Edward Hand Medical Heritage Foundation
 

The Lancaster County Cholera Epidemic of 1854 and the Challenge to the Miasma Theory of Disease

 

 

 


EARLY ON THE MORNING OF SUNDAY, September 10, 1854, the fellows
of the College of Physicians of Philadelphia received an
urgent appeal for medical aid from the hastily assembled Sanitary
Committee of Columbia, Pennsylvania, seventy-five miles to the west, on
the eastern bank of the Susquehanna River. Cholera had broken out in
the town, and by Saturday, September 9, it had killed thirty people,
including one of the town’s six physicians. The desperate townspeople
turned naturally to the College of Physicians. Founded in 1777 by a group
of prominent medical men in Philadelphia to advance the medical profession
and to promote public health, the college had become the most
prestigious medical society in the country. Henry Hartshorne, MD, a fellow
of the college and noted Quaker humanitarian, responded immediately,
leaving for Columbia that day. T. Heber Jackson, MD, of
Philadelphia, arrived the same day. The next day, Monday, September 11,
the college held a special meeting and resolved that a delegation of five
fellows be sent to Columbia, including the eminent physicians Wilson
Jewell and Rene La Roche. They arrived in Columbia on September 12,
joining other volunteer physicians in aiding the sick and instituting measures
intended to curb the further spread of the disease.1 Believing they
knew the etiology of cholera, they came to Columbia to discover its
source, not its cause.
The committee that went to Columbia was made up of outspoken
advocates of the miasma theory and were convinced that cholera was
spread by foul air emanating from filth. The committee’s observations in
Columbia confirmed their beliefs, and the fellows focused their efforts on
finding the source of filth they believed to be responsible for the miasma.
When they discovered rotting carcasses of animals in the river, they
deduced that these were the sources of the corruption responsible for the
epidemic. Having prescribed sanitary measures for the city, the majority
of the fellows returned to Philadelphia the next day convinced that “the
prevailing affection presented no peculiar features.”2
Dr. Jackson remained in Columbia gathering data on the disease, and
he reassessed the validity of the miasma theory subscribed to by the fellows.
Little is known about T. Heber Jackson. His name does not appear
on the rolls of the College of Physicians of Philadelphia or in either contemporary
or modern medical biographical dictionaries. Like Jackson,
John Atlee, a physician and associate fellow of the College of Physicians,
found that his observations of a less severe cholera outbreak in nearby
Lancaster could not be explained by the conventional miasma theory. The
professional debate that ensued between Jackson and Atlee and the leadership
of the College of Physicians can be pieced together from articles in
medical journals, essays, and the records of the meetings of the College of
Physicians. Their efforts were part of a larger challenge to then current
medical orthodoxy and helped to pave the way for the rejection of the
miasma theory of disease and the acceptance of the germ theory in
America.
Cholera, which was endemic to India, escaped the subcontinent in
1817, striking Moscow in September 1830. It then spread westward
across Europe, reaching England in 1831 and North America in 1832.
The pandemic would return to Europe and America in 1849, 1854, and
1866, each time filling the population with terror and revulsion; the mystery
surrounding the cause of the disease only exacerbated the situation.
Its effects were both rapid and devastating, and death was agonizing to
those who succumbed to the disease. The victims were attacked by diarrhea
and vomiting, followed by intense thirst, cramps in the trunk and
legs, shortness of breath, and a radical shrinking of the flesh as the body
became dehydrated. The afflicted person’s bodily fluids were excreted as
“rice water.” He or she collapsed and turned blue, with death following
quickly for the more fortunate ones. As many as 50 percent of those who
contracted cholera died.
The etiology of cholera, not proven with certainty until the 1880s, was
a bacterium, vibro cholerae, transmitted through the ingestion of human
feces, primarily through drinking polluted water.With no certain knowledge
as to the cause of cholera, speculation about its etiology divided
European and American physicians into two camps: those who believed
it to be spread by contagion and those who thought it was caused by
miasmic vapors emanating from filth and rotting organic matter. Each of
these theories had roots in antiquity. From the time of the ancient Jews,
it had been recognized that certain diseases were transmitted either
through direct contact between humans or through objects or animals
that had been in physical contact with a victim. By the sixteenth century,
plague, smallpox, measles, tuberculosis, rabies, and syphilis were recognized
as diseases spread by contagion.3 The advocates of the contagion
theory for cholera justified their position on the grounds that cholera followed
trade routes and often broke out first among those newly arrived in
cities. Believing as they did that contagious diseases were always spread
by individual contact with a victim or things with which a victim had
come into direct contact, the contagionists were unable to explain why
outbreaks of cholera could occur over long distances and attack whole districts
at once. They were unaware of either the existence of the cholera
bacterium or that the ingestion of water containing this bacterium was
the primary means by which large numbers of people some distance from
the original victim could be infected. Thus their narrow definition of a
contagious disease as one that spread through individual human contact
and their lack of understanding of the etiology of cholera left the conta-
gionists with no evidence to substantiate their theory.
The rival miasma theory also had ancient roots. Both Hippocrates and
Galen believed that many epidemic diseases were caused by atmospheric
and climatic conditions. By the eighteenth century, this belief had been
refined into the theory that epidemic diseases were caused by environmental
conditions, such as noxious gasses emanating from human wastes,
unhygienic living conditions, rotting animal and vegetable matter, and
swamps. As these conditions could be ameliorated by human intervention,
advocates of the miasma theory began to subscribe to sanitarianism,
or the theory that providing humanity with hygienic living conditions
could eliminate disease. They also came to believe that differences among
epidemic diseases were due to variations in local conditions. Unable to
account for the fact that miasmas sickened some people and not others
living in the same atmospheric conditions, the supporters of the miasma
theory posited that certain individuals had a predisposition to catching
epidemic diseases due to physical infirmity, diet, corrupted morals, and
emotional excitement.4
In his seminal essay on the rise of anticontagionism, the eminent pioneer
medical historian Erwin H. Ackerknecht demonstrated that, with
insufficient medical knowledge to make a scientific judgment on the
question, the medical community often took sides in the contagion-miasma
dispute based on social, economic, and political considerations. The advocates
of the contagion theory believed the best way to control the disease
was through the traditional practice of state-run quarantine. As autocratic
bureaucracies in Russia and Prussia used the theory to justify quarantines,
liberal physicians, in an age of laissez-faire liberalism, viewed it as a tool
of repressive governments and an enemy of trade and commerce.5 With
the arrival of cholera in the West, the contagion theory quickly fell into
disfavor in Great Britain and the United States. Also aiding in the demise
of the contagion theory was the failure of quarantine to contain cholera.
Thus, because of the lack of conclusive evidence about the etiology of
cholera, the miasma theory, with its accompanying stress on sanitary
reform, triumphed in medical circles for political and hygienic reasons.
The miasma theory “reached its highest peak of elaboration, acceptance,
and scientific respectability on the eve of the cholera epidemics of 1854.”6
American physicians refused to admit that the epidemic was a new
disease imported by European immigrants. Even before cholera’s first
arrival in the Americas in 1832, the College of Physicians of Philadelphia
had concluded that the disease was merely a more virulent form of a diarrhea-
producing disease known since ancient times and named cholera by
Hippocrates.7 Members of the college who went to Montreal in 1832 to
study the first outbreak of cholera in the New World returned convinced
that the disease they had witnessed was neither imported nor spread by
contagion, a conviction they continued to hold in 1854.8
The anticontagionist beliefs of the fellows of the College of Physicians
of Philadelphia were strongly influenced by their commitment to sanitarianism,
a doctrine that stressed that cities must be cleansed and the conditions
of the lower classes improved if the spread of epidemic diseases
was to be controlled. They subscribed to the doctrines of Edwin
Chadwick, the English leader of this movement, who claimed that “all
smell is disease.”9 He had been the driving force behind the creation of
the British Central Board of Health in 1848 to police the sanitation of
Britain’s cities. Believing that the deadly cholera miasma was generated in
filth, sanitarians such as the fellows of the College of Physicians of
Philadelphia were certain that cleaning up cities would end the pestilence.
This conviction was confirmed for them as early as 1832, during the first
American cholera epidemic, when the city of Philadelphia’s cholera death
rate was one-quarter that of New York’s and one-twelfth that of
Montreal’s. The medical community attributed this success in part to the
fact that the city used clean water from the Fairmount Reservoir to wash
the filth from the streets.10 Ironically, while the fellows of the College of
Physicians searched for sources of airborne miasmas to explain the
cholera epidemic, it was Philadelphia’s unique supply of clean drinking
water from the Fairmount Reservoir that spared the city, as Philadelphia’s
drinking water was not polluted by human feces, which spread the bacterium
cholera.
Cholera outbreaks in Lancaster County, Pennsylvania, and Broad
Street, London, in late August and early September 1854 provided case
studies for physicians attempting to discover the true etiology of the disease.
Dr. John Snow in London and Drs. T. Heber Jackson and John
Atlee in Lancaster County, Pennsylvania, would use data gathered during
these outbreaks to question the widely held medical belief that cholera
was generated in filth and spread through the air by miasma. Theorizing
that cholera was spread by some form of contagion, these physicians challenged
the prevalent sanitarian, anticontagionist theories of the time.
They also questioned the generally accepted doctrine of predisposing
causes, which posited that ethnicity, class, and one’s physical, hygienic,
and moral condition dictated the likelihood of one’s catching the disease.
Snow’s research, which enabled him to prove that cholera was spread
primarily through contaminated drinking water, made him justifiably
famous in medical circles. In recent years, Snow has been the subject of
numerous scholarly studies and popular biographies.11 The March 2003
issue of the journal Hospital Doctor selected him as the most important
doctor of all time. However, as Charles Rosenberg, the author of the classic
account of cholera in the United States, has pointed out, Snow was not
alone in challenging medical opinion on the etiology of cholera. His was
one of dozens of theories on the cause of cholera being put forward in the
early 1850s.Yet, he was set apart from the rest by the exhaustive and comprehensive
nature of the research data upon which he based his theory of
the etiology of the disease.12
Dr. Jackson’s and Dr. Atlee’s theories on the cholera epidemics in
provincial Lancaster County in 1854 were neither as comprehensive as
Snow’s, nor based upon detailed data like that which Snow assembled.
However, like Snow, who disputed the anticontagionist theories of the
British General Board of Health and the professional leadership of the
three medical corporations of London, Jackson and Atlee raised doubts
about the validity of the miasma theory.13 They also challenged the opinions
of members of the prestigious College of Physicians of Philadelphia
who had come to Columbia to study the epidemic.
Both the London, England, and Lancaster, Pennsylvania, cholera epidemics
claimed huge numbers of victims. As many as 697 people died in
the densely populated London district of Soho.14 Dr. Snow was able to
trace the source of the Soho epidemic to a pump on Broad Street and
thence to a sewer that leaked the original victim’s excrement into the well.
His findings provided the evidence needed to confirm his 1849–54 studies
connecting outbreaks of cholera with local water supplies. Although
Snow was not immediately successful in persuading England’s medical
elite of the validity of his theory, within a decade his work became the
new medical orthodoxy. Like Snow in London, T. Heber Jackson and
John L. Atlee discovered that the miasma theories for cholera espoused
by their colleagues failed to explain the progression of the disease that
they observed in Lancaster County. All three drew upon innovative medical
technology such as microscopy, statistics, and epidemiological mapping
to gather the evidence needed to make their cases.
Columbia had been untouched by cholera until September 1854. The
town is located on the eastern bank of the Susquehanna River and, in
1854, was one of the great transportation and industrial centers of
Pennsylvania. It was the terminus of two canals and three railroads. A
canal on the west bank at Wrightsville linked Columbia to the
Chesapeake Bay. A canal starting at Columbia on the east bank went as
far north as the mouth of the Juniata River north of Harrisburg. A dam
below the town provided the water to feed the Chesapeake canal and created
a basin in which barges could be loaded and unloaded. Columbia was
connected to Philadelphia, Lancaster, Harrisburg, and Port Deposit,
Maryland, by rail and became a major transfer point for coal brought
down the river. Each spring, log rafts from forests in the central part of
the state were floated down the river to sawmills in the town. Iron ore,
discovered near Columbia, led to the establishment of foundries and a
rolling mill to serve the railroads. Silk mills also provided a major source
of employment in the town.Trade and commerce generated by this activity
transformed the main street of Columbia into a commercial center
that some said rivaled the shopping districts of Philadelphia. The
Columbia Bank, with five hundred thousand dollars in capitalization, was
the largest bank in the county. Founded by Quakers, the town became a
haven for runaway slaves. A mile-long bridge that connected the town
with the western bank of the Susquehanna provided a convenient crossing
point for runaway slaves coming north as well as for immigrants going
west. By 1850, almost 20 percent of the population of Columbia was
African American. Numerous German and Irish immigrants also lived in
the town, drawn there by employment in the railroads, canals, coal yards,
and warehouses.15
In August 1854, the inhabitants of a house in Columbia fell victim to
what was diagnosed as cholera, and the house in which they lived was
ordered destroyed by the town authorities. No further cholera cases were
recorded until September 6, 1854, when two German immigrants, sick
with cholera, were left at the railroad terminus in Columbia while their
party continued west. The men died the next day. Four Columbians who
had tried to aid them came down with cholera and died shortly thereafter.
16 By September 9, cholera had spread to almost every section of the
town, and 30 people had died, many of whom had visited the stricken
immigrants. Physicians had no doubt that the disease that they were witnessing
was cholera. The virulence of the epidemic that struck Columbia
caused Jackson to observe that two-thirds of the victims died within five
hours of showing symptoms of the disease.17 Although only 127 victims
died in Columbia—out of a population of five thousand—Dr. Wilson
Jewell of the College of Physicians of Philadelphia and president of the
Philadelphia Board of Health estimated that if a similar outbreak had
occurred in Philadelphia, it would have killed 75 people an hour.18
Columbia’s rail link to Philadelphia was a conduit for medical assistance
as well as cholera. Drs. Hartshorne, La Roche, and Jewell, who traveled to
Columbia from Philadelphia by rail, were all outspoken sanitarians and anticontagionists.
They were committed to creating new public health standards
that would address city sanitation, water supply, and waste disposal and
thus improve the dismal state of public hygiene in American cities. All
three fellows were convinced that filth was the primary threat to the
health of both Columbia and Philadelphia.
An 1848 report on the public health of Philadelphia written for the
American Medical Association described the sanitary conditions in that
city as being atrocious; streets were never cleaned, sewers were clogged,
and water supplies were contaminated. The report criticized the Board of
Health for inactivity and lack of control over those responsible for cleaning
the streets. Even though Philadelphia responded to the criticism of
the AMA report by attempting to cleanse itself, these efforts did not meet
the College of Physicians’ standards.19 At a June 26, 1849, meeting of the
college, Dr. Charles D. Meigs, who would be appointed chairman of the
committee that went to Columbia, decried the lack of support politicians
gave the medical community. He commented, “Were our municipal and
state governments aware of their duty and responsibility as guardians of
the people, they would take measures to reach the reason and conscience
of every citizen” on the importance of civic hygiene in the control of
cholera.20
Meigs and the fellows of the college who traveled to Columbia would
have concurred with Dr. Hartshorne “that mortality from cholera is
almost invariably commensurate with the filth and destitution of the
inhabitants and their abodes.”21 For Hartshorne, the filth that was
endemic in mid-nineteenth-century cities provided an incubator for diseases
and was most prevalent among the poor. He gave credence to the
idea that microscopic life might be responsible for causing cholera,
although he avoided speculating on how the cholera “germs” came to be
in the offending filth. Hartshorne observed that “cholera is generated
only in the presence of a certain unknown contingent, whose capriciousness
of migration, partial subjection to temperature, and other habitudes,
suggest the probability of the animalcular hypothesis.”22 Hartshorne was
more interested in practical solutions for defeating cholera than in hypo
thetical explanations of its nature. He concluded that:
Whatever the theory, the lesson from all the facts is one . . . of hygiene and
prevention. Cities should be built and regulated to prevent epidemics, as
they should be to afford security from conflagrations. The laws of public
benevolence, like those of private morality, are an essential part of the
economy of the world. As personal vice brings misery, by violation of the
physical laws, so the aggregate vice of communities, and the neglect of the
higher classes to do their best for those around them, meet with retribution,
in those scourges, which under the forms of plague, cholera, typhus,
and yellow fever, desolate populations almost in proportion to the errors
of their local life.23
Hartshorne strongly objected to the practice of personal quarantine
against cholera, arguing that it was noncontagious and that the only protection
against the disease was “local, municipal and domestic sanitation.”
24 He believed communities, led by the upper orders of society,
should work together to promote the health of their citizens. It was a
responsibility that civic leaders neglected to fulfill.
Rene La Roche was a member of the Philadelphia Board of Health,
and his anticontagionism theory dominated the board’s thinking in the
1850s.25 His book on the history, pathology, and etiology of yellow fever
was considered to be the definitive study of the disease when it was published
in 1855. He was more skeptical than Hartshorne of the idea that
cholera might be caused by microscopic “germs.” In an address given
before the College of Physicians on April 5, 1854, he commented that
while he was willing to admit the possibility that diseases might be caused
by “microscopic beings produced out of pre-existing germs under peculiar
and favorable circumstances of locality and atmosphere,” he found the
idea to “smack more of poetry than sound theory.”26 Like Hartshorne, he
contended that the source of cholera was local in origin.27 Believing filth
and local meteorological and geographic conditions to be responsible for
the creation of the disease, he was therefore an ardent advocate of sanitary
reform.
Wilson Jewell was president of the Philadelphia Board of Health and
a prime mover in the creation of the national Quarantine and Sanitary
Commission that met annually between 1857 and 1860.28 His writings
demonstrate the validity of Ackerknecht’s observation that the debate
over contagion was never just a theoretical one, but was always tied to the
question of quarantines and the bureaucracies that enforced them.29
Jewell observed that:
The doctrine . . . of specific contagion, or the spread of epidemic diseases
by contagion, which was universally received when quarantines were first
instituted, has, within the present century, undergone almost an entire revolution.
. . . A judicious modification of the present unsound, ill-advised
and ancient code of quarantine law is therefore not only called for, but
absolutely necessary.30
Arriving in Columbia with preconceived ideas as to the causes of
cholera, and determined to collect evidence to support their sanitarian
and public-health reform agenda, the fellows from the College of
Physicians of Philadelphia quickly became convinced that they had discovered
the source of the deadly disease in the filth from the river. They
disputed newspaper reports that attributed the epidemic to waterborne
pollution. A telegraphic newspaper dispatch from Columbia on
September 13 reported that “the river is very low, and at the point where
the water is drawn up into the basin of the water works, two slaughter
houses empty their garbage. There being no current to carry the filth off,
the water became strongly impregnated with the poisonous matter, and
was freely drunk by our unsuspecting inhabitants.” It was further reported
that “while those who used water from that source [the town reservoir,
whose water came from the polluted river] have perished by dozens, those
who used spring water have not been affected.”31
Convinced of the validity of the miasma theory, the doctors from the
College of Physicians rejected the idea that the epidemic was spread
through the town’s water supply. Dr. Jewell challenged the idea that only
those who drank from the reservoir became ill. He was emphatic that the
“exciting cause of this epidemic is in the atmosphere, and not the water,
as the victims have been indiscriminately from among those who used the
water from the reservoir, and those who drink nothing but spring
water.”32
Hartshorne gave a somewhat different description of the condition in
which he found the river and the town reservoir, but he still emphasized
that the epidemic was due to airborne miasma:
an exceeding drought had reduced the channel of the river to an unusually
low ebb, and that, in its bed, a short space above the town, a number of
carcases [sic] of sheep and other animals, thrown from the railroad trains,
etc., were putrefying rankly in the sun. A reservoir which supplied many
of the people with drinking water was filled from the river not far from
that spot, and the wind blew from it directly over the town. If we are correctly
informed, the first subsidence of the disease attended a change of
the wind.
In his 1855 essay on cholera, Hartshorne described and rejected Snow’s
theory, put forward in an 1853 article, that cholera was transmitted from
victim to victim through the water supply, writing, “water cannot be
shewn to consist in its serving as a vehicle for a poison, a contagion, generating
specially in the bodies of those who have suffered from the disease.
We have seen that this cannot be, since there is no such contagion
generally speaking, if it even can exist.”While denying that the vomit and
diarrhea of victims propagated cholera, he argued that if left at a specific
temperature for several days, these discharges would give off miasma. He
believed they “undergo a process of fermentation; they are then capable of
exciting cholera in healthy individuals.”33
Not surprisingly, the Philadelphia physicians, with their strong commitment
to sanitarianism, “on their arrival . . . had met the resident physicians,
and . . . sanitary measures were agreed upon and published. Means
were also adopted for obtaining supplies for the place.” This latter action
addressed a major problem because, convinced that cholera was conta
gious, the “country people round the devastated town refuse[d] to hold
any intercourse with the citizens, and much suffering from the want of
wholesome food ha[d] been the result.” According to Jackson, a “notable
improvement in the health of the town” followed the supplying of the
population with food.34
The doctors’ recommendations were standard treatment for the time.
They prescribed that victims be given large doses of opium combined
with an astringent, with opium enemata to be administered in severe
cases. Beef teas and broths rehydrated the victims, while preparations of
mercury and bleeding were used as a last resort. The fellows from the
College of Physicians found little that was unique in the Columbia epidemic,
concluding that “the prevailing affection presented no peculiar
features.” Having no further interest in the epidemic, several of the physicians,
including Jewell, returned to Philadelphia on Wednesday,
September 13.35
However, believing that the intensity of the Columbia epidemic provided
optimum conditions for studying cholera’s causes,T. Heber Jackson
remained in Columbia. He envisioned Columbia as a laboratory and a
relatively contained environment that would enable him to study the
“conditions under which cholera prevails.” He hoped “to discover its
cause, and the laws by which it is governed” and noted that “it is no easy
matter to follow distinctly the progress of an epidemic when it prevails
extensively in a large and populous city; but in a small town, its origin and
progress can be more readily traced.”36 Historian Charles Rosenberg has
observed that during the 1849–54 epidemics, as in 1832, the general public
viewed cholera as “a disease of poverty and sin”:
By 1849 the connection between cholera and vice had become almost a
verbal reflex. The relationship between vice and poverty was a mental
reflex even more firmly established. . . . Cholera was an exercise of God’s
will. The religious of every sect, in 1849, as in 1832, accepted cholera as a
chastisement appropriate to a nation sunk in materialism and sin.37
Ebenezer Erskine, Columbia’s Presbyterian minister, was most fervent
in his advocacy that cholera was sent by God to punish sinners. Erskine
was not an unknown, uneducated preacher. He had earned his bachelor’s
degree from Jefferson (now Washington and Jefferson) College in
Pennsylvania and graduated from the Presbyterian Seminary at
Princeton.38 In his October 1854 sermons, Erskine compared the
Columbia cholera epidemic to the plague. He cited 2 Samuel 24:15, in
which “the Lord sent a pestilence upon Israel” to “punish the people for
their transgressions.” Erskine had no doubt that one must “acknowledge
such a pestilence to be a message from God . . . to chastise communities
for their impiety and wickedness.” He saw drunkenness, gambling, licentiousness,
an absence of brotherly love and charity among the business
classes, impiety and irreligion, a spirit of lawlessness among the young,
profanation of the Sabbath and of God’s name, and a “cold formal, worldly
spirit . . . among the professed people of God” as having influenced God to
inflict the people with cholera.39
Erskine, like both the public and the medical establishment of the
time, believed that cholera most readily struck the poor and certain ethnic
groups. He singled out the poor and immigrants for special condemnation,
focusing especially on Irish Roman Catholics whom, he claimed,
lived in the thrall of “a besotted and rapacious priesthood who teach their
unhappy and deluded followers” false doctrines. Erskine belittled the
physicians’ attempts to discover the cause of cholera, saying that “the most
eminent in medical science were compelled to acknowledge that the law
of its progress was veiled in mystery.” Employing an odd use of the new
science of statistics for one who was dismissive of scientific enquiry,
Erskine pointed out that only six pious individuals had died during the
epidemic, in contrast to the hundred sinners who professed no religion.
He observed that what was a severe judgment upon the ungodly “might
be only a fatherly chastisement to the people of God.”40
The popular press mirrored Erskine’s judgments. The editor of the
Wrightsville newspaper also saw God’s hand in the epidemic, commenting
that “truly the lord has visited in sore judgment; may we learn right
eousness, and humble ourselves under his mighty hand.” The Lancaster
Inland Weekly echoed this assessment, noting that “it is a visitation from
Deity . . . to teach us all, as we jog along, a valuable lesson.”41
In contrast, Jackson drew upon his observations in Columbia to challenge
this widely accepted belief that poverty, ethnicity, and filth bred
cholera. He reported his findings on the disease the next year in the
American Journal of Medical Science. Neither Jackson nor the other
Philadelphia physicians gave credence to the popular theory that cholera
was a punishment from God. However, “the closely related doctrine of
predisposing causes, which claimed that physical and psychological conditions
made certain individuals susceptible to the disease, was unquestioned
by the medical profession.”42 The fellows of the College of
Physicians of Philadelphia and the vast majority of their medical colleagues
believed that cholera was predominantly a disease of the poor and
the profligate, a consequence of ethnic background, immorality, poor
health, or living in a filthy environment. Filth, endemic in nineteenthcentury
cities, was seen as providing the catalyst for the growth of the
cholera poison—perhaps by zymotic action. The wind was thought to
carry the resulting miasma to the victims. Because the disease was
believed to be airborne, many thought it began in the lungs. The fact that
it would strike some while passing over others was explained by the theory
that certain people had a constitutional predisposition to catching the
disease.
Neither the College of Physicians’ assumptions that the poor, intemperate,
and certain ethnic groups were predisposed to catching cholera,
nor popular leaders’ beliefs that it was God’s revenge, were ultimately
born out by the events in Columbia. The Harrisburg Morning Herald
announced with alarm that “some of the most prominent citizens, including
two physicians, are reported being among the victims. The epidemic
is confined to no locality or class of citizen but prevails in all parts of the
town, and strikes down the high and low, the rich and poor, the healthy
and feeble.” The Lancaster Examiner and Herald was even more explicit
in its astonishment, commenting that cholera had attacked “not only the
vicious and imprudent but those who have been remarkable for the
consistency and regularity of their lives.”43 There was general agreement
that Columbia’s ethnic minorities were the ones who suffered most from
the epidemic. However, while the press believed that the large poor black
population was most affected by the disease, Jackson found that it was the
poor German laborers who fell ill most frequently.44 The fact that the
Columbia epidemic spared neither the prosperous nor the virtuous, but
struck rich and poor, virtuous and profligate, and various ethnic groups
alike, led Jackson to question to validity of the theory of predisposing
causes.
Jackson believed that poor people’s inability to escape the town made
it appear that “the working class was much more obnoxious to the disease
than they really were.” Jackson reported that during the first night the
epidemic broke out “all portions of the town, all classes of people were
compelled impartially to contribute victims to the merciless pestilence.” A
panic “seized upon the citizens, and many of those whose means enabled
them to leave, fled from the devoted town.” By Monday, he noted, “more
than half the population . . . had left, and numerous persons left daily,
until the week was far advanced. . . . [H]ad all the citizens remained, no
distinction of class would have availed as a protection, but all would have
suffered alike, in proportion to their numbers.” Like Snow, Jackson rejected
the idea that degeneration and lack of cleanliness among the poor made
them uniquely susceptible to cholera.45
Jackson and Snow used maps to demonstrate the validity of their theories.
Jackson referred his readers to “the accompanying plan of the
town,” on which he had marked the sites of the early victims’ dwellings.
He argued that it “will clearly appear” that the epidemic struck the homes
of the prosperous and poor alike.46 Similarly, Snow used a map of the
Broad Street neighborhood to demonstrate that it was those who
depended upon the deadly pump for their water who caught cholera,
regardless of class or other factors. Snow also used maps to illustrate the
connection between sources of household water supply and the percentage
of cholera deaths in the areas supplied by two London water companies.47
Jackson expanded his enquiry into the cause of the disease and evaluated
Jewell and La Roche’s miasma theory against his own data. He found
that his Philadelphia colleagues had failed to explain the phenomenon he
had observed. Jackson argued that:
Before it is determined that emanations from the river, wafted into the
town by this southeast wind, were productive of the cholera it will be
worth while to remember that during a long series of years Columbia had
been exposed to precisely the same influences, the same combination of
circumstances and yet remained happily free from cholera. It is not denied
that the condition of the river air . . . might have afforded a suitable nidus
for the disease. . . . [I]f the river and its shores are to be accused of having
generated the cholera poison, why and how did the people of Wrightsville,
on the opposite bank from Columbia, escape? especially when, as on
Sunday, the strong northerly wind was blowing. And yet escape they did,
without a single case.48
Jackson was of two minds about the possibility that cholera in
Columbia was propagated by contagion. He questioned the popular belief
that the epidemic had been spread by the two German immigrants just
because they, and those who had communicated directly with them, were
the first victims. He pointed out that between midnight of the evening
the immigrants died and dawn, there were thirty reported cases of
cholera. Subscribing to the contemporary belief that contagion depended
on person-to-person contact, Jackson observed that “contagious diseases
do not seize upon great numbers at once, but progress from case to case.”
Therefore, it did not appear that the disease was simply contagious. On
the other hand, an individual who visited Columbia during the epidemic
fell sick and died of the disease only when he reached home, seventeen
miles away. The friend who attended him and the individual who buried
him also contracted cholera and died. Jackson believed that the only way
these two people could have contracted cholera was from the man who
had visited Columbia. Thus, it was very probable that cholera was, in this
case, contagious. Faced with contradictory evidence, Jackson refused to
ascribe the epidemic to any single cause and ultimately left the question
of contagion open.49While Jackson raised serious doubts about the validity
of the miasma theory and its corollary doctrine of predisposing causes,
he did not believe that he had the evidence necessary to advocate a contagionist
theory of cholera’s etiology.
Unlike T. Heber Jackson, John Atlee was a well-known and prominent
physician. He received his MD from the University of Pennsylvania in
1820 and from 1850 to 1852 studied medicine in Paris and Berlin, where,
in all likelihood, he developed his skills as a microscopist.50 Atlee’s entire
medical career was spent in Lancaster, where he earned the accolades of
his colleagues for his skills as a surgeon. He was an associate member of
the College of Physicians of Philadelphia and a founder of the Lancaster
County Medical Society (1844) and the Pennsylvania Medical Society
(1848), serving a term as president of each of those organizations. Atlee
also was a founding member of the American Medical Association
(1847), where he held both the office of vice president (1865) and president
(1882). His assessments of the cholera outbreak in Lancaster, while
differing from Jackson’s evaluation of the Columbia epidemic, were
equally critical of the miasma theory to which the fellows of the College
of Physicians subscribed.
The city of Lancaster, where Atlee had his practice, was a little over
ten miles east of Columbia and was also visited by cholera late in the summer
of 1854. The city of Lancaster was the county seat, and with an estimated
population of fourteen thousand, it was almost three times the size
of Columbia. The city was undergoing a period of rapid growth, which
was reflected in the major civic, commercial, and academic construction
projects; a new courthouse, market house, jail, opera house, and city reservoir
were built in the early 1850s. In addition, the newly merged Franklin
and Marshall College was constructing a campus on College Hill.
Situated in or near the city were a thriving rifle works, textile mills, and
the Lancaster Locomotive Engine and Machine Manufacturing
Company as well as other foundries and over one hundred licensed retail
establishments.51
Lancaster was set in what contemporaries considered to be a healthy
location on high ground a mile north of the Conestoga River, a tributary
of the Susquehanna, where it was presumably relatively free from the
river’s miasmic mists. Despite its location, though, Lancaster, like all
other cities of the era, was extremely unhygienic. The editor of the
Lancaster Inland Daily subscribed to the filth theory of disease and chastised
the city’s fathers for not ordering the city’s cleaning:
The streets are, some of them, very filthy. Stagnant waters, impure matter
and filthy gutters are to be found in many of our streets. This is wrong.
The streets should be kept clean and in good order, and if the private
premises of our citizens be also kept clean and pure, and people are prudent,
there need be little fear of the cholera.52
In the summer of 1854, Atlee was in charge of both the Lancaster
County hospital and the almshouse. His actions, intended to minimize
the potential for a cholera outbreak in those facilities, suggest that he gave
some credence to the filth theory of disease. Having heard of the prevalence
of cholera in Philadelphia, Atlee ordered that both institutions be
thoroughly cleaned and whitewashed, that the sewers be cleansed, and
that decomposed animal and vegetable materials be removed. The outhouses
were purified with lime to remove the noxious odors that were
believed to carry the disease.53
On August 2, Patrick Tute, the first cholera victim in Lancaster,
arrived at the railroad station from Philadelphia, collapsed, and was
placed in the county hospital without the medical authorities’ knowledge.
On August 4, John Carr, the second Lancaster cholera victim, was
brought to the hospital from Columbia after suffering from diarrhea. In
his Report to the Sanitary Committee of Lancaster County, Atlee
implied that Tute and Carr introduced the disease to the hospital.
Although there were three hundred inmates in the hospital and the adjacent
almshouse when cholera broke out in August 1854, Atlee believed
his actions had kept the disease in check. Only twenty-six people died of
cholera, most of whom, according to Atlee, were aged and insane. Altee’s
observation suggests that he still gave some credence to the theory of predisposing
causes. He also had not yet completely rejected the theory that
miasma could spread the epidemic. Atlee noted that “it was remarked that
during the prevalence of warm southerly winds blowing directly from the
river, there were more cases of the disease.” But Atlee then proceeded to
speculate on the etiology of the disease and identified “a few cases that
which in my opinion bear very decidedly upon this point.”54 These cases
demonstrated that he subscribed to the theory that cholera could be
spread by contagion.
In early August, a Lancaster city resident and her sister went to
Cleveland to help a daughter who had caught cholera. The daughter died
immediately after their arrival. She had been nursing a doctor who had
contracted cholera while helping victims of the disease and who boarded
in her house with his family. The doctor, his wife, and their child all died
of cholera, as did the daughter’s younger sister and hired girl. After settling
the daughter’s affairs, the women returned to Lancaster with the victim’s
five-month-old child and a bundle of the deceased woman’s clothes.
Shortly after her arrival in Lancaster, the child died of a cholera-like disease.
Within two weeks, four more members of the family died. All had
had contact with the child. Further supporting his suspicions about the
contagious nature of cholera was the fact that one of the dead family
members had worn a dress that had belonged to her diseased sister.
Another of the victims had contracted the disease after washing the
clothing that was brought from Cleveland. Atlee was convinced that the
disease was brought to Lancaster on the victim’s clothing and was spread
by contagion to the other family members. According to Atlee, “No case
of cholera existed in or near the city at this time, except at the hospital;
nor were there, at any time any cases in . . . the northwest portion of it.”
He did not believe that the cholera could have come from any other
source, as the house in which the family lived was in “a high and healthy
quarter of this city, but thinly built up, and having in its immediate vicinity
no stagnant water, nor source of miasma.”55
While discounting the idea that cholera was self-generating in filth,
Atlee did acknowledge the possibility that heat, moisture, putrefying animal
and vegetable matter, and improper cleanliness and diet could
encourage the spread of the disease.56 However, though he felt that filth
probably propagated cholera, Atlee thought that the disease itself was
imported and did not develop spontaneously in the locality. His study of
the cholera epidemics in Columbia and at the Lancaster County hospital
and almshouse led him to reassess his belief in the miasma theory and
caused him to hypothesize that the disease was spread through contagion
by immigrants passing through Lancaster on their way west. He posited
that these same immigrants carried cholera with them to Columbia,
infecting the inhabitants of the house that was burned down some weeks
before the epidemic struck. From this evidence Dr. Atlee concluded:
From a careful and unprejudiced survey of the above facts and circumstances,
it appears to me that but one conclusion can be arrived at—one
until now, opposed to my own opinion as to the etiology of cholera, viz:
That a specific poison emanating from the bodies of the sick, was eliminated,
which produced a similar disease in those who were exposed to it.
Call it contagion, infection, or by any other name we please, it has the
same characteristic properties as the poison of smallpox, of measles, and of
scarlatina—that of reproducing in those susceptible of its influence the
same specific disease.57
Atlee cited eminent British physicians who had great experience in the
treatment of the disease to justify further his conviction that cholera was
spread by contagion. He commented critically that “we have been
deceived upon this subject since its first appearance in India in 1817.”
One of these physicians,Dr. Copland of Edinburgh, had pointed out that
medical officers in India had sent “a mass of testimony which to his mind
was conclusive upon the contagiousness of cholera; yet those whose duty
it was to make up the general reports for publication, whether from preconceived
opinion, or from a different view of the testimony, strongly
opposed this idea, and attributed the diseases exclusively to atmospheric
influences.”58
Atlee’s medical studies in France in the early 1850s, where the theory
of epidemic contagionism was regaining support in medical circles,
undoubtedly helped to persuade him of the contagious nature of
cholera.59 Like Jackson, Atlee’s primary concern was to develop a rational,
scientific explanation for the means by which cholera was spread through
populations. They both advocated putting aside traditional medical theories
in favor of what would come to be regarded as an epidemiological
approach to the disease. As Atlee explained:
Let us endeavor, casting aside all preconceived opinion, to arrive at the
truth. The sooner it is known, the sooner shall we be enabled to contend
against this fell destroyer. It is only by the careful collection of facts in the
history of any epidemic, and the logical deduction from them, that correct
principles can be formed, and successful practice established.60
Unlike the doctors from the College of Physicians, whose preconceived
ideas about the causes of the disease and generalized beliefs about
filth resulted in hasty judgments about the source of the Columbia epidemic,
Atlee investigated the spread of the disease scientifically. He
described his research as an attempt to discover the etiology of the disease
and suggested that it was zymotic in nature. Atlee drew upon the new
medical methods to which he must have been exposed, either in Europe,
or perhaps from Professor Samuel Jackson, MD (no relation to Dr. T.
Heber Jackson), who was professor of the institutes of medicine at the
University of Pennsylvania. Professor Jackson had been sent to Montreal
in the spring of 1832 and was put in charge of cholera hospitals in
Philadelphia during the 1832 epidemic. At an emergency meeting of the
college to address the cholera crisis of 1849, Professor Jackson had called
for the lesions of the intestinal mucous membrane to be examined microscopically,
“systematically and thoroughly, without prejudice and unbiassed
by the authority of names or systems.”61 Atlee also called for an
unbiased scientific investigation of the cause of cholera, observing that
“the means of investigation are rapidly multiplying. Chemical analysis
and microscopic investigation are continually exposing the errors of earlier
observers, and unfolding new views of the phenomena of healthy and
diseased action.”62
While Jackson and Snow were using statistics and maps to present
their data, another methodology, microscopy, developed in Paris and
Berlin, was being used by Dr. Atlee in Lancaster to challenge the validity
of the miasma theory. Unlike most of his colleagues, Atlee either owned
or had access to a powerful microscope. By examining discharges from the
bowels and stomachs of different cholera victims, he discovered extremely
minute foreign bodies, which he suspected might be causing the disease.
Atlee did not speculate on whether these microscopic objects were living
organisms or merely chemical compounds. He sent a drawing of the particles
to Professor Jackson at the University of Pennsylvania.63
Atlee was not the first physician to observe microscopic particles that
he presumed were associated with cholera. Dr. William Budd described
the microscopic particles he discovered in the excreta of cholera victims
in 1849. Filippo Pacini published a report in Florence in 1854 in which
he described the cholera bacterium he found in the excreta and intestinal
contents with such accuracy that it still bears the name he gave to it. Snow
had read about Pacini’s discovery in December 1854 and, according to
historian Richard J. Evans, “at least four other scientists working along
similar lines in the 1850s also have a claim to be regarded as the discoverers
of the bacillus, though in every case their claim is a good deal less
strong.”64
Dr. Atlee appears not to have continued his microscopic research, perhaps
because like so many American doctors, the daily challenges and
demands of his medical practice consumed his time.65 Atlee and the other
researchers lacked the scientific methodology for furthering their investigations.
Neither Louis Pasteur’s seminal discovery that a disease organism
can be cultured outside the body nor Robert Koch’s perfection of the
pure-culture techniques for doing so had been developed. It would be two
decades before Koch created the analytical techniques needed to isolate,
examine, and propagate the cholera bacillus. He applied these medical
research methods to identify the cause of cholera definitively in 1883.
There is no written record of direct attacks from the medical establishment
upon Atlee and Jackson after the publication of their articles
challenging the orthodox view of cholera’s etiology. However, from the
comments of Hartshorne, Jewell, and others, there is little doubt that
many of the fellows of the College of Physicians strongly disagreed with
Atlee’s and Jackson’s conclusions. Atlee specifically referred to being challenged
by Philadelphia doctors because of an article he wrote proving that
cholera was contagious. In his “Reminiscences,” he recounted, “when in a
medical convention in Baltimore some of the Philadelphia physicians
took exception to an article that I had published to this effect in a med
ical review, I easily controverted them with an account of our experience
in 1832, and demonstrated that with a proper quarantine in Philadelphia,
Lancaster would have been protected from the spread of the disease hither.”66
In 1854, the editor of the York, Pennsylvania, People’s Advocate put
little faith in the powers of medical science to discover the cause of
cholera, “for the cure of the disease physicians have much or—if we
should judge from their want of success at Columbia—everything to
learn.” Considering how many years had passed since cholera first
appeared in America, “we almost despair of its ever being brought . . .
within the power of medicine.”67 Despite this pessimistic assessment, the
dispute over the etiology of cholera raised by Jackson and Atlee and the
question of contagion, quarantine, and public health that was so forcefully
argued by the doctors from the College of Physicians of Philadelphia
would be settled within the next two decades. The miasma theory would
fall into disrepute after the Civil War, invalidated by a new contagion theory
based on John Snow’s research and the growing acceptance of the
germ theory.What, to the editor of the York newspaper, appeared to be
the hopeless impotence of the medical profession should be seen instead
as an example of how scientific disputation and the application of the latest
medical theory and methodology permitted researchers to find the
cause of, and a possible prevention for, cholera.
As Ackerknecht has pointed out, in an era that saw the triumph of
anticontagion, the efforts of a handful of physicians to challenge the
miasma theory of etiology and their attempts to use scientific enquiry to
develop a valid contagion theory helped pave the way for the acceptance
of the work of Snow and others.68 Within a decade of the Broad Street
epidemic, Snow’s views would become accepted orthodoxy. Although the
work of Drs.T. Heber Jackson and John Atlee are little known, their challenges
to the miasma theory of cholera demonstrated a growing skepticism
of that paradigm, which led to its eventual rejection by the medical
community.

Millersville University

JOHN B. OSBORNE

 

1 Summary of the Transactions of the College of Physicians of Philadelphia, n.s., 2 (1856): 313;
Whitfield J. Bell, The College of Physicians of Philadelphia (Canton, MA, 1987), 97–98;Cummings’
Evening Bulletin (Philadelphia), Sept. 13, 1854; American and Commercial Advertiser (Baltimore),
Sept. 15, 1854; T. Heber Jackson, “Account of the Asiatic Cholera, as It Prevailed in Columbia,
Lancaster County, Pa., in the Autumn of 1855,” American Journal of the Medical Sciences 58 (1855):
336–47, reprinted as “Report of T. Heber Jackson, M.D.” in “Cholera in Lancaster and Columbia in
1854,” Journal of the Lancaster County Historical Society 62 (1958): 127.
2 Cummings’ Evening Bulletin, Sept. 13 and 14, 1854; Summary of the Transactions of the
College of Physicians (1856): 314.
3 Peter Baldwin, Contagion and the State in Europe, 1830–1930 (Cambridge, 1999), 2–3.
4 Ibid., 2–3, 127–28.
5 Erwin H. Ackerknecht, “Anticontagionism between 1821 and 1867,” Bulletin of the History of
Medicine 22 (1948): 567, 588–89.
6 Ackerknecht, “Anticontagionism between 1821 and 1867,” 565.
7 John B. Osborne, “Preparing for the Pandemic: City Boards of Health and the Arrival of
Cholera in Montreal, New York, and Philadelphia in 1832,” Urban History Review 36 (spring 2008):
31.
8 Ibid., 33
9 Baldwin, Contagion and the State in Europe, 127.
10 Osborne, “Preparing for the Pandemic,” 38.
11 Most prominent among these studies are: Peter Vinten-Johansen et al., Cholera, Chloroform,
and the Science of Medicine: A Life of John Snow (New York, 2003); Tom Koch, Cartographies of
Disease: Maps, Mapping, and Medicine (Redlands, CA, 2005); Steven Johnson, The Ghost Map:
The Story of London’s Most Terrifying Epidemic—and How It Changed Science, Cities, and the
Modern World (New York, 2006); and Sandra Hempel, The Strange Case of the Broad Street Pump:
John Snow and the Mystery of Cholera (Berkeley, CA, 2007).
12 Richard J. Evans, Death in Hamburg: Society and Politics in the Cholera Years, 1830–1910
(Oxford, 1987), 268; Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849,
and 1866 (Chicago, 1987), 193.
13 On Snow, see Vinten-Johansen et al., Cholera, Chloroform, and the Science of Medicine, 341.
14 Ibid., 334.
15 H. M. J. Kline, Lancaster County, Pennsylvania, A History (New York, 1924), 307–8, 314;
Frederic Shriver Klein, Lancaster County, 1841–1941 (Lancaster, PA, 1941), 33; Leroy Hopkins,
“Bethel African Methodist Church in Lancaster; Prolegomenon to a Social History,” Journal of the
Lancaster County Historical Society 90 (1986): 226; Jackson, “Cholera in Lancaster and Columbia
in 1854,” 123.
16 Jackson, “Cholera in Lancaster and Columbia in 1854,” 124; John L. Atlee, Report to the
Sanitary Committee of Lancaster County, May 26, 1855, Extracted from the Transactions of the
Medical Society of the State of Pennsylvania (Philadelphia, 1855), 7.
17 American and Commercial Advertiser, Sept. 15, 1854.
18 Cummings’ Evening Bulletin, Sept. 13, 1854.
19 Bell, College of Physicians of Philadelphia, 92–94; Elizabeth M. Geffen, “Industrial
Development and Social Crisis, 1841–1854,” in Philadelphia: A 300-Year History, ed. Russell F.
Weigley (New York, 1982), 318.
20 Summary of the Transactions of the College of Physicians of Philadelphia 2 (1849): 433.
21 Henry Hartshorne, On Animal Decomposition as the Chief Promotive Cause of Cholera
(Philadelphia, 1855), 7.
22 Ibid., 12.
23 Ibid.
24 The National Cyclopaedia of American Biography, vol. 8 (New York, 1898), 203.
25 Edward T. Morman, “Scientific Medicine Comes to Philadelphia: Public Health Transformed,
1854–1899” (PhD diss., University of Pennsylvania, 1986), 77–78.
26 Summary of the Transactions of the College of Physicians (1856): 260–61.
27 John A. Garraty and Mark C. Carnes, eds., American National Biography (New York, 1999),
s.v. “Rene La Roche,” by Smita Dutta.
28 Howard A. Kelly and Walter L. Burrage, Dictionary of American Medical Biography: Lives of
Eminent Physicians of the United States and Canada, from the Earliest Times (1928; repr. Boston,
1971), s.v. “Wilson Jewell.”
29 Ackerknecht, “Anticontagionism between 1821 and 1867,” 567.
30 Wilson Jewell, Historical Sketches of Quarantine. Address Delivered before the Philadelphia
County Medical Society (Philadelphia, 1857), 27.
31 Cummings’ Evening Bulletin, Sept. 13, 1854; National Intelligencer (Washington, DC), Sept.
16, 1854.
32 Cummings’ Evening Bulletin, Sept. 13, 1854.
33 Hartshorne, On Animal Decomposition, 8, 9, 11.
34 “Report by Dr. Morris to College of Physicians, 4 October 1854,” Summary of the
Transactions of the College of Physicians (1856): 314; Cummings’ Evening Bulletin, Sept. 13, 1854;
Jackson, “Cholera in Lancaster and Columbia in 1854,” 129.
35 Jackson, “Cholera in Lancaster and Columbia in 1854,” 129–30; Summary of the Transactions
of the College of Physicians (1856): 314; Cummings’ Evening Bulletin, Sept. 13, 1854.
36 Jackson, “Cholera in Lancaster and Columbia in 1854,” 123.
37 Rosenberg, Cholera Years, 120–21.
38 Necrological Report, vol. 3, Alumni Association of Princeton Theological Seminary
(Princeton, NJ, 1900), 126–27.
39 Ebenezer Erskine, God in the Pestilence, or Cholera a Visitation from God (Philadelphia,
1854), 2, 12, 13–18.
40 Ibid., 11, 19, 30.
41 York County Star and Wrightsville Advertiser, Sept. 21, 1854; Inland Weekly, Sept. 30, 1854.
42 Charles Rosenberg, “The Cause of Cholera,” in Sickness and Health in America: Readings in
the History of Medicine and Public Health, eds. Ron Numbers and J. W. Leavitt (Madison, WI,
1978), 261.
43 Harrisburg Morning Herald, Sept. 12, 1854; Lancaster Examiner and Herald, Sept. 13, 1854.
44 York Gazette, Sept. 12, 1854; Cummings’ Evening Bulletin, Sept. 12, 1854; Jackson, “Cholera
in Lancaster and Columbia in 1854,” 124.
45 Ibid., 124, 125–26; Vinten-Johansen et al., Cholera, Chloroform, and the Science of Medicine,
352.
46 Jackson, “Cholera in Lancaster and Columbia in 1854,” 124, 132.
47 Koch, Cartographies of Disease, 90–101.
48 Jackson, “Cholera in Lancaster and Columbia in 1854,” 126.
49 Ibid., 125–26, 127.
50 Garraty and Carnes, eds., American National Biography, s.v. “John Light Atlee,” by Monique
Bourque; Martin Kaufman, S. Galishoff, and T. L. Savitt, eds., Dictionary of American Medical
Biography, vol. 1 (Westport, CT, 1984), 20.
51 J. D. B. DeBow, Statistical View of the United States; A Compendium of the Seventh Census
(Washington, DC, 1854); Klein, Lancaster County, 17–26
52 Inland Daily, July 29, 1854.
53 Atlee, Report to the Sanitary Committee of Lancaster County, 4.
54 Ibid., 4–5, 8.
55 Ibid., 5–7, 9.
56 Ibid., 8–9.
57 Ibid., 7–8.
58 Ibid., 9.
59 On medical theory in France, see Baldwin, Contagion and the State in Europe, 147.
60 Atlee, Report to the Sanitary Committee of Lancaster County, 9.
61 Bell, College of Physicians of Philadelphia, 97.
62 Atlee, Report to the Sanitary Committee of Lancaster County, 9–10.
63 Ibid., 10
64 Kenneth F. Kiple, ed., The Cambridge World History of Human Disease (Cambridge, 1993),
643; Vinten-Johansen et al., Cholera, Chloroform, and the Science of Medicine, 303; Evans, Death
in Hamburg, 268.
65 W. F. Bynam, Science and the Practice of Medicine in the Nineteenth Century (Cambridge,
MA, 1994), 102.
66 “70 Years in Medicine, Reminiscences of an Active Professional Career in Lancaster,”
Lancaster Historical Society, MG22, 4.
67 People’s Advocate, Sept. 19, 1854.
68 Ackerknecht, “Anticontagionism between 1821 and 1867,” 590.