THE SOH0 CHOLERA EPIDEMIC 1854 by Mr. W. R. Winterton

Cholera IS an infection which has been endemic in many parts of the world for centuries. In India there is a statue of the time of Alexanderthe Great of a cholera vict~mbut the flrst appearance of the infection in the British Isles is comparatively recent, only 150 years ago. Cholera was thought to be caused by emanations from foul drains and that spread by contagion did not occur. Consequently it was not understood how it was conveyed from one major town to another which were only connected by roads. The traders who travelled these roads were not considered possible carriers.

There have been four major out- hospitals refused, sheltering behind continued and there were deaths breaks of cholera in this country.' their laws. throughout the first six months of 1831 - 1833; 1848 - 1849; 1953 - The Royal Free Hospital on the 1854, but during the summer the death 1854 and 1866. There has been none other hand opened its doors for the rate rose until at the end of August and since. The first diagnosed case of first time in order to help with this beginning of September the numbers: cholera was in Sunderland in February epidemic. This hospital began in 1828 reached a dramatic peak. In October 1831. This originated from an as a dispensary on the ground floor of and November the numbers fell until epidemic in Bengal which had spread a four story building at 16 Greville in December they dropped to zero. overland through Russia to West Street, Hatton Garden, and was called Diarrhoea and cholera are referred Europe and was brought to England the General Institution for the to as separate diagnoses, with the by seamen from Hamburg. From Gratuitous Cure of Malignant former sometimes progressing to the Sunderland it eventually spread to Diseases. In 1832 the tenants of the latter. Without bacteriological assist- London in 1832. It died down during upper floors at Greville Street were ance an exact differentiationis imposs- the winter of that year to reappear in given notice to quit and the cholera iible. The definitions used at the time the summer of 1833. Naturally it sufferers became the first in-patients.2 and in the Board of Health report are caused great distress and panic and A point of particular interest is that as follows. there was an interesting number of William Stevens treated these cases Diarrhoea theories as to how it arose. Since there by the administration orally and intra- Simple: Stools faecal. No was more overcrowding in the poorer venously of up to four pints of ~aline.~ vomiting, no cramps. parts of towns the incidence of infec- The Royal Free Hospital claims to Choleraeic: Watery stools, but tion was greater there and this lead to have treated in this 1832 epidemic tinged with bile. Vomiting, no the suggestion that the rich were 566 patients with only 135 deaths. cramps. deliberately poisoning the poor. The Stevens' treatment was much in cholera Christian Observer put the epidemic advance of the accepted treatment Rice water stools, colourless. down to the prevalence of infidelity even in the 1854 outbreak. Cramps. No urine passed. and profaneness, while The Presby- By some miracle cholera did not Temperature lowered. Poor terian Coventor felt th% it was a appear again until 1848 - 1849 and by pulse. visitation of God upon England for this time London was to some extent . ', In London generally the 1849 having granted Catholic Emancipation prepared. Treatment mainly consisted outbreak was more severe than that of in 1829! of purging and emetics, in order to 1854 apart from the Golden Square - This was some years before the eliminate the poisons, astringents and area of . The study of bacteriology and nearly fifty alteratives (calomel). Records of this total deaths in 1849 being 14,600, or years before Koch discovered the outbreak are more complete. It was 6.2 per 1,000 living, whereas in 1854 vibrio-cholerae in 1883. Records at the most widespread of the four, partly the death rate was 11,000 or 4.5 per this time were poor; the official due to the freer movement of people 1,000. registration of deaths did not begin as a result of improved transport. The report of the Committee for until 1837. During the summer of 1853 there Scientific Eaquiries set up by the In London the infection spread had been some diarrhoea and in July General Board of Health4 investigated along the banks of the Thames which the reports state that the diarrhoea as the epidemic in relation to density of included the lower parts of well as the common form of cholera population, Elevation, Atmospheric Westminster. The Department of became serious and some deaths were Influences and Water Supply, both Health took some steps to deal with recorded, and beside the river a few the chemical content and microspic the outbreak and asked the hospitals, deaths from cholera of the Asiatic form content.- including The Middlesex Hospital, to were registered. In the autumn the There had been a lower incidence admit cases of cholera but most of the number of cases fell but the diarrhoea ofcholera in the St. James' area in the CHOLERA

183 1 and 1848 epidemics than in was considerably older. Untrapped to this the corridors and stairs of some many areas of London, 1.3 and 1.6 gullies drained into all the sewers and houses were occupied at night by per 1,000, and it was regarded as a there were open ventilating grills. those of no fixed abode, with healthy place, probably because it was Most of the houses had privies in the insanitary consequences. The inhab about 60 feet above Trinity High basement yard, some were in the front itants of the attics emptied everything Water, although other conditions were area and a few were in the house. on to the roof so that the gutters not so good. When therefore the exple Many of these were untrapped and became secondary cesspools. sion of cases of cholera occurred there opened straight into cesspools. Every The district was also considered on the night of 3 1st August and I st house had a cesspool which was rarely bad from the point of view of ventila- , September, greater than anywhere emptied and it was only the overflow tion because the streets were shon else in London, some explanation had from them which drained into the and shut in so there was poor to be found. sewers. These cesspools should have aeration. Apart from the smells from The Golden Square and Berwick been filled in when the sewers were the drains, there were also outside ' Street Subdistricts of St. James' connected but that had not been done. nuisances. There were eight butchers, Westminster with which this paper is Many of the cesspool walls were of every one of which had his own mainly concerned had been fashion- rotten bricks and leaked. The rarity of abbatoir and his own cattle shed. As I able in the early 18th century but had water closets and the small small well as these individual butchers there I become much decayed by the mid- volume of water meant that there was was one very large wholesale abbatoir. I 19th century. The houses were still very little flow to flush the sewers Much of the blood of the animals went considered of a good standard and while in addition the fall was only 1 in into the cesspools where it went bad were highly rated, but the over- 250: as a result the sewers became while the intestines were left outside i crowding was great. In Broad Street silted up. and supposed to be collected each ' the average number of inhabitants per Following a doctor's complaint evening by contract. There was also a 1 house was 18. The St. James' district of the smell outside his surgery the tripe house, a bone boiling house and covered 164 acres with a population sewer was opened up. A six inch brewery, all very smelly affairs. At ! of 36,000. This was divided into three channel carrying a trickle was found 38 Broad Street was a percussion cap subdistricts, St. James' Square, running through the silt of which 200 factory owned by Mr. Eley. Berwick Street and Golden Square. loads were taken away from a length The two last covered an area of 80 of a few yards. The sewers emptied Water Supply acres with a population of 25,000, a untreated into the Thames at the end The mains water was from two rate of 300 persons to the acre, one of of Northumberland Avenue and a sources, the New River Water Co, the highest in London at that time.= high tide would wash the sewage back and the Grand Junction Water Co. again. Many of the yards of the houses The New River brought its water from Sewer Systems were unpaved and most were filthy. Hertfordshire while the Grand There were three sewer systems Children frequently used the yards Junction took its water from the to serve the area, the last twoof which rather than the privies, which were Thames at Kew where it is tidal and were put in during the three years often without seats, only having a rail therefore polluted with sewage, before the 1854 outbreak. The third which was too high for them. Added although this water was by no means as heavily infected as some other supplies in London. The only attempt at purification consisted of no more than straining with wire mesh. In 1852 a law was brought in requiring filtration but the first proper filter beds did not come into use until 1856, two years after the epidemic. The rhains water was only turned on SODIUM CROMOGLYCATE B.P. for half to one hour a day and not at all on Sundays so it was a very precious i Helps asthmatics fluid which was collected in butts and cisterns in the basement yards; there lead normal active lives. being not enough pressure for it to be ~scr~blng11ifor1~1~31101i IS d\i~~l~hIo (311 I~(:LICSI fro~:i Ficri~L~mltpd Pharmdc~ut~dDI\~ISIOII, I? De\rh\, Radd Lo~~ghhoroogh delivered higher. The butts and cisterns were rarely cleaned and SO added to the pollution, although they did act as settling tanks. After the 1 History of Medicine MarchfApril 1980 i CHOLERA

earlier epidemic of 1848 - 1849, Dr. John Snow, of whom more later, canied out an investigation5of the water supply of South London. In that area there were two supplies, the Vauxhall and Southward Company, which took its water from Battersea, and the Lambeth Company which took its water by Hungerford Bridge, almost opposite the Northumberland Avenue sewage outfqll. The two companies were rivals and their mains ran along the same roads which made compari- sons easy. Snow's investigation showed that there was a significantly greater incidence of cholera among those who took their water from the Lambest Company, that is from Hungerford Bridge. In 1852 the Larnbeth Company moved their works fiom Hungerford Bridge to Thames Ditton, which is above the tidal part of the river and above the London output of sewage. In 1854 South London had 334 deaths from cholera. In those areas supplied by Vauxhall and Southwark there were 71.4 deaths per 10,000 houses while Lambeth had only 5.3 deaths per 10,000. That is, there were 14 cases of cholera among the houses supplied by the Southwark and Vauxhall Companies, taking water from Battersea, to every case FARAD-4Y GIVING EIIS CARD TO FATHER THAME! among the houses supplied by the Lambeth Company, taking its water And we hope the Dirty Fellow will consult the learned Rofeseor. from Thames Ditton above the tidal c,~~~~~from Punch part. This was a fine piece of invest- igation by Dr. Snow. In a letter to The Times, 7th July 1855, Professor Michael Faraday , wrote how he had dropped white cards into the Thames which became invisible when they reached adepth of one inch below the surface. lntal Compound" Even in recent times, A.P Herbert wrote of the Thames: Sweet efluent, dear Father Drain Helps asthmatics Whose generous bosom doth contain lead normal active lives. A lot of oil, a little rain rescr~bi~iglnformat~on 1s ava~iableon request from F~sonsL~m~ted. And all the muck Pharn~aceut~calD~v~sion, 12 Derby Road. Loughborough. Le~cestersh~re, of Middlesex. LEI1 OBB Reg~sterrdTrade Mark. CHOLERA

In 1853, a report on the 1849 did through North and South Wales, mouth. Added to this there were his epidemic was presented to the Royal calling on an uncle in Bath on the way. convincing investigations and College of Physicians by the disting- He studied at the Little Windmill comparisons of the two water supplies, uished authorities, Baly and G~ll.~Street School of Anatomy and did his Vauxhall and Southwark, taking in The authors quote Dr. Snow's theory clinical training at the Westminster polluted Thames water from the lower of spread by contamination of water Hospital. At this time he lived off reaches, and Lambeth from pure supply by evacuations but state that , in Bateman buildings. Thames Ditton water, with the figures "he gives no facts to prove that they He then went into general practice at of 71 cases of cholera in the former have the power he attributes to them 54 Frith Street, also off Soho Square, and 5 in the latter, per 10,000 houses. nor have we any evidence that they later moving to Sackville Street. He can excite the disease." became a vegetarian and remained so The Epidemic The other source of water was for eight years. When his health began The outbreak of cholera began in from wells, mostly shallow wells. The to fail, he then decided that it was July, 1853 in Southampton. An un- subsoil in the area is gravel and most inconsistent to be a vegetarian and usual number of cases of diarrhoea of the wells went through the gravel wear leather boots so he gave it up. He were admitted to The Middlesex but only as far as the clay, so that the was a rigid teetotaler and it is perhaps Hospital from surrounding districts, water in the well came from the gravel unfortunate that his best known with an occasional death. In London, above the clay. The important Broad memorial in the area is the John generally, there were 600 deaths in Street Well was thirty feet deep and Snow, Public House, in Broad Street. October and November 1853. It then the level of the water was only seven Dr. Snow is remembered for two settled down until July 1854, although to eight feet below the bottom of the entirely separate achievements. He diarrhoea persisted and so another cesspools. Since every house had a was a pioneer anaesthetist, beginning outbreak was expected. cesspool, often old with leaking walls, within a few weeks of the fmt reported One of the difficulties is a defin- it can readily be seen where much of anaesthetic which was given in Boston ition of cholera. In The Middlesex at the water reaching the wells came U.S.A. in October, 1846. He admin- this time there were four diagnoses from. istered anaesthetics to Queen Victoria madee; diarrhoea, which had a definite Dr. Snow was told by an engineer for the births of Prince Leopold and mortality; choloraeic diarrhoea; that a cesspool in clay had to be Princess Beatrice. Queen Victoria Anglican cholera and Asian or Malig- emptied every six to eight months, thought it was wonderful, but there was nant cholbra. There is no way of while one in gravel could go on for an outcry because the Bible says "in sorting these out so that the cases twenty years. That illustrated how pain shalt thou travail." labelled dlarrhoea have been omitted . porous the brick walls of the cesspool Snow's other great achievement - from the figures although the Medical were. In general the water from the was to prove that cholera was a water Council cdnsidered that these cases mains was used for making tea but for borne infection contrary to the then were niild cholera which had a thirst quenching the cool water from held view that it was airborne and mortality of 8%. the well was preferred. Those living therefore impossible to eradicate. During August 1854 there was on the Thames bank usually just filled He gave up his general practice increased infection in this area with their buckets straight from the river. in 1848 in order to investigate the an average of about seven deaths a This may seem to be an exaggeration spread of cholera. He argued that week, and then without any prelim- bit it is taken from official contem- since cholera began with diarrhoea inary build up came the explosion of porary reports. and vomiting the poison must be acting cases on the night of 3 1st August - on the alimentary canal by direct 1st September. At The Middlesex Dr John Snow (1813 - 1858) contact. Emanations on the other hand Hospital which had two hundred beds, Dr. John Snow was an interesting would first enter the lungs, then the a hundred and twenty cases were character.' The 'son of a Yorkshire blood stream before it could get to the admitted in three days; eighty per cent farmer he was born in 18 13 and died gut, in which case there would be of these cases were from St. James' in 1858 at the early age of 45. At general symptoms, temperature, rigors, Westminster, of whom two thirds died. fourteen he was apprenticed to a headache and rapid pulse. From his Others were admitted to University surgeon in Newcastle-upon-Tyne. own experience during the 183 1 out- College Hospital and Charing Cross During the 183 1 epidemic he break he knew that the miners worked Hospital and the Workhouse, but the was sent as an unqualified medical ten hours a day, brought their own majoti died at home. To read the assistant to some coal mines where he meals and had no opportunity to t descriptive notes of these noted the complete absence of any wash their hands and since there were patien a hundred and twenty-five attempt at sanitation or washing no sanitary arrangements there would years f1 ter, fills one with pity and facilities. In 1836 he decided to walk be every chance that faeces could be horror for the terrible sufferings that to London from Newcastle, which he on the hands and so conveyed to the must have occurred. Whole families, CHOLERA

or perhaps even worse, large parts of somewhat unwillingly as it was against particular, while using the mains water families, were wiped out. The death all the accepted theories, they removed for teamaking and washing. The rate in the two subdistricts was 21 per the handle of the pump on 8th Workhouse with 5 36 inmates had onlv 1000 - three times that of the rest of September. The result was not so five deaths apart from those broudt London. It was probably considerably dramatic as is often stated, as the out- in %already infected, but they higher than that as hundreds fled from break had already passed its peak. It had their own well. the area and deaths were registered in would, however, be unfair to detract In the brewery in Broad Street no the parish in which they died. For from the famous story, as later it one died, except the proprietor, though instance, those who died in The proved how right Snow's simple but no water was ever drunk. They also Middlesex Hospital were registered brilliant deductions were. Snow wrote had their own deep well. At the Eley as Marylebone and not Westminster. a report on his investigations in which percussion cap factory, 38 Broad The number of admissions to he pointed out that many of the inhabi- Street, which employed 200 people, The Middlesex Hospital fell after the tants preferred well water generally for 18 died. Their drinking water was first week to about seven a day and in drinking, and the Broad Street well in brought from the pump and stood the third week to three a day. This rapid falling off in numbers was partly due to the fact that three quarters of the inhabitants had left the district. Snow estimated that 200 died on 1st12nd September and over 500 from these two Soho subdistricts then and later. The Broad Street Pump Snow visited the place daily, taking water from the Broad Street pump on the 3rd September. At first it was clear, but on the fifth day there appeared "small white flocculent particles and the water smelt on standing." He had these particles examined microscopically - they were structureless and probably decayed organic material. The Broad Street pump had a reputation for particularly good water, better than the other seven pumps in the area and people came from some distance to get it. The fact that it was infected, as judged by the organic content and numbers of protozoa seen on microscopic examination, was confirmed the following year. The water was used in public houses, dining rooms and coffee shops and was sold in shops to mix with sherbet to make fizzy drinks. Snow considered that the well must be the source of trouble, having been infected by the evacuations of someone living nearby and that the well had later cleared itself. On the evening of September 7th Snow went to St. James Vestry and asked permission to give his Washing shirts in drinking water as victims taken to the cemetery He begged them to remove the handle of the pump. To their credit, though CHOLERA

stored in tubs. Snow also mentions a affected while among the non-drinkers ulated slaughtering and other offensive man from Brighton who came to visit it was only 20 to 279. Whitehead trades. There was some of the worst his brother in Poland Street. His showed that the greatest pollution overcrowding, but they asked why it brother was dead by the time he was on 3 1 st August and partial purif- should select particular foci for arrived, and he did not see the body, ication had occurred by 3rd extreme outbreaks. They had the Snow but he had a brandy and water. The September. This was followed by his and Whitehead reports before them water came from the pump, and most dramatic discovery. On 2nd and referred to Dr. Snow's theory of although he stayed only twenty September an infant of five months the well in Broad Street but reported minutes, he died 48 hours later. whose attack of cholera began on "we do not find it established that the Another case was Mrs. Eley, widow 28th August had died at 40 Broad water was more contaminated nor that of the percussion cap factory pre Street. The i~nportanccofthis rests on the inhabitants using the well were prietor, she livedin Hampstead where the fact that thshouse was the nearest particularly affected." Their only there was no cholera. She never went to the pump and the date of the onset, explanation was that "the trouble to Broad Street but liked the pump allowirlg 24 - 36 hours incubation depended on other organic impurities water and a bottle was brought to her n~atched the rnajur outbreak. The participated in the atmospheric on 3 1st August. She drank it that day mother of the dead child had washed infection of the district." and died of cholera on 2nd September. its napkins and emptied the pails into The following quotation taken A niece who was visiting her also drank the cesspool m front of the house and from the report gives the view of Dr. some, she returned to Islington, where this was less than three feet from the Hassall, one of the members of the there was no cholera, and she alsodled. well. Whitzhoube reported this to the Scientific Committee who carried out Mr. Gould, the famous ornith- Comrmttee who thereupon ordered the microscopic examination of the ologist, had been out of London and an inspection of the cesspool. This different waters. The examinations returned honle on 2nd Septenibel . He irispection showed that the brickwork were carried out at St. Thomas's sent for some of the well water and he was very decayed a~~dalso showed Hospital and the following extract was surprised to find that although it that there had undoubtedly been gives the views of the time: was clear it had an offensive srnell and seepage into the well. The child's "Many of the public believe so did not drink it. His servant however father contracted cholera on the 8th that everything we eat and drink did drink it and developed cholera, September. the day that the handle of teams with life, and that even but she was lucky, she recovered. the pump was removed. This man our bodies abound with minute There was a number of theories also d~edand could well have started living and parasitic productions. on the causation of the outbreakof the another outbreak if the handle had This is a vulgar error and the disease which were dismissed. One remained on the pump allowing the notion is as disgusting as it is was that putting in the new sewers a well water to be used. By this time erroneous." few rnonths pleviously had disturbed Whitehead had himself become a The St. James Vestry also held latent infection in the soil. The Broad strong supporter of Snow. an enquiry headed by Dr. Lancaster, Street sewer was put in in 1852. Whitehead interviewed those who three local doctors and Whitehead.l l Another theoiy was that the old plague had recovered, rzlations of the dead They had Snow's and Whitehead's , pit by had been dis- and those who never contracted the reports before them, both of which turbed. This however was outs~dethe disease. He showed overwhelmingly were included in the Committee's area. by statistics that the well water was to published findings. Unlike the Board An extremely important invest- blame. of Health Enquiry they accepted these igation was carried out in 1855 by the theories, perhaps not quite whole- Rev. Henry Whiteheade, the curate of Enquiries heartedly. Their recommendations St. Luke's Berwick Street, who was The members of the Council of show:- then aged 29 and had been appointed Enquiry set up by the Board of Health 1. That there should be flushing of the curate in 185 1. Snow had presented the year following the epidemic in sewers. h~mwith his book on his 1849 1855 reportedlo that they still could not 2. The wells should be closed and iiivestigations on cholera, but ur~derstaiid this sudden rise in the artesian wells dug. Whitehead was not convinced and incidence over the two days, 3 1st 3. Cisterns should be abolished. wrote to Snow and told him so. August and 1st September, although 4. There should be stand-pipes on Whitehead then set out on his own admitting that the sanitary conditions water mains. very searching enquiries prejudiced were appalling. The report states hat against Snow's hypotheses. However the atmosphere was offensive wih his figures showed that of those who effluvia from ill-conditioned sewers, drunk the wtiter from the Broad Street from defects of drainage and clean- pump a ratio of 80 to 57 had been liness in the houses and from unreg- continued on Page 20 CHOLERA

Hospital Care staff and students of The Middlesex the River Lee. As the epidemic began The Apothecary to The Hospital in what must have been a the St. James's Committee chose this Middlesex Hospital wrote a full report terrifying experience. He states time to replace the handle on the of the outbreak from the hospital point specifically that no one ran away. Broad Street pump. of view. He stated that he was most Large pans were put in each Whitehead moved to Carlisle in impressed by the devotion of the ward generating chlorine gas as a 1870 and to his dying day he had a nursing staff (at a time when nursing disinfectant and the windows were all picture of Snow on his desk. At his was not what it is today). He was also kept open. An interesting part of the farewell banquet before departing to impressed by the porters who had to preventative care for the nurses was the north he replied to his toast with a carry the patients to the wards, (there to send them by cab to the nearest three hour after-dinner speech were no lifts,) and the hundred or so piece of country for fresh air and describing his work in London. bodies back to the Dead House. recreation each day. Every resident in Conclusion Each patient was given a warm the hospital was given two chops and This is a fascinating but horrific bath by the nurse, rubbed over with three ounces of brandy extra daily. story of Dickensian London but it is mustard, and hot bottles were put Only one patient who was already an illustration of what two dedicated along the sides of the patient in bed. in the hospital when the epidemic and intelligent men, John Snow and Turpentine fomentations were put on began developed cholera and she Henry Whitehead, achieved by simple the abdomen and the limbs were recovered. One nurse died of cholera observation and without laboratory massaged to allay the terrible cramps, and another was affected but she help. Though official obstinacy existed such a feature of cholera. A purge and recovered. A laundry assistant also then as now, thanks to the work of an enema were given, frequent developed it and recovered. When these two men the whole attitude to brandies, constant changing of linen, one thinks of all the handling of sanitation and water supply eventually the giving of other medicines and the infected linen by nurses and laundry changed in this country. Unfortunately last attentions to the dying patients staff it is a remarkable achievement. there are still some parts of the world surrounded by lamenting relations. There was another outbreak of where 1854 conditions still exist. All this must have been a tremendous cholera in 1 866.j3 It was largely Finally to quote some down-te strain. It must be remembered that fhe confined to the East End of London earth Victorian practical sense from normal nursing complement was one and along the banks of the Thames. It Lord Palmerston. When asked by the sister and one~nurseto each ward of lasted for about 1 - I5 weeks and Presbyter of Edinburgh for a day of twenty beds by day and only one resulted in 7,000 deaths in London, a fasting and humiliation to check the nurse for some wards at night. (Other rate of 3.6 deaths per 1,000. Dr. progress of cholera, he replied: "Only wards had no nurse at night). Neither Snow was dead (he died of a stroke in when Edinburgh frees itself of the sisters nor nurses had received any 1858), but Henry Whitehead, still a gaseous exhalations arising from over- training. During this time of stress, curate, was asked to help. He showed crowded dwellings and undisposed with some difficulty, six to nine day that it was due to the East London filth would it be time to ask the nurses and eight to eleven night nurses Water Company of Lee Bridge Road Maker of the Universe to interfere." were hired to help. Among the extra using unfiltered polluted water from I nurses was Florence Nightingale who was then superintendant of a nursing References home in Harley Street. We know little of her experiences except a letter 1. Br~ggs,'Past and Present'. 1961 7. D N 8 and 8 W Richardson. Foreward to John Snow. 1858 quoted by Mrs. Ga~kell'~.Speaking 2. Royal Free Hosp~tal,Board M~nutes. 8. Middlesex Hospital. Board Minutes, cholera in The Middlesex Hospital. 20 February 1832. Dr Gilchr~st October 1854 she said;, "The prostitutes come in Personal Commun~cat~ons perpetually, poor creatures staggering 9. Henry Wh~teheadreport. 1835, to off their beats. It took them worse 3. W~ll~arnMarsen. 'Cholera 1848'. St James' Vestry (see Ref 11) 2nd Ed~t~on,London than any." This is probably Victorian 10. Repon of Medical Committee to Board of Health, 1856 sanctimonious rubbish. The notes of 4. Report of Medical Counc~lto Board the time suppiy no evidence for this of Health 1 1. St James' Vestry repon on Outbreak and Snow definitelv states that the of Cholera mortality appears to have fallen 5. John Snow, 'On Mode of Commun- ication of Cholera'. 2nd Edit~on 12. Elizabeth Haldane. 'Mrs Gaskell equally amongst all classes. Florence and Her Fr~ends', Hodder Nightingale also said, "three students b Stoughton 6 Baly and Gull. 'Epidem~cCholera'. came in smoking cigars, had one look report to Royal College of 13. Privy Council Report of Med Off, and went away," yet Dr. Sibley gave Physic~ans.1853 1866. Lancet great praise to every member of the