Cholera had originally come from the East, transported by ship around the world. The first notes in a British Medical Journal come from a doctor in India in the year 1817. From then on the spreading of the disease could be followed, until it reached the port of Sunderland in 1831.
John Snow had his first contact with cholera care as an assistant apothecary in the mining fields of the north of England in the year 1832. As a senior apprentice to William Hardcastle, also the Poor Law medical officer, Snow was looking after the miners in Killingsworth when the second wave of this first outbreak started. Colliery villages with their cramped conditions were exceptionally hard hit when cholera swept through them.
After the first outbreak followed a 16 year reprieve, before cholera returned.
But in the late summer of 1848, cholera returned to England. By October 1848, when it reached London, the three medical corporations had been working on treatment advice since the first outbreaks. Guidance from the Board of health was manifold, but without success as the third outbreak on the 1850s finally showed.
Cholera first struck in England at a time of turmoil due to increasing industrialisation which resulted in unemployment, poverty, and unrest. Miasma theory was the basis of the disease’s explanation. Radical reformers around Edwin Chadwick believed in a review of sanitation and closure of crowded alleyways and tenements, as social conditions were seen by some as the main cause for the spreading of this disease.
Others around Jeremy Bentham saw the efficiency of poor relieve as the centre of the problem since cholera and other infectious diseases spread especially in poorer neighbourhoods. This movement led to the Poor Law of 1834. This shifted care for the poor away from 15,000 individual parishes to Boards of Guardians of 600 unions. This then formed the base to construct and administer large workhouses. The followers of this theory also favoured statistical analysis. This was supposed to identify the sources they considered were predisposed for constitutional illnesses and epidemics.
A correspondent in the Lancet I. 1837 compared influenza and cholera: ‘both are of an epidemic nature, arising, passing over the face of the earth, and disappearing , in a mysterious manner. Both seem to be influenced by the season of the year, or by the state of the atmosphere as regards heat and moisture. The course of both is, mostly, from east to west.’ John Snow agreed with this theory in 1842, when he discussed an outbreak of influenza at the Westminster Medical Society that year.
In another meeting of the Society in 1848, Mr Francis Hird stated in a paper on the pathology and treatment of cholera, that he came to the conclusion after postmortems of victims of earlier outbreaks, that there were ‘no known remedies that have any specific power of counteracting the peculiar agency of the poison’. Remedies with an effect on the symptoms such as chalk power, opium, calomel, sugar or mustard and starch enemics had been recommended by the three Medical Bodies. After 1846, chloroform was added to this list.
John Snow, following his usual clinical route, started working on his own theory and in August 1849, he had written and paid for the publication of the essay On the Mode of the Communication of Cholera.
The first thing he established, was that death from cholera was not caused by asphyxiation, as had generally been assumed. He determined that ‘the disease is communicated by something that acts directly on the alimentary canal’, much like intestinal worms. As the digestive membranes of cholera victims showed distinct signs of irritation, which could only be caused by contact to internal parasites, he dismissed the common assumption that cholera took the respiratory route.
He establish his theory from a mix of epidemiological and pathological observations. Firstly, the main outbreaks in towns and villages after a person contaminated with it arrived pointed to humans beings as the centre of the disease. Secondly, as transmission by respiration had been dismissed, the poison must have been ingested.
Although the cholera bacteria had not been discovered yet, Snow, like the German researcher Jacob Henle, assumed that agents or particles were the most likely cause for ingested transmission. He identified the faecal matter to be the transmitter. The typical ‘rice water’ diarrhoea with cholera would easily spread over bedding, surfaces, and clothes. It lacked the typical faecal look and smell and could easily missed when got in contact with. He also reasoned that it could enter with other sewage waters into the drinking water supply.
Most of this hypothesis was formulated in late 1848. He was reluctant about publishing his theory, because he expected newly emerging evidence to dispel them. Only in August 1849 did he hear about the events that proved his line of thought.
On 9 August 1849 John Grant, the assistant surveyor for the Commission of Sewers reported on the conditions of Surrey Court, Horsleydown, where there had been nine or ten cholera deaths in five days:
“There are thirteen houses in the court, which is built up at both ends, and badly ventilated; Enid an open ditch at the end, and the house-drainage is into cesspools, with common privies in small back areas. The houses in this court and those in Truscott’s Buildings (another court) have a double set of small privies, cesspools, and small area between the back of them. Although there has been such mortality in Surrey court, there has been but one case (that of an infant) of cholera in Truscott’s Buildings. The only apparent cause to which this difference can be attributed is, that in Surrey court the inhabitants used the water of a well in the court, the mouth of which was on a level with the paving and a gutter to side channel by which foul water was admitted into the well. This well the parish authorities have had cleaned out, and the mouth of it raised.”
In this report, Snow saw the correlation between solid matter that was ingested by the victim, as he had anticipated in his theory. A later local outbreak on Albion Terrace supported this further. Nevertheless, he expected criticism and objects to his theory, especially from the sanitary authorities. The miasma theory was still predominant, although efforts had been made to improve sanitary conditions in areas of cholera outbreak. Snow himself did not completely reject the ‘airborne’ transmission theory, but made clear that this was not the same as in usual infection theory. His interpretation meant that particles released from the patient into the air were ingested by a healthy person, who subsequently would suffer cholera as well.
In 1854, the investigation into the latest outbreak in Broad Street, in Soho, was based on the principles laid out in the Modes of Communication of Cholera.
By the end of August 1854, Sarah Lewis’ 5 months old daughter had developed diarrhoea and five days after the first treatment also started to vomit. As the mother was weak, her daughter had been fed ground rice and milk from a bottle. Her condition had not immediately diagnosed as such, because her brother had been a weak bottle fed child, who had died at ten months. But as her condition didn’t get better, more cases started o spread around the area of Soho Square and Broad Street.
On 3 September, John Snow abandoned his studies in the south of London and his attention was drawn to the outbreak in Soho. As he had lived in the area as a student, he knew it well. On Monday 4 September, the outbreak had been reported in the Times in form of a notice of the General Board of Health.
John Snow applied his theory and on the evening of 3 September had visited the Broad Street pump to test these. He reported that his inquiry had showed him that there were no other conditions in common in the area cholera had occurred than the pump.
But before he could concentrate on the cholera, he was required as part of his busy practice to administer chloroform for a tooth extraction and other such cases.
The following day, the Board of Governors came together to discuss the normal routine of poor relieve, when Snow requested an interview with them. He was allowed to present his investigation in front of them and as a result, the committee ordered that the pump handle was to be removed on next day, Friday 8 September.
The event, though it was noticed and not necessarily appreciated by the locals, went unnoticed by the newspapers and other publications until a couple of days later. John Snow used the following days to review his 1849 publication regarding the new evidence he had collected in the meantime. Also, the Commission of Sewers inspected the well under the Broad Street pump and discovered a crack in the wall, which had allowed sewage from the nearby cesspit to enter the fresh water.
Vinten-Johansen, Peter, et al. 2003. Cholera, Chloroform, and the Science of Medicine: A Life of John Snow. Oxford: Oxford University Press.
To cite this post : Iris Millis, “John Snow, the first English Anaesthetist. Part 5-John Snow and the Pump Handle”, Museum Highlights (blog on oldoperatingtheatre.com), May 16th, 2017. [On line] http://oldoperatingtheatre.com/john-snow-the-first-english-anaesthetist-part-6-John-Snow-and-the-Pump-handle/
Iris Millis is currently a museum officer at the Old Operating Theatre Museum and Herb Garret. She has previously worked for the Anaesthesia Museum and Bodyworlds. She is member of the History of Anaesthesia Society and the John Snow Society. Follow her on Twitter, @historical_iris.