Edward Ballard and the Practice of Epidemiology in the 19th-Century United Kingdom

Abstract

This article recovers the history of Victorian epidemiology through the career of British physician Edward Ballard (1820–1897). Ballard’s career provides a useful window into the practices of epidemiology in the 19th century because he held notable public health posts as medical officer of health for Islington and inspector at the Medical Department of the Local Government Board. By the time of his death, in 1897, he typified the transition toward professional epidemiology. In exploring some of the most important environmental and health-related problems in preventive medicine in the 19th century, Ballard was part of a group of influential epidemiologists who studied infectious disease. In particular, he was noted for his research into typhoid fever and industrial health. Yet Ballard’s career has largely been forgotten. In this article, I explore Ballard’s work as a window into the everyday practices of Victorian epidemiology and suggest that the process of professionalizing epidemiology in the 20th century was about forgetting epidemiology’s Victorian past as much as it was about championing it.

Edward Ballard (1820–1897) occupies a curious place in the history of epidemiology. Known during his life as a leading British epidemiologist, he is seldom mentioned today. Born in 1820 to a middling family who resided in the north London suburb of Islington, Ballard apprenticed with a workhouse medical officer. At age 19 years he entered University College London, receiving an MD in 1844. From there, he plied his trade in private practice, with posts at the St. Pancras Royal General Dispensary, St. George’s Hospital, and University College London. He was inducted as a fellow of the Royal Medical and Chirurgical Society of London in 1848, joined the New Sydenham Society and the Epidemiological Society, and was elected into the Royal College of Physicians in 1853. It was his appointment as Islington’s medical officer of health (MOH) in 1856 that began his career in public health. Ballard began practice shortly after John Snow’s hypothesis as to the waterborne nature of cholera, and during William Budd’s most prolific period of epidemiological activity on typhoid fever. Ballard spent 16 years as the MOH for London’s largest metropolitan district, and was one of the most assiduous MOHs in London and most outspoken members of the Metropolitan Association of Medical Officers of Health. During this time, Ballard honed and tweaked inductive epidemiological methods, providing a model for epidemiologists of his time. The first part of this article focuses on Ballard’s time as MOH.

Ballard gave up life as an MOH in 1871; by then, he was known as “among the foremost representatives of English sanitary knowledge and practice.”¹ He was 50 years old, and accepted an invitation from John Simon to join the Medical Department of the Local Government Board. Ballard’s work as a government epidemiologist forms the subject of the second part of this article. He spent the next—and last—20 years of his life working what he called “out-of-doors” conducting outbreak investigations throughout Britain. Department inspectors considered themselves the first professional epidemiologists. They were polymathic in their sanitary scope. From 1871, Ballard studied the etiology of cholera, typhoid fever, diphtheria, scarlet fever, and infantile diarrhea. He investigated smallpox vaccination—and revaccination—and a gamut of urban-industrial pollutants. He worked alongside many leaders in British public health, including John Burdon Sanderson, William Farr, Edward Klein, Richard Thorne Thorne, Edward Seaton, and John Netten Radcliffe.

When he died in 1897, epidemiology had come of age and was contending with laboratory-based bacteriology. And although he had adduced no law for the statistical distribution of disease, or scheme for its determinants, Ballard’s career serves as a microcosm of broader developments in British public health. He worked tirelessly to use epidemiological methods to campaign for sanitary reform and state medicine, and although certainly not alone in that task, he was often in the thick of professional debates. Upon Ballard’s death, Simon reflected that “my impression is that in times long after our own, Dr. Ballard will be recorded as one of the chief confirmers and extenders of the sanitary science of his age.”²

Ballard gets very brief mention today, perhaps because he was, to use Simon’s phrase, a “confirmer.” But his career trajectory—from urban MOH to nationwide inspector for the Local Government Board—and his willingness to adapt and innovate epidemiological methods—from inductive to deductive approaches—helps us to understand the broader ways in which epidemiology was professionalized in the 19th century.³ Ballard’s was a workmanlike career, an “arduous devotion to the interests of public health.”⁴ And, although we may not consider him one of the “great” epidemiologists, Ballard was at the center of a nexus of British epidemiologists—working as MOHs and for the Local Government Board—who formed the generation after John Snow and William Budd that pushed epidemiological theories and practices to the center of preventive medicine.

THE INDUCTIVE METHODS OF THE MEDICAL OFFICER OF HEALTH

In his first annual report as MOH for St. Giles, George Buchanan, later Ballard’s supervisor, noted in 1857 that an MOH can never be popular as “his functions bring him into constant collision with the apparent interests of many influential persons, and he is gratefully welcomed only by the poor.”⁵ Liverpool was the first city to have an MOH, appointing William Henry Duncan in 1847. London followed in 1848, electing John Simon. Although largely permissive, the Public Health Act of 1848 expanded the appointment of MOHs in 38 cities. By the mid-1850s, as Anne Hardy has argued, the London Metropolitan Medical Officers of Health Association forged a corporate identity.⁶ In his capacity as MOH, Ballard was an eclectic mix of original researcher, reformer, and administrator, a combination that provided a rubric for later progressive MOHs such as Arthur Newsholme—MOH for Brighton in the 1890s—who John Eyler has categorized as an “applied epidemiologist.”⁷ Ballard was not alone as a progressive MOH, and his methods and advocacy were similar to those of Henry Letheby, John Syer Bristowe, and George Buchanan.

In his years as MOH, Ballard held eclectic etiological views, best described by the term “contingent-contagionism.” This approach relied on what Michael Worboys notes was a “seed and soil” metaphor, whereby infectious diseases were understood to be specific entities with disease-causing “seeds” (sometimes called “animal poisons” by William Farr and “germs” by others, including Ballard) that underwent fermentation-like periods in the environment before being infective to humans via either air or water. Such an approach was linked to the Bavarian hygienist Max von Pettenkofer. Farr’s term “zymotic” characterized this view in England, which Eyler argues was representative of most British physicians around midcentury.⁸

Although his views were eclectic, Ballard was keen to use vital statistics to solve local problems. For example, the office of the registrar-general officially distinguished typhoid and typhus fever in 1869, yet Ballard had recognized as early as the late 1850s that typhoid was

a distinct disease characterized by certain specific changes in the glands of the intestines . . . connected more or less closely with the emanations from decomposing organic matter and organic impurities in the water that is drunk.⁹

Edward Ballard

Source. “Obituary for Edward Ballard,” Lancet (January 30, 1897): 342–343.

In his original investigations of rinderpest in 1865 and 1866, he was adamant that the disease was caused by a specific poison. Yet, like most MOHs, he was cautious in adopting a singular germ theory, and held until his career at the Local Government Board that air and water were disease mediums. His inductive methodology led him to consider disease mediums broadly. In his years as MOH, his epidemiological fieldwork—and the empirical evidence he gleaned from it—directed his etiological views, not the other way around.

Ballard was an early adopter of using differential mortality and morbidity statistics, disease spot maps, and observational case-tracing. Each year he calculated death rates, tabulating deaths adjusted by age at death (into periods of one year up to age five years, thereafter quinquennially), gender, class, and occupation. He corrected the comparative mortality statistics by subdistricts and street-by-street comparisons according to socioeconomic status, extending novel statistical methods pioneered by Farr at the Registrar-General’s Office. This allowed Ballard, for example, to determine case-fatality risks within subgroups of the local population, as well as the risk of dying in each of the eight wards in the parish.¹⁰ Whereas many MOHs simply reprinted data from Farr’s office, Ballard produced his own to further group comparison, which Alfredo Morabia has recently argued was “epidemiology’s greatest contribution to health care and public health.”¹¹

Like other MOHs, Ballard used group comparisons to advocate reform. He found in 1856, for example, that half of all Islington deaths took place in those younger than five years; within that group, half were in the first year of life. The rate of dying for all residents of Islington in 1857 was 17.7 per 1000; the same rate for children younger than five years was 60 per 1000. Although mortality statistics and death rates were powerful indicators, Ballard bemoaned that they were imperfect indexes of the health of a population. “If then, it were possible to collect the experience of the profession from time to time,” he argued, “we should be in possession of a mass of facts from which we might positively declare how many persons were sick, from what complaints, and with what result.”¹² Ballard had identified one of the chief problems of Victorian epidemiology, a dearth of morbidity statistics. Trying to more accurately gauge the health of Islington through sickness rates, Ballard forged close networks with local institutions like the Holloway and North Islington Dispensary, the local workhouse, the Pentonville Prison, and the local fever hospitals. As Graham Mooney has recently shown, there was greater interest in the use of morbidity statistics than we have previously assumed, a point corroborated by Ballard’s career as MOH.¹³ Although he was not alone in noticing the insufficiency of mortality rates, his data from Islington contributed to long-running debates about the use and collection of vital statistics.

Epidemic crises, such as the final visitation of cholera to London in 1866, also help to situate Ballard’s career as MOH.¹⁴ He first submitted to the local authority a joint memorandum issued by the Metropolitan Medical Officers of Health, which he had in part drafted, and a handbill on disinfection. Acting on the Medical Department’s cholera order, he and his team helped to disinfect local houses. Through intricate case-tracing and statistical analysis, Ballard provided Islington officials with an account of cholera’s spread. He identified what he believed was the index case, a local washerwoman who worked in the East End, and calculated 341 total local attacks and 75 deaths, including what was deemed true cholera (60% fatality rate) and “choleraic diarrheoa” (4% fatality rate).¹⁵

Ballard constructed a multivariable cholera “sanitary map” of Islington (he was one of the only metropolitan MOHs to do so), where he marked both cholera deaths and confirmed cases of cholera in which the patient recovered. Inductive in its approach of gathering specific examples to draw a general conclusion, the map marked lines of elevation and a host of symbols on the houses of the parish in relation to cholera morbidity and mortality. Ballard measured houses inhabited by “a low and negligent population,” those “partially by a low and negligent population,” large and small houses, new houses in construction, and persons occupying each house. Throughout his subsequent career, Ballard relied on visual techniques of understanding disease, from statistical charts and spot maps to diagrams and later photographs.

The visual data showed that the incidence of cholera was concentrated in three areas of the parish, all low-lying in elevation and predominately lower-class, with houses that had small, close, confined rooms. Ballard argued that cholera had spread westward to Islington from the East End of London, from a lower elevation “gradually rising, as a ground mist would do, towards our higher level,” placing him in conversation with Farr’s elevation theory of cholera.¹⁶ During an earlier outbreak of cholera, in 1849, Farr had introduced an elevation law for cholera, arguing that cholera deaths would be greater at lower elevations and decrease among inhabitants with higher soils. By the 1866 outbreak, Snow’s waterborne hypothesis had been bolstered by William Budd and a host of MOHs, leading to “partial accommodation” to Snow’s theory and an acceptance of both air and water as mediums. The 1866 cholera outbreak, as Eyler has argued, “proved decisive in establishing the water-borne theory for cholera.”¹⁷ Ballard’s study was representative, in that he acknowledged the role Farr had attributed to elevation in relation to cholera, but, finding it unsatisfactory, turned toward a waterborne explanation.

Ballard’s eclectic etiological views in 1866 still held that cholera might have made its way to Islington via the air, but spread in the parish via water. “One, at least,” he argued, “of the modes in which it [cholera] gains access to the system, is through the contamination of drinking water by the viruses of the disease.”¹⁸ Here, Ballard stood alongside Farr in adapting to the waterborne hypothesis; neither one went as far as contemporary John Netten Radcliffe, whose investigation of the 1866 outbreak for the Medical Department focused solely on proving the role of infected water. Ballard had demonstrated a middle-of-the-road compromise common to MOHs at the time, although we can say that his focus on the movement of the disease via mediums put him on the cusp of spatial thinking. Each new case of cholera, he argued, had the potential to be a new “centre” of infection.¹⁹

In his last year as MOH, Ballard conducted his most well-known and widely celebrated investigation of an outbreak of typhoid fever, which he traced to an infected milk supply.²⁰ Ballard’s fellow MOH at the time and future superior, George Buchanan, called the work “the best and clearest piece of Medical reasoning he had ever heard,” and later Richard Thorne Thorne noted that Ballard’s Islington study was “a masterpiece of medical logic.”²¹ Ballard only considered milk as a medium because of his inductive epidemiological methods: “[A]fter considering every other possible theory of the cause of the outbreak,” Ballard “was forced to the conclusion that it was in some way connected with the milk.”²² That Ballard was willing to consider the role of infected milk in spreading disease is perhaps unsurprising considering his expanding toolkit. As MOH, he was interested in what we would now call the ecology of urban-industrial health. From his earliest reports as MOH, Ballard had been keen to regulate specific nuisances originating at the Holloway Cattle Market and the glue-making, soap-boiling, pottery, and varnish factories of Belle Isle.²³ A founding member of the metropolitan MOHs’ Committee on Trade Nuisances, Ballard was a witness for the Royal Commission on Rinderpest in 1866 and a close ally with the sanitarian and veterinary expert John Gamgee. The logical jump to milk as a disease medium was consistent with his inductive approach of examining a variety of variables before coming to an etiological conclusion.²⁴ Simon went as far as to say that Ballard had found “a new line of epidemiological accuracy.”²⁵ However, his 1871 investigation also marks the beginning of a change in Ballard’s approach to epidemiology, from an inductive process of gathering data and forming conclusions to a deductive process of eliminating variables to isolate the route of communication.

Ballard understood epidemiology as a set of powerful political practices rather than a cogent profession. An MOH, Ballard thought,

has not only to point out where disease (fatal or otherwise) prevails, to lay his finger on the very streets, courts, or houses, but also to say why it presents itself where it does, to distinguish among its several causes those which the legislature has empowered the local authority to remedy, and those which can only be removed or guarded against by measures adapted to call into exercise the intelligence of the people and to rouse them to individual effort for the private maintenance of health.²⁶

Ballard Statistical Tables, 1865

Source. E. Ballard, Report on the Sanitary Condition of St. Mary, Islington During the Year 1865 (London, UK: J&I Tirebuck, 1866).

Ballard represented the majority of MOHs in advocating an inductive approach of localizing where disease exists followed by theorizing why it was present. The political dimensions of public health in this period were dependent on epidemiological methods: locating disease in individuals as well as populations, and “rousing” individuals and officials into sanitary action. John Welshman has argued that this kind of public health work was influential well into the 20th century.²⁷

DEDUCTIVE METHODS AT THE MEDICAL DEPARTMENT

Ballard’s life radically changed when he began work at the Medical Department. From 1858, Simon, the Chief Medical Officer of the Medical Department, sought to “develop a scientific basis for the progress of sanitary law and administration.”²⁸ The department had two duties: to superintend the public vaccination of 3500 vaccination districts and to investigate outbreaks of epidemic disease.²⁹ Relying on a part-time inspectorate for a decade, in 1869, Parliament approved the employment of six permanent staff, including Edward Seaton, George Buchanan, John Netten Radcliffe, and John Burdon Sanderson.³⁰ In 1871, Simon appointed three additional inspectors, one of whom was Ballard.³¹ In part, the use of sickness data was what propelled Ballard into his career post at the Local Government Board. In 1869, he sent a copy of a 12-year statistical study of Islington sickness to Simon, who saw that Ballard could play a critical role in defining the nation’s health.³²

The department’s investigations were remarkably consistent; most inspectors shared the belief that infectious diseases were caused by living “germs” that followed particular distribution patterns. Searching the known routes of transmission, inspectors would falsify each through a deductive process until they found the probable cause. Ballard and his colleagues were at the forefront of the transition in epidemiology, going from providing weak causal inferences to providing strong ones.

Whereas his MOH post kept him confined to walking the Islington streets, as inspector Ballard was responsible for traversing the entirety of Britain. There was both breadth and depth to this epidemiological work, but the hectic life of a traveling epidemiologist slowed for Ballard in the mid-1880s—he was by then in his 60s— and he gradually conducted fewer outbreak investigations. He spent the last two decades of his life enamored with the health effects of industrial pollution, no doubt sparked during his time as MOH.

Following a parliamentary investigation by the Committee on Noxious Business in 1873, Simon tasked Ballard with exploring the “nuisances which arise in connexion with various manufacturing and other branches of industry, specially with regard to the effect upon health.”³³ He began the study in 1875, in addition to his normal slate of outbreak investigation. For Ballard, it was an unprecedented study in scope and methodology, one that took a groundswell approach. It was also unique at the Medical Department: Simon had entrusted other members of the department to conduct “auxiliary” scientific studies, but such investigations were typically chemical (by J. L. W. Thudichum), pathological (Burdon Sanderson) or bacteriological (E. E. Klein and A. C. Houston). It was Simon’s vision in the mid-1870s—himself at the end of his formal career in public health—for Ballard to conduct an epidemiological study into industrial health. What united both was their former experience as MOHs.

While on outbreak investigation, Ballard would also visit the local industries, such as slaughterhouses, abattoirs, and piggeries. He left few industrial areas of Britain untouched, visiting Leeds, Manchester, Bristol, Reading, Hull, Liverpool, Lancaster, Glasgow, Portsmouth, Birmingham, and Nottingham, among others, keeping copious notes as to the condition of each factory, the neighborhood, and the health of the population. At times he even took photographs.

Ballard periodically published updates in the Annual Reports of Local Government Board, and in 1882 in Effluvium Nuisances. Ballard, by then expert at sleuthing local outbreaks of disease, was challenged to frame the problem of industrial health. He would have been familiar with Henry Mayhew’s journalistic probing into the relationship between urban environmental conditions and poverty, but Ballard was unique in searching—with the urban ecological geography of the nation as his canvas—for the direct ways that industry might cause disease.

It was a test to his epidemiological methods as well as his etiological views. The majority of MOHs believed that industrial effluvia, particularly those produced by decomposing animals, produced disease in humans. Until the early 1870s, Ballard had favored the process of inductive reasoning, gathering specific observations about an outbreak before making general theories. This was shaken in his investigation of industrial nuisances. In his first official publication on industrial health, in 1878, he lamented,

It must be at once apparent that it is not practicable to apply the pure method of induction to the solution of the present problem. I have myself been unable, in the time at my disposal, to gather together a sufficient basis of unquestionable facts and duly to differentiate the influence of concurrent morbific conditions; and the opinions of medical men, in a position to form just opinions from facts under their local observation, have not been found always to agree in respect of the influence exerted by particular kinds of trade effluvia. . . . The method of induction, however, is not the only method which may be adopted in this report. We are at liberty to look at probabilities, and, arguing partly deductively, to take into consideration the question how far offensive trade effluvia can be regarded as falling into some category to which an established axiom is applicable.³⁴

By the mid-1870s, he was moving into the direction of deductive reasoning. “Statistical argument is practically inapplicable,” he noted, and turned toward case-tracing, environmental description, and interviews with business owners, factory managers, and employees.³⁵ He consulted local MOHs, carrying decades-long correspondences with David Davies, MOH of Bristol, for example, and James Russell, MOH of Glasgow.

Searching for noxious effluvia, Ballard was struck by miasmatic influences not only on local inhabitants but even on himself in the course of his investigation. In his report to the Local Government Board in 1878, he mentioned that the odors from catgut scraping and fish liver oil manufacturers

adheres to the person and clothing for a long time after a very few minutes visit to one of these houses. . . . I myself on one occasion of a visit to such an establishment had the greatest difficulty to restrain vomiting, and the memory of the smell almost makes me feel sick as I recall it.³⁶

But did such smells cause disease? Gut-scraping factories produced the worst kind of effluvia, yet Ballard could find no link in towns across Britain between “putrid animal effluvia” and “septic disease.” Although these smells made “a strong impression on the senses,” Ballard argued that “I have had no satisfactory evidence given me of injury to health of a deeper kind.”³⁷

This was a difficult position to be in; Ballard was repelled by the “nuisances” produced by melting-houses and catgut scrapers, but the fumes alone, he found, were not disease mediums. The difficulty was in making the case for sanitary reform: condemning filthy industrial factories while at the same time concluding that bad smells did not directly cause disease. Ballard’s research into industrial nuisance was a departure from that of his well-known contemporary John Snow, who Ballard once called “my old friend.”³⁸ Before the Parliamentary Select Committee on the Nuisances Removal Act, Snow argued that the effluvia produced by offensive trades were not public health threats directly leading to epidemic disease. As David Lilienfeld has shown, Snow’s stance angered Thomas Wakley and the Lancet, who saw Snow as siding with traders and manufacturers rather than public health reform.³⁹ Etiologically, Ballard and Snow had reached the same conclusion; where Ballard departed was in taking a broader view of environment and disease.

Ballard was not blindsided by the potential long-term health-related effects of industry. Perhaps, he argued, the immediate effects of breathing noxious smells were localized to headache or vomiting, but the more serious health effects came months or years later. He could prove bodily discomfort, or temporary functional disturbance, but not the shortening of life. Ballard’s conclusions would not be validated until well after his lifetime, yet by the early 1880s he saw the path forward: scientific knowledge, money, and regulation.

CONCLUSIONS

When he officially retired, in January 1892, Ballard had been in public health for more than 35 years. He was granted a retirement allowance of £400 per year, and the Local Government Board noted in a private memo, “The Board desire to place on record on the retirement of Dr. Ballard their high appreciation of the zeal, fidelity and ability which have always marked the discharge of his official duties.”⁴⁰ Yet Ballard’s life was not one of public acclaim, in spite of the fact that his research into typhoid and industrial health had made lasting impacts on public health. In 1887, Chief Medical Officer George Buchanan pleaded with Ballard to accept a promotion to assistant medical officer, which would have put Ballard in line to become chief medical officer. He refused, stating that he had not yet fulfilled a “mission . . . to add my quota of labour to the clearing-up of some obscure questions as to the causation of disease.”⁴¹ Ballard was never the figurehead, but rather the tireless plodder on the street, sniffing out noxious fumes and wading into filth-laden mews.

By the 1930s, British epidemiology was at least in part Sherlockian, deductive even as it became influenced by biostatistics with the likes of Austin Bradford Hill.⁴² Although he was in the vanguard, the course of Ballard’s career maps onto the broader challenges in establishing epidemiology at the center of local and state medicine. Ballard, like many other understudied Victorian epidemiologists, was instrumental in that uneven historical process. This does not make him a “great epidemiologist,” but instead forces us to reconsider the practices of 19th- and 20th-century epidemiology on the ground, and what impact they had on populations and governments.