Faeces with your fish, madam?
Excrement with your ice cream, sir?

While these were not menu options you would expect to be offered in Victorian London, there was a reasonable chance you might have got them anyway. London was the largest city in the world in the 1800s, a city overwhelmed by the waste products of its ever-growing population. Overcrowded into decaying, stinking slums, the poorest citizens were literally surrounded by their own filth. Piled up in courtyards or overflowing from basement cesspits, into which toilets were drained, raw sewage was everywhere, and so was its stench.

The spread of cholera

In such conditions disease was inevitable, but Victorian London's experience of cholera in 1832 would have a huge social impact. Spread via the bacteria-laced diarrhoea of its victims, cholera's violent and rapid assault on the human body was terrifying. Although it killed fewer than other contemporary diseases - such as influenza or - it was cholera that provided a deadly backdrop to this era of social and economic upheaval. There was no known cure - although plenty were offered by quacks. Commonly known as Asiatic cholera, it seized the public's imagination with India, supposedly the crown jewel in Britain’s expanding empire, identified as its origin.

Poor housing and slums in London

The appearance of cholera prompted debate about the nature of the emerging society. From the slums of India to the equally filthy slums of London, was this the price to pay for the gruesome urban landscapes being created in Britain? And for the ruling classes, the dark, hidden alleyways of much of London were just as strange and exotic as the back streets of Delhi. In the wake of the 1848-49 , social reformer Henry Mayhew voiced the connection, describing the centre of the outbreak, Bermondsey, as "the very capital of cholera, the Jessore of London" - Jessore being the Indian town from where a major cholera was believed to have originated in 1817. Driven by a combination of genuine concern for the poor and self-preservation by the elite, the fear of cholera became a crucial element in the development of public health in Britain. It inspired some of the first investigations into the living conditions endured by much of the population.

Chadwick: the link between disease and living conditions

In the wake of the cholera epidemic, leading social reformer Edwin Chadwick was commissioned to inquire into the state of public sanitation. His report, 'The Sanitary Conditions of the Labouring Population' (1842), made a clear link between disease and living conditions and he called for urgent action. By 1848, when the 'Times' was describing cholera as 'the best of all sanitary reformers', Chadwick had been appointed to the first Board of Health and was Sanitary Commissioner of London. He now had the power to change things. But his actions were firmly guided by the miasma theory of disease. To eliminate sources of foul air through which diseases were thought to spread, he supported the rapid removal of human waste through improvements to the disorganised sewage and drainage systems. Unfortunately this led to a greater flow of raw sewage into the River Thames - the main source of drinking water for London. By further contaminating London's water supply, the risk of cholera was greatly increased.

Snow and the study of the spread of diseases

Unlike many of his contemporaries, Dr John Snow was no miasmatist - he publicly stated in 1849 that cholera was transmitted through water. He was already researching links between water supply and deaths from cholera when the disease returned in 1854. This time, a single water supply - the Broad Street pump - was contaminated by a single domestic sewer pipe. As a result, hundreds of local people were rapidly poisoned after visiting the well, or from eating or drinking the products made using its waters. The outbreak provided Snow with the ammunition to confirm his theory.

Parliamentary action - a new sewer system

Unfortunately the importance of Snow's work was not immediately recognised; the belief in miasmas would last for a little longer. Appropriately it was the Great Stink of 1858 that ultimately banished cholera for good. Unable to ignore the stench of the Thames and fearful of the miasmatic belief that 'all smell is disease', parliament sanctioned one of the century's great engineering projects - a new sewer network for London. Designed by Joseph Bazalgette, the first section was opened in 1865.

The slow effects of government intervention

The following year cholera returned one final time. The circumstances both justified the expense of Bazalgette's sewers and provided further evidence for Snow's theory, evidence that would persuade leading sceptics, including pioneering epidemiologist William Farr. The victims of this outbreak were almost entirely confined to areas of east London not yet connected to the new sewers. These slum dwellers were left with little option but to drink water contaminated by the faeces of fellow Londoners. For them - as for thousands of their London predecessors, and their Indian counterparts - reform simply didn’t come quickly enough.