The Blue Death Read online

  Within an hour, Dr. Kell and Dr. Clanny entered the home of the Sproats, a comfortable house on Fish Quay overlooking the harbor. Fearing the worst, William Sproat’s family, including his adult son and his eleven-year-old granddaughter, waited anxiously as the two doctors attended to their gravely ill patriarch.

  When they saw his pale, shriveled face and his sunken eyes, Kell and Clanny immediately suspected the worst. Their fears grew as they heard the faint whispers of Sproat’s story. Then Kell lifted one of Sproat’s cold, pale hands. What had been the powerful hands of a boatman were limp and heavy. At the base of the thumb, Kell could feel the weak remnants of a pulse. As he knelt by the poor man’s side, Kell’s remaining doubts lifted and the horror of recognition took hold.

  Kell had seen many strong, young British soldiers gripped by cholera. Just two years earlier he had been responsible for controlling an outbreak that struck a British regiment on the island outpost of Mauritius. Having seen cholera once, he could not forget it. Cholera had come to England.

  More precisely, Asiatic cholera had arrived. The principles of British medicine that John Snow was dutifully learning just a few miles to the north painted a muddled picture of cholera. Hardcastle had taught his diligent pupil that good health required a proper balance of the four bodily humors: blood, phlegm, black bile, and yellow bile. The last of these, yellow bile, was also known as choler. Imbalance meant disease. Cholera, as noted in a medical book of the day, was “occasioned by a putrid acrimony of the bile.”

  Because of this fundamental misunderstanding, cholera’s name was pasted across what we know today to be many different diseases, most of which involved severe vomiting and diarrhea. Snow had almost certainly seen cases of so-called common English cholera, a relatively nonspecific term for gastrointestinal diseases thought to be endemic to England. But as the epidemic approached from Calcutta, he quickly learned that this new sort of cholera was something entirely different. This new disease, according to the predominant medical thinking of the time, was a particular form of cholera known as either Asiatic cholera, to reflect its source, or cholera morbus, to reflect its severity. Today this is the only disease that we still refer to as cholera.

  Most waterborne diseases cause diarrhea, vomiting, or both. They kill, ironically, by dehydrating their victims. Remarkably William Sproat hung on for several more days as cholera* sapped the life from his body. By Monday his blood began to grow thick and tarlike and his heart strained to pump the viscous fluid. Blood’s most important role is to feed the fires of metabolism and haul away the smoke and ashes. As Sproat’s blood slowed, those oxygen-starved fires dimmed. Slowly the color faded from his skin.

  Kell had judiciously turned the care of Sproat over to Drs. Holmes and Clanny who did what they could, but medicine of the day had little to offer. The prevailing theories held that his body was trying to purge itself of some mysterious epidemic poison. Vomiting and diarrhea were to be encouraged. Recommended therapies routinely included emetics and enemas.

  Three days later there was so little blood flowing to William Sproat’s brain that he fell into a coma. As death moved in, his fingers and legs turned dark blue. That night Sproat died the “blue death” of cholera.

  For the Sproat family, the tragedy was not over. Within hours, the disease had the dead boatman’s granddaughter in its grip. By the next morning it had reached out to take the poor girl’s father.

  As the week wore on, the number of cases rose steadily. The medical men of Sunderland held a meeting and concluded that cholera had undoubtedly arrived. They sent word on to London. In early November, health officers dispatched by the Privy Council in London had placed a quarantine of fifteen days on all ships originating from Sunderland. The epidemic was official and it had cut off Sunderland from the world.

  But the fortunes of Sunderland, the fourth busiest port in England, rose and fell with the ships that filled her narrow harbor. A few weeks of unfavorable weather in the North Sea would send the local economy into a tailspin. An open-ended quarantine would cripple it.

  Faced with this bleak reality, the medical men of Sunderland held a second meeting a week after the quarantine was announced. Kell and Clanny were not included. The assembled doctors, surgeons, and apothecaries declared that their earlier inference had been a misguided rush to judgment. They expressed their unanimous conclusion that the disease that had felled the Sproats (and several others in the days since) was not Asiatic cholera after all, but simply common English cholera. There was no epidemic.

  The sloppiness of nineteenth-century diagnosis made this possible. Cholera, in 1831, was simply a set of symptoms. Today cholera is a specific disease and a definitive diagnosis is based exclusively on finding evidence that the Vibrio cholerae bacteria is responsible. In 1831 these doctors had no idea that such an agent existed. Microscopes were not a part of medical training and the notion that something undetectable to human senses might have the power to kill seemed ridiculous.

  The ignorance of medical science made it possible to pretend that this was not Asiatic cholera. Overwhelming pressure from commercial interests made this sleight of hand expedient. Unfortunately renaming the disease failed to stop it. Over the next few days, the number of cases mounted and denial became untenable.

  Just thirteen miles to the north, in the busy port of Newcastle-on-Tyne, an eighteen-year-old surgeon’s apprentice attended to his duties. For four years Snow had ground and mixed medicines for Dr. Hardcastle, taken his messages, managed his appointments, and written up the daily entries in Latin. He had assisted Hardcastle in everything from pulling teeth to delivering babies. As he gained experience, he had begun to see some of Hardcastle’s indigent patients on his own.

  Snow followed the approach of cholera intently. He picked up information from any source available and tried to comprehend the convoluted web of primitive thinking as to its cause. Events in Sunderland also taught him about the capacity of the medical establishment to turn from the truth when economic and political forces make it desirable and ignorance makes it plausible, a process recapitulated in his own career many times over.

  As November wore on, the medical community of Newcastle braced itself for the epidemic and John Snow attended to his duties. England was at war with cholera. Within a month, he would join the battle.

  Cholera moved steadily north along muddy streets lined with human and animal waste. By late November it had reached the working class town of Tynemouth, just a mile downstream from Newcastle. It spread easily in this unsanitary world. The path upstream was short. On December 7, 1831, cholera arrived in Newcastle.

  An unwashed hand, a dirty spoon, a bit of soiled linen. All innocent and harmless under normal circumstances. In the presence of cholera, however, they become the carriages in which death can ride. And so, in Newcastle, it did. Steadily from one person to the next. A touch, the sharing of a poisoned object, and the disease moved.

  Epi-demos. Upon the people. An epidemic, by definition, afflicts large populations. Most epidemics, however, do not spread at a steady pace, but in fits and starts. Slow spread is punctuated by periodic, explosive outbreaks. In Newcastle cholera was picking off victims one by one. As Christmas approached, only a few dozen had died. Although the presence of the disease spread fear throughout the community, it had yet to show its potential for a sudden devastating outbreak. That was about to change.

  As the residents of Gateshead sat to eat their Christmas dinners, Thomas Fife, a local apothecary, made his way through the narrow streets to a small, low-ceilinged room on Oakwellgate Lane. Like the other doctors of Gateshead, Fife had been following the news of the slowly growing outbreak in Newcastle, just across the river Tyne. As he walked through quiet streets of Christmas, Fife could hope that Gateshead, with only two deaths, might still be spared. A week earlier an impoverished ragpicker had died from cholera. The second case, a poor woman from Pipewellgate, had just fallen ill on Christmas Eve, but as Fife approached the tiny apartment of Margaret Taylor, h
e could still believe Gateshead would not feel the full wrath of cholera.

  The air in the single room that Margaret Taylor shared with her sister, Isabella, was oppressive and still. The two women made a meager living as spinners at the twine yards. As he approached Margaret’s bed, her sunken eyes gazed up from a face that appeared far older than her forty-two years. The illness had taken its warmth and vigor leaving it shriveled and gray. Margaret Taylor had been fighting for her life since four in the morning and was now struggling to breathe. Fife sat next to her and laid his fingers across the cold skin of her wrist. He waited in silent concentration, but her feeble pulse eluded his touch.

  Fife saw that she had entered the later stages of cholera in which the disease seems to asphyxiate its victims. Concluding that he needed to stimulate her and to excite her vascular system, he gave her a combination of ammonia, camphor, opium, and menthol. As the cold blue death crept in, he tried to warm her by rubbing her with heated flannel and administering warm water enemas. Fearing he was facing his first case of Asiatic cholera, Fife sent word to his colleagues, including Tom Brady, the man who had cared for the first two cases in Gateshead. Soon several doctors including Brady crowded into the room. Brady confirmed Fife’s conclusion that Margaret was in the final stages of the disease.

  As Margaret Taylor lay dying, Fife was summoned to the bedside of a twelve-year-old girl, Mary Wheatley, who had been suddenly stricken with violent diarrhea and vomiting. Fife began to suspect that the epidemic had arrived in Gateshead as he rushed to examine the poor child. Relying on the confused concepts of disease and health that defined medicine in his day, Fife chose to purge her of the offending bile. He gave her ipecac to improve the effectiveness of her vomiting and an enema with turpentine in gruel.

  Across town an apothecary by the name of Greenhow sat by the bed of Margaret Walker, the mother of nine children, who had been sick for three hours. When he had finished, he prepared several slices of toast, soaked them in vinegar, and coated them with black pepper. He then arranged them on her abdomen in hopes of improving her condition.

  Throughout Gateshead, the story repeated itself over the course of Christmas Day as doctors, surgeons, and apothecaries rushed to offer useless remedies. With no real understanding of the disease, doctors selected their mode of treatment based on an amalgam of archaic beliefs interpreted according to the idiosyncrasies of their own particular misconceptions. As a result it is often impossible to discern the method in their madness. In treating the first two cases of cholera, Mr. Brady had spread a poultice of bran between two sheets and wrapped it around the legs of the victims. Another local doctor advocated the use of tobacco enemas during the course of the outbreak.

  Fife’s efforts to help his two patients eliminate cholera’s poisons only hastened their death by dehydration. Margaret Taylor would not survive the night. Twelve-year-old Mary Wheatley died early the next morning. Greenhow’s warm toast was laudable only in its uselessness. It did no harm, but his patient fared no better than Fife’s. That same morning, the nine Walker children would lose their mother.

  Fife did have one success. Just a few blocks from where the spinster, Margaret Taylor, lay dying, Joseph Laws, a twenty-four-year-old laborer, began to feel uneasy. Unsure of what to do to calm his queasy stomach, Laws sat down to a plate of cold mutton. He would soon discover that the stirring in his belly was not hunger, but cholera. When he called for Mr. Fife, the surgeon apothecary suggested he drink as much thin gruel as he wanted. By providing him with a mechanism to replace the fluids he was losing, Fife almost certainly saved Joseph Laws’s life. He failed, however, to recognize that he had stumbled on the only effective treatment for cholera.

  Fife was too busy to think much about the mechanisms of cholera’s attack. At three in the morning of December 26, he was summoned back to Oakwellgate Lane to see Isabella Taylor, the sister of the spinster who had died the previous night. He found Isabella in a neighbor’s apartment. Death haunted the air. The cholera-ravaged corpse of her sister, Margaret, lay next door in the room where she had died. Now the disease had moved to Isabella. She would die by nightfall. Before the next day was over, cholera had attacked 119 people and 52 of them had fallen to the blue death.

  The frail, the old, and the very young were most likely to die at the hands of cholera. A desperate mother with bowls of chicken broth might naively save her child’s life by staving off dehydration. In 1829 survival might have involved nothing more than avoiding medical care.

  Like the other doctors in Newcastle, John Snow interpreted the outbreak in the context of the prevailing thinking about epidemic disease. The medical science of the day held that the spread of an epidemic disease such as cholera must involve a miasma, a foul-smelling airborne poison. An explosive outbreak such as occurred in Gateshead signaled the sudden presence of a particularly dense miasma in the afflicted community. Only the air could spread a disease this widely and rapidly. Snow would spend the rest of his career proving these theories wrong.

  Although no one realized it at the time, Gateshead had just witnessed the tremendous capacity of water to spread cholera. In the months before the arrival of cholera, a severe water shortage had forced the local water company to pump water directly from the Tyne in order to ensure an adequate supply. Residents of Newcastle and the surrounding towns consumed bottles carefully filled with untreated river water. As the epidemic grew, the chance that cholera would crawl through the pumps and into those bottles increased. In the days before Christmas 1831, in the town of Gateshead, across the river from Newcastle, cholera had gotten into the water.

  Cholera had established itself, but it was winter. In the cold, the disease slowed, hunkered down, and waited for better weather. With the arrival of spring, it began to travel again. As the summer warmed the coal-stained towns of northern England, the disease exploded all over the kingdom. The toll in Newcastle rose steadily.

  In August 1832, with cholera raging, William Hardcastle called John Snow aside. Cholera, he told him, had spread to Killingworth, a coal town two miles to the north. In addition to his responsibilities in Newcastle, Hardcastle was Killingworth’s only physician. At the same time, the vestry of St. John in Newcastle had recently given Hardcastle responsibility for overseeing the care of the poor in the parish. Given the new assignment together with his existing clinical responsibilities in Newcastle, he simply could not take on this new outbreak. After five years of training, Hardcastle believed Snow was ready to work on his own. At the age of nineteen John Snow set out for Killingworth to take on cholera single-handed.

  The Killingworth Colliery was one of dozens of shafts sunk into the vast coal seam that ran under the northeast corner of England. Snow knew that cholera loved nothing more than a mining town. In January the initial wave of the epidemic had struck at Newburn, a mining village of 550 people. Within a few weeks, cholera had attacked 330 of them, killing 65.

  Rotting garbage, excrement, and poor ventilation were all presumed to contribute to miasmas and the spread of epidemics. Had miasmas existed, they would have found a warm welcome at the bottom of a mineshaft. The miners worked and ate in filth that was unparalleled, even in the gritty world of the working class in early nineteenth-century England. There were absolutely no regulations to protect the men, women, and children that worked in the mines. (It would be eleven years before Parliament passed a law prohibiting women, girls, and boys under ten from working in the mines.) Miners routinely worked shifts of twelve hours or more. Whatever food and drink they needed for those twelve hours, they would take with them into the mine. There, in a dark narrow cave with no privy or water, they would live, eat, and defecate.

  For John Snow the weeks he spent in Killingworth left the most enduring memories of his entire apprenticeship as he watched the miners emerge from the coal pits stricken with the disease. Snow worked tirelessly throughout the outbreak. Day after day he visited the one-room houses that stood in rows around the mine. Night after night he cared for the sick and d
ying miners and their families.

  Despite his best efforts, he watched again and again as cholera wreaked sudden and deadly havoc on its victims. Away from Hardcastle’s supervision, he had greater freedom to think for himself and to learn from his failures. He began to sense that there was something fundamentally wrong in the prevailing wisdom about cholera.

  Later, as he reflected on the outbreak, he wondered why cholera had struck at Killingworth while sparing other mining towns. With Robert Stephenson, the famed designer of steam locomotives, as its engineer, this mine was at least as well designed and ventilated as other mines in the area. What sort of miasma would strike at this mine and not others?

  In the humid tropics, cholera becomes endemic, simmering in the population, limited only by the immunity of those who have survived the disease and the caution of those never afflicted. In colder climates, a bitter winter can pull the disease up by its roots and in 1832 that is precisely what happened. After killing more than twenty thousand Britons, cholera left England, but the question would stay with John Snow. For the next sixteen years, in cholera’s absence, the question lingered as he moved on to other projects. He completed his apprenticeship with Hardcastle and then two more apprenticeships with surgeons in nearby towns. In 1836, after he had finished his final apprenticeship at the age of twenty-two, he walked home to York.