STUDENT OVERVIEW London 1854: Cesspits, Cholera and Conflict Over

Home , Dean Street, Great Windmill Street, Henry Seymour Conway, Henry Whitehead (priest), House of St Barnabas, Meard Street

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 ([email protected]) and Eric B. Nelson ([email protected]) 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?

1 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.

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!

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

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.

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.

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…

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MEN

NIGHT-SOIL THE 7

28 AUGUST MONDAY, 6 9 8 MONDAY, AUGUST 28 THE NIGHT-SOIL MEN

them through another sensory channel: smell. No extended descrip waste-recycling system that helped London grow into a true metrop tion of London from that period failed to mention the stench of the olis, by selling the waste to farmers outside the city walls. (Later en city. Some of that stench came from the burning of industrial fuels, trepreneurs hit upon a technique for extracting nitrogen from the but the most objectionable smells—the ones that ultimately helped ordure that could be reused in the manufacture of gunpowder.) prod an entire public—health infrastructure into place—came from While the rakers and their descendants made a good wage, the work the steady, relentless work of bacteria decomposing organic matter. conditions could be deadly: in 1326, an ill—fated laborer by the name Those deadly pockets of methane in the sewers were themselves pro of Richard the Raker fell into a cesspool and literally drowned in hu duced by the millions of microorganisms diligently recycling human man shit. dung into a microbial biomass, with a variety of gases released as By the nineteenth century, the night-soil men had evolved a pre waste products. You can think of those fiery, underground explosions cise choreography for their labors. They worked the graveyard shift, as a kind of skirmish between two different kinds of scavenger: between midnight and five am., in teams of four: a “ropeman,” a sewer—hunter versus bacterium—living on different scales but none “holeman,” and two “tubmen.” The team would affix lanterns at the theless battling for the same territory. edge of the cesspit, then remove the floorboards or stone covering But in that late summer of 1854, as the toshers and the mud—larks it, sometimes with a pickax. If the waste had accumulated high and the bone collectors made their rounds, London was headed enough, the ropeman and holeman would begin by scooping it out toward another, even more terrifying, battle between microbe and with the tub. Eventually, as more night soil was removed, the men man. By the time it was over, it would prove as deadly as any in the would lower a ladder down and the holeman would descend into the city’s history. 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 to Mayhew: LONDON’S UNDERGROUND MARKET OF SCAVENGING HAD ITS offered a bottle of gin for their labors. As one reported own system of rank and privilege, and near the top were the night- “I should say that there’s been a bottle of gin drunk at the clearing of soil men. Like the beloved chimney sweeps of Mary Poppins, the every two, ay, and more than every two, out of three cesspools emp night—soil men worked as independent contractors at the very edge of tied in London; and now that I come to think on it, I should say that’s the legitimate economy, though their labor was significantly more re been the case with three out of every four.” volting than the foraging of the mud-larks and toshers. City landlords The work was foul, but the pay was good. Too good, as it turned hired the men to remove the “night soil” from the overflowing out. Thanks to its geographic protection from invasion, London had cesspools of their buildings. The collecting of human excrement was become the most sprawling of European cities, expanding far be a venerable occupation; in medieval times they were called “rakers” yond its Roman walls. (The other great metropolis of the nineteenth and “gong-fermors,” and they played an indispensable role in the century, Paris, had almost the same population squeezed into half 10 MONDAY, AUGUST 28 THE NIGHT-SOIL MEN Ii the geographic area.) For the night—soil men, that sprawl meant bright light it appeared the colour of strong green tea, and positively longer transport times—open farmland was now often ten miles looked as solid as black marble in the shadow—indeed, it was more away—which drove the price of their removing waste upward. By like watery mud than muddy water; and yet we were assured this was the Victorian era, the night-soil men were charging a shilling a the only water the wretched inhabitants had to drink. As we gazed in cesspool, wages that were at least twice that of the average skilled la horror at it, we saw drains and sewers emptying their filthy contents borer. For many Londoners, the financial cost of removing waste into it; we saw a whole tier of doorless privies in the open road, com exceeded the environmental cost of just letting it accumulate— mon to men and women, built over it; we heard bucket after bucket particularly for landlords, who often didn’t live on top of these over of filth splash into it; and the limbs of the vagrant boys bathing in it flowing cesspools. Sights like this one, reported by a civil engineer seemed by pure force of contrast, white as Parian marble. And yet, as hired to survey two houses under repair in the I 840s, became com we stood doubting the fearful statement, we saw a little child, from monplace: “I found whole areas of the cellars of both houses were one of the galleries opposite, lower a tin can with a rope to fill a large full of nightsoil to the depth of three feet, which had been permitted bucket that stood beside her. In each of the balconies that hung over for years to accumulate from the overflow of the cesspools. . . . Upon the stream the self—same tub was to be seen in which the inhabitants passing through the passage of the first house I found the yard cov put the mucky liquid to stand, so that they may, after it has rested for ered in nightsoil, from the overflowing of the privy to the depth of a day or two, skim the fluid from the solid particles of filth, pollution, nearly six inches and bricks were placed to enable the inmates to get and disease. As the little thing dangled her tin cup as gently ac possi across dryshod.” Another account describes a dustheap in Spitalfields, ble into the stream, a bucket of night-soil was poured down from the in the heart of the East End: “a heap of dung the size of a tolerably next gallery. 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 Victorian London had its postcard wonders, to be sure—the Crystal they are fi-equently stirred for that purpose.” Mayhew described this Palace, Trafalgar Square, the new additions to Westminster Palace. grotesque scene in an article published in the London Morning Chron But it also had wonders of a different order, no less remarkable: arti icle in 1849 that surveyed the ground zero of that year’s cholera out ficial ponds of raw sewage, dung heaps the size of houses. break: The elevated wage of the night—soil men wasn’t the only culprit behind this rising tide of excrement. The runaway popularity of the

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 invented in the late sixteenth century by SirJohn Harington, who ac fearful virulence; but this year it appeared at the opposite end, and ran tually installed a functioning version for his godmother, Queen Eliz down it with like severity. As we passed along the reeking banks of abeth, at Richmond Palace. But the device didn’t take off until the the sewer, the sun shone upon a narrow slip of the water. In the late 1700s, when a watchmaker named Alexander Cummings and a I 12 MONDAY, AUGUST 28 THE NIGHT-SOIL MEN 13 cabinetmaker named Joseph Bramah filed for two separate patents ing itself by laying waste to its habitat. Five hundred years after the fact, on an improved version of Harington’s design. Bramah went on to London was slowly re-creating the horrific demise of Richard the build a profitable business instaffing water closets in the homes of the Raker: it was drowning in its own filth. 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 ALL OF THOSE HUMAN LIVES CROWDED TOGETHER HAD AN closets for public use in Hyde Park during the Great Exhibition of inevitable repercussion: a surge in corpses. In the early 1840s, a 1851. An estimated 827,000 visitors used them. The visitors no doubt twenty-three-year-old Prussian named Friedrich Engels embarked on marveled at the Exhibition’s spectacular display of global culture and a scouting mission for his industrialist father that inspired both a clas modern engineering, but for many the most astonishing experience sic text of urban sociology and the modern Socialist movement. Of was just sitting on a working toilet for the first time. his experiences in London, Engels wrote: Water closets were a tremendous breakthrough as far as quality of life was concerned, but they had a disastrous effect on the city’s The corpses [of the pnorj have no better fate than the carcasses of an— sewage problem. Without a functioning sewer system to connect to, imnals. The pauper burial ground at St Bride’s is a piece of open most WCs simply flushed their contents into existing cesspools, marshland which has been used since Charles IT’s day and there are greatly increasing their tendency to overflow According to one esti heaps of bones all over the place. Wednesday the remains of mate, the average London household used 160 gallons of water a day dead paupers are thrown in to a hole which is 14 feet deep. A clergy in 1850. By 1856, thanks to the runaway success of the water closet, man gabbles through the burial service and then the grave is filled they were using 244 gallons. with loose soil. On the following Wednesday the ground is opened But the single most important factor driving London’s waste- again and this goes on until it is completely full. The whole neigh removal crisis was a matter of simple demography: the number of peo borhood is infected from the dreadful stench. 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, One privately run burial ground in Islington had packed 80,000 making it the most populous city on the planet, up from around a corpses into an area designed to hold roughly three thousand. A million at the turn of the century. Even with a modern civic infia gravedigger there reported to the Times of London that he had been structure, that kind of explosive growth is difficult to manage. But “up to my knees in human flesh, jumping on the bodies, so as to cram without infrastructure, two million people suddenly forced to share them in the least possible space at the bottom of the graves, in which ninety square miles of space wasn’t just a disaster waiting to happen— fresh bodies were afterwards placed.” it was a kind of permanent, rolling disaster, a vast organism destroy- Dickens buries the mysterious opium—addicted law—writer who 14 MONDAY. AUGUST 28 THE NIGHT-SOIL MEN 15 overdoses near the beginning of Bleak House in a comparably grim within. Marx took that insight, wrapped it in Hegel’s dialectics, and setting, inspiring one of the book’s most famous, and famously im transformed the twentieth century. But the idea itself sprang out of passioned, outbursts: 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 a hemmed-in churchyard, pestiferous and obscene, whence malignant conditions that defiled both the dead and the living. diseases are communicated to the bodies of our dear brothers and sis But in one crucial sense Dickens and Engels had it wrong. How

ters who have not departed. . . . With houses looking on, on every ever gruesome the sight of the burial ground was, the corpses them side, save where a reeking little tunnel of a court gives access to the selves were not likely spreading “malignant diseases.” The stench was iron gate—with every villainy of life in action close on death, and offensive enough, but it was not “infecting” anyone. A mass grave of every poisonous element of death in action close on life—here, they decomposing bodies was an affront to both the senses and to personal lower our dear brother down a foot or two: here, sow him in cor dignity; but the smell it emitted was not a public-health risk. No one ruption, to be raised in corruption: an avenging ghost at many a sick- died of stench in Victorian London. But tens of thousands died be bedside: a shameful testimony to future ages, how civilization and cause the fear of stench blinded them to the true perils of the city, barbarism walked this boastful island together. and drove them to implement a series of wrongheaded reforms that only made the crisis worse. Dickens and Engels were not alone; prac To read those last sentences is to experience the birth of what would tically the entire medical and political establishment fell into the same become a dominant rhetorical mode of twentieth-century thought, a deadly error: everyone from Florence Nightingale to the pioneering way of making sense of the high-tech carnage of the Great War, or reformer Edwin Chadwick to the editors of The Lancer to Queen the Taylorite efficiencies of the concentration camps. The social the Victoria herself. The history of knowledge conventionally focuses on orist Walter Benjamin reworked Dickens’ original slogan in his enig breakthrough ideas and conceptual leaps. But the blind spots on the matic masterpiece “Theses on the Philosophy of History,” written as map, the dark continents of error and prejudice, carry their own Inys the scourge of fascism was enveloping Europe: “There is no docu tery as well. How could so many intelligent people be so grievously ment of civilization that is not also a document of barbarism.” wrong for such an extended period of time? How could they ignore The opposition between civilization and barbarism was practi so much overwhelming evidence that contradicted their most basic cally as old as the walled city itself. (As soon as there were gates, there theories? These questions, too, deserve their own discipline—the so were barbarians ready to storm them.) But Engels and Dickens sug ciology of error. gested a new twist: that the advance of civilization produced barbar The fear of death’s contamination can sometimes last for cen ity as an unavoidable waste product, as essential to its metabolism turies. In the middle of the Great Plague of 1665, the Earl of Craven as the gleaming spires and cultivated thought of polite society The purchased a block of land in a semirural area to the west of central barbarians weren’t storming the gates. They were being bred from London called Soho Field. He built thirty-six small houses “for the 16 MONDAY, AUGUST 28 THE NIGHT-SOIL MEN 17

reception of poor and miserable objects” suffering from plague. The one of England’s greatest poets and artists. In his late twenties, he re rest of the land was used as a mass grave. Each night, the death carts turned to Soho and opened a printing shop next door to his late fa would empty dozens of corpses into the earth. By some estimates, ther’s shop, now run by his brother. Another Blake brother opened a over four thousand plague-infected bodies were buried there in a mat bakery across the road at 29 Broad shortly thereafter, and so for a few ter of months. Nearby residents gave it the appropriately macabre— years, the Blake family had a mini-empire growing on Broad Street, sounding name of “Earl of Craven’s pest—field,” or “Craven’s field” for with three separate businesses on the same block. short. For two generations, no one dared erect a foundation in the The mix of artistic vision and entrepreneurial spirit would define land for fear of infection. Eventually, the city’s inexorable drive for the area for several generations. As the city grew increasingly indus shelter won out over its fear of disease, and the pesthouse fields trial, and as the old money emptied out, the neighborhood became became the fashionable district of Golden Square, populated largely grittier; landlords invariably broke up the old townhouses into sepa by aristocrats and Huguenot immigrants. For another century, the rate flats; courtyards between buildings filled up with impromptu skeletons lay undisturbed beneath the churn of city commerce, until junkyards, stables, jury—rigged extensions. Dickens described it best in late summer of 1854, when another outbreak came to Golden Square Nicholas Nickleby: and brought those grim souls back to haunt their final resting grounds once more. 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

CRAVEN’S FIELD ASIDE, SOHO IN THE DECADES AFTER THE countenance years ago. The very chimneys appear to have grown dis plague quickly became one of London’s most fashionable neighbor mal and melancholy from having had nothing better to look at than hoods. Almost a hundred titled . families lived there in the 1690s. In the chimneys over the way. . To judge from the size of the houses, 1717, the Prince and Princess of Wales set up residence in Leicester they have been, at one time, tenanted by persons of better condition House in Soho. Golden Square itself had been built out with elegant than their present occupants; but they are now let off, by the week, Georgian townhouses, a haven from the tumult of Piccadilly Circus in floors or rooms, and every door has almost as many plates or bell- several blocks to the south. But by the middle of the eighteenth cen handles as there are apartments within. The windows are, for the tury, the elites continued their inexorable march westward, building same reason, sufficiently diversified in appearance, being ornamented even grander estates and townhouses in the burgeoning new neigh with every variety of common blind and curtain that can easily be borhood of Mayfair. By 1740, there were only twenty titled residents imagined; which every doorway is blocked up, and rendered nearly left. A new kind of Soho native began to appear, best embodied by the impassable. by a motley collection of children and porter pots of all son of a hosier who was born at 28 Broad in 1757, a talented and trou sizes, from the baby in arms and the half-pint pot, to the full-grown bled child by the name of William Blake, who would go on to be girl and half-gallon can.

Kensington. and of Mayfair

houses

piece one not is There bedroom. the it behind drawing-room, the

town

opulent the

surrounded

industry foul-smelling and

poverty

being street of the view the with one the rooms, two has fiatj [The

of an working island of city: the End West prosperous otherwise the

an in

anomaly of something was Soho But loaded.) were they course,

1850s: early the in

standards,

mud—lark (By class.

middle entrepreneurial the and poor

penned

Street, on Dean residence typical one of a description is Here

tions,

the a working

of mix were they standards

Victorian

though

it.

appalled not squalor, the by energized been have to seem They

industrialized of today’s by standards

the

destitute, poor, almost

Soho. of

streets crowded the along homes their made first Shelley

were residents

neighborhood’s The

boilers.) tripe

plants, facturing

and

Hogarth and Blake when settlement urban of pattern new a was

manu

slaughterhouses,

of share industry: had also its Soho

however,

decay—but the relish even neighborhood, a decaying appropriate

environment, urbanist new typical the

(Unlike space.

commercial

renegades

and now—artists by us to familiar is trope The to-do.

larger

occasional the

with interlaced address,

nearly

every at fronts

well- the

by ago century a abandoned been had that shells integrating

store

with buildings

residential

two—to-four-story

cities: successful

dis

in the living radicals and eccentrics and visionaries of a class Age:

of the

bedrock celebrate

urbanists” “new

today’s that borhood

Industrial the of dawn the around Soho to perfectly applies maxim

neigh

diverse economically mixed-use,

of classic

the into kind

self

the and

wrote, once Jacobs Jane buildings,” old need ideas “New

it turned

had the to neighborhood Soho, got Marx the By

time

1839—1840. in London visiting when neighborhood

of Marx. Karl by the

name radical something

the

stayed also Wagner Richard and Liszt Franz 1764. in gang,

thirty-

was see, you husband, The Museum. the

British Room

Wolf

prodigy eight-year-old the son, his with visiting while Street

the for

Reading a

such fondness he

developed why see can one

easily

Frith

on a flat leased Mozart Leopold lives. their in points various

though

productivity, the

husband’s hinder

noticeably not did quarters

residents Soho were Hogarth—all William Shelley, Percy Burney,

tattered

cramped, these somehow Yet

to dusting.) aversion an with

Fanny Burke,

Edmund culture. British Enlightenment-era on book

maid a

maid.

a and

(Apparently

children, four their couple,

migrant

a text to

an index like reads period this during Soho in lived who

im a Prussian

individuals:

seven were attic

in two—room this

Living

philosophers and sculptors and musicians and poets of list The ativity.

cre of

hotbed a was neighborhood the conditions, unsanitary and

to dust;

down. sit is dangerous

it with covered

crowded increasingly of—the because perhaps despite—or But

is everything dirty; Everything few objects. a notice

gradually you

two. was acre per number the contrast, by

a fog, as

and, fumes the get to used

eyes

your until in a

cave,

were

Kensington, In acre. per houses thirty had Soho in Luke’s St. of parish

you as

at first

around grope you

that so smoke

by coal and

tobacco

The

acre.) per 100 around houses only today Manhattan scrapers,

dimmed sight your flat, the.

enter you

When

disorder.

. est .

. .

. sky

its with

(Even acre. the to people 432 with London, Greater up

great in

the

everything and everywhere, dust

finger—thick torn, and

made that

subdistricts 135 all of populated densely most the was Soho

tattered is broken,

flat. Everything entire

in the

furniture solid good,

side west the on

Street Berwick of subdistrict the 1851, By

MEN NIGHT-SOfl THE

28 AUGUST MONDAY, 18

ginning,

promising more

her than constitution late brother.

Sarah

coming. seen it have would blocks squalid those visited had who

Sarah 1854,

a to birth gave Lewis

girl, who the from

be possessed,

anyone streets”; “bad and houses” “meaner the devastated had plague

their boy; little

a who sickly

ten child at died

In months.

of March

the course Of away. blocks only lived that sort better over the passing

Sarah

Thomas

and

in Lewis the lived 40

Broad, at parlor

first with

while destitute, and the debauched the attacking plague the book:

city the

where

houses most five

averaged

occupants room. per

the in cliché elitist every to confirm appeared attack selective That

twenty

These inhabitants. were a spacious

for accommodations part

unharmed. utterly neighborhoods surrounding the but left Soho

to single hold

a and family

of servants. handful

Now

it contained

struck scourge terrible a when 1854, of summer late the in unfolded

It pub.

was

an eleven-room

that had house originally

been

designed

that events the in role pivotal a play would topography social This

and wife 40 moved his Lewis Broad up into one Street, door the from

bad streets.” all the east

a in

the late Sometime 1840s,

London

named policeman Thomas

the to out to leave and classes higher the by occupied streets the all to

and shopkeepers,

dressmakers.

entrance eastern the cross should street new the that was purpose My

the the

numbcr, same

were

shoemakers, servants,

domestic masons,

community.... the of part the trading and by mechanics occupied

a by other

relatively trade

margin. wide at the After

tailors, roughly

houses meaner and Streets narrower the and Gentry, and Nobility the

In of terms Newcastle-on-Tyne.

tailors professions, any

outnumbered

by occupied streets the between separation complete “a create to was

a facturer,

wardrobe dealer, boot-tree

The pub, and manufacturer,

intention explicit Nash’s Soho. of community working-class growing

a engraver,

and

a seller, ironmonger, trimming manu percussion-cap

the from

Mayfair

the well—to—do separating sanitaire cordon of

cer, a a a maker,

a bonnet baker,

grocer, saddle-tree an

manufacturer,

kind a as thoroughfare the planned he House, Carlton at home new

Square, Golden

one

have would

in progression: encountered, gro

Regent’s Prince with the Park Marylebone connect to Street Regent

In August of a walking 1854,

down Street, of north block Broad

designed Nash John When a barricade. as serve to designed plicitly

mineral and chinists

teeth business doing manufacturers

them. beside

ex was layout street the indeed, And away. feet few a only is know

out of in an urban place but today; center the there

also were

that you the reaching avenue from you prominent keeping erected,

ear.

modern were the There

and be bakeries grocers wouldn’t that

has been barricade a if as almost it feels neighborhood, the around

ness. The

of assortment to storefronts

quaint generally the sounds

Walking Street. Regent onto directly open that conduits few very

merce,

residence every with of almost small

busi kind some housing

are there because largely Soho, western of and alleys lanes smaller

Soho.

The

engine a was neighborhood of veritable com local

the from imperceptible almost is Street Regent of and bustle fic

tradesmen

and by to the

get managed mechanics

the in

houses mean

traf the nonstop But somehow day. this to posh Mayfair, of enclave

on the

of side But

wrong behind Street,

the Regent the barricade,

tony the enter you Street Regent of West façades. commercial white

you.

why That’s

in built they’d the barricades

first place.

gleaming its with Street, Regcnt of avenue wide the by defined is

as disease where

prospered,

of anyone

social good tell standing

would

neighborhood the of border western The Soho. around streets of the

and and Poverty an breeding depravity

low created

environment

layout the physical in encoded still is discontinuity economic This

THE MEN NIGHT-SOIL

28 AUGUST MONDAY. 20 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 ‘ri. scattered by the chance winds of history. We do not know her name, 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 —3..-— up in certain .— — 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.

THE

TOM

EPIDEMICS

MAPS

DISEASE

•. •

UNIVERSITY

•

••.

•

. •.

•. •

CHICAGO

•.•

KOCH

•.•

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•.

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PRESS

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CHICAGO

•

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GROUND

•

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LONDON

•

•.

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43•

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•.

•

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•

••

•0•

• • 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 rIGURE 2.1 Peter Gould’s famous map series describes the spread of AIDS in the United States at the county level as Organization, and the World Health Organization each produce annually hundreds of part of the work toward a model that could accurately predict future diffusion in U.S. communities. 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. Typicallythese maps are based upon to maps of patient infection in local and regional communities (Verghese, Berk, and the work of medical researchers, but others bring forward conditions at the fine scale Sarubbi 1989). Famously, in the 1980s geographer Peter Gould and coworkers not of very local health concerns, mapped realities advanced by citizens that officials only mapped AIDS at the county level in the United States (fig. 2.1) but did so in a to have overlooked or rejected. Maps of disease and health are collected in atlases and manner generating the first accurate predictive model (mapped) of its spread, iden 1 U,bi produced in books whose job it is to unravel the skeins of often conflicting research tifying contiguous and hierarchical elements to its pattern of diffusion (Gould 1993). 0 conclusions about this or that health threat. Together, all these maps emphasize this HIV isa 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, 0 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 F 0 for bovine friends, it is in its of WNV Bossy and her worse for us human variant, Creutzfeldt noshing on birds and mammals. Once confined to a small area Uganda, >- (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. reported in New York State in 1999 (Nasci et al. 1999) through the a case 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. able are national maps with county data of cognate viral conditions, including St. a 2 F There have been hundreds, perhaps thousands of maps of HIV/AIDSsince 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 YorkState. 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 Yorkbut 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 airlinetravelers (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, similarlysevere epidemic. Figure 2.3 is one of a series of maps that modeled the effect today of a 1918-style, killeroutbreak 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 similarlysevere 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 to be understood. Put another way, mapping is a method of assemblage within which was a single pulmonary condition is now a familyof related diseases whose members I ideas are constituted and then argued about specific experiences. are separately considered and distinctly 3named. The variants share similar symptoms, In its method of assemblage the map changes the individual and particular, trans but each is caused by a different ifrelated bacterial agent and each requires a distinct forms discrete rows in tables of occurrence into a common experience, an event treatment. Current estimates are that perhaps a third of the planet’s population is in class whose members are assumed to be related somehow, one to another, through fected with at least a latent form of one or another tuberculosis and that in the United the evidence of disease symptoms. In this way the individual rows of morbidity and States alone ten to fifteen millionpeople are affected (Markel 2004, 16). mortality tables are transformed in the two-dimensional plane of the map into a uni The list goes on but the message is clear: ifit is a disease we map it at every stage tary thing, a single reality composed of multiple occurrences of similar attributes. By of our knowing, from the first collection of symptoms across decades of investigation. making a map—any map—relationships are asserted between sets of phenomena

What are we doing when we map these problems and what do we learn from the in a manner that is inherently both analytic and experimental. “The former is about exercise? More importantly, perhaps, what is it that really we map? 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). MAPS AND MAPPING The map’s intellectual service lies in this conjunction of analytic presentation and Maps make arguments about disease, their pattern of incidence, and their method of experimental argumentation in a visual exposition. The elments assumed to define diffusion. They are workbenches on which we craft our theories about the things that this or that disease state, and this or that place of occurrence, are spatially arranged

cause health to fail, imaging data collected in this or that disease outbreak. They are in an assemblage proposing that a congress of symptoms (cramps, dehydration, diar not, as some argue, either mere representations of the world or simple illustrations rhea) is one thing (amoebic dysentery) or another (cholera) whose reality we seek to of work completed in other media (Millerand Wentz 2003). It is true but insufficient document as a single condition. We do this in the hope that we can limit,or better, to say that “disease maps provide a rapid visual summary of complex geographic eliminate, its presence in our communities. By including in the map environmental ele information and may identifysubtle patterns in the data that are missed in tabular pre ments that may be related causally (air temperature, food outlets, sewer lines, water sentations” (Elliottand Wartenberg 2004, 999). Certainly, mapping permits a visual sources, and the like)we create a medium in which their likelyrelation to this or that statement of spatially grounded data accumulated on the basis of theories whose illness is asserted in a manner inviting systematic assessment. exposition—and mode of analysis—is lodged in the map itself. More fundamentally, In this the map is both the subject, an evidentiary statement in its own right, and however, maps are cognitive instruments whose mode of argument and not the tech an object on which ideas are played out in the two-dimensional plane of the map. In niques of imaging is their raison d’être. this way mapping produces a type of knowledge, one rooted in a relational space, UI) As it Franco Moretti put more generally: “Mapping it—is not the conclusion of which has been critical to disease studies for centuries. This is not a characteristic U (I) geographical work; it’sthe beginning. After which begins in fact the most challenging unique to disease mapping but an attribute of mapping generally. As David Turnbull (3 part of the whole enterprise: one looks at the map, and thinks. You look at a specific argues, “Maps are the paradigmatic examples of the kind of spatial knowledge that z configuration—those roads that run towards Toledo and Sevilla; those mountains, is produced in the knowledge space we inhabit. Not only do we create spaces

such a long way from London; those men and women that live on opposite banks of by linkingpeople, practices and places, thus enabling knowledge to be produced, UI) 0 the Seine—you look at these patterns and try to understand:’ (Moretti 1998, 7—8; we also assemble the diverse elements of knowledge by spatial means” (Turnbull I— 12 original emphasis). 2000, 89). >- Ui) It is this visual thinking, grounded and spatial, that the map promotes. To map the Allthis is to say mapping is an experimental system that is at once graphic, nu z(3 incidence of a thing is to create a shared range of experience in a manner that i not merical, spatial, and theoretical. “Experimental systems are the units within which merely descriptive but more importantly “constative’ bringing forth a meaning acces the signifiers of science are generated. They display their meanings within spaces of sible to analytic address (Austin 1975). Descriptive statements report and reflect a representation, in which graphemes, that is, material traces such as fraction patterns 12 13 “simple” reality, while “constative” statements indicate “the circumstances in which or arrays of counts are produced, articulated, and placed, displaced, replaced . r’J the statement is made or reservations to which it is subject or the way in which it is to scientists create spaces of representation through graphemic concatenations that IU be taken and the like”(p. 3). This constative essence enables the map’s performative represent their epistemic traces as engravings, that is, generalized forms of ‘writing” 3: ability to argue how a subject, in this case a recurring class of disease symptoms, is (Rheinberger 1997, 2). U This particular experimental system employs the map surface as a type of inscrip Toronto LosAngeles tion device, a technology that embeds in the map page a set of arrangements for 44,854 London Paris 221494 15,449 labeling, naming, and counting things. In that process relations between elements New York Minneapolis/ Chicago 372 StPauI 126,345 L 111,531\ of a set are proposed, creating a range set in relation to other, similarly constructed 64,495 ranges. Based on the constative backcloth of its form, the argument advanced is Houston 70,776 -‘ 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 FIGURE 2.4 The map of travel from Mexico City to other world a hypothesis based upon it (Chrisman 1997, 24—26). It is this matrix that is constan cities was used in a project attempting to determine the number tive, among mapped attributes located on the page in asserting potential linkages 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 airtravel 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 millionpassengers 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 AirTransport 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’srecord-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 aI 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 >- U, ing from Mexico, the origin of the new outbreak. Implicitin each bar is the assumption we have known for millennia, and its diffusion from Mexico City to .. . everywhere. 0 z that cities receiving Mexican air travelers also were cities where Hi Ni influenza could In reading the map we reflexivelytranslate 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 of sixteenth and seventeenth centuries chapter 3 willargue). Within this a Finally,with all it, this ment the (as disease transported by humans. this behind the map makes ‘4 I— space the map creates an urban sphere, a collection of cities among which travel proposition: ifthis 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 require more Each virus has its own level of intensity. Some 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. I WEST NILE VIRUS: THE U.S. EXPERIENCE

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 or denied by their predicates. All evidence is propositional, its validity accepted or rejected on the basis4 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, “IFthis 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 L/) 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— 0 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 (viralinfec 3.) z 0 tion) located in the map can be considered a single entity, creating an event c/ass 0 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 16 its 1999 introduction in the United States. 17 are the same thing, together. Through identical symbolization and consistent lettering Allare based on data collected and by the Centers for Disease Control and published (3/ 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 2004 U The repetition of these propositions, map by map, gives to each (and to the map We trust these maps not because we trust the data collectors in this or that U.S. set) added weight. We see in the maps the progress of the virus. In the seeing, the county (we know nothing about them), or because we trust the anonymous mapmak maps propose a way of thinking about events (in this case, WNV in humans) occur ers. Assumptions of validity rest upon our trust in the CDC and its system of data ring injurisdictional boundaries assumed to be the appropriate scale at which disease collection. We believe in the maps to the degree we believe in the CDC and its com data can be collected, posted in the map (and its database), and trusted. In these petence. We also believe in the integrity of the continental United States, a political maps, that scale is that of the United States, its resolution that of U.S. counties in reality defined by borders drawn on the map but not the land. Similarly,we believe in which cases were reported. Individuallyand together the maps and their data assert the integrity of U.S. counties as catchments for bureaucratic data. Simply,the geogra the broad geography of the continental United States and its local political entities as phy posted in the map is appropriate because the CDC (and scores of other federal both existential realities and as appropriate vehicles for WNV study. We accept this agency and maps) says it is so. For the purpose of American disease studies it ap as real and relevant geography even though northern and southern boundaries are pears irrelevant that WNV also attacked thousands of people in Canadian provinces wholly porous political fictions that exist without a physical geographic referent. and Mexican estados. After all, if it were important it would be in the map. These borders are not relevant landforms (not like the oceans to west and east, There is nothing magical in this. It is simply to say that maps aggregate facts for example) and not necessarily relevant to any study of bacterial or viral incidence. in a manner that creates evidentiary classes in service of an idea. The evidentiary Insects, birds, humans, and trade goods all constantly travel across them, carrying value of any one datum, any single row in a table of incidence by U.S. county is as the bacteria and viruses that become disease. And yet the map insists its geography sumed to be the same as any other. Data from Cerro Gordo County, Idaho, Sonoma is sufficient; on the basis of that posting we assume the appropriateness of U.S. County, Washington, Worcester County, Massachusetts, and Yonkers, New York,are county, state, and national borders—bureaucratic artifacts with little natural rationale. assumed to hold an equal truth value; contributing to the whole. Ifthis were not true, if

The map says the borders are as real as mountains and .. . we accept that. The map points of mapped fact are disputed or plain fiction, the mapped class dissipates into says “we’llsee WNV in this frame at this resolution” and we accept that, too, without conjecture. It is not that ‘all maps are wrong:’ as the saying goes, but that all maps

reflection. Were it otherwise, it would be mapped differently. We might then include are as right or wrong as the data collected on the basis of the assumptions made Canadian and Mexican WNV to transform the American epidemic into a North Ameri about its importance and validity. can pandemic. The utilityof all data is bounded by our confidence in it and the assumptions we Each dot in the map posts not a case of WNV but a U.S. county in which West seek to argue on its basis. What makes mapping unique, and a uniquely valuable tool, Nile virus was reported to local health officials. It does not say how many cases is that it anchors the isolated, evidentiary fact—an entry in a table of incidence—in an occurred or the percentage of the population that were infected, only that one or event class at a location. The map then builds from its fields of common incidence to

more persons were diagnosed with this condition in a certain time period. We could assert their relation. If this was WNV in continental U.S. counties in 2000 and this bJ U, use graduated symbols to show the number of cases, grouping them in was WNV in U.S. counties in 2004, then the epicenter of the viral attack expanded classes U U, (1—50,51—150, 151—300, more than 300, for example). And we could calculate the westward from New Yorkin those years. The central argument of the map space as 0 incidence per, say, one million persons. These statistical refinements, which have serts both the validity of data classes and the importance of their juxtaposition. z become standard, were part of a revolution in medical mapping and statistics in the

nineteenth century (and will be described in later chapters). U, A LOCAL EXAMPLE The map of WNV activity in 2000—the virus was first introduced to the United 0 0I-. States in late summer of 1999—shows a very limitednumber of cases in the New York West Nile virus was a national concern and one heavily studied (and continuously U, City area. In 2001 the virus progressed contiguously, spreading out down the eastern mapped) by entomologists, epidemiologists, public health experts, and veterinarians. 0 z seaboard to Washington, D.C., jumped—there is no Florida. It may be easier to see how disease mapping works—intellectually and practically— 0 and then better word—to 0 There is little activity in the Carolinas or Georgia where one on the simple basis of in a larger scale, more common example of a simple, local disease outbreak. Con proximityone might have expected it.By 2002 WNV was rampant across the sider an outbreak of severe diarrhea that occurred in metropolitan Vancouver, British 18 Midwest 19 ern states as well as the eastern seaboard. In 2003 the virus spread more slowly and Columbia, in 2000. As an example it serves admirably because there was nothing N unusual it. It similar in contiguously, from the Midwest to the Southwest and into California. Its travel north, about was one of scores—probably hundreds—of outbreaks Si I-. to either Washington State or Maine, seems to have been inhibited by something. By that year in North America. If it is special it is only because data about this outbreak I 2004 incidence was declining and the level of activity seemed diminished. were made 5accessible. U West Vancouver West Vancouver North Vancouver Went Vancouver North Vancouver Welt Vancouver North Vancouver North Vancouver I

- Vancouver . . L. COqutharri Vancouver Coquitlain I- .i •r Burnaby Coquittain! Burnaby Vancouver Burnaby I • { . • / :: I I- - . . ‘‘ •:. Surrey Sun Richmond : Richmond Richmond Richmond Surrey . . 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 prior to treatment. Each dot symbolizes an individual case, asserting, “a person with 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. these symptoms reported livinghere’ 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 Figure 2.6A is a map of Greater Vancouver, an area containing about 2.3 million class of mapped patient homes. persons in Canada’s westernmost province. The map is an arrangement of lines The map implies accuracy and a completeness it cannot deliver. To protect patient symbolizing streets within the political boundaries of a region bounded by the sea confidentiality, all addresses in the official database were randomized to within two

and its intrusions upon the land, the creeks, inlets and rivers that are also mapped. It blocks of their actual location, creating a set of cases each of whose members is bi U, to of Nor is the was created using a computerized mapping program, ArcGIS 9.2. With the program inscribed near but not at the precise coordinates a patient’s home. UI U, came prepared files of geographical data we accept as real (the boundaries of na completeness of the map guaranteed. Each dot is a case reported to local health of 0 tions and local jurisdictions, of mountains, and rivers, and the like). ficials but, almost certainly, there were additional but unreported cases. Some people z We projected elements of this data set onto the map page as Greater Vancouver. experiencing only moderately severe diarrhea may not have sought hospital treatment Different mapping would create a different city, perhaps one of sewer and power lines but self-medicated in their homes. Others may have consulted a family physician U, like 0 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 I— but 0 this at least one or two were probably misreported, entered incorrectly into the streets are absent in this map they could be added ifwe thought them important to cases >- U, We could populate the map with economic data, elevation contours, or database with a keystroke error. And even ifall were reported without error, there were 0 this project. z population housing density.. whatever seemed relevant to the problem at hand. So likelypatients 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 visitors without a local address or homeless persons with no fixed address. porting severe diarrhea to hospital officials) is different from, say, the Vancouver pro A single case, or two, or even three in dispersed areas of the region would create 20 21 duced in a Google map created for a tourist seeking local restaurants or museums. a set of cases that we would not care about. Infigure 2.6B, for example, two cases of Ii’ nj 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 IUI 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 I 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 Vibriocholerae 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 •uu_• might somehow have contaminated local drinking water. Second, it was thought that . • .sepu,5.d .055. food • suspect 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 likelywould 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 likely is not included here. To food a source meant tion as and consider tainted as bJ LI) considering products from all the food outlets where the sixty-one hospital-treated 4 U U, patients had eaten in the eight to twelve hours prior to the onset of their symptoms. 0 Local health officials gathered that data, critical ifthese were, indeed, cases of food z poisoning. As a group, diarrhea suffers reported eating or ordering food from one 4 FIGURE 2.7A-C Combining maps of both of twenty-one food outlets, restaurants, and stores offering a variety of cuisines and U) reported cases of severe diarrhea and food sale products. These are mapped separately in fig. 2.6D. In the map, their common 0 outlets where patients had eaten (A) permit aI 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 >- the outbreak to be tested using buffers (B) U) tronized by one or more of the diarrhea patients during the outbreak. 0 and surface analytics (C). z By merging the maps of diarrhea patients and of where at least one member of 0 a- 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 (ifit is accurate and complete, then it is the area within identified and similarlylocated (ifa diarrhea patient ate or purchased food at a place, r’J which, and only within which, these related events occurred). Second, that a class of then it in was a place this set). U I— 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 (/fthese 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 r

(red dots) have a similar source in a contaminated food product (blue squares), then 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 later discovered that the bakery used raw eggs in its custard products. Richmond of them. The idea that geographic proximitymight imply causality is itself a proposition, ficials tentatively identified that bakery as the origin of the outbreak, and its products a “thing” whose validityis based on prior assumptions and whose history in medicine the source of the hospital-reported diarrhea 7cases. is told later in this book. A provisional report on the outbreak by British Columbia Centre for Disease Con Sometimes (although rarely) mappings likethese reveal one and only one possible trol researchers was published in the Canada Communicable Disease Report in source. You can look at the map and say, “This is itl More commonly the result is a October 2000; a final, definitive report was published several years later (Strauss map likefigure 2.7A in which no single, suspected source (or collection of sources) is and Fyfe, 2005). Those reports took so long to produce because they required bacte

clearly indicted. A coworker, Ken Denike, and I later carried out two types of analysis riological testing of patient stool samples and of foods from suspected sources. The to demonstrate how a relationship that was not immediately evident in the map could result identified the bacterium Salmonella enteritidis as the agent whose source was be uncovered (Koch and Denike 2007b). First, we drew overlapping buffers (circles) the pastry product sold by truck across the lower mainland. Just as the map promised around individual food outlets in a way that allowed their combination, building suc completeness it did not deliver; so did the bacteriology. Samples for all sixty-one per cessive circles until we had two “superbuffers’ each with its own epicenter (figure sons were not tested, only enough were to assert with statistical confidence that the 2.7C). We counted the cases in each and found the southern buffer was the one with majority of the cases were caused by this single agent. Nor was every possible food by far the most cases and that a small number of food outlets were at its center. In product tested, only those that seemed most likely.That one or another of the sixty- this way we identified a subset of suspected sources that, on the basis of proximity, one diarrhea suffers may have eaten another, contaminated food product elsewhere became “prime suspects” as the origin of the outbreak. was possible but, in light of the general report, inconsequential. Like the map, the Inanother, more sophisticated test, we used an analytic combining surface density bacteriological work proceeded on assumptions of commonality and completeness (kerneling) and a measure of proximitybetween cases and nearby food outlets (near that was necessarily limited. est neighbor analysis). Inthe first case the goal was to identify areas with the highest This type of mapping goes on allthe time. Often, there is no bacteriology or virology, density of cases. The assumption was that the source of the outbreak would likelybe no handy laboratory to identify the specific agent and its source. In those cases the centered inthe area where disease incidence is greatest. Using the “nearest neighbor mapped study is the only way an outbreak can be quickly investigated. A recent survey analysis:’ we calculated the distance between each reported diarrhea case and the of CDC reports of suspected food-related diarrhea outbreaks in the United States nearest food source on the assumption that the source would be near the most cases found that “in64 percent of allfood-related outbreaks inthe U.S. state and local health that were closest to a food outlet. Combining these sets created a new space inwhich departments failed to isolate the specific bacterium or virus responsible; the cause the density of cases was simultaneously mapped in a metric that relates food outlets to officiallylisted unknown” (Hargrove 2007, 30). Without such testing, one only was as Cdi C,, nearby diarrhea cases. Inthis manner the incidence of disease was generalized across has mapping that may point to the origin of an outbreak but cannot clearly identify its Cdi U, the surface of the map and the dots of individualincidence became irrelevant except as agent. Bacteriology, where available, may identify the agent of an outbreak and thus (7 data permitting a precise argument about intensity and density to be inscribed in the confirm (or disprove) a theory of the disease’s likelysource identified in the map. z map. The second approach (figure 2.7C, which shows the density gradient) identified These maps of food poisoning and those of West Nile virus seem to be of a

a very small set of suspect food outlets in the southern buffer. similar nature. They use points and the mapped geography of the space in which U) 0 In this map we noticed a north-south bias to the data (it’s pretty obvious) and disease has occurred. In this case the purpose was to apply a well-accepted theory I— 2 upon a narrowly oval, elliptical to both bacteriology. For this testing, there was indeed north-south, pattern of a disease, one whose conclusions could be tested through >- U,

data sets, but especially to the location of suspected food sources. This “deviational we did not need population denominators or more sophisticated statistics. The maps C-:, z it a ellipse” suggested—because we had seen before—not a single stable origin point of West Nile virus began in a similar manner and revealed what appeared to be a0 but one that traveled, something or someone moving across the range of food out- more complex pattern of multispecies incidence that proposed a new idea about the lets. Because Vancouver is the most densely populated municipality in the region we spread of virus. While the diarrhea outbreak maps were hypothesis confirming, 24 that 25 were not surprised to see a spike in the central part of the city where the northern testing an idea based on experience, the West Nile virus maps were hypothesis III r’J buffer’s epicenter had been. Inserting into the map the highway and road system for generating, using patterns of spatial incidence to propose a human vector based on ICdi metropolitan Vancouver showed the food outlets were almost all clustered along travel and trade. For West Nile virus and its finer resolution data, the mapping was a I a very few north-south arterial roads. One of the suspected sources was a bakery 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 BODY4----f WORLD BODY4----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 these cases rested upon the application of a scientific ideal about the nature and (headache) • City • Inhaled • Water to organ to place • 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 (Miamatic) • Bacteria gumentation, (4) have been established and are accepted. The analysis required a • Humors (local) • Gastro- • 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. Inthe 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 in “English cholera:’ the former originating in India while the latter was common the L,J treated: “Where is it?” “What is it?” and “Who is responsible for it?” All three are U, Nile in Uganda but found summer months in Great Britain. There is West virus, born 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, of the often-messy realities disease study can be made clearer. 1.8 0 World War Ifa condition is epidemic or pandemic a critical element of its knowing 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 or the becomes where it might be in the 0 understand this that disease question 0 “Toname 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 2007, 277). Naming requires both a “what” and a “where:’ To think about location row)? Ifit 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 I is of the symptoms that affect us: was it inhaled (pneumonia), ingested (diarrhea), in it may lie with the patient and not the physician or society. But ifthe disease perva troduced through contact (poison ivy rash) or perhaps always there, latent in the sive and many are affected, then individual responsibilities rarely serve as a sufficient affair, a task for person’s genome, or in classical medicine, his or her humoural makeup? If inhaled, explanation. Treatment and ultimate prevention become a communal

what in the air made us illand if it is ingested what in the food or water caused this society at large. Inthe Vancouver example the patients were blameless and responsi

complaint? And perhaps most importantly, is it a static and unchanging agent unique bilityassignable in part to the local bakery whose cream custards were the apparent and to one place (or one family)or is it mobile and dynamic, moving from place to place, source of the outbreak. But the local baker bought supplies from wholesalers with infecting populations as it moves? they carried a predicate responsibility. Ultimately,the final responsibility rested “What” and “where” are collaborating elements of the same question. “What” the hospitals that treated the patients and the health agencies that in theory but not describes the symptoms that result from its influence on the body, wherever it origi always in practice assure restaurants and food producer practices are safe. 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 CURIOUS THING its source local or imported, unique to a few or a complaint common among many? THAT over Its description determines how we categorize it, seeking an agent that may be ad These questions are an integral part of a process of knowing slowly constructed

... a way dressed experimentally and therapeutically. Ifit is in the heart it is cardiology; the gut centuries to permit the study of the conditions that affect our populations gastrointestinal, a broken bone is orthopedic, and onwards. Allthis ultimately permits of thinking that was neither inevitable nor intuitive. One may construct this history in the symptoms to be named and a disease constructed in a manner that permits the a variety of ways, taking any of several points in time as a beginning. The question I practical question: what do we do about it? began with is: when did we first begin to see disease in a certain way, to visualize its The “what” and “where” influence our thinking toward the condition and responsi reality in populations as well as individuals? The answer to that question is the sub of bilityfor it. Ifthe origin lies in individual lifestyle (gluttony, for example), the answer to ject of the next chapter’s brief review of the sixteenth-century marriage intellectual and technological advances. Itwas 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 What to do about it? that was fundamental.

RESPONSIBILITY

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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) 192 who in been Once would end lenge, ST. while anesthesia. gist, the pers. theory. trip early Street, wrote ably “Within 1855a, “The

THE

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and BROAD a in Snow young neighborhood fashionable of in of of

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STREET: a of that rose Snow Street, ever reported seek cholera South Communication where have attacks In the on he the Square, It with

DISEASE 2006, occurred St. to Stanwick future was carried seemed wrote a London Cambridge mid-eighteenth use James few outbreak of there, his there cholera 16—17). this and poet, fame brief his out in to in was Street study, outbreak he the first this the him minutes his of who as of in Street cared Old a Cholera, adjoining seminal an such late ten professional a kingdom:’ haven and at returned century, personal money anesthesiolo the days’ summer to by for joins with fierceness for prove foot southern work “is patients streets:’ disap (Snow a Broad those it Snow there prob chal from side had and pa his on were self and apartments chants maps peared ground ease. Craven of Reception acre, and three working erected market more In taken of propriate southeast granted subdistricts Street London (Porter one outbreak modate ing per proof and the the the The As By “I to acre, was from residential, of Poland requested the manifest, subdistricts that generally Because deaths of the upper place 1720 was population 1750 more who lands in beginnings to for 1999, (Johnson this on . . . sufficiently population St. the began. in most the cemeteries. his 1851 provide corner of constructed the to plague the Eighty-nine of streets. map plied James social within the than class, British were early from theory poor accommodate Golden 129). densely burying could heart populated of the census, permission, land are of 2006, fifteen . their grew, the a cholera, nineteenth transformed transformation . . had victims a of and in diminished from Privy Lord countryside. place of Here, The the of on short on be this approximately 1720 Square, cholera wares place deaths become populated St. at miserable proceeding 18). income an in which housed. the “pest-house Craven’s Council creation the the where transformation Snow h study the registered James distance whose average and therefore, While the upscale of century district’s at old as from Berwick to the into the a levels h Carnaby the rising would 1750 By those On solely serve pest-field. the the working as of pest-fields. interment of Objects in pest-houses 1665 cholera housing, of to the of 30 area 1, all as the Kensington one during homes density area pest-houses fields,” to the population fell from western 10 the Street, suspected as argue, waterborne. the time the percent take land plague can way persons class spot the ni,by until, was was pump” were stately 135 . . It the the fMayfair. of and of was lands was was Market. be were a shabby and was to . border I Charles physically located week list, afflicted neighborhood stood British found registration mortality epidemic there the seen registered, isolate of 30 often in of townhouses St. (Snow per was acquired 1851, the “thirty-six at The immigrant this plague, Poland houses nig2nd ending Ann’s In setting to were the had that house in origin Library’s at New Dickens, barred seen the pump area and separate with figures St. reformed there 1855a, the victims. General been nearly an Soho, subdistricts nineteenth during Street in or James, buildings, per of in thus (fig. small that by intersection a workers was with average were 1665 from in Nicholas was the direful Crace reclaimed Golden lOlA acre Lord September, all 9.6A). the 39). whom the which contain a Register the workhouse 432 as Houses, outbreak the also broken once otherwise block by 1854 streets with, well. Craven “The from week, of commercial Pestilence) century and Collection. deaths people the To symptoms in was Square Nickleby. burying a 2 of a from the Greater accord by accom cholera Regent houses up Ireland for 10.1B, pump:’ Office, Earl refuge Broad of and kindly in in mer was and dis into had ap per the the the the the the of it a 193 U 0 I— LI bi I— LI U I a I— LI I 0 LI 0 I lOlA the lifeof 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 biB 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). FIGURE IO.1A This 1720 engraving by cartog In this first study Whitehead focused on what he knew best: “It is the writer’s rapher Richard Blame presents St. James as intention to confine his observations to the district of St. Luke’s Berwick Street, with a well-to-do parish. In the 1800s its population would grow with a vastly increased emigrant the houses and people of which he has long been acquainted” (Whitehead 1854, population. 1). For those who did not know the parish, Whitehead included a map that served FIGURE lo.1B In 1720 the seventeenth-century first to define the area of his authority and second as an index to the locations he plague burial site remained undeveloped land I described in his report (fig. 10.2). Where were the inhabitants of the “model lodging LJ in St. James, Westminster, a block from Broad LJ

Street. By the mid-nineteenth century the former houses now building:’ a site of sanitary pride in the parish, so devastated by cholera I— liii pest-fields would be overbuilt with housing. 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 REVEREND HENRY WHITEHEAD w of Whitehead’s parish in which cholera’s occurrence was to be seen, its pattern of -J 0 Snow was not alone in investigating this local outbreak. The Board of Health carried incidence questioned. C-) out its own investigation. So, too, did the Metropolitan Commission of Sewers in Whitehead’s short pamphlet was an inventory and analysis of 373 cholera deaths, 194 195 hopes of countering a popular belief that airs bad traveling through new sewer lines “nearly all of which took place in the first fortnight, and 189, at least, in the first four 0 caused the outbreak. The first published study, however, was by Reverend Henry days” (Whitehead 1854, 3). He listed these August and early-September deaths Iw Whitehead, a young curate assigned to St. Luke’s Church in the heart of the Broad street by street, providing for each street the number of houses, the total popula a Street district. Today we might call ZIZ Whitehead an outreach worker. He came ‘to live tion, and the total number of deaths. Whitehead filled his short report with a series C-) ______JL

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). At least at the beginning, the problem cholera presented for Whitehead was as CRF.ATMERLBOROUGHSTREETIW E_ STR EEl much theological as scientific. “Atan 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 ‘‘ the young curate. In his studies he found “the very old and the very poor have not H::sEr 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 EDWARDSTREET; “the streets and parts of streets throughout which the disease may be said to have literallyperformed a house-to-house visitation”extended beyond the parish boundaries

xC (Whitehead 1854, 2; original emphasis). He described the precise boundaries of this a’ greater visitation in which his parish was embedded: “Takea point on the east side of SILVER STREET - Poland Street, half-way between Portland Street and the level ofGreat Marlborough ‘1._I Street; draw from thence two straight lines, one to the north-west corner of KingStreet, 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 houses escaped, and outside of which comparatively few suffered” (Whitehead 1854, w — 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 figure 10.3, Whitehead’s polygon of the intense area of cholera occurrence is overlaid I Ui on the mapped boundaries of the parish described in figure 10.2. I- ___j 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 0I - - 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. Li FIGURE 10.2 The Reverend Henry Whitehead included this map of his parish in his 1854 report, “The I- a. Cholera in Berwick contemporaries (ecclesiastic, medical, and secular), that cholera was miasmatic Street:’ where St. Luke’s Church was located. I in its diffusion and natural in origin: “It may be, as one writer has philosophically 0 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: “Ishould 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, Ifound 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 was one he . / outbreak some FIGURE 10.3 In 1854 Whitehead times described as located near Golden Square. But for those like Whitehead, who described cholera mortality in were more intimately involved, it was the Broad Street or Berwick Street outbreak. his parish (the red rectangular area) within the general area of Snow did what might be called an institutional survey in the area nearest the Broad greatest cholera activity. This Street pump. He interviewed “the keeper of a coffee-shop in the neighborhood” who St Lukes Ch - map was made by the author - - on September 6 told him she knew of nine customers who drank from the local pump BroadSt. based on Whiteheads textual Pump Parish boundaries 35 Cholera description of cholera in his par and were already dead of cholera. Snow learned the Poland Street Workhouse, which deaths Choleraarea j 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, Fraser of Oakley Square; and of course Henry Whitehead. Their support gave Snow THE BROAD STREET PUMP 0 the luxury ofbeing able to focus his attention, and very limited time, on apparently 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 0Li tember’ Snow later wrote, “I suspected some contamination of the water of the break. “Insome of the instances, where the deaths are scattered a little further from _1 0 much-frequented street-pump in Broad Street, near the end of Cambridge Street” the rest of the map, the malady was probably contracted at a nearer point to the U (Snow 1855a, 38—39). The pump 198 was the closest public water source to the homes pump;’ Snow hypothesized. As proof, he identified children who lived on Angel Court, of the 199 neighborhood’s first cholera victims and therefore, Snow reasoned, the likely 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, Ifound 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 I continued. “There were 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. Inview of the Broad Street pump (Snow 1855a, 41—44). U

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Broad

the

street

map

than

autopsy

Snow

was

(figs.

treatise

Snow

the wholly

part

second,

GRO,

similar inhaled

the

and

assistant

Great

one

Broad

and

could

fever

water

cast

cholera

plan

should

to St.

Mode

centered

Street’

map

London

5.6—5.7).

sub-district

structures

needed

pumps. of

was

then

the

Berwick

different

Anne,

reports

Windmill

those

a of

registration

Snow

the

its

structurally

dot-and-dash

Street

not

sources

single

every

the

(Johnson

wide

one

treatment”:

New

looking

regions.

cholera

made

case

physician

the

topography

engraver

street

Soho,

Communication

Third,

something

closest

for

premonitory

wrote,

First,

point

Street,

conclusions.

well

evidentiary

range

epicenter

study

York

considered

presentation

the

Street,

Broad

this

and

which

used

for

based

1855).

Second,

location

extending

St.

and

the to

subdistrict

Snow

Broad

where

connection:

to in

cases

and

area

castor

“that

St.

that

line

James

argue

Poland

Street. and

both

King’s

pump

occurrence

more.

James,

demonstrate

mapmaker

complicit

added An

“surrounds

net

the

proposed

diarrhea,

the

Street

had

definitive.

Seaman

to the

Brewer

Snow

oil

the

which

from

becomes

Seaman

Square

anonymous

its

for

596

the

outbreak:’

Street

boundaries College

deaths

not

(Anonymous

street

outbreak

dissection case

together

miasmatic

may

Cholera,

the

his

pump,

west Wardour

brought

for

cholera

water

Street”

the

whose

mapping

had

who

source

a study.

Workhouse.

enclosed

also

the

Others

its

histories.

addresses.

either embedded,

that

study

decidedly

Hospital

map

his

used

treatment

“the

Made

drew

sub-dis

source.

with

reviewer

Regent

Snow’s that

forth

cholera

deaths

theater

(Snow

Street

nature.

mem It’s

maps Snow

1855,

very

area

spot

used

no-

the

brief

set

the

the the

for

All

was

was ticed

Street FIGURE

in intellectual

representation

propaganda.. Mark more

turn

his

These

Some

tested

the

pump

that

Monmonier,

readily rivals

10.4

was

embodiment

today

the

and

grounded

were

this

the

obtained”

scientific

deaths

the

similar of

map

incidence

dismiss

and

map.

for

deduction of

any

copycat

are

his

the

critics

This force:

(Snow

Snow’s of

value

Broad

Snow’s

most

part,

theory

disease.

was

“Snow’s

miss

propaganda

Street

dismisses

from

numerous

1855a,

now

not

generating

proposition

the

outbreak,

propaganda

iconic

theory

map

47).

pathology

point.

entirely

near

Snow

map

insightful

that”

that

Snow

the

transmission

attempted

the

but

epidemic

(Monmonier

nothing

cholera

cholera”

developed

pump

idea

hypotheses.

attempt

that

where

area

show

but

was

developed

(Brody

Snow’s

2002,

was the

waterborne

the

spatial

illustration

science.

centrality

Snow’s

simply

water

155).

map

al.

earlier,

theory

2000,

was

the

“or

could

The

the

without

then

which

those

visual

Broad

pure

map

66).

that

its

201 0 0 I Ui -J Ui 0 bi bi

0 I ix 0 0 I ix 0 U, I

.5 5i ix I— j source had to be water, in this case, the Broad Street pump at the epicenter of the Perhaps the most interesting thing about Snow’s mapping was its omissions. He outbreak. The map was perhaps the critical statement of Snow’s argument based on did not calculate the number of deaths in his walking area compared to the rest of the the available data. In it the cases of Snow’s (and Whitehead’s) circumstantial report study area. He did not create a similar area for, say, the Rupert Street pump in a man age became members of a class of cholera cases whose location to the maps was ner permitting him to say that two-thirds of all deaths were in the Broad Street pump

transformed into truthful conclusion. “Itmay be noticed . . .“ was all the proof Snow vicinityand less than 12 percent in the second pump’s vicinity.Nor did Snow attempt offered (1855a, 47; 1855b, 109). The argument was the map. If one agreed that to calculate mortality ratios based on the population of the areas he constructed. He proximityimplied causality, then the map’s evidentiary value would be overwhelming, assumed others would see in the map what he saw and that they would draw the assuming no other confounding sources resided at the epicenter of the outbreak. same conclusions. But without even basic quantification of the mapped incidence In a second version of the Broad Street map (fig. 10.5) included with Snow’s Snow could not translate the obvious concentration of deaths near the Broad Street report to a St. James Parish committee inquiry into the outbreak, Snow added an ad pump into a meaningfully rigorous argument. Nor in his mapping did Snow attempt ditional seventeen deaths for which addresses had earlier been unavailable; he also to consider with any rigor other possible sources of contagion, for example the old, rectified minor topographic 3errors. To this second map Snow added a wandering, seventeenth-century plague burial pit (Fig. 10.18) many—laypersons and profession dotted line creating an irregular area nearer to the Broad Street pump than to other als alike—believed to be a likelysource of disease generation. On September 7, for pumps in the study area (Snow 1855b). Snow did not describe how this area was example, “AnOld Subscriber” wrote to Bell’s New Weekly Messenger, quoting Har constructed but it is almost certainly based on walking time between local pumps, a rison’s History of London on the location of the old pest-field from the 1665 plague kind of “Manhattan metric” based on pedestrian rather than shortest distance path epidemic. To some, the old plague burial site over which new homes had been built ways. What today would be called a nearest neighbor boundary bolstered Snow’s 5and under which new sewer lines had been laid (all agreed the smell from these argument. Because more deaths appeared nearer to the4Broad Street pump than any sewer lines was noxious, and therefore potentially disease generating) was as obvi other, logically,for Snow, the pump was necessarily the origin of the outbreak. 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 Dean Street at the edge of the Broad Street 6area. Rogers, who visited many of the 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 7street:’ 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 effluviafrom 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,

CJ if Snow was to convince others not simply that the local pump was a source of the bJ Broad Street outbreak but the only possible source. -J I0 U 202 203 CA USAT I N 0 0

Others with an interest in the cholera outbreak in St. James were able to draw differ In FIGURE 10.5 In a second map of the Broad Street outbreak, Snow included I a dotted line to create an ir ent conclusions based on the same data Snow drew upon, mortality reported by the regular polygon enclosing the area closer to the Broad Street pump than to other pumps. GRO. In September 1854 Farr’s office published an interim report on cholera and di- U I

iJI

204

from

Commission

visual

added,

Square”

for

the

“Unlike

in Some

came

REVEREND probably

many water

the

pump

looks

tion?

identified of case

tion.

rain

temperatures

seemed

ishing. the

and

five

September

wick

arrhea

“to

show the

yellow

Produced

hospitalization,

number

understanding

/ithe

water,

Broad

assist

pestilence

and

days

Where

from

analytic,

parish pumps

Street,

of farther more

made

was

for

may

Snow’s

the deaths

neither

these

(Paneth,

improved

wind,

obvious

have

fever

Broad

the

his

earlier

which

why

others,

Street

area

drunk?

inquiry

most

Farr

the

Golden

parish

for

index

cholera

drawing

Sewers

had

concerns

hoped

occurring

incorporating

this

better

which

should

the

Street

investigation

the

had

proof Vinten-Johansen,

New

WHITEHEAD’S

study his

and

use

cholera

the

both

upon

dropped,

one

district,

committee

case—Snow’s

effect

inquiry

lithographers

contamination

water,

reports

the

known

reported Square,

deaths

been

has

that

tallied

of relationship

(fig.

Snow

York

attention

not

pump

the

were

it;

between

local

raged

map cholera’s

activity

the

his

the

10.6).

that

committee

but

Daily

City

would

version, in

deaths

them

anticipates

answered pains of

was

St.

review

inhabitants

report

cholera

source

other

that,

the

wherever

persons

the

atmospheric

with

another

had the

News

James;

Edmund

Day August

analysis

the

still

complicit,

area

and

spread

1854

Broad

his

climatic

“owing

epidemic

words,

this

identified

made his

such

declining

report,

nonresidents

epicenter note

parish

have

take

and

Brody

who

Snow’s

and

SECOND

argument,

map

the

Cooper

this

Street

have

an frightful

tracing

Cooper,

was

its

Son,

climatic

origins, at

prevailed

Anne,

the

outbreak

the

outbreak—it

lived

and

cause

what

and

collaboration

extraordinary

included

vicinity”

outbreak’

the

1998,

large

much

temperatures

seen

open

second

weekly

outbreak

manner

the

was

supposing

its

September

people same

sailor

favourable

severity

was

Soho;

the

Snow

who

and

variables,

than

environs. 9

circle

the

map

1547).

ordered

had

equally

MAP

engineer

(Parkes

greater

all

outbreak

the

interpretation.

time

thus

Bell’s

from

worked

That

edition.

worst

any

streets

who

simply

and

did

would

simultaneously

taken

. .

centered

map

with

Seaman,

source

that

this

other’

the

Snow and 9

report

change

everywhere

including

This

There

All

left distance,

1855a,

Life

the

for

(fig.

place,

investigate

and

ignored

“If

ship

district

Souls,

deaths

miasmatic

the

those

the

declining

circle or

St.

the

Board

map

on it

identify

10.7A)

Whitehead was

Parkes

who

are,

news,

visited

districts

were

visitation:’ 8

neighborhood

London,

its

Luke

Polly.

“This

458).

Metropolitan

Broad

temperature,

though

the

would nearest

served

Whitehead

Marylebone,

were

them. has

republished

contamina

indeed,

borrowed

where

included

owing

the

updated

the

his

Parish.

wrote

certainly

mortality

Golden

weather,

Without

distribu

Health.

abated,

Street

dimin

which

study

then

most

index

they

who

Ber

the

The

the

the the

ary of the T-

ation

and

were of

location “non-medical cholera

Unfortunately, he common

might reported; house. break. laid.

—

the

used

Whitehead

Cooper

authority

old

outbreak

incorrectly

Included

of stacked

that

outbreak

area

Cooper

Half

plague

cases

the

expelled.

suspicion

:1 instead •

1118

area,

the

in other

mapped

the

supposed I’,,

(fig.

which

people”

L 1

under

Cooper

former

mapped

site

included

against

a :

homes

located far

analytic—Cooper

well

they

sewer

mapped

10.1).

,.-‘-L..

that

greater on

the

-1

thick those

were

used

plague

thought

the

was

surveyed

pit

oval an

-.—

new

351

chief

commissioner,

This in

..m.i black

inventory

is,

and basis

symbols

than

cesspools

wrong.

Little the

his to ---

—

cholera

sewer

however, was

burial

mortality

symbolize

the

locations

map

bar

Cooper’s

were

Marlborough _—-

IIIII•I

one

old

location

reported

its lines

symbolized

site

to of

deaths

Cooper’s

pest-field

not

distance

sewer

show

apparent

occurred”

said

who

I’

might

store

the

connected mapped

-,-‘— which

“‘

‘1

sewer

reported

had

the

old lines,

sewer

household

Street,

obvious

homes

oval

from

Craven

source number

it I

houses

the

/lu

(Snow

I-i

Little

grates noting -

oval,

1..

lines

the

source

central,

the

northwest

correspondence

well

the

Marlborough

the

Hill was

-j

1 waste.

outbreak’s

cholera of

—

1855a,

had

the

authority

from

Snow’s

deaths

GRO

new

plague

the

year

Snow

been

which

block

the

Looking

study sewer The of sion sized. sewer

burial victims; neer

FIGURE

54).

in in

cholera

occurring

Broad

easy

pit

built.

correct

the

epicenter.

the

wrote, which of location

for

from Street,

area

Cooper’s

foul He

lines

area. that

Sewers,

lines, 10.6 first

the

epicenter

between

dismissal

thinner

The had is

deaths

Street sewer

the

they

he “The Metropolitan Edmund

incorrectly size the

fortnight

just

Cooper

in bound

mapped

this

shrank

map— Broad

the While

Broad

were

each

map. bars

(black

situ

out

and

airs

out the

former

of of Cooper, located Street a bars) partial Commis plague engi area. and and 205 set U

U I 0 I 0 -J 0 a I— bJ lii C-) I— Li I 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 should reveal a correlation with one or more of those attributes (water, sewer lines, plague burial site, or the like). Each of these might be individuallytested in the map. 55 = S!:Th Ifthe 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 proximityof clusters of deaths to a suspected source might argue one or another association. Whitehead’s principal analytic was a circle, encompassing almost allthe reported cases of cholera, whose center was almost precisely at the location of the Broad Street pump. In effect, by using his dividers to 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 ,,*l,:!Z Snow during the months of their mutual investigations, convinced Whitehead of the pump’s complicity inthe outbreak. As he would write in 1865 in a MacMillan’smagazine

article, Whitehead became convinced, “slowlyand Imay add reluctantly that the use of this water was connected with the commencement and continuance of the outburst’ 1 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 4: drank from it less frequently (Chave 1958, 95). Itwas not God’s presence but the stair - climbing limits ofage 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, I SKEWING TUE ASCERTAINED DEATHS FROM CHOLERA 0 like Cooper’s and Snow’s, Whitehead’s was on GRO mortality A0(h,. . data set based 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, Iwas 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

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

account of the circumstances” (Snow 1855a, 41)—Whitehead accomplished.

208

many

FIGURE

believed

1O.7B

for

Street

While

days

ous

daughter,

and

building

the

London

1840s,

hood:

young

mous

never

water

the

Mrs. which

the

Whitehead

the

Not

comphcrt

outbreak

before

lined

was

well,

death”

anesthesiologist,

August

parish they

the

CR0

apothecary

bereaved

Lewis

living

and

surprisingly,

that

constable

aged

most

not

later

with

Sarah’s

knew

then

correctly

had

lived.

the

weekly

and

(Johnson

inquiry

with

first

told

simply

five

garrulous

was

bricks, Broad

been

tossed

him

local

the

became

their

Whitehead’s

Thomas

Reverend

with

months:

demise.

located

mortality

found

therefore,

committee

that

and

Street

method

cut

worker

2006,

the

growing

the

local

specialist

Snow

into

the

outbreak.

ill

Lewis

cesspool,

Mrs.

men,

exhaustion,

wastewater

Whitehead

knew

with

Craven

reports

leak

178).

flats.

than

practice

did

mission

(York

Lewis family

was

which

was

and

“promontory

when

them

Dotted

whose

Their

was

not

Estate

put

less

his

Whitehead

1855).

soaked

through

have

after

the

into was

examined

daughter

and

plague

wife

it:

Firth suited

practice

than

Broad

diarrhea

“At young

solid

way

the

The

had

her

diarrhea”

Street.

pit,

40, the

serve

attack

time

cesspool

lines

that

yard

Sarah

who

daughter’s

incorrectly

water

moved

Street

was

curate.

the

Broad

1850s

symbolize

had

and

Snow

local

the

from

business

identified

not

was

She

line

begun diarrhoea

that

the

pump

troubled

Street,

Snow

engineer

located

bound

the

could

the

different

born

died

soiled

a 1

Whitehead

850s

former

edge

the

Broad

was

front on

was the

not.

visits

four

August

Coooper’s

diapers

sewer

cesspool

March

Jeremiah

Snow

contaminated.

the

September

September,

index

the

single-family

Street

days

the

community

did.

lines.

longer

neighbor

the

was

28,

case

house.

Broad

map,

previ

Snow,

1854

pails

York

was

home

five

the

2. that

a I

the

onstrate

(Snow “Whether

on that

for

his

sumed

1547). croscopy,

enter;

showed

(Snow

state to

the

index

well

before

1855a, local

Famously,

THE

after

report

Snow

physical the

the

Because

higher

the

St.

the

the the

what

own

cesspools,

When

water

might

Broad

Here

chain

still

cesspool.

Snow

citizens

James’s

this

case

consequently

printers

Board

kind

pump

1855a,

Snow

was

for

the 1855a,

purity,

LIMITS

than

the

microscopic

the

40).

contained

“no

support

was

the

said,

Arthur

the

had

only

the

negative

Street

Snow

use

enormously

Broad

near

finished

centrality

hole

infection

that

water’s admitted

identified But

from

physical

impurities

second

parish

53).

become

parish,

Snow

both

52).

the

Health

the

Hill

which

or had

would of

the

Street

the

drinking

Lewis

evidence

handle

crevice

the

writing

then,

it. 1 °

examination—forced

Broad

Hassall,

inquiry.

pump.

complicity

had

water

on stopped

petitioned

cholera

edition

that

evidence

inquiry,

this

free

pleased

latter

the

well,

later

index

BROAD

Unfortunately,

the

well.

household

not

Snow

the

its

respect

contaminant

from

both

Street

well

was

Nor

evening

was become

whose

yet

there

who

the

All

declared poison water.

the

case

when

absence

water

with

detailed

and

stopped, to

did

On On

it”

acknowledged,

Snow

received

pump

added

brickwork

the

examined

well

have

are

(Snow

the

and

STREET

Sarah

the Whitehead’s

walls

had

pump the

“I

were

ill

outbreak

that

had

a Thursday,

knew

water.

contamination

(Chave

have

Mode

was

(Paneth,

the

Mode

number

the easy

“relatively

that

him

the

observable

were

active

likely

1855a,

Lewis

but

some

derived

supporting

handle

the

acknowledged

was

removed

news

interview

access

England’s

only

the

1958,

(Snow

surrounded

hand is

source

water

“hesitate state,

“the

Vinten-Johansen,

in Communication

died

7th

that argument,

Communication

51—52).

impossible

well,

bereft

assert,

the

from

the

September..

attacks

contaminants—he

York’s

even

96).

the

Whitehead’s

or on

from

material

neighborhood, 1855a,

instances

cursory with

the

first

the

whether,

the

pump

deductively,

the

which

Not

though

microscopic

the

and

quality,

the

cesspool

come

sewers,

report

water

great

had

following

well’s

surprisingly,

39).

external soil

was

Broad

Board

with

decide

removed

any

previously

from

so and

to other

authority

contaminated

discovery

and

discovered

Cholera

engineer

contamination.

far

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I— w I— 210 not of refusal century medicine and saw to environment the cleanliness directions: will 1856, mark upon another far many did There of that broader tion Board show contaminated different crowding its that of to complicity Broad his a Equally Health easily from Snow the city, achieve separate the It different not be areas Nor, Snow the more contemporaries at was “each a potentially to was 27). whether visible seemed water-supply of house get unsanitary each Street where map the theory Broad consider handed of translate conclusion: Health mapped not committee of limiting than and therefore room sick, is many, in and, course, epidemic Broad theory In others report, in place “atmospheric rare, that the at plan well it in the want in his Street other inhabitants to and confounding is apparently, for a the 1855, down which outbreak. evidence dotted was the and suggest conditions into a the report glance Street where of map and of saw doubt the those could habitual of manner of could members inhabitants remained the “We other disease. of pump atmospheric problem, the definitive cleanliness from its its 52). cholera Board the a cholera on about city pump one who in . . range different apparently do Snow scale a of impurity” was argue, possibilities That, believed epidemic the was this Hippocrates alleged, miasmatic complaint . that variables (as that not of [T]heir of Simon appeared wondered unconvinced. exemplified lacking and in but 1854 general these of local of of in may however, solely Health’s prove find resulted district, on confined which the purity the districts, London potentially that that were he nor pure distribution saw the conveniently case, it epidemic: was had occurred) district study but that correlation. in responsible established:’ beyond had proofs mapping on to is impossible; always through basis not his about Cholera drinking as in waters; yet was that a “visible there have stenches and has the and being produced. the class disease itself. map, all to who explanatory the not of therefore of basis any borne those “When map known become attend be before crowded the may Sydenham did of the Inquiry evidence he from as his modified at Snow be the Neighborhood-level drank ruled for reasonable waterborne broad they many, the arose a inducing. Whitehead could of not done nature mapping, be who a definitive that glance,” to it” the us the Farr’s strict close sick only out. skepticism from wrote, Committee noticed guarantee prefer conditions, (Snow courts, any features on from 211 drank neighborhood by well, also was only of to As even saw the other sufficient stamping relation quarters 1852 In the deaths the but doubt disease. the the proof insufficient argue John “that its by had suffered South southern 1855a, from especially water, where though waters. disease. of mid-nineteenth poverty, in sewer” wells” centrality toward a study in came Simon the the each he the solution. to inductively the his are studies his, of London evidence a The and 56—57). had domestic water the in epidemic they outbreak. the black mapped assertion well slope mapped and (General the to to (Simon related Snow’s propor and There said in Board in nature hoped prove a poor of lived jury two did the Too and his was very he ink the of the of to its In

r filtered was where produce to eccentrically represent ity with scale “Everywhere yellow from the local same become alluvial lative: Cholera generally the Columbia, ness” This equally ease Jackson and for Other borne. fatal who upon “all reservoirs? 1854 contain of It example, plague such 1 nothing the cholera included one water did confined 850s, outbreak’s effect” an of way” the (Snow cholera “The researchers fever, loaded through Unlike soil, complete the terminus open of more Snow had o help not person conditions share development the excremental has was (Snow the natives that Some and particular other Pennsylvania: obvious (Jackson he local filtering Dr. noted, 1855a, drainage the Snow, question with themselves, outbreak and been Broad but proposed a not the continued, source also T. to local solely of that mortality to thought diseases, 1 using Heber more of another scanty 855a, nitrates peculiar data pump two as present most the in 127). about from Gurhwal, Street one [1855] in geography, of and and might spreading waterborne matter but in universal. convinced canals. supported similar the a Jackson 125). waterborne thickness considered waters Columbia, could so: a from From in great resembled propagation reports or the it not to including for dangerous well,—containing second 1854 articles was reasonably 1958, “It ammonia; it’ only a The the one Broad techniques habit, there Was agree was province manure-bed; This drew which impossible, greatly published last in that evidence a source imperfectly that of 126). edition of well Pennsylvania. cholera plague, it the other to to disease was Street cholera surrounding with thirty from diet, the of many proximity easily meant the the everywhere be where subject known in the This the was worked water, Lea countries. such fact of the local supposed years, use an here pump that typhoid other Simon and epidemic” the and general could as the On oxidized” ruled a extraordinarily or north-west there that of to as simple wells. of to was a was results impurities everywhere Snow waters the soil:’ believe the with pump-water, Jackson’s all and general diseases h nature the a cesspools be containing argued, communicable out fever, jar the is at principally state Most plague Mode to Dr. definitively equal its a step best (Jackson of arguing the (Simon of have of physicians that want water. Simon and of ghee” organic category of the of transferred to reservoirs are of only anecdotal diligence goal British by thorough liable the it and these exerted yellow and generalize Susquehanna of evidence Communication were may miasmatic flourishing the propagated 1856, Snow “Bad wrote, for 1855, wells personal settled. was origin decomposition sewers; diseases at be India, that likelihood concluded, Snow. that attacked fever. any an and to because as transmitted to and study 12). of noted. 123_31).12 “this of very that included influence consider from the London: was moment in In and the at cleanli in specu “I At every which 1855, in might qual many of River have least they local “low And of with the dis the the the air an as of in a 211 0 w F 0 ZIZ 0 I 0 -J 0 0 C I 0

ml’ 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, of this or that theory, I. S from Snow’s perspective and that of other strident advocates ? Jill 1 ‘H’ 3 but honest in its assessments and knowledgeable about the limits with which mid- nineteenth-century science could argue definitivelythe etiology of an invisibledisease lLiu%(raiiicat jr ihiirru if-iiei,iic 1‘,,ir,lI,i i$.4. whose symptoms were glaringly evident in the patient.

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 FIGURE 10.8 In this 1855 map of the 1854 cholera outbreak in Columbia, Pennsylvania, the location of and therefore air quality was the strongest correlation with cholera deaths. For each 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 likelymiasmatic.

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? “Itwould appear that the cause of the appearance and spread of malignant , : I— cholera in Columbia, was manifestly connected with the air and locality; that it U was 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 0XE fullyconsidered 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: U or well)—to come to his conclusion. The progression of ideas stated, considered, and -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 212 study Jackson 213 included a simple schematic of Columbia, the bare geography instantiating the city 0 with its streets, rail lines, river 0: and the itself. Embedded in the map were the locations U FIGURE 10.9 Acland’s map of cholera in Oxford argued the airborne nature of the disease, using contour F— of 27 of the 127 deaths that occurred across the epidemic. For 13 cases there was 0 lines to show altitude as a correlate to disease intensity in the city. IXE no locational data and presumably he saw no reason to map the other 87 deaths. 0

214

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a 215 bi

I— a F -J bJ LI, 0 (-L La 0 Li Li 0 Li F Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2009;38:7–21 ß The Author 2009; all rights reserved. doi:10.1093/ije/dyn254

REPRINTS AND REFLECTIONS Anticontagionism between 1821 and 1867¨* The Fielding H. Garrison Lecture

Erwin H Ackerknecht

Accepted 30 October 2008

Nothing might perhaps orient us quicker in our grand nombre d’auteurs qui ont´ ecrit sur l’animal- subject matter than perusal of what Hippolyte Marie isation des contages ...nous ne perdrons pas de temps 4

Bernheim (1840-1919) (who was a contagionist a` confuter ces hypothe`ses absurdes.’’ [‘‘We know a Downloaded from himself and an authority on epidemic diseases great number of authors who wrote about the trans- before he became famous as a psychotherapist) had mission of contagion by microscopic organisms ...we to say in 1877 concerning Jacob Henle, the teacher of will not waste time in refuting these absurd hypoth-

Robert Koch.1 Henle lives in our minds and textbooks eses.’’] Wunderlich speaks in 1843 of the ‘‘remnants ije.oxfordjournals.org as the man who ‘‘produced the first clear statement of of childish ideas.’’5 J.K. Mitchell, one of the inventors the idea of a contagium animatum,’’ who fought a of the fungus miasma, regrets in 1848 that ‘‘Morgan bold vanguard action. To Bernheim the situation and Holland reverted to the exploded animalcular 6 appeared as follows: theory of Kircher and Linnaeus,’’ ‘‘which has hith- at Cornell University Library on October 4, 2011 ‘‘The serious observers recognized the emptiness of erto been so feebly sustained by proofs, as to have at these fantastic concepts. Towards the middle of the no time received general favor from the profession, century the doctrine of the contagium animatum was although supported by some eminent men in almost generally abandoned as a product of the imagination, every period of medical history.’’7 E.A. Parkes states lacking scientific foundations. Among medical leaders in 1849: ‘‘During the last sixty years, however, the Henle was perhaps the last who defended in 1853 study of several diseases imperfectly known to the with strong determination the doctrine of the older physicians has added so many new facts to our contagium vivum which he had defended already in knowledge of the several specific epidemic diseases, 1840 with great logical vigor. Yet the parasitary that the strict contagion theory has been insensibly doctrine has during the last 10 years regained con- undergoing alteration, until in the present day it siderable credit in public opinion as the result of new tends to become merged in a higher generalization.’’8 research and more positive findings.’’ C.F. Riecke states in 1859 that the contagious doctrine It becomes thus obvious that what to us appears a has made no progress in centuries, and recent res- vanguard action, impressed Henle’s contemporaries earch has reversed the whole old authoritarian rather as a rearguard action, the last gallant defense building of the contagion doctrine.9 Even a modern of a dead hypothesis. That the theories of contagion author, Major Greenwood, feels that Henle’s essay ‘‘is and the contagium animatum appeared old and worth reading, but not better worth reading than a obsolete to many in the first half of the 19th century book published in 1546 and written by a Veronese is easily seen from the following examples: physician, Hieronymus Fracastorius.’’10 And Charles Trotter speaks contemptuously in 1804 of the Singer, who has been a most indulgent and sympa- ‘‘relicts of the old animalcular hypothesis of con- thetic historian of animate contagionism, states that, tagion.’’2 ‘‘Alpha’’ states in the Lancet in 1832 that except for a small school at the beginning of the 18th certainly not within the last fifty years have any century, no real progress was achieved between diseases been added to the list of the contagious Fracastorius and Pasteur.11 ones.3 Ozanam writes in 1835: ‘‘Nous connaissons un As a matter of fact, contagion and the contagium animatum were rather old theories around 1800. The * 1821 is the date of the famous Barcelona yellow fever youthful appearance they enjoy in our mind today is outbreak and 1867 of the last great European cholera epidemic. In preparation of this paper the Library of the ¨Ackerknecht EH. Anticontagionism between 1821 and 1867. College of Physicians in Philadelphia and Dr. W.B. McDaniel Bulletin of the History of Medicine 1948; 22, 562-593. Abridged II have been most helpful through liberal book loans. and with portions translated. Reprinted with permission.

7 8 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY exclusively due to the very thorough rejuvenation they The men who brought about this last victory of underwent in the 1870’s and 80’s. Once we realize the anticontagionism worked with unprecedented energy. oldness of both theories we can hardly be surprized in The fact that such outstanding leaders of modern finding that their development was by no means uni- ‘‘contagionism’’ and thoroughly unromantic characters linear, but a continuous series of ups and downs, of as William H. Welch and C.-E. A. Winslow have found acceptance and refutation. The notion of contagion, understanding words for anticontagionism, seems to almost unknown to classic antiquity, had become firmly justify closer occupation with this movement. entrenched in Western culture after the acceptance of ‘‘The official opinion, as expressed by sanitary the (contagionist) Jewish Old Testament as a holy book authorities at that time (1848) was definitely hostile in Christianity. After the introduction of quarantines in to the germ theory of disease. I attach, however, no most Christian countries in the 15th and following great importance to this circumstance, for it is not centuries the notion of contagion had in addition the clear what practical use sanitarians would have made official backing of the state, the worldly authority. of this theory with the knowledge existing at that The idea of the contagium animatum had been time. Hypotheses born before their time are often formulated first in the 16th century by Cardanus, sterile. They must have some relation to the state of Paracelsus, and above all, by Fracastorius (1546). It knowledge existing at the time, and history affords had been further developed by V. de Bonagens, Fallo- many instances of the useful purpose served for a pius, Mattioli and many others. It had not fared too time by inadequate and even erroneous theories. It is well under the hands of Montanus, Valeriola, Sanctor- doubtful whether any more useful working hypoth- ius, and particularly Facio. But it had victoriously esis concerning the sources of epidemics would have returned in the 17th century with the microscopic been framed in 1848 than that which guided most of Downloaded from ‘‘worms’’ of A. Hauptmann, Father Kircher (1659), the sanitary activities at that period and for many Chr. Lange, etc. Around the turn of the 17th century it subsequent years, erroneous as it was, and tenaciously had reached perhaps its highest elaboration with as it was held after it had served its primary purpose. Lancisi, Andry, Vallisnieri, and after the Marseilles This doctrine, as is well known, was the so-called filth ije.oxfordjournals.org plague of 1721 with Bradley, Goiffon, and Lebe`gue. The theory of the generation of epidemic diseases.’’15 satirical Syste`me d’un Me´decin Anglois (by M.A.C.D. Paris, ‘‘We cannot dismiss the resistance of the medical 1726) had almost ruined it through ridicule. But profession to the doctrine of contagion as merely an though now undergoing progressive degeneration, evidence of hidebound conservatism. There were sound at Cornell University Library on October 4, 2011 according to Singer,12 it had still inspired a Linne´ reasons for this attitude. The layman perceived the (1757), Plenciz, Lorry, etc., and in the 19th century broad truth of contagion as he watched the plague Rasori, H. Holland, and Henle. With Ag. Bassi (1838), spread from country to country and from seaport to Davaine (1850), Villemin it started on a new experi- seaport; but the physician knowing the facts more mental basis; but how was one to differentiate at that intimately realized that no existing theory of contagion moment solid acquisitions from the uncritical produc- taken by itself could possibly explain those facts. tions of Donne´ or Hallier? The day belonged to Woehler Contagion, before the germ theory, was visualized as and Liebig’s cruel anticontagionist jokes (1839), fash- the direct passage of some chemical or physical ioned after the Parisian ‘‘M.A.C.D.’’ of 1726.13 influence from a sick person to a susceptible victim It was, curiously enough, in the first half of the 19th by contact or fomites or, for a relatively short distance, century, that is shortly before their final and over- through the atmosphere. The physician knew that such whelming victory, that the theories of contagion and a theory was clearly inadequate. Cases occurred with- the contagium vivum experienced the deepest depres- out any possibility of such a direct influence. Cases sion and devaluation in their long and stormy career, failed to occur when such a direct influence was and it was shortly before its disappearance that present. Epidemics broke out without the introduction ‘‘anticontagionism’’ reached its highest peak of ela- into the locality of any recognizable cases from with- boration, acceptance, and scientific respectability. It out; and within the city or country they raged in a might contribute to our understanding of the phe- particular section and failed completely to spread nomenon when we realize that what happened to beyond the border of that area. Outbreaks began and medicine in the first half of the 19th century and what outbreaks ceased without any causes that would be looks now to us only like normal birth pains or vigorous directly related to the presence or the absence of the growth, might just as well be regarded as a deep sick. Until the theory of inanimate contagion was crisis.14 Rene´ la Roche called it downright a revolution, replaced by a theory of living germs, and until to that an event which is know to produce new things in the theory were added the concepts of long-distance midst of a maximum of confusion and disorder. It is by transmission by water and food supplies and, above no means incidental that the medical revolution all, of human and animal carriers – the hypothesis of paralleled everywhere so many political revolutions, contagion simply would not work.’’16 and that the ‘‘anticontagionist revolution’’ in France The anticontagionists were motivated by the was preceded, just like her political sister, by an new critical scientific spirit of their time. (Griesinger American anticontagionist revolution. calls it somewhat sourly ‘‘Zweifelsucht’’17). ANTICONTAGIONISM BETWEEN 1821 AND 1867 9

Contagionism was so old that it seemed never to have Chervin, Lassis, Costa, Lapis, and Lasserre,24 and the been submitted to rational examination. So they did cholera self-experiments of Fay, Scipio Pinel, Wayrot,25 submit it. It is no accident that so many leading and J.L. Guyon. The amazing thing is that almost all of anticontagionists were outstanding scientists. To them these experiments failed to produce the disease. They this was a fight for science, against outdated therefore greatly increased the faith of and in the authorities and medieval mysticism; for observation anticontagionists. We hear only of a Dr. White dying in and research against systems and speculation. a plague self-experiment, the suicide of a Paris student Chervin’s battle cry was ‘‘non verbis, sed factis.’’ who had too well succeeded with a syphilis inocula- [‘‘not words, but actions’’] J.A. Rouchoux stated that tion,26 and the death of the contagionist E. Valli from experience of the typhus and yellow fever epidemics yellow fever in Havana in 1816 (V. overdid a little; he of the Napoleonic wars had more than anything else had already survived a successful plague vaccination undermined the belief in contagion,18 and coldly self-experiment in Istanbul in 1803).27 declared in the Academy of Medicine in 1832 that the In their positive theories the anticontagionists were experience with cholera ‘‘va achever le discredit des anything but uniform and often blissfully unaware of me´sures sanitaires (quarantines)’’.19 [‘‘will discredit the fact that their theories were, especially when they the use of quarantine as a sanitary measure’’.] adhered to the classic Hippocratic epidemic constitu- Still, the vigor of our movement would remain tion or ‘‘atmospheric influences,’’ even older than largely unexplained, did we not realize the powerful contagionism. Many followed a more modern and social and political factors that animated this see- localized ‘‘miasma’’ theory (poison arising from mingly scientific discussion. Contagionism was not a decaying animal or vegetable matter, ‘‘filth’’). From mere theoretical or even medical problem. Contagion- the miasmatic or ‘‘filth’’ theory to a purely social Downloaded from ism had found its material expression in the quaran- concept was but a short step. tines and their bureaucracy, and the whole discussion In our discussions there did exist, like in all such was thus never a discussion on contagion alone, but situations, besides the two extremist wings, a large always on contagion and quarantines. Quarantines meant, center of ‘‘moderates’’ that tried to compromise, the ije.oxfordjournals.org to the rapidly growing class of merchants and indus- so-called ‘‘contingent contagionists,’’ counting in its trialists, a source of losses, a limitation to expansion, ranks such highly respected men as Milroy, James a weapon of bureaucratic control that it was no longer Johnson, Parkes, Riecke, etc. And it is precisely the willing to tolerate, and this class was quite naturally attitude of this center which decided on the practical at Cornell University Library on October 4, 2011 with its press and deputies, its material, moral, and applications, and which best illustrates the general political resources behind those who showed that the orientation of a given period. It is extremely typical scientific foundations of quarantine were naught, and for our period that the center, though admitting who anyhow were usually sons of this class. Con- theoretically contagion in certain limits and as tagionism would, through its associations with the one possible factor of many, practically, that is in the old bureaucratic powers, be suspect to all liberals, condemnation and abolition of quarantines, the trying to reduce state interference to a minimum. supreme test of one’s convictions, followed the anti- Anticontagionists were thus not simply scientists, contagionists. The anticontagionists, though castigating they were reformers, fighting for the freedom of the the center cheerfully for its inconsistencies, were well individual and commerce against the shackles of aware of this fundamental closeness of both tenden- despotism and reaction. This second aspect of antic- cies28. The change of the orientation of the center ontagionism contributed probably no less than its since the times of Richard Mead (1721), when on the scientific aspects to its gaining over the majority of basis of a similar theoretical compromise it headed those parts of the medical profession that were towards contagionism, is very significant. independent of the state. In spite of the name, none of the anticontagionists That the anticontagionists were usually honest men was an absolute anticontagionist, denying the exis- and in deadly earnest is shown, among other things, tence of any contagious diseases. Even such radical by the numerous self-experiments to which they sub- anticontagionists as Ch. Maclean or J.A. Rochoux mitted themselves to prove their contentions. Between admit the existence of such contagious diseases as the plague auto-inoculation of Desgenettes in 1798 syphilis, gonorrhea, smallpox, measles, and the itch29 and Pettenkofer’s swallowing of a cholera culture in But the actual and imaginary clinical and epidemio- 1892, (both men, by the way, were rather ‘‘contingent logical difference between these diseases and those contagionists’’ than pure anticontagionists), a verita- ‘‘big three’’ against which the quarantines were ble epidemic of self-experimentation seems to have mainly directed: plague, yellow fever, and cholera, shaken the medical profession. Yellow fever self- confirmed them in their anticontagionism. Around experiments are reported e.g. from Pfirth v. Salun, these three diseases, which together with typhus Lavalleé, Musgrave, Potter, Chervin,20 Prost, Dorsey, constituted the main health problem of the period, O’Connor, Govin,21 Ffirth, Cathrall,22 Guyon,23 and did the discussion primarily evolve, and it is through Puhlschneider. Famous are the plague self-experiments a more detailed discussion of the attitude of the of Clot-Bey, the offers for plague self-experiment by medical profession towards yellow fever, cholera, 10 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY plague, and typhus that we intend to picture antic- as non-contagious.) You all remember how through ontagionism between 1821 and 1867. Epidemics of his 1793 experiences Benjamin Rush was converted smallpox, influenza, meningitis dysentery, etc. from contagionism to anticontagionism, how in 1799 ravaged Europe in the same period. But none of the anticontagionist Philadelphia Academy of them found a similar scientific and emotional Medicine was founded. When Chervin 20 years later response, partly probably because none did kill quite came to Philadelphia, he found but 4 or 5 contagio- as dramatically and extensively as the ‘‘big three’’, nist physicians left.34 The writings of the North partly because none of these ‘‘minor evils’’ resulted in American anticontagionists made a deep impression so hated an institution as the quarantine. upon European doctors, which was reinforced Limited in time and space, I am obliged to omit through the fact that all the leading physicians of from my discussion more or less the American the ill-fated Napoleonic expedition to San Domingo prologue of the anticontagionist revolution (Rush– (1802-3), that was wiped out by the yellow fever, Webster) and to treat in a very summary way its later returned as confirmed anticontagionists. (Trabue, FV representatives, the English sanitarians (Chadwick, Bally (1775-1866), A François (1775-1840), L Valentin Southwood Smith, John Simon, etc) or Pettenkofer (1758-1829), etc.) and an international authority like and his followers. I feel justified in this procedure as Alexander von Humboldt sided with the anticonta- 30 there exist for Rush-Webster as well as Chadwick gionists (1802). 31 Simon very excellent and detailed recent discussions Through the Napoleonic Wars the French and by Winslow and others. Because of the same English became sensitive to the fact that in Spain limitations, I have also quoted only a few of the they had a center of yellow fever right in their back most significant contributions out of a practically yard. Outstanding French army doctors like Downloaded from inexhaustible contemporary literature on yellow fever, P. Assalini (1750-1840) and FP Blin (1756-1834) cholera, plague, and typhus. found in 1805 and 1801 the Cadiz yellow fever epidemics, that killed 20 per cent of Cadiz’ inhabi- ÃÃÃ tants, to be of a non-contagious character. Robert ije.oxfordjournals.org 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 ANTICONTAGIONISM AND majority of the local physicians voted anticontagionist at Cornell University Library on October 4, 2011 YELLOW FEVER in a kind of referendum.36 It was of great consequence for the success and When in 1821 a very fatal epidemic of yellow fever spreading of anticontagionism in the 19th century that broke out in Gibraltar, the (contagionist) French yellow fever, a disease which through its mechanism government and the Academy of Medicine, becoming of transmission is far less of a ‘‘contagious’’ disease more and more alarmed, despatched a study commis- than either cholera, or plague, or typhus, was the first sion consisting of the Academy secretary Et. Pariset 37 subject of the great 19th-century discussions between (1770-1847), Bally, and François to Barcelona in contagionists and anticontagionists, and that in the order to clear up the fundamental problems of the yellow fever discussion the anticontagionists were disease in view of future protective legislation. The represented by a man of unusual intelligence, three musketeers of contagion returned with a very perseverance, and poise: Nicolas Chervin. It is also contagionist report, obtained a life pension of 3000 typical that practically all ‘‘professional anticontagio- Frs. per year; and a very stringent quarantine law was nists,’’ that is those men who not only accepted passed through the chambers in 1822. anticontagionism, but made the fight against the The anticontagionists too had flocked to Barcelona, theory of contagion and quarantines their life work, to study the epidemic, and in 1822 a manifesto on the had had their first epidemiological experiences with 1821 outbreak appeared, signed by such well-known yellow fever. The easy victory of anticontagionism in anticontagionists as the Frenchmen, S. Lassis (1772- the yellow fever discussion set a fatal pattern for later 1835), JA. Rochoux (1787-1852), the British Th. discussions on cholera and plague. O’Halloran and Charles Maclean (ca. 1766-1825), It seems that modern anticontagionism in regard to the American John Leymerie, and 11 local physicians, yellow fever really started in the famous Philadelphia among them 4 recent converts to anticontagionism, F. yellow fever epidemic of 1793. Rene´ La Roche gives to Piguillem, M. Duran, J. Lopez, and S. Campmany.38 Jean Deve`ze (1753-1825),32 one of the many French The manifesto showed that there was no positive refugee physicians from San Domingo (La Roche proof that the disease was imported from Cuba; that himself was the son of such a San Domingo it could satisfactorily be explained through the physician), the credit of having brought an idea that miasms of local filth, particularly sewers; that no had been apparently long prevalent in the West infection through fomes had occurred during the Indian and other tropical yellow fever centers,33 to a epidemic; that it was strictly seasonal; that attendants theater from which it was to conquer the world to the sick showed below average morbidity; and that (Deve`ze regarded also plague, typhus and dysentery numerous cases were struck for the second time. ANTICONTAGIONISM BETWEEN 1821 AND 1867 11

The manifesto helped Maclean defeat a quarantine for Chervin throughout the years.42 The four friends law in the Cortes in 1822, but produced little reaction Chervin mentioned in his own testament – Re´veille´- abroad. Especially in France everything seemed under Parise, Londe43, Rochoux, and Civiale – were all control. At this moment Nicolas Chervin (1783-1843) outstanding medical men. In 1863, 20 years after returned from America, where since 1814, first Chervin’s death, the contagionist Charcot regarded practicing in Guadeloupe, then travelling all along Chervin’s work on yellow fever still as final.44 the East coast of the continent from Guiana to Maine, Chervin’s influence was not so much due to the he had studied yellow fever and collected a truly arguments he used, which are similar to those of all amazing and well-authenticated documentation in anticontagionists, e.g. coincidence of outbreak and favor of anticontagionism. In North America, e.g. he ship’s arrival, not importation; non-transmission to had found 568 yellow fever anticontagionist physi- nurslings of affected mothers or hospital attendants; cians as compared to 28 contagionists.39 Chervin the disease strikes only in certain localities, sick immediately went to Spain to check Pariset’s report, fugitives do not infect; fomes do not infect; the and the documentation he brought back did not leave contagionists do not observe their own laws, etc. much of the permanent secretary’s hasty, hysterical etc45. It was due to his great conscientiousness, pudding. In 1825-26 Chervin bombarded the Chamber precision, and honesty – he submitted material with petitions to reopen the case of yellow fever adverse to his theory with the same industry as quarantines on the basis of his documentation. The favorable material – and his poise – he kept the Chamber passed the problem to the Academy of lunatic fringe of anticontagionism at a safe distance; Medicine. The Academy appointed a committee of 18 he limited himself to what he actually knew – and to that examined the documentation for 11 months. In his perseverance, even more than to his brilliant Downloaded from 1827 Coutanceau (1775-1831) submitted a report to intelligence and enormous knowledge, which made the Academy, (primarily the work of Villerme´, the him tower above most contemporary contagionists greatest living French sanitarian, Re´veille´-Parise, and anticontagionists. His personal integrity and Emery and Lanbert) that in spite of its diplomatic disinterestedness were above any doubt. Although ije.oxfordjournals.org terms, criticized by Chervin, adopted Chervin’s point representing the interests of a very wealthy class, he of view, completely demolished Pariset’s report, and died a poor man. His published work consists only of recommended stopping further enforcement of the pamphlets. His magnum opus on yellow fever 1822 quarantine law. The Coutanceau report was, remained unfinished. It is one of the tragic jokes of at Cornell University Library on October 4, 2011 after long discussions, where especially RND fate that Chervin’s many talents and virtues were Desgenettes (1791-1858), the former head of spent on a lost cause. Napoleon’s Medical Corps, and JB Louyer-Villerme´ In the above-mentioned Gibraltar epidemic of 1828 (1776-1837) championed Chervin’s cause, and in spite the majority of the garrison’s doctors and the majority of the violent resistance of Pariset, of heavy govern- of the official British inspecting commission, although mental pressure and maneuvers, adopted by a presided by the violent contagionist Sir William Pym, majority of the Academy in January, 1828, and gave a verdict against contagion.46 The same conclu- quarantine credits accordingly cut down by the sion was reached by the Inspector General of Army Chamber. The Academy of Science took a similar Hospitals, JL Gillkrest (d. 1845). This, by the way, was stand40. Chervin received the Grand Prix de Me´decine the last large yellow fever epidemic in Europe (except of the ‘‘Institut’’ for 1828. for the outbreaks in Lisbon in 1857 and Madrid in It is almost impossible to exaggerate the importance 1878) which made it all the easier for yellow fever of this step of the French Academy, the leading anticontagionism to stay. medical corporation in the leading medical country of In 1850 D. Blair and the local physicians of Guiana, the period. It set the pattern for the Western world. It under approval of J. Davy, Inspector General of the set the pattern for the Academy’s own attitude in British Army, declared yellow fever to be non- later discussions on cholera and plague. Only deep contagious.47 The same conclusion was reached by conviction could bring the Academy to withstand the British Yellow Fever Commission in 1852,48 and official pressure and to expose its own permanent the General Board of Health in 1853. Riecke defended secretary. The Academy remained faithful to Chervin. this opinion in 1854. In 1855 the Philadelphian R. La Together with P. Louis and Trousseau it delegated Roche’s great anticontagionist classic on yellow fever him to Gibraltar to study there the yellow fever came out. ‘‘As a work of profound erudition, at once epidemic of 1828. In 1832, the cholera year, it elected complete and exhaustive, written in a scholarly style, him a member, not because of his political radicalism, and evincing the most patient and extra-ordinary as the Lancet had claimed, but in spite of it.41 Chervin research, the monograph on yellow fever, by Dr. La made a deep and lasting impression on the profession Roche, is without a rival in any language.’’49 In like no other contagionist. Even most of his adver- 1859 G. Milroy (1828-1886), the famous English saries spoke with respect of him. J. Raige-Delorme sanitarian, asked for removal of the useless yellow (b.c.1795), editor of the Archives Ge´ne´rales from 1823 fever quarantines for the sick,50, just as JK Mitchell to 1854, remained full of an unchanging admiration had done in 1846.51 12 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

By 1868 opinion of the majority, under the influence coˆte´ de ceux qui ne l’admettaient plus; leurs ideés of men like F. Me´lier (1789-1866) and W. Griesinger étaient conside´reés comme des ideés de nature (1817-1868), and of new observations, seems to have libe´rale par excellence, d’autant plus en rapport avec swung back to the concepts of contagiousness and la dignite´ humaine que leur conse´quence pratique importation of yellow fever, except for the English, who était la suppression de toute entrave portant atteinte a` according to Dutrolau, were prejudiced through their la liberte´ de l’homme; l’esprit du temps´ etait, en un commercial interests.52 In the United States the mot, l’inverse de celui d’aujourd’hui; et, au lieu d’eˆtre reaction seems in general to have set in even earlier, voue´ au culte de la spećificite´ étiologique, on traitait just as the wave of anticontagionism had started earlier. volontiers d’esprits re´trogrades 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 AND cholera epidemic at the same time as there was the ANTICONTAGIONISM greatest faith in the prophylactic effects of cordons Yellow fever, fortunately, remained but a potential sanitaires, the well-being of so many people who were, danger for Europe and discussion of its contagious- on the contrary, in open communication with affected ness more or less an academic problem. Cholera areas, also diminished public confidence in quaran- overran Europe and the world in four major pan- tine measures. This brought doubt about the absolute demics during the 19th century, spreading terror like manner of transmission of this disease, from man to the medieval plague, killing millions (in England and man, and one came back to the notion of a ‘genie’ of Wales alone ca. 15,000), and constituting everywhere epidemiology; contagion was nearly always dealt with Downloaded from a tremendous medical, political, economic, and as a fanciful belief and progress seemed to be on the human problem. side of those who accepted no more than this; their ideas were regarded as those of a progressive nature, Cholera had been a native of India for centuries, and ije.oxfordjournals.org the Anglo-Indian physicians became thus the first all the more so since they seemed more in line with authorities on cholera for their Western colleagues, human dignity in that the consequent practice was to like the West Indian physicians had once been on remove any obstacles to man’s freedom of movement. yellow fever. These Anglo-Indians, especially those The spirit of the time was, in a word, the opposite of at Cornell University Library on October 4, 2011 reporting on the 1817 epidemic, were confirmed today; and instead of being dedicated to the notion of anticontagionists. The whole medical body of Bengal a specific aetiology, readily treated as retrograde and the majority of the Bombay physicians decided spirits those who still admitted the contagious this way.53 The Anglo-Indians were among the last to nature of cholera, typhus and many other diseases.] abandon anticontagionism in cholera. European doctors could not fail to be impressed by The 1817 Indian cholera had advanced to the Near the fact that the majority of those Western physicians, East in 1821 and knocked so loudly at the door of who encountered cholera first, rendered a verdict of 55 56 Europe that farseeing observers, contagionists non-contagious (eg Astrachan , Moscou ). The (Moreau de Jonne`s, born 1778) and anticontagionists numerous commissions that the French and other (Maclean) alike foresaw that the next cholera wave, European governments sent into the cholera regions starting in India in 1826, would probably enter claimed the same results and found quarantines Europe. Governments, especially those of France and useless: Gerardin and Gaymard, who with Jules 57 Russia, took early precautions in the form of rigid Cloquet formed a Russian commission; the Polish military cordons and quarantines. To no avail; in 1831 commission (Dalma, Sandras, Boudard, Dubled, 58 cholera overran Russia, and in 1831-32 the rest of Alibert, Ch. Londe). The same holds good for the Europe. Leon Colin54 has left an excellent summary of great sanitarians F. Foy (1793-1867) and RHJ the effect of the first great victory of cholera on Scoutetten (1799-1870) who were sent to Warsaw epidemiological thought: and Berlin59. Hammett’s report on Dantzig was ‘‘lost’’ Cette marche rapide, a` travers l’Europe´ de la by the contagionist English Health Council60. premie`re´ epide´mie de chole´ra au moment meˆme ou` When cholera struck England in 1831 the authorities l’on avait le plus grand espoir dans l’influence and the overwhelming majority of physicians were prophylactique des cordons sanitaires, la pre´servation contagionist. Thomas Wakley stopped an anticontagio- de tant de pays qui, au contraire,´ etaient demeure´sen nist series by ‘‘Alpha’’ in the Lancet and came out libre communication avec les re´gions atteintes, dimin- strongly for contagion61. The adoption of ‘‘contingent ue`rent aussi de beaucoup la confiance publique dans contagionism’’ by James Johnson (1777-1845), the les mesures quarantainaires. On sait qu’alors on international authority on tropical diseases and physi- re´voqua en doute d’une manie`re absolue la transmis- cian extraordinary of the king, and of a straight sibilite´ de cette maladie, de l’homme a` l’homme, et anticontagionism by the highly respected A. Bozzi qu’on en revint a` la doctrine du geńie´ epide´mique; la Granville (1793-1871), who had so valiantly defended contagion fut presque, d’une manie`re geńe´rale, traiteé contagionism and quarantines in the plague discus- de croyance chime´rique, le progre`s semblaitˆ etre du sions of the 1820’s, marks the turning of the tide.62 ANTICONTAGIONISM BETWEEN 1821 AND 1867 13

In 1832 the editor of the Edinburgh Medical and German medicine at the time it was of small Surgical Journal turned anticontagionist.63 The books importance. of J. Lizars (1793-1860) and T. Molison reinforced the The pandemic of 1848-49 confirmed the anticontagio- anticontagionist trend, the Westminster Medical nist beliefs of 1831-32 in practically all observers, and Society, probably the most active medical society in won even new adherents to the cause. The reports of London at the time, voted anticontagionist (24:22)64. the Anglo-Indian surgeons, collected by the antic- G. Sigmond (b.1790), himself a convert, stated in May ontagionist Rogers, continued to emphasize antic- that probably the majority of physicians was now anticontagionism.81 Prof. EA Parkes (1819-1876), who ontagionist,65 and even Wakley tuned down his contagion- made for the General Board of Health a much ism considerably.66 JG Gillkrest came out in favour of admired analysis of the earliest cases of the London the anticontagionists67, and H. Gaultier’s book on the 1848 epidemic, had been formed in India, and it is Manchester epidemic illustrated well the current therefore not surprising that his ‘‘modified contagion- anticontagionist approach.68 ism’’ practically excluded the contagiosity of cholera Perhaps the outstanding promoter of anticontagion- as well as yellow fever and plague.82 WF Chambers ism in France in the 1832 epidemic was the famous (1786-1853), physician of the Queen, and the physiologist, pathologist, pharmacologist, and clinician, respected JA Wilson (1795-1883) preached Franc¸ois Magendie (1783-1855). In December 1831, anticontagionism.83 when France was still free of cholera, he went to The significant change in 1848 as compared to 1831 Sunderland to study the disease. His conclusions, as was that now for the first time in centuries a presented in the Academy, were that the disease was governmental agency was defending the tenets of not imported and contagious but due to incredible anticontagionism: the General Board of Health (Ashley, Downloaded from social conditions – humidity, lack of ventilation and Edwin Chadwick, and its medical member Dr T light, ‘‘filth’’ – and that quarantines were therefore Southwood Smith (1788-1861)). The 1849 Report on useless. He won an easy victory against Moreau de Quarantines of the Board is clearly opposed to Jonne`s.69. In the following Paris epidemic he showed quarantine. Its 1848 Instructions84 and its 1850 ije.oxfordjournals.org great courage and skill in fighting the disease. His Report on the Epidemic Cholera of 1848 and 1849 (based opinions were but reinforced through this experience,70 mainly on the surveys of Drs. J Sutherland (1808-91), and the events of 1848. Magendie felt that four out of RD Grainger (1801-65), and J Milroy), were openly the five quarantine diseases – leprosy, typhus, yellow and pronouncedly anticontagionist. Grainger made at Cornell University Library on October 4, 2011 fever, and cholera – were certainly not contagious, the the same point in his Hunterian Oration of 1841. The fifth, plague, was probably also non-contagious.71 It is Board of Health was not the least surprised by the probably under his impulsion that the doctors of the increased morbidity and mortality of 1848-49 as Hoˆtel-Dieu (Petit, Recamier, Dupuytren, Husson, compared to 1831-32. Far from attributing it to a Magendie, Breschet, Honore´,Gue´neau de Mussy, relaxation of quarantines, it attributed it to the Samson, Caillard, Gendrin, Bailly) published an antic- increase since 1831 of those conditions which it ontagionist declaration72. An Academy of Medicine regarded as the causes of the disease and sources of report and instruction of the same year, written by de the ‘‘miasma’’: overcrowding, filth, dampness, faulty Mussy, Biett, Husson, Chomel, Andral, Bouillaud, and drainage, vicinity of graveyards, unwholesome water, Double, is clearly anticontagionist by implication.73 JB and unwholesome food.85 The Board and its medical Bouillaud (1796-1881) expanded his anticontagionist followers were strengthened in their beliefs through views in a lengthy treatise of the same year and the fact that they had been able to predict such an defended anticontagionism vigorously as a member of increase in morbidity and to designate in advance the the Chamber in 184674. To this long and brilliant list of very houses where cholera would break out.86 French anticontagionist clinicians we have still to add (Usually houses infected also with typhus.) Their the names of Broussais,75 Piorry,76 HMF Desruelles own ‘‘model buildings’’ – buildings struck in 1831, (1791-1858),77 of the hygienists F. Foy (1793-1867),78 but remodeled since – remained this time free after Ch. ES Gaultier de Claubry (1785-1855),79 Ch. F sanitation.87 The anticontagionists of the General Tacheron (b. 1790), and of the naval medical officers Board of Health were pragmatists insofar as their JJ Souty and F Levicaire. emphasis was no longer on a discussion of the It is practically impossible to list all outstanding scientific problem of contagion, but on exposing and French physicians who became anticontagionists. A list removing those conditions whose elimination would of the contagionists is far more feasible. It consists more prevent cholera, no matter what the rationale. It is in or less of the two great surgeons Velpeau and Delpech, this spirit that they were enthusiastically followed, eg and the two psychiatrists Foville and Parchappe. And, by the British and Foreign Medico-Chirugical Review.88 of course, Pariset and Moreau de Jonne`s. This group thus illustrates most clearly the positive The trend towards anticontagionism in the 1831 side of anticontagionism, although this positive epidemic was the same in Germany as elsewhere (see tendency existed in all outstanding anticontagionists the writings of HW Buek, N Weigersheim, Koelpin, (eg B Rush, Chervin, the Barcelona Manifesto of 1822, etc.80). But due to the general low status of etc.). The sanitary activities of the General Board of 14 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Health, at least as objectionable a ‘‘waste of money’’ in 1849 to contagionism in 1865.102 This seems to be to the merchant class as quarantines, also show that fairly typical, though some, of course, changed their the anticontagionists were more than mere mouth- positions earlier, some later, some never. pieces of a ruthless and economy-minded bourgeoisie. It is significant that the Archives Ge´ne´rales, still under The depth of anticontagionism in the England of 1848 Raige-Delorme´’s leadership, softened their attitude is visible from the fact that the conservative London toward contagion considerably and progressively after College of Physicians, Maclean’s old pet enemy, came 1850, being 100% contagionist by 1865. In 1853 the out in October, 1848 with a document admitting the Royal College of Physicians made a strongly antic- impotency of cordons and quarantines.89 And yet ontagionist statement on cholera.103 The roˆles had been 1849 sees also the first publications of J Snow on reversed within 60 years, the College and government cholera which were probably among the most being now anticontagionist, the profession increasingly effective gravediggers of anticontagionism. contagionist. A Hirsch stated in a survey in 1854 that 1848-49 brings a reconfirmation of anticontagionism after a prevalence first of contagionists, then of antic- also in France. AA Tardieu (1818-1879), the great ontagionists, now some compromise theory was 104 105 French hygienist, states in his interesting 1849 book ruling. He quoted Snow still disparagingly. Only that ‘‘it is very evident that measures taken in view of two years later the same author claimed that the the contagion are entirely without avail, and that majority were contagionist (though he still gave a long consequently the contagion itself is very improbable’’.90 list of anticontagionists) and spoke with the greatest 106 He was joined in this opinion eg by the hygienists sympathy of Snow’s and Budd’s work. Although CF P Jolly (1790-1879) and JL Collineau (1781-1860), and Riecke adopted formally an eclectic position in his 1854 the clinicians Martin-Solon (1795-1856), E Emery book (spontaneous generation plus contagion plus Downloaded from (1780-1856)91 and JHE Monneret (1810-68).92 epidemic constitution) his violent opposition to quar- In Germany the Medizinische Zentral Zeitung was antine revealed his fundamentally anticontagionist anticontagionist in regard to cholera.93 So was the position which to a large extent he derived from Hecker and Haeser. On the other hand, he had an ije.oxfordjournals.org bright young star of German science, Rudolf 107 Virchow.94 CF Riecke’s (born 1802) anticontagionist inkling of the roˆle of the healthy typhoid carrier. This writings were successful. The famous and very most important and revolutionary notion of the healthy carrier was more fully developed by Pettenkofer for influential chemist Justus Liebig came out for antic- 108 ontagionism.95 The majority of Russian physicians cholera in and after 1855. In 1857 Griesinger felt at Cornell University Library on October 4, 2011 96 that since about 1852 the contagiosity of cholera was was anticontagionist. 109 A Cholera Quarantine Conference, organized in Paris generally recognized. In 1859 Milroy held cholera to be ‘‘feebly contagious,’’ but continued to oppose quar- by Me´lier in 1851, was practically without result, 110 mostly because of English anticontagionist opposition antines. In his 1861 book on puerperal fever even I. under Sutherland. This is understandable in view of Semmelweis called cholera still ‘‘non-contagious’’. the fact that the evidence on the effect of quarantines SA Fauvel’s (1813-84) report of 1866 seemed to many definitely to prove contagiosity of cholera. Me´lier in the first two pandemics remains rather contra- reintroduced cholera quarantines in 1866, having dictory and bewildering. Copenhagen was free of re-established those for yellow fever for 1853. One of cholera with quarantine in 1831, heavily struck in the most signal defeats of anticontagionism was the adoption of 1852 after abolition.97 Belgium reported good experi- the importation and contagiousness of cholera by the Anglo- ences with quarantine in 1831 and 1848.98 On the Indian medical men in 1866, after a resistance of more than 60 other hand, Tardieu and Lase`gue (the latter had made years.111 And Virchow, the anticontagionist of 1848, a personal study of the problem in Russia) claimed admitted in 1869 that ‘‘all the more recent research that there was no difference between the 1830 suggests an independent organism, especially a epidemic (with cordons) and the 1848 epidemic 112 99 fungus’’ (as the cause of cholera). That anticon- (without cordons). Copeland’s explanation of the tagionism died hard is visible from the fact that the higher mortality in 1848 because of relaxation of 100 French Academy still received 36 anticontagionist (as quarantines is balanced by the above-mentioned against 109 contagionist) reports in an 1884 outbreak of argument of the Board of Health. The Austrian cholera (Philippe Ricord (1800-89) defended in these emperor, the Prussian king, the French government discussions the non-contagiousness of cholera), and (1832), the Dutch government, the London College of that the British government denied the imported Physicians – all admitted publicly the ineffectiveness character of a cholera epidemic in Egypt as late as 1885. of quarantines and cordons.101 It seems that during the third cholera epidemic (1852-55) and even more so during the fourth (1865- PLAGUE AND 67) – these two connected with major wars while their two predecessors had been connected with ANTICONTAGIONISM revolutions – the majority of the profession returned When plague struck the English and French troops to contagion. Winslow has traced recently John during the Napoleonic expedition in Egypt in 1798-99, Simon’s gradual development from anticontagionism the medical commanders of the French (Assalini, ANTICONTAGIONISM BETWEEN 1821 AND 1867 15

Desgenettes) as well as of the English troops (Sir (primarily yellow fever, plague, typhus, and cholera) Robert Wilson) agreed that the disease was non- had protean forms, were clearly seasonal, and could contagious.113 This fact can be found in the 1819 attack the same person repeatedly. The burden of the report of a committee of the House of Commons on proof that these diseases were contagious was, in plague and quarantine, representing ‘‘the first official Maclean’s opinion, with the other party. But he drew inquiry ever made concerning this institution’’. attention to such facts as that attendants, doctors, the Although the result of this inquiry was procontagio- family of the sick, etc. experienced in his ‘‘epidemic’’ nist, the mere fact of having obtained it at all was a diseases no above average morbidity (quite different considerable performance. It was due to the persever- in this respect from ‘‘contagious’’ diseases like ance of Charles Maclean (born c. 1768) who deserves smallpox); these epidemic diseases remained localized some more detailed attention because of the great roˆle and seasonal. They would not spread in time and he played in the development of anticontagionism. space without limit, as they should, were they Maclean had entered the service of the East India contagious. Maclean also claimed that plague fomes Company in 1788, studied yellow fever in Jamaica in proved to be harmless in Turkey, recurrence of plague 1790, and worked in India since 1792. In 1796 he in the same person frequent, and quarantines published his first anticontagionist book in Calcutta, completely ineffective to prevent epidemic diseases. 114which obviously found wide attention in and outside In his positive theories Maclean was far less of India. An American edition appeared in 1797 and a consistent: plague was to him entirely dependent on German translation in 1805. Expulsed from India in atmospheric influences;121 Irish typhus resulted from 1798 because of a radical political pamphlet, he drifted want of food, employment, and hope;122 yellow fever around observing, writing, agitating, serving with the from filth;123 and cholera from ‘‘local causes’’ and Downloaded from English army in 1804-5, and joining eventually the ‘‘winds’’.124 Quarantines were really the cause of 19/ Levant Company in 1815. In the Eastern Medi- 20 of all cases in epidemics by enforcing confinement terranean he did serious research on the contagiosity in pestilential air; producing concealment of the of plague, which he promptly contracted in an Istambul disease, desertion of the sick, and deadly terror. ije.oxfordjournals.org plague hospital, and on which he published a two- Quarantines were amoral, ineffective, and the source volume book in 1817.115 This book induced the of enormous gratuitous expenses and vexation. Government to consult the arch-contagionist London Maclean’s ideas were too extreme, his character too College of Physicians in 1818 on plague and quar- unbalanced, his death too early to effect the general at Cornell University Library on October 4, 2011 antines, and resulted in the above mentioned Commit- change of ideas concerning the contagiosity of plague. tee of the House of Commons in 1819. We have This deed is attributed by Griesinger to Clot-Bey.AB encountered Maclean already in the Barcelona yellow Clot (1793-1868), French-born and educated, had fever epidemic of 1821, and obtaining rejection of a become the chief army surgeon of the Egyptian quarantine law by the Cortes, Oct. 18, 1822. Maclean dictator Mehmet Ali in 1825. His abilities as a seems to have died shortly before his final triumph, surgeon, his work as an organizer of sanitary that is the relaxation of the plague quarantine by the improvements, of a medical school, a school of British government in 1825. pharmacy, and a school for midwives in Egypt won There is no lack of evidence that Maclean made a him international fame. In a great plague epidemic in deep and lasting impression on his contemporaries. 1835 Clot’s countryman, LR Aubert-Roche (1809-74), Se´guier, the French consul general in London, another remarkable character, convinced him of the reported in a letter to his government of May 20, non-contagiosity of plague and the uselessness of 1825, ‘‘the opinion of Dr Maclean, who pretends that quarantines. From now on Clot-Bey spent a great deal plague is not contagious, is prevalent in England’’.116 of his considerable energies and prestige on fighting Tweedie, himself a contagionist, stated for the same the theory of plague contagion and plague quaran- period the ‘‘more general disbelief in the contagious tines. His last book, written in 1866, two years before nature of the plague’’.117 A collaborator of the Lancet his death, at the age of 75, is called Derniers mots sur la in 1825 declared on the authority of Maclean that peste [Last words on the plague]. In their antic- cholera was not contagious.118 ontagionist attitude Clot-Bey and Aubert-Roche seem Maclean gave a summary of his opinions in a to have been in full harmony with the majority of the memorandum to the Spanish Cortes in 1822 during European physicians practicing in Egypt. Egypt was his campaign against the pending quarantine laws.119 for centuries regarded as the home of plague, like the He differentiated ‘‘epidemic’’ from ‘‘contagious’’ dis- West Indies ranked as the home of yellow fever, and eases. While the true contagious diseases (syphilis, India as the home of cholera. And the Egyptian smallpox, etc) had a specific virus (Maclean was one physicians were anticontagionists in regard to their of the few at the time to poke fun of the idea of main ‘‘native’’ disease, like the West Indians and spontaneous generation of disease virus120); had a Anglo-Indians had been in the corresponding case.125 clear-cut clinical picture; occurred independently of England and Austria had abolished plague quar- season, the state of air, and other circumstances; and antine in 1841. In France it was felt that clarity on struck a person but once; the ‘‘epidemic’’ diseases the subject was needed before one could overcome 16 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY administrative opposition, especially in Marseilles, to general anticontagionist wave, and was of relatively similar changes. The Academy of Medicine charged a short duration. Among the first to deny the con- committee with a report which was submitted by CR tagiosity of typhus were Elliotson,130 and Corrigan,131 Prus (1793-1850) in 1846, hotly debated for many the great Irish clinician and statesman who saw in months, and eventually adopted after the usual bick- famine the sole cause of the terrifying Irish outbreaks ering with the contagionist government and smooth- of 1800, 1817-18, and 1826. ing of formulations. This report, which among other When Virchow, at the occasion of the Upper Silesia things served as a model of Virchow’s famous Upper epidemic of 1848, declared that ‘‘no facts exist that Silesia report of 1848, followed in its details more the prove contagion, and certain experiences speak against brand of anticontagionism as represented by Aubert- contagion’’,132 he was well aware of the novelty of the Roche, a ‘‘localist’’, ‘‘miasmatist’’, and sanitary refor- statement. He was, on the other hand, not a little proud mer, than the one of Clot-Bey, a ‘‘tellurist’’ and of it, regarding it as truly scientific and modern. The Hippocratic believer in ‘‘atmospheric conditions’’. anticontagionism of Grainger, Adams, and Armstrong Prus’ main conclusions were that plague was not in regard to typhus showed that the English sanitary imported either in Egypt or Syria or Turkey, but arose movement was equally radical.133 spontaneously out of humid houses, putrifying animal The contagionist Millies, in discussing the problem in matter and other filth. That neither contagion nor the 1857, stated that numerous anticontagionists did still contagiousness of fomes nor the inoculability of exist, especially in Paris.134 This might, of course, be a plague were proven; that the miasma was propagated confusion with typhoid. But Murchison (also a through the air, not through patients; that ships were contagionist) made the same statement in 1862.135 136 dangerous only in ports suffering themselves from an And it is reiterated by Foerster in 1863. Yet by 1868 Downloaded from epidemic constitution; and that, therefore, progress of Virchow, one of the authors of anticontagionism in civilization was the only preventive against plague, typhus, declared: ‘‘There is much exaggeration, yet the and Egypt needed mostly a good administration. In fact remains that the typhus diseases and especially the discussion the main champions of contagionism petechial fever may become contagious; that some- ije.oxfordjournals.org were Pariset and Bousquet, of anticontagionism F times they may acquire even this quality to the highest Dubois d’Amiens (born 1799; he became the successor degree’’. And by 1871 he admitted: ‘‘As much as I of Pariset one year later), Londe, Piorry, and Rochoux. hesitated formerly to admit that contagion is the

In adopting the Prus report on plague the Academy ordinary way in which typhus epidemics develop, I at Cornell University Library on October 4, 2011 sided again with anticontagionism, as it had done in must confess today that I, like so many earlier the case of yellow fever in 1828 and cholera in 1832. observers, am more and more forced, through contin- The discussion lost much of its practical value uous experience, into the contagionist camp.’’137 through the long absence of plague epidemics in Egypt after 1845. PRACTICAL AND THEORETICAL ASPECTS OF ANTICONTAGIONISM TYPHUS AND After having studied the scientific triumphs of antic- ANTICONTAGIONISM ontagionism in the 1820’s, 1830’s, and 1840’s, and its An analysis of the attitude towards typhus in our decline in the 1850’s and 1860’s, it might be indicated period is made somewhat difficult by the fact that to summarize the practical results obtained by the explicit differentiation between typhus and typhoid anticontagionists in the relaxation and abolition of was rare even in the 1850’s, in spite of the classic work quarantines and cordons, which, after all, was their of Bretonneau (1826), Louis (1829), and particularly main goal. WW Gerhard and Pennock (1837). Still, the disease to The first to change their quarantine acts were the which we now apply the term typhus was so obviously English and the Dutch in 1825.138 Further relaxations contagious that it was recognized as such even by an occurred after 1831 and 1841.139 From 1849 on up to arch-anticontagionist like Rochoux,126 (who, by the the 1880’s English official bodies came out with anti- way, was one of the first to separate typhus and quarantine declarations. The first changes in France typhoid). Typhoid, on the other hand, seemed so little occurred in 1828 and 1832. In 1835 even Marseilles, contagious that its ‘‘non-contagiousness’’ served long super-contagionist since the plague of 1721, softened as one of the differentiating criteria. Especially the her quarantines.140 In 1849 quarantines were sup- Paris School (eg Andral, Chomel in 1834) upheld its pressed altogether, reinstated in 1850, abolished for non-contagiousness.127 Murchison found it only cholera again in 1853, and reinstated in 1866.141 In ‘‘feebly contagious’’ in 1862,128 and in 1863 the the general disappointment with quarantines and contagionist Charcot had still to report on many cordons after 1831 large concessions were made to the typhoid anticontagionists.129 anticontagionists in Austria (1841) and Russia (1847). The idea of the non-contagiousness of true typhus The practical successes of anticontagionists were developed thus late, rather as a by-product of the not limited to their victories over quarantines. ANTICONTAGIONISM BETWEEN 1821 AND 1867 17

Their operations against ‘‘filth’’ increased greatly their led doctors to a belief in a contagious form in all small prestige. While it was difficult for the contagionists to localities ...nothing was lacking in their observations, prove that a respective epidemic would have been but their words lack authority.]150 Griesinger too even worse without quarantines, health improve- explains anticontagionism through the rule of big city ments after removal of ‘‘filth’’ seemed to be causally doctors. ‘‘But in Paris, as in all big cities, the facts of related to the latter action. Barcelona and Alicante did contagion of as frequent a disease (as typhoid) can not experience further yellow fever epidemics after rarely be observed conclusively.’’151 The great triumphs such campaigns in 1827, respectively 1804. The of a rapidly growing chemistry, the influence of a General Board of Health could point in the cholera Liebig, the recent victories over ‘‘vitalism’’ would of 1848-49 to the immunity of its cleaned ‘‘model particularly militate against a biological explanation houses’’. (Those parts of Hamburg that had burned of epidemics as given by the contagium vivum. down after 1831 and had been rebuilt also remained I am afraid that, forced to decide ourselves a healthy in 1848.)142 Typhus morbidity143 and mortal- hundred years ago on the basis of the existing ity144 had considerably decreased from the 1840’s to materials, we would have had a very hard time. the 1860’s, thanks to the sanitary measures of the Intellectually and rationally the two theories balanced each anticontagionist Board of Health and its successors. other too evenly. Under such conditions the accident of The anticontagionist Aubert-Roche had an enviable personal experience and temperament, and especially eco- health record during the construction of the Suez nomic outlook and political loyalties will determine the Canal in the 1850’s and 1860’s. decision. These, being liberal and bourgeois in the majority In examining critically the theoretical foundations of the physicians of the time brought about the victory of of anticontagionism, we should be aware of the fact anticontagionism. It is typical that the ascendancy of Downloaded from that certain basic weaknesses were common to both anticontagionism coincides with the rise of liberalism, parties, anticontagionists and contagionists. Both its decline with the victory of the reaction. Of course, parties occasionally used unreliable information. Both the latter was not the only factor of the decline parties were still obsessed with the Hippocratic idea of of anticontagionism. Was it new discoveries as ije.oxfordjournals.org the air as primary medium of transmitting the noxious Bernheim and others declared? Certainly, Snow and element, whether miasma or contagium, at the expense Budd made quite an impression. Yet, some doubts are of any other possibility (this idea prevails even with at least allowed, in view of the fact that the change Henle and Holland). In both parties those were still was prior to the decisive discoveries of Pasteur, Koch, at Cornell University Library on October 4, 2011 numerous who believed in the fundamental unity of etc. The discoveries of Davaine and Villemin fevers145 Both parties suffered from the ‘‘fallacy of a were isolated and little known. Henle’s crown single cause’’.146 Both parties were reduced to reason- witnesses, the itchmite or the fungi in skin diseases, ing by analogy, a procedure the dangers of which were could most easily be dismissed as inconclusive and clearly shown by Wunderlich.147 Both parties used the bad analogies by the anticontagionists,152 when even animal experiment still very little, and what experi- a contagionist like Trousseau reacted to these dis- menting they did lacked method and inventiveness. coveries only by no longer counting scabies and favus Though the experiments of the next generation did not among the contagious diseases, but transferring solve all problems either, they afforded an uncompar- them to the parasitary group.153 Roy states quite ably higher degree of certainty than the mere observa- correctly in 1869: tions on which both parties based their reasoning. ‘‘Mais la difficulte´ que les fauteurs de cette doctrine Among these observations the contagionists would (Henle and Holland)´ eprouve`rent a` geńe´raliser des usually pick a set of more or less true facts that faits de parasitisme externe aux maladies du sang la confirmed their theory, leaving out another set of laissa tomber assez longtemps dans l’oubli et tous les equally true, but incompatible facts, which in their turn pathologistes s’en tinrent` a la theórie que M. Liebig the anticontagionists would triumphantly present as commença` a de´velopper de`s 1839.’’ proof of their theory. Or, ‘‘facts’’ and ‘‘observations’’ [But the difficulty for the instigators of this doctrine being highly complex and ambiguous, both parties (Henle and Holland) proved to be to generalise the would take up the same fact, but succeed in inter- fact of external parasitism to diseases of the blood. It preting it in the contrary sense.148 One of the truest had lain forgotten for so long, and all the pathologists statements in this direction is that of Wakley that the stuck to the theory which M. Liebig began to develop most disturbing facts (like low morbidity of atten- in 1839.] 154 dants) were fundamentally not explained by either theory.149 A. Hirsch makes a somewhat revealing statement in Some have not been explained up to this very day. 1856: ‘‘The more the belief in the contagious nature of ‘‘Observations’’ depended also to a large extent on the cholera became widespread in the medical world, the location of the observer. Brochard writes in 1851: ‘‘Les smaller became the number of facts in which contagious me´decins conduits par leur observation a` la croyance genesis could not be proven.155 This suggests that to a d’une forme contagieuese habitent tous de petites certain extent emotional conversion, based on the localite´s ...rien ne manque a` leurs enqueˆtes; mais accumulated despair of repeated cholera epidemics l’autorite´ manque a` leurs paroles.’’ [Their observations and on the normal ‘‘swing of the pendulum,’’ preceded 18 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY intellectual insight and discovery, rather provoking The political background of the anticontagionist than being provoked by the latter. While contagionism discussion was no less obvious. The leading anticonta- had ‘‘pragmatically’’ hardly done better than antic- gionists – Maclean, Chervin, Magendie, Aubert-Roche, ontagionism, it could claim one major accomplishment Virchow, etc. – were known radicals or liberals. The at this turning point: it had kept alive interest in that leading contagionists (with the lone exception of the part of experimental research that would bring the liberal professor Henle) were high ranking royal solutions of the future. Henle had produced Koch. military or navy officers like Moreau de Jonne`s, Far from underplaying the economic implications of Kerandren, Audouard, Sir William Pym, Sir Gilbert their fight, the anticontagionists usually emphasized Blane, or bureaucrats like Pariset, with the corre- readily this popular aspect of the problem. They wrote sponding convictions. The anticontagionists skillfully long and detailed dissertations of exactly how many interspersed political arguments in their discussion. millions of pounds, francs, or dollars were yearly lost Maclean did not tire to trace contagionism back to the through the contagionist error.156 Chervin, who Pope’s political maneuver of transferring the Council characterized the whole as a political, administrative, of Trent in 1547, made possible by the ad hoc con- moral, medical, and commercial problem,157 was not tagionist theories of his servant Fracastorius,163 afraid of such revealing word combinations as published, by the way, in 1546. This was also a fine ‘‘question du plus haut inte´reˆt pour l’humanite´ et le occasion to mobilize anti-catholic and antireligious commerce’’ [question of the greatest interest for emotions. Appealing to the ‘‘irreverence of the age for humanity and for trade] or ‘‘entraver le commerce mere authority,’’164 Maclean thundered against the et consacrer une erreur funeste a` l’humanite´’’. [to ‘‘monopoly’’ of the College of Physicians.165 The same block commerce and to create a disastrous error for spirit was kindled by reminders of the shooting of Downloaded from humanity.]158 Gaultier wrote in 1833: ‘‘Quarantine is three anticontagionists in Thorea in 1815, the same useless, and the injury it inflicts on the commercial act of violence in Noja in Apulia in 1815, the burning relations and maritime intercourse of the country is of Dr Armesto’s anticontagionist book in Spain in an absolute and uncompensated evil.’’159 Anticonta- 1800, and the hanging of an anticontagionist doctor ije.oxfordjournals.org gionist medical journals reprinted speeches of and tailor in Brandenburg in 1707.166 To Maclean the commerce-minded deputies.160 Liberal and commer- very worst aspect of the quarantines was that they cial newspapers like the Journal de Commerce, the were ready ‘‘engines of despotism’’.167 Chervin Constitutionel, and the Courier supported Chervin in expressed freely his disgust with the ‘‘servile spirit’’ at Cornell University Library on October 4, 2011 1827. French medical authors of the 60’s and 70’s saw that penetrated French contagionists, but satisfied very clearly the connections between anticontagion- himself that those in power would not be there ism and commercial interests – in England.161 Still, to tomorrow.168 Writing this three years before 1830, he call the anticontagionists simply ‘‘mouthpieces of proved not too bad a prophet. commercial interest’’ would be a regrettable over- Economic factors did not only determine the stand simplification of the situation. To many of them both of many in the anticontagionism discussion. Economic slogans: freedom of commerce (no quarantines), and factors were consciously used by many to give a causal freedom of science (anticontagionism) were, together explanation of epidemics in our period (see Maclean with others, like freedom of the individual (against above, Villerme´, Magendie, etc.). This ‘‘sociological’’ any bureaucracy), the natural expression of the same (as contrasted to biological) theory of epidemics can fundamental attitude and social position. Some, as be found already in the 18th century under the the following quotation from Maclean shows, were influence of enlightenment. (JP Frank, Chassanis, perhaps not so much interested in commerce at all, Targioni-Tozzetti). Yet its spread is a feature of the but tried, in appealing to commercial interests, to 19th century. I have already discussed in my doctor’s mobilize every possible ally: thesis in detail Virchow’s famous social epidemiolog- ‘‘I am rather at a loss to conceive how their being ical ideas, which were one of the reasons for his later injurious to commerce could, in a commercial country, reluctance to accept the results of bacteriology,169 and be regarded as an argument against seeking the more recently Virchow’s French predecessors.170 In abolition of otherwise pernicious establishments .... listing the epidemiological theories of the 19th For my part, far from thinking it culpable to have century, I feel it would be justifiable to add to the availed myself of the support of commerce in combat- two great divisions: the physico-chemical or geographic ting the ridiculous but very pernicious dogmas of (including the ‘‘tellurists’’ and ‘‘miasmatists’’) and medical schools .... I am very free to confess that I the biological (parasitists, bacteriologists), a third one, have, upon this occasion, diligently sought to range the sociological, represented by such men as Virey, every interest, over which I could exercise the smallest Villerme´,Me´lier, Aubert-Roche, Alison, Davidson, and influence, on the side of truth.’’162 Virchow. The lines of division will not always be It should also not be overlooked that into the clear-cut and coincide with other lines of division. A contagionist attitude no less earthly factors entered, ‘‘sociologist’’ might, for instance, be a contagionist like the needs of real estate interests in denying ‘‘local (Davidson) or, more often, an anticontagionist.171 The causes’’ of epidemics. essential characteristic of the sociologist is that all ANTICONTAGIONISM BETWEEN 1821 AND 1867 19 these problems become of a very secondary impor- in Essays presented to A. Castiglioni (Supp. Bull. H. Med. tance when compared to social factors. Typical in this No. 3), Baltimore, 1944, pp.89-102. respect are: the message of Gerardin and Gaymard 5 Arch. Phys. Heilk. 2:321, 1843. from Poland: ‘‘Les Commissaires pensent que le 6 Mitchell, J.K., Five Essays, Phila. 1859, p.111. principal pre´servatif du cholera consiste dans l’ame´- 7 Ibid., p.4. lioration de la condition sociale des populations.’’ 8 Brit. For. Med. Chir. Rev. 4:252, 1849. [The Commissioners think that the principal protec- 9 Riecke, C.F., Die Reform der Lehre von der Contagion, tion against cholera lies in the improvement of the Quedlinburg, 1854, pp. XVII, 177. See also social condition of the people.]172 Aubert-Roche’s Virchow’s diatribe against unscientific, antiquated motto for his plague book, which is also the basis of contagionism (in his Archiv, 2:263; 1849) the Prus report of 1846: ‘‘La civilisation seule a de´truit 10 Greenwood, Epidemics and Crowd-Diseases, N.Y., 1935, la peste en Europe, seule elle l’aneántira en Orient,’’ p.58. [Civilisation alone destroyed the plague in Europe, it 11 Singer, Ch. and D., The Development of the is the only thing which will destroy it in the East]. or Doctrine of Contagium vivum, 1500-1750., 17th 173 the typhus studies of Alison, Bateman, Corrigan, Int. Med.Congress (1913), Sect.XXIII, p.188, London, 174 and Franque. I cannot take up the whole Virchow 1914. complex here again, but I would like to refer at least 12 Singer, l.c., p. 205 to such typical features as the conclusions of his 1848 13 Most of the above data are taken from Singer 1914, 175 report, his paper on the epidemics of 1848, his Singer, Ch. and D., The Scientific Position of thesis that social conditions determine whether Girolamo Fracastoro, . 1: 1 ff., 1917, 176 Ann. Med. Hist typhus or typhoid develops, his interpretation of Downloaded from 177 and Loeffler, F. Vorlesungen ueber die geschichtliche cretinism as a social disease, etc. The sociological Entwicklung der Lehre von den Bakterien, Leipzig, 1887. theory, claiming a kind of ‘‘social epidemic constitu- 14 The crisis aspect of this period has been empha- tion,’’ suffers often from the same haziness that is so sized by Shryock, e.g. in his Development of Modern characteristic of the theories of telluric ‘‘epidemic Medicine (Phila. 1936). See also Ackerknecht, E.H., ije.oxfordjournals.org constitution.’’ Beitraege zur Geschichte der Medizinalreform von This strange story of anticontagionism between 1821 1848, Sudhoff’s Archiv 25 (1932), chs. III and IV. and 1867 – of a theory reaching its highest degree of 15 Welch, W.H., Public Health in Theory and Practice, scientific respectability just before its disappearance; New Haven, Yale University Press, 1925, p.27. at Cornell University Library on October 4, 2011 of its opponent suffering its worst eclipse just before 16 Winslow, C.-E., A., The Conquest of Epidemic Disease, its triumph; of an eminently ‘‘progressive’’ and Princeton, Princeton University Press, 1943, p.182. practically sometimes very effective movement based 17 Griesinger, W., Infektionskrankheiten, Erlangen, 1857, on a wrong scientific theory; of the ‘‘facts,’’ including p. 120. a dozen major epidemics, and the social influences 18 Dictionnaire de me´decine, Paris, 1834, Vol, VIII, p.503. shaping this theory – offers so many possible 19 Archives geńe´rales de me´decine, 28:286, 1832 conclusions that I feel at a loss to select one or the 20 Thomassen, E.H., Untersuchung ob das gelbe Fieber other, and would rather leave it to you to make your ansteckend sey., Bremen, 1832, p.27. choice. I am convinced that whatever your conclu- 21 Chervin, N., Examen des principes de l’administration sions, whether you primarily enjoy the progress in en matie`re sanitaire, Paris, 1827, p.29. scientific method and knowledge made during the 22 La Roche, R., Yellow Fever Considered in its Historical, last hundred years, or whether you prefer to ponder Pathological, Etiological and Therapeutical Relations, those epidemiological problems, unsolved by both Philadelphia, 1855, Vol. II, p.527. parties at the time and unsolved in our own day, all 23 Ibid., p.262. your conclusions will be right and good except for the 24 Lancet, 1834-35, I, p.862; Lancet, IX, 1825-26, p.134. one, so common in man, but so foreign to the spirit of 25 Tardieu, A., Treatise on Epidemic Cholera, Boston, history: that our not committing the same errors 1849, p.239. today might be due to an intellectual or moral 26 , 1829-30, II, p.291 superiority of ours. Lancet 27 Hirsch-Gurlt, Biographisches Lexikon der hervorragen- den Aerzte, Wien-Leipzig, 1888, Vol. VI, p.62. 28 La Roche, l.c., p.569 Notes 29 Maclean, Ch., Evils of Quarantine Laws and Non- 1 Dict.Encycl.Sc.Med (A. Dechambre ed) 1. Ser., vol. Existence of Pestilential Contagion Deduced from the XX, p.7, 1877. Phenomena of the Plague of the Levant, the Yellow Fever 2 Scott, H.H., A History of Tropical Medicine, Baltimore, of Spain, and the Cholera Morbus of Asia, London 1824, 1942, p.29. p.136 Rochoux (Dictionnaire de me´dicine vol. 8, 1834, 3 Lancet 1831-32, II, p.21; see also Holland, H., Med. p. 504) even adds rabies, scarlet fever, anthrax, Notes and Reflections, Phila. 1839, p.342. hospital gangrene. 4 Ozanam, J.A.F., Histoire me´dicale des maladies epide´mi- 30 Winslow, l.c., p. 193 ff.; Spector, B., Noah Webster’s ques, Paris, 1835, III, p.6. On Ozanam see Galdston, I., Letters on Yellow Fever, (Suppl. Bull. H. Med. No. 9), 20 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Baltimore, 1947, and especially that extraordinary 66 Ibid., 156, 178. product of American medical scholarship: La 67 Lancet, 1832-33, I., p.113 Roche’s book on yellow fever, Phila., 1855. 68 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, Deve`ze 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). anticontagionists. 69 Arch. Geń. 28: 430, 1832. 34 Ibid., p.237 70 See his 1832 book on cholera. 35 La Roche, l.c., 245. 71 Lancet, 1843-35, I., p.224, 273. 36 Maclean, l.c., p.76. 72 Tardieu, l.c., p.244. 37 La Roche, l.c., p.257 73 Arch. Geń. 29:122, 1832 38 Maclean, l.c., p.141. Maclean reprints the whole 74 Arch. Geń. 4, ser. 11:370 manifesto, p. 122 ff. 75 Lancet, 1831-32, II. P.148. 39 Chervin, 1827, p.15. 76 Arch. Geń. 28: 608, 1832. 40 Archives Geńe´rales de Me´decine, 2 s., 1: 609, 1853. 77 Arch. Geń. 27: 140, 1831 41 Lancet, 1832-33, I, p.373 78 Arch. Geń. 28: 452, 1832. 42 e.g. Arch. Geń. 16: 310, 1828; 22: 437, 1830. 79 Arch. Geń. 2 s., 1:532, 1833. 43 For Re´veille´-Parise, Londe, Villerme´, and many 80 Haeser, H. Lehrbuch d. Gesch.der Medizin. Jena,

other anticontagionists as hygienists see 1882, Vol III, p.921 ff. Downloaded from Ackerknecht, E.H., Hygiene in France 1815-49, 81 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 Charcot, J-M, Oeuvres comple`tes, Vol. VIII, p.144, 82 Brit. For. Med. Chir. Rev., 1849, vol.4: 251 ff. 1889. 83 Lancet, 1849, I., p.166, Lancet, 1848, II., p.502 ije.oxfordjournals.org 45 Chervin, 1827:59. 84 Tardieu, l.c., p.154. 46 Chervin, Lettre sur la fie`vre jaune qui a re´gne´ a` 85 See Report, pp.37-63 Gibraltar en 1828, Paris, 1830, p.16. For a good 86 Report, p.18 87 analysis of the Gibraltar epidemic by the contagio- Ibid., p.69 at Cornell University Library on October 4, 2011 nist Peter Wilson, with emphasis on ‘‘filth’’, see 88 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 Brit. For. Med. Chir. Rev. 6: 428, 1850. the work of John Forbes. See also the significant 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. Philadelphia, 1875, p.25 89 Ibid., p.32. 50 Milroy, G., Quarantine As It Is and As It Ought to Be. 90 Tardieu, l.c., p.111. London, 1859. 91 Arch. Geń. 4.s. 20:110 ff., 1849 51 Mitchell, J.K., l.c., p.115. 92 Arch. Geń. 4.s. 16:521, 1848 52 Dutrolau, AF., Traite´ des maladies des Europeéns dans 93 Schmidt’s Jahrb. 62:142, 1849. 94 les pays chauds, Paris, 1868 Virchow, Ges. Abhandlungen aus dem Gebiet der 53 Chervin, 1827, p.26. Maclean, l.c., p.397. Maclean oeffentlichen Medizin, Berlin, 1879, Vol.1, p.24. attributes this to his teachings and publications in 95 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; Lase`gue, Arch. Geń, 4.s. 54 Dict. Encycl. Sc. Me´d. (Dechambre ed.) 3. ser. vol I, 18:114,1848 100 p.51, Paris, 1874. Lancet, 1849, I, p.292 101 55 Arch. Geń. 28: 131, 1832 Lancet, 1831-32, I., p.182; Arch. Geń. 27:137,1832.; 56 Arch. Geń. 27: 554; Lancet, 1831-32, I, p.17 Dict. Encycl. Sc. Me´d. 3. ser., Vol. I, p.51; Lancet, 57 Arch. Geń. 30: 138 1831-32, II., 572; GJ Mulder in Arch. Physiol. Heilk., 58 Arch. Geń.28: 134, 1832; Lancet, 1831-32,I.,p.113 1849, 8:489 ff. 102 59 Arch. Geń.28: 452, 1832, ib. p.451 Winslow, l.c., p.255 ff. 103 60 Lancet, 1832-33, I., p.372 Lancet, 1853, II, p.399 104 61 Lancet, 1831-32, I., p.261 Schmidt’s Jahrb. 84:90, 1854. 105 62 Lancet, 1831-32, II., p.299, 301 Ibid., 84:92. The same does even the contagionist 63 Lancet, 1831-32, II., p.23 Lancet, 1849, II, p.318. 106 64 Ibid., 150. Schmidt’s Jahrb. 92:252, 259 107 65 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 Milroy, l.c., p.10. 147 Wunderlich, l.c. p. 323. 111 Dict. Encycl. Sc. Me´d, 1. ser. Vol. 16, p.755, Paris 148 Londe developed this point in Arch. Geń 4.s., 1874. 11:489, 1846 112 Arch. f. path. An. 1869, 45:279 149 Lancet, 1831-32, II, p.156 113 Maclean, l.c., p.90. 150 Arch. Geń. 4.s. 23:123 114 Maclean, Ch, and Yates, W., A View of the Science of 151 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 Lancet, 1826-27, 12:777 152 Riecke, l.c., p.30. 118 Lancet, 1825, 6:275 153 Dict. Encycl. Sc. Me´d. 1. ser. Vol.20, p.1-2,7,1877. 119 Reprinted in Maclean 1824, pp. 198-261. 154 Roy F. Revue historique des diffe´rentes theóries 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 Ibid., p.6. 155 Schmidt’s Jahrb. 92:255, 1856 123 Ibid., p.129. 156 Maclean, l.c., p. 30 ff.; Chervin in Arch. Geń.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 126 Dict. de Me´d. XIX, p. 601 ff., 1839 158 Ibid., p. 107, 116. 127 Murchison Ch, A Treatise on the Continued Fevers of 159 L.c., p. 34. Great Britain, London 1862, p.428; see also 160 e.g. Arch. Geń. 27:134, 1831. Griesinger, l.c., p.120. 161 Dutrolau, l.c., p. 444; Dict. Encycl. Sc. Me´d. 3.s., Vol. ije.oxfordjournals.org 128 Ibid., p.2. I, p.97-98 129 Charcot, l.c., p.19. 162 Maclean, l.c., p. XXIII. 130 Lancet, 1829-30, II, 543. 163 Ibid., p.6, 213. 131 164 Lancet, 1829-30, II, 600. Ibid., p.69. at Cornell University Library on October 4, 2011 132 Archiv. 2:263,1849 165 Ibid., p.21. 133 Lancet, 1849, I., p. 106, 202. 166 Riecke, l.c., p. 5. 134 Schmidt’s Jahrb. 1857, 96:250 167 Maclean, l.c., pp. 35, 214, 271 135 Murchison, l.c., p.79. He alludes here to the 168 Chervin, 1827, p. XVIII ‘‘Sanitary Movement.’’ 169 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 Scott, l.c., p.752; Arch. Geń. 2. ser. 3:147, 1833 170 Id. Hygiene in France 1815-1848. Bull. Hist. Med. 139 Arch. Geń. 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 Murchison, l.c., p.8. 171 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 As a matter of fact no anticontagionist ever made 172 Arch. Geń. 28: 427, 1832. a statement comparable in absurdity to the one of 173 Murchison, l.c., p. 75. Pariset that the Cadiz yellow fever was trans- 174 Schmidt’s Jahrb. 96: 251, 1857. formed cholera and imported by a ship from 175 Ges. Abh. 1879, I., p.117 ff. Calcutta (La Roche, l.c., p. 204). 176 Ibid., p. 284-285. 146 Winslow, l.c., 250 (Another version of the same 177 Ges. Abh., 1856:927 fallacy: S Smith, Henderson, and Florence SOIIO A HISTORY OF LONDON’S MOST COLOURFUL NEIGHBOURHOOD

JUDITH SUMMERS

BLOOMS BURY Downhill All the Way —

to harbour him, but he fell sick the next day, and died in three 5 more.’ Theodore died on ii December 1756, and the kind tailor, who Downhill All the Way 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. There had always been poverty in Soho. Few of its foreign residents had arrived with money in their pockets. Like all immigrants before The grave, great teacher, to a level brings and since, they had to work extremely hard for their success. And Heroes and beggars, galley-slaves and kings. 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 Fate pour’d its lesson on his living head, make ends Bestow’d a kingdom, and denied him bread. but three — others had found it hard, or impossible, to 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 were incredibly harsh, ranging from death by hanging to transporta Neuhoff, he had spent his youth travelling round Europe — first tion to the colonies and unlimited imprisonment. Still, to make as a page in the service of the Duchess of Orleans, later as an money one had to spend it first, and in doing so one ran a serious adventurer. At one point he even sold his wife’s jewels in order risk of getting into debt, as Mrs Cornelys had found out to her to pay off his debts. cost. For, despite the popularity of her assemblies, the contents He ended up in Genoa, at a time when the republic was at war of Carlisle House had been seized several times under distress with the island of Corsica. Fired by sympathy for the Corsican warrants — even in 1762. and 1763, two of her most successful prisoners of war he met there, he determined to become their years. Her aura of wealth had in fact been a façade. As Casanova saviour, and set sail for their island with a cargo of 4,000 muskets had reported, she ‘who seemed to be living so luxuriously. . . was to help them fight off the Genoese. The islanders were so impressed in reality poverty-stricken’ and Sunday was ‘thc only day on which by his grand arrival that they invited him to become their King, an Madame Cornelys could go abroad without fear of the bailiff’. offer which he naturally accepted. He was duly crowned with a Still, in the i8th century Soho had for the most part been a garland of laurel and oak leaves. thriving area of prosperous people, and what poverty there was After a short reign, the Corsicans lost confidence in him, and had been limited and somewhat picturesque. Standards had been he was forced to leave the island under a cloud. He eventually kept up, even by the penniless but enterprising trompe l’oeil artist came to London, where he soon got into debt and ended up in Capitsoldi, who, because he could not afford to buy any furniture the King’s Bench Prison. He managed to get himself freed only by for his ‘Warwick Street lodgings, ‘proceeded to paint chairs, pictures registering ‘his kingdom of Corsica for the use of his creditors’. I and window curtains on the walls of his sitting room . . . so Horace Walpole told the story of what happened next in a letter admirably executed that, with an actual table and a couple of to Sir Horace Mann: ‘As soon as Theodore was at liberty he took real chairs, he was able to entertain on occasion a friend in an a chair and went to the Portuguese minister, but did not find him apartment that appeared adequately furnished’. at home; not having sixpence to pay, he prevailed on the chairman By the time philosopher Thomas Dc Quinicey arrived in London to carry him to a tailor he knew in Soho, whom he prevailed upon 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 of St Anne’s, would one day call ‘a prolific place for suicides’. evokes a vivid evening picture of a Soho house at a poignant turning A gifted child from a comfortably-off family, Thomas De Quincey in the area’s history: point 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 or establishment days’, as he wrote of himself. He was a brilliant scholar, who by 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 poor, friendless child, Yet he suffered from what he called a ‘chronic passion of anxiety’ apparently ten years old; but she seemed hunger bitten; and sufferings coupled with a rebellious temperament which drove him away from of that sort often make children look older than they are. From this respectability and towards the hidden underbelly of life. By the age of forlorn child I learned, that she had slept and lived there alone for 17 he had had enough of his grammar school in Manchester, and after some time before I came: and great joy the poor creature expressed, quarrelling with one of his guardians, who demanded ‘unconditional when she found that I was, in future, to be her companion through submission’ from him, he did what many thousands of teenagers the hours of darkness. The house was large; and, from the want of before and since have done: he ran away and dropped out. furniture, the noise of the rats made a prodigious echoing on His first stop was Wales. Then, when he had spent most of the spacious staircase the and hail; and, amidst the real fleshly ills allowance his mother had given him, he came to London, a city and, I fear, of cold, hunger, the forsaken child had found leisure to which, then as now, exerted a gravitational pull on the young more suffer still (it appeared) from the self-created one of ghosts. I and disaffected. Here he ended up practically penniless and almost protection promised her against all ghosts whatsoever! but alas! I could starving, at the offices of an attorney and money-lender known no other offer her assistance. We lay upon the floor, with a bundle sometimes as Mr Brown and at other times as Mr Brunell, whose law of cursed papers for a pillow: but with no other covering premises were on the east corner of Greek Street and Soho Square. than a sort of large horseman’s . . cloak . The poor child crept close to me for warmth, and for security The house [De Quincey wrote in his Confessions of an English against her ghostly enemies. When I not more than was Opium Eater] was not in itself, supposing that its face had been usually ill, I took her in my arms, so that, in she was tolerably general, washed now and then, at all disrespectable. But it wore an unhappy warm, and often slept when I could not. countenance of gloom and unsocial fretfulness, due in reality to If it had not been for the long neglect of painting, cleansing, and in some instances of Brown’s love of classical literature, De Quincey would probably have starved repairing . . . the deep silence that invested the house, not only to death during the following weeks. As it was, Brown, though from the absence of all visitors, but also of the common household ‘one of those anomalous practitioners in lower departments of the functionaries, bakers, butchers, beer-carriers, sufficiently accounted law’ who himself lived ‘in constant fear of bailiffs’, loved intelligent company, for the desolation, by suggesting an excuse not strictly true — viz., and De Quincey kept alive by himself that it might be tenantless. walking in on Brown while he was breakfasting chatting downstairs, to him ‘and, with an air of as much indifference Through Brown’s office, l)e Quincey applied for the loan of a small assume, as I could took up such fragments as he had left’. sum of money, and while he waited for it to arrive he eked out By day, De Quincey wandered the streets of the West End, weak, a meagre existence while lodging in a nearby boarding house. A sleepless and almost delirious through lack of food. ‘When he was couple of months later he was penniless. Rather than let the boy 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 whose business in the empty rooms above the office. it was to keep up the tone of the neighbourhood. It was at this time 1

— Soho Downhill All the Way that he got to know some of the scores of prostitutes who had bound over to keep the peace after ‘threteninge to burne the houses already begun to frequent Soho and the parish of St Giles. In these at So:ho’. Anna’s presence was followed by that of high-class ‘sisters in calamity’ he found what he felt was missing from the more courtesans like Elizabeth Price, a resident of Frith Street, described prosperous echelons of society: ‘humanity, disinterested generosity, as ‘a Player and mistress to several persons’, and Elizabeth Flint, courage that would not falter in defence of the helpless, and fidelity ‘generally slut and drunkard; occasionally whore and thief’, who betraying’. that would have scorned to take bribes for had lived in ‘genteel lodgings’ in Meard Street in the 175oS, along Among these ‘female peripateticS’, as De Quincey called them, with her spinnet and a servant-boy ‘that walked before her chair’. was one who grew special to him — a destitute, timid and friendless Attitudes towards prostitution in the i7th and i8th centuries i5-year-old girl whom he called his ‘noble-minded Ann’. Night after were not governed by the hypocrisy which was to become endemic night they wandered the cold, inhospitable streets of the West End in Victorian society. Mistresses were openly acknowledged, and together. Then, De Quincey reported, prostitutes could operate freely where they chose to. It was even said in the i8th century that ‘their business One night when we were pacing slowly along Oxford-street, and is so far from being considered as unlawful, that the list of those after a day in which I had felt more than usually ill and faint, who are in any way eminent in this profession is publicly cried I requested her to turn off with me into Sohosquare: thither we about the streets: the list, which is very numerous, points went; and we sat down on the steps of a house, which, to this hour, out their places of abode, and gives . . . the several qualifications for which I never pass without a pang of grief, and an inner act of hommage to they are remarkable. A new one is published every year, and sold the spirit of that unhappy girl, in memory of the noble action which under the piazza of Covent garden, with the title of The she there performed. Suddenly, as we sat, I grew much worse: I had New Atlantis.’ The licentious goings-on at Carlisle been leaning my head against her bosom; and all at once I sank from House were legendary. And, by the late 1770s, its neighbour, the her arms and fell backwards on the steps. From the sensations I then old Spanish Embassy, had become a notorious high-class brothel, had, I felt an inner conviction of the liveliest kind that without some known both as The White House or Hooper’s Hotel, powerful and reviving stimulus, I should either have died on the after its proprietor, Thomas Hooper. exhaustion from The wealthy and noble-born Londoners who frequented Hooper’s spot — or should at least have sunk to a point of included ‘Old the Duke which all re-ascent under my friendless circumstances would soon Q’, of Queensberry, and George, Prince of Wales. Clients entered the building have become hopeless. Then it was, at this crisis of my fate, that discreetly through a side door in Sutton Street, and each room inside was named and decorated my poor orphan companion — who had herself met with little but in a different style. There was a Silver, a Gold and a Bronze room, injuries in this world — stretched out a saving hand to me. Uttering each inlaid with mirrors in appropriate a cry of terror, but without a moment’s delay, she ran off into colours; a Painted Chamber; a Grotto; and a Skeleton Oxford-street, and in less time than could be imagined, returned to Room, where a mechanical skeleton leaped out of a closet. Since the brothel me with a glass of port wine and spices, that acted upon my empty later got a mention in a book called The Mysteries of Flagellation, stomach, (which at that time would have rejected all solid food) with it seems that all sorts of sexual tastcs were catered for in these theme rooms. an instantaneous power of restoration: and for this glass the generous The mind boggles as to what went on in The Coal Hole. girl without a murmur paid out of her own humble purse at a time By the time I)e Quincey befriended Ann, the fun and games had — wherewithal to — be it remembered! when she had scarcely the gone out of commercial purchase the bare necessaries of life, and when she could have no sex. Prostitution was no longer a respected profession by which women reason to expect that I should ever be able to reimburse her. could earn money and position, but a matter of dire necessity for thousands of destitute young girls and Prostitutes were well-known in Soho. One of its earliest residents women with no other means of support. Over the weeks he knew had been ‘a lewd woman’ named Anna Clerke, who in 1641 was 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 confined to a ‘brutal ruffian’. Her desperate story of victimization was by no in their many days together Houses . . by rain . The means atypical. There was no one she could turn to for help. ‘The Balustrades over the Colonnades will form Balconies to the stream of London charity,’ De Quincey reflected, ‘flows in a channel Lodging-rooms over the Shops, which the occupiers of from which, though deep and mighty, is yet noiseless and underground; the Lodgings can see and converse those passing in the carriages with 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 a huge drift of country people to the metropolis. Cut off from their complained that their premises were dark, nor the customers: The Quadrant, rural roots, and untrained in the traditional skills of London’s Leigh Hunt wrote in 86x in his Saunter Through the West 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 “sweep” so much boasted of, is not sufficiently long or wide 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 use the south is to screen people from Bloomsbury, and St Giles-in-the-Fields clubbed together to buy the have not the sun: but here we enough sun to render them necessary lease of 76 Dean Street, in the year i8oo, in order to house children Though on that account.’ Nash may not have made the Street from their workhouses there, the parishioners of St Anne’s objected, architectural an overwhelming success, the creation of Regent pointing out that the house might become ‘a common receptacle for at Piccadilly Street and a circus gave Soho a definite and your promiscuous poor’. the west, important boundary in so helping it to keep its village The increasingly stark division between posh Mayfair and poor the individuality atmosphere long after of other central London areas Soho was recognized by architect John Nash in his plans for a created a social had gone. It also division in an area where rich and new road to link Marylebone Park with Canton House, the Prince then, lived cheek poor had, up till by jowl3 separating the so-called Regent’s home. Nash saw Regent Street as providing ‘a complete of Mayfair from good, rich area decaying Soho, which was from separation between the Streets occupied by the Nobility and Gentry, to run down. then on allowed 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 thousands of poor, semi or unskilled labourers moved into cleanly through the parish of St James, roughly following the line hotels the cheap lodginghouses and tenements that now spread of the ancient trackway now called Swallow Strcet and once called across Soho streets like a fungus. Slum clearances in the parish 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 penniless residents. And the Revolution and the Irish potato by the higher classes and to leave out to the east all the bad streets, influxes famine both led to large of poor immigrants from overseas. and as a sailor would express himself, to hug all the avenues that After the potato blight of 1845 and went to good streets.’ Irish ‘846, nearly two million people left their country to seek At the south end of the new thoroughfare was to be a curved a better life overseas. The vast majority braved the arduous voyage colonnaded walkway called The Quadrant, designed by Nash to to America; but the shorter and cheaper trip to England was an be a fashionable shopping centre where ‘those who have nothing easier option, especially for families with young children. In 1841, the to do but walk about and amuse themselves may do so every day in Irish community in London had stood at a low 75,000. By i8i, the number of Irish had more than Soho Downhill All the Way Like St Giles, Soho was becoming one doubled. io years later, the figure had risen to 178,000. Mostly of the most densely populated areas in London. It was to remain agricultural labourers who had never visited a city before, they now that way for the next 6o years. The old decaying houses groaned under found themselves completely out of their element in what was an the weight of their numerous residents. In Nicholas Nickleby, alien and inhospitable world. There were two main areas of the West Dickens caught their atmosphere perfectly: End where the Irish poor congregated: around the slaughterhouses of the Newport Market district; and in the nearby Rookery, a In that quarter of London in which notorious slum on Soho’s doorstep, in the parish of St Giles. Golden Square is situated, there is a bygone, faded, tumble-down street, with two irregular rows of tall meagre houses, which seem St Giles [wrote 2.4-year-old Frederick Engels in The Condition of to have stared each other out of countenance years ago. The very the Working Class in England (1844)] ‘is in the midst of the most chimneys appear to have grown dismal and melancholy, populous part of town, surrounded by broad, splendid avenues in from having had nothing better to look at than the chimneys over the which the gay world of London idles about, in the immediate neigh way. Their tops are battered, and broken, and blackened with bourhood of Oxford Street, Regent Street, of Trafalgar Square and smoke; and, here and there, some taller stack than the rest, inclining the Strand. It is a disorderly collection of tall, three or four-storied heavily to one side and toppling over the roof, seems to meditate taking houses, with narrow crooked, filthy streets, in which there is quite revenge for half a century’s neglect by crushing the inhabitants of . as much life as in the great thoroughfares of the town, except that, the garrets beneath To judge from the size of here, people of the working-class only are to be seen. A vegetable the houses, they have been, at one time, tenanted by market is held in the street, baskets with vegetables and fruits, persons of better condition than their present occupants; but they are naturally all bad and hardly fit to use, obstruct the sidewalk still now let off, by the week, in floors or rooms, and every door further, and from these, as well as from the fish-dealers’ stalls, has almost as many plates or bell-handles as there are apartments arises a horrible smell. The houses are occupied from cellar to within. The windows are, for the same reason, sufficiently diversified garret, filthy within and without, and their appearance is such in appearance, being ornamented with every variety of common that no human being could possibly wish to live in them. But all blind and curtain that can easily be imagined; while every doorway is this is nothing in comparison with the dwellings in the narrow blocked up, and rendered nearly impassable, by a motley courts and alleys between the streets, entered by covered passages collection of children and porter pots of all sizes, from the baby in between the houses, in which the filth and tottering ruin surpass all arms and the half-pint pot, to the full-grown girl and 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 doors of old boards nailed together, or altogether wanting in this conditions in parts of Soho soon matched those in the more thieves’ quarter, where no doors arc needed, there being nothing notorious East End slums, as report after report testifies. In Ragged London, to steal. Heaps of garbage and ashes lie in all directions, and the published in i86i, John Hollingshead gave an unforgettable foul liquids emptied before the doors gather in stinking pools. Here picture of life in one of the crumbling Soho mansions: live the poorest of the poor, the worst paid workers with thieves Every room is and the victims of prostitution indiscriminately huddled together, crowded with a different family, and four, if not more, landlords are interested in . . the majority Irish, or of Irish extraction, and those who have the rent . Dwellings that originally sheltered eight not yet sunk in the whirlpool of moral ruin which surrounds or ten persons are now crowded with thirty, forty, or fifty them, sinking daily deeper, losing daily more and more of their inmates. The carved wainscotings are torn to pieces, or covered, an inch deep, power to resist the demoralizing influence of want, filth, and evil with black grease. The old banisters are

broken down. The stairs are rugged, . . surroundings. dark, and uneven . one of 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 of furniture and in a horrible state of uncleanliness, and a large the rubbish,’ and 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 starved children, clothed more with nakedness than with rags. So the idea of destitution of the monster city than all the findings slept in that room!’ and reports ten human beings existed and 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 slums were Guy Pearce, a member of the West London Mission, describing cooped up the animals on which the local inhabitants and tradesmen his visit to one Soho tenement: ‘A space 3ft by 4ft was filled with depended. Dickens writes of ‘dingy, ill-plumed, drowsy’ hens hop furniture, and in a recess was the bed. On it lay a poor girl of ping ‘from stone to stone, in forlorn search of 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 Downhill All the Way which had never been drained. It was only a matter of time before passed from victim to victim through sewage-tainted water; and this hidden festering time-bomb exploded. It finally did so in the he had traced a recent outbreak in South London to contaminated summer of 1854. water supplied by the Vauxhall Water Company — a theory that the authorities and the water company itself were, not surprisingly, When a wave of Asiatic cholera first hit England in late 1831, it reluctant to believe. Now he saw his chance to prove his theories was thought to be spread by ‘miasma in the atmosphere’. By the once and for all, by linking the Soho outbreak to a single source time of the Soho outbreak 2.3 years later, medical knowledge about of polluted water. the disease had barely changed, though one man, Dr John Snow, a From day one he patrolled the district, interviewing the families surgeon and pioneer of the science of epidemiology, had recently of the victims. His research led him to a pump on the corner of published a report speculating that it was spread by contaminated Broad Street and Cambridge Street, at the epicentre of the epidemic. 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 place within a short distance of the pump.’ In fact, in houses much

— 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 five victims had always drunk the water from the Broad Street pump, industrial cities, leaving tens of thousands dead in its wake. The and three were schoolchildren who had probably drunk from the year 1853 saw outbreaks in Newcastle and Gateshead as well as in pump on their way to school. London, where a total of 10,675 people died of the disease. In the Dr Snow took a sample of water from the pump, and, on 1854 London epidemic the worst-hit areas at first were Southwark examining it under a microscope, found that it contained ‘white, and Lambeth. Soho suffered only a few, seemingly isolated, cases flocculent particles’. By 7 September, he was convinced that these in late August. Then, on the night of the 31st, what Dr Snow later were the source of infection, and he took his findings to the Board called ‘the most terrible outbreak of cholera which ever occurred of Guardians of St James’s Parish, in whose parish the pump fell. in the kingdom’ broke out. Though they were reluctant to believe him, they agreed to remove It was as violent as it was sudden. During the next three days, the pump handle as an experiment. When they did so, the spread 127 people living in or around Broad Street died. Few families, of cholera dramatically stopped. rich or poor, were spared the loss of at least one member. Within At the end of September the outbreak was all but over, with the a week, three-quarters of the residents had fled from their homes, death toll standing at 6i6 Sohoites. But Snow’s theories were yet to leaving their shops shuttered, their houses locked and the streets be proved. There were several unexplained deaths from cholera that deserted. Only those who could not afford to leave remained there. did not at first appear to be linked to the Broad Street pump water It was like the Great Plague all over again. — notably, a widow living in West End, Hampstead, who had died By 10 September, the number of fatal attacks had reached 500 of cholera on z September, and her niece, who lived in Islington, and the death rate of the St Anne’s, Berwick Street and Golden who had succumbed with the same symptoms the following day. Square subdivisions of the parish had risen to TZ.8 per cent more Since neither of these women had been near Soho for a long time, than double that for the rest of London. That it did not rise even Dr Snow rode up to Hampstead to interview the widow’s son. He higher was thanks only to Dr John Snow. discovered from him that the widow had once lived in Broad Street, Snow lived in Frith Street, so his local contacts made him ideally and that she had liked the taste of the well-water there so much placed to monitor the epidemic which had broken out on his that she had sent her servant down to Soho every day to bring back doorstep. His previous rescarches had convinced him that cholera, a large bottle of it for her by cart. The last bottle of water — which ‘always commences with disturbances of her niece — which, as he had noted, had also drunk from had been fetched on 31 August, the functions of the alimentary canal’, was spread by a poison 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 . . . The overcrowding of the cholera to the Broad Street pump. For instance, appears to of the 530 . . increase .‘ The Builder went on to inmates of the Poland Street workhouse, which recommend ‘the immediate was only round the abandonment and clearing away of corner, only five people had contracted all cesspools — not the disguise cholera; but no one from 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 well. Among the 70 workers in to remain a dangerous a Broad Street brewery, where the 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 of Soho — danger died after dining in Wardour ous ideas. The place had been Street, where a magnet for dissidents since 1683, he too had drunk a glass of water from the Broad when Algernon Sidney, Lord Leicester’s second son, was executed Street well. for his part in the Rye House plot. As Lord Mayor Beckford Still no one believed Snow. A report by the Board of Health a demonstrated had so eloquently in front of George III, Sohoites few months later dismissed his ‘suggestions’ that ‘the real cause never were afraid to speak their mind. Even today, ask a of whatever was peculiar in the case lay in the general use of Sohoite his or one her opinion of a film, or the price of potatoes, particular well, situate [sic] at Broad Street in the middle of or the future of the their neighbourhood and they will tell you district, straight out — in fact, and having (it was imagined) its waters contaminated by they will probably tell you what they think whether you the rice-water evacuations of cholera patients. After careful inquiry,’ to or not. ask them the report concluded, ‘we see no reason to adopt this belief.’ Field-Marshal MP Henry Seymour Conway, who, like Beckford, So what had caused the cholera outbreak? The Reverend Henry had lived in Soho Square during the 176os, had been a Whitehead, vicar of St Luke’s church, Berwick Street, believed that of champion the free press. When John Wilkes was arrested for it had been caused by divine intervention, and he undertook his own attacking Lord Bute in the newspaper The North Briton, Conway report on the epidemic in order to prove his point. However, had argued tooth his and nail against the general warrant to findings merely confirmed what Snow had claimed, search for and question every a fact that he writer, publisher and printer connected was honest enough to own up to. Furthermore, with the case. Eventually Whitehead helped he had swung the House of Snow to isolate a single probable Commons over to his opinion, and cause of the whole infection: just the general warrant had been before the Soho epidemic had declared illegal — an action that had occurred, a child living at number resulted in “(1ilkes’s release. 40 Broad Street had been taken ill with cholera symptoms, and its In 1837 number nappies had been steeped 25 Soho Square was leased by Thomas Barnes, in water which was subsequently tipped the editor of The Times, into a leaking cesspool who had already made his own contribution situated only three feet from the Broad to press freedom by Street well. supporting his old school friend Leigh Hunt after he was arrested for Whitehead’s findings libelling the Prince Regent in his radical were published in The Builder a year later, weekly, The Examiner, along with in March 1872. It is not clear whether a report on living conditions in Soho, undertaken by the Prince objected the magazine more strongly to the charge that he was itself. They found that no improvements at all had been of his ‘a violator word, a libertine over head and ears in disgrace, made during the intervening year. ‘Even in Broad-street it would of domestic a despiser ties, the companion of gamblers and demi-reps, appear that little has since been done. . . a man In St Anne’s-Place, and St who has just closed half a century Anne’s-Court, the without one single claim on the open cesspools are still to be seen; in the court, so gratitude of his country or the respect of posterity!’ or to being far as we could learn, no change has been made; so that here, in spite called a ‘corpulent man of fifty’. Whichever, Leigh Hunt of the late numerous deaths, we have all the materials for a fresh brother and his John, who were joint proprietors of The Examiner, epidemic . . . In some [houses] the water-butts were in deep cellars, both imprisoned were for two years and fined £zoo each for publishing Soho I Downhill All the Way the article. As well as visiting the Hunts in prison, Barnes kept The sedition and anti-monarchy was preached and sung about at the Examiner going in their absence, with the help of friends Charles Spencean tavern clubs, where a favourite toast was ‘May the last of Lamb and William Hazlitt. the kings be strangled with the guts of the last of the priests.’ Natu were Although Beckford, Conway and Barnes staunch supporters rally, these goings-on attracted the attention of the government, who revolutionaries modern of democracy, they were hardly in the sense sent in spies to see what was happening and concluded, in a House of of the word. Probably the first real one of those to live in Soho was Lords report of June 1817, that ‘the minds of those who attend their prominent figures Jean-Paul Marat, one of the most in the French meetings are tainted and depraved; they are taught contempt for all Disappointingly, however, Marat, who lodged 31 Revolution. at Decency, Law, all Religion and Morality, and are thus prepared for 1776, more interested Romilly Street in was at that time far in the most atrocious scenes of outrage and violence.’ That same year his work as an oculist than in spreading dissident ideas. The only both Evans and his son were arrested on charges of high treason, known produced Soho were pamphlets he is to have while living in and until their release the following January, Evans’s wife Janet, an An Enquiry Into the Nature, Cause, and Cure of a Singular Disease activist in her own right, was left to run the organization and keep of the Eye and an Essay on Gleets. the family business going. spring of i8ii, when Shelley was sent down from Oxford, By the Early in i8i8 the Spenceans moved from the Cock tavern to unconventional free-thinking Soho was the natural place for an and Archer Street, where they established a more serious ‘chapel’, i9-year-old to graduate to. Shelley may well have been attracted to calling themselves Christian Philanthropists. Here Evans preached existence of radical debating society which met the area by the a at with a sailor and tailor named Robert Wedderburn, whose ‘fero Cock tavern in Grafton Street (in the part of the Newport Market the cious rhetoric’ and ‘horridly blasphemous’ language caused such a district demolished in the late i9th century to make way for the split in the Spenceans that Wedderburn decamped to the corner of Road). The founder of this informal club of political Charing Cross Brewer Street and Hopkins Street, taking the seats and a good part free-thinkers, republicans and subversives was a land-reformer and of the congregation with him.

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 reached by ladder — Wedderburn continued to preach revolution to 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 congregation in the use of weapons, and even assembled a cache of fanatic called Thomas Evans. pikes, the armed insurrection that he had planned to take place in leadership Evans, braces-maker Under the of a from the Strand November 1919 was a wash-out. That same month the Hopkins and a one-time resident of Frith Street, the Society of Spencean Street chapel broke up for good.

Philanthropists — as it was now known — flourished. Meetings were Karl Marx, that most famous of revolutionaries, arrived in Eng Grafton held twice weekly in Soho: at the Cock in Street and at the land on 2.4 August 1849, having been expelled from the Continent, Nag’s Head in Carnaby Market; and there were meetings in the but leaving behind him his three children and his pregnant wife Borough and in Moorfields as well. Speakers came from all over the Jenny. After a few weeks his family joined him, and they moved country to talk to the members of London’s radical underworld who from a small furnished room off Leicester Square to a flat in congregated at these meetings, and anyone who arrived looking too Chelsea, where their sickly son, Heinrich, was born amidst the smart was accused of being a government informer and thrown out. uproar of Guy Fawkes night. The debates were certainly not dry affairs. In fact, they were more Before long, their Chelsea landlady took a dislike to them, and like drunken and very ribald entertainments, and were perhaps the the Marx family moved into the German Hotel in Leicester Street, forerunners of today’s alternative comedy revues. one of a number of guest-houses that had opened in Soho to cater A heady blend of anti-clerical blasphemy, crudeness, violent 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 great by the British government. Romantic as it would be to think that 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 of the cheap. woman’s sewing things, next to it a few teacups with broken rims, Before long the proprietor of the hotel, who at first gave them dirty spoons, knives, forks, candlesticks, inkpot, glasses, dutch clay ‘a humane reception for £5 lOS a week’, had had enough of Jenny, pipes, tobacco-ash, in a word all kinds of trash, and everything on Karl and their children, and they were forced to move yet again. one table; a junk-dealer would be ashamed of it. When you enter Eventually they found a more permanent home in the house of a the Marx flat your sight is dimmed by tobacco and coal smoke Jewish lace-dealer at number 64 Dean Street, where their fellow so that you grope around at first as if you were in a cave, until revolutionary, Heinrich Bauer, had taken rooms. your cyes get used to these fumes and, as in a fog, you gradually Being the wife of a penniless revolutionary was no laughing notice a few objects. Everything is dirty, everything covered with matter. While Karl plotted regicide, collaborated with Engels on dust; it is dangerous to sit down. Here is a chair with only three the final numbers of the Neue Rheinische Zeitung, and prepared a legs, there the children play kitchen on another chair that happens course of lectures which he gave in a room above the Red Lion pub to — be whole; true it is offered to the visitor, but the children’s in Great Windmill Street, Jenny and her mother’s ex-maid, Lenchen, kitchen is not removed; if you sit on it you risk a pair of trousers. who lived with them, struggled to keep the children alive. Jenny also But nothing of this embarrasses Marx or his wife in the least; you had to put up — and put up with — visiting Party comrades, who are received in the friendliest manner, are cordially offered a expected to be accommodated in the tiny flat. 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 reconciled better things, and their hand-to-mouth existence wore her down. because of the company, find it interesting, even original. This is the When in the summer of i85o — and pregnant again — she travelled faithful portrait of the family life of the communist leader Marx. to Holland to beg help from Karl’s uncle, the man barely recognized her, and she came home, as she wrote, ‘empty-handed, disappointed, This written portrait might have been faithful, but Karl certainly torn apart and tortured by a fear of death’. On her return, she found was not. When Jenny was in Holland, he had an affair with her son Foxchën dying of pneumonia — he was to be the first of Lenchen, and there were now two pregnant women in the tiny three children she would lose in Dean Street. flat. Karl’s hints that his friend Engels was the putative father did At the beginning of i8i, Marx, Jenny, Lenchen and the four not convince Jenny, and though she had to accept the situation out children moved down the road to a two-roomed attic flat in number 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 articles teacher. The rooms, which had no lavatory or running water, cost for the New York Tribune, and the postal orders sent to them by Marx £zz a year. A Prussian agent who visited them there reported Engels, who had taken a job in his father’s Manchester factory. that they lived They were so poor that when their daughter Franziska died in April i8z, Jenny was forced to beg from ‘a French fugitive who in one of the worst, and hence the cheapest quarters of London. lives near us. He received me with friendliness and sympathy and He has two rooms, the one with the view of the street being the gave me two pounds and with that money the coffin in which my drawing-room, behind it the bedroom. There is not one piece of 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 Downhill All the Way 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 workshops, hungry immigrants, a Soho where wooden partition was at his wits’ end. He wrote to Engels that summer: walls are encrusted with 250 years’ worth of cheap paint. To enter the door on the left is to find oneself in Karl and My wife is ill, little Jenny is ill, Lenchen has a sort of nervous fever, Jenny Marx’s living-room. It is a bare room, thankfully devoid I cannot and could not call the doctor because I have no money for of unnecessary Marxiana, with a simple oval table, a narrow bed medicine. For 8-io days I have fed the family on bread and potatoes with an appropriately red cover, and one faded poster chronicling of which it is still questionable whether I can rustle up any today the life and times of Mr Marx. Through another door, at the back, I had put off until the beginning of September all the creditors is the second room, a little larger than a cupboard, but smaller than who, as you know, are only paid off in small sums. Now there is a a double divan. 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 Dean Street. But time stands strangely still in there. The two throw me out of the house. At least I would then be quit of the rooms are airless, and, despite the care that has been taken to sum of £22. But I can scarcely trust her to be so obliging. Also furnish them, neglect festers in the corners. And the dust, oh, the baker, milkman, the man with the tea, greengrocer, old butcher’s dust is finger-thick everywhere, much as it was on the day when bills. How can I get clear of all this hellish muck? the Prussian agent came to see how the world’s most dangerous revolutionary lived. 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 The Soho which the Marxes left behind them was a ‘festering sore’ Bloomsbury. But his family were not to escape their ‘evil, frightful of overcrowding, petty crime and prostitution. And its proximity rooms’ in Dean Street until Jenny received two small inheritances, to the smart districts of the West End made it much harder for the first from a Scottish uncle, the second from her mother, who the upper and middle classes to ignore than the equally run-down died in July 1855. Then, ‘with joyful heart’, they moved into a East End, which was tucked conveniently out of sight on the far small terraced house near Primrose Hill. “When we slept in our side of the City. Consequently, in the second half of the century, own beds for the first time,’ she wrote, ‘sat on our own chairs do-gooders and philanthropists moved in on Soho in force. Six and even had a parlour with second-hand furniture of a rococo hospitals were opened to help deal with local health problems, style, or rather bric-a-brac, then we really thought we were living as were a number of missionary organizations, including a soup in a magic castle . . .‘ kitchen in Leicester Square, and various temporary shelters for Since 1926, number z8 Dean Street has been part of Leoni’s Quo homeless men and women, such as the House of Charity, which Vadis restaurant. The elegant ground floor dining-room gives no opened in i 847 at number 9 Rose (later Manette) Street, and which hint of what once went on upstairs. Patrons who do not mind the five years later moved round the corner to Richard Beckford’s old climb can, if they wish, be escorted to see the Marxes’ old apartment. house, number i Greek Street, where it still is today. Anyone who has had a glass too much wine must be warned: as In 1884, the Soho Club and Home for Working Girls, another carpet gives way to lino, and the lino to bare boards on the steep, venerable Victorian institution, was started across the road from the narrow stairs, one can easily imagine one is climbing back in time. House of Charity by the Hon. Maude Stanley. The club, which was Dizzy from the altitude, the Marx pilgrim emerges in a small attic open every evening, organized classes in drawing, French, singing, hall with a sagging ceiling and doors the colour of Cornish cream, needlework, music, gymnastics and mathematics, as well as having each bearing the scar of a torn-off padlock. This is a Soho that has, a library, a canteen, a Penny Bank and a low-cost medical dispensary for the most part, long since disappeared: a Soho of rooms-for-rent, 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 who for between 3S 7S his missionary meddling and 6d a week could rent a bed in a dormitory with a keen appreciation or even a private of a pretty face’, as MP Henry Labouchere room, including the use of a sitting-room, gas fire said. Though a deeply and clean religious Christian, there is no doubt that bed linen. In addition, the advertisement advised that Gladstone deliberately ‘courted evil’, as he put it himself, by ‘Teachers or Students coming to London to pass Examinations can himself placing in a position of temptation where his will-power be Lodged at is. per night. Breakfast, Tea and Supper z’/1d each, It was might fail. as if every encounter with a prostitute was a test Dinner 6d.’ faith. of his own The Soho Club had originally started in three rooms in Por In 1853 the Chancellor of the Exchequer’s ter Street, Newport Market, then at the centre of Soho’s very rescue work involved him in a notorious blackmail case. worst slums, where a refuge had been set up in the old market While walking through Long Acre on the night of 10 May, he was buildings. The Newport Market Refuge, as this was called, also approached by a woman and, after talking to her for some time, agreed provided training and meals for young boys. One of the most to accompany her to her lodgings in King Street, Soho. When distinguished members of its committee was they reached her house, a young the politician William man stepped out of the Ewart Gladstone. shadows, and told Gladstone that he had been following him. He then made one of the Gladstone’s ‘rescue work’ with prostitutes was well-known, at most bizarre blackmail demands of all times: he threatened to tell times notoriously so. Night after night, he walked by himself the world that Gladstone had picked up a prostitute, unless through the most dangerous areas of the West End, observing Gladstone either gave him some money or secured him a job with the Inland first-hand the street-life of prostitutes, of which there were estimated Revenue — a place most people would blackmail to get out of. Since to be about 8o,ooo working in the centre of town. Whenever he Gladstone had nothing to hide, he told the man to publish or could, he stopped and talked to them about their lives and if be damned, and the case subsequently came to court. The possible, he persuaded them to come home with him for would-be blackmailer, William the night. Wilson, a commercial traveller ‘What will your wife say if you bring this woman from Lambeth, was sentenced to home with you?’ a year’s hard labour. But his amazed Private Secretary the Chancellor, as charitable as ever, asked him on one occasion when the persuaded the Home two men were together. Secretary to release him after he had served ‘Why,’ Gladstone answered innocently, ‘it only six months. is to my wife that I am bringing her.’ Due partly to the Gladstones’ efforts, Back at the Gladstones’ house, William’s wife Catherine took the rescue work eventually became a respectable, not to mention girls in, gave them a meal peppered with lashings of good advice, popular, hobby for the leisured classes, though there were few people and found a bed for them to sleep in overnight. The next day, she who went so far as to invite ladies of the night into their homes. or William tried to secure them a place in one of the As the Contagious Diseases temporary Act of 1864 clearly demonstrated, shelters such as the House of St Barnabas, or the House of Victorian society operated a Mercy double standard which blamed at Clewer, near Windsor, which the Gladstones had also women entirely for the existence helped of prostitution and its accompanying to found. The girls were not always grateful to be whisked off the ills — namely, the spread of venereal disease. Yet the Gladstones were street: conditions in the shelters were often extremely depressing. As well aware that society was as much to blame for the existence one prostitute wrote to Gladstone after running away from Clewer, of the oldest profession as any ‘weakness’ in the girls. As Catherine ‘I did not fancy being shut up in such a place as that for perhaps Gladstone once wrote, it was ‘a common thing for [servants] 12. months. I should have committed suicide.’ to be engaged without wages or clothes and only for food every There were plenty of people who thought chatting up prosti other day. Who can wonder at girls so situated yielding to temptation tutes was, to say the least, a dubious pastime for a prominent and sin?’ Not every prostitute went on the member of the government. To make matters worse, Gladstone game of her 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 6 ‘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 Enterprise and Entertainment 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 Co-existing with the prostitution, crime and poverty were areas of without foundation, for when her case came to court, the judge respectability — even of wealth — like Soho Square, which remained let her off with a small fine, instead of imprisoning her as he ought relatively upmarket well into the i9th century, due partly to the to have done. continuing presence of the wealthy botanist Sir Joseph Banks and But despite the work of a few upper-class philanthropists, the his family at number 32.. social conditions of Soho did not improve during the rest of the Banks was a born Sohoite, if not a born-and-bred one: though century. In the early i88os the parish was still, in the words of one born in Argyll Street in 1743, he was educated at Harrow, Eton report, ‘a reeking home of filthy vice’, and the Newport Market and Christ Church College, Oxford — all establishments well-suited district in particular was said to be ‘a veritable focus of every danger to the education of a young member of the landed gentry. When his which can menace the health and social order of a city. The houses, father, William, died in 1761, i8-year-old Joseph inherited a large from their insanitary condition, are horribly disgusting, and can estate in Lincoinshire, and enough money to indulge the passion for only be fitly designated as well prepared propagating ground for the natural sciences that had developed when he was at school. 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 fellow Etonians that Banks first fell in love with nature. He had never mere children.’ been a scholarly child, but, as he walked alone down a country lane It was undoubtedly Soho’s darkest time. 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.