It went on to close with a wisp of faint praise:
Notwithstanding our opinion that Dr. Snow has failed in proving that cholera is communicated in the mode in which he supposes it to be, he deserves the thanks of the profession for endeavouring to solve the mystery.
Snow pored over the reviews, looking not for affirmation, but for a hint as to what it would take to convince his audience. The London Medical Gazette spelled it out:
The experimentum crucis would be, that the local water conveyed to a distant locality, where cholera had been hitherto unknown, produced the disease in all who used it, while those who did not use it escaped.
Even as he shot back at the London Medical Gazette with a letter correcting the errors in their review, John Snow had begun to search for a place where cholera and chance had performed an experimentum crucis.
Snow pored over any and every publication that described the impact of cholera on communities throughout the kingdom. He read through the voluminous reports of the registrar general that tabulated the deaths from cholera throughout the epidemic, searching for areas where cholera had either taken an extreme toll or hardly visited. In each case he paid particular attention to the water supply, searching for cholera’s path. Where the reports lacked detail, he sent letters to local physicians seeking their help.
Example after example poured into Snow’s small apartment on Firth Street in Soho. One report came from his hometown of York where a terrible outbreak had struck the narrow lanes along the River Ouse where he had spent his childhood. He could still remember watching neighbors draw their water from the river. The deaths from cholera in York, he learned, came to an abrupt halt when local health officials brought in water from far upstream and began anew when the importation of water stopped.
Snow made note of other towns where a change in water supply had accompanied a change in the death toll. Exeter, which had seen 345 cholera deaths in 1832 during the first epidemic, saw only 20 in 1849. Between the two outbreaks the town, which had been using a polluted millstream, built a new waterworks in cleaner waters far upstream. Hull, on the other hand, had seen a sixfold increase in cases after moving the water supply from small streams in the hills to the river flowing through the center of town.
As new reports came in, Snow assembled them into a paper that would give far more evidence to support his theory. Less than a month after the Lancet and the London Medical Gazette had printed dismissive reviews of his original monograph, he had presented his new findings to the Westminster Medical Society. At the time medical journals often carried the proceedings of medical society meetings. Two weeks later the London Medical Gazette published the first half of a two-part report by John Snow, “On the Propagation and Mode of Communication of Cholera.”
By the time the second half of the report appeared a month later, on November 23, cholera had lost its grip on the city. After a high of more than 1,532 deaths during the week of August 7, cholera mortality declined steadily through the fall. During the last week of November, only one Londoner died of cholera. It was to be the final death of the epidemic.
Even after its disappearance, John Snow continued his work on cholera, but at a less frenzied pace. Cholera had disappeared for fifteen years after the last epidemic. To all parties it seemed there would be plenty of time for a full examination of the evidence and a reasoned debate on the prevailing theories.
Everyone had something to say on the subject. In just one issue, the London Medical Gazette carried reviews of seventeen different monographs on the causes and treatment of cholera, together with the first half of Snow’s article, and four other articles on the disease. Only Snow pointed the finger at drinking water.
Snow hoped that the many official reports on the epidemic, all written with far greater resources than he could muster, would unearth additional evidence to help prove his theory. But he underestimated the ability of those threatened by the truth to weave armor from twisted facts and distorted logic.
Snow understood that he was laying siege to the entrenched beliefs of the medical establishment, but their opposition paled in comparison to the financial and political forces marshaled against him. If Snow were proven correct about the ability of drinking water to transmit disease, the anticompetitive cartel that allowed London’s water companies to enrich their stockholders with little attention to water quality might crumble. If his belief that cholera was contagious were true, quarantines would have their ultimate justification, a conclusion that put him squarely at odds with the vast economic interests that relied on international trade. Ironically the greatest source of opposition to Snow’s ideas came from politicians bent on protecting the public health. Snow’s ideas put him on a collision course with a group that came to be known as the sanitarians. At their head was a great bull of a man whom John Stuart Mill called the most effective politician of his time. His name was Edwin Chadwick, and his perspective before, during, and after England’s second cholera epidemic in 1848–1849 was far different from Dr. Snow’s.
3
ALL SMELL IS DISEASE
On a cool September morning in 1840, Edwin Chadwick descended the winding streets of Glasgow into one of the city’s most notorious slums. As he and his three colleagues snaked down from Argyll Street along the narrow alleys that lead toward the River Clyde, a world of decay closed in around them. More than one sixth of the cases in the fever hospitals of Glasgow during the past year had come from this single district. A local expert, Dr. Robert Cowan, was leading the four men on a search for the causes of this pestilence. As they approached the river, he turned and ducked through a low doorway. Chadwick followed, squeezing his burly frame through the opening, unprepared for what he would find.
The passageway opened onto a courtyard unlike any he had seen before. In its center rose a vast dunghill, the product of the destitute who crowded into the rooms around it. Relying on a strong stomach and an unrelenting will, Chadwick made his way along a narrow path that skirted the courtyard and passed through a second corridor on its far side. He walked through it and found, to his horror, a second courtyard, identical to the first with a second immense pile of human feces.
As Chadwick and his well-dressed entourage continued their tour, the denizens of this grim world, clothed in rags and tatters, crowded together for warmth, looked out at the intruders through hungry eyes. Unafraid to look this broken world in the face, Chadwick directed the men into one of the crumbling buildings. The desperate conditions inside the buildings matched the horrifying state of their courtyards. In one room, they found a group of women, huddling naked beneath a blanket. Their clothes, the men learned, were in use by their roommates. Without enough clothes for all the occupants of the room, the women took turns using what they had to venture out in the cold. The four well-dressed men had soon seen enough and returned to the courtyard.
The narrow path around the second courtyard led to a third passageway on its far side. Again Chadwick and his colleagues entered the portal and braced themselves as they navigated the dank, dirty tunnel. Chadwick emerged to find himself in a third courtyard with another dunghill at its center. As he gazed at this monument to human desperation, he must have felt that he had slipped from reality into a world sprung from the mind of Dante.
In the course of their tour, the men paused to ask the inhabitants why they allowed their own waste to accumulate in such an appalling manner. It was then that Chadwick learned that the vast piles of human excrement in every courtyard were not simply the product of sloth. The residents of the buildings that surrounded them had created the three mounds and retained them for a purpose. When the piles grew large enough, they summoned the night soil rakers of Glasgow who carted them away for sale to local farms as fertilizer. For this pile of their own manure, they received a pittance from the rakers, an amount they relied on to pay their rent.
As secretary of the Poor Law Commission, Chadwick was preparing a report on the living conditions of the nation’s working class. This netherworld
was only one of the kingdom’s many darkened corners that Chadwick visited in preparing his report, although he would recall it as the worst. Even before he began his tour, Chadwick was convinced that, as he put it, “All smell is disease.” Given the horrors he experienced in Glasgow and elsewhere, and the many similar reports he received from correspondents throughout Great Britain, one can forgive his unshakeable adherence to this belief. His intransigence however was to have disastrous consequences.
A strident utilitarian, Chadwick saw the diseases that afflicted the working class as a vast drag on the efficiency of the nation. Mortality rates, which had declined throughout the eighteenth century and into the early nineteenth century, were now rising. Between 1831 and 1841, they had risen fifty percent. The increase was worst in the rapidly growing urban areas.
The report grew out of an effort to address this crisis and no one could match Chadwick when it came to assembling government reports. He had put himself through law school by working as a journalist and could spin tales with relative ease. Back in his London office, Chadwick immediately set to work. Work was a reliable old friend. He would spend most of his life working ten-to twelve-hour days, rarely taking a day off. To prepare this report, Chadwick worked even longer hours, compiling stories to support his case.
Chadwick filled the 457-page Report on the Sanitary Conditions of the Labouring Population of Great Britain with example after example of the horrifying conditions of the country’s poor. He concluded that the diseases that afflicted them were propagated by “atmospheric impurities produced by decomposing animal and vegetable substances.” Odor was the problem and, Chadwick proposed, water was the solution.
According to Chadwick the disorganized and ineffective system of carting away the vast accumulation of dung and rotting garbage that was choking the towns and cities of the kingdom had to be replaced. With a steady supply of water, the cities of the kingdom could literally wash away their troubles. By his accounting a water-based system would cost less than half as much as the army of carts it would replace.
The water closet played a key role in Chadwick’s plan. This early version of the toilet had been available since its invention by Sir John Harrington in 1596. At the time the proud inventor had installed one in his house and one in the house of his godmother, the Queen of England. Even with this royal endorsement, it would spend almost three hundred years as little more than a curiosity. Harrington’s invention, it seems, had a flaw. It relied on water but, unless you were the queen, you were unlikely to be able to get rid of the water. If Chadwick wanted to enlist Harrington’s invention to help remove London’s waste, he had to solve this problem.
In our world of modern plumbing and sanitary sewers, the toilet’s magic is almost invisible as the water flows underground to far off sewage treatment plants. In the early nineteenth century however, landlocked cesspools could not tolerate a flushing toilet and any effort to connect them to a sewer could send the enterprising plumber to prison. Sewers were reserved for rainwater.
From the time Henry VIII passed the Bill of Sewers in 1535 until the early nineteenth century, sewers were intended to drain the streets. Putting sewage into them was unthinkable. The word sewage would not even exist until 1849. In 1842 London’s rainwater flowed through the sewers while the city literally sat on top of its wastewater—buried beneath London were more than 300,000 decaying cesspools.
Chadwick seemed to have an answer for everything and this was no exception. Under his master plan, household wastewater and the water from flushing water closets would flow directly into a new system of earthen pipes that would replace London’s existing sewers. Cesspools would be eliminated. Routine flushing of the new sewers with a steady supply of water would keep the neighborhoods free from “atmospheric impurities.”
Chadwick saw the answer in the sewers, but he still had to find a place to send all that dirty water. His long-term solution involved a system to carry the nutrient rich wastewater to outlying farmland for use as fertilizer. In the short term however, London would send a growing stream of raw sewage into the river that flowed through its very heart, the Thames.
Chadwick understood that sending thousands of tons of rotting waste into the Thames was not a perfect solution, but perfection would need to wait. In the short term, polluting a river that was already contaminated by the slop that ran off the city streets was a minor inconvenience compared to achieving his sanitary goals. As he put it:
The chief objection to the extension of this system is the pollution of the water of the river into which the sewers are discharged. Admitting the expediency of avoiding this pollution, it is nevertheless proved to be of almost inappreciable magnitude in comparison with the ill health occasioned by the constant retention of several hundred thousand accumulations of pollution in the most densely-peopled districts.
Chadwick’s ringing, dismissive phrase, “inappreciable magnitude,” haunts us to this day. Even those who held to the sanitarians’ views about smell and disease would, in a few years, concede that Chadwick had miscalculated. The return of cholera would turn Chadwick’s blunder into a public health disaster.
In the hands of a lesser politician, Chadwick’s vision might have never left the printed page. The scale of the project was unprecedented and the political obstacles immense, but he was never one to shy away from a task, even if it required redefining the government of Metropolitan London.
The sprawling metropolis was an unruly patchwork of countless local fiefdoms. There were eight different sewer commissions in the metropolis with more than 240 members. The streets under which Chadwick’s improvements would run were the province of more than 300 parishes, improvement commissions, and boards of trustees controlled by thousands of influential local politicians. Chadwick sought the power to eliminate them all.
A large, imposing man with patrician roots, an abrasive personality, and a grand swoosh over his balding head, Chadwick had risen to prominence as a bureaucrat on the force of his will and the strength of his convictions. He exhibited little reluctance to offend. If bringing his proposal to life required taking on the entrenched power structure, so be it. He barged forward, driven by the absolute conviction that he was acting in the public good. His colleagues on the Poor Law Commission, however, were not so fearless. They refused to have their names on the report, leaving Chadwick alone on the title page.
Chadwick turned that isolation to his advantage. He focused his powers of promotion on getting the report into as many hands as possible. Chadwick’s efforts to market the report, together with its shocking revelations about the appalling living conditions of the working poor, sparked unprecedented demand. Its printing exceeded ten thousand copies, dwarfing anything the government had ever published. In a single stroke, the report defined the sanitary movement, imbued it with great political power, and placed Chadwick at its helm.
The report’s broad distribution also helped bring a vast army of influential supporters into the ranks of the sanitarians. From Disraeli to Dickens, from Florence Nightingale to the queen’s physicians, Londoners had little difficulty accepting the need to purge the city of its stench and rallied behind Chadwick. That support led, in December 1847, to the creation of a single Metropolitan Commission of the Sewers with Chadwick in control.
A plan conceived by Chadwick and his ally in the legislature, Lord Morpeth, also dealt with the problem of the existing sewer commissions. Rather than eliminate them, the two men had a plan that would simply make the six most critical sewer commissions irrelevant. First they packed the newly formed Metropolitan Commission of the Sewers with devoted sanitarians. At the same time they arranged for these men to receive simultaneous appointments to six existing local sewer boards. By doing so, Chadwick replaced more than six hundred local bureaucrats with a small, select group of his followers.
Chadwick immediately launched a crusade to eliminate London’s cesspools. One of the Metropolitan Commission of the Sewers’ first new regulations required direct connection
to the sewers in any new construction. In the spring of 1848, work crews spread out across the city, tearing up streets to begin the construction of new sewer lines.
Never satisfied, Chadwick wanted more power to implement his grand vision. Control of the sewers was not enough if he was to create his sanitary city. He needed a way to ensure there was enough water to flush his new sewers. Riding a wave of popular support, Chadwick and his political allies convinced Parliament to create the General Board of Health in September 1848. With no scientific or medical training, Chadwick was one of three commissioners. The Board of Health would have as its mandate the removal of the local sources of miasma, a task that would require water.
Chadwick worked at a feverish pace to realize his vision. Experience had taught him that political ascendancy did not last. When cholera slithered off the docks of London to begin the second epidemic in the fall of 1848, he responded by pushing his agenda even harder. As a result between the spring of 1848 and the summer of 1849, the flow of sewage into the Thames doubled. Chadwick’s “improvements” had some unintended consequences. The first cholera epidemic killed one of every twenty-seven Londoners in a two-year period. The second would kill one of sixteen.
John Snow and Edwin Chadwick never met. Chadwick viewed Victorian medicine with something approaching disdain, an opinion not entirely unjustified. His medical contacts were limited to a few physicians who shared his devotion to the sanitary movement and provided the necessary scientific cover. However, as the wastewater of London poured into the Thames, the vision of Edwin Chadwick collided with the wisdom of John Snow in ways that changed the lives of both men.
John Snow looked with some horror on the agenda of the sanitarians. The same river that Chadwick saw as the solution to the problem of disease in London, Snow recognized as a primary source of the city’s worst scourge. The Thames flowed not only through the center of the city, but through homes throughout London.
The Blue Death Page 5
