William Budd published his paper on malignant cholera a month after Snow’s paper entitled On the Mode of Communication of Cholera1 appeared. As Budd explains in a footnote on page 19, Snow’s paper came into his hand while preparing his own work. With reference to transmission of the disease by faecally contaminated water, Budd clearly states that Snow must have ‘the whole merit’ of being the first to develop the conclusion ‘as to the part which water plays in diffusion of the disease’. The question as to priority was to occur again in 1856 with the publication of an address to the Manchester Medical School by Sir James Kay-Shuttleworth, in which he gave credit to Budd for first putting forward the faecally contaminated water theory.2 Allison had made the same assertion in the Edinburgh Medical Journal. Snow, a sensitive character, wrote at once to repudiate these views, writing in the Lancet3 ‘As my researches respecting cholera were conducted with great labour and very much to the detriment of my more immediate interest (i.e. private practice) I feel it a duty not to allow the credit for them to pass from me by a mere mistake’. This letter was promptly followed by one from Budd4 stating ‘There can be no question the Dr Snow was the first to publish the view that cholera is propagated by the specific discharges from the sick’.
Yet it is certain that Budd from his experiences as a student in Paris from 1828 to 1832 was fully cognisant of the danger of contaminated water. He set up practice in Bristol in 1842, at that time a city filled with insanitary dwellings, fever-ridden streets and narrow dark lanes. The houses were crowded together round damp courts with no decent drainage and water only available from a single pump. Many houses in the centre of the city backed onto the river Frome and their privies discharged into this stream that supplied many of these pumps. There were frequent outbreaks of diarrhoea, typhoid was endemic and the city was an easy prey to cholera. A parliamentary commission took evidence from Budd and he gave them a vivid description of conditions in the city. To rectify this situation, the Bristol Waterworks Company was established in 1845 with Budd as one of the original directors.5 Before accepting this appointment he insisted that the water should be drawn from sources beyond the reach of sewage contamination and that it should be delivered under constant pressure. This was achieved by bringing water from the Dundry hills outside the city. Thus it is apparent that, before the 1848 epidemic of cholera, William Budd was fully aware of the lethal properties of contaminated water.
Budd delayed publication of his paper on cholera to allow his colleagues Joseph G. Swayne6 and Frederick Brittan7 to announce their microscopical observations on the stools in the disease. This was a time when greatly improved compound microscopes were becoming readily available. The Bristol Microscopical Society had been founded in 1843 and became closely linked with the Bristol Medico-Chirurgical Society and was commissioned to investigate the stools in cholera.8 The objects they observed, illustrated in Figure 1 of Budd’s paper, were thought to be fungi and they concluded that these were the cause of the disease. This was an idea proposed by a Dr Charles Cowdell in 1848, and Budd and his colleagues enthusiastically embraced it. Alas, it was a mistake that was to influence Budd for many years and was said to delay the publication of his views on the infectious nature of tuberculosis. The second erroneous conclusion Budd drew, mentioned in both his 1849 and 1856 papers, was that, in addition to propagation by water, cholera was also caused by contaminated air.
These two misconceptions should not detract from the other conclusions that he enunciated in his papers. His description of the pathogenesis of the disease is as apt today as it was in 1849. He stated that cholera was a disease caused by a living organism of distinct species and this, before the days of clinical bacteriology, was not a concept universally accepted. It is unfortunate that the observations of the Bristol microscopists did not include the masses of the Vibrio that are indeed to be found in the stools of cholera patients. Budd’s realization that the infecting organism was confined to the alimentary canal, and was not found in the blood, was crucial to understanding cholera. This was in contrast to many other infectious diseases, in particular typhoid, where he realized that spread of organisms in the blood was an essential feature. This lack of involvement of the cholera organisms in the blood provided one reason why later attempts at immunization by means of intramuscular injection of vaccine were doomed to failure.
Although this was years before the discovery of enterotoxins, Budd was convinced that the offending organism acted only on the intestinal mucosa. He mentions the profound loss of fluid into the intestine from the blood and the consequent dehydration. In subsequent papers he draws attention to the dramatic effects of intravenous saline, something also referred to by his brother George in an article written in 1840.9 George wrote ‘The immediate effects of this treatment are very striking and show that a large share of the symptoms of malignant cholera is due to loss of the serous part of the blood’.
Budd’s final conclusion that the organisms are disseminated through society in the air, in contact with articles of food and principally in the drinking water, requires some comment. The conundrum remains concerning his views on propagation of the disease by air. He did not think the organism was inhaled, indeed he advanced this as a reason for it not gaining access to the blood. He postulated that the pathogen was swallowed. This misconception may have been a relic of the education he received in Paris and Edinburgh regarding miasmata. Facts drilled into medical students are difficult to displace and this was especially true in the Victorian era.
By the time of the 1854 epidemic Budd’s views on the nature of cholera had not been universally accepted, but this did not stop him instituting measures then and in 1866 for the prevention and containment of the disease.10 He insisted that ‘all discharges from the body to be taken into vessels containing zinc chloride’. Budd was adamant as to the importance of personal hygiene and he emphasized the importance of handwashing and general cleanliness being observed by both doctors and nurses. He realized at this early date, before the advent of clinical bacteriology, that cholera and typhoid could be transmitted by faecally contaminated fingers and fomites. Of even more significance, he insisted that all drinking water should be boiled. Finally he advocated the treatment of sewage with chlorine gas, a measure originally recommended by William Herapath, a lecturer in chemistry at the Bristol Medical School. That these procedures were very effective in controlling the epidemics of 1854 and 1866 is evident from the mortality figures. In 1849 there were 1979 deaths, in 1854 there were 430 deaths and in 1866 only 29 deaths.
William Budd was a man with a great social conscience, as illustrated in the concluding paragraph of his 1849 paper. The principles that he enunciated were ones he carried out in his personal life. This was evident not only in his private practice in Bristol but in his concern for British troops involved in the Crimean war where cholera was responsible for many deaths before the army engaged in any fighting. Alas, the hygiene measures he suggested to those in charge for the medical arrangements for the expeditionary force were largely ignored.
In Britain he is renowned for his studies on the pathology, diagnosis and prevention of typhoid fever.11 In Bristol he was influential in the appointment of a medical officer of health, in improvement in the quality of nursing care and in the training of medical students. He was among the first to realize the importance of personal transmission of infectious diseases such as tuberculosis and scarlet fever and was insistent on isolation of such cases in prevention of their spread. Budd was of the firm opinion that examination of a small community was likely to be more fruitful in studying the spread of epidemic disease than working with enormous numbers in the metropolis. One of the reasons he chose to settle in Bristol was that he realized the value of one practitioner seeing all the cases if the origin and progress of an epidemic were to be monitored. This was possible in a country practice or among the relatively stable population in a city the size of Bristol at that time. His great interest in prevention of disease was stimulated by his scepticism of much of the current therapy, and he was one of the first to advocate a controlled clinical trial. He suggested that skin diseases were especially suitable for assessment by this method as many dermatological conditions affected the body symmetrically (letter to Richard Budd, 30 November 1843. Wellcome Institute, reference WMAC 5153/A/33). Thus the efficacy of any local application of ointment could be easily judged by using it on one side of the body and not on the contralateral side.
It is fitting that, as one of the founders of modern epidemiology, the name of William Budd should be celebrated along with that of John Snow.