Truth is mighty and will prevail, but sometimes it is centuries before its voice can be heard and additional centuries before its language is understood. As early as 350 B. C., Hippocrates, the Father of Medicine, pointed out the danger of unsterilized water and advised boiling or filtering a polluted water supply before drinking. He further believed that the consumption of swamp water in the raw state produced enlargement of the spleen. Had his warning been heeded the lives of millions of people who were carried to untimely graves by the scourges of pestilence which swept over Europe, Asia and Great Britain, might have been saved. Some idea of the ravage caused by filth diseases can be gained by reviewing the mortality due to cholera in London during the epidemics of 1832, 1848, 1849, 1853 and 1854.

On account of its size and lack of sanitary provisions, the London of that period was the kind of place in which, with our present knowledge of disease, we would expect a plague to reach its height. Prior to 1700, the city of London had no sewers and was without water supply, except such as was obtained from wells and springs in the neighborhood. The subsoil of London we can readily believe was foul from cesspool leachings and from slops and household refuse deposited on the surface of the ground, so that water from the wells within the city limits, while cool perhaps and palatable, could not have been wholesome. Many public wells with pumps had been installed at certain intervals on the public highways, and an epidemic of cholera traced to one of these wells, was the means of pointing out the danger to public health, caused by an infected water supply, and of showing the channel by which the infectious matter from people suffering from intestinal diseases was transmitted to healthy individuals. The story is well told by Sedgwick:[5] "One of the earliest, one of the most famous, and one of the most instructive cases of the conveyance of disease by polluted water, is that commonly known as the epidemic of Asiatic cholera connected with the Broad Street, London, well, which occurred in 1854. For its conspicuously circumscribed character, its violence and fatality, and especially for the remarkable skill, thoroughness and success with which it was investigated, it will long remain one of the classical instances of the terrible efficiency of polluted water as a vehicle of disease.

As a monument of sanitary research, of medical and engineering interest and of penetrating inductive reasoning, it deserves the most careful study. No apology therefore need be made for giving of it here a somewhat extended account.[6]

The parish of St. James, London, occupied 164 acres in 1854, and contained 36,406 inhabitants in 1851. It was subdivided into three subdistricts, viz., those of St. James Square, Golden Square and Berwick Street. As will be seen by the map, it was situated near a part of London now well known to travellers, not far from the junction of Regent and Oxford Streets. It was bounded by Mayfair and Hanover Square on the west, by All Souls and Marylbone on the north, St. Anne's and Soho on the east, and Charing Cross and St. Martin's-in-the-Fields on the east and south.

In the cholera epidemics of 1832, 1848, 1849 and 1853, St. James' Parish suffered somewhat, but on the average decidedly less than London as a whole. In 1854, however, the reverse was the case. The inquiry committee estimated that in this year the fatal attacks in St. James' Parish were probably not less than 700, and from this estimate compiled a cholera death rate, during 17 weeks under consideration, of 220 per 10,000 living in the parish, which was far above the highest in any other district. In the adjoining sub-district of Hanover Square the ratio was 9; and in the Charing Cross district of St. Martin's-in-the-Fields (including a hospital) it was 33. In 1848-1849 the cholera mortality in St. James' Parish had been only 15 per 10,000 inhabitants.

Within the parish itself, the disease in 1854 was very unequally distributed. In the St. James Square district, the cholera mortality was only 16 per 10,000, while in the Golden Square district it was 217 and in the Berwick Street district 212. It was plain that there had been a special cholera area, a localized circumscribed district. This was eventually minutely studied in the most painstaking fashion as to population, industries, previous sanitary history, meteorological conditions and other general phenomena common to London as a whole, with the result that it was found to have shared with the rest of London a previous long continued absence of rain, a high state of temperature both of the air and of the Thames, an unusual stagnation of the lower strata of the atmosphere, highly favorable to its acquisition of impurity, and although it was impossible to fix the precise share which each of the conditions enumerated might separately have had in favoring the spread of cholera, the whole history of that malady, as well as of the epidemic of 1854 and indeed of the plague of past epochs, justifies the supposition that their combined operation, either by favoring a general impurity in the air or in some other way, concurred in a decided manner, last summer and autumn (1854) to give temporary activity to the special causes of that disease. The inquiry committee did not, however, rest satisfied with these vague speculations and conclusions, but as previously shown in the history of this local outbreak, the resulting mortality was so disproportioned to that in the rest of the metropolis and more particularly to that in the immediately surrounding districts, that we must seek more narrowly and locally for some peculiar conditions, which may help to explain this serious visitation.

Accordingly special inquiries were made within the district involved in regard to its elevation of site, soil and subsoil, including an extended inquiry into the history of a pest field said to have been located within this area in 1665, 1666, to which some had attributed the cholera of 1854; surface and ground plan; streets and courts; density of population; character of the population; dwelling houses; internal economy as to space, light, ventilation and general cleanliness; dust bins and accumulations in yards, cellars and areas; cesspools, closets and house drains; sewers, their water flow and atmospheric connection; public water supply and well water supply. No peculiar condition or adequate explanation of the origin of the epidemic was discovered in any of these, even after the most searching inquiry, except in the well water supply. Abundant general defects were found in the other sanitary factors, but nothing peculiar to the cholera area, or if peculiar, common to those attacked by the disease, could be found excepting the water supply.

At the very beginning of the outbreak, Dr. John Snow, with commendable energy, had taken the trouble to get the number and location of the fatal cases, as is stated in his own report:

"I requested permission, on the 5th of September, to take a list, at the general register office, of the deaths from cholera registered during the week ending the 2nd of September, in the subdistricts of Golden Square and Berwick Street, St. James' and St. Anne's, Soho, which was kindly granted. Eighty-nine (89) deaths from cholera were registered during the week in the three subdistricts, of these only six (6) occurred on the first four days of the week, four occurred on Thursday, August 31, and the remaining 79 on Friday and Saturday. I considered therefore that the outbreak commenced on the Thursday, and I made inquiry in detail respecting the 83 deaths registered as having taken place during the last three days of the week.

On proceeding to the spot I found that nearly all the deaths had taken place within a short distance of the pump in Broad Street. There were only ten deaths in houses situated decidedly nearer to another street pump. In five of these cases the families of the deceased persons told me that they always sent to the pump in Broad Street, as they preferred the water to that of the pump which was nearer. In three other cases the deceased were children who went to school near the pump in Broad Street. Two of them were known to have drunk the water and the parents of the third think it probable that it did so. The other two deaths beyond the district which the pump supplies, represent only the amount of mortality from cholera that was occurring before the eruption took place.

With regard to the 73 deaths occurring in the locality belonging, as it were, to the pump, there were 61 instances in which I was informed that the deceased persons used to drink the water from the pump in Broad Street, either constantly or occasionally. In six (6) instances I could get no information, owing to the death or departure of every one connected with the deceased individuals; and in six (6) cases I was informed that the deceased persons did not drink the pump water before their illness.

The result of the inquiry consequently was that there had been no particular outbreak or increase of cholera in this part of London, except among the persons who were in the habit of drinking the water of the above mentioned pump well.

I had an interview with the Board of Guardians of St. James' Parish on the evening of Thursday, 7th of September, and represented the above circumstances to them. In consequence of which the handle of the pump was removed on the following day.

The additional facts that I have been able to ascertain are in accordance with those related above, and as regards the small number of those attacked, who were believed not to have drunk the water from the Broad Street pump, it must be obvious that there are various ways in which the deceased persons may have taken it without the knowledge of their friends. The water was used for mixing with spirits in some of the public houses around. It was used likewise at dining rooms and coffee shops. The keeper of a coffee shop which was frequented by mechanics and where the pump water was supplied at dinner time, informed us on the 6th of September that she was already aware of nine of her customers who were dead."

On the other hand, Dr. Swan discovered that while a workhouse (almshouse) in Poland Street was three-fourths surrounded by houses in which cholera deaths occurred, out of 525 inmates of the workhouse, only five cholera deaths occurred. The workhouse, however, had a well of its own in addition to the city supply, and never sent for water to the Broad Street pump. If the cholera mortality in the workhouse had been equal to that in its immediate vicinity, it would have had 50 deaths.

A brewery in Broad Street employing seventy workmen was entirely exempt, but having a well of its own, and allowances of malt liquor having been customarily made to the employees, it appears likely that the proprietor was right in his belief that resort was never had to the Broad Street well.

It was quite otherwise in a cartridge factory at No. 38 Broad Street, where about two hundred work people were employed, two tubs of drinking water having been kept on the premises and always filled from the Broad Street pump. Among these employees eighteen died of cholera. Similar facts were elicited for other factories on the same street, all tending to show that in general those who drank the water from the Broad Street pump well suffered either from cholera or diarrhoea, while those who did not drink that water escaped. The whole chain of evidence was made absolutely conclusive by several remarkable and striking cases, like the following:

"A gentleman in delicate health was sent for from Brighton to see his brother at No. 6 Poland Street, who was attacked by cholera and died in twelve hours, on the 1st of September. The gentleman arrived after his brother's death, and did not see the body. He only stayed about twenty minutes in the house, where he took a hasty and scanty luncheon of rump steak, taking with it a small tumbler of cold brandy and water, the water being from Broad Street pump. He went to Pentonville, was attacked with cholera on the evening of the following day, September 2d, and died the next evening.

The death of Mrs. E. and her niece, who drank the water from Broad Street at the West End, Hampstead, deserves especially to be noticed. I was informed by Mrs. E.'s son that his mother had not been in the neighborhood of Broad Street for many months. A cart went from Broad Street to West End every day, and it was the custom to take out a large bottle of the water from the pump in Broad Street, as she preferred it. The water was taken out on Thursday, the 31st of August, and she drank of it in the evening and also on Friday. She was seized with cholera on the evening of the latter day, and died on Saturday. A niece who was on a visit to this lady also drank of the water. She returned to her residence, a high and healthy part of Islington, was attacked with cholera, and died also. There was no cholera at this time either at West End or in the neighborhood where the niece died. Besides these two persons only one servant partook of the water at West End, Hampstead, and she did not suffer, at least not severely. She had diarrhoea."

Dr. Snow's inquiry into the cases of cholera which were nearer other pumps showed that in most the victims had preferred, or had access to, the water of the Broad Street well, and in only a few cases was it impossible to trace any connection with the pump. Finally, Dr. Snow made a statistical statement of great value which is here given in its original form:

The Broad Street, London, Well and Deaths from Asiatic Cholera near it in 1854

In addition to the original and general inquiry conducted from the time of the outbreak by Dr. Snow, the Rev. H. Whitehead, M. A., curate of St. Luke's in Berwick Street, and like Dr. Snow, a member of the Cholera Inquiry Committee, whose knowledge of the district both before and during the epidemic, owing to his official position, gave him unusual advantages, made a most elaborate and painstaking house-to-house investigation of one of the principal streets affected, viz., Broad Street itself.

The Rev. H. Whitehead's report, like that of Dr. Snow, is a model of careful and extended observation and study, cautious generalizing and rigid verification. It is an excellent instance of inductive scientific inquiry by a layman in sanitation. Mr. Whitehead found the number of houses on Broad Street 49; the resident householders 35; the total number of resident inhabitants 896; the total number of deaths among these 90. Deaths among non-residents (workmen, etc.) belonging to the street, 28. Total deaths chargeable to this street alone, 118. Only 10 houses out of 49 were free from cholera.

The dates of attack of the fatal cases resident in this single street were as follows:

The Broad Street, London, Well and Deaths from Asiatic Cholera near it in 1854

Mr. Whitehead's detailed investigation was not made until the spring of 1855, but in spite of this fact it supplied most interesting and important confirmatory evidence of Dr. Snow's theory that the Broad Street well was the source of the epidemic. Mr. Whitehead, moreover, went further than Dr. Snow, and endeavored to find out how the well came to be infected, why its infectious condition was so limited, as it appeared to have been, and to answer various other questions which occurred in the course of his inquiry. As a result, he concluded that the well must have been most infected on August 31st, that for some reason unknown a partial purification began on September 2d, and thereafter proceeded rapidly. There was some evidence that on August 30th the water was much less infected than on the 31st, so that its dangerous condition was apparently temporary only. He further discovered that in the house No. 40 Broad Street, which was the nearest house to the well, there had been not only four fatal cases of cholera contemporaneous with the epidemic, but certain earlier cases of an obscure nature, which might have been cholera, and that dejecta from these had been thrown without disinfection into a cesspool very near the well. On his reporting these facts in April, 1855, to the main committee, Mr. J. York, secretary and surveyor to the committee, was instructed to survey the locality and examine the well, cesspool and drains at No. 40 Broad Street. Mr. York's report revealed a startling condition of affairs. The well was circular in section, 28 feet 10 inches deep, 6 feet in diameter, lined with brick, and when examined contained 7 feet 6 inches of water. It was arched in at the top, dome fashion, and tightly closed at a level 3 feet 6 inches below the street by a cover occupying the crest of the dome. The bottom of the main drain of the house No. 40 Broad Street, lay 9 feet 2 inches above the water level, and one of its sides was distant from the brick lining of the well only 2 feet 8 inches. It was constructed on the old fashioned plan of a flat bottom, 12 inches wide, with brick sides rising about 12 inches high, and covered with old stones. As this drain had but a small fall or inclination outward to the main sewer, the bottom was covered with an accumulation of soil deposit about 2 inches thick, and upon clearing this soil away the mortar joints of the old stone bottom were found to be perished, as was also all the jointing of the brick sides, which had brought the brickwork into the condition of a sieve, and through which the house drainage water must have percolated for a considerable period.

ASIATIC CHOLERA
- AND -
THE BROAD STREET WELL.
LONDON 1854.