 1867 9
Chervin, Lassis, Costa, Lapis, and Lasserre,24 and the
cholera self-experiments of Fay, Scipio Pinel, Wayrot,25
and J.L. Guyon. The amazing thing is that almost all of
these experiments failed to produce the disease. They
therefore greatly increased the faith of and in the
anticontagionists. We hear only of a Dr. White dying in
a plague self-experiment, the suicide of a Paris student
who had too well succeeded with a syphilis inocula-
tion,26 and the death of the contagionist E. Valli from
yellow fever in Havana in 1816 (V. overdid a little; he
had already survived a successful plague vaccination
self-experiment in Istanbul in 1803).27
In their positive theories the anticontagionists were
anything but uniform and often blissfully unaware of
the fact that their theories were, especially when they
adhered to the classic Hippocratic epidemic constitu-
tion or ‘‘atmospheric influences,’’ even older than
contagionism. Many followed a more modern and
localized ‘‘miasma’’ theory (poison arising from
decaying animal or vegetable matter, ‘‘filth’’). From
the miasmatic or ‘‘filth’’ theory to a purely social
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concept was but a short step.
In our discussions there did exist, like in all such
situations, besides the two extremist wings, a large
center of ‘‘moderates’’ that tried to compromise, the
so-called ‘‘contingent contagionists,’’ counting in its
ranks such highly respected men as Milroy, James
Johnson, Parkes, Riecke, etc. And it is precisely the
attitude of this center which decided on the practical
applications, and which best illustrates the general
orientation of a given period. It is extremely typical
for our period that the center, though admitting
theoretically contagion in certain limits and as
one possible factor of many, practically, that is in the
condemnation and abolition of quarantines, the
supreme test of one’s convictions, followed the anti-
contagionists. The anticontagionists, though castigating
the center cheerfully for its inconsistencies, were well
aware of this fundamental closeness of both tenden-
cies28. The change of the orientation of the center
since the times of Richard Mead (1721), when on the
basis of a similar theoretical compromise it headed
towards contagionism, is very significant.
In spite of the name, none of the anticontagionists
was an absolute anticontagionist, denying the exis-
tence of any contagious diseases. Even such radical
anticontagionists as Ch. Maclean or J.A. Rochoux
admit the existence of such contagious diseases as
syphilis, gonorrhea, smallpox, measles, and the itch29
But the actual and imaginary clinical and epidemio-
logical difference between these diseases and those
‘‘big three’’ against which the quarantines were
mainly directed: plague, yellow fever, and cholera,
confirmed them in their anticontagionism. Around
these three diseases, which together with typhus
constituted the main health problem of the period,
did the discussion primarily evolve, and it is through
a more detailed discussion of the attitude of the
medical profession towards yellow fever, cholera,
10 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
plague, and typhus that we intend to picture antic-
ontagionism between 1821 and 1867. Epidemics of
smallpox, influenza, meningitis dysentery, etc.
ravaged Europe in the same period. But none of
them found a similar scientific and emotional
response, partly probably because none did kill quite
as dramatically and extensively as the ‘‘big three’’,
partly because none of these ‘‘minor evils’’ resulted in
so hated an institution as the quarantine.
Limited in time and space, I am obliged to omit
from my discussion more or less the American
prologue of the anticontagionist revolution (Rush–
Webster) and to treat in a very summary way its later
representatives, the English sanitarians (Chadwick,
Southwood Smith, John Simon, etc) or Pettenkofer
and his followers. I feel justified in this procedure as
there exist for Rush-Webster30 as well as Chadwick
Simon31 very excellent and detailed recent discussions
by Winslow and others. Because of the same
limitations, I have also quoted only a few of the
most significant contributions out of a practically
inexhaustible contemporary literature on yellow fever,
cholera, plague, and typhus.
  
ANTICONTAGIONISM AND
YELLOW FEVER
It was of great consequence for the success and
spreading of anticontagionism in the 19th century that
yellow fever, a disease which through its mechanism
of transmission is far less of a ‘‘contagious’’ disease
than either cholera, or plague, or typhus, was the first
subject of the great 19th-century discussions between
contagionists and anticontagionists, and that in the
yellow fever discussion the anticontagionists were
represented by a man of unusual intelligence,
perseverance, and poise: Nicolas Chervin. It is also
typical that practically all ‘‘professional anticontagio-
nists,’’ that is those men who not only accepted
anticontagionism, but made the fight against the
theory of contagion and quarantines their life work,
had had their first epidemiological experiences with
yellow fever. The easy victory of anticontagionism in
the yellow fever discussion set a fatal pattern for later
discussions on cholera and plague.
It seems that modern anticontagionism in regard to
yellow fever really started in the famous Philadelphia
yellow fever epidemic of 1793. René La Roche gives to
Jean Devèze (1753-1825),32 one of the many French
refugee physicians from San Domingo (La Roche
himself was the son of such a San Domingo
physician), the credit of having brought an idea that
had been apparently long prevalent in the West
Indian and other tropical yellow fever centers,33 to a
theater from which it was to conquer the world
(Devèze regarded also plague, typhus and dysentery
as non-contagious.) You all remember how through
his 1793 experiences Benjamin Rush was converted
from contagionism to anticontagionism, how in 1799
the anticontagionist Philadelphia Academy of
Medicine was founded. When Chervin 20 years later
came to Philadelphia, he found but 4 or 5 contagio-
nist physicians left.34 The writings of the North
American anticontagionists made a deep impression
upon European doctors, which was reinforced
through the fact that all the leading physicians of
the ill-fated Napoleonic expedition to San Domingo
(1802-3), that was wiped out by the yellow fever,
returned as confirmed anticontagionists. (Trabue, FV
Bally (1775-1866), A François (1775-1840), L Valentin
(1758-1829), etc.) and an international authority like
Alexander von Humboldt sided with the anticonta-
gionists (1802).
Through the Napoleonic Wars the French and
English became sensitive to the fact that in Spain
they had a center of yellow fever right in their back
yard. Outstanding French army doctors like
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P. Assalini (1750-1840) and FP Blin (1756-1834)
found in 1805 and 1801 the Cadiz yellow fever
epidemics, that killed 20 per cent of Cadiz’ inhabi-
tants, to be of a non-contagious character. Robert
Jackson (1750-1827), the famous English army
physician, came to the same conclusion in 1821.35
In the yellow fever epidemic of Gibraltar of 1814 the
majority of the local physicians voted anticontagionist
in a kind of referendum.36
When in 1821 a very fatal epidemic of yellow fever
broke out in Gibraltar, the (contagionist) French
government and the Academy of Medicine, becoming
more and more alarmed, despatched a study commis-
sion consisting of the Academy secretary Et. Pariset
(1770-1847), Bally, and François37 to Barcelona in
order to clear up the fundamental problems of the
disease in view of future protective legislation. The
three musketeers of contagion returned with a very
contagionist report, obtained a life pension of 3000
Frs. per year; and a very stringent quarantine law was
passed through the chambers in 1822.
The anticontagionists too had flocked to Barcelona,
to study the epidemic, and in 1822 a manifesto on the
1821 outbreak appeared, signed by such well-known
anticontagionists as the Frenchmen, S. Lassis (1772-
1835), JA. Rochoux (1787-1852), the British Th.
O’Halloran and Charles Maclean (ca. 1766-1825),
the American John Leymerie, and 11 local physicians,
among them 4 recent converts to anticontagionism, F.
Piguillem, M. Duran, J. Lopez, and S. Campmany.38
The manifesto showed that there was no positive
proof that the disease was imported from Cuba; that
it could satisfactorily be explained through the
miasms of local filth, particularly sewers; that no
infection through fomes had occurred during the
epidemic; that it was strictly seasonal; that attendants
to the sick showed below average morbidity; and that
numerous cases were struck for the second time.

The manifesto helped Maclean defeat a quarantine
law in the Cortes in 1822, but produced little reaction
abroad. Especially in France everything seemed under
control. At this moment Nicolas Chervin (1783-1843)
returned from America, where since 1814, first
practicing in Guadeloupe, then travelling all along
the East coast of the continent from Guiana to Maine,
he had studied yellow fever and collected a truly
amazing and well-authenticated documentation in
favor of anticontagionism. In North America, e.g. he
had found 568 yellow fever anticontagionist physi-
cians as compared to 28 contagionists.39 Chervin
immediately went to Spain to check Pariset’s report,
and the documentation he brought back did not leave
much of the permanent secretary’s hasty, hysterical
pudding. In 1825-26 Chervin bombarded the Chamber
with petitions to reopen the case of yellow fever
quarantines on the basis of his documentation. The
Chamber passed the problem to the Academy of
Medicine. The Academy appointed a committee of 18
that examined the documentation for 11 months. In
1827 Coutanceau (1775-1831) submitted a report to
the Academy, (primarily the work of Villermé, the
greatest living French sanitarian, Réveillé-Parise,
Emery and Lanbert) that in spite of its diplomatic
terms, criticized by Chervin, adopted Chervin’s point
of view, completely demolished Pariset’s report, and
recommended stopping further enforcement of the
1822 quarantine law. The Coutanceau report was,
after long discussions, where especially RND
Desgenettes (1791-1858), the former head of
Napoleon’s Medical Corps, and JB Louyer-Villermé
(1776-1837) championed Chervin’s cause, and in spite
of the violent resistance of Pariset, of heavy govern-
mental pressure and maneuvers, adopted by a
majority of the Academy in January, 1828, and
quarantine credits accordingly cut down by the
Chamber. The Academy of Science took a similar
stand40. Chervin received the Grand Prix de Médecine
of the ‘‘Institut’’ for 1828.
It is almost impossible to exaggerate the importance
of this step of the French Academy, the leading
medical corporation in the leading medical country of
the period. It set the pattern for the Western world. It
set the pattern for the Academy’s own attitude in
later discussions on cholera and plague. Only deep
conviction could bring the Academy to withstand
official pressure and to expose its own permanent
secretary. The Academy remained faithful to Chervin.
Together with P. Louis and Trousseau it delegated
him to Gibraltar to study there the yellow fever
epidemic of 1828. In 1832, the cholera year, it elected
him a member, not because of his political radicalism,
as the Lancet had claimed, but in spite of it.41 Chervin
made a deep and lasting impression on the profession
like no other contagionist. Even most of his adver-
saries spoke with respect of him. J. Raige-Delorme
(b.c.1795), editor of the Archives Générales from 1823
to 1854, remained full of an unchanging admiration
ANTICONTAGIONISM BETWEEN 1821 AND 1867 11
for Chervin throughout the years.42 The four friends
Chervin mentioned in his own testament – Réveillé-
Parise, Londe43, Rochoux, and Civiale – were all
outstanding medical men. In 1863, 20 years after
Chervin’s death, the contagionist Charcot regarded
Chervin’s work on yellow fever still as final.44
Chervin’s influence was not so much due to the
arguments he used, which are similar to those of all
anticontagionists, e.g. coincidence of outbreak and
ship’s arrival, not importation; non-transmission to
nurslings of affected mothers or hospital attendants;
the disease strikes only in certain localities, sick
fugitives do not infect; fomes do not infect; the
contagionists do not observe their own laws, etc.
etc45. It was due to his great conscientiousness,
precision, and honesty – he submitted material
adverse to his theory with the same industry as
favorable material – and his poise – he kept the
lunatic fringe of anticontagionism at a safe distance;
he limited himself to what he actually knew – and to
his perseverance, even more than to his brilliant
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intelligence and enormous knowledge, which made
him tower above most contemporary contagionists
and anticontagionists. His personal integrity and
disinterestedness were above any doubt. Although
representing the interests of a very wealthy class, he
died a poor man. His published work consists only of
pamphlets. His magnum opus on yellow fever
remained unfinished. It is one of the tragic jokes of
fate that Chervin’s many talents and virtues were
spent on a lost cause.
In the above-mentioned Gibraltar epidemic of 1828
the majority of the garrison’s doctors and the majority
of the official British inspecting commission, although
presided by the violent contagionist Sir William Pym,
gave a verdict against contagion.46 The same conclu-
sion was reached by the Inspector General of Army
Hospitals, JL Gillkrest (d. 1845). This, by the way, was
the last large yellow fever epidemic in Europe (except
for the outbreaks in Lisbon in 1857 and Madrid in
1878) which made it all the easier for yellow fever
anticontagionism to stay.
In 1850 D. Blair and the local physicians of Guiana,
under approval of J. Davy, Inspector General of the
British Army, declared yellow fever to be non-
contagious.47 The same conclusion was reached by
the British Yellow Fever Commission in 1852,48 and
the General Board of Health in 1853. Riecke defended
this opinion in 1854. In 1855 the Philadelphian R. La
Roche’s great anticontagionist classic on yellow fever
came out. ‘‘As a work of profound erudition, at once
complete and exhaustive, written in a scholarly style,
and evincing the most patient and extra-ordinary
research, the monograph on yellow fever, by Dr. La
Roche, is without a rival in any language.’’49 In
1859 G. Milroy (1828-1886), the famous English
sanitarian, asked for removal of the useless yellow
fever quarantines for the sick,50, just as JK Mitchell
had done in 1846.51
12 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
By 1868 opinion of the majority, under the influence
of men like F. Mélier (1789-1866) and W. Griesinger
(1817-1868), and of new observations, seems to have
swung back to the concepts of contagiousness and
importation of yellow fever, except for the English, who
according to Dutrolau, were prejudiced through their
commercial interests.52 In the United States the
reaction seems in general to have set in even earlier,
just as the wave of anticontagionism had started earlier.
CHOLERA AND
ANTICONTAGIONISM
Yellow fever, fortunately, remained but a potential
danger for Europe and discussion of its contagious-
ness more or less an academic problem. Cholera
overran Europe and the world in four major pan-
demics during the 19th century, spreading terror like
the medieval plague, killing millions (in England and
Wales alone ca. 15,000), and constituting everywhere
a tremendous medical, political, economic, and
human problem.
Cholera had been a native of India for centuries, and
the Anglo-Indian physicians became thus the first
authorities on cholera for their Western colleagues,
like the West Indian physicians had once been on
yellow fever. These Anglo-Indians, especially those
reporting on the 1817 epidemic, were confirmed
anticontagionists. The whole medical body of Bengal
and the majority of the Bombay physicians decided
this way.53 The Anglo-Indians were among the last to
abandon anticontagionism in cholera.
The 1817 Indian cholera had advanced to the Near
East in 1821 and knocked so loudly at the door of
Europe that farseeing observers, contagionists
(Moreau de Jonnès, born 1778) and anticontagionists
(Maclean) alike foresaw that the next cholera wave,
starting in India in 1826, would probably enter
Europe. Governments, especially those of France and
Russia, took early precautions in the form of rigid
military cordons and quarantines. To no avail; in 1831
cholera overran Russia, and in 1831-32 the rest of
Europe. Leon Colin54 has left an excellent summary of
the effect of the first great victory of cholera on
epidemiological thought:
Cette marche rapide, à travers l’Europé de la
première épidémie de choléra au moment même où
l’on avait le plus grand espoir dans l’influence
prophylactique des cordons sanitaires, la préservation
de tant de pays qui, au contraire, étaient demeurés en
libre communication avec les régions atteintes, dimin-
uèrent aussi de beaucoup la confiance publique dans
les mesures quarantainaires. On sait qu’alors on
révoqua en doute d’une manière absolue la transmis-
sibilité de cette maladie, de l’homme à l’homme, et
qu’on en revint à la doctrine du génie épidémique; la
contagion fut presque, d’une manière générale, traitée
de croyance chimérique, le progrès semblait être du
côté de ceux qui ne l’admettaient plus; leurs idées
étaient considérées comme des idées de nature
libérale par excellence, d’autant plus en rapport avec
la dignité humaine que leur conséquence pratique
était la suppression de toute entrave portant atteinte à
la liberté de l’homme; l’esprit du temps était, en un
mot, l’inverse de celui d’aujourd’hui; et, au lieu d’être
voué au culte de la spécificité étiologique, on traitait
volontiers d’esprits rétrogrades ceux qui admettaient
encore la contagion du cholera, du typhus, et de
beaucoup d’autres maladies.
[This rapid progress across Europe of the first
cholera epidemic at the same time as there was the
greatest faith in the prophylactic effects of cordons
sanitaires, the well-being of so many people who were,
on the contrary, in open communication with affected
areas, also diminished public confidence in quaran-
tine measures. This brought doubt about the absolute
manner of transmission of this disease, from man to
man, and one came back to the notion of a ‘genie’ of
epidemiology; contagion was nearly always dealt with
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as a fanciful belief and progress seemed to be on the
side of those who accepted no more than this; their
ideas were regarded as those of a progressive nature,
all the more so since they seemed more in line with
human dignity in that the consequent practice was to
remove any obstacles to man’s freedom of movement.
The spirit of the time was, in a word, the opposite of
today; and instead of being dedicated to the notion of
a specific aetiology, readily treated as retrograde
spirits those who still admitted the contagious
nature of cholera, typhus and many other diseases.]
European doctors could not fail to be impressed by
the fact that the majority of those Western physicians,
who encountered cholera first, rendered a verdict of
non-contagious (eg Astrachan55, Moscou56). The
numerous commissions that the French and other
European governments sent into the cholera regions
claimed the same results and found quarantines
useless: Gerardin and Gaymard, who with Jules
Cloquet formed a Russian commission;57 the Polish
commission (Dalma, Sandras, Boudard, Dubled,
Alibert, Ch. Londe).58 The same holds good for the
great sanitarians F. Foy (1793-1867) and RHJ
Scoutetten (1799-1870) who were sent to Warsaw
and Berlin59. Hammett’s report on Dantzig was ‘‘lost’’
by the contagionist English Health Council60.
When cholera struck England in 1831 the authorities
and the overwhelming majority of physicians were
contagionist. Thomas Wakley stopped an anticontagio-
nist series by ‘‘Alpha’’ in the Lancet and came out
strongly for contagion61. The adoption of ‘‘contingent
contagionism’’ by James Johnson (1777-1845), the
international authority on tropical diseases and physi-
cian extraordinary of the king, and of a straight
anticontagionism by the highly respected A. Bozzi
Granville (1793-1871), who had so valiantly defended
contagionism and quarantines in the plague discus-
sions of the 1820’s, marks the turning of the tide.62

In 1832 the editor of the Edinburgh Medical and
Surgical Journal turned anticontagionist.63 The books
of J. Lizars (1793-1860) and T. Molison reinforced the
anticontagionist trend, the Westminster Medical
Society, probably the most active medical society in
London at the time, voted anticontagionist (24:22)64.
G. Sigmond (b.1790), himself a convert, stated in May
that probably the majority of physicians was now antic-
ontagionist,65 and even Wakley tuned down his contagion-
ism considerably.66 JG Gillkrest came out in favour of
the anticontagionists67, and H. Gaultier’s book on the
Manchester epidemic illustrated well the current
anticontagionist approach.68
Perhaps the outstanding promoter of anticontagion-
ism in France in the 1832 epidemic was the famous
physiologist, pathologist, pharmacologist, and clinician,
François Magendie (1783-1855). In December 1831,
when France was still free of cholera, he went to
Sunderland to study the disease. His conclusions, as
presented in the Academy, were that the disease was
not imported and contagious but due to incredible
social conditions – humidity, lack of ventilation and
light, ‘‘filth’’ – and that quarantines were therefore
useless. He won an easy victory against Moreau de
Jonnès.69. In the following Paris epidemic he showed
great courage and skill in fighting the disease. His
opinions were but reinforced through this experience,70
and the events of 1848. Magendie felt that four out of
the five quarantine diseases – leprosy, typhus, yellow
fever, and cholera – were certainly not contagious, the
fifth, plague, was probably also non-contagious.71 It is
probably under his impulsion that the doctors of the
Hôtel-Dieu (Petit, Recamier, Dupuytren, Husson,
Magendie, Breschet, Honoré, Guéneau de Mussy,
Samson, Caillard, Gendrin, Bailly) published an antic-
ontagionist declaration72. An Academy of Medicine
report and instruction of the same year, written by de
Mussy, Biett, Husson, Chomel, Andral, Bouillaud, and
Double, is clearly anticontagionist by implication.73 JB
Bouillaud (1796-1881) expanded his anticontagionist
views in a lengthy treatise of the same year and
defended anticontagionism vigorously as a member of
the Chamber in 184674. To this long and brilliant list of
French anticontagionist clinicians we have still to add
the names of Broussais,75 Piorry,76 HMF Desruelles
(1791-1858),77 of the hygienists F. Foy (1793-1867),78
Ch. ES Gaultier de Claubry (1785-1855),79 Ch. F
Tacheron (b. 1790), and of the naval medical officers
JJ Souty and F Levicaire.
It is practically impossible to list all outstanding
French physicians who became anticontagionists. A list
of the contagionists is far more feasible. It consists more
or less of the two great surgeons Velpeau and Delpech,
and the two psychiatrists Foville and Parchappe. And,
of course, Pariset and Moreau de Jonnès.
The trend towards anticontagionism in the 1831
epidemic was the same in Germany as elsewhere (see
the writings of HW Buek, N Weigersheim, Koelpin,
etc.80). But due to the general low status of
ANTICONTAGIONISM BETWEEN 1821 AND 1867 13
German medicine at the time it was of small
importance.
The pandemic of 1848-49 confirmed the anticontagio-
nist beliefs of 1831-32 in practically all observers, and
won even new adherents to the cause. The reports of
the Anglo-Indian surgeons, collected by the antic-
ontagionist Rogers, continued to emphasize antic-
ontagionism.81 Prof. EA Parkes (1819-1876), who
made for the General Board of Health a much
admired analysis of the earliest cases of the London
1848 epidemic, had been formed in India, and it is
therefore not surprising that his ‘‘modified contagion-
ism’’ practically excluded the contagiosity of cholera
as well as yellow fever and plague.82 WF Chambers
(1786-1853), physician of the Queen, and the
respected JA Wilson (1795-1883) preached
anticontagionism.83
The significant change in 1848 as compared to 1831
was that now for the first time in centuries a
governmental agency was defending the tenets of
anticontagionism: the General Board of Health (Ashley,
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Edwin Chadwick, and its medical member Dr T
Southwood Smith (1788-1861)). The 1849 Report on
Quarantines of the Board is clearly opposed to
quarantine. Its 1848 Instructions84 and its 1850
Report on the Epidemic Cholera of 1848 and 1849 (based
mainly on the surveys of Drs. J Sutherland (1808-91),
RD Grainger (1801-65), and J Milroy), were openly
and pronouncedly anticontagionist. Grainger made
the same point in his Hunterian Oration of 1841. The
Board of Health was not the least surprised by the
increased morbidity and mortality of 1848-49 as
compared to 1831-32. Far from attributing it to a
relaxation of quarantines, it attributed it to the
increase since 1831 of those conditions which it
regarded as the causes of the disease and sources of
the ‘‘miasma’’: overcrowding, filth, dampness, faulty
drainage, vicinity of graveyards, unwholesome water,
and unwholesome food.85 The Board and its medical
followers were strengthened in their beliefs through
the fact that they had been able to predict such an
increase in morbidity and to designate in advance the
very houses where cholera would break out.86
(Usually houses infected also with typhus.) Their
own ‘‘model buildings’’ – buildings struck in 1831,
but remodeled since – remained this time free after
sanitation.87 The anticontagionists of the General
Board of Health were pragmatists insofar as their
emphasis was no longer on a discussion of the
scientific problem of contagion, but on exposing and
removing those conditions whose elimination would
prevent cholera, no matter what the rationale. It is in
this spirit that they were enthusiastically followed, eg
by the British and Foreign Medico-Chirugical Review.88
This group thus illustrates most clearly the positive
side of anticontagionism, although this positive
tendency existed in all outstanding anticontagionists
(eg B Rush, Chervin, the Barcelona Manifesto of 1822,
etc.). The sanitary activities of the General Board of
14 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
Health, at least as objectionable a ‘‘waste of money’’
to the merchant class as quarantines, also show that
the anticontagionists were more than mere mouth-
pieces of a ruthless and economy-minded bourgeoisie.
The depth of anticontagionism in the England of 1848
is visible from the fact that the conservative London
College of Physicians, Maclean’s old pet enemy, came
out in October, 1848 with a document admitting the
impotency of cordons and quarantines.89 And yet
1849 sees also the first publications of J Snow on
cholera which were probably among the most
effective gravediggers of anticontagionism.
1848-49 brings a reconfirmation of anticontagionism
also in France. AA Tardieu (1818-1879), the great
French hygienist, states in his interesting 1849 book
that ‘‘it is very evident that measures taken in view of
the contagion are entirely without avail, and that
consequently the contagion itself is very improbable’’.90
He was joined in this opinion eg by the hygienists
P Jolly (1790-1879) and JL Collineau (1781-1860), and
the clinicians Martin-Solon (1795-1856), E Emery
(1780-1856)91 and JHE Monneret (1810-68).92
In Germany the Medizinische Zentral Zeitung was
anticontagionist in regard to cholera.93 So was the
bright young star of German science, Rudolf
Virchow.94 CF Riecke’s (born 1802) anticontagionist
writings were successful. The famous and very
influential chemist Justus Liebig came out for antic-
ontagionism.95 The majority of Russian physicians
was anticontagionist.96
A Cholera Quarantine Conference, organized in Paris
by Mélier in 1851, was practically without result,
mostly because of English anticontagionist opposition
under Sutherland. This is understandable in view of
the fact that the evidence on the effect of quarantines
in the first two pandemics remains rather contra-
dictory and bewildering. Copenhagen was free of
cholera with quarantine in 1831, heavily struck in
1852 after abolition.97 Belgium reported good experi-
ences with quarantine in 1831 and 1848.98 On the
other hand, Tardieu and Lasègue (the latter had made
a personal study of the problem in Russia) claimed
that there was no difference between the 1830
epidemic (with cordons) and the 1848 epidemic
(without cordons).99 Copeland’s explanation of the
higher mortality in 1848 because of relaxation of
quarantines100 is balanced by the above-mentioned
argument of the Board of Health. The Austrian
emperor, the Prussian king, the French government
(1832), the Dutch government, the London College of
Physicians – all admitted publicly the ineffectiveness
of quarantines and cordons.101
It seems that during the third cholera epidemic
(1852-55) and even more so during the fourth (1865-
67) – these two connected with major wars while
their two predecessors had been connected with
revolutions – the majority of the profession returned
to contagion. Winslow has traced recently John
Simon’s gradual development from anticontagionism
in 1849 to contagionism in 1865.102 This seems to be
fairly typical, though some, of course, changed their
positions earlier, some later, some never.
It is significant that the Archives Ge´ne´rales, still under
Raige-Delormé’s leadership, softened their attitude
toward contagion considerably and progressively after
1850, being 100% contagionist by 1865. In 1853 the
Royal College of Physicians made a strongly antic-
ontagionist statement on cholera.103 The rôles had been
reversed within 60 years, the College and government
being now anticontagionist, the profession increasingly
contagionist. A Hirsch stated in a survey in 1854 that
after a prevalence first of contagionists, then of antic-
ontagionists, now some compromise theory was
ruling.104 He quoted Snow still disparagingly.105 Only
two years later the same author claimed that the
majority were contagionist (though he still gave a long
list of anticontagionists) and spoke with the greatest
sympathy of Snow’s and Budd’s work.106 Although CF
Riecke adopted formally an eclectic position in his 1854
book (spontaneous generation plus contagion plus
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epidemic constitution) his violent opposition to quar-
antine revealed his fundamentally anticontagionist
position which to a large extent he derived from
Hecker and Haeser. On the other hand, he had an
inkling of the rôle of the healthy typhoid carrier.107 This
most important and revolutionary notion of the healthy
carrier was more fully developed by Pettenkofer for
cholera in and after 1855.108 In 1857 Griesinger felt
that since about 1852 the contagiosity of cholera was
generally recognized.109 In 1859 Milroy held cholera to
be ‘‘feebly contagious,’’ but continued to oppose quar-
antines.110 In his 1861 book on puerperal fever even I.
Semmelweis called cholera still ‘‘non-contagious’’.
SA Fauvel’s (1813-84) report of 1866 seemed to many
definitely to prove contagiosity of cholera. Mélier
reintroduced cholera quarantines in 1866, having
re-established those for yellow fever for 1853. One of
the most signal defeats of anticontagionism was the adoption of
the importation and contagiousness of cholera by the Anglo-
Indian medical men in 1866, after a resistance of more than 60
years.111 And Virchow, the anticontagionist of 1848,
admitted in 1869 that ‘‘all the more recent research
suggests an independent organism, especially a
fungus’’ (as the cause of cholera).112 That anticon-
tagionism died hard is visible from the fact that the
French Academy still received 36 anticontagionist (as
against 109 contagionist) reports in an 1884 outbreak of
cholera (Philippe Ricord (1800-89) defended in these
discussions the non-contagiousness of cholera), and
that the British government denied the imported
character of a cholera epidemic in Egypt as late as 1885.
PLAGUE AND
ANTICONTAGIONISM
When plague struck the English and French troops
during the Napoleonic expedition in Egypt in 1798-99,
the medical commanders of the French (Assalini,

Desgenettes) as well as of the English troops (Sir
Robert Wilson) agreed that the disease was non-
contagious.113 This fact can be found in the 1819
report of a committee of the House of Commons on
plague and quarantine, representing ‘‘the first official
inquiry ever made concerning this institution’’.
Although the result of this inquiry was procontagio-
nist, the mere fact of having obtained it at all was a
considerable performance. It was due to the persever-
ance of Charles Maclean (born c. 1768) who deserves
some more detailed attention because of the great rôle
he played in the development of anticontagionism.
Maclean had entered the service of the East India
Company in 1788, studied yellow fever in Jamaica in
1790, and worked in India since 1792. In 1796 he
published his first anticontagionist book in Calcutta,
114
which obviously found wide attention in and outside
of India. An American edition appeared in 1797 and a
German translation in 1805. Expulsed from India in
1798 because of a radical political pamphlet, he drifted
around observing, writing, agitating, serving with the
English army in 1804-5, and joining eventually the
Levant Company in 1815. In the Eastern Medi-
terranean he did serious research on the contagiosity
of plague, which he promptly contracted in an Istambul
plague hospital, and on which he published a two-
volume book in 1817.115 This book induced the
Government to consult the arch-contagionist London
College of Physicians in 1818 on plague and quar-
antines, and resulted in the above mentioned Commit-
tee of the House of Commons in 1819. We have
encountered Maclean already in the Barcelona yellow
fever epidemic of 1821, and obtaining rejection of a
quarantine law by the Cortes, Oct. 18, 1822. Maclean
seems to have died shortly before his final triumph,
that is the relaxation of the plague quarantine by the
British government in 1825.
There is no lack of evidence that Maclean made a
deep and lasting impression on his contemporaries.
Séguier, the French consul general in London,
reported in a letter to his government of May 20,
1825, ‘‘the opinion of Dr Maclean, who pretends that
plague is not contagious, is prevalent in England’’.116
Tweedie, himself a contagionist, stated for the same
period the ‘‘more general disbelief in the contagious
nature of the plague’’.117 A collaborator of the Lancet
in 1825 declared on the authority of Maclean that
cholera was not contagious.118
Maclean gave a summary of his opinions in a
memorandum to the Spanish Cortes in 1822 during
his campaign against the pending quarantine laws.119
He differentiated ‘‘epidemic’’ from ‘‘contagious’’ dis-
eases. While the true contagious diseases (syphilis,
smallpox, etc) had a specific virus (Maclean was one
of the few at the time to poke fun of the idea of
spontaneous generation of disease virus120); had a
clear-cut clinical picture; occurred independently of
season, the state of air, and other circumstances; and
struck a person but once; the ‘‘epidemic’’ diseases
ANTICONTAGIONISM BETWEEN 1821 AND 1867 15
(primarily yellow fever, plague, typhus, and cholera)
had protean forms, were clearly seasonal, and could
attack the same person repeatedly. The burden of the
proof that these diseases were contagious was, in
Maclean’s opinion, with the other party. But he drew
attention to such facts as that attendants, doctors, the
family of the sick, etc. experienced in his ‘‘epidemic’’
diseases no above average morbidity (quite different
in this respect from ‘‘contagious’’ diseases like
smallpox); these epidemic diseases remained localized
and seasonal. They would not spread in time and
space without limit, as they should, were they
contagious. Maclean also claimed that plague fomes
proved to be harmless in Turkey, recurrence of plague
in the same person frequent, and quarantines
completely ineffective to prevent epidemic diseases.
In his positive theories Maclean was far less
consistent: plague was to him entirely dependent on
atmospheric influences;121 Irish typhus resulted from
want of food, employment, and hope;122 yellow fever
from filth;123 and cholera from ‘‘local causes’’ and
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‘‘winds’’.124 Quarantines were really the cause of 19/
20 of all cases in epidemics by enforcing confinement
in pestilential air; producing concealment of the
disease, desertion of the sick, and deadly terror.
Quarantines were amoral, ineffective, and the source
of enormous gratuitous expenses and vexation.
Maclean’s ideas were too extreme, his character too
unbalanced, his death too early to effect the general
change of ideas concerning the contagiosity of plague.
This deed is attributed by Griesinger to Clot-Bey. AB
Clot (1793-1868), French-born and educated, had
become the chief army surgeon of the Egyptian
dictator Mehmet Ali in 1825. His abilities as a
surgeon, his work as an organizer of sanitary
improvements, of a medical school, a school of
pharmacy, and a school for midwives in Egypt won
him international fame. In a great plague epidemic in
1835 Clot’s countryman, LR Aubert-Roche (1809-74),
another remarkable character, convinced him of the
non-contagiosity of plague and the uselessness of
quarantines. From now on Clot-Bey spent a great deal
of his considerable energies and prestige on fighting
the theory of plague contagion and plague quaran-
tines. His last book, written in 1866, two years before
his death, at the age of 75, is called Derniers mots sur la
peste [Last words on the plague]. In their antic-
ontagionist attitude Clot-Bey and Aubert-Roche seem
to have been in full harmony with the majority of the
European physicians practicing in Egypt. Egypt was
for centuries regarded as the home of plague, like the
West Indies ranked as the home of yellow fever, and
India as the home of cholera. And the Egyptian
physicians were anticontagionists in regard to their
main ‘‘native’’ disease, like the West Indians and
Anglo-Indians had been in the corresponding case.125
England and Austria had abolished plague quar-
antine in 1841. In France it was felt that clarity on
the subject was needed before one could overcome
16 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
administrative opposition, especially in Marseilles, to
similar changes. The Academy of Medicine charged a
committee with a report which was submitted by CR
Prus (1793-1850) in 1846, hotly debated for many
months, and eventually adopted after the usual bick-
ering with the contagionist government and smooth-
ing of formulations. This report, which among other
things served as a model of Virchow’s famous Upper
Silesia report of 1848, followed in its details more the
brand of anticontagionism as represented by Aubert-
Roche, a ‘‘localist’’, ‘‘miasmatist’’, and sanitary refor-
mer, than the one of Clot-Bey, a ‘‘tellurist’’ and
Hippocratic believer in ‘‘atmospheric conditions’’.
Prus’ main conclusions were that plague was not
imported either in Egypt or Syria or Turkey, but arose
spontaneously out of humid houses, putrifying animal
matter and other filth. That neither contagion nor the
contagiousness of fomes nor the inoculability of
plague were proven; that the miasma was propagated
through the air, not through patients; that ships were
dangerous only in ports suffering themselves from an
epidemic constitution; and that, therefore, progress of
civilization was the only preventive against plague,
and Egypt needed mostly a good administration. In
the discussion the main champions of contagionism
were Pariset and Bousquet, of anticontagionism F
Dubois d’Amiens (born 1799; he became the successor
of Pariset one year later), Londe, Piorry, and Rochoux.
In adopting the Prus report on plague the Academy
sided again with anticontagionism, as it had done in
the case of yellow fever in 1828 and cholera in 1832.
The discussion lost much of its practical value
through the long absence of plague epidemics in
Egypt after 1845.
TYPHUS AND
ANTICONTAGIONISM
An analysis of the attitude towards typhus in our
period is made somewhat difficult by the fact that
explicit differentiation between typhus and typhoid
was rare even in the 1850’s, in spite of the classic work
of Bretonneau (1826), Louis (1829), and particularly
WW Gerhard and Pennock (1837). Still, the disease to
which we now apply the term typhus was so obviously
contagious that it was recognized as such even by an
arch-anticontagionist like Rochoux,126 (who, by the
way, was one of the first to separate typhus and
typhoid). Typhoid, on the other hand, seemed so little
contagious that its ‘‘non-contagiousness’’ served long
as one of the differentiating criteria. Especially the
Paris School (eg Andral, Chomel in 1834) upheld its
non-contagiousness.127 Murchison found it only
‘‘feebly contagious’’ in 1862,128 and in 1863 the
contagionist Charcot had still to report on many
typhoid anticontagionists.129
The idea of the non-contagiousness of true typhus
developed thus late, rather as a by-product of the
general anticontagionist wave, and was of relatively
short duration. Among the first to deny the con-
tagiosity of typhus were Elliotson,130 and Corrigan,131
the great Irish clinician and statesman who saw in
famine the sole cause of the terrifying Irish outbreaks
of 1800, 1817-18, and 1826.
When Virchow, at the occasion of the Upper Silesia
epidemic of 1848, declared that ‘‘no facts exist that
prove contagion, and certain experiences speak against
contagion’’,132 he was well aware of the novelty of the
statement. He was, on the other hand, not a little proud
of it, regarding it as truly scientific and modern. The
anticontagionism of Grainger, Adams, and Armstrong
in regard to typhus showed that the English sanitary
movement was equally radical.133
The contagionist Millies, in discussing the problem in
1857, stated that numerous anticontagionists did still
exist, especially in Paris.134 This might, of course, be a
confusion with typhoid. But Murchison (also a
contagionist) made the same statement in 1862.135
And it is reiterated by Foerster in 1863.136 Yet by 1868
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Virchow, one of the authors of anticontagionism in
typhus, declared: ‘‘There is much exaggeration, yet the
fact remains that the typhus diseases and especially
petechial fever may become contagious; that some-
times they may acquire even this quality to the highest
degree’’. And by 1871 he admitted: ‘‘As much as I
hesitated formerly to admit that contagion is the
ordinary way in which typhus epidemics develop, I
must confess today that I, like so many earlier
observers, am more and more forced, through contin-
uous experience, into the contagionist camp.’’137
PRACTICAL AND THEORETICAL
ASPECTS OF ANTICONTAGIONISM
After having studied the scientific triumphs of antic-
ontagionism in the 1820’s, 1830’s, and 1840’s, and its
decline in the 1850’s and 1860’s, it might be indicated
to summarize the practical results obtained by the
anticontagionists in the relaxation and abolition of
quarantines and cordons, which, after all, was their
main goal.
The first to change their quarantine acts were the
English and the Dutch in 1825.138 Further relaxations
occurred after 1831 and 1841.139 From 1849 on up to
the 1880’s English official bodies came out with anti-
quarantine declarations. The first changes in France
occurred in 1828 and 1832. In 1835 even Marseilles,
super-contagionist since the plague of 1721, softened
her quarantines.140 In 1849 quarantines were sup-
pressed altogether, reinstated in 1850, abolished for
cholera again in 1853, and reinstated in 1866.141 In
the general disappointment with quarantines and
cordons after 1831 large concessions were made to the
anticontagionists in Austria (1841) and Russia (1847).
The practical successes of anticontagionists were
not limited to their victories over quarantines.

Their operations against ‘‘filth’’ increased greatly their
prestige. While it was difficult for the contagionists to
prove that a respective epidemic would have been
even worse without quarantines, health improve-
ments after removal of ‘‘filth’’ seemed to be causally
related to the latter action. Barcelona and Alicante did
not experience further yellow fever epidemics after
such campaigns in 1827, respectively 1804. The
General Board of Health could point in the cholera
of 1848-49 to the immunity of its cleaned ‘‘model
houses’’. (Those parts of Hamburg that had burned
down after 1831 and had been rebuilt also remained
healthy in 1848.)142 Typhus morbidity143 and mortal-
ity144 had considerably decreased from the 1840’s to
the 1860’s, thanks to the sanitary measures of the
anticontagionist Board of Health and its successors.
The anticontagionist Aubert-Roche had an enviable
health record during the construction of the Suez
Canal in the 1850’s and 1860’s.
In examining critically the theoretical foundations
of anticontagionism, we should be aware of the fact
that certain basic weaknesses were common to both
parties, anticontagionists and contagionists. Both
parties occasionally used unreliable information. Both
parties were still obsessed with the Hippocratic idea of
the air as primary medium of transmitting the noxious
element, whether miasma or contagium, at the expense
of any other possibility (this idea prevails even with
Henle and Holland). In both parties those were still
numerous who believed in the fundamental unity of
fevers145 Both parties suffered from the ‘‘fallacy of a
single cause’’.146 Both parties were reduced to reason-
ing by analogy, a procedure the dangers of which were
clearly shown by Wunderlich.147 Both parties used the
animal experiment still very little, and what experi-
menting they did lacked method and inventiveness.
Though the experiments of the next generation did not
solve all problems either, they afforded an uncompar-
ably higher degree of certainty than the mere observa-
tions on which both parties based their reasoning.
Among these observations the contagionists would
usually pick a set of more or less true facts that
confirmed their theory, leaving out another set of
equally true, but incompatible facts, which in their turn
the anticontagionists would triumphantly present as
proof of their theory. Or, ‘‘facts’’ and ‘‘observations’’
being highly complex and ambiguous, both parties
would take up the same fact, but succeed in inter-
preting it in the contrary sense.148 One of the truest
statements in this direction is that of Wakley that the
most disturbing facts (like low morbidity of atten-
dants) were fundamentally not explained by either theory.149
Some have not been explained up to this very day.
‘‘Observations’’ depended also to a large extent on the
location of the observer. Brochard writes in 1851: ‘‘Les
médecins conduits par leur observation à la croyance
d’une forme contagieuese habitent tous de petites
localités . . . rien ne manque à leurs enquêtes; mais
l’autorité manque à leurs paroles.’’ [Their observations
ANTICONTAGIONISM BETWEEN 1821 AND 1867 17
led doctors to a belief in a contagious form in all small
localities . . . nothing was lacking in their observations,
but their words lack authority.]150 Griesinger too
explains anticontagionism through the rule of big city
doctors. ‘‘But in Paris, as in all big cities, the facts of
contagion of as frequent a disease (as typhoid) can
rarely be observed conclusively.’’151 The great triumphs
of a rapidly growing chemistry, the influence of a
Liebig, the recent victories over ‘‘vitalism’’ would
particularly militate against a biological explanation
of epidemics as given by the contagium vivum.
I am afraid that, forced to decide ourselves a
hundred years ago on the basis of the existing
materials, we would have had a very hard time.
Intellectually and rationally the two theories balanced each
other too evenly. Under such conditions the accident of
personal experience and temperament, and especially eco-
nomic outlook and political loyalties will determine the
decision. These, being liberal and bourgeois in the majority
of the physicians of the time brought about the victory of
anticontagionism. It is typical that the ascendancy of
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anticontagionism coincides with the rise of liberalism,
its decline with the victory of the reaction. Of course,
the latter was not the only factor of the decline
of anticontagionism. Was it new discoveries as
Bernheim and others declared? Certainly, Snow and
Budd made quite an impression. Yet, some doubts are
at least allowed, in view of the fact that the change
was prior to the decisive discoveries of Pasteur, Koch,
etc. The discoveries of Davaine and Villemin
were isolated and little known. Henle’s crown
witnesses, the itchmite or the fungi in skin diseases,
could most easily be dismissed as inconclusive and
bad analogies by the anticontagionists,152 when even
a contagionist like Trousseau reacted to these dis-
coveries only by no longer counting scabies and favus
among the contagious diseases, but transferring
them to the parasitary group.153 Roy states quite
correctly in 1869:
‘‘Mais la difficulté que les fauteurs de cette doctrine
(Henle and Holland) éprouvèrent à généraliser des
faits de parasitisme externe aux maladies du sang la
laissa tomber assez longtemps dans l’oubli et tous les
pathologistes s’en tinrent à la théorie que M. Liebig
commença à développer dès 1839.’’
[But the difficulty for the instigators of this doctrine
(Henle and Holland) proved to be to generalise the
fact of external parasitism to diseases of the blood. It
had lain forgotten for so long, and all the pathologists
stuck to the theory which M. Liebig began to develop
in 1839.] 154
A. Hirsch makes a somewhat revealing statement in
1856: ‘‘The more the belief in the contagious nature of
cholera became widespread in the medical world, the
smaller became the number of facts in which contagious
genesis could not be proven.155 This suggests that to a
certain extent emotional conversion, based on the
accumulated despair of repeated cholera epidemics
and on the normal ‘‘swing of the pendulum,’’ preceded
18 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
intellectual insight and discovery, rather provoking
than being provoked by the latter. While contagionism
had ‘‘pragmatically’’ hardly done better than antic-
ontagionism, it could claim one major accomplishment
at this turning point: it had kept alive interest in that
part of experimental research that would bring the
solutions of the future. Henle had produced Koch.
Far from underplaying the economic implications of
their fight, the anticontagionists usually emphasized
readily this popular aspect of the problem. They wrote
long and detailed dissertations of exactly how many
millions of pounds, francs, or dollars were yearly lost
through the contagionist error.156 Chervin, who
characterized the whole as a political, administrative,
moral, medical, and commercial problem,157 was not
afraid of such revealing word combinations as
‘‘question du plus haut intérêt pour l’humanité et le
commerce’’ [question of the greatest interest for
humanity and for trade] or ‘‘entraver le commerce
et consacrer une erreur funeste à l’humanité’’. [to
block commerce and to create a disastrous error for
humanity.]158 Gaultier wrote in 1833: ‘‘Quarantine is
useless, and the injury it inflicts on the commercial
relations and maritime intercourse of the country is
an absolute and uncompensated evil.’’159 Anticonta-
gionist medical journals reprinted speeches of
commerce-minded deputies.160 Liberal and commer-
cial newspapers like the Journal de Commerce, the
Constitutionel, and the Courier supported Chervin in
1827. French medical authors of the 60’s and 70’s saw
very clearly the connections between anticontagion-
ism and commercial interests – in England.161 Still, to
call the anticontagionists simply ‘‘mouthpieces of
commercial interest’’ would be a regrettable over-
simplification of the situation. To many of them both
slogans: freedom of commerce (no quarantines), and
freedom of science (anticontagionism) were, together
with others, like freedom of the individual (against
any bureaucracy), the natural expression of the same
fundamental attitude and social position. Some, as
the following quotation from Maclean shows, were
perhaps not so much interested in commerce at all,
but tried, in appealing to commercial interests, to
mobilize every possible ally:
‘‘I am rather at a loss to conceive how their being
injurious to commerce could, in a commercial country,
be regarded as an argument against seeking the
abolition of otherwise pernicious establishments . . ..
For my part, far from thinking it culpable to have
availed myself of the support of commerce in combat-
ting the ridiculous but very pernicious dogmas of
medical schools . . .. I am very free to confess that I
have, upon this occasion, diligently sought to range
every interest, over which I could exercise the smallest
influence, on the side of truth.’’162
It should also not be overlooked that into the
contagionist attitude no less earthly factors entered,
like the needs of real estate interests in denying ‘‘local
causes’’ of epidemics.
The political background of the anticontagionist
discussion was no less obvious. The leading anticonta-
gionists – Maclean, Chervin, Magendie, Aubert-Roche,
Virchow, etc. – were known radicals or liberals. The
leading contagionists (with the lone exception of the
liberal professor Henle) were high ranking royal
military or navy officers like Moreau de Jonnès,
Kerandren, Audouard, Sir William Pym, Sir Gilbert
Blane, or bureaucrats like Pariset, with the corre-
sponding convictions. The anticontagionists skillfully
interspersed political arguments in their discussion.
Maclean did not tire to trace contagionism back to the
Pope’s political maneuver of transferring the Council
of Trent in 1547, made possible by the ad hoc con-
tagionist theories of his servant Fracastorius,163
published, by the way, in 1546. This was also a fine
occasion to mobilize anti-catholic and antireligious
emotions. Appealing to the ‘‘irreverence of the age for
mere authority,’’164 Maclean thundered against the
‘‘monopoly’’ of the College of Physicians.165 The same
spirit was kindled by reminders of the shooting of
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three anticontagionists in Thorea in 1815, the same
act of violence in Noja in Apulia in 1815, the burning
of Dr Armesto’s anticontagionist book in Spain in
1800, and the hanging of an anticontagionist doctor
and tailor in Brandenburg in 1707.166 To Maclean the
very worst aspect of the quarantines was that they
were ready ‘‘engines of despotism’’.167 Chervin
expressed freely his disgust with the ‘‘servile spirit’’
that penetrated French contagionists, but satisfied
himself that those in power would not be there
tomorrow.168 Writing this three years before 1830, he
proved not too bad a prophet.
Economic factors did not only determine the stand
of many in the anticontagionism discussion. Economic
factors were consciously used by many to give a causal
explanation of epidemics in our period (see Maclean
above, Villermé, Magendie, etc.). This ‘‘sociological’’
(as contrasted to biological) theory of epidemics can
be found already in the 18th century under the
influence of enlightenment. (JP Frank, Chassanis,
Targioni-Tozzetti). Yet its spread is a feature of the
19th century. I have already discussed in my doctor’s
thesis in detail Virchow’s famous social epidemiolog-
ical ideas, which were one of the reasons for his later
reluctance to accept the results of bacteriology,169 and
more recently Virchow’s French predecessors.170 In
listing the epidemiological theories of the 19th
century, I feel it would be justifiable to add to the
two great divisions: the physico-chemical or geographic
(including the ‘‘tellurists’’ and ‘‘miasmatists’’) and
the biological (parasitists, bacteriologists), a third one,
the sociological, represented by such men as Virey,
Villermé, Mélier, Aubert-Roche, Alison, Davidson, and
Virchow. The lines of division will not always be
clear-cut and coincide with other lines of division. A
‘‘sociologist’’ might, for instance, be a contagionist
(Davidson) or, more often, an anticontagionist.171 The
essential characteristic of the sociologist is that all

these problems become of a very secondary impor-
tance when compared to social factors. Typical in this
respect are: the message of Gerardin and Gaymard
from Poland: ‘‘Les Commissaires pensent que le
principal préservatif du cholera consiste dans l’amé-
lioration de la condition sociale des populations.’’
[The Commissioners think that the principal protec-
tion against cholera lies in the improvement of the
social condition of the people.]172 Aubert-Roche’s
motto for his plague book, which is also the basis of
the Prus report of 1846: ‘‘La civilisation seule a détruit
la peste en Europe, seule elle l’anéantira en Orient,’’
[Civilisation alone destroyed the plague in Europe, it
is the only thing which will destroy it in the East]. or
the typhus studies of Alison, Bateman, Corrigan,173
and Franque.174 I cannot take up the whole Virchow
complex here again, but I would like to refer at least
to such typical features as the conclusions of his 1848
report, his paper on the epidemics of 1848,175 his
thesis that social conditions determine whether
typhus or typhoid develops,176 his interpretation of
cretinism as a social disease,177 etc. The sociological
theory, claiming a kind of ‘‘social epidemic constitu-
tion,’’ suffers often from the same haziness that is so
characteristic of the theories of telluric ‘‘epidemic
constitution.’’
This strange story of anticontagionism between 1821
and 1867 – of a theory reaching its highest degree of
scientific respectability just before its disappearance;
of its opponent suffering its worst eclipse just before
its triumph; of an eminently ‘‘progressive’’ and
practically sometimes very effective movement based
on a wrong scientific theory; of the ‘‘facts,’’ including
a dozen major epidemics, and the social influences
shaping this theory – offers so many possible
conclusions that I feel at a loss to select one or the
other, and would rather leave it to you to make your
choice. I am convinced that whatever your conclu-
sions, whether you primarily enjoy the progress in
scientific method and knowledge made during the
last hundred years, or whether you prefer to ponder
those epidemiological problems, unsolved by both
parties at the time and unsolved in our own day, all
your conclusions will be right and good except for the
one, so common in man, but so foreign to the spirit of
history: that our not committing the same errors
today might be due to an intellectual or moral
superiority of ours.
Notes
1 Existence of Pestilential Contagion Deduced from the
Dict.Encycl.Sc.Med (A. Dechambre ed) 1. Ser., vol.
XX, p.7, 1877.
2
Scott, H.H., A History of Tropical Medicine, Baltimore,
1942, p.29.
3
Lancet 1831-32, II, p.21; see also Holland, H., Med.
Notes and Reflections, Phila. 1839, p.342.
4 30
Ozanam, J.A.F., Histoire me´dicale des maladies epide´mi-
ques, Paris, 1835, III, p.6. On Ozanam see Galdston, I.,
ANTICONTAGIONISM BETWEEN 1821 AND 1867 19
in Essays presented to A. Castiglioni (Supp. Bull. H. Med.
No. 3), Baltimore, 1944, pp.89-102.
5
Arch. Phys. Heilk. 2:321, 1843.
6
Mitchell, J.K., Five Essays, Phila. 1859, p.111.
7
Ibid., p.4.
8
Brit. For. Med. Chir. Rev. 4:252, 1849.
9
Riecke, C.F., Die Reform der Lehre von der Contagion,
Quedlinburg, 1854, pp. XVII, 177. See also
Virchow’s diatribe against unscientific, antiquated
contagionism (in his Archiv, 2:263; 1849)
10
Greenwood, Epidemics and Crowd-Diseases, N.Y., 1935,
p.58.
11
Singer, Ch. and D., The Development of the
Doctrine of Contagium vivum, 1500-1750., 17th
Int. Med.Congress (1913), Sect.XXIII, p.188, London,
1914.
12
Singer, l.c., p. 205
13
Most of the above data are taken from Singer 1914,
Singer, Ch. and D., The Scientific Position of
Girolamo Fracastoro, Ann. Med. Hist. 1: 1 ff., 1917,
and Loeffler, F. Vorlesungen ueber die geschichtliche
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Entwicklung der Lehre von den Bakterien, Leipzig, 1887.
14
The crisis aspect of this period has been empha-
sized by Shryock, e.g. in his Development of Modern
Medicine (Phila. 1936). See also Ackerknecht, E.H.,
Beitraege zur Geschichte der Medizinalreform von
1848, Sudhoff’s Archiv 25 (1932), chs. III and IV.
15
Welch, W.H., Public Health in Theory and Practice,
New Haven, Yale University Press, 1925, p.27.
16
Winslow, C.-E., A., The Conquest of Epidemic Disease,
Princeton, Princeton University Press, 1943, p.182.
17
Griesinger, W., Infektionskrankheiten, Erlangen, 1857,
p. 120.
18
Dictionnaire de me´decine, Paris, 1834, Vol, VIII, p.503.
19
Archives générales de médecine, 28:286, 1832
20
Thomassen, E.H., Untersuchung ob das gelbe Fieber
ansteckend sey., Bremen, 1832, p.27.
21
Chervin, N., Examen des principes de l’administration
en matie`re sanitaire, Paris, 1827, p.29.
22
La Roche, R., Yellow Fever Considered in its Historical,
Pathological, Etiological and Therapeutical Relations,
Philadelphia, 1855, Vol. II, p.527.
23
Ibid., p.262.
24
Lancet, 1834-35, I, p.862; Lancet, IX, 1825-26, p.134.
25
Tardieu, A., Treatise on Epidemic Cholera, Boston,
1849, p.239.
26
Lancet, 1829-30, II, p.291
27
Hirsch-Gurlt, Biographisches Lexikon der hervorragen-
den Aerzte, Wien-Leipzig, 1888, Vol. VI, p.62.
28
La Roche, l.c., p.569
29
Maclean, Ch., Evils of Quarantine Laws and Non-
Phenomena of the Plague of the Levant, the Yellow Fever
of Spain, and the Cholera Morbus of Asia, London 1824,
p.136 Rochoux (Dictionnaire de me´dicine vol. 8, 1834,
p. 504) even adds rabies, scarlet fever, anthrax,
hospital gangrene.
Winslow, l.c., p. 193 ff.; Spector, B., Noah Webster’s
Letters on Yellow Fever, (Suppl. Bull. H. Med. No. 9),
20 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

66
Baltimore, 1947, and especially that extraordinary Ibid., 156, 178.
67
product of American medical scholarship: La Lancet, 1832-33, I., p.113
68
Roche’s book on yellow fever, Phila., 1855. Gaultier H., The Origin and Progress of the Malignant
31
Winslow, l.c., 236 ff.; Newsholme, A., Evolution of Cholera in Manchester. London 1833. G. regards the
Preventive Medicine, Baltimore, 1927, p. 121, ff. relation between the arrival of sick persons and a
32
La Roche, l.c., p.239, Devèze regarded also plague, new outbreak as purely coincidental in view of the
typhus, and dysentery as non-contagious. many exceptions (p.14). He accuses effluvia of
33
La Roche, l.c., 247 ff. gives long lists of tropical excrements as the source of the disease (p.112).
69
anticontagionists. Arch. Ge´n. 28: 430, 1832.
34 70
Ibid., p.237 See his 1832 book on cholera.
35 71
La Roche, l.c., 245. Lancet, 1843-35, I., p.224, 273.
36 72
Maclean, l.c., p.76. Tardieu, l.c., p.244.
37 73
La Roche, l.c., p.257 Arch. Ge´n. 29:122, 1832
38 74
Maclean, l.c., p.141. Maclean reprints the whole Arch. Ge´n. 4, ser. 11:370
75
manifesto, p. 122 ff. Lancet, 1831-32, II. P.148.
39 76
Chervin, 1827, p.15. Arch. Ge´n. 28: 608, 1832.
40 77
Archives Ge´ne´rales de Me´decine, 2 s., 1: 609, 1853. Arch. Ge´n. 27: 140, 1831
41 78
Lancet, 1832-33, I, p.373 Arch. Ge´n. 28: 452, 1832.
42 79
e.g. Arch. Ge´n. 16: 310, 1828; 22: 437, 1830. Arch. Ge´n. 2 s., 1:532, 1833.
43 80
For Réveillé-Parise, Londe, Villermé, and many Haeser, H. Lehrbuch d. Gesch.der Medizin. Jena,
other anticontagionists as hygienists see 1882, Vol III, p.921 ff.

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81
Ackerknecht, E.H., Hygiene in France 1815-49, Rogers, S., Report on the Asiatic Cholera in the Madras
Bul., Hist. Med., XXII, pp. 117-155, 1948. Army from 1828 to1844., London, 1848.
44 82
Charcot, J-M, Oeuvres comple`tes, Vol. VIII, p.144, Brit. For. Med. Chir. Rev., 1849, vol.4: 251 ff.
83
1889. Lancet, 1849, I., p.166, Lancet, 1848, II., p.502
45 84
Chervin, 1827:59. Tardieu, l.c., p.154.
46 85
Chervin, Lettre sur la fie`vre jaune qui a re´gne´ à See Report, pp.37-63
86
Gibraltar en 1828, Paris, 1830, p.16. For a good Report, p.18
87
analysis of the Gibraltar epidemic by the contagio- Ibid., p.69
88
nist Peter Wilson, with emphasis on ‘‘filth’’, see Brit. For. Med. Chir. Rev., Vol. V, p.216 ff., 1850, VII: 1
Lancet, 1829-30., I., p.395 ff. ff., 1851 These very eloquent articles are probably
47 the work of John Forbes. See also the significant
Brit. For. Med. Chir. Rev. 6: 428, 1850.
48
Scott, l.c., p.352. Southwood Smith quotation in Newsholme, l.c., p.
49
Gross, S.D., History of American Medical Literature, 126, for this pragmatic attitude.
89
Philadelphia, 1875, p.25 Ibid., p.32.
50 90
Milroy, G., Quarantine As It Is and As It Ought to Be. Tardieu, l.c., p.111.
91
London, 1859. Arch. Ge´n. 4.s. 20:110 ff., 1849
51 92
Mitchell, J.K., l.c., p.115. Arch. Ge´n. 4.s. 16:521, 1848
52 93
Dutrolau, AF., Traite´ des maladies des Europe´ens dans Schmidt’s Jahrb. 62:142, 1849.
94
les pays chauds, Paris, 1868 Virchow, Ges. Abhandlungen aus dem Gebiet der
53 oeffentlichen Medizin, Berlin, 1879, Vol.1, p.24.
Chervin, 1827, p.26. Maclean, l.c., p.397. Maclean
95
attributes this to his teachings and publications in Lancet, 1848,II., p.454.
96
India (Calcutta, 1796). See also Charles Searle, Brit. For. Med. Chir. Rev., 3:26,1849.
97
(Madras) Cholera, London, 1830. W Twining (1780- Scott, l.c., 699.
98
1835) Practical Account of Epidemic Cholera, London, Lancet, 1848,II., p.196.
99
1833, etc. Tardieu, l.c., p.111; Lasègue, Arch. Ge´n, 4.s.
54
Dict. Encycl. Sc. Méd. (Dechambre ed.) 3. ser. vol I, 18:114,1848
100
p.51, Paris, 1874. Lancet, 1849, I, p.292
101
55
Arch. Ge´n. 28: 131, 1832 Lancet, 1831-32, I., p.182; Arch. Ge´n. 27:137,1832.;
56
Arch. Ge´n. 27: 554; Lancet, 1831-32, I, p.17 Dict. Encycl. Sc. Me´d. 3. ser., Vol. I, p.51; Lancet,
57 1831-32, II., 572; GJ Mulder in Arch. Physiol. Heilk.,
Arch. Ge´n. 30: 138
58 1849, 8:489 ff.
Arch. Ge´n.28: 134, 1832; Lancet, 1831-32,I.,p.113 102
59 Winslow, l.c., p.255 ff.
Arch. Ge´n.28: 452, 1832, ib. p.451 103
60 Lancet, 1853, II, p.399
Lancet, 1832-33, I., p.372 104
61 Schmidt’s Jahrb. 84:90, 1854.
Lancet, 1831-32, I., p.261 105
62 Ibid., 84:92. The same does even the contagionist
Lancet, 1831-32, II., p.299, 301
63 Lancet, 1849, II, p.318.
Lancet, 1831-32, II., p.23
64 106
Ibid., 150. Schmidt’s Jahrb. 92:252, 259
65 107
Ibid., 147. Riecke, l.c., p.165.
 ANTICONTAGIONISM BETWEEN 1821 AND 1867 21

108
Griesinger, l.c., p.252, 254. Nightingale felt that all fevers had one cause.
109
Ibid., p.255. Murchison, l.c., p.4.)
110 147
Milroy, l.c., p.10. Wunderlich, l.c. p. 323.
111 148
Dict. Encycl. Sc. Me´d, 1. ser. Vol. 16, p.755, Paris Londe developed this point in Arch. Ge´n 4.s.,
1874. 11:489, 1846
112 149
Arch. f. path. An. 1869, 45:279 Lancet, 1831-32, II, p.156
113 150
Maclean, l.c., p.90. Arch. Ge´n. 4.s. 23:123
114 151
Maclean, Ch, and Yates, W., A View of the Science of Griesinger, l.c., p. 120. This does, of course, only
Life, Calcutta, 1796. mean that the tendency towards anticontagionism
115
Id. Results of an Investigation Respecting Epidemic and was stronger in big cities. There were also plenty
Pestilential Diseases. 2 vols. London 1817-18. of anticontagionists in small places. See e.g. Lancet,
116
Chervin, 1827, p.124. 1831-32, I, 796.
117 152
Lancet, 1826-27, 12:777 Riecke, l.c., p.30.
118 153
Lancet, 1825, 6:275 Dict. Encycl. Sc. Me´d. 1. ser. Vol.20, p.1-2,7,1877.
119 154
Reprinted in Maclean 1824, pp. 198-261. Roy F. Revue historique des diffe´rentes the´ories qui ont
120
Ibid., p.204. eu course pour expliquer l’origine des maladies infec-
121
Ibid., pp. 94, 219. tieuses. Strassbourg, 1869, p.15
122 155
Ibid., p.6. Schmidt’s Jahrb. 92:255, 1856
123 156
Ibid., p.129. Maclean, l.c., p. 30 ff.; Chervin in Arch. Ge´n.2.s.
124
Ibid., pp. 410, 414. 3:147.1833.
125 157
Riecke, l.c., 96; Lancet, 1828-29, I. p.390. Chervin, 1827, p. 132.

Downloaded from ije.oxfordjournals.org at Cornell University Library on October 4, 2011

126 158
Dict. de Me´d. XIX, p. 601 ff., 1839 Ibid., p. 107, 116.
127 159
Murchison Ch, A Treatise on the Continued Fevers of L.c., p. 34.
160
Great Britain, London 1862, p.428; see also e.g. Arch. Ge´n. 27:134, 1831.
161
Griesinger, l.c., p.120. Dutrolau, l.c., p. 444; Dict. Encycl. Sc. Me´d. 3.s., Vol.
128
Ibid., p.2. I, p.97-98
129 162
Charcot, l.c., p.19. Maclean, l.c., p. XXIII.
130 163
Lancet, 1829-30, II, 543. Ibid., p.6, 213.
131 164
Lancet, 1829-30, II, 600. Ibid., p.69.
132 165
Archiv. 2:263,1849 Ibid., p.21.
133 166
Lancet, 1849, I., p. 106, 202. Riecke, l.c., p. 5.
134 167
Schmidt’s Jahrb. 1857, 96:250 Maclean, l.c., pp. 35, 214, 271
135 168
Murchison, l.c., p.79. He alludes here to the Chervin, 1827, p. XVIII
169
‘‘Sanitary Movement.’’ Ackerknecht, E.H. Beitraege zur Geschichte der
136
Schmidt’s Jahrb. 1863, 117:94 Medizinalreform von 1848, Sudhoffs Arch.
137
Virchow, Ges. Abh. I, p.447,449 25:62-183, 1932.
138 170
Scott, l.c., p.752; Arch. Ge´n. 2. ser. 3:147, 1833 Id. Hygiene in France 1815-1848. Bull. Hist. Med.
139
Arch. Ge´n. 4.s. Vol. X, 487, 1846. 22:117-155, 1948. Especially for the post-1848
140
Dict. de Me´d. Vol. 19,7:601 ff., 1839 developments of these theories see the excellent
141
Dict. Encycl. Sc. Me´d., 3. ser., Vol. 1:136, 1874 study of G. Rosen: What is Social Medicine?, Bul.,
142
Brit. For. Med. Chir. Rev., 7:38, 1851 Hist. Med. 21: 674-733, 1947.
143 171
Murchison, l.c., p.8. Like the editorial writer of the Brit. For. Med Chir.
144
Dict. Encycl. Sc. Me´d. 2 s., Vol. 7, p.526, 1873 Rev. 5:217 ff., 1850.
145 172
As a matter of fact no anticontagionist ever made Arch. Ge´n. 28: 427, 1832.
173
a statement comparable in absurdity to the one of Murchison, l.c., p. 75.
174
Pariset that the Cadiz yellow fever was trans- Schmidt’s Jahrb. 96: 251, 1857.
175
formed cholera and imported by a ship from Ges. Abh. 1879, I., p.117 ff.
176
Calcutta (La Roche, l.c., p. 204). Ibid., p. 284-285.
146 177
Winslow, l.c., 250 (Another version of the same Ges. Abh., 1856:927
fallacy: S Smith, Henderson, and Florence
SOIIO
A HISTORY OF LONDON’S MOST
COLOURFUL NEIGHBOURHOOD

JUDITH SUMMERS

BLOOMS BURY

5 more.’
Downhill All the Way
There had always been poverty in Soho. Few of its foreign residents
had arrived with money in their pockets. Like all immigrants before
and since, they had to work extremely hard for their success. And
though some had achieved it, beyond their wildest expectations — But Theodore this moral learn’d e’er dead;
Domenico Angelo, Angclica Kauffman, Leopold Mozart, to name
but three others had found it hard, or impossible, to make ends
—
meet.
The King of Corsica was one such penniless foreigner though
— The threat of bankruptcy haunted ordinary people. The penalties
his stay in Soho was a very short one. Born Theodore Anthony
Neuhoff, he had spent his youth travelling round Europe first —
as a page in the service of the Duchess of Orleans, later as an
adventurer. At one point he even sold his wife’s jewels in order
to pay off his debts.
He ended up in Genoa, at a time when the republic was at war
with the island of Corsica. Fired by sympathy for the Corsican
prisoners of war he met there, he determined to become their
saviour, and set sail for their island with a cargo of 4,000 muskets
to help them fight off the Genoese. The islanders were so impressed
by his grand arrival that they invited him to become their King, an
offer which he naturally accepted. He was duly crowned with a
garland of laurel and oak leaves.
After a short reign, the Corsicans lost confidence in him, and
he was forced to leave the island under a cloud. He eventually
came to London, where he soon got into debt and ended up in
the King’s Bench Prison. He managed to get himself freed only by
registering ‘his kingdom of Corsica for the use of his creditors’.
Horace Walpole told the story of what happened next in a letter
to Sir Horace Mann: ‘As soon as Theodore was at liberty he took
a chair and went to the Portuguese minister, but did not find him
at home; not having sixpence to pay, he prevailed on the chairman
to carry him to a tailor he knew in Soho, whom he prevailed upon
Downhill All the Way —
to harbour him, but he fell sick the next day, and died in three
Theodore died on ii December 1756, and the kind tailor, who
lived in Chapel Street, was now landed with his corpse. Luckily,
an oilman from Compton Street called John Wright volunteered
to pay for the ‘King’s’ burial, and a grand tombstone was erected
at Walpole’s expense, bearing the following inscription penned by
Walpole himself.
The grave, great teacher, to a level brings
Heroes and beggars, galley-slaves and kings.
Fate pour’d its lesson on his living head,
Bestow’d a kingdom, and denied him bread.
were incredibly harsh, ranging from death by hanging to transporta
tion to the colonies and unlimited imprisonment. Still, to make
money one had to spend it first, and in doing so one ran a serious
risk of getting into debt, as Mrs Cornelys had found out to her
cost. For, despite the popularity of her assemblies, the contents
of Carlisle House had been seized several times under distress
warrants even in 1762. and 1763, two of her most successful
—
years. Her aura of wealth had in fact been a façade. As Casanova
had reported, she ‘who seemed to be living so luxuriously. was . .
in reality poverty-stricken’ and Sunday was ‘thc only day on which
Madame Cornelys could go abroad without fear of the bailiff’.
Still, in the i8th century Soho had for the most part been a
thriving area of prosperous people, and what poverty there was
had been limited and somewhat picturesque. Standards had been
kept up, even by the penniless but enterprising trompe l’oeil artist
Capitsoldi, who, because he could not afford to buy any furniture
for his ‘Warwick Street lodgings, ‘proceeded to paint chairs, pictures
I and window curtains on the walls of his sitting room . so. .
admirably executed that, with an actual table and a couple of
real chairs, he was able to entertain on occasion a friend in an
apartment that appeared adequately furnished’.
By the time philosopher Thomas Dc Quinicey arrived in London
in i8oz, the cast of Soho’s poverty had changed and the area was
 Soho — Downhill All the Way —

well on the way to becoming what the Reverend Cardwell, vicar The building which Dc Quincey entered at
dusk that first evening
of St Anne’s, would one day call ‘a prolific place for suicides’. evokes a vivid picture of a Soho house at a
A gifted child from a comfortably-off family, Thomas De Quincey poignant turning point
in the area’s history:
was from birth ‘an intellectual creature: and intellectual in the highest
sense my pursuits and pleasures have been, even from my schoolboy Unoccupied, I call it, for there was no household
days’, as he wrote of himself. He was a brilliant scholar, who by or establishment
in it; nor any furniture, indeed, except a
table, and a few chairs.
the age of 15 ‘not only composed Greek verses in lyric metres, But I found, on taking possession of my
new quarters, that the
but could converse in Greek fluently and without embarrassment’. house already contained one single inmate, a
Yet he suffered from what he called a ‘chronic passion of anxiety’ poor, friendless child,
apparently ten years old; but she seemed hunger
coupled with a rebellious temperament which drove him away from bitten; and sufferings
of that sort often make children look older than
respectability and towards the hidden underbelly of life. By the age of they are. From this
forlorn child I learned, that she had slept and
17 he had had enough of his grammar school in Manchester, and after
lived there alone for
some time before I came: and great joy the
quarrelling with one of his guardians, who demanded ‘unconditional poor creature expressed,
when she found that I was, in future, to be
submission’ from him, he did what many thousands of teenagers her companion through
the hours of darkness. The house was large;
before and since have done: he ran away and dropped out. and, from the want of
furniture, the noise of the rats made a prodigious
His first stop was Wales. Then, when he had spent most of the echoing on the
spacious staircase and hail; and, amidst the real
allowance his mother had given him, he came to London, a city fleshly ills of cold,
and, I fear, hunger, the forsaken child had found
which, then as now, exerted a gravitational pull on the young leisure to suffer still
more (it appeared) from the self-created one of
and disaffected. Here he ended up practically penniless and almost ghosts. I promised her
protection against all ghosts whatsoever! but
starving, at the offices of an attorney and money-lender known alas! I could offer her
no other assistance. We lay upon the floor,
sometimes as Mr Brown and at other times as Mr Brunell, whose with a bundle of cursed
law papers for a pillow: but with no other
premises were on the east corner of Greek Street and Soho Square. covering than a sort of
large horseman’s cloak . .The poor child crept close to me for
.

The house [De Quincey wrote in his Confessions of an English
Opium Eater] was not in itself, supposing that its face had been
washed now and then, at all disrespectable. But it wore an unhappy
countenance of gloom and unsocial fretfulness, due in reality to
the long neglect of painting, cleansing, and in some instances of
repairing the deep silence that invested the house, not only
. . . the following weeks.
from the absence of all visitors, but also of the common household
functionaries, bakers, butchers, beer-carriers, sufficiently accounted
for the desolation, by suggesting an excuse not strictly true viz.,
—
warmth, and for security against her ghostly
enemies. When I was
not more than usually ill, I took her in my
arms, so that, in general,
she was tolerably warm, and often slept
when I could not.
If it had not been for Brown’s love of classical
literature, De Quincey
would probably have starved to death during
As it was, Brown, though ‘one of those
anomalous practitioners in
lower departments of the law’ who himself
lived ‘in constant fear
of bailiffs’, loved intelligent company, and De
Quincey kept himself
alive by walking in on Brown while he was

that it might be tenantless. breakfasting downstairs,

chatting to him ‘and, with an air of as much
Through Brown’s office, l)e Quincey applied for the loan of a small indifference as I could
assume, took up such fragments as he had
sum of money, and while he waited for it to arrive he eked out
left’.
By day, De Quincey wandered the streets
a meagre existence while lodging in a nearby boarding house. A of the West End, weak,
sleepless and almost delirious through lack of
couple of months later he was penniless. Rather than let the boy food. ‘When he was
too exhausted to keep moving, he would
sit for a while in some
sleep out in the cold streets, Brown gave him permission to stay doorway, before being moved on by the watchmen
in the empty rooms above the office. it was to keep up the tone of the
whose business
neighbourhood. It was at this time
 1
— Soho
that he got to know some of the scores of prostitutes who had
already begun to frequent Soho and the parish of St Giles. In these
‘sisters in calamity’ he found what he felt was missing from the more
prosperous echelons of society: ‘humanity, disinterested generosity,
courage that would not falter in defence of the helpless, and fidelity
that would have scorned to take bribes for betraying’.
Among these ‘female peripateticS’, as De Quincey called them,
was one who grew special to him a destitute, timid and friendless
— Attitudes towards prostitution in the i
-year-old girl whom he called his ‘noble-minded Ann’. Night after
5
i were not governed by the hypocrisy which was to become endemic
night they wandered the cold, inhospitable streets of the West End
together. Then, De Quincey reported,
One night when we were pacing slowly along Oxford-street, and
after a day in which I had felt more than usually ill and faint,
I requested her to turn off with me into Sohosquare: thither we
went; and we sat down on the steps of a house, which, to this hour,
I never pass without a pang of grief, and an inner act of hommage to
the spirit of that unhappy girl, in memory of the noble action which
she there performed. Suddenly, as we sat, I grew much worse: I had
been leaning my head against her bosom; and all at once I sank from
her arms and fell backwards on the steps. From the sensations I then
had, I felt an inner conviction of the liveliest kind that without some
powerful and reviving stimulus, I should either have died on the
spot or should at least have sunk to a point of exhaustion from
—
which all re-ascent under my friendless circumstances would soon
have become hopeless. Then it was, at this crisis of my fate, that
my poor orphan companion who had herself met with little but
—
injuries in this world stretched out a saving hand to me. Uttering
—
a cry of terror, but without a moment’s delay, she ran off into
Oxford-street, and in less time than could be imagined, returned to
me with a glass of port wine and spices, that acted upon my empty
stomach, (which at that time would have rejected all solid food) with
an instantaneous power of restoration: and for this glass the generous
girl without a murmur paid out of her own humble purse at a time
— be it remembered! when she had scarcely the wherewithal to
—
purchase the bare necessaries of life, and when she could have no
reason to expect that I should ever be able to reimburse her.
Prostitutes were well-known in Soho. One of its earliest residents
had been ‘a lewd woman’ named Anna Clerke, who in 1641 was
Downhill All the Way
bound over to keep the peace after ‘threteninge to burne the houses
at So:ho’. Anna’s presence was followed by that of high-class
courtesans like Elizabeth Price, a resident of Frith Street, described
as ‘a Player and mistress to several persons’, and Elizabeth Flint,
‘generally slut and drunkard; occasionally whore and thief’, who
had lived in ‘genteel lodgings’ in Meard Street in the 175oS, along
with her spinnet and a servant-boy ‘that walked before her chair’.
th and i8th centuries
7
in Victorian society. Mistresses were openly acknowledged, and
prostitutes could operate freely where they chose to. It was even
said in the i8th century that ‘their business is so far from being
considered as unlawful, that the list of those who are in any way
eminent in this profession is publicly cried about the streets: the
list, which is very numerous, points out their places of abode, and
gives the several qualifications for which they are remarkable.
. . .
A new one is published every year, and sold under the piazza of
Covent garden, with the title of The New Atlantis.’
The licentious goings-on at Carlisle House were legendary. And,
by the late 1770s, its neighbour, the old Spanish Embassy, had
become a notorious high-class brothel, known both as The White
House or Hooper’s Hotel, after its proprietor, Thomas Hooper.
The wealthy and noble-born Londoners who frequented Hooper’s
included ‘Old Q’, the Duke of Queensberry, and George, Prince of
Wales. Clients entered the building discreetly through a side door in
Sutton Street, and each room inside was named and decorated in a
different style. There was a Silver, a Gold and a Bronze room, each
inlaid with mirrors in appropriate colours; a Painted Chamber; a
Grotto; and a Skeleton Room, where a mechanical skeleton leaped
out of a closet. Since the brothel later got a mention in a book called
The Mysteries of Flagellation, it seems that all sorts of sexual tastcs
were catered for in these theme rooms. The mind boggles as to what
went on in The Coal Hole.
By the time I)e Quincey befriended Ann, the fun and games had
gone out of commercial sex. Prostitution was no longer a respected
profession by which women could earn money and position, but a
matter of dire necessity for thousands of destitute young girls and
women with no other means of support. Over the weeks he knew
her, De Quinccy discovered that his ‘youthful benefactrice’ had been
 Soho
Downhill All the Way
forced into her way of life, having lost what little property she had the week, instead of being frequently
to a ‘brutal ruffian’. Her desperate story of victimization was by no in their Houses by rain confined many days together
means atypical. There was no one she could turn to for help. ‘The The Balustrades over the
. .
.

will form Balconies to the Colonnades

stream of London charity,’ De Quincey reflected, ‘flows in a channel Lodging-rooms over the Shops, from
which the occupiers of the Lodgings
which, though deep and mighty, is yet noiseless and underground; can see and converse with
those passing in the carriages
not obvious or readily accessible to poor houseless wanderers: and underneath, and which will add
to the gaiety of the scene, and
it cannot be denied that the outside air and frame-work of London induce single men, and others
who only visit Town occasionally,
society is harsh, cruel and repulsive.’ to give a preference to such
Lodgings.’ As it was, the covered
The Industrial Revolution and the Napoleonic Wars had brought walkways were Popular with
neither the shopkeepers, who complained
a huge drift of country people to the metropolis. Cut off from their dark, nor the customers: The Quadrant, that their premises were
rural roots, and untrained in the traditional skills of London’s in his Saunter Through the West Leigh Hunt wrote in 86x
craftsmen, they managed in the inhospitable capital as best they End, ‘except in very hot weather,
looked dull, narrow, and heavy. The
could, which was not very well. The local parish poorhouses could is not sufficiently long or wide “sweep” so much boasted of,
not cope with them. Poverty and prostitution became inseparable to produce the impression which
was intended to make.’ And he it
problems, which each London parish did its best to get rid of added, completely missing Nash’s
original point, ‘Piazzas . .
are not fit for this country
by moving them out of its parish boundary when St George’s,
—
of them in the south is to screen
.
The use
. .
.

Bloomsbury, and St Giles-in-the-Fields clubbed together to buy the people from the sun: but here we
have not enough sun to render them
lease of 76 Dean Street, in the year i8oo, in order to house children necessary on that account.’
Though Nash may not have made
from their workhouses there, the parishioners of St Anne’s objected, the Street an overwhelming
architectural success, the creation of
pointing out that the house might become ‘a common receptacle for at Piccadilly gave Soho a Regent Street and a circus
your promiscuous poor’. definite and important boundary
the west, so helping it to keep in
The increasingly stark division between posh Mayfair and poor its village atmosphere long
the individuality of other central after
Soho was recognized by architect John Nash in his plans for a London areas had gone. It also
created a social division in an area
new road to link Marylebone Park with Canton House, the Prince where rich and poor had, up till
then, lived cheek by jowl
3 separating the so-called
Regent’s home. Nash saw Regent Street as providing ‘a complete of Mayfair from decaying Soho, good, rich area
separation between the Streets occupied by the Nobility and Gentry, which was from then on allowed
to run down.
and the narrower Streets and meaner houses occupied by mechanics Over the next three or four decades,
and the trading part of the community’. Regent Street was to cut skilled or unskilled labourers moved thousands of poor, semi
cleanly through the parish of St James, roughly following the line into the cheap lodginghouses
hotels and tenements that now
spread
of the ancient trackway now called Swallow Strcet and once called fungus. Slum clearances in the parish across Soho streets like a
Shugge Lane. ‘My purpose,’ Nash later wrote, ‘was that the new of St Giles in the 18305
brought in a whole flew group of
street should cross the eastern entrance to all the streets occupied French Revolution and the Irish penniless residents. And the
by the higher classes and to leave out to the east all the bad streets, potato famine both led to large
influxes of poor immigrants from
and as a sailor would express himself, to hug all the avenues that overseas.
After the potato blight of 1845
went to good streets.’ and ‘846, nearly two million
Irish people left their country to
At the south end of the new thoroughfare was to be a curved seek a better life overseas. The
majority braved the arduous vast
colonnaded walkway called The Quadrant, designed by Nash to voyage to America; but the shorter
cheaper trip to England was an easier and
be a fashionable shopping centre where ‘those who have nothing option, especially for families
with young children. In 1841, the Irish
to do but walk about and amuse themselves may do so every day in stood at a low 75,000. By i8i, the community in London had
number of Irish had more than
 Soho Downhill All the Way

doubled. io years later, the figure had risen to 178,000. Mostly
agricultural labourers who had never visited a city before, they now
found themselves completely out of their element in what was an
alien and inhospitable world. There were two main areas of the West
End where the Irish poor congregated: around the slaughterhouses
of the Newport Market district; and in the nearby Rookery, a
notorious slum on Soho’s doorstep, in the parish of St Giles.
St Giles [wrote 2.4-year-old Frederick Engels in The Condition of
the Working Class in England (1844)] ‘is in the midst of the most
populous part of town, surrounded by broad, splendid avenues in
which the gay world of London idles about, in the immediate neigh
bourhood of Oxford Street, Regent Street, of Trafalgar Square and
the Strand. It is a disorderly collection of tall, three or four-storied
houses, with narrow crooked, filthy streets, in which there is quite
as much life as in the great thoroughfares of the town, except that,
Like St Giles, Soho was becoming one of the most densely populated
areas in London. It was to remain that way for the next 6o years. The
old decaying houses groaned under the weight of their numerous
residents. In Nicholas Nickleby, Dickens caught their atmosphere
perfectly:
In that quarter of London in which Golden Square is situated, there
is a bygone, faded, tumble-down street, with two irregular rows of
tall meagre houses, which seem to have stared each other out of
countenance years ago. The very chimneys appear to have grown
dismal and melancholy, from having had nothing better to look
at than the chimneys over the way. Their tops are battered, and
broken, and blackened with smoke; and, here and there, some taller
stack than the rest, inclining heavily to one side and toppling over the
roof, seems to meditate taking revenge for half a century’s neglect
by crushing the inhabitants of the garrets beneath
.

To judge from the size of the houses, they have been, at one
here, people of the working-class only are to be seen. A vegetable
time, tenanted by persons of better condition than their present
market is held in the street, baskets with vegetables and fruits,
occupants; but they are now let off, by the week, in floors or
naturally all bad and hardly fit to use, obstruct the sidewalk still
rooms, and every door has almost as many plates or bell-handles as
further, and from these, as well as from the fish-dealers’ stalls,
there are apartments within. The windows are, for the same reason,
arises a horrible smell. The houses are occupied from cellar to
sufficiently diversified in appearance, being ornamented with every
garret, filthy within and without, and their appearance is such
variety of common blind and curtain that can easily be imagined;
that no human being could possibly wish to live in them. But all
while every doorway is blocked up, and rendered nearly impassable,
this is nothing in comparison with the dwellings in the narrow
by a motley collection of children and porter pots of all sizes, from
courts and alleys between the streets, entered by covered passages
the baby in arms and the half-pint pot, to the full-grown girl and
between the houses, in which the filth and tottering ruin surpass all
half-gallon can.
description. Scarcely a whole window-pane can be found, the walls
are crumbling, door-posts and window-frames loose and broken,
The dreadful living conditions in parts of Soho soon matched those
doors of old boards nailed together, or altogether wanting in this
in the more notorious East End slums, as report after report testifies.
thieves’ quarter, where no doors arc needed, there being nothing
In Ragged London, published in i86i, John Hollingshead gave an
to steal. Heaps of garbage and ashes lie in all directions, and the
unforgettable picture of life in one of the crumbling Soho mansions:
foul liquids emptied before the doors gather in stinking pools. Here
live the poorest of the poor, the worst paid workers with thieves
Every room is crowded with a different family, and four, if not more,
and the victims of prostitution indiscriminately huddled together,
landlords are interested in the rent
the majority Irish, or of Irish extraction, and those who have . Dwellings that originally
. .

sheltered eight or ten persons are now crowded with thirty, forty,
not yet sunk in the whirlpool of moral ruin which surrounds
or fifty inmates. The carved wainscotings are torn to pieces, or
them, sinking daily deeper, losing daily more and more of their
covered, an inch deep, with black grease. The old banisters are
power to resist the demoralizing influence of want, filth, and evil
broken down. The stairs are rugged, dark, and uneven one of
surroundings. . . .
 Soho Downhill All the Way

the worst features of the district is a tendency to live in kitchens cellars are nothing but kennels where the hapless
people of Israel
and cellars The dirt arises partly from long-settled carelessness
. . . are crowded pell-mell. In each one can be seen six,
seven or eight
about domestic cleanliness, partly from the impossibility of keeping dirty urchins, thin, gaunt, lying on the bare floor
among the old
one room tidy when six or eight people have to live in it, and partly shoes, the filthy rags, and crawling up and down the
ladder like the
from the neglect of landlords to whitewash, paint and paper the slugs one sees crawling on cellar stairs . Poor creatures! There
. .

dwellings. are thousands of human beings in these cellars,

English subjects
who speak English and to whom no one pays any
attention: one
Eight to a room was a conservative estimate of the West End’s merely says with disdain: “They are Jews . .

overcrowding problem. In 1850, eight people had been found in The indifference of rich and middle-class Londoners to
the living
the Rookery sleeping in a space six foot by five, the inhabitants of conditions of the poor extended to their working
conditions too.
one house numbered ioo, and, in a picture straight out of Oliver Many children worked i6-hour days, and were
virtual slaves to
Twist, 17 young thieves were discovered living in one tiny chamber. their masters: those apprenticed to tradesmen
frequently worked
These conditions were not to be alleviated for many years. In for eight years, only for their bed and board.
Women who could
1890, a lay reader of St Anne’s church, visiting lodgings on the not get work in service or in the tailoring industry
wcre forced
second floor of a house in St Anne’s Court, recorded that ‘the into prostitution. Unemployed Irishmen in the
Rookery drank
door was furtively opened by a half-naked girl of about i. She themselves into oblivion, or took to petty crime. The
West End
was quite relieved to find it was not the “Tally-man”, to whom her Jews scraped a living as cobblers or old clothes
dealers. ‘Oh,
mother was considerably indebted. The room was almost devoid the sight of the thousands of old worn-out shoes,
the rags and
of furniture and in a horrible state of uncleanliness, and a large the rubbish,’ wrote Flora Tristan of her visit to
their makeshift
bedstead occupied a third of the space. Hearing some shuffling old-clothes market near Newport Market, ‘and all of
it making
under the bed, I looked and enticed out one by one seven half up such an important branch of commerce gives
a truer idea of
starved children, clothed more with nakedness than with rags. So the destitution of the monster city than all the
findings and reports
ten human beings existed and slept in that room!’ that could be published. It makes one shudder!’
As late as 1897, the Daily Chronicle published a letter from Mr Side by side with the humans imprisoned in the Soho
Guy Pearce, a member of the West London Mission, describing slums were
cooped up the animals on which the local inhabitants
ft by 4ft was filled with and tradesmen
his visit to one Soho tenement: ‘A space 3 depended. Dickens writes of ‘dingy, ill-plumed, drowsy’
furniture, and in a recess was the bed. On it lay a poor girl of ping ‘from stone to stone, in forlorn search of hens hop
some hidden eatable
seventeen, dying of consumption. Here lived a wife and children, in the mud’. Hollingshead sighted ‘nearly four
hundred stables, in
and the husband, when he was at home, sharing the bed with the which are kept more than one thousand horses. Over
these stables
invalid girl. Here, too, all the cooking had to be done on an
. . are a number of small close rooms, in which about
nine hundred
open grate.’ people reside and bring up their families, or
one-fortieth part of
Though the Irish remained the largest group of immigrants in the whole parish. Another nuisance arises from
cows, of which
London until the 187os influx of Eastern European and Russian there are at least two hundred kept at eight stations
in as many
Jews, there was a small and extremely poor Jewish community in streets.’
Newport Market and Seven Dials as early as the 183os. Writer By the middle of the 19th century, Soho had
become an insarii
Flora Tristan, whose London Journal was published in i 840, gave tary place of cow-sheds, animal droppings,
slaughterhouses, grease-
a graphic picture of this ‘Jewish Quarter’. Like Hollingshead, she boiling dens and primitive, decaying sewers. And
underneath the
wrote of families living in dank kitchen cellars, accessible only floorboards of the overcrowded cellars lurked something
even
by ladders let down from the street through grimy shutters: ‘The worse a foctid sea of cesspits as old as the houses, and
many of
—
 Soho
which had never been drained. It was only a matter of time before
this hidden festering time-bomb exploded. It finally did so in the
summer of 1854.
When a wave of Asiatic cholera first hit England in late 1831, it
was thought to be spread by ‘miasma in the atmosphere’. By the
time of the Soho outbreak 2.3 years later, medical knowledge about
the disease had barely changed, though one man, Dr John Snow, a
surgeon and pioneer of the science of epidemiology, had recently
published a report speculating that it was spread by contaminated
water an idea with which neither the authorities nor the rest of
— ‘I found,’ he wrote afterwards, ‘that nearly all the deaths had taken
the medical profession had much truck. Whenever cholera broke
out which it did four times between 183 i and 1854 nothing
—
— nearer another pump, there had only been io deaths and of those,
whatsoever was done to contain it, and it rampaged through the
industrial cities, leaving tens of thousands dead in its wake. The
year 1853 saw outbreaks in Newcastle and Gateshead as well as in
London, where a total of 10,675 people died of the disease. In the
1854 London epidemic the worst-hit areas at first were Southwark
and Lambeth. Soho suffered only a few, seemingly isolated, cases
in late August. Then, on the night of the 3 1st, what Dr Snow later
called ‘the most terrible outbreak of cholera which ever occurred
in the kingdom’ broke out.
It was as violent as it was sudden. During the next three days,
127 people living in or around Broad Street died. Few families,
rich or poor, were spared the loss of at least one member. Within
a week, three-quarters of the residents had fled from their homes,
leaving their shops shuttered, their houses locked and the streets
deserted. Only those who could not afford to leave remained there.
It was like the Great Plague all over again.
By 10 September, the number of fatal attacks had reached 500
and the death rate of the St Anne’s, Berwick Street and Golden
Square subdivisions of the parish had risen to TZ.8 per cent more
than double that for the rest of Londo n. That it did not rise even
higher was thanks only to Dr John Snow.
Snow lived in Frith Street, so his local contacts made him ideally
placed to monitor the epidemic which had broken out on his
doorstep. His previous rescarches had convinced him that cholera,
which, as he had noted, ‘always commences with disturbances of
the functions of the alimentary canal’, was spread by a poison
Downhill All the Way
passed from victim to victim through sewage-tainted water; and
he had traced a recent outbreak in South London to contaminated
water supplied by the Vauxhall Water Company a theory that
—
the authorities and the water company itself were, not surprisingly,
reluctant to believe. Now he saw his chance to prove his theories
once and for all, by linking the Soho outbreak to a single source
of polluted water.
From day one he patrolled the district, interviewing the families
of the victims. His research led him to a pump on the corner of
Broad Street and Cambridge Street, at the epicentre of the epidemic.
place within a short distance of the pump.’ In fact, in houses much
—
five victims had always drunk the water from the Broad Street pump,
and three were schoolchildren who had probably drunk from the
pump on their way to school.
Dr Snow took a sample of water from the pump, and, on
examining it under a microscope, found that it contained ‘white,
flocculent particles’. By 7 September, he was convinced that these
were the source of infection, and he took his findings to the Board
of Guardians of St James’s Parish, in whose parish the pump fell.
Though they were reluctant to believe him, they agreed to remove
the pump handle as an experiment. When they did so, the spread
of cholera dramatically stopped.
At the end of September the outbreak was all but over, with the
death toll standing at 6i6 Sohoites. But Snow’s theories were yet to
be proved. There were several unexplained deaths from cholera that
did not at first appear to be linked to the Broad Street pump water
— notably, a widow living in West End, Hampstead, who had died
of cholera on z September, and her niece, who lived in Islington,
who had succumbed with the same symptoms the following day.
Since neither of these women had been near Soho for a long time,
Dr Snow rode up to Hampstead to interview the widow’s son. He
discovered from him that the widow had once lived in Broad Street,
and that she had liked the taste of the well-water there so much
that she had sent her servant down to Soho every day to bring back
a large bottle of it for her by cart. The last bottle of water which
—
her niece had also drunk from had been fetched on 31 August,
—
at the very start of the Soho epidemic.
 Soho Downhill All the Way
There were many other factors that led Snow to isolate the cause close to the undrained cesspool
of the cholera to the Broad Street pump. For instance, of the 530 .The overcrowding appears to
. .

increase . The Builder went on to recommend ‘the immed

. .‘
inmates of the Poland Street workhouse, which was only round the abandonment and clearing away of all cesspools iate
corner, only five people had contracted cholera; but no one from not the disguise
of them, but their complete removal.’
—

the workhouse drank the pump water, for the building had its own Nothing much was done about it. Soho was to remain
well. Among the 70 workers in a Broad Street brewery, where the a dangerous
place for some time to come.
men were given an allowance of free beer every day and so never
drank water at all, there were no fatalities at all. And an army There were other dangers fermenting in the streets
officer living in St John’s Wood had died after dining in Wardour of Soho danger
ous ideas. The place had been a magnet for —

Street, where he too had drunk a glass of water from the Broad dissidents since 1683,
when Algernon Sidney, Lord Leicester’s second
Street well. son, was executed
for his part in the Rye House plot. As Lord
Still no one believed Snow. A report by the Board of Health a Mayor Beckford had
demonstrated so eloquently in front of George III,
few months later dismissed his ‘suggestions’ that ‘the real cause Sohoites were
never afraid to speak their mind. Even today, ask
of whatever was peculiar in the case lay in the general use of one a Sohoite his or
her opinion of a film, or the price of potatoes,
particular well, situate [sic] at Broad Street in the middle of the or the future of
their neighbourhood and they will tell you
district, and having (it was imagined) its waters contaminated by straight out in fact,
they will probably tell you what they think —

the rice-water evacuations of cholera patients. After careful inquiry,’ whether you ask them
to or not.
the report concluded, ‘we see no reason to adopt this belief.’
So what had caused the cholera outbreak? The Reverend Henry MP Field-Marshal Henry Seymour Conway, who, like Beckford,
had lived in Soho Square during the 176os, had
Whitehead, vicar of St Luke’s church, Berwick Street, believed that been a champion
of the free press. When John Wilkes was arreste
it had been caused by divine intervention, and he undertook his own d for attacking Lord
Bute in the newspaper The North Briton, Conwa
report on the epidemic in order to prove his point. However, his y had argued tooth
and nail against the general warrant to search for
findings merely confirmed what Snow had claimed, a fact that he and question every
writer, publisher and printer connected with
was honest enough to own up to. Furthermore, Whitehead helped the case. Eventually
he had swung the House of Commons over
Snow to isolate a single probable cause of the whole infection: just to his opinion, and
the general warrant had been declared illegal
before the Soho epidemic had occurred, a child living at number — an action that had
resulted in “(
ilkes’s release.
1
40 Broad Street had been taken ill with cholera sympto
ms, and its In 1837 number 25 Soho Square was leased by
nappies had been steeped in water which was subsequently tipped Thomas Barnes,
the editor of The Times, who had already made
into a leaking cesspool situated only three feet from the Broad his own contribution
to press freedom by supporting his old school
Street well. friend Leigh Hunt
after he was arrested for libelling the Prince
Whitehead’s findings were published in The Builder a year later, Regent in his radical
weekly, The Examiner, in March 1872. It is not
along with a report on living conditions in Soho, undertaken by the clear whether the
Prince objected more strongly to the charge that
magazine itself. They found that no improvements at all had been he was ‘a violator
of his word, a libertine over head and ears in
made during the intervening year. ‘Even in Broad-street it would disgrace, a despiser
of domestic ties, the companion of gamblers and
appear that little has since been done. In St Anne’s-Place, and St demi-reps, a man
. .
who has just closed half a century without one
Anne’s-Court, the open cesspools are still to be seen; in the court, so single claim on the
gratitude of his country or the respect of posteri
far as we could learn, no change has been made; so that here, in spite ty!’ or to being
called a ‘corpulent man of fifty’. Whichever, Leigh
of the late numerous deaths, we have all the materials for a fresh Hunt and his
brother John, who were joint proprietors of
epidemic In some [houses] the water-butts were in deep cellars, The Examiner, were
. . .
both imprisoned for two years and fined £zoo
each for publishing
 Soho
the article. As well as visiting the Hunts in prison, Barnes kept The
I Downhill All the Way
Examiner going in their absence, with the help of friends Charles
Lamb and William Hazlitt.
Although Beckford, Conway and Barnes were staunch supporters
of democracy, they were hardly revolutionaries in the modern sense
of the word. Probably the first real one of those to live in Soho was
Jean-Paul Marat, one of the most prominent figures in the French
Revolution. Disappointingly, however, Marat, who lodged at 31
Romilly Street in 1776, was at that time far more interested in
his work as an oculist than in spreading dissident ideas. The only
pamphlets he is known to have produced while living in Soho were
An Enquiry Into the Nature, Cause, and Cure of a Singular Disease
of the Eye and an Essay on Gleets.
By the spring of i8ii, when Shelley was sent down from Oxford,
Soho was the natural place for an unconventional and free-thinking
-year-old to graduate to. Shelley may well have been attracted to
9
i calling themselves Christian Philanthropists. Here Evans preached
the area by the existence of a radical debating society which met at
the Cock tavern in Grafton Street (in the part of the Newport Market
district demolished in the late i th century to make way for the
9 split in the Spenceans that Wedderburn decamped to the corner of
Charing Cross Road). The founder of this informal club of political
free-thinkers, republicans and subversives was a land-reformer and
pamphleteer called Thomas Spence. When Spence died in 1814 — In this so-called Unitarian Chapel in reality a ‘ruinous hay loft’
his followers carried his coffin with ‘due pomp’ up the Tottenham
Court Road to the burial ground of St James’s, Hampstead Road — audiences of male and female extremists. But though he drilled his
the debating club was kept going by one of his disciples, a political
fanatic called Thomas Evans.
Under the leadership of Evans, a braces-maker from the Strand
and a one-time resident of Frith Street, the Society of Spencean
Philanthropists as it was now known flourished. Meetings were
— —
held twice weekly in Soho: at the Cock in Grafton Street and at the
Nag’s Head in Carnaby Market; and there were meetings in the
Borough and in Moorfields as well. Speakers came from all over the
country to talk to the members of London’s radical underworld who
congregated at these meetings, and anyone who arrived looking too
smart was accused of being a government informer and thrown out.
The debates were certainly not dry affairs. In fact, they were more
like drunken and very ribald entertainments, and were perhaps the
forerunners of today’s alternative comedy revues.
A heady blend of anti-clerical blasphemy, crudeness, violent
sedition and anti-monarchy was preached and sung about at the
Spencean tavern clubs, where a favourite toast was ‘May the last of
the kings be strangled with the guts of the last of the priests.’ Natu
rally, these goings-on attracted the attention of the government, who
sent in spies to see what was happening and concluded, in a House of
Lords report of June 1817, that ‘the minds of those who attend their
meetings are tainted and depraved; they are taught contempt for all
Decency, Law, all Religion and Morality, and are thus prepared for
the most atrocious scenes of outrage and violence.’ That same year
both Evans and his son were arrested on charges of high treason,
and until their release the following January, Evans’s wife Janet, an
activist in her own right, was left to run the organization and keep
the family business going.
Early in i8i8 the Spenceans moved from the Cock tavern to
Archer Street, where they established a more serious ‘chapel’,
with a sailor and tailor named Robert Wedderburn, whose ‘fero
cious rhetoric’ and ‘horridly blasphemous’ language caused such a
Brewer Street and Hopkins Street, taking the seats and a good part
of the congregation with him.
—
reached by ladder Wedderburn continued to preach revolution to
—
congregation in the use of weapons, and even assembled a cache of
pikes, the armed insurrection that he had planned to take place in
November 1919 was a wash-out. That same month the Hopkins
Street chapel broke up for good.
Karl Marx, that most famous of revolutionaries, arrived in Eng
land on 2.4 August 1849, having been expelled from the Continent,
but leaving behind him his three children and his pregnant wife
Jenny. After a few weeks his family joined him, and they moved
from a small furnished room off Leicester Square to a flat in
Chelsea, where their sickly son, Heinrich, was born amidst the
uproar of Guy Fawkes night.
Before long, their Chelsea landlady took a dislike to them, and
the Marx family moved into the German Hotel in Leicester Street,
one of a number of guest-houses that had opened in Soho to cater
for the foreign political refugees mostly Italians and Germans
—
 Soho Downhill All the Way
— who had taken advantage of the open political asylum offered and torn, finger-thick dust everywhere, and everything in the
by the British government. Romantic as it would be to think that great
est disorder; a large, old fashioned table, covered with waxcioth,
the Marxes chose to return to Soho because of its reputation as a stands in the middle of the drawing-room, on it lie manuscripts,
hot-bed of radicalism, they probably ended up there because it was books, newspapers, then the children’s toys, bits and pieces
cheap. of the
woman’s sewing things, next to it a few teacups with broken
Before long the proprietor of the hotel, who at first gave them rims,
dirty spoons, knives, forks, candlesticks, inkpot, glasses,
‘a humane reception for £5 lOS a week’, had had enough of Jenny, dutch clay
pipes, tobacco-ash, in a word all kinds of trash, and everything
Karl and their children, and they were forced to move yet again. on
one table; a junk-dealer would be ashamed of it. When you
Eventually they found a more permanent home in the house of a enter
the Marx flat your sight is dimmed by tobacco and coal
Jewish lace-dealer at number 64 Dean Street, where their fellow smoke
so that you grope around at first as if you were in a cave,
revolutionary, Heinrich Bauer, had taken rooms. until
your cyes get used to these fumes and, as in a fog, you
Being the wife of a penniless revolutionary was no laughing gradually
notice a few objects. Everything is dirty, everything covered
matter. While Karl plotted regicide, collaborated with Engels on with
dust; it is dangerous to sit down. Here is a chair with
the final numbers of the Neue Rheinische Zeitung, and prepared a only three
legs, there the children play kitchen on another chair that
course of lectures which he gave in a room above the Red Lion pub happens
to be whole; true it is offered to the visitor, but the
in Great Windmill Street, Jenny and her mother’s ex-maid, Lenchen,
—

children’s
kitchen is not removed; if you sit on it you risk a pair of
who lived with them, struggled to keep the children alive. Jenny also trousers.
But nothing of this embarrasses Marx or his wife in the
had to put up and put up with visiting Party comrades, who least; you
— —
are received in the friendliest manner, are cordially offered
expected to be accommodated in the tiny flat. a pipe,
tobacco, and whatever else there is; a spirited conversation makes
The daughter of a well-off Prussian minister, Jenny was used to up for the domestic defects and in the end you become
better things, and their hand-to-mouth existence wore her down. reconciled
because of the company, find it interesting, even original. This
When in the summer of i85o and pregnant again she travelled is the
— —
faithful portrait of the family life of the communist leader
to Holland to beg help from Karl’s uncle, the man barely recognized Marx.
her, and she came home, as she wrote, ‘empty-handed, disappointed, This written portrait might have been faithful, but Karl
torn apart and tortured by a fear of death’. On her return, she found certainly
was not. When Jenny was in Holland, he had an affair
her son Foxchën dying of pneumonia he was to be the first of with
—
Lenchen, and there were now two pregnant women in the
three children she would lose in Dean Street. tiny
flat. Karl’s hints that his friend Engels was the putative
At the beginning of i8i, Marx, Jenny, Lenchen and the four father did
not convince Jenny, and though she had to accept the
children moved down the road to a two-roomed attic flat in number situation out
of sheer necessity, it almost broke her heart.
a8 Dean Street an ‘old hovel’, as Marx called it, also occupied
—
Throughout their stay in Soho, the Marx family were practically
by an Italian chef, an Italian confectioner and a foreign language destitute, despite the small income Karl received for writing
teacher. The rooms, which had no lavatory or running water, cost articles
for the New York Tribune, and the postal orders sent
Marx £zz a year. A Prussian agent who visited them there reported to them by
Engels, who had taken a job in his father’s Manchester
that they lived factory.
They were so poor that when their daughter Franziska
died in
April i8z, Jenny was forced to beg from ‘a French fugitive
in one of the worst, and hence the cheapest quarters of London. who
lives near us. He received me with friendliness and sympathy
He has two rooms, the one with the view of the street being the and
gave me two pounds and with that money the coffin in
drawing-room, behind it the bedroom. There is not one piece of which my
child could rest peacefully was paid for.’
good, solid furniture in the entire flat. Everything is broken, tattered Lenchen was frequently dispatched to the pawn shop to
raise
 Soho
money to buy food or writing paper sometimes on such dubious
— where every four walls shut in another family, a Soho of cramped
pledges as Karl’s well-worn overcoat or shoes. At times even Marx
was at his wits’ end. He wrote to Engels that summer:
My wife is ill, little Jenny is ill, Lenchen has a sort of nervous fever,
I cannot and could not call the doctor because I have no money for
medicine. For 8-io days I have fed the family on bread and potatoes
of which it is still questionable whether I can rustle up any today
I had put off until the beginning of September all the creditors
who, as you know, are only paid off in small sums. Now there is a
general storm. I have tried everything, but in vain . . The best and
. The windows are open, letting in the sounds of zoth-century
most desirable thing that could happen would be that the landlady
throw me out of the house. At least I would then be quit of the
sum of £22. But I can scarcely trust her to be so obliging. Also
baker, milkman, the man with the tea, greengrocer, old butcher’s
bills. How can I get clear of all this hellish muck?
To get away from his troubles, Karl spent much of his time studying
in the peace and quiet of the British Library’s Reading Room in
Bloomsbury. But his family were not to escape their ‘evil, frightful
rooms’ in Dean Street until Jenny received two small inheritances,
the first from a Scottish uncle, the second from her mother, who
died in July 1855. Then, ‘with joyful heart’, they moved into a
small terraced house near Primrose Hill. “When we slept in our
own beds for the first time,’ she wrote, ‘sat on our own chairs
and even had a parlour with second-hand furniture of a rococo
style, or rather bric-a-brac, then we really thought we were living
in a magic castle . . .‘
Since 1926, number z8 Dean Street has been part of Leoni’s Quo
Vadis restaurant. The elegant ground floor dining-room gives no
hint of what once went on upstairs. Patrons who do not mind the
climb can, if they wish, be escorted to see the Marxes’ old apartment.
Anyone who has had a glass too much wine must be warned: as
carpet gives way to lino, and the lino to bare boards on the steep,
narrow stairs, one can easily imagine one is climbing back in time.
Dizzy from the altitude, the Marx pilgrim emerges in a small attic
hall with a sagging ceiling and doors the colour of Cornish cream,
each bearing the scar of a torn-off padlock. This is a Soho that has,
for the most part, long since disappeared: a Soho of rooms-for-rent,
Downhill All the Way
workshops, hungry immigrants, a Soho where wooden partition
walls are encrusted with 250 years’ worth of cheap paint.
To enter the door on the left is to find oneself in Karl and
Jenny Marx’s living-room. It is a bare room, thankfully devoid
of unnecessary Marxiana, with a simple oval table, a narrow bed
with an appropriately red cover, and one faded poster chronicling
the life and times of Mr Marx. Through another door, at the back,
is the second room, a little larger than a cupboard, but smaller than
a double divan.
Dean Street. But time stands strangely still in there. The two
rooms are airless, and, despite the care that has been taken to
furnish them, neglect festers in the corners. And the dust, oh, the
dust is finger-thick everywhere, much as it was on the day when
the Prussian agent came to see how the world’s most dangerous
revolutionary lived.
The Soho which the Marxes left behind them was a ‘festering sore’
of overcrowding, petty crime and prostitution. And its proximity
to the smart districts of the West End made it much harder for
the upper and middle classes to ignore than the equally run-down
East End, which was tucked conveniently out of sight on the far
side of the City. Consequently, in the second half of the century,
do-gooders and philanthropists moved in on Soho in force. Six
hospitals were opened to help deal with local health problems,
as were a number of missionary organizations, including a soup
kitchen in Leicester Square, and various temporary shelters for
homeless men and women, such as the House of Charity, which
opened in i 847 at number 9 Rose (later Manette) Street, and which
five years later moved round the corner to Richard Beckford’s old
house, number i Greek Street, where it still is today.
In 1884, the Soho Club and Home for Working Girls, another
venerable Victorian institution, was started across the road from the
House of Charity by the Hon. Maude Stanley. The club, which was
open every evening, organized classes in drawing, French, singing,
needlework, music, gymnastics and mathematics, as well as having
a library, a canteen, a Penny Bank and a low-cost medical dispensary
for its members. On top of that, it provided long- or short-term
 Soho
Downhill All the Way
lodgings for ‘Young Women engaged in business, and students’, somehow always managed ‘to combine his missionary
who for between 3S and 7S 6d a week could rent a bed in a dormitory with a keen appreciation of a pretty face’, as MP meddling
or even a private room, including the use of a sitting-room, gas fire Henry Labouchere
said. Though a deeply religious Christian, there
and clean bed linen. In addition, the advertisement advised that is no doubt that
Gladstone deliberately ‘courted evil’, as he put it
‘Teachers or Students coming to London to pass Examinations can himself, by placing
himself in a position of temptation where his
be Lodged at is. per night. Breakfast, Tea and Supper z’/ d each,
1 will-power might fail.
It was as if every encounter with a prostitute was
Dinner 6d.’ a test of his own
faith.
The Soho Club had originally started in three rooms in Por In 1853 the Chancellor of the Exchequer’s rescue
ter Street, Newport Market, then at the centre of Soho’s very work involved
him in a notorious blackmail case. While walking
worst slums, where a refuge had been set up in the old market through Long
Acre on the night of 10 May, he was approached
buildings. The Newport Market Refuge, as this was called, also by a woman and,
after talking to her for some time, agreed to accompany
provided training and meals for young boys. One of the most her to her
lodgings in King Street, Soho. When they reached
distinguished members of its committee was the politician William her house, a young
man stepped out of the shadows, and told
Ewart Gladstone. Gladstone that he had
been following him. He then made one of the most
Gladstone’s ‘rescue work’ with prostitutes was well-known, at bizarre blackmail
demands of all times: he threatened to tell the world
times notoriously so. Night after night, he walked by himself that Gladstone
had picked up a prostitute, unless Gladstone
through the most dangerous areas of the West End, observing either gave him some
money or secured him a job with the Inland Revenue
a
first-hand the street-life of prostitutes, of which there were estimated people would blackmail to get out of. Since Gladstone place most
—

to be about 8o,ooo working in the centre of town. Whenever he had nothing

to hide, he told the man to publish or be damned,
could, he stopped and talked to them about their lives and if and the case
subsequently came to court. The would-be
possible, he persuaded them to come home with him for the night. blackmailer, William
Wilson, a commercial traveller from Lambeth,
‘What will your wife say if you bring this woman home with you?’ was sentenced to
a year’s hard labour. But the Chancellor, as
his amazed Private Secretary asked him on one occasion when the charitable as ever,
persuaded the Home Secretary to release him after
two men were together. ‘Why,’ Gladstone answered innocently, ‘it he had served
only six months.
is to my wife that I am bringing her.’ Due partly to the Gladstones’ efforts, rescue
Back at the Gladstones’ house, William’s wife Catherine took the work eventually
became a respectable, not to mention popular, hobby
girls in, gave them a meal peppered with lashings of good advice, for the leisured
classes, though there were few people who went
and found a bed for them to sleep in overnight. The next day, she so far as to invite
ladies of the night into their homes. As the
or William tried to secure them a place in one of the temporary Contagious Diseases
Act of 1864 clearly demonstrated, Victorian
shelters such as the House of St Barnabas, or the House of Mercy society operated a
double standard which blamed women entirely
at Clewer, near Windsor, which the Gladstones had also helped for the existence
of prostitution and its accompanying ills
to found. The girls were not always grateful to be whisked off the — namely, the spread of
venereal disease. Yet the Gladstones were well
street: conditions in the shelters were often extremely depressing. As aware that society
was as much to blame for the existence of the
one prostitute wrote to Gladstone after running away from Clewer, oldest profession as
any ‘weakness’ in the girls. As Catherine
Gladstone
‘I did not fancy being shut up in such a place as that for perhaps was ‘a common thing for [servants] to be engaged once wrote, it
12. months. I should have committed suicide.’ without wages
or clothes and only for food every other day.
There were plenty of people who thought chatting up prosti Who can wonder at
girls so situated yielding to temptation and sin?’
tutes was, to say the least, a dubious pastime for a prominent Not every prostitute went on the game of her
member of the government. To make matters worse, Gladstone own free will.
Children as young as 10 years old were pushed
into it by their
 I
Soho
parents; bullies (as pimps were then called) specialized in seducing
‘respectable’ girls and then forcing them on to the streets. There was
also an active white slave trade in women and children operating
both ways across the English Channel. In the 185os a certain Mrs
Jeffries, the ‘madam’ of a string of West End brothels, was known
to be shipping English prostitutes to France, Belgium and Italy,
and to be importing girls from the Continent to work in Britain.
But although an action was brought against her for keeping a
disorderly house, her boasts of friends in high places were not
without foundation, for when her case came to court, the judge
let her off with a small fine, instead of imprisoning her as he ought
to have done.
But despite the work of a few upper-class philanthropists, the
social conditions of Soho did not improve during the rest of the
century. In the early i88os the parish was still, in the words of one
report, ‘a reeking home of filthy vice’, and the Newport Market
district in particular was said to be ‘a veritable focus of every danger
which can menace the health and social order of a city. The houses,
from their insanitary condition, are horribly disgusting, and can
only be fitly designated as well prepared propagating ground for
every kind of contagious and loathsome disease . . The grossest
. It was apparently after swimming in the Thames with a group of
immorality flourishes unabashed from every age downwards to
mere children.’
It was undoubtedly Soho’s darkest time.
6
Enterprise and Entertainment
Co-existing with the prostitution, crime and poverty were areas of
respectability even of wealth like Soho Square, which remained
— —
relatively upmarket well into the i th century, due partly to the
9
continuing presence of the wealthy botanist Sir Joseph Banks and
his family at number 32..
Banks was a born Sohoite, if not a born-and-bred one: though
born in Argyll Street in 1743, he was educated at Harrow, Eton
and Christ Church College, Oxford all establishments well-suited
—
to the education of a young member of the landed gentry. When his
father, William, died in 1761, i8-year-old Joseph inherited a large
estate in Lincoinshire, and enough money to indulge the passion for
the natural sciences that had developed when he was at school.
fellow Etonians that Banks first fell in love with nature. He had never
been a scholarly child, but, as he walked alone down a country lane
on the way back to school in the late afternoon sunshine, the idea
came to him that it would be far more interesting to study plants
and animals than dead languages like Latin and Greek. His interest
in botany, which started that day, was to dominate the rest of his life.
In April 1766, Banks sailed on an expedition to Newfoundland
and Labrador in the Niger, in search of plant and animal specimens.
In 1768 he set off with Captain Cook in the Endeavour on a
dangerous round-the-world voyage that lasted three years. (During
their visit to New Zealand, Banks named Botany Bay.) Soon after
his return, he set off for Iceland. In 1777, the year before he was
elected president of the Royal Society, he went swimming again
— this time against the tide of fashion, when, with his mother,
his new wife Dorothea and his sister Sarah Sophia, he moved
from New Burlington Street, Mayfair, to number 3 a Soho Square,
where he established an extensive botanical library and museum in
an outbuilding backing on to Dean Street.