The Blue Death Page 6
Nine different companies sent forty-four million gallons of water each day into the British capital. Almost ninety percent of homes had access to this supply. Some of the water came from relatively pure sources such as the springs and artesian wells that supplied the Hampstead waterworks, but these supplies were limited. Most of the water came from the rivers that flowed toward and through the city. Of the nine suppliers, five drew their water from the Thames.
Many limited their use of piped water to washing and cooking, relying on well water for drinking. Over time, however, the thought of trekking to the nearest well and lugging back buckets of drinking water had the remarkable ability to purify the water that flowed so effortlessly from the tap. Ease of use nurtured a dangerous delusion. With sewage flowing into the Thames, tap water turned deadly.
As a stranger to the strange land of politics, Snow refrained from criticizing Chadwick directly. In his original monograph, On the Mode of Communication of Cholera, his critique of the sanitarians was limited to the advice that people avoid drinking “water into which drains and sewers empty themselves.” Snow preferred evidence to policy critique. The report demonstrated that the rate of cholera mortality among people living south of the Thames was seven times higher than the rate on the north side of the river. All the water supplied to the south side, he noted, came from the Thames.
In the fall of 1849, emboldened by his growing body of evidence and outraged by the actions of the Commission of the Sewers, Snow took more direct aim at Chadwick and his allies. The update of his monograph published in the London Medical Gazette described cholera’s devastating assault on the residents of Rotherhithe who drew their water from tidal ditches filled by the Thames. In many cases the ditches received the contents of surrounding privies. Seeing the consequences of drinking what he called “Thames water rendered a little richer in manure,” Snow could not hold his pen. What the victims had drawn from these filthy ditches was, he pointed out, “probably equal to what Thames water would be if certain of our sanitary advisers could succeed in washing the contents of all our cesspools into the river.”
Through his outrage Snow also saw that the increased pollution of the Thames had set in motion an experiment that might give him the final piece to his puzzle. If he could show marked differences in cholera rates among customers of different water companies according to the source of their water, particularly when those customers lived side by side, his critics would lose their refuge.
The retreat of cholera following the epidemic of 1848–1849 allowed John Snow to focus his energies on his own career and success built on success. In the spring of 1850, John Snow sat before the senior members of the Royal College of Physicians and endured a barrage of questions on classic medical texts. Passing the exam would make him a licentiate of the Royal College. His examiners sat at the peak of a hierarchy so rooted in the past that, until that year, the entire exam was given in Latin.
British medicine no longer intimidated the unflappable Dr. Snow. When the day was done, the college nodded its approval, granting him the highest medical credential available to a man with his plebian pedigree. Becoming a licentiate was a great achievement, but Snow could not hope to climb higher. The peak of British medicine, Fellowship in the Royal College, was the exclusive province of graduates of Cambridge and Oxford.
Nonetheless his success gave him entrée to exclusive medical societies and put him on a path that would lead to the presidency of the Medical Society of London in 1855. John Snow’s acknowledged skill as an anesthetist also meant a dramatic improvement in his finances. In 1852 he moved from his apartment on Firth Street in Soho to a home of his own at a prestigious address on Sackville Street, just off Piccadilly. His income even permitted him to hire away his former landlady’s housekeeper.
But no measure of success could compare to a single call for his services late in the winter of 1853. A woman living across from St. James’s Park had experienced a series of difficult deliveries and had heard that Dr. Snow’s anesthesia could ease her pain. She and her husband wanted to meet with him to discuss their options. Her name was Victoria.
It is hard to say which Queen Victoria disliked most, pregnancy, childbirth, or infants. Most likely she viewed them together as a troika of misery that afflicted women with oppressive frequency. That the interminable wretchedness of pregnancy and the agony of labor produced such a “nasty object” as a baby seemed a cruel joke. She viewed infants as “mere little plants for the first six months” characterized only by that “terrible frog like action.” Both pregnancy and the postpartum period were marked by depression mixed with fits of irrational rage directed at her beleaguered husband, Prince Albert.
Despite her feelings she spent more than half of the first ten years of her marriage in what she called the “unhappy condition” of pregnancy and almost seven of those years with infant children. Before the birth of her seventh child, Prince Arthur, in 1850, Victoria and Albert had asked that her obstetrician consider anesthesia during labor, a practice frowned upon by much of the medical establishment. At the time the queen’s obstetrician, Dr. Charles Locock, had sought out and consulted with the nation’s foremost authority on the administration of chloroform, John Snow.
The dramatic appearance of ether on the medical stage had sparked a frenzied search for other anesthetic agents. Snow had been among the most rigorous researchers in this effort, testing dozens of agents not only on his small zoo of laboratory animals, but also on himself. He had been among the first to recognize that chloroform, which produced an anesthesia less overwhelming than ether, had advantages in certain procedures, particularly childbirth.
The queen’s physicians considered anesthesia too risky. At their urging she had forgone anesthesia for the birth of Arthur, but now she was pregnant again. She and her husband had had enough of labor. Taking matters into their own hands, Victoria and Albert decided it was time to meet Dr. Snow themselves.
Almost twenty years after he had first marveled at the sight of the royal residence as a young surgeon, Dr. John Snow walked through its ornate entrance to meet his queen. Although the details of the meeting are lost, he must have impressed the royal couple. When the time came, the queen overruled her physicians and insisted on anesthesia.
On the morning of April 7, 1853, John Snow received an urgent message from Sir James Clark requesting his presence. The queen was in labor. Snow rushed down Piccadilly and across the St. James’s Park. When he arrived at the palace, he was ushered to a sitting room a few discreet steps from the queen’s chambers where her doctors had gathered. After two hours Victoria called for relief.
With the utmost care, Dr. Snow measured out fifteen minims of chloroform, poured it onto a handkerchief, and held it to the queen’s nose. As she lost her connection to pain, he monitored her every breath and heartbeat. Within an hour Prince Leopold was born.
Many in the medical community considered it scandalous that the queen should have chosen to interfere with the natural course of childbirth. The Lancet responded to the news with a scathing editorial. After pointing to the deaths associated with the administration of chloroform, the editors opined, “[W]e could not imagine that any one had incurred the awful responsibility of advising the administration of chloroform to her Majesty during a perfectly natural labor.” The editors considered this use of anesthesia “unnecessary.” The queen held no such opinion. Chloroform was, in her estimation, “soothing, quieting, and delightful beyond measure.” Four years later, when her ninth and final child was born, she would make sure that Dr. Snow and his “blessed chloroform” were by her side.
Cholera had departed, but it left Londoners reeling from its impact and struggling to understand its causes. Early in the spring of 1852, a stout, balding man looked out with dark, sunken eyes over a crowd that had gathered around his podium just off St. James’s Square. They listened intently as he spoke out on man’s natural place in the broad sweeping uplands of the world:
An instinctive sense draws [ma
n] to the healthy places of the earth, and makes the lands in which his race dies and is degraded, repulsive. In dank marshes surrounded by stagnant waters, and in hollow places of the earth covered with reptiles, we feel oppressed; on the plain, where the breezes sweep over the herbage, the mind as well as the body is at ease.
Just prior to expounding on the healing virtues of the windswept highlands and warning against the race-degrading dangers of low places, the speaker had presented a precise mathematical formula to predict the rise in cholera rates as populations descend toward the sea. He next launched into a sweeping thesis on the deleterious effects of the lowlands throughout history. In the higher altitudes, he argued:
[T]he chest expands in the elastic air, and the soul seems to drink in deeper draughts of Life. On the high lands men feel the loftiest emotions…. Man feels his immortality in the hills.
He explained how miasmas collect in lower altitudes and laid out the consequences of settling in such undesirable settings. “Wherever the human race, yielding to ignorance, indolence, or accident, is in such a situation as to be liable to lose its strength, courage, liberty, wisdom, lofty emotions,” he warned, “the plague, the fever, or the cholera comes.” These unhealthy environs lead not only to disease, but also, over the course of generations, to a profound degradation of the population. He presented examples from India to ancient Rome to demonstrate the tendency for races that had descended toward the oceans and estuaries of the world to enter a slow, steady decline.
Clearly the English people had come from the healthful highlands and belonged there still. “No race of men living in maremmas, marshes, deltas, low sea-coasts, low river-sides, could have acquired or wielded the power of this empire,” he observed. Cholera was perhaps a clarion call for a return to pastoral roots, a bit of tough love from the deity. After all, he observed, “to a nation of good and noble men, Death is a less evil than Degradation of the Race.”
The attentive crowd that stayed to the end of this diatribe on the preservation of the English race was not a fringe group, but the Statistical Society of London. The speaker was not an eccentric, but William Farr, the leading medical statistician of his day. As the Compiler of Abstracts for the General Registrar, he was the man responsible for the tabulation of all vital statistics, including mortality rates. No one knew the cholera statistics better than he. His report based on the principles outlined in this speech became one of the most widely cited works on the cause of cholera in his time.
Farr had been refining this idea since the epidemic of 1848–1849. He was committed to the sanitary cause and the sanitarians had relied on his observation to dismiss Snow’s findings about the relationship between water supply and disease. Snow, they argued, had correctly described the occurrence of cholera, but had identified the wrong cause. The districts that relied on the Thames for their water supply were lower in altitude. Where Snow saw the effects of contaminated drinking water, Farr, along with Chadwick and his allies, saw miasmas sinking toward sea level.
For the sanitarians the devastation of the epidemic of 1848–1849 demonstrated not that they had been mistaken in dumping the city’s sewage into the river, but that they had not moved fast enough in purging the city of fermenting organic matter. Through the early 1850s, they redoubled their efforts. By 1855 thirty thousand cesspools had been eliminated and far more had been bypassed. The amount of sewage pouring into the river soared as Chadwick pressed his agenda.
Still the truth has an annoying resilience. The sanitarians did not need to accept Snow’s thinking, but they could not entirely ignore it. In 1850 the General Board of Health issued an investigation of the city’s water supply. The report made no direct mention of Snow, but implied that the sanitarians had always recognized the link between water quality and health. Of course, it explained, excessive organic matter in the water supply will ferment and contribute to the miasma. Even Hippocrates had warned of the ill effects associated with certain types of water. Snow had simply taken an obvious relationship and carried it too far with his strange notions about ingestible, self-replicating agents of disease.
The report also argued for the consolidation of the nine private water companies into a single entity, controlled by the government with a single source, far from the tidal reach of the Thames. In extolling the advantages of the supply they had identified, the board spent more time on the superior softness of the water than on any sort of biological purity. By avoiding the mineral content of the Thames, they boasted, the new water system would save five million pounds per annum in soap and cut tea consumption for the metropolis in half.
Once again Chadwick’s report created an alliance of powerful enemies. The water companies had established a formidable oligopoly through a series of anticompetitive agreements. This lucrative arrangement had filled their coffers and given them the guaranteed allegiance of at least a hundred members of Parliament. By the time the Metropolitan Water Act passed in 1852, Sir William Clay, spokesman for the water companies, had been enlisted to draft the final bill. It gave the water suppliers until 1855 to cover their reservoirs, filter their water, and move any intakes in the Thames upstream, to put them out of reach of the tides. In return the water companies were left standing. Chadwick however, with too many enemies, stood on the brink of political destruction.
When John Snow held his chloroform-soaked handkerchief to Victoria’s nose in the spring of 1853, both he and England were at the height of their powers. With her rich coal reserves and vast merchant and military fleets, Britain dominated the industrial revolution and the international trade it generated. Just two years earlier, the world had made a pilgrimage to the Crystal Palace, a spectacle of glass and steel with a monumental glass fountain and three fully grown elm trees at its heart. Erected in the center of Hyde Park, its two vast arms sheltered the Great Exposition. The two arms stretched out in perfect symmetry, balanced like an immense, glittering scale. In one arm it held the wonders of the British Commonwealth. In the other the accomplishments of the remainder of the world made the perfect counterweight.
The nightmare of cholera was fading into history. The collective expertise of this magnificent empire must have the capacity to solve its riddles and prevent a third epidemic. That illusion would soon be shattered.
Snow’s prestige as an anesthesiologist did not translate into acceptance of his ideas about cholera. In 1853, the same year he attended to the queen, the editors of the Lancet expressed their frustration at the lack of a satisfactory explanation for cholera’s cause:
What is cholera? Is it a fungus, an insect, a miasma, an electrical disturbance, a deficiency of ozone, a morbid off-scouring of the intestinal canal? We know nothing; we are at sea in a whirlpool of conjecture.
As an epidemiologist, Snow had to rely on the epidemic for his data. Cholera’s retreat in 1849 had halted its natural experiment, but Snow kept working. For five years, as he maintained a burgeoning anesthesia practice and a busy agenda for research on new anesthetic agents, he assembled data. He learned everything he could about London’s water suppliers: where did they draw their water, how did they filter it, if at all, and whom did they serve? His analysis of these data would be the centerpiece of a revised monograph. He had nearly completed his study of the first two epidemics when in 1853 cholera began to experiment again.
4
THE EXPERIMENTUM CRUCIS
As the steel gate slammed shut behind him, a lone figure emerged from the gloomy corridors of Millbank Prison and crossed the bare, graveled wedge of the outer yard. At its far end, he entered a triangular room occupied by a single table. On it was a list of those who would be leaving the prison that day. As William Baly approached the table, the gatekeeper had no need to check the list. As physician for the prison, Dr. Baly was always free to leave. His reputation however would remain forever locked within.
It was the winter of 1854 and the vast, brooding fortress of Millbank Prison loomed over the north bank of the Thames. It was not only the largest prison i
n England, but also one of the largest buildings in London, encompassing more than sixteen acres within its hexagonal walls. Oppressive in every way, a contemporary critic called it “the most successful realization, on the large scale, of the ugly in architecture.”
In time the outer gate swung open and Baly walked toward the Thames, crossing the narrow field that had once been a moat surrounding the prison. A nauseating stench drifted upstream from the bone-crushing yards and the gasworks of Lambeth, but a far more worrisome cloud followed the man as he climbed into a waiting coach. Even the acrid yellow smoke that poured out of the gasworks and smothered the district every Friday would fade as he rode away from the prison, but his oppressive troubles would travel with him.
Five years earlier Dr. Baly had agreed to prepare a report for the Royal College of Physicians on the cholera epidemic of 1848–1849. With the full scientific and medical authority of the Royal College behind it, the report was to have been the definitive word on the cause of cholera. The college’s cholera committee surveyed hundreds of physicians from throughout Great Britain and combed through mortality data to ensure they had a complete and accurate picture of the epidemic and its possible causes. The survey included a set of questions on local water supplies and John Snow had eagerly anticipated the “considerable amount of information” on drinking water and cholera that would soon be available to the medical community. That was 1849. Five years later the report had yet to be published.
For those five years, Dr. Baly had been under growing pressure to complete the report. The return of cholera early in the fall of 1853 increased the clamor for its release and forced Baly to finish it. By December the report was written, but his problems were far from over. The report had been intended to demonstrate the intellectual and scientific superiority of the Royal College as compared to the General Board of Health, which had issued its own report. If anything Baly had done the opposite, stretching the tolerance of the college toward the breaking point and reflecting a sense that the medical elite were at a loss when it came to protecting the public from cholera. Later in December, when Baly sat down to write the letter that would accompany the published report, he faced problems far more critical than a late assignment. Cholera was on the loose in Millbank Prison.