The Blue Death

by Dr. Robert D. Morris

  Whitehead made no secret of his belief that Snow was wrong and his determination to prove him so. He routinely worked until 4 A.M. assembling data. He visited every home on Broad Street, many of them several times, to ask in detail about the outbreak. He was convinced that he had identified a key flaw in Snow’s work and in many ways he had.

  Snow had looked almost exclusively at those who had died from cholera and asked about their exposure to water from the pump. However he did not investigate those people who did not die. What if everyone in the area drank from the Broad Street pump? In that case the fact that most of the victims had used the pump would mean nothing more than that they had resided in the neighborhood.

  Despite their fundamental disagreement, Snow and Whitehead developed a growing respect for one another as the work of the committee progressed. They both worked tirelessly on their study of cholera and were both scrupulously objective in their review of the data. In January, when Snow published a revised and substantially expanded version of his monograph, On the Mode of Communication of Cholera, he gave a copy to Whitehead. The most prominent addition to the new version was an exhaustive account of his study of cholera rates among the London water companies. Snow viewed this as his masterwork, the definitive proof his critics had been demanding. He had also included a substantial section on his study of the Broad Street pump.

  Upon receiving the slender volume, Whitehead read the section on the Broad Street outbreak with great interest. He pored over it, looking for two critical numbers, the rate of cholera deaths among those around Broad Street who drank from the pump and the rate of cholera deaths among those who did not drink from the pump. If the rates were similar, as Whitehead expected, it would confirm his belief that the pump water had not caused the outbreak. Snow had not included these key numbers, so Whitehead decided to generate them himself.

  Over the next months, Whitehead worked feverishly to amass the data needed to calculate the death rates. He focused exclusively on Broad Street since this would leave no ambiguity about the proximity of the pump. Well-liked and highly respected among local residents, he visited homes again and again until he was certain as to their source of drinking water during the days surrounding the outbreak.

  On one such visit, he sat with a man and woman whose adult daughter had died of cholera. The husband sat quietly as his wife told Whitehead that they all drank exclusively from their cistern, which stored piped water. Whitehead asked specifically what they drank on September 1, the day before their daughter died. She remembered her husband and daughter drinking gin and water that evening and assured Whitehead that the water was from the cistern. Unlike any of the others investigating the outbreak, Whitehead knew the people he interviewed. Knowing that the husband was almost deaf, he asked in a loud voice if his wife’s recollections were accurate. No, the old man informed the priest, he and his daughter had used water from the Broad Street pump on that evening. He boiled his water, preferring a hot drink. His daughter drank it cold. Twenty-four hours later, she was dead.

  That spring the General Board of Health finally issued their report on the outbreak. They put little stock in Snow’s contention that “the real cause of whatever was peculiar in the case lay in the general use of one particular well, situate [sic] at Broad Street in the middle of the district, and having (it was imagined) its waters contaminated by the rice-water evacuations of cholera patients. After careful inquiry,” the report concluded, “we see no reason to adopt this belief.” Instead they rambled on for more than three hundred pages in a convoluted effort to explain how unique atmospheric conditions conspired with the inadequate sanitation in the district to ignite the epidemic.

  By then however Whitehead’s late nights parsing data were leading him to an entirely different conclusion. After interviewing more than four hundred residents of Broad Street, he determined that those who drank from the Broad Street pump in the days surrounding the outbreak were nine times more likely to have died from cholera than those who used water from other sources. Epidemiologists now refer to these comparison rates in exposed and unexposed groups as a relative risk, but Whitehead had no such term. He only knew that his endless hours of work to establish the innocence of the pump had done the opposite. He had developed compelling evidence that Snow was right.

  Still no one could find the source of the contamination that had caused the cholera. Where was the index case, the case that preceded all others? Then on March 27, 1855, long after others had closed their casebooks on the outbreak, Henry Whitehead was scrutinizing death records when something caught his eye. An infant had died of diarrhea on September 2 after an illness of four days. That would put the onset of illness at August 29, two days before the start of the outbreak, roughly the time it takes to contract cholera. The line that stopped Whitehead in his tracks was the address, 40 Broad Street, right in front of the pump.

  He rushed off to speak to the mother of the baby. He found the grieving widow dressed in black in the shuttered darkness of her room on 40 Broad Street. In addition to losing her child to diarrhea, she had lost her husband to cholera. Her name was Susan Lewis. She described her desperation on August 29, as she struggled to attend to her daughter who suffered from profuse diarrhea. She had worked constantly to keep her clean, returning time and again to the basement where she washed the soiled diapers. For two days she had poured bucket after bucket of wash water into the sink, which drained into the building’s decaying cesspool.

  Next Whitehead consulted Dr. Rogers, the physician who had cared for the dying baby. Rogers felt that the symptoms were not at all typical for cholera and believed that this was some other ailment. Undeterred Whitehead convinced the Cholera Inquiry Committee of St. James to commission the excavation of both the well and the cesspool for 40 Broad Street. When the subsurface was laid naked, it showed a clear muddy trail. Each bucket of water from the dying infant had sent a plume of contaminated water into the soil around the cesspool. From there it had seeped across three feet of saturated soil, and down into the well for the Broad Street pump.

  In mid-nineteenth-century London, one in eight children never reached their fifth birthday. The plight of this infant would have received little notice but for the chain of events touched off by the simple act of a mother caring for her dying baby. Henry Whitehead had traced the river of cholera to its headwaters.

  In his efforts to discredit Snow, Henry Whitehead had proved himself to be the doctor’s most apt and disciplined student. The two had worked closely together for months and a lasting friendship founded on mutual respect emerged. Whitehead held Snow in such high esteem that twenty years later a portrait of his friend was still hanging on his wall, a portrait that, he said, “ever serves to remind me that in any profession the highest order of work is achieved not by fussy demand for ‘something to be done,’ but by patient study of the eternal laws.”

  On one day during that long winter of 1854, as the two men worked together to understand the “eternal laws” that governed the spread of cholera, Snow turned to Whitehead and said, “You and I may not live to see the day, and my name may be forgotten when it comes, but the time will arrive when great outbreaks of cholera will be things of the past; and it is the knowledge of the way in which the disease is propagated which will cause them to disappear.”

  6

  THE GREAT STINK

  John Snow’s scientific writings cast a narrow, but bright, shaft of light on the workings of his remarkable mind. His heart, however, lies hidden in the shadows of history. He never married and left no children to preserve any letters or personal diaries. His closest correspondent was probably his uncle Charles Empson, but he too died childless and unwed, so Snow’s letters to him were lost. To reconstruct the man, we have only a few frozen images offered by the remembrances of colleagues.

  Of all the unrecorded moments in his life, few, if any, would have better illuminated the hidden soul of Dr. Snow than a single long conversation that took place in September 1856, as he and his uncle
sailed to Calais and then rolled on through western France. Almost thirty years had passed since Empson had launched the adolescent John Snow on his remarkable climb to the heights of British medicine. Now as they passed vineyards heavy with grapes and wheat fields ripe with grain, the two men could reflect on the arc of his formidable career. If the reserved, self-contained Dr. Snow ever shared his innermost feelings, his frustration at the resistance to his ideas on cholera or the pleasure he found in his success as an anesthesiologist, he would have done so on their long journey from London to Paris.

  We do know that the years since Newcastle had mellowed the strong-minded Dr. Snow. The stringent teetotaler now took an occasional glass of wine. The man who had so valued the truth that he refused to read fiction could now be seen at the opera. In 1856 the Yorkshire boy left the shores of Britain for the first time in his life and landed in a world wholly unlike Victorian England.

  Upon arriving in Paris, Snow and his uncle found themselves in the midst of a construction site that seemed to have no end. In 1851, just five years earlier, Napoleon III had resolved to correct what he saw as the city’s imperfections. Taking a pen to the map, he had extended, connected, and redirected major streets as if the existing buildings in the city were nothing more than sand. With a flick of his imperial wrist, he had mobilized armies of workers to raze entire city blocks and relocate landmarks that obstructed his grand vision. As Snow and Empson explored Paris, demolition and construction crews were reshaping the rue de Rivoli, the rue de Strasbourg, the rue de Rennes, and the boulevard St. Michel. Before the construction crews were finished, they would create the central markets and the Bois de Boulogne, demolish and rebuild the Paris Opera House, and create a dramatic connection between the Palace of the Tuileries and the Louvre. But Charles Empson had not invited his favorite nephew to Paris to see the sights. He had come to introduce him to an old friend. John Snow, anesthetist to the queen of England, was about to meet the emperor of France.

  Empson had befriended Napoleon while the would-be emperor was living in exile in Bath. After his dramatic return to power, Napoleon III remembered his old friend and welcomed him to Paris. Empson must have believed that his nephew’s ideas would interest Napoleon as he reconstructed Paris. The last cholera epidemic had killed nineteen thousand Parisians and most of the city still drank from the Seine. With 250 miles of streets, the city had only 82 miles of sewers. On the long ride to Paris, Snow had carried a copy of his monograph, On the Mode of Communication of Cholera.

  There is no definitive proof that Snow’s conversation with Napoleon influenced the reconstruction of Paris, but by the time the dust settled, the city would have two hundred miles of new sewers and two new water supplies. Each new water source required pipelines more than eighty miles long. One of them ran eighty-one miles to the Marne with some sixty tunnels and bridges and eleven miles of siphons. The other pipeline took an even longer and more tortuous course to the pure waters of Vanne.

  Despite Snow’s royal connections in England and France, acceptance of his discoveries continued to prove elusive. He left his monograph at the Institute of France, which was offering ten thousand francs for any discovery that offered a means to treat or prevent cholera. The French medical establishment, however, found nothing worthy in Snow’s heretical ideas and never acknowledged his submission.

  Two years earlier, on a chilly December day in 1854, John Snow had walked into the Soho office of John Churchill and Sons and handed them the precisely edited manuscript that would become the monograph he carried to Paris. It had tripled in length since his original version to make room for the mountain of evidence he had accumulated in the interim. His commentary brimmed with growing confidence in his theory. He drew on reports from throughout Great Britain to make his case and included detailed analyses of the role of water in all three epidemics in London including his study of the Broad Street pump. The centerpiece of this new monograph was an extended report of his research on the water supply of South London.

  Through the fall of that year, even as he worked on his study of the Broad Street pump, John Snow had directed most of his energy into determining the water supply of cholera victims on the south bank of the Thames. Again and again he returned to the homes of Brixton, Clapham, and Waterloo and stood in the doorways of cholera’s victims asking survivors about the source of their water. If, as was often the case, they did not know, he would fill a vial with tap water to bring back to his lab.

  When all the samples had been tested and the data tabulated, the results confirmed the preliminary findings he had shared with William Farr the preceding summer. Those residents of south London who had the misfortune to purchase their water from the Southwark and Vauxhall Water Company, which drew water from the Thames in the heart of London, died from cholera at a rate four times that of their neighbors whose water came from Lambeth. More than anything else, this evidence justified the considerable expense of publishing the revision to his monograph.

  Snow never received a penny for his research on cholera, and for a man who was far from wealthy, his expenses were not trivial. He had not only hired an assistant for the first time, but had also drastically reduced his clinical activities and lost several months of income. Even the cost of publishing the monograph came from his own shallow pockets.

  Every time Snow had shown a relationship between water and cholera, his critics argued that some factor other than water distinguished the victims of the disease from their unafflicted neighbors. In the South London study, he defeated this objection by providing detailed data on two groups of people with only two conceivable differences between them: their water supply and their death rate from cholera. Nonetheless John Snow now understood his opposition far better than he had six years earlier. He had learned that old ideas do not yield quickly or easily. Proponents of those ideas had first ignored him and then attempted to dismiss his findings. When his data proved stubborn, they had tried to twist and distort their old theories to make room for a new set of facts. Snow had seen all this and was fully prepared to see it happen again. He could never have prepared himself, however, for the grave injustice that lay ahead.

  The first two official reports on the 1854 epidemic followed predictable lines. The first came from the medical council to the General Board of Health (GBH). As president of the GBH, Benjamin Hall had stacked the council with ardent sanitarians, including Neil Arnott, who had accompanied Chadwick on his tour of the slums of Glasgow and was now physician to the queen; William Baly, who still served as physician to Millbank Prison; William Farr, from the Registrar General’s Office; and John Simon, Officer of Health in the City of London. John Sutherland, one of Chadwick’s closest advisers, wrote the report. Chadwick was gone from the GBH, but his political ghost remained firmly in control.

  Writing on behalf of the medical council, Sutherland described their efforts to evaluate the sources of odor and the quality of ventilation in neighborhoods where cholera struck hardest. The report opened the door to the possibility that water contributed to the outbreak, but only a crack. Contaminated water was one of many factors that predisposed people to cholera. They offered the following to local health officials:

  PRECAUTIONS AGAINST CHOLERA.

  Apply for medicine immediately to stop looseness of the bowels, or it may bring on cholera.

  Do not take any strong opening medicine without medical advice.

  Beware of drink, for excess in beer, wine, or spirits is likely to be followed by cholera.

  Drink no water that has not been boiled; and avoid that which is not quite clear and well tasted.

  Avoid eating meat that is tainted, decayed or unripe fruit, and stale fish or raw vegetables. Cooked vegetables, or ripe and cooked fruit, in moderation, are a necessary part of diet at all times.

  Avoid fasting too long; be moderate at meals.

  Avoid great fatigue, and getting heated and then chilled.

  Avoid getting wet, or remaining in wet clothes.

  Keep yours
elf clean, and your body and feet as dry and as warm as your means and occupation will permit.

  Keep your rooms well cleaned and lime-washed; remove all dirt and impurities immediatately.

  Keep your windows open as much as possible to admit fresh air; and, if necessary, use chloride of lime or zinc to remove any offensive smells.

  If there are any dust or dirt heaps, foul drains, bad smells, or other nuisances in the house or neighborhood, make complaint without delay to the local authorities having legal power to remove them, or if there be no such authorities, or if you do not know who they are, complain to the Board of Guardians.

  Item 4, though a welcome addition to the list, is buried in a manure pile of sanitarian misperception.

  The report from Sutherland, however, was only a placeholder for a much longer report from the General Board of Health, which it issued in July 1855. Its appendices alone stretched over 320 pages. An analysis of the meteorology of London during the epidemic accounted for more than a third of those pages and set the tone for the report. Temperature, air pressure, wind speed, wind direction, atmospheric electricity, cloud cover, rainfall, and ozone concentrations were reviewed in excruciating detail.

  While avoiding reference to John Snow, the report gave special attention to what it referred to as the outbreak at Golden Square. An odd title as only one resident of Golden Square had died as compared to 108 people who had lived or worked on the five blocks of Broad Street. Even the name suggested a preemptive effort to dismiss Snow’s theory. Instead the board members who had combed through the area of the outbreak catalogued the sources of odor and organic matter in the district. They suggested, for example, that the blood and entrails from the seven sheep and five oxen killed each day at the busy slaughterhouse on Marshall Street had helped launch the disaster. They worried about the effluvia from the twenty-seven dogs that lived in a single room at 38 Silver Street. They bemoaned the number of apartments without rear windows where the lack of cross-ventilation allowed miasmas to accumulate with such deadly results.