Letter to Editor

VP4 localized with the peroxisomal markers, suggesting through the waters of the rivers or of ponds into which its peroxisomal targeting. Transient transfection of VP4 cholera dejections had found their way and been min- gene lacking the CRL signal resulting in diffused cyto- gled with sewage by the churning tides’ [5]. The Lancet plasmic pattern of the protein, further confirming the applauded Farr’s report, commenting that ‘the elabo- signal-dependent VP4 transport to the organelle. rate array of facts which Dr Farr has set forth with so much skill, will render irresistible the conclusions at The discovery and demonstration of functional type 1 which he has arrived in regard to the influence of the peroxisomal targeting signal in a viral protein opens up water-supply in the causation of the epidemic’ [6]. novel avenues of research on disease mechanisms of medically important viruses. Miasma

Neither Farr nor The Lancet had always held this view. In 1831, during Britain’s first cholera epidemic, it Received: 2002.03.21 reported [7] that a community of Jews living near Vienna had escaped infection by rubbing their bodies William Farr, The Lancet and Epidemic with a linament containing wine, vinegar, camphor powder, mustard, pepper, garlic and ground beetles. In Cholera 1853 its writer speculated on the nature of the disease: ‘What is cholera? Is it a fungus, an insect, a miasma, an electrical disturbance, a morbid off-scouring of the Stephen Halliday intestinal canal?’ [8]. It came down on the side of the conventional ‘miasmatic’ explanation as expressed by Author’s email address: [email protected] William Farr in his Report on the Mortality of Cholera in England, 1848-9) [9] which The Lancet described as ‘one Dear Editor, of the most remarkable productions of type and pen in any age or country’ [10]. In 1867 William Farr published his report into the cholera epidemic which, in 1866, had killed over five In this verdict The Lancet was in the company of many thousand people living in the Whitechapel area of East eminent Victorians. Florence Nightingale in her Notes London. It was the last of the four epidemics which rav- on Nursing condemned the practice of laying house aged the capital in the mid-nineteenth century [1]. Farr, drains beneath dwellings, suggesting that odours would after an early career writing for The Lancet under its escape from them, penetrate the dwellings and cause founding editor Thomas Wakley, had been appointed epidemics of scarlet fever, measles and smallpox [11]. ‘compiler of abstracts’ (chief statistician) to the Edwin Chadwick, the sanitary reformer, told a Registrar-General of births, marriages and deaths when Parliamentary Committee in 1846 that ‘All smell is, if it the latter post was created in 1838. He used his position be intense, immediate acute disease’ [12]. In the year of to campaign for better sanitary conditions and became his death, 1890, in furtherance of this belief, he advocat- well known for his work throughout Europe and the ed to the Royal Society of Arts ‘the bringing down of United States. He became a Fellow of the Royal Society fresh air from a height, by means of such structures as in 1855 and was made a Companion of the Bath in 1880 [2]. the Eiffel Tower, and distributing it, warmed and fresh, in our buildings’ [13]. Dr W. H. Duncan, Liverpool’s After a thorough investigation of the Whitechapel epi- (and Britain’s) first city medical officer told another demic, he concluded that it had been caused by polluted Parliamentary Committee in 1844 that ‘By the mere water drawn from the river Lea by the East London action of the lungs of the inhabitants of Liverpool, a Water Company. This was the only densely inhabited stratum of air sufficient to cover the entire surface of the area of London not yet connected to the comprehensive town, to a depth of three feet, is daily rendered unfit for system of intercepting sewers that was being built by Sir the purposes of respiration’ [14]. Joseph Bazalgette [3]. The company had failed to pro- tect its reservoirs from the outpourings of nearby water- John Snow and the Broad Street pump closets and one of these, in Bromley, had belonged to a man called Hedges who had been the first casualty of Farr had served on a committee which examined the the epidemic. The company had also tried to cover up 1853-4 epidemic and had to address the evidence pro- its failure [4]. duced by Dr John Snow whose observations of the mor- tality occurring among people using the pump outside Farr’s report condemned the company in forthright his surgery in Broad (now Broadwick) Street, Soho, per- terms and, in the process, dealt a severe blow at the suaded him that polluted water rather than foul air was orthodox ‘miasmatic’ explanation of disease causation the problem. Farr himself drew a diagram which was which held that epidemics were caused by diseased designed to demonstrate that cholera deaths were great- atmosphere rather than by polluted water. He wrote: est where the smell from the sewage-polluted Thames ‘The population in London probably inhaled a few was worst and that deaths diminished with altitude. cholera corpuscles floating in the open air but the quan- Unfortunately, the diagram showed an embarrassing tities thus taken from the air would be insignificant in its concentration of deaths at the relatively high level of the effects in comparison with the quantities imbibed Broad Street pump. Nothing could better demonstrate

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Letter to Editor

the strength of Farr’s miasmatic convictions than his Edwin Chadwick, who died in 1890 and Florence explanation for this anomaly. He wrote that the deaths Nightingale who followed him in 1910 remained con- in the vicinity of the pump ‘may have arisen, not in its vinced that epidemics were caused by foul smells, or containing choleraic excrements, but simply in the fact miasma, rather than polluted water. Nevertheless Farr’s of its impure waters having participated in the atmos- careful statistical work and the clarity of his arguments pheric infection of the district’ [15]. represented a major step towards understanding the cause of epidemics and the role of properly designed The 1866 Whitechapel epidemic, and the attempt of the sanitation in their prevention. East London company to conceal the true cause, was a crucial episode in identifying polluted water as the true REFERENCES: source of cholera. In his report on the 1866 epidemic Farr acknowledged that John Snow’s theory ‘turned the 1. 1831-2, 6, 536 deaths in London; 1848-8, 14, 137; 1853-4, 10, 738; current in the direction of water, and tended to divert 1866, 5, 596; statistics quoted in Creighton, C. A History of attention from the atmospheric [i.e. miasmatic] doc- Epidemics in Britain, Oxford University Press, 1894, page 858 trine’. The Lancet was similarly converted and expressed 2. An account of Farr’s life and work is given by the present author in Journal of Medical Biography, 2000, volume 8, pages 220-27 the view that it was ‘greatly to be regretted that a heavy 3. The Great Stink of London: Sir Joseph Bazalgette and the penalty has not been levied for the infraction of the law’ Cleansing of the Victorian Metropolis (Sutton publishing, 2001) by [16]. the present author gives an account of Bazalgette’s work 4. Parliamentary Papers 1867-8, volume 31 contains Farr’s report

The epidemic that didn’t happen 5. Ibid, pages 79-80

6. The Lancet, 15th August, 1868, page 223 The 1866 epidemic was the last one suffered by Lon- 7. The Lancet, 12th November, 1831 page 216 don. In 1892 there was a severe outbreak in Hamburg, 8. The Lancet, 22nd October, 1853 pages 393-4 one of the capital’s principal trading partners. The bac- 9. Included in Mortality in 19th century Britain, W. Farr, edited by teriologist Robert Koch, who had identified the cholera H. Ratcliffe, Gregg reprint, London, 1974 bacillus in polluted water in India in 1883, was chosen 10. The Lancet, 13th March, 1852, page 268 by the Kaiser to combat the Hamburg epidemic and the 11. Florence Nightingale, Notes on Nursing, 1859, Harrison facsimile British government set up a committee to prepare for reprint, page 16 an epidemic in London. The system of intercepting sew- 12. ParliamentaryPapers, 1846, volume 10, page 651 ers built by Sir Joseph Bazalgette between 1859 and 13. The Builder, 1st February 1889, pages 78-9 1875 ensured that the capital’s water supply was pro- 14. Parliamentary Papers, 1844, volume page 50 tected from its sewage. Farr who was, like The Lancet, a 15. Parliamentary Papers, 1854-5, volume 21, page 48 late convert to the belief that cholera could be water- 16. The Lancet, 2nd November 1867 page 501 borne, paid his tribute to Bazalgette’s system: ‘The ele- 17. 29th Annual Report of the Registrar-General, 1869, page iv ment influencing mortality, which has undergone the 18. The Lancet, 5th May, 1883, page 800-01 greatest change in recent times, is the system of 19. Leone Levi (1821-1888), Professor of Commerce at King’s College, drainage. The salutary effect of this great engineering London, prolific writer on law, commerce and statistics; vice-presi- dent of the Statistical Society work is, as has already been shown, patent’ [17]. Farr died on 14th April 1883 and was the subject of generous 20. The Times, 23rd April, 1883, page 10 21. Creighton, C. A History of Epidemics in Britain, Oxford University obituary tributes. The Lancet recorded that he had ‘laid Press, 1894, page 854 the foundation of our knowledge of vital statistics in England…it is impossible to doubt either the value of his work or its influence upon public opinion in health matters’ [18]. Perhaps the last word on William Farr should be left to the distinguished jurist and statistician Leone Levi [19] who, in a letter to The Times the week after Farr’s death attributed much of his success in per- suading his fellow citizens of the significance of his work in the unfamiliar field of statistics was attributable to the fact that ‘the language he used was always characterised by lucidity, simplicity and common sense’ [20].

Not everyone was convinced either by Farr’s careful rea- soning or by Koch’s discovery of the cholera bacillus in village ponds in India, an event which occurred in the year of William Farr’s death. . Even the writer of the definitive history of epidemics in Britain, Charles Creighton, expressed a note of scepticism when in 1894 he wrote of John Snow’s ‘speculative essay in 1849 upon the probability of cholera being conveyed by water…although he had enthusiastic followers at the time and has probably more now’ [21].

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