The Ghost Map

by Steven Johnson

  But within the crowded parlors of Golden Square, the fear was inescapable. The outbreak hit a new peak a few hours before midnight on Thursday. Hundreds of residents had been seized by the disease within a few hours of one another, in many cases entire families, left to tend for themselves in dark, suffocating rooms.

  Those fearful scenes—a family crammed together in a room, suffering through the most excruciating private torture as a group—are perhaps the most haunting of all the images of the Broad Street outbreak. Families continue to perish together in the developed world, of course, but such catastrophes usually unfold over the space of seconds or minutes, in car accidents and plane crashes or natural disasters. But a family dying together, slowly, agonizingly, with full awareness of their fate—that is a supremely dark chapter in the book of death. That it continues on as a regular occurrence in certain parts of the world today should be a scandal to us all.

  Overnight, Henry Whitehead’s sociable rounds as assistant curate of St. Luke’s had become a death vigil. Within a few minutes of dawn, he had been called to a house where four people lay near death, their skin already taut and blue. Each house he visited that morning presented the same horrifying scene: a neighborhood on the edge of oblivion. Just before noon, he ran across the scripture reader and another curate from St. Luke’s, and found both men had encountered the same devastation in their passages through the neighborhood.

  Whitehead’s travels took him to four houses along Peter Street near Green’s Court, where he found the disease in full fury. Half the occupants, it seemed, had fallen ill in the past twenty-four hours. In one of the grandest of the homes, standing at the northwest corner of Green’s Court, all twelve residents would eventually perish. Yet the cholera had largely spared the cramped and grubby quarters on Green’s Court itself. (Only five of the two hundred living there would eventually die.) When Whitehead stopped by one of the filthiest houses in the district, he found, to his amazement, that not one of its inhabitants had fallen ill.

  The contrast was striking, especially as the four houses on Peter Street had been commended by the parish authorities for their cleanliness during a 1849 survey of the neighborhood, while the survey had found nothing but squalor and soot in the surrounding houses. It occurred to Whitehead that, contrary to the prevailing wisdom, the sanitary conditions of the homes seemed to have no predictive power where the disease was concerned.

  Such observations were characteristic of the young deacon, on a number of levels. There is, first, his composure and probing intelligence in a time of great chaos, but also his willingness to challenge orthodoxy, or at least submit it to empirical scrutiny. That scrutiny itself relied on his firsthand knowledge of the neighborhood and its residents. He detected these early patterns in the disease’s course precisely because he possessed such a fine-grained understanding of the environment: the houses that had been praised for their sanitary conditions, and the ones considered to be the filthiest on their blocks. Without that kind of knowledge, the platitudes would have been far easier to settle back on.

  There were other medical detectives on the streets of Soho that day, looking for clues, building chains of cause and effect. Minutes before sunrise on Saturday morning, John Rogers, a medical officer based on Dean Street, made his way from Walker’s Court to Berwick Street, struggling to schedule visits to all the patients who had fallen ill in the previous twenty-four hours. Rogers had seen cholera outbreaks before, but already it was clear that something exceptional was under way in Golden Square. Cholera rarely exploded through a population; it could kill by the thousands, of course, but the carnage usually took months or years to unfold. Rogers was starting to hear accounts of entire households falling ill overnight. And this strain of the disease seemed to do its damage with a terrifying velocity: sufferers were going from complete health to death in twelve hours.

  Rogers’ itinerary took him past 6 Berwick Street, home to a well-regarded local surgeon by the name of Harrison whom Rogers knew professionally. As Rogers crossed the front of the house, a powerful stench overtook him and he stumbled on the sidewalk for a few seconds, holding back the urge to vomit. He would later describe it as one of the “most sickening and nauseating odours it has ever been misfortunate to inhale in this metropolis.” Once Rogers had composed himself, he stepped back and observed that the smell was coming from a gulley hole by the side of the road, a slit on the edge of the curb designed to capture water runoff during storms. Rogers didn’t stay long enough to determine what foul combination of decaying matter lay behind the hole. But he thought to himself as he marched onward that the stench was strong enough to pervade the entire residence at number 6.

  A few hours later he learned that the surgeon Harrison had expired that morning. Rogers burst out with an immediate diagnosis: “That gulley hole has destroyed him!” He began fulminating against the dreadful sanitary conditions in the city that had led to the catastrophe around him. But the deaths were just beginning. By the end of the week, seven other residents of 6 Berwick would come down with cholera. All but one would perish.

  Back at 40 Broad Street, the Lewis infant had descended into an exhausted silence over the night. In the mid-morning hours, her parents called their Dr. Rogers, who had treated the infant earlier in the week. By the time he arrived, a few minutes past eleven, baby Lewis was dead.

  THAT AFTERNOON, WHITEHEAD VISITED A FAMILY OF SIX (call them the Waterstones, since no record of their names exists) with whom he had long enjoyed a close connection: two grown sons and two adolescent girls living with their parents in three connected ground-floor rooms off of Golden Square. When he arrived, he found the younger sister, whose wit and good cheer had always impressed Whitehead, fading in and out of consciousness, after a violent and sleepless night suffering from the disease. She was surrounded by her brothers and by a neighbor who had valiantly dropped in to lend a hand. While Whitehead spoke to the men in hushed tones, huddled together in the small center room of the flat, the girl seemed to regain some of her acuity.

  At one point she pulled her head up and asked after her mother and sister. Her brothers fell silent. The girl looked anxiously toward the two closed doors at either side of the room. She knew the truth before a word was spoken: behind each door there lay a coffin. She could hear the weeping of her father, draped over the body of his dead wife in the dark of the shuttered front parlor.

  Half the neighborhood, it seemed, had shuttered themselves inside, either to suffer in isolation or to ward off whatever foul effusion had brought the plague to the neighborhood. Outside, in the strangely incongruous glare of a summer afternoon, at the top of Berwick Street, a yellow flag was raised to alert the residents that the cholera had struck. The gesture was superfluous. You could see the dead being wheeled down the street by the cartload.

  JOHN SNOW

  Sunday, September 3

  THE INVESTIGATOR

  BY SUNDAY MORNING, A STRANGE QUIET HAD OVERTAKEN the streets of Soho. The usual chaos of the streetsellers had disappeared; most of the neighborhood’s residents had either evacuated or were suffering behind their doors. Seventy of them had perished over the preceding twenty-four hours, hundreds more were at the very edge of death. Out in front of 40 Broad, the pump attracted only a handful of stragglers. The most common sight on the streets were the priests and doctors making their frantic rounds.

  Word of the outbreak had traveled through the wider city and beyond. The chemist’s son who had enjoyed his pudding days before on Wardour Street died on that Sunday at his home in Willesden. The entire city held its breath as it took in refugees from the embattled neighborhood, waiting to see if the outbreak in Golden Square would be re-created on a larger scale in the coming days. Seventy deaths in a single parish was not an uncommon number to hear in an age of cholera epidemics. But it normally took months for the disease to chalk up so many victims. The Broad Street strain of cholera—whatever it was, wherever it had come from—had managed that terrible feat in a single day.

&
nbsp; While the disease had remained largely confined to an area of roughly five square blocks, the rest of Soho was on high alert. Many packed their bags and visited friends or family who lived in the country or other parts of the city; some locked the doors and shuttered the windows. The vast majority steered clear of the Golden Square neighborhood at all cost.

  But one Soho regular had been following the case closely from his residence at Sackville Street on the southwestern edge of the neighborhood. Sometime near dusk he set out from his home, marching through the empty streets, directly into the heart of the outbreak. When he reached 40 Broad, he stopped and examined the pump for a few minutes in the fading light. He drew a bottle of water from the well, stared at it for a few seconds, then turned and made his way back to Sackville Street.

  JOHN SNOW WAS IN HIS FORTY-SECOND YEAR, AND SINCE his early thirties he had by any measure enjoyed a remarkable streak of professional achievement. Unlike most members of the medical establishment or the sanitary reform movement, Snow had been born into a family of modest means, the eldest son of a Yorkshire laborer. A quiet, serious child with intellectual ambitions beyond his humble origins, Snow had apprenticed at the age of fourteen to a surgeon in Newcastle-on-Tyne. At the age of seventeen he read John Frank Newton’s influential 1811 manifesto The Return to Nature: A Defence of the Vegetable Regimen and promptly converted to vegetarianism. Shortly thereafter, he became a strict teetotaler. He would largely avoid meat and alcohol for the rest of his adult life.

  As an apprentice in Newcastle, Snow saw the ravages of cholera firsthand when the disease struck in late 1831. He treated the survivors of a particularly brutal outbreak in a local mine, the Killingworth Colliery. The young Snow observed that the sanitary conditions in the mine were dreadful, with workers granted no separate quarters to relieve themselves, thus forcing them to eat and defecate in the same dark, stifling caverns. The idea that the cholera outbreak was rooted in the social conditions of these impoverished workers—and not in any innate susceptibility to the disease—lodged in the back of Snow’s mind as the cholera ran its course. It was only a partially realized thought, nowhere near a genuine theory. But it stayed with him, nonetheless.

  A young Englishman interested in the medical life during the first half of the nineteenth century had three primary career paths open to him. He could apprentice with an apothecary and then eventually land a license from the Society of Apothecaries, which would grant him the right to concoct medicines prescribed by physicians. After some training, he would be free to embark on his own practice, treating patients with the woeful remedies of the day, probably dabbling in minor surgery or dentistry on the side. The more ambitious individual would go on to study at a medical school, and later join the Royal College of Surgeons of England, becoming a bona fide general practitioner and surgeon, performing a host of different tasks: everything from treating minor colds to excising bunions to amputating limbs. Beyond that lay the university degree Doctor of Medicine, whose recipients were conventionally called physicians, as opposed to the lower orders of surgeons and apothecaries. A university degree opened doors to the private hospitals, where one could rub shoulders with the wealthy benefactors who endowed them.

  Snow realized at an early age that his ambitions extended beyond that of a provincial apothecary. He had moved back to York in 1835 and involved himself in the growing temperance movement there. But at the age of twenty-three, he decided to follow the classic itinerary of the bildungsroman genre that dominated the nineteenth-century novel: a provincial young man with dreams of greatness sets out for the big city to make a name for himself. Snow’s journey to London was typical of the earnest young doctor-in-training: he eschewed both horse and carriage and walked a meandering two-hundred-mile route alone.

  In London, Snow settled in Soho and enrolled in the Hunterian School of Medicine. Within two years he had received both his apothecary and surgeon’s license and established a general practice at 54 Frith Street in London, about a five-minute walk east from Golden Square. Setting up shop as a doctor in those days required an entrepreneurial spirit. The competition was intense among London’s new medical middle class—four other surgeons had offices within a few blocks of Snow, though the only physicians nearby resided across Soho in Golden Square. Despite the proximity of so many rivals, Snow quickly established a successful practice. Temperamentally he was not the cliché of the friendly, garrulous general practitioner; his bedside manner was taciturn and emotionally flat. But he was a superb doctor: observant, quick-witted, and possessed of an exceptional memory for past cases. Snow was as free from superstition and dogma as it was possible to be in those days, though he was inevitably limited in his effectiveness by the conceptual dead ends and distortions of early Victorian medicine. The idea of microscopic germs spreading disease would have been about as plausible as the existence of fairies to most practicing doctors of the day. And as Surgeon-in-Chief G. B. Childs’ letter-writing campaign to the Times suggested, laudanum was regularly prescribed for almost any ailment. The Victorian medical refrain was, essentially: Take a few hits of opium and call me in the morning.

  Seemingly bereft of anything resembling a traditional social life, Snow spent his time away from patients working on side projects that grew out of his surgeon’s practice but which also suggested the ultimate range of his ambition. He began writing in to the local journals, opining on medical and public-health issues of the day. His first published paper, addressing the use of arsenic in the preservation of cadavers, appeared in The Lancet in 1839. He went on to publish nearly fifty articles in the following decade, on a staggering range of subjects: lead poisoning, resuscitating stillborn children, blood vessels, scarlet fever, and smallpox. He wrote in to The Lancet with so many critiques of sloppy science that the editor eventually scolded him gently in print, suggesting that “Mr. Snow might better employ himself in producing something, than in criticizing the production of others.”

  Snow clearly had his mind set on producing something of his very own, and he saw advanced degrees as a crucial bridge to that end. In 1843, he earned his bachelor of medicine degree from the University of London. A year later he had passed the challenging M.D. exams, placing in the first division of students. He was now, officially, Dr. John Snow. By most standards, he was already a remarkable success story: a laborer’s son who now had a thriving medical practice and a vibrant career as a researcher and lecturer. At the recommendation of one of his former professors, he had been invited to join the Westminster Medical Society, where he quickly became a respected and active member. Any number of physicians would have settled into that comfortable realm, pursuing only the incremental advances of tending to increasingly well-to-do clientele and elevating their own social prestige in the process. But Snow was oblivious of the trappings of London’s polite society; what drove him, more than anything, were problems that needed solutions, filling in the blind spots in the medical establishment’s vision of the world.

  Snow would continue to work as a practicing physician for the rest of his life, but his eventual fame would come from his pursuits outside the consulting room. Snow did not aim low in his investigations. He would play a defining role in the battle against the era’s most relentless killer. But before he could tackle cholera, John Snow set his sights on one of the most excruciating deficiencies of Victorian medicine: pain management.

  WHERE SHEER PHYSICAL BRUTALITY WAS CONCERNED, THERE was little in Victorian society that rivaled the professional medical act of surgery. Lacking any form of anesthesia beyond opium or alcohol—both of which could only be applied in moderation, given their side effects—surgical procedures were functionally indistinguishable from the most grievous forms of torture. Surgeons prided themselves on their speed above all else, since extended procedures were unbearable for both doctor and patient. Procedures that would now take hours to complete were executed in three minutes or less, to minimize the agony. One surgeon boasted that he could “amputate a shoulder in the time it took to
take a pinch of snuff.”

  In 1811, the British author—and longtime Soho resident—Fanny Burney underwent a mastectomy in Paris. She described the experience in a letter to her sister a year later. After drinking a wine cordial as her sole form of painkiller, she settled into the ominous closet that had been assembled by the team of seven doctors in her home, lined with compresses and bandages and gruesome surgical tools. She lay down on the makeshift bed, and the doctors covered her face with a light handkerchief. “When the dreadful steel was plunged into the breast, cutting through veins, arteries, flesh, nerves, I needed no injunction not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision, and I almost marvel that it rings not in my ears still! So excruciating was the agony.… I then felt the knife rackling against the breastbone, scraping it! This performed, while I remained in utterly speechless torture.” Before passing out in near shock after the procedure, she caught a glimpse of her primary doctor—“pale nearly as myself, his face streaked with blood and its expression depicting grief, apprehension, and almost horror.”