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A Pest Field, Plague Pits, New Sewers, and a Cholera Outbreak in St. James, Westminster

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The opening is as follows: During September 1854, three special investigators from the General Board of Health undertook systematic inquiries in neighborhoods affected by the cholera outbreak in St. James, Westminster and a small portion of St. Anne’s, Soho. They frequently encountered the opinion that “disturbance of the old burial ground was the chief cause of the outbreak of cholera, the ravages of which (many of the inhabitants maintained) followed the line of the new sewer.” These investigators employed a euphemism,“the old burial ground,” for a mass grave site used during the bubonic plague epidemic of 1665/66. This plague pit, as it was frequently termed, had been dug somewhere in a pest-field established in St. James, Westminster by the Earl of Craven ... The opening paragraph of the Commentary is as follows: This episode is more than a contemporary kerfuffle about plague pits and sewer gases. It’s historically significant because it highlights a major medical and popular disagreement that existed in nineteenth century London: Was cholera an epidemic or a contagious disease, as they defined those adjectives?
A Pest Field, Plague Pits, New Sewers, and a Cholera
Outbreak in St. James, Westminster
Peter Vinten-Johansen
December 2022
During September 1854, three special investigators from the Gen-
eral Board of Health undertook systematic inquiries in neighbor-
hoods aected by the cholera outbreak in St. James, Westminster
and a small portion of St. Anne’s, Soho. ey frequently encoun-
tered the opinion that “disturbance of the old burial ground was
the chief cause of the outbreak of cholera, the ravages of which
(many of the inhabitants maintained) followed the line of the new
ese investigators employed a euphemism,“the old burial
ground,” for a mass grave site used during the bubonic plague
epidemic of 1665/66. is plague pit, as it was frequently termed,
had been dug somewhere in a pest-eld established in St. James,
Westminster by the Earl of Craven, a resident of the parish who
lived in Drury
Lane, near the
western border of
the City of London.
As one of the ben-
ets he extended to
the poor during the
epidemic, the Earl
of Craven initially
rented, eventually
purchased, a three-
acre eld some-
where in the Soho
area east of Regent
Street and north
of Golden Square.
1. Donald Fraser, Thomas Hughes, and John Ludlow (F, H, & L),
“Report on a sanitary inspection of the Golden-Square District,” 16, http://; offprint of General
Board of Health, Medical Council, Appendix to the Report of the Committee
 (London: HMSO, 1855), 138–65, http://kora.matrix.
cerpt in Peter Vinten-Johansen (V-J), 
pest: Contracted form of pestilence,
which from the early fourteenth until the
mid-nineteenth centuries meant “any
fatal epidemic disease, affecting man or
beast.” Typically during this period, pest
was reserved for references to bubonic
Pest-Field (PF) from John Oliver, 
Courtesy of Kathleen Weessies, Head
of the Map Library at Michigan State
Craven chose a site large enough to contain a
lazaretto for plague victims from the poorer
classes while they suered from the disease,
as well as one or more plague pits (common
burial grounds). e completed lazaretto
“consisted of thirty-six small houses,”2 rooms
for a physician and a surgeon. A brick wall
enclosed the entirety,3 depicted “in a conven-
tional manner as a single block of buildings”4
in this detail (to the right) from a Morden
map dated 1700.5
e epidemic, which began in the
spring of 1665, peaked in the fall with six-to-
seven thousand deaths per week. e sheer
3. “Marshall Street Area: Pesthouse Close,” in F. H. W. Sheppard,
ed., 
5. Detail from Robert Morden, -
leen Weessies.
number of dead overwhelmed local cemeteries, although the belief
that bubonic plague was contagious had already elicited wide-
spread opposition to intramural burials. It was generally believed
at the time that bubonic plague was an infectious contagion,
spread by decomposing plague matter emitted into the ambient
atmosphere by living victims and plague corpses. e Earl of Cra-
ven’s pest houses oered an alternative to the ocial quarantine
practice of locking the sick in their homes; the plague pits would
be available to St. James, Westminster and neighboring parishes,
thereby eliminating the necessity of burying infectious corpses in
local burial grounds.
Two decades later, the Earl
entrusted the eld and its houses
to St. James, Westminster and
three neighboring parishes to be
used for care of the poor if plague
returned in epidemic proportions
to the London metropolis. But the
disease did not reappear. By 1734,
the unused pest eld was becoming
surrounded by streets and houses
(map detail to the left6). A private
act of Parliament that year released
the pest-eld from a trust
status when the Craven
estate agreed to construct
duplicate pest houses on a three-acre eld in Paddington
that would be donated as a charitable trust to the original
four parishes. e three-acre parcel now referred to as
Pesthouse Close could now be sold.7
More than a century later, development had erased all
visible signs of the ancient pest eld long before the
Metropolitan Sewer Commission decided to construct
deep sewers in neighborhood streets north of Golden
Square. New sewer work occurred in protracted phases—
throughout 1851 in part of Marshall Street, Broad Street
and streets to their south; a two-year hiatus after the
death of the chief engineer; the appointment of a replace-
ment, Joseph Bazalgette, as chief engineer; resumption of
construction during the latter part of 1853 in Marshall
Street and nearby streets, working westward to connect
with the Regent Street sewer main; and nishing the
project in mid-February 1854.
Seven months later, a massive cholera outbreak
broke out north of Golden Square. A rumor emerged
in the early days: Sewer work in streets that passed through the
6. Detail from Robert Morden, -
of Kathleen Weessies. New streets and housing are already visible in this
detail from a later edition of the Morden map, printed prior to the Parlia-
7. “Pesthouse Close,” in Sheppard, .
Adjusted detail from Oliver, 
C of L City of London
CH Craven House, Drury Lane
HM Holywell Mount, location of
a plague pit
L of W Liberty of Westminster
PH Pest house, northern suburbs
Detail from Ordnance Survey, 
, 
three neighboring parishes: St. Clem-
ceived charitable trusts.
the belief that bubonic plague was
contagious: We now know what they
did not—only the pneumonic form of
plague is infectious via person-to-person
transmission. The bubonic form, charac-
lymph nodes), is transmitted by a vector,
A parallel disease to bubonic plague
is Lyme disease, transmitted by a differ-
ent vector (the black-legged deer tick)
diseases, only individuals actually bitten
by their respective vectors may become
On the north [of the future Regent Street,] the Oxford
road ran between hedges.... On the west was a meadow
renowned for a spring from which, long afterwards,
Conduit Street was named. On the east was a eld ...
[where] had been dug ... when the great plague was
raging, a pit into which the dead carts had nightly shot
corpses by scores. It was popularly believed that the
earth was deeply tainted with infection, and could not
be disturbed without imminent risk to human life. No
foundations were laid there till two generations had
passed without any return of the pestilence, and till the
ghastly spot had long been surrounded by buildings.10
Whoa! Hold the phone. Macaulay positioned the plague pit
somewhere in a eld east of what would become Regent Street.
One who lives near Regent-Street had inserted an interpolation in
Macaulay’s text that placed the pit’s location across from a nine-
teenth-century intersection:
“On the east” of Regent-street, opposite Conduit-street,
“was a eld [where] ... had been dug ... a pit ....”
e letter writer properly distinguished their insertion (what is
now generally placed within square brackets) from Macaulay’s text,
which is set o by quotation marks. But they misinterpreted that
text’s reference to Conduit Street. Macaulay wrote that the pest
eld lay somewhere to the east of Conduit Mead—a large mead-
ow with a natural channel (conduit) carrying spring
water—not the street named after this mead. Even if
the eld had been contiguous to what would become
Regent Street, Macaulay did not specify where within
this eld the plague pit lay.
John Phillips’ letter to the editor of the Times, printed
the following day, used One-who-lives’ misinterpre-
tation as validation of his own pet theory about the
former plague pit’s location:
e pit alluded to by Macaulay as having been dug
at the east of Regent-street, opposite Conduit-
street ... is situated within the area bounded by
Argyll-place, King-street, Tyler-street, and Marl-
borough-street. Little Marlborough-street stands
directly over the pit. In excavating for sewers here
some time since, the ground disturbed was found
to consist chiey of black decayed animal matter,
mixed with bones.11
the maps which Kathleen Weesies eventually provided me as download-
able PDFs.
reprinted in 
former pest eld had penetrated a plague pit, unearthing morbid
matter that festered for months until exploding during the dog
days of late summer.
Misinterpreting Macaulay
On the sixth full day of the outbreak, a resident who lived near
Regent Street used a letter to the editor to accuse the Metro-
politan Commission of Sewers of grossly endangering the public
health and welfare by undertaking new-sewer construction dur-
ing a cholera visitation. ey had ignored warnings from public
health authorities that it was very risky as long as the disease was
active in the metropolis. Nonetheless, construction began north of
Golden Square as the 1853 epidemic waned, even though it was
common knowledge that a pest eld had been used to house and
bury plague victims somewhere in this part of the parish nearly
two centuries before.
e resident quoted a passage from T. B Macaulay’s His-
tory of England that placed the location of the pest eld and plague
pit east of the current intersection of Regent and Conduit Streets
(see adjusted
detail8), and
then made
the follow-
ing com-
is is the
spot which
the Com-
of Sewers
... chose to
disturb to
the low-
est depths
for months .... e consequences we are now seeing....In one
street upward of 100 dying of the cholera in less than three
days....Scarcely a house in the district without its dead or
I found the quoted passage in Macaulay’s description of a rural
part of seventeenth-century Westminster, bisected by Swallow
Street, which, along with several other streets, had been replaced
in the 1820s by Regent Street—named for George, the Prince
Regent (the eventual George IV). Macaulay actually wrote:
8. General Board of Health, Medical Council, 
, in Appendix
, 6 Sep-
Adjusted detail from Morden, 
C Channel carrying water from
springs in Conduit mead
(meadow) to Water House
C St Carnaby Street
SwSt Swallow Street
WH Water House
Adjusted detail, General Board of Health,
Medical Council, (1855).
opposite Conduit Street in which the
Commission constructed sewers in late
bars indicating cholera deaths.
Adjusted detail, General Board of
Health, Medical Council, (1855).
Street and erased bars indicating
cholera deaths.
now being instituted by Mr. Cooper.”15
Edmund Cooper, the commission’s engineer for the eastern
division of Westminster, headed a team (comprised of six sewer
workers and one or more cartographers) tasked with investigat-
ing complaints that mephitic gases from new sewers constructed
in 1851 and 1853/54 were responsible for the cholera outbreak.
Cooper’s nal report to the commissioners armed Bazelgette’s
preliminary ndings that the sewers were blameless and the likely
cause was concentrated privy atmosphere from defective drainage
in overcrowded houses. According to Cooper’s report:
• All new sewers constructed in 1851 and 1853/54 “are in a
perfect state and entirely free of accumulation.”16
• A drain mouth or eye, with ap, was left opposite each house”
during construction of the new sewers. As a temporary mea-
sure, the workers re-connected overow drains from cesspools
(where they existed) to the drain mouths with the expectation
that property owners would soon eliminate the cesspools and
install water closets connected to the sewers via pipe drains.
However, fewer than ve per cent had done so at the time of
the cholera outbreak (3).
• Consequently, house drainage of the locality remains in the
same imperfect state as previous to the new sewers being built,
with but few exceptions” (3) such as parts of Broad Street.
Cooper based this generalization of a Schedule17 the team
prepared after inspecting the sanitary state of every house in
which, according to the General Register Oce, at least one
person died of cholera during the rst ten days of the outbreak.
• Although Broad Street residents suered high mortality, many
of the houses with ecient drainage were without cholera
deaths (2).
• “e houses in which the great majority of deaths have taken
place are not situate opposite to gullies or ventilating shafts”
(3), according to a map18 prepared by the commission’s cartog-
raphers (see detail, top of next page).
Sewers in metropolitan London were used exclusively to
15. “Metropolitan Commission of Sewers,
cal numbers in the bullet list hereafter refer to pages in this report.
18. MCS, 
Richard Swain, a property-owner in Little Marlborough Street,
disagreed in his own letter to the editor the following day: “In all
our excavations [when improving drainage in this area], I have
never seen nor heard of any animal matter whatever.”12 Phillips
replied several days later: “It [the plague pit] is where I stated.”13
“What can have produced the fearful mortality in this
neighborhood I cannot conceive,” Phillips wrote in his rst letter
to the editor. But he was certain the sewer commission was not to
blame. Yes, sewer construction in Little Marlborough and Tyler
Streets did penetrate the nearly two hundred year-old plague pit
and workers had removed a small amount of decomposing animal
matter and bones to make room for a new sewer line. But this soil
disturbance was professionally handled. e workers covered the
mixture of decomposed organic matter and bones “with quick-
lime and carted [it] away.” ereafter, the workers covered the new
sewers with fresh ll dirt and “the contract [was] hastily complet-
ed.” According to Phillips, the sewer lines east of Regent Street
“are[, with one exception,] as perfect as sewers can be, and free
from accumulation”; they are much less likely to have caused the
cholera outbreak than the unusually dense and “dilapidated” hous-
ing stock, the absence of interspersed open spaces, and extreme
overcrowding characterizing the cholera eld.14
e Metropolitan Commission of Sewers exonerates itself
What happened next doesn’t strike me as coincidental.
Ten days after Phillips’ letter appeared in the Times, Jo-
seph Bazalgette, chief engineer at the Metropolitan Commission
of Sewers, reported to his bosses that sewer construction in Little
Marlborough Street may have disturbed a mass burial ground
from the time of the seventeenth-century plague. Although the
excavated “subsoil was a dark mould or clay, ... beyond a few bones
found at the west end of the street and some slight smell, there
was no marked indication of animal remains ... [and] none of the
workmen employed on them were aected with illness.” Bazal-
gette undertook a “personal inspection and special inquiry” about
the role of the sewers in “the late fearful outbreak of cholera in the
district of St. James’s” and found “that those houses which were
properly drained into the sewers have been remarkably exempt
from the epidemic.” He speculated the outbreak burst forth with
unmitigated violence mainly in overcrowded houses with over-
charged cesspools and obstructed drainage.” However, he deferred
a denitive assessment until completion of the “minute inquiry ...
remains of hundreds of the victims of that dreadful visitation”; apparently,
the sewer workers unearthed no such remains during construction of the
new sewers.
mephitic: “Pertaining to mephitis; offen-
sive to the smell; (of a vapour or exhala-
tion) pestilential, noxious, poisonous.
privy atmosphere: Stench associated
with organic decomposition “arising
non-contagionists to be a predisposing
cause of epidemic diseases in susceptible
(Quotation from Richard Grainger, Ap-
pendix B to General Board of Health,
 (London: 1851);
extract in V-J, 
• With respect to the “supposed position of the Plague pit,
situate between King-street and Carnaby-street, ... no deaths
occurred in Little Marlborough-street, which is pointed out
to be in its centre, and through which a sewer was built ... and
the houses drained into it, as shown upon the Plan” (3).
Cooper’s unstated conclusion is evident from the preced-
ing quotations taken from his Report to the Commissioners. He
did not consider the Metropolitan Commission of Sewers irre-
sponsible when it resumed construction of deep sewers during the
nal weeks of the 1853 cholera epidemic. Even if workers inad-
vertently disturbed an ancient plague pit under Little Marlbor-
ough Street, a cholera outbreak occurring in late summer would
not be caused by an alleged release of centuries-old, pestilential
gases into the street the previous winter; no resident in the houses
lining Little Marlborough Street died of cholera during the out-
break. None of the men on his team who spent hours within the
sewers during the outbreak came down with cholera or any other
epidemic disease. Moreover, residents of houses near gullies and
ventilators did not experience excessive cholera mortality. Sewer
gases are not deleterious when those closest to the source are un-
e sewer commission map depicted the plague pit pre-
cisely where John Phillips said it was—just east of the Conduit/
Regent Street intersection. However, Cooper, who supervised the
map-making, may have had some misgivings about Phillips’ s
location; he had it marked as “supposed position.”
Did the plague pit become a parish burial ground?
On the same day Phillips’ letter appeared in a competing news-
paper, the Daily News published a letter from An Old Subscriber
who believed that a local history from the previous century ex-
plained why “the most virulent of the [cholera outbreak] cases
have occurred in the neighborhood of Broad-street and Carnaby-
street.”20 He then quoted a footnote from an eighteenth-century
history and guidebook to the London metropolis by Walter Har-
Carnaby Market [located on the east side of Carnaby
Street] stands on part of a piece of ground formerly
distinguished by the name of Pest-eld, where there was
a lazaretto for the reception of persons seized with the
plague in 1665; and a small distance from it was a com-
mon cemetery, where some thousands of persons were
buried in that calamitous year.21
Since the Metropolitan Commission of Sewers had been active
convey surface-water runo
into nearby waterways until
1815, when an Act of Par-
liament permitted property
owners to use them for
house drainage. Eventu-
ally all sewer lines became
combined surface/waste-
water sewers. Surface water
in streets entered the sewers
via gullies (sometimes
termed gully holes)—basins
the size of large sinks, designed to catch debris—covered by metal
grates. Some gullies were tted with stink-traps—usually a U-
bend in the pipe leading to the sewer—intended to hinder gases
from escaping into the street; others were untrapped.
• “Since the outbreak, six men have been employed in these
lines of sewers getting up information on this subject, all of
whom ... are quite healthy, and entirely free from disease’” (3).19
old sewers or upon new sewer works, there has been but one death from
cholera within the last fortnight”;
stink-traps: Variant of stench-trap, “A
device in a drain, etc. to prevent the
upward passage of noxious gas” (Oxford
Detail from MCS, .
Adjusted detail from MCS, 
SE 
T Trapped sewer grates (gullies)
U Untrapped sewer grates (gullies)
X Ventilators
______ Old sewers; the one in Broad Street
__ . __ Sewers constructed in 1851.
The solid red line depicts separa-
tion space between the two sewers
in the middle third of Marshall
in this area, the old subscriber recommended that “every precau-
tion ought to be taken whenever the ground is opened.” For “it
is but a short time since ... an immense quantity of human bones
were found” when the parish dug foundations for public baths and
washhouses near Dufour’s Place, just north of Broad Street—that
is, within the former pest eld mentioned by Harrison. “ese
bones were, no doubt,” continued the old subscriber, “the remains
of those who suered from the dreadful scourge of 1665.22
In short, words of caution about future sewer works, not an
accusation about irresponsible construction in the past.
e same may not be said for a resident at 28 Broad Street, who
was also concerned about human remains uncovered during con-
struction “some two years back” of the parish baths and washhous-
es in an area that was once “the old parish burial ground.... I saw
... esh and hair, as well as bones ... which, from the dates on the
cons, must have been underground 100 years in a most wonder-
ful state of preservation.” Since “the earth in this neighbourhood
appears to possess in a great degree the power of retarding animal
decomposition,” the Broad Street resident thought it “reasonable
to suspect” that when sewer workers penetrated the old plague pit
in Little Marlborough Street, they “most injuriously disturbed the
soil, saturated with the remains of persons deposited here dur-
ing the great plague of London (as mentioned ... by a resident of
Regent-street).” In the months since this disturbance,
a deadly miasmatic atmosphere has been arising
through the gully holes connected with this sewer,
poisoning the surrounding atmosphere and predispos-
ing the inhabitants to any epidemic [disease] that might
visit this metropolis.
It has been observed by all that this disease [cholera]
has more especially followed line for line on either side
the courses of this new main sewer.... Hardly a house in
Broad Street, a street of 50 houses, has escaped without
three, four, or even ve deaths in it....23
at is, the Broad Street resident thought it likely that sewers
laid in 1853/54 penetrated an ancient plague pit—not the 1851
sewer construction in Broad Street—caused the ongoing, horric
cholera outbreak. Although water in the two sewer lines owed in
dierent directions, an atmospheric connection did exist through
which (if the resident was so aware) miasmatic gases from still-
decomposing plague victims could have passed into the Broad
Street sewer.24
A comparison of details from maps by John Rocque25 and Robert
Morden (see footnote #2) arms Walter Harrison’s note that the
Carnaby Market occupied ground formerly part of the Craven
Pest-Field. e Pest House identied in the Morden map may
have been the lazaretto for plague victims Harrison mentioned; its
location is roughly equivalent to the parish burying ground in the
Rocque map. e Broad Street resident was correct; the partially
decomposed bodies and cons dating back a hundred years came
from an old parish cemetery, not (as the Old Subscriber specu-
lated) from a seventeenth-century plague pit.
So, where in the pest eld was the plague pit? A parish
investigative committee provided a compelling answer, long after
the outbreak ended.
e St. James, Westminster Cholera Inquiry Committee
In November 1854, the vestry of St. James, Westminster parish
approved a motion to appoint a committee “for the purpose of
investigating the causes arising out of the present sanitary condi-
tion of the parish of the late outbreak of cholera.”26 Eight vestry-
men composed the initial committee, soon supplemented by eight
other parish residents and a secretary. During the winter and
of Kathleen Weessies.
Records/D—St. James, Piccadilly, City of Westminster Archives Centre; for
Adjusted detail (Grayscale) from Rocque,
Detail from Morden, 
resident at 28 Broad Street: Probably,
, 1853.)
Adjusted detail from MCS, 
(1855), highlighting the public baths and
spring months of 1855, some members of the committee conduct-
ed house-to-house inquiries in the most severely aected streets,
whilst others compiled information on twenty-two sanitary
subjects. e committee’s nal report included a “slight digres-
sion” on the “ancient pest-eld used by the neighbouring parishes
in the time of the Great Plague,” taken to resolve the “consider-
able doubt and error [that] still prevail in regard to the site of this
e committee obtained outside assistance in their search
for the precise location of Craven’s Pest-Field. e solicitor to the
Craven family estate gave the committee access to relevant docu-
ments, one of which included “‘a description of the abutments and
boundaries of the eld ... [which] contains three acres, more or
less, ... [plus] a passage of sixteene [sic] foot wide.’”28 Mr. Crace
loaned the committee a book containing a “unique impression of
Blome’s Map of St. James’s parish (44), circa 1689, which depict-
ed both the passage and the pest eld.29
W. Sheppard, ed., 
A 1720 edition of the Blome map30 shows the parish burying
ground prior to its expansion (as depicted in Rocque’s 1746 map),
when the vestry purchased a small portion of the pest eld from
the Craven Estate in 1733.
e committee and at least two outside volunteers
used the updated Blome map and boundary descriptions provided
by the Craven estate to position the original pest eld site in the
current street and building layout north of Golden Square. Al-
though not drawn to scale, the Blome map provided clues about
the potential location of original boundary markers (abutments)
obscured by urban development. e researchers focused initially
the short, narrow piece
of Marshall Street next
to Silver Street, ... un-
doubtedly corresponds
with the way or passage
mentioned in the Act
[of 1734]. For in what
appears to be the original
trust deed now existing
in the Craven oce, this
way is described as ex-
cepted out of the premis-
es abutting the pest eld
on the south.31
Adjusted detail (Grayscale)
from Rocque, 
solicitor: Perhaps Henry Wickens of
Regent Street.
Crace: Perhaps Henry Winfried Crace, a
, 1616).
Detail from Blome,
Details from Blome, 
two outside volunteers: Perhaps G. B.
Farrant and Charles Goodwyn, both bar-
, 1617–18.)
ed with that house (whether the person died there or elsewhere)—
horizontal bars for residents, vertical bars for non-residents. Onto
this “Plan” of the outbreak, the lithographers superimposed “the
exact position of the pest eld ... as well as the spot where the
Commissioners of Sewers erroneously represented it to have been
situated.”32 e board gave their lithographers permission to give
the Cholera Inquiry Committee “some impressions of this map to
illustrate ... [their] Report.”33
e Cholera Inquiry Committee added a circle, high-
lighted sewer lines, and cut the map in half to accommodate their
presentation.34 e superimposed circle showed that the cholera
outbreak aected only a “singularly well dened portion of ” St.
James, Westminster and Strand parishes. e idea came from
Henry Whitehead, a committee member, who had previously
written “that the limits of the cholera [outbreak] district are ...
very accurately dened within an irregular four-sided gure....
e centre of this gure falls at the junction of Cambridge Street
Appendix to Report of the Committee
Report, v.
in Report-
al (Silver Spring, MD) from copy held by the History of Medicine Division,
National Library of Medicine (Bethesda, MD).
After establishing the latitude and extent of the south-
ern boundary, it was a straight line to the northwestern corner
of the pest eld, just above the former location of Carnaby Mar-
ket (C Mkt). ereafter, they connected alterations in the local
streetscape, undertaken after the pest eld from its charitable
trusts, to establish the remainder of the original site: From the
northwest corner, east to Brown’s Court (B’s Ct) and the work-
house in the burying ground (B Grd) prior to their expansions
into the pest eld when it was severed from its charitable trusts;
then south through the future public baths and washhouses, along
Dufour’s Place (D’s Pl)and into the premises behind 56 Broad
Street. e length from Brown’s Court to 4 Marshall Street was
“rather less than eight chains,” the mid-way width ““about four
chains ... forming a tolerably exact parallelogram [slightly larger
than three acres], twice as long as it is wide” (44).
Subsequently, a deputation from the committee collabo-
rated with two of the local inspectors from the General Board
of Health to construct a mortality map of the cholera outbreak
area. Lithographers at the board made minor adjustments to the
basic frontage plan constructed by the Metropolitan Commission
of Sewers for Edmund Cooper’s investigation. ey added a bar,
placed behind the house number, for every cholera death associat-
locations of plague pits, according
Report and the 
square over the public baths and
Red lines Sewers constructed in
Blue lines Sewers constructed in
Black lines Older sewers.
The bluish mark in the lower left is
tape used to repair a tear.
Adjusted detail, General Board
of Health, Medical Council, 
deaths, added contractions for the
following place names:
B’s Ct 
B Grd Burying Ground
C Mkt Carnaby Market
D’s Pl 
M St Marshall Street (gray
circle includes intersection with
Silver Street).
workhouse: St. James, Westminster
chain: 1 chain = 66 feet.
with Broad Street.” During meetings of the committee, White-
head had remarked that it could also “be shewn with compasses
upon the map that a circle, having a radius of 210 yards, struck
from the northwest angle of Cambridge Street includes almost
the entire [outbreak] area,” totaling almost thirty acres, containing
a population of about 13,500 residing in 825 dwellings, plus 500
people in the parish Workhouse.35 With respect to sewer lines,
the joint GBoH/CIC map was “founded on the map published
in Mr. Cooper’s report to the Commissioners of Sewers,” which
employed dots, dashes, and straight lines to demarcate dates of
construction. e committee decided to highlight those recently
constructed in the parish, manually coloring sewer lines construct-
ed in 1851 blue, those installed in the winter of 1853/54 pink
(aged to red in this copy) on every map attached to 500 copies of
the printed report. During publication, either the committee or
the publisher, John Churchill, decided to cut these maps and glue
both halves after page 96, rather than have a single fold-out map.
Craven’s Pest-Field lay entirely within the encircled chol-
era area on the CIC map, and the committee was well aware of
the popular notion that “remains of decomposing animal mat-
ter, or indeed of the plague matter itself, lying in the soil of this
district” caused the cholera outbreak.36 It was “well known that
the whole of the pest eld was not used as a burial place” (46),
but “considerable doubt exists as to the precise part or parts of
the eld in which the burial pit or pits were dug” (45). Based on
evidence gathered “in quire recent times,” the committee believed
there had been at least two plague pits: e current site of Craven
Chapel in the northwest quadrant of the pest eld; and “in the
right-hand, lower corner of the former eld (45), a location that
matched Maitland’s comment that a plague pit had existed in
1665at the lower end of Marshall Street, contiguous to Silver
Street.37 Sewer lines constructed in 1851 and 1853/54 did pass
through the pest eld but bypassed both of the likely burial sites.
Sewer workers had only unearthed “a ne gravelly soil” when
making the deep cuttings in the former pest eld during both
construction phases. e human bones and cons exposed when
digging foundations for public baths and washhouses were within
a portion of the pest eld rst rented, then purchased, by the par-
ish from the Craven Estate for use as a burial ground. at sector
of the pest eld had not been used for common burials during the
plague year of 1665 (43).
Although the committee considered it “improbable that
animal matters ... enclosed for so long a period in a gravelly soil
should retain noxious qualities of any kind,” they examined three
scenarios proposed by those who believed otherwise. First, soil
disturbance by sewer workers had “taint[ed] the air” with mor-
bid matter. But how could that have happened, they asked? “e
whole of the pest-eld was not used as a burial place,” and neither
the blue nor the red sewer line penetrated parts of the eld where
there had been plague pits. During construction in the pest eld,
Report, 17–18.
37. Maitland, .
“no immediate ill consequences ensued to the health of ... inhabit-
ants,” whereas an aerial poison should have felled many suscep-
tible individuals. Even if morbid matter had been released in the
winter of 1853/54, how could it remain active in ambient air and
cause a cholera outbreak at the end of August?38
Second, the committee considered the opinion expressed
by others in the parish that “leakage of gases or uids [from the
former plague pits] into the sewers” or well water had caused the
outbreak.39 e committee considered contamination of the sewers
unlikely. Even if morbid gases or body-uid leachate had perco-
lated beyond the burial pits into the rest of the eld where sewers
were laid, it was improbable that either could have penetrated the
stone and mortar work in newly constructed sewers. On the other
hand, the stone lining of wells was, by design, highly permeable.
Consequently, “noxious contents” in uids draining from the pest
eld could theoretically have contaminated well water in the area
during early stages of urban development around, and eventually
within, the pest eld boundaries (46–47). Excavations required by
such development over a span of more than a hundred years, how-
ever, would have removed much of the actual plague deposit” and
accelerated drainage from the pest eld. “Hence, the chances of
the contamination of the well water by the pest-eld uids would
become less and less every year, and would certainly be greater in
1832 and 1849 [when there was little cholera in the parish] than
in 1854” (47–48).
e committee’s conclusion was unqualied: “e supposi-
tion of the injurious inuence of the pest eld as a special cause of
the cholera outbreak in St. James’s is not supported by any impor-
tant facts.“40
is episode is more than a contemporary kerfue about plague
pits and sewer gases. It’s historically signicant because it high-
lights a major medical and popular disagreement that existed in
nineteenth century London: Was cholera an epidemic or a conta-
gious disease, as they dened those adjectives?
ree General Board of Health inspectors conducted inquiries
with residents of nearly eight hundred houses in St. James, West-
minster during September 1854. ey often confronted inhabit-
ants who believed that sewer construction through “the old burial
ground [from the plague year of 1665] was the chief cause of the
outbreak of cholera.41 Later, the Cholera Inquiry Committee
learned during their retrospective investigation of this outbreak
that there existed a subset of this “popular opinion [who main-
tained] ... that the disease of last autumn was not cholera, but
a direful kind of black fever”42—that is, construction within the
F, H, & L, Report, 16; V-J, 
contiguous to Silver Street: Contiguous
means proximity, so there may also have
been another plague pit in the lower left
tion of Marshall and Silver Streets; for
“the discovery in more recent years of
(Sheppard, ,
Craven Chapel:
of the open ground of the old Carnaby
(, Report
former pest eld released morbid plague matter that eventuated in
a new outbreak of plague/black death. In short, plague matter was
e 1854 infectious plague argument
e reasoning underlying the black-fever subset of public
opinion amongst inhabitants of the outbreak area could be ex-
plained as follows:
• Active disease matter in deceased bubonic plague victims,
thrown into plague pits nearly two centuries previously, had
retained its morbid qualities since soil in the former pest eld
allegedly retarded animal decomposition.
• Many residents believed as much, particularly after observ-
ing hundred-year-old corpses “in a most wonderful state of
preservation”43 unearthed in 1852 when the parish constructed
public baths on a portion of the pest eld subsequently pur-
chased for use as a parish burial ground.
• is notion, that disturbance of “plague matter ... lying in the
soil”44 had resulted in a recurrence of plague, indicates an unar-
ticulated assumption that bubonic plague is a specic disease.
• Specic disease matter only reproduces itself or a variant in
susceptible individuals; it cannot cause a dierent disease, such
as cholera.
• e “black fever” of the September outbreak was likely a
plague variant that produced fever, chest pain, and bloody
mucous, less common than the bubonic form characterized by
painful buboes (inamed lymph nodes).
• e view that rejuvenated plague matter resulted in an out-
break meant that this portion of “public opinion” considered
plague contagious—capable of reproducing itself inside the
bodies of contemporary victims and spreading to others.
• is subset of the resident population would have considered
infection the most likely mode of transmission since they
would not have touched or swallowed morbid plague matter
around the time of the outbreak. e infectious route assumed
that susceptible individuals (those with debilitating environ-
mental and/or constitutional predispositions)45 living/work-
ing in the vicinity of the former pest eld had at some point
inhaled sucient morbid plague matter to produce an onset of
black fever.
As noted previously, Macaulay stated the following about
dumping plague corpses in the seventeenth-century, Westminster
pest eld: “It was popularly believed” for many decades thereafter
“that the earth was deeply tainted with infection.” Infection wasn’t
just a popular opinion in the seventeenth century, however. om-
tor,” 
as Sydenham, a clinician practicing in Westminster during the
plague of 1665/66, also believed the disease was communicable
(contagious), spreading “chiey by way of infection—that is, by
means of euvia or miasms which, emanating either directly from
the body of the sick or from fomites that had been charged with
them, become diused in the atmosphere and are thus received
into the lungs.”46
• But how might residents nearly two centuries later, living in
buildings constructed atop a former pest eld, have explained
why an explosive outbreak of black fever occurred half a year
after sewer workers allegedly disturbed incompletely decom-
posed, plague pit soil?
Sydenham oered a useful speculation: When plague has
established a presence in a locality and the “atmosphere is favor-
able, ... ‘the whole air of the [region] ... becomes contaminated
[with morbid plague matter,] both from the breath of the diseased
and also from the exhalations arising from the bodies of the dead.
So, there is no longer any need of infected fomites or of direct in-
tercourse with the sick for the propagation of this dreadful mala-
dy. ’ ”47 Applying Sydenham’s reasoning to popular opinion about
the origin of black fever in 1854, it could be argued that morbid
plague matter released during winter sewer construction settled
within the dense housing and higgledy-piggledy streetscape in
this part of St. James. In late August, some atmospheric factor
caused this infectious matter to disperse and cause a plague out-
break among susceptible people.
Such reasoning isn’t solely hypothetical. e General
Board of Health inspectors believed “the structural peculiarity
of the streets and ... the stagnant condition of the atmosphere, ...
remarked at the time to have little or no horizontal movement,”
were signicant contributory factors in the outbreak—although
they believed it was an outbreak cholera, not plague.48
Sydenham’s epidemic constitution and plague
Sydenham developed his views on plague as part of a broader
doctrine on the origin and nature of epidemic diseases, which he
named the epidemic constitution. He formulated this doctrine
in an attempt to explain the seasonal appearance of certain dis-
eases, particularly those that “are apt to prevail epidemically.”49
Sydenham hypothesized that a new epidemic constitution occurs
whenever the atmosphere in a particular geographical region is
composed of morbid emanations from the earth, conducive to the
emergence of one or more distinct epidemic diseases. When sev-
eral diseases occur during an epidemic constitution, “the sensible
 (17 April
 (1676).
within the single quotation marks.
F, H, & L, Report
in V-J, 
a plague variant: Pneumonic plague,
occurring when the bacterium, Yersinia
pestis, invades the lungs. This form of
plague is contagious, communicated
disease matter.
mode of transmission: Three long-
standing modes of contagious transmis-
sioneach with a different 
morbid matter produced within existing
victims to enter new hostshad been
via the , with victims and/or their
belongings (fomites
the , when potential hosts inhale
volatile morbid matter emitted by a vic-
, when potential hosts
inadvertently swallow morbid disease
tract (adapted from V-J, 
John Snow rejuvenated the ingestion
hypothesis, relying in part on an analogi-
cal comparison to the manner by which
ova of intestinal worms enter new hosts.
contagious: “Contagionists argued that
the unknown morbid matter causing a
communicable disease arose from mo-
(V-J, , 11.)
Contagious diseases are produced
either by a  {Latin, pronounced
pox ...; or by miasmata proceeding from a
and in measles.
(Robley Dunglison, 
a contagion transmitted via the
infectious route described below.)
fomites: Substances capable of retaining
ton and woolen goods, etc.
epidemically: An increase in the num-
ber of cases of a disease beyond what
is normally expected for a geographical
area; case numbers and rate of growth of
a disease determine epidemic status, not
mere presence in a population. Non-con-
tagious diseases can become epidemic.
, Sydenham
proposed that the origin of a new epi-
demic constitution was the result of “a
certain secret and inexplicable alteration
in the bowels of the earth, whence the air
becomes impregnated with such kinds
particular distempers so long as that kind
of constitution prevails.
(V-J,  71.)
distinct ... diseases: Gavin Milroy sum-
to certain determinate species with the
same diligence and exactitude we see
employed by botanical writers in their
description of plants” (from excerpt in
V-J, 
makeup or constitution.
qualities of the air” determine which disease predominates; sea-
sonal meteorological conditions aect only the severity and rate
of transmission of epidemic diseases, not their appearance. e
“disease which rages most severely about the autumnal equinox,
and causes the greatest devastation, gives its name to the consti-
tution of the year.”50 Plague, which Sydenham considered conta-
gious, gave its name to the London epidemic constitution of 1665
and 1666.
Sydenham’s doctrine of the epidemic constitution and
view that plague was a contagious disease remained inuential and
largely un-amended for many decades. For example, in the eigh-
teenth century, William Maitland described the “direful pestilence,
Anno 1665 ... [as a] dreadful and virulent contagion.51 Maitland
did not limit the belief that plague was an infectious contagion to
popular opinion the way T. B. Macaulay would in 1848 (quoted
It was popularly believed that the earth was deeply
tainted with infection, and could not be disturbed
without imminent risk to human life. No foundations
were laid there till two generations had passed without
any return of the pestilence, and till the ghastly spot had
long been surrounded by buildings.52
Why did he not know that no building could occur in the pest
eld for three generations because it remained in charitable trusts
to several parishes? By excluding London medical profession-
als and public health authorities from this popular belief, was
Macaulay suggesting that they considered it unlikely that buried
morbid plague matter would remain active for very long? Or, was
he interpreting a past event from the predominant medical view in
the mid-nineteenth century, when “the contagion of plague ... [is]
denied by many”53 and the doctrine of epidemic constitution no
longer incorporated contagious diseases? Since epidemic plague
did not re-appear in London after 1666, this shift in medical
opinion is better demonstrated by reactions to pandemic cholera.
First cholera pandemic disagreements
about the nature of cholera
“It is supposed to exist in the atmosphere,” wrote Mr. Anderson,
a surgeon in the East India Company’s Bombay Presidency, about
the virulent strain of cholera that had erupted in the Ganges River
delta in 1817 and reached them the following year. Yet, how could
it “spread in opposition to a continual current of air, namely the
southwest monsoon?” A colleague, Mr. Jukes, agreed it was a “very
singular epidemic. e laws by which it has been moving from
place to place are very unlike those of common epidemics,” which
51. Maitland, 
53. Robley Dunglison,  (Philadelphia:
spread via the prevailing winds in a region and often appear,
simultaneously, in dierent places. Although this disease “seems
to be creeping from village to village,” “the idea of its being con-
tagious is entertained by few” because medical attendants rarely
become sick.54
ese two accounts appeared, among others, in a letter
Frederick Corbyn, a surgeon in the Bengal Presidency where the
epidemic began, mailed to Gilbert Blane, M.D. in London. Blane
read and commented on Corbyn’s letter in a meeting of the Royal
Medico-Chirurgical Society in 1820. Blane pointed out that the
Bombay Medical Board had a contrary opinion: “it appears to us
incontrovertible that it is capable of being transported from one
place to another, as in cases of ordinary contagion or infection.”55
Blane agreed:
e circumstance which most obviously discriminates
an epidemic arising from the morbid poison engendered
in the human body, that is contagion, from those which
arise from aections of the atmosphere, ... is that the
progress of the former will necessarily be progressive
and traceable to human intercourse, whereas the inu-
ence of the latter will as certainly be contemporaneous
in situations more or less distant.... [e medical reports
from India indicate] that the spread of this malady has
been strictly progressive and evidently carried by human
beings from one district to another (60–61).
Blane recognized that needless panic, “dereliction of the sick,”
and economic hardship would occur if the medical profession and
government authorities decided cholera was an infectious conta-
gion if, in reality, it was a non-contagious, epidemic disease. “But
on the other hand, the mischief would be innitely greater should
it really be infectious and the contrary opinion prevail” (60).
Ten years later when cholera reached Great Britain, the
Central Board of Health appointed Blane medical advisor. On his
recommendation, the board chose to minimize potential mischief.
roughout the 1831 and 1832 cholera epidemic, the government
established policies such as quarantine, sanitary corridors, and lim-
iting access to infected towns and villages on the assumption that
cholera was contagious.
1848: A course reversal
A decade and a half later, a newly instituted General Board of
Health took a decidedly dierent stance from the outset when
epidemic cholera re-appeared in London in September 1848. e
Board claimed, in its rst circular, that the country’s experience
with cholera during the rst epidemic and an analysis of its recent
progress in other countries provided sucient evidence
, 57.
55. Blane, “Account”; V-J, 
Chirurgical: Medieval and early modern
word for surgery, occasionally still used
contagion: From Latin, to have contact
with; “the communication of disease
from body to body by contact direct or
mediate”; from the Latin, touching and
Ordinary contagions were limited to
diseases like smallpox which are trans-
mitted by touching victims (direct) or
their belongings (mediate) capable of
harboring morbid disease matter.
infection: Another form of contagious
mediate contact in which morbid disease
matter emanating from victims are in-
haled by others.
in itself:
to discredit the once prevalent opinion that cholera is,
in itself, contagious.... Although it is so far true that
certain conditions may favour its spread from person to
person, as when great numbers of the sick are crowded
together in close, unventilated apartments, yet this is not
to be considered as aecting the general principle of its
non-contagious nature.56
is passage shows one of the ways non-contagionists had re-
sponded to the manifest failure of the general atmospheric theory
to explain the slow, progressive spread of cholera during the rst
pandemic; they acknowledged that person-to-person transmission
had occurred. But, they claimed, the rarity and circumstantial na-
ture of such occurrences only proved that cholera was a non-con-
tagious disease that could temporarily “be converted into a disease,
capable of producing emanations [in victims], which may excite
[cause] a similar disease in those exposed to them.”57 In short,
contingent-contagion was possible, unlikely in most situations,
and easily reversible by “placing the victim in well-ventilated, sani-
tary conditions.” e medical advisor and both chief medical in-
spectors to the General Board of Health were non-contagionists.
ey outlined sanitary proposals that local authorities and prop-
erty owners should take as preventive measures during the coming
epidemic, as well as instructing local boards of health in England,
Wales, and Scotland to initiate specic inspection protocols.
e Board’s post-epidemic autopsy
Local inspectors submitted their ndings to the central govern-
ment in the winter of 1849/50 cholera epidemic had petered out.
In 1850, the chief inspectors collated these reports and prepared
summations (published in 1851 as appendices to the main report),
which the Board’s two commissioners and medical advisor uti-
lized in writing an overview of their ndings about the “epidemic
cholera of 1848 and 1849” in Britain, part of the pandemic that
began when a series of local outbreaks in Afghanistan and north-
ern India in 1845 gradually spread throughout European Russia,
reaching Hamburg in September 1848 and crossing the channel
to Scotland a few weeks later.
e Board considered several aspects of this progress
particularly signicant. First, major cholera outbreaks only oc-
curred in European cities that had recently endured virulent
outbreaks of another epidemic disease such as inuenza, diarrhea,
dysentery, scarlet fever, or typhus. Second, isolated attacks oc-
curred at the same time in localities quite distant from each other.
ey could nd no exceptions to these two generalizations, so the
Board proposed “isolated cases occurring in any locality during
the prevalence of a general epidemic constitution are unequivocal
and certain signs that an outbreak is impending over that place.”58
56. “The Public Health,
57. “Contagion,” in Dunglison, 
58. GBoH,  (Lon-
note are to this report; excerpts also in V-J, 
ird, in cities and towns where cholera reached epidemic propor-
tions, the disease was “a succession of local outbreaks” (23), fre-
quently reappearing in “the same streets, houses, and rooms which
it ravaged in 1832 ... except,” Fourth, “in some few instances in
which sanitary measures had in the meantime been eected” (18).
Fifth, the Board was unaware of a single reputable instance “in
which a [cholera] infected individual came into a healthy locality
... [and afterwards] attacked other persons in the [same] house or
immediate neighbourhood ... and spread from thence as from a
centre,” as allegedly occurred in 1831–32 and was considered solid
evidence of contagious, person-to-person transmission (32). Sixth,
whenever epidemic cholera outbreaks occurred, they were “invari-
ably connected with one or more of the following local defects:”
—“narrow, closely built and conned neighbourhoods”;
—“lthy streets”;
—“proximity to graveyards and other nuisances [such as
slaughterhouses and suet-rendering establish-
ments] pigsties, oensive sewers”;
—”bad water” from uncovered cisterns lled by the private
water companies and contaminated street pumps;
—overly crowded, poorly ventilated houses;59
—houses with a “privy atmosphere,” gaseous emanations
“arising from neglected privies and overowing
Seventh, all these local defects have one thing in common: the
presence of “invisible, but all-powerful euvia proceeding from
decomposing organic matter, whether animal or vegetable, in
“lth, the prolic parent of all ... epidemic diseases.”60 Eighth,
cholera spreads according to xed laws, the most important of
which is localization—the concurrence of “certain states of the
[epidemic] constitution [and] certain ... characteristics of special
localities, by virtue of which the epidemic obtains ... power over
the resisting vital forces of [susceptible] individuals.”61 Ninth, the
discovery that cholera follows a law of localization means that it
“spread[s] epidemically, ... not by [contagion, which depends on]
contact of the sick with the healthy.”62
In their retrospective analysis of the second time cholera
visited Great Britain, therefore, the General Board of Health
endorsed the notion gaining traction among non-contagionists
that cholera was essentially what they considered typhus, scar-
let fever, inuenza, etc. to be—”a true epidemic, divested of any
contagious character.”63 As such, the Board no longer considered
it “true that certain conditions may favour [cholera’s] spread from
person to person”;64 there was not a single, conrmed instance
Appendix A to GBoH, Report on the Epidemic
 (London, 1851), 7; V-J, 
 to GBoH, Report on the Epi-
 (London: HMSO, 1851), 85, 38;V-J, ,
61. Sutherland, Appendix A
contingent contagion: James Johnson,
M.D. proposed this compromise notion in
an 1831 letter to the editor, published by
the . The quotation in this sentence
is from the Glossary in V-J, 
two commissioners: Lord Ashley
(Anthony Ashley-Cooper), Member of
Poor Law Commission and head of Met-
ropolitan Sanitary Commission.
in V-J, -
medical advisor: Thomas Southwood
Smith, physician at the London Fever
chief medical inspectors: John Suther-
Richard Grainger, MRCS; surgeon and
anatomy lecturer at St. Thomas Hospital
and Medical School.
epidemic:A disease which ... is referred
to some particular , or
condition of the atmosphere, with which
we are entirely ignorant.”
(Dunglison, 
Soon after an epidemic constitution set in, therefore,
chronically unhealthy localities became fever nests. Epidemic
morbid matter hung in the air and settled on surfaces. ey wore
clothing infused with it. ey walked on it. ey slept on bed-
ding covered in it. People inhaled it; they ingested it; their blood
thickened with poison because of it—the perfect breeding ground
for a blood disease like cholera, in which vomiting and diarrhea
reduced the body’s uid volume and turned the blood tar-like.
Individuals with strong vital powers fought o this morbid assault.
e susceptible, with weaker constitutions and multiple chronic
maladies, could not.
e sanitarian solution
e General Board of Health team cited the ecacy of sanitary
improvements as proof of the localization theory. e two com-
missioners who wrote the overview report stated that “outbreak[s]
of the pestilence [in 1848–49 were] sometimes averted” whenever
sanitary improvements were undertaken after the rst cholera
epidemic. “Where its outbreak has not been prevented,
its course has been gradually, and in several instances
suddenly, arrested. Where material improvements have
been made in the condition of the dwellings of the
labouring classes, there has been an entire exemption
from the disease. Where minor improvements have been
introduced, the attacks have been less severe and less
extensive, and the mortality comparatively slight.”67
Sunderland thought his theory about the weaponization
of localized lth emanations oered a simple, if expensive, way to
defang epidemic diseases such as cholera: It was only necessary “to
raise the sanitary condition of the districts which suer to that of
those which escape.” Unfortunately, “the most extraordinary apa-
thy exist[s] in regard to” granting everyone protection from epi-
demic diseases via permanent sanitary improvements. Less com-
prehensive responses, such as targeted cleansing of lthy localities
early in an epidemic, are eective but rarely undertaken with one
exception: “Lime-washing of houses and entire neighbourhoods.”
Local authorities who employed “this measure of prevention had
remarkable results. “e disease was immediately checked in many
Grainger’s bailiwick as chief inspector was the London
metropolis. He used reports submitted by district and subdistrict
inspectors when preparing an assessment of cholera morbidity
and mortality during the 1848–49 cholera epidemic, conclud-
ing that the disease “belongs to the great epidemic class. In his
view, cholera was especially close to the typhoid form of typhus.
Both favored the same localities and spread similarly. erefore, if
“typhus is diminished or eradicated” by eective sanitary improve-
ments, cholera “may come [again] but it will acquire little or no
67. GBoH, Report
68. Sutherland, Appendix A
of contingent-contagion in the entire kingdom in 1848–49. On
the contrary, the evidence received from local inspectors showed
that cholera “spreads by an atmospheric inuence,” as many non-
contagionist surgeons serving in India suspected as early as 1817.
It took several decades of medical experience with the disease to
realize that the law of localization explained why “its progress
consist[ed] of a series of local outbreaks,”65 rather than the entire
area subjected to an epidemic constitution conducive to the emer-
gence of cholera. But the Boards localization theory broke with
Sydenham’s doctrine when it declared that cholera was a non-con-
tagious disease because it “spread epidemically and not by contact
of the sick with the healthy.”66
Sutherlands metaphysical conjecture
John Sutherland felt the need to oer a tentative explanation for
why epidemic diseases in general, cholera in particular, mainly
attacked individuals in localities rife with impurities from decom-
posing organic matter.All the facts I have observed,” he wrote
early in his report to the General Board of Health, “point to a
solution ... [whereby] the epidemic [inuence] ... produces results
closely approximating those of aerial poisons.” My interpretation
of Sutherlands reasoning follows:
When the atmosphere in a geographical region produced a gen-
eral epidemic constitution, particular types of suspended organic
matter determined which epidemic diseases would prevail for the
duration of the constitution. is matter contained the unique
poisonous qualities that distinguished each epidemic disease. But
it was inert; it required some other substance to activate the poi-
sonous qualities that made it morbid. If the general atmospheric
epidemic matter were active, every epidemic constitution would
destroy entire populations as soon as it developed. In actuality,
many, if not most, people are never aected by an epidemic disease
once it appears. So, thought Sunderland, something must limit an
epidemic’s lethality.
It had long been recognized that individuals who lived or
worked in certain localities were particularly susceptible to epi-
demic diseases. In the mid-1830s, a group of non-contagionists
had hypothesized that lth and organic decomposition was the
immediate cause of epidemic malignancy in the same localities,
year after year, not incomprehensible changes in the general at-
mosphere. Sutherland believed that observations made during the
cholera epidemic of 1848–49 conrmed this hypothesis: Cholera
ourished in mini-atmospheres of concentrated, volatile organic
matter emanating from decomposing material and/or from waste
products of living bodies. But why? Although such conditions
were always unhealthy and unpleasant, lth emanations alone
could not cause epidemic disease. Something else was necessary.
Sunderland hypothesized that the epidemic inuence infused lo-
cal organic matter with its poisonous essence.
65. GBoH, Report
66. GBoH, Report
epidemically: Sydenham did not invent
but endorsed the view that the epidemic
status of any disease, whether contagious
or non-contagious, was determined by
case numbers and rate of growth for a
particular geographical area.
All the facts
have appeared to point to a solution of
the following kind: . . . Under the un-
power of intensifying itself or, in other
words, multiplying its force of attack
until at last it produces results closely
appears as if some peculiar organic mat-
ter which constitutes the essence of the
epidemic, when brought in contact with
other organic matter proceeding from
living bodies or from decomposition, has
the power of so changing the condition of
the latter as to impress it with poisonous
qualities of a peculiar kind similar to its
ganic impurities, existing in the atmo-
sphere of unhealthy neighbourhoods,
passed into the blood through the lungs
so as to follow the circulation; and that
similar impurities taken into the stom-
ach with articles of food or drink were
likewise absorbed into the blood; if we
could moreover suppose that the epi-
of assimilating such organic matter to
its own poisonous nature, we should be
enabled to include a number of complex
phenomena under a hypothesis which
would indicate the requisite measures of
(Sutherland, Appendix A, 8;
V-J, 
“The view here advocated is . . . that
which attributes cholera to a poisoning
of the blood. The profuse discharges ...
the blood of cholera patients is thicker,
less water and more solid matter than is
(Grainger, 
V-J, , 113.)
Sunderland considered it “a law of the
parts of towns as are in a bad sanitary
condition and to leave the healthy por-
tions untouched.
(Sutherland, Appendix A
V-J, 
within the parish of St. James, Westminster who believed the
outbreak was an infectious recurrence of plague, not cholera.
• Contagionist surgeons and physicians who believed cholera
was infectious, like measles—transmitted by emanations from
a cholera victim’s breath and skin—would not have considered
it physiologically possible for a cholera outbreak to be caused
by morbid matter from a dierent disease. I have found no
letters to the editor from this group about potential impacts of
unearthing parts of a former pest eld.
• Snow’s 1849 cholera hypothesis required swallowing a victim’s
choleraic discharge for transmission to occur. Snow recognized
that certain unsanitary conditions, often mentioned by local-
ization non-contagionists, dramatically increased the likeli-
hood that the transmission he had in mind would occur. For
example, in 1853 he wrote: “Nothing assists the communica-
tion of disease more than the want of personal cleanliness,” of-
ten unavoidable among vagrants and the poor. “is has been
particularly observed in regard to plague {and] cholera.”71 He
noted that plague was the only epidemic disease that Syden-
ham considered communicable72 and “a great number of facts
in the history of the Plague ... led [Snow] to believe that it is
communicated in exactly the same way as cholera.”73
Snow agreed with localization theorists that “certain
localities are favourable to the communication of particular
epidemic diseases, whilst others are unfavourable; for instance,
in this metropolis, the low-lying districts on the south of the
ames have proved more favourable to the propagation of
plague and cholera than the more elevated districts on the
north.... Such situations are sometimes said to be productive
of diseases; but this expression is obviously incorrect, when
applied to those disorders [like cholera] which are communi-
cable from person to person, either directly or indirectly.”74
• e Cholera Inquiry Committee concluded that the cholera
outbreak “beginning on 31 August and lasting for the few
early days of September—was, in some manner, attributable
to the use of the impure water of the well in Broad Street....
e committee [found] support from the gradually accumulat-
ing evidence collected in other localities as to the important
inuence of contaminated water in increasing cholera,” citing
Sutherland, among others. But “the committee refrain[ed],
71. John Snow, -
ancient medical literature, the communication of diseases was not gener-
communicability of any acute febrile disease except the plague. He did not
even recognise the communicability of small-pox.
73. John Snow, “On the mode of propagation of cholera,” 
ing these “facts,” or evidence when he made a similar comment in ,
footing in a locality thus prepared for resistance.”69
Contagionists were also sanitarian minded. Like the non-conta-
gionists, they believed sanitary reforms were necessary to elimi-
nate the host of environmental predisposing causes that enhanced
susceptibility to epidemic diseases, particularly overcrowding
and poor ventilation. Unlike non-contagionists, their concern
was that many unhealthy conditions increased person-to-person
communication of morbid disease matter by all three contagious
modes of transmission. For example, overcrowding was a major
cause of smallpox outbreaks, since the virus of this contagious
disease spreads quickly by contact among people living cheek by
jowl. Other contagious diseases such as measles, scarlatina, plague,
and cholera—which the majority of contagionists believed were
caused when healthy individuals inhaled volatile morbid euvia
produced within sick bodies—thrived in conditions with compro-
mised ventilation.
John Snow became a clean-water sanitarian during his
apprenticeship years. But it wasn’t until the winter of 1848/49 that
he applied this principle to the mode of transmission of cholera.
He concluded the essay (in which he rst presented the hypothe-
sis that person-to-person communication occurs whenever some-
one inadvertently swallows choleraic morbid matter contained in
a victim’s vomit or diarrheal dejections) as follows: e belief in
the communication of cholera is a much less dreary one than the
For what is so dismal as the idea of some invisible
agent pervading the atmosphere and spreading over
the world? If the writer’s opinions be correct, cholera
might be checked and kept at bay by simple measures....
It would only be necessary for all persons attending or
waiting on the patient to wash their hands carefully
and frequently, never omitting to do so before touch-
ing food; for everybody to avoid drinking, or using for
culinary purposes, water into which drains and sewers
empty themselves; or, if that cannot be accomplished, to
have the water ltered and well boiled before it is used.
e sanitary measure most required in the metropolis
is a supply of water ... from some source quite removed
from the sewers.”70
I’ll conclude this essay with an interpretation of the theoretical
stances taken by the commentators on the impact of sewer con-
struction that allegedly disturbed a seventeenth-century plague
pit, several months prior to the massive St. James cholera outbreak
in September 1854.
• I’ve already discussed a subset of contagionist public opinion
 (London:
Amongst the poor, who are less un-
fortunately situated, there is often very
little cleanliness, and, when a number of
persons reside, sleep, and eat in a small
room, in which also the cooking is con-
to prevent his excretions being partaken
of by all the inmates ; indeed, with the
uncleanly habits of many of the poor, this
is altogether impossible. Under these cir-
fever or cholera enters such a dwelling,
it is very apt to go through the house, as
also, who visit and eat and drink with the
inmates, whilst the medical and clerical
visitors escape.
(Snow, , 167-68.)
CIC formulation of localization
“The undeniably impure well water,
impregnated with matters from the
cesspool and the soil, may have acted
, but only as a predisposing
cause of the outbreak by occasioning a
gradual deterioration in the health of
those who drank it or a more sudden
able to the invasion of the disease or less
able to resist it if attacked. Or, the water
acting as an accessory cause may directly
have enhanced the activity or aggravated
italics mine).
CIC formulation of Snow’s theory
“The water may have played a more
direct part, as the vehicle of a -
 in various ways.... Thus, as Dr. Snow
believes, such poison may have entered
it in the evacuations of some patient who
had cholera or choleraic diarrhoea imme-
diately antecedent to the great outbreak”
however, from expressing an opinion in favour of any hypoth-
esis of [cholera’s] mode of action.75
e views of the following contain one or more aspects of the
General Board of Health’s localization argument, as formulated by
Sunderland and Grainger and summarized by the two commis-
• One who lives near Regent Street implied that unearthing
decomposing organic matter would only have morbid conse-
quences during an epidemic constitution. Disturbing an an-
cient plague pit, in itself, wasn’t the problem. It was the timing
that elicited the resident’s accusation that the sewer commis-
sioners showed “total disregard for any sanitary or hygienic
principle” when the allowed workers to undertake sewer con-
struction during an ongoing epidemic. eir exposure of de-
composing animal matter precisely where Macaulay supposedly
positioned the plague pit surely caused the massive cholera
outbreak in the parish. But would the commissioners heed this
warning? “Will not the ground in other parts be now let alone
by the commissioners till the epidemic be somewhat abated?”
Why this concern? It was common knowledge that the top
eight-to-twelve foot layer of soil “in districts long covered
with houses, is composed principally of accumulated rubbish
charged with various débris.”76 e resident feared additional
sewer work would unearth another decomposition hot-spot.
• John Phillips disagreed. He thought the commission had been
very sanitary-minded. Workers removed just enough of the
decomposing organic matter and bones to make room for the
new sewer line and immediately covering the remainder with
quick-lime and fresh till dirt. In his opinion, neither sewer con-
struction nor sewer gases caused the cholera outbreak. As likely
suspects, Phillips mentioned several of the General Board of
Health’s “local defects”: “e houses generally are closely built
together, and are very delapidated, with little or no open areas
or yards back or front. ey are, moreover, densely populated by
the poor, most of the oors and rooms being let o to separate
families and persons.”77
• According to the chairman of the Metropolitan Commission
of Sewers, Edmund Cooper’s team discovered “the real cause of
the fearful outbreak of the cholera: ... the lthy and undrained
state of the houses” in a locality approximately “a quarter of
a mile in diameter.”78 eir conclusion rested on two factors,
proximity and ventilation. Six men walked through every sewer
line in this locality, counting the number of drain mouths t-
ted with proper pipe drains from houses; all remained healthy.
ree people died of cholera within the area that supposedly
78. “Metropolitan Commission of Sewers,
contained the plague pit, none in the street where workers un-
earthed decomposing animal matter; the center of the outbreak
area lay to the southeast. e greatest mortality occurred in
houses that were not near untrapped sewer grates or ventilat-
ing shafts. So, the chairman was condent that “sewers were
not the cause of the cholera” or “in any way connected with the
disease.” But the ventilation required to dissipate sewer gases
did not exist in many of the houses (with cholera deaths) that
Cooper’s team investigated. e team found overowing cess-
pools, lthy privies, stairwells with rubbish piles, overcrowded
and stuy rooms—unhealthy conditions, teeming with decom-
position gases.
• e three General Board of Health special inspectors as-
signed to the St. James cholera eld took issue with the sewer
commission chairman’s assertion that “the sewers ... were not
in any way connected with” the cholera outbreak. For example,
“several of the houses in which the greatest mortality occurred
are situated opposite gullies [street drains].” Moreover,most
oensive smells proceed[ed]” from some trapped gullies and
ventilating shafts, which “must have an injurious eect on the
health” of the inhabitants. Slaughterhouses and tripe-boiling
establishments ush their waste into the sewers, which “cause
the sewers in the immediate neighbourhood ... to send forth
from the street gullies and into the untrapped house drains
such noxious exhalations as must, of necessity, not only produce
a predisposition to disease but also engender it and greatly
increase the mortality in any district where epidemic disease
prevails”—not just cholera.79 As to the cause of the cholera
outbreak, the inspectors endorsed the local defects argument:
“We are inclined to believe that there existed a pecu-
liar condition of the atmosphere which has been called
choleraic wherein the exhalations from sewers, impure
water, bad house drainage, overcrowding, intemper-
ance, [and] fear may operate on individuals so as to
produce the disease. . . . We cannot help thinking that
the outbreak mainly arose from the multitude of un-
trapped and imperfectly trapped gullies and ventilat-
ing shafts constantly emitting an immense amount of
noxious, health-destroying exhalations.”80
• e Old Subscriber who wrote a letter to the editor of the
Daily News accepted the localization notion that unearthing
decomposing organic matter during an epidemic constitution
could trigger a disease outbreak. e Old Subscriber thought
the “immense quantity of human bones” found in 1852 when
the parish dug foundations for public baths and washhouses
indicated that the soil in the cholera outbreak retarded organic
decomposition, since he assumed the remains were part of a
seventeenth-century plague pit. Hence, the letter writer recom-
mended that “every precaution ought to be taken whenever the
F, H, & L, Report
F, H, & L, Report
“Night soil (human excrement) must
be regarded as consisting essentially of
decomposing animal matter.”
(Grainger, Appendix B, 88;
V-J, 
special inspectors: Johm M. Ludlow,
barrister; Thomas Hughes, barrister; and
Donald Fraser, MD.
ground is opened”81—to avoid exacerbating the current out-
break or setting o another one.
• e resident at 28 Broad Street used the localization hypoth-
esis to explain “the extraordinary virulence of the [cholera]
outbreak in our district, ... considering its limited extent and
good drainage.” e precipitating cause (local defect), claimed
the resident, occurred when sewer workers “most injuri-
ously disturbed the soil, saturated with the remains of persons
deposited here during the great plague of London.” Surely,
unearthing these remains initiated a resumption of organic
decomposition; exposure of hundred-year old “esh and hair,
as well as bones” during excavation works in the old parish
burial ground two years ago proved that “the earth in this
neighbourhood appears to possess in a great degree the power
of retarding animal decomposition.” e preponderance of
cholera morbidity and mortality in streets through which sew-
ers were dug in 1853/54 makes “it reasonable to suspect that
... a deadly miasmatic atmosphere has been arising through
the gully holes connected with this sewer, poisoning the sur-
rounding atmosphere and predisposing the inhabitants to any
epidemic [disease] that might visit this metropolis.” 82e last
phrase needed no elaboration at the time: A cholera outbreak
occurred since had been the preponderant disease in the epi-
demic constitution that set in during the summer of 1853.
81. An Old Subscriber, 
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