As usual the Sunday evening traffic was light as he made his way across Regent Street. Not only did John Snow understand cholera, he knew the Broad Street neighborhood as well as anyone. His first two residences in London were just a few blocks east of Broad Street and now he lived in a comfortable home a few blocks to its west. There was only one pump that could have caused the pattern of death that his medical friends had described to him and he was walking straight toward it.
His footsteps echoed across the cobblestones as he walked through Golden Square and turned onto Silver Street. Even for a Sunday, this gritty, commercial neighborhood was unusually quiet and empty. He continued on past the National School and onto a wide street that was just over four blocks long. Passing beneath the watchful eye of the stone lion perched above the Lion Brewery, he could see the yellow pestilence flags that hung limply from the lampposts. Throughout the deserted street, the shuttered windows of mourning marked the homes of those who had already died. Halfway down the street, he stopped. He carefully removed a small bottle from his pocket, lifted the handle of the Broad Street pump, and held it under the spout.
Even Snow had to rely primarily on his senses to test the water. He examined the contents of the bottle looking for any hint of contamination. He saw and smelled nothing to suggest the presence of organic matter in the water. His years of scientific training had taught him the value of skepticism, particularly in the evaluation of one’s own, best ideas. He left unconvinced that he had found the source of the outbreak.
He continued on through the neighborhood, determined to find the water pump that cholera had used to launch its attack. At the Warwick Street pump, he saw small white, flocculent particles in the water. He found similar impurities in the water at Bridle Lane. The dirtiest water came from the pump on Marlborough Street, but passersby informed him that this was well known in the area. Most people, he learned, preferred to gather their water from the pump on Broad Street.
When John Snow returned home that night, he remained convinced that a water pump had caused the ongoing disaster. The pump on Broad Street remained the prime suspect. He was equally certain that finding the exact cause and demonstrating its role to a deeply skeptical audience would require far more work. No one in London shared John Snow’s concern about the water from the Broad Street pump. Those who remained in the area continued to collect its water, just as they always had.
As the last hour of that tragic weekend slipped away, Reverend Henry Whitehead sat down to rest. This had been a weekend like no other in his life. All his waking hours had been spent as an observer at death’s door trying to bring some measure of comfort to the dying and the desperate. Drained of his physical, emotional, and spiritual energy, he sought to soothe his own soul with a glass of brandy. He diluted it with water he had drawn from the Broad Street pump.
John Snow’s continued inquiries led him with increasing certainty to a single explanation for the pattern he saw in the mounting cholera deaths. On Monday, after providing chloroform for a tooth extraction, he returned to the Broad Street pump. Even if he could not see it, smell it, or taste it, cholera’s cause must be hiding in the well. This time, he took several samples to test.
Using one of the few reliable tests available to him, Snow added a few grains of silver nitrate to the sample. He shook it and the water grew cloudy with crystals of silver chloride. The fine grains sank in the water and accumulated on the bottom of the flask. Even before he weighed them, experience told Snow that the amount of chloride in the water was high. Chloride marked the presence of sodium chloride or salt. Since pure well water should contain very little salt, something must be contaminating the well.
Snow took another sample to Dr. Arthur Hill Hassall, one of London’s most eminent microscopists and author of an authoritative book on the minuscule inhabitants of water. Hassall reported finding organic matter and oval “animalcules” in the sample. These may well have included Vibrio cholerae, but at the time Snow had no way of knowing this. Instead he only took this to be evidence of organic contamination, all the evidence he needed to continue to focus on the Broad Street pump. Somewhere in those contaminants, he reasoned, cholera’s demon was hiding.
The members of the medical establishment would not see the evidence the same way. After all hadn’t Snow’s own examination shown that other pumps were also contaminated, perhaps more contaminated than the one at Broad Street? Snow’s theory required them to believe not only that undetected contaminants could kill, but also that this would happen only when a special variety of these invisible killers was present. At a time when microbiology did not exist as a science, he would need the tools of epidemiology to make his case. But the tools he needed did not exist, would not exist, until John Snow invented them.
On Tuesday, at his first opportunity, he set out across Piccadilly Circus and then through the maze of London’s streets until he reached the Strand, a grand promenade in front of the imposing buildings that lined the north bank of the Thames. There he entered Somerset House, a vast stone edifice that was home to the government’s leading societies of science and art. Deep in its marbled bowels, he made his way to the Office of the General Registrar, where William Farr and his employees would be assembling the official record of cholera deaths for the preceding week.
That same morning the British Government had taken official notice of the outbreak. Sir Benjamin Hall, president of the General Board of Health, toured the scene of the disaster. Three-quarters of the area’s residents had fled. Those that remained and were able clustered around Dr. Hall in the hope that the attention of the authorities would bring them some relief. Tall and handsome, Hall’s striking figure earned him a nickname he would one day share with the largest clock in London, Big Ben. On this grim day, there was no missing him and his entourage as they walked the streets around the Broad Street pump. As they moved the hearses were busy again. On that day alone, forty-five people would die.
The next day as he monitored his anesthetized patients, John Snow’s mind buzzed with thoughts of the unfolding outbreak. The general registrar had given him a list of all cholera deaths in London for the period from Thursday, August 31, through Saturday, September 2, the first weekend of the outbreak. Of the eighty-nine people on the list all but six had died within a few blocks of Broad Street.
As soon as he finished his clinical work, he returned to Broad Street and began to work his way down the list. At each household where someone had died of cholera, he would express his condolences and in a quiet, husky voice, he would inquire as to the habits of the deceased. Eighty-three times, he asked if cholera’s victim had used the water from the Broad Street pump.
Within twenty-four hours, he had eighty-three answers and a clear pattern had emerged. Seventy-three of the victims had lived closer to the Broad Street pump than any other and every one of them routinely drank its water. Of the ten who lived closer to other pumps, five had preferred the water from the Broad Street pump and always requested it and three others were children who went to school on Broad Street and routinely drank from the pump. Out of all the cholera deaths in the area, only two of the deceased drew their water from other wells.
On the following Thursday, one week after the outbreak began, the Board of Guardians of St. James Parish assembled in an emergency meeting. Hundreds had already died in their small parish and the death toll continued to mount. By virtue of England’s poor law, the board was charged with overseeing care for the indigent in an area of northeast London that included Broad Street and Golden Square. As they met to discuss the crisis in their midst, a stranger arrived at the Vestry Hall requesting an audience.
A balding man with intense, deep-set eyes entered the room and introduced himself as Dr. John Snow. He had spoken in the building before at the meetings of the Westminster Medical Society, but never had his message been so urgent. Standing in the elegant boardroom with floor to ceiling windows overlooking Piccadilly, Snow laid out his indictment of the pump and implored the board to
close it. The board members listened as he described his investigation of the eighty-three cholera deaths and his indictment of the Broad Street pump. They doubted that drinking water could have caused such an epidemic, but ready to try anything, they relented. After all, anyone who could had fled in the face of the outbreak. When those still in the neighborhood came for water the next day, they found that the Broad Street pump had no handle. For the first time in history, a governing authority had taken action intended to halt an outbreak of waterborne disease.
In the fields of epidemiology and public health, removing the pump handle has become the stuff of legend, but even Snow himself was not convinced that doing so had saved any lives. Even though thirty-two people died of cholera on that Thursday, the outbreak was in decline and might well have abated without the closure of the pump.
Ultimately 623 people in this small neighborhood died of cholera in just over a week. Hundreds if not thousands more had contracted the disease, but managed to escape with their lives. London had not seen an outbreak of such focused ferocity since the darkest days of the bubonic plague. Most of the survivors had left the area, turning the normally busy commercial district into a ghost town.
Some had nowhere to go. In the wake of the disaster, a struggling intellectual by the name of Karl Marx sat in a sparsely furnished Soho apartment and recorded his impressions in a letter to Friedrich Engels.
[T]he total absence of money is the more horrible—quite apart from the fact that family wants do not cease—as Soho is a choice district for cholera, the MOB is dropping dead right and left (e.g. an average of 3 per house in Broad Street) and victuals are the best defense against the beastly thing.
As cholera burned itself out, tragedy gave way to mystery. The outbreak had ended, but the investigation of its cause was just beginning.
By the middle of September, the disaster had spawned no fewer than four studies, each relying on its own particular brand of epidemiology and sending investigators scurrying through the neighborhood in search of cholera’s cause. The most prominent among these came from Benjamin Hall and the General Board of Health, which had charged three of its members with investigating a long list of concerns including atmospheric conditions, ventilation, the presence of nuisances and noxious trades, bad smells, privies and cesspools, the state of basements, and the quantity and quality of the water supply in the affected area. The fact that the water supply was included at all may have been a begrudging nod to the theories of Dr. Snow, but its place at the bottom of the list and the nature of the remainder of their tasks leaves little doubt that they were on a mission to find the miasma that had unleashed the epidemic.
As the Board of Health team sniffed its way through the neighborhood, the worst stink of summer had already diminished. Instead the acrid odor of lime overwhelmed the district. As part of a daily cleansing ritual, the Board of Guardians had ordered workers to coat the streets where cholera had struck with the heavy white powder. The blackened figures of mourning survivors cast somber shadows on what appeared at first glance to be a late summer snowfall. It seemed as if cholera had drained the color from Broad Street. Day after day John Snow made his way around snow white puddles to the homes of the mourners and asked about drinking water.
Snow had been a regular visitor to the Office of the General Registrar since the outbreak began and his list of names had grown steadily as the death toll continued to rise. In addition he had recognized that the official tally was missing many deaths of people who had not died in their homes. Those who lived solitary lives clinging to the lowest rungs of society’s ladder found their only care at Middlesex Hospital, five blocks south of Broad Street. Years later Florence Nightingale would recall her experience as a young nurse there during the first weekend of the outbreak. For three days she had worked without sleep as a steady stream of dying prostitutes and their fellow denizens of the street arrived with the icy hand of cholera around their throats. For days she could do nothing more than comfort them and watch them die.
Others were lost to the system because they had suffered the fatal misfortune of consuming the water from the pump before leaving to die elsewhere. At a chance meeting with Dr. Charles Frasier, the only physician on the team sent by the General Board of Health, Snow learned of two such cases. The first involved a man from Brighton who had come to care for his brother, but arrived to find he had died. The man saw no reason to linger in the presence of cholera, but he was hungry from his journey and had a long trip home. His sister-in-law prepared him a quick meal of rump steak. He washed it down with a tumbler of brandy and water from the Broad Street pump. After twenty minutes he was back on the road to Brighton carrying a lethal dose of cholera.
The second case involved the mother of three sons, all of whom worked on Broad Street. For Snow it was the exception that proved the rule. He had already spent considerable time talking to the brothers as they ran a business where sixteen workers had died of cholera. The business was Eley Brothers’ Percussion Cap Factory and one of the three brothers told him of the regular deliveries of water to their now deceased mother. After following the path of the cart out to the home of Susannah Eley in Hampstead, Snow learned that the widow’s ill-fated niece had died on the same day as her aunt, miles away in Islington. Cholera was a stranger to both of these districts. The only thing that connected the isolated and simultaneous cases was a bottle of water from Broad Street.
Snow’s conclusions may seem painfully obvious to us, but we have the advantage of knowing he was right. The rest of London was looking elsewhere for the answers. In the words of Dr. Edwin Lankester, a prominent physician and member of the Board of Guardians who had listened to Snow’s plea to remove the pump handle, “not a member of his own profession, not an individual in the parish believed that Snow was right.”
As the neighborhood sought to regain its equilibrium, many of the survivors developed their own theory as to what had happened. Almost two hundred years earlier, William Earl of Craven had lived in an estate on Drury Lane, not far from what would become Broad Street. As the black plague ravaged the city, he had built several dozen pest houses in an area that included the west end of the future Broad Street. Victims of the plague, instant pariahs in a world that fled at the sight of their sore-ridden bodies, would come to this pest field to find refuge and in most cases to die. Their corpses accumulated in vast pits near the field. Many survivors of the cholera outbreak became convinced that recent excavations for new sewer lines had disturbed the pest pits and unleashed the remnants of this long-buried evil on the neighborhood.
This belief gained such credibility in the neighborhood that Karl Marx wrote in another letter to Friedrich Engels,
The cholera epidemic, now much abated, is said to have been particularly severe in our district because the sewers made in June, July, and August were driven through the pits where those who died of the plague in 1668…were buried.
Spurred on in part by this concern, the Commission of the Sewers sent an engineer by the name of Edmund Cooper to investigate the condition of the sewers in the neighborhood. The commission however had no intention of accepting blame for this disaster. His report, issued after just two weeks of peering down gully holes, concluded that bad smells had indeed caused the outbreak, but went on to state that the smells had come from within the houses. The sewers, he affirmed, were in good shape and could not have played a role.
One evening late in September, Reverend Henry Whitehead paid one of his frequent visits to the oil shop on Broad Street. Outside the shop a large barrel labeled CHLORIDE OF LIME in bold block letters offered its contents to passersby. A few minutes later he left carrying a large tin of kerosene. He would be staying up far into the night, working by the warm light of a flickering lamp to put the finishing touches on his own study of the outbreak that had struck at the heart of his congregation. Within a few weeks, he had issued his report, The Cholera in Berwick Street. It made no mention of the Broad Street pump.
As a priest of St. Ja
mes Parish, he knew of Snow’s theory about the pump, but was convinced that Snow was wrong. After all Whitehead had drunk from the pump himself with no apparent ill effects. (He could not have known that brandy at high concentrations could protect him from contaminated water. We can suspect that, in the midst of the outbreak, he did not add much water to his brandy.) Furthermore he had been at the homes of three cholera victims who had consumed quart after quart of water from the pump during their illness and had recovered fully from the deadly disease. Whitehead boasted to a medical friend that he understood the dynamics of the outbreak far better than Snow and could prove the irrelevance of the pump if given the time. He would soon be given the opportunity to do just that.
As the fall wore on, the community had no real answers as to the cause of the outbreak. The General Board of Health had finished gathering data, but there was no sign of a report. If, as expected, the report blamed uncontrolled odors within the neighborhood, it would represent an implicit indictment of the Board of Guardians and by extension the Vestry of St. James, since they were responsible for the public health of the district. On November 23, 1854, almost three months after the start of the outbreak, the vestry commissioned its own study.
Epidemiology is deceptively difficult. The committee assembled by the Board of Guardians discovered this after a questionnaire sent to every home in the neighborhood produced no useful information. The board then summoned Dr. Snow for his input, as he was already a respected epidemiologist regardless of his views on water and cholera. After a meeting on December 12, the Board of Guardians added eight new members to the committee. The additions included Dr. Snow and the Reverend Henry Whitehead. This would be the beginning of a remarkable relationship.
The Blue Death Page 9
