by Bill Bryson
At Leeds in the 1830s, a survey of the poorer districts found that many streets were “floating with sewage”; one street, housing 176 families, had not been cleaned for fifteen years. In Liverpool, as many as one-sixth of the populace lived in dark cellars, where wastes could all too easily seep in. And of course human waste was only a small part of the enormous heaps of filth that were generated in the crowded and rapidly industrializing cities. In London, the Thames absorbed anything that wasn’t wanted: condemned meat, offal, dead cats and dogs, food waste, industrial waste, human feces, and much more. Animals were marched daily to Smithfield Market to be turned into beefsteaks and mutton chops; they deposited forty thousand tons of dung en route in a typical year. That was, of course, on top of all the waste of dogs, horses, geese, ducks, chickens, and rutting pigs that were kept domestically. Gluemakers, tanners, dyers, tallow chandlers—indeed, chemical enterprises of all sorts—all added their by-products to the sea of daily sludge. Much of this rotting detritus ultimately found its way into the Thames, where the hope was that the tide would carry it out to sea. But of course tides run in both directions, and the tide that carried waste out toward sea brought a good deal of it back when it turned. The river was a perpetual “flood of liquid manure,” as one observer put it. Smollett, writing in Humphry Clinker, said that “human excrement is the least offensive part,” for the river also contained “all the drugs, minerals and poisons, used in mechanics and manufacture, enriched with the putrefying carcases of beasts and men; and mixed with the scourings of all the wash-tubs, kennels, and common sewers.” The Thames grew so noxious that when a tunnel being dug at Rotherhithe sprang a leak, the first matter through the breach was not river water but concentrated gases, which were ignited by the miners’ lamps, putting the miners in the absurdly desperate position of trying to outrun incoming waters and clouds of burning air.
The streams that fed into the Thames were often even worse than the Thames itself. The River Fleet was in 1831 “almost motionless with solidifying filth.” Even the Serpentine in Hyde Park became so progressively putrid that park users stayed upwind of it. In the 1860s, a layer of sewage fifteen feet deep was dredged from the bottom.
Into this morass came something that proved, unexpectedly, to be a disaster: the flush toilet. Flush toilets of a type had been around for some time. The very first was built by John Harington, godson to Queen Elizabeth. When Harington demonstrated his invention to her in 1597, she expressed great delight and had one immediately installed in Richmond Palace. But it was a novelty well ahead of its time, and almost two hundred years passed before Joseph Bramah, a cabinetmaker and locksmith, patented the first modern flush toilet in 1778. It caught on in a modest way. Many others followed. In America in 1801, at the White House—or President’s House, as it was then called—Thomas Jefferson improved on the indoor privies he had installed at Monticello by installing three of the first flushing toilets to be found in the new nation. They were powered by rainwater cisterns in the attic.
But early toilets often didn’t work well. Sometimes they backfired, filling the room with even more of what the horrified owner had very much hoped to be rid of. Until the development of the U-bend and water trap—which create that little reservoir of water that returns to the bottom of the bowl after each flush—every toilet bowl acted as a conduit to the smells of cesspit and sewer. The backwaft of odors, particularly in hot weather, could be unbearable.
This problem was resolved by one of the great and surely most extraordinarily appropriate names in hygiene history, Thomas Crapper (1837–1910), who was born into a poor family in Yorkshire and reputedly walked to London at the age of eleven. There he became an apprentice plumber in Chelsea. Crapper invented the classic and, in Britain, still familiar toilet with an elevated cistern activated by the pull of a chain. Called the Marlboro Silent Water Waste Preventer, it was clean, leak-proof, odor-free, and wonderfully reliable, and its manufacture made Crapper very rich and so famous that it is often assumed that he gave his name to the slang term crap and its many derivatives. In fact, crap in the lavatorial sense is very ancient, and crapper for a toilet is an Americanism not recorded by the Oxford English Dictionary before 1922. Crapper’s name, it seems, was just a happy coincidence.
The breakthrough event for flush toilets was the Great Exhibition, where they became one of the featured attractions. More than eight hundred thousand people patiently endured long queues to experience the flush toilets—a novelty for most of them—and were so enchanted by the noise and cleansing swirl of water that they rushed to have them installed in their own homes. Perhaps no expensive consumer item in history has taken off more quickly. By the mid-1850s, some two hundred thousand of them were working away in London.
The problem was that London’s sewers were designed only to drain off rain water and couldn’t cope with a steady deluge of solid waste. The sewers filled up with a dense, gloopy sludge that wouldn’t wash away. People known as flushermen were employed to find blockages and clear them. Other sewery professions included toshers and mudlarks, who delved through muck, in sewers and along fetid riverbanks, for lost jewelry or the odd silver spoon. Toshers made a good living, all things considered, but it was dangerous work. The air in the sewers could be lethal. Since the sewer network was vast and unrecorded, reports abounded of toshers getting lost and failing to find their way out. Many were rumored to have been attacked and devoured by armies of rats.
Murderous epidemics were routine in the lightly sanitized, pre-antibiotic world. The cholera outbreak of 1832 left an estimated sixty thousand Britons dead. It was followed by a devastating influenza epidemic in 1837–38 and further cholera outbreaks in 1848, 1854, and 1867. Between and amid these attacks on the nation’s tranquillity came deadly bursts of typhoid fever, rheumatic fever, scarlet fever, diphtheria, and smallpox, among many others. Typhoid fever alone killed fifteen hundred people or more a year from 1850 to 1870. Whooping cough killed about ten thousand children a year from 1840 to 1910. Measles killed even more. There were, in short, an awful lot of ways to die in the nineteenth century.
Cholera wasn’t terribly feared at first, for the decidedly unworthy reason that it was thought primarily to affect poor people. It was accepted wisdom almost everywhere in the nineteenth century that the poor were poor because they were born to be. Although a few impoverished people might generously be described as undeserving, most were by nature “improvident, reckless and intemperate, and with habitual avidity for sensual gratification,” as one government report crisply summarized it. Even Friedrich Engels, a far more sympathetic observer than most, could write in The Condition of the Working Class in England: “The facile character of the Irishman, his crudity, which places him but little above the savage, his contempt for all humane enjoyments, in which his very crudeness makes him incapable of sharing, his filth and poverty, all favour drunkenness.”
So when in 1832 people in the crowded inner cities began to drop in large numbers from a brand-new disease from India called cholera, it was generally viewed as just one of those unfortunate things that befell the poor from time to time. Cholera became known as “the poor man’s plague.” In New York City, more than 40 percent of the victims were poor Irish immigrants. Blacks were disproportionately affected, too. The state medical commission in New York actually declared that the disease was confined to the dissolute poor and “arises entirely from their habits of life.”
But then cholera began to strike down people in well-to-do neighborhoods, too, and very quickly the terror became general. People had not been so unnerved by a disease since the Black Death. The distinguishing feature of cholera was its quickness. The symptoms—violent diarrhea and vomiting, agonizing cramps, crushing headache—came on in an instant. The mortality rate was 50 percent, and sometimes higher, but it was the swiftness of it—the fearful, headlong transition from complete wellness to sudden agony, delirium, and death—that people found terrifying. To see a loved one well at breakfast and dead by suppertime was a
horrifying experience.
Other diseases actually wrecked more lives. Those who survived cholera generally recovered completely, unlike scarlet fever victims (who were often left deaf or brain-damaged) or smallpox sufferers (who could be horribly disfigured). Yet it was cholera that became a national obsession. Between 1845 and 1856, over seven hundred books on cholera were published in English. What particularly troubled people was that they didn’t know what caused it or how to escape it. “What is cholera?” The Lancet wrote in 1853. “Is it a fungus, an insect, a miasma, an electrical disturbance, a deficiency of ozone, a morbid off-scouring of the intestinal canal? We know nothing.”
The most common belief was that cholera and other terrible diseases arose from impure air. Anything that was wasted or foul—sewage, corpses in graveyards, decomposing vegetation, human exhalations—was thought to be disease-producing and potentially lethal. “Malarious aromata rampage invisible through every street,” wrote one chronicler, a touch colorfully, at midcentury. “Atmospheric poison and pungent factor and gaseous filth cry aloud and spare not, and the wayfaring man inhales at every breath a pair of lungs full of vaporized decomposing gutter mud and rottenness.” Liverpool’s chief medical officer in 1844 calculated with confident precision the actual extent of the damage, reporting to Parliament: “By the mere action of the lungs of the inhabitants of Liverpool a stratum of air sufficient to cover the entire surface of the town to a depth of three feet is daily rendered unfit for the purposes of respiration.”
The most devoted and influential believer in miasma theory was Edwin Chadwick, a secretary of the Poor Law Commission and author of A Report on the Sanitary Condition of the Labouring Population of Great Britain, which became a somewhat improbable best seller in 1842. Chadwick’s fundamental belief was that if you got rid of smells, you got rid of disease. “All smell is disease,” he explained to a parliamentary inquiry. His wish was to clean up poor neighborhoods and the habitations within them, not to make conditions more agreeable for the inhabitants, but simply to get rid of the smells.
Chadwick was an intense and cheerless figure, much given to petty jealousies and arguments over position. A lawyer by training, he spent most of his life working on various royal commissions: on making improvements to the poor laws; on conditions in factories; on levels of sanitation in cities; on preventing avoidable deaths; on reorganizing the registration of births, deaths, and marriages. Almost no one liked him. His work on the poor law of 1834, which introduced a national system of workhouses that were almost penal in their nature, made him widely despised among working people—“the most unpopular single individual in the whole United Kingdom,” according to one biographer. Even his family seems not to have had any great affection for him. Chadwick’s mother had died when he was small, and his father remarried and started a second family in the west of England. Eventually, this second family emigrated to Brooklyn and relations between the American branch and Edwin Chadwick appear to have ceased.
One of the children of the second marriage was Henry Chadwick, whose career path went in a different direction altogether. He became a sportswriter and an energetic early promoter of organized baseball. Indeed, Henry Chadwick is sometimes described as the father of the modern game. He devised the scorecard, box score, batting average, earned run average, and many of the other statistical intricacies on which baseball enthusiasts dote. The reason that a baseball box score and cricket summary are so strikingly similar is that he modeled the former on the latter. It was Henry Chadwick who decided, oddly and endearingly, that the symbol for a strikeout should be a K because it is the last letter of the word struck. (He had already used S’s for so many actions on the field that he felt he needed to enlist another letter for striking out.)*
The miasma theory had just one serious flaw: it was entirely without foundation. Unfortunately only one man saw this, and he couldn’t get others to see it with him. His name was John Snow.
Snow was born in York in 1813 in modest circumstances—his father was a common laborer—and however much that might have colored his life socially, it served him well in terms of insightfulness and compassion, for almost uniquely among medical authorities he did not blame the poor for their own diseases, but saw that their conditions of living left them vulnerable to influences beyond their control. No one had ever brought that kind of open-mindedness to the study of epidemiology before.
Snow studied medicine in Newcastle, but settled in London. There he became one of the leading anesthesiologists of his day, at a time when anesthesia was still an unnervingly unproven field. Rarely has the word practice been more apposite with respect to a doctor’s endeavors. Even now anesthesia is a delicate business, but in the early days when dosages were based on little more than hunches and hopeful assumptions, coma, death, and other dire consequences were all too common. In 1853, Snow was called in to administer chloroform to Queen Victoria as she underwent labor in her eighth pregnancy. The use of chloroform was highly unexpected because it was not only new—it had been discovered, by a doctor in Edinburgh, just six years before—but also decidedly dangerous. Many people had died under its application already. To use it merely to help the queen cope with the pain of childbirth would be, in the view of most medical men, wildly incautious. The Lancet reported the matter as a worrying rumor and professed itself astonished that any qualified medical man would take such risks with the royal personage in any circumstance less than a crisis. Yet Snow seems to have had no hesitation in applying chloroform then or later, even though he was vividly and continually reminded of the risks of anesthetics in his practice. In April 1857, for instance, he killed a patient by experimenting on him with a new type of anesthetic, amylene, and misguessing what was the tolerable dosage. Exactly one week later he was applying chloroform to the queen again.
When not helping people lose consciousness before surgery, Snow spent a great deal of time trying to understand where diseases came from. He particularly wondered why cholera devastated some neighborhoods while sparing others. In Southwark, the rate of cholera deaths was six times higher than in next-door Lambeth. If cholera was caused by bad airs, then why would people in contiguous boroughs, breathing the same air, have such discrepant rates of infection? Besides, if cholera was spread by smell, then those who dealt most directly with bad odors—toshers, flushermen, nightsoil handlers, and others whose livelihood was human waste—ought to be the most frequent victims. But they weren’t. After the 1848 outbreak, Snow couldn’t find a single flusherman who had died of cholera.
Snow’s lasting achievement was not just to understand the cause of cholera but also to collect the evidence in a scientifically rigorous manner. He made the most careful maps showing the exact distributions of where cholera victims lived. These made intriguing patterns. For instance, Bethlehem Hospital, the famous lunatic asylum, had not a single victim, while people on facing streets in every direction were felled in alarming numbers. The difference was that the hospital had its own water supply, from a well on the grounds, while people outside took their water from public wells. In the same way, the people of Lambeth drank water that was piped in from clean sources outside the city, whereas those in neighboring Southwark took their water directly from the polluted Thames.
Snow announced his findings in a pamphlet of 1849, On the Mode of Communication of Cholera, which demonstrated a clear link between cholera and water contaminated with human feces. It is one of the most important documents in the history of statistics, public health, medicine, demographics, forensic science—one of the most important documents, in short, of the nineteenth century. No one listened, and the epidemics kept coming.
In 1854, a particularly virulent outbreak hit Soho. In a single small neighborhood around Broad Street, more than five hundred people died in ten days, making it, as Snow noted, probably the most devastating occurrence of sudden mortality in history, worse even than the great plague. The toll would have been much higher except that so many people fled the district.
; The patterns of deaths presented some puzzling anomalies. One of the victims died in Hampstead and another in Islington—both miles away. Snow hiked out to where the outlying victims lived and interviewed relatives and neighbors. It turned out that the Hampstead victim was a fan of Broad Street water—she liked it so much that she had it delivered regularly to her house—and had taken a draft shortly before becoming ill. The Islington victim was her niece, who had come to visit and had drunk some water, too.
Snow managed to persuade the parish council to remove the handle from a water pump on Broad Street, after which cholera deaths in the neighborhood vanished—or so it is commonly reported. In fact, the epidemic was already subsiding by the time the handle was removed, largely because so many people had fled, thinking the very air was poisonous.
Despite the accumulated evidence, Snow’s conclusions were still rejected. When Snow appeared before a parliamentary select committee, the chairman, Sir Benjamin Hall, found it impossible to credit his findings. In a dumbfounded tone, Hall asked Snow: “Are the Committee to understand, taking the case of bone-boilers, that no matter how offensive to the sense of smell of effluvia that comes from the bone-boiling establishments may be, yet you consider that it is not prejudicial in any way to the health of the inhabitants of the district?”
“That is my opinion,” replied Snow, but unfortunately his manner, always diffident, was less forthright than his conclusions, and authorities continued to reject them.
It is hard now to appreciate just how controversial and unwelcome Snow’s views were. Many authorities actively detested him for them. The Lancet concluded that he was in the pocket of business interests which wished to continue to fill the air with “pestilent vapors, miasms and loathsome abominations of every kind,” and make themselves rich by poisoning their neighbors. “After careful enquiry,” the parliamentary inquiry concluded, “we see no reason to adopt this belief.”
