The Blue Death

by Dr. Robert D. Morris

  He had been gone for over seven years and much had changed in his long absence. The hard work of his parents had continued to pay off for his family. They now owned a farm on the outskirts of York and his older siblings were already on track to become teachers, clergymen, and businessmen. Two more Snows had been born in his absence. One of them, a brother, had died from an infection before John ever had a chance to see him.

  The reunion did not last long. John, as always, was looking forward. The 120-mile walk from Newcastle to the family’s farm was merely a warm-up. After visiting York, John Snow planned to continue on to London where he would enroll in medical school.

  Even if he had taken the most direct route, the trip to London would have required him to walk almost two hundred miles, heading southeast along the Great North Road. Young, full of energy, and eager for the challenge, John bid good-bye to his parents and his seven siblings on a September morning in 1836. He began to walk, not toward London and the rising sun, but toward Liverpool, a hundred miles to the west. This was to be a grand adventure.

  Snow had planned a circuitous route to London that would not only expand his universe, but would also take him to see one of the most important people in his life, his uncle and mentor, Charles Empson. Charming, dapper, and worldly, Empson had come to Newcastle shortly after the arrival of his nephew from York. Through most of Snow’s apprenticeship, Empson owned a shop in Newcastle where he dealt in fine art, antiquities, and exotic shells and minerals, many of which he had collected during travels in South America. The shop was just a few blocks from Hardcastle’s surgery. It was a hub for the cultural elite of Newcastle and Snow was a frequent visitor.

  But the shop in Newcastle had closed its doors long before John Snow finished his apprenticeship. Empson left under a cloud. A note in a local paper stated that he had been “the victim of a cruel, malicious, and slanderous report, fabricated and propagated by a vile wretch whom he had employed as a tradesman.” The precise nature of those accusations was never recorded, but they were sufficient to cause Empson to close his shop and move to Bath.

  So after a stop in Liverpool, Snow turned south, toward Bath. Again he shunned the direct route, embarking on a tour through the Welsh countryside that added another hundred miles to his trip. He walked through beautiful mountains and past coal towns at least as dirty as those around Newcastle, coal towns that had been largely spared by the cholera epidemic. After walking almost four hundred miles, he arrived in Bath, found his way to an apartment above a small gallery at 9 Cleveland Place, and knocked.

  When Charles Empson opened the door, John Snow had not seen him for two years. The two men spent their days together in Bath catching up on the events since their time together in Newcastle and discussing Snow’s future in London. Given the expenses that lay ahead for Snow, it is likely that he received financial support from his increasingly prosperous uncle. Then, after a warm farewell, John Snow began the final leg of his journey.

  For ten days Snow walked past the fertile fields of southern England. The farms buzzed with the activity of the harvest. Carts laden with produce filled the roads. As he approached London, the traffic thickened. Coaches and carriages joined the farmers’ carts. Finally the countryside gave way to Kensington Gardens and Hyde Park. John Snow’s sense of exhilaration grew as he walked past Buckingham Palace and into the heart of the city that, perhaps more than any other, defined the nineteenth century. His trip ended on Great Windmill Street in Soho where he would continue his medical education as a student at the Hunterian School of Medicine. To get there he had walked almost five hundred miles.

  As cholera faded from the consciousness of London, John Snow threw himself into his medical training. He did not forget cholera, although it would not return to England for twelve years. The disease would find him again, but it would also find that those years had made him a far more formidable adversary.

  2

  SNOW ON CHOLERA

  John Snow was a mere teenager the first time he watched a patient’s flesh turn pale and cold from the tourniquet’s grip. Almost twenty years later, the lingering images still haunted his memory. Above all, he remembered patients in pain. He could still hear their screams as the razor-sharp blade sliced deep into the limb, shredding the protective haze of morphine. Each cut nerve brought a new wave of agony, but, as the incision revealed the bone, a new kind of anguish began. As his mentor, William Hardcastle, cut into the clusters of densely packed nerve endings that surrounded the bone, they translated the intrusion into a thousand rivers of anguish that overwhelmed the patient’s very soul. The lingering passage through the dense mineral matrix seemed more like torture than surgery. Faces crushed by pain still howled across the years for relief, but that relief never began before the thud of the limb in the catch basket.

  Surgical pain was Snow’s grim tutor throughout his medical training. Since coming to London, he had spent endless hours in the operating rooms of Westminster Hospital. After finishing medical school, he had served as one of the hospital’s house surgeons (the equivalent of today’s surgery resident). He had participated in hundreds of surgical procedures and each one was a race against pain. A good surgeon was a fast surgeon. Every surgeon in Napoleon’s army had to prove he could amputate a leg in less than three minutes. Until the winter of 1846, speed was the patient’s only friend.

  That year, on the morning of December 28, John Snow and two colleagues walked through the bitter cold that had gripped the city since Christmas Eve. The implications of what they had just seen consumed his thoughts. The fate of a rotten tooth had just revealed to them the future of surgery.

  The tooth belonged to a female patient of Dr. James Robinson, a friend of John Snow. On that late December morning, Snow and his companions had observed as Robinson picked up his pliers, grasped the tooth, rocked it back and forth, and pulled. The astonished audience watched and listened in awe as the bloody tooth emerged. Their amazement arose not from what they saw or heard, but from what they did not. The patient had not cried out, moaned, or even flinched. Robinson’s patient had no special resistance to pain. The incredible quiet had come from a bottle of ether.

  Just nine days earlier, Robinson had given the first demonstration of ether in England. Until that moment, pain and the struggle to control it had pervaded the practice of the British surgeon. By the time Snow saw Robinson in action, he had performed half a dozen procedures and was, by default, the country’s leading expert on the use of ether, a technique he had imported from America just weeks after the publication of the first paper describing its use appeared in Boston. On that late December morning, the three men stayed to question Robinson, drawing from his relatively shallow well of experience as the patient recovered.

  They emerged from Robinson’s office into the oppressive air of winter. Tens of thousands of stoves and furnaces that had burned through the cold heart of the British night filled the air with smoke. The coal-fired engines of London’s factories added thick black clouds to the pall of soot that sank steadily downward on the populace. At the same time, another cloud was rising from the streets themselves. The steady hammering of hundreds of thousands of horseshoes was grinding the cobblestones into a fine powder. The result was a gritty mixture of stone dust and burned coal that accumulated in every corner of the lives and lungs of the city’s inhabitants.

  After ten years Snow had learned to live with London’s abuses. As the three men parted company and Snow walked toward his home in Soho, he gave little thought to the city’s cold, gritty air. On that morning in December, his mind was fixed on the miracle of silent surgery.

  Snow knew that ether would change everything. He also recognized the danger inherent in ether’s magic. Physicians would need to walk a fine line between the reemergence of pain because of too little ether and the disaster of an overdose.

  The power of ether had impressed him, but Robinson’s technique had been crude and his methods imprecise. The dentist had simply allowed the patient to inhale ether
from a flask until she faded from consciousness. Snow’s knowledge of chemistry told him that the evaporating ether cooled the inhaler. As it cooled, the amount of ether vapor rising from the flask and entering the patient’s lungs decreased. This meant that Robinson had no way to know precisely how much ether he was giving the patient. Furthermore he had no real way to control the amount she inhaled during the operation. At a time when no one else in London seemed to see these problems, Snow had already begun to imagine how to solve them.

  In the years since he arrived in London, Snow had turned his apartment into a buzzing laboratory, an outlet for his inquisitive mind. Even as a medical student, he had pieced together enough equipment to perform a study demonstrating that the arsenic used to preserve cadavers was rising from the dissecting table and sickening his fellow medical students.

  At the time Londoners often used candles made from palm oil. Manufacturers added arsenic to help them burn brighter and more evenly. Snow’s attempt to study arsenic levels released by burning candles almost ended his research career. He and a fellow medical student were hunched over their experiment, when an apparatus he had designed to collect the fumes from the candle burst into flames. Fortunately the two were quick enough to extinguish the blaze before it consumed Snow’s nascent laboratory.

  In the years since, his experimental technique had improved and his laboratory had grown to a point where he was ideally prepared to investigate the use of ether. He had the instruments needed to measure the temperature and pressure of gases with a high degree of precision. He had the cages and tanks he needed to test ether on a broad range of animals and, during the month that followed, he filled them with finches, thrushes, frogs, mice, rats, and even fish. He knew and had worked with high-precision machinists capable of turning his designs for medical devices into working prototypes.

  So for the next month, he brought all his skills, experience, and laboratory resources to bear as he focused on the single goal of understanding and refining the administration of ether. He devoted all his free time to the task and before two weeks were over he had the data necessary to predict the dose of ether over a broad range of conditions. Before the end of January, he had administered ether in precise doses to the menagerie of small animals in his lab and recorded their response in fine detail. At the same time, he had designed and assembled an ether inhaler intended to maintain a constant temperature and deliver a stable dose throughout a surgical procedure.

  So by early February Snow had developed a detailed understanding of the effects of the drug, generated data essential for its controlled administration, and invented an inhaler far superior to any other. He arranged to present his findings at the regular evening meeting of the Westminster Medical Society.

  It is no exaggeration to say that the society was the closest thing John Snow had to a family during his time in London. For much of his time there, he had no relatives in the city. There is no record of any romantic relationship during those years. His life was medicine. His friends were members of the society and he rarely missed their weekly meetings. From his first paper on the resuscitation of newborn infants to his last, he tested every new idea on his medical family.

  Snow had presented his research to the meetings of the society before, but never with such overwhelming authority. Less than two months after first learning of ether’s power, he had established himself as an expert in its use. His presentation impressed his colleagues and their acclaim came as a great triumph to the young doctor.

  Snow however does not appear to have been motivated by any need for praise or money. He made no effort to patent his inventions. Instead he published detailed descriptions to allow others to copy them for their own use. Initially he did not even have notions of establishing a practice in the administration of ether. That changed on a January morning in 1847 as Snow was leaving the hospital.

  Years later, a friend recounted the story:

  [H]e met a druggist whom he knew bustling along with a large ether apparatus under his arm. “Good morning!” said Dr. Snow. “Good morning to you, doctor!” said the friend; “but don’t detain me, I am giving ether here and there and everywhere, and am getting quite into an ether practice. Good morning, doctor!” Rather peculiar! said the doctor to himself; rather peculiar, certainly! for this man has not the remotest physiological idea. An “ether practice! If he can get an ether practice, perchance some scraps of the same thing might fall to a scientific unfortunate.

  At the time, Snow was, indeed, a “scientific unfortunate.” He had tried to establish a clinical practice for more than eight years and was still struggling to make ends meet. He had contracts with several sick clubs, a system akin to a crude HMO in which doctors received a fixed fee and in return provided whatever care was required by members of the clubs. He also worked at the dispensary of Charing Cross hospital. In both cases, he was providing care to the working poor with minimal compensation.

  To some extent, the cause of his financial struggle lay in the peculiar nature of the man. John Snow was an acquired taste. His voice, which a friend described as “painful” on first hearing, left a poor first impression. He also had the annoying habit of telling patients the truth rather than what they wanted to hear. In Newcastle his inclination to tell patients that Victorian medicine had little to offer them had resulted in bitter arguments with William Hardcastle and may have contributed to his decision to leave the city for further training. In London it left patients dissatisfied and cut into Snow’s ability to generate an income. Last, but not least, he lacked the breeding, elite credentials, and connections necessary to attract the members of London’s upper crust.

  To make his financial matters worse, he had poured all that he could save of his meager income into research. That chance encounter with a druggist began a merger of Snow’s research and his clinical work that would redefine his professional life. On January 28, exactly one month after observing Richardson’s tooth extraction, John Snow put his first patient to sleep.

  Over the next year, John Snow administered ether more than a hundred times for everything from mastectomies to dental procedures. His anesthesia practice opened a door to wealthier patients and brought a new source of income that allowed him to substantially increase his research activity. At a time before the specialty even had a name, he was on his way to becoming one of the most respected anesthesiologists in England.

  But as his career developed, cholera was making its way across Europe to find him again.

  After 1832 cholera had retreated to India where it festered until the hot summer of 1845 when it marched on Kabul. By 1846 it had reached into the Middle East, killing twelve thousand people in Teheran and thirty thousand in Baghdad. On a single, horrible night in 1847, almost three thousand pilgrims died at Mecca. In 1848 it made its way to a district on the banks of the Thames known as Horsleydown.

  Named after a pasture used to graze horses in the sixteenth century, Horsleydown no longer appears on maps of London. Tower Bridge bisected the riverfront neighborhood when it was built in the late nineteenth century, relegating Horsleydown to the history books. In the 1840s however it was very much alive. An exotic blend of immigrants had settled there and established the breweries, tanneries, and warehouses that dotted the area. Above all else, its proximity to the docks made it the rough-and-tumble home to the seamen and dockworkers who serviced the endless stream of merchant ships that flowed into the city from all over Europe.

  Two events have kept Horsleydown from disappearing entirely into the mists of history. The most dramatic was a fire that started in a jute warehouse on Tooley Street in 1861, near the wharf. A neighboring building containing resin, oil, and tallow exploded in flames and spewed its burning contents across the neighborhood. The resulting fire raged through the district for weeks, consuming the low wooden buildings in a blaze that could be seen for fifty miles.

  The buildings that burned had provided the setting for a less dramatic, but ultimately more significant moment thirteen years e
arlier in September 1848. A seaman by the name of John Harnold had just returned from the port of Hamburg aboard the merchant ship Elbe. With cholera raging in the German port city, British troops placed the ship in quarantine.

  Harnold was feeling a bit out of sorts and wanted nothing more than to lie down in a proper bed and rest. He could not tolerate the foul, cramped confines of a merchant ship when the city and freedom were so close at hand. In the busy, buzzing confusion of the docks, slipping ashore was far easier than the masters of quarantine liked to pretend.

  So he made land and walked through Horsleydown to a rented room on Gainsford Street, just two blocks from the docks. He lay down to rest, carrying the seeds of the epidemic in his belly.

  When cholera struck at John Harnold, it did so with such force that the sturdy seaman died in just two hours. Within days the nightmare had begun to replay itself throughout the district. The second great epidemic of cholera had begun.

  The disease that was once a stranger to London’s physicians had taken on a terrifying familiarity. The first epidemic, which began in Sunderland in 1831, had killed 8,500 Londoners before ending in 1833. When Mr. Russell, an apothecary, came to see the stricken man, he knew in a moment what had happened. Dr. Parkes from the Board of Health confirmed that Asiatic cholera had arrived. The news raged through the city’s medical community and quickly reached the busy anesthesiologist John Snow.

  Fourteen years had passed since the young John Snow watched cholera slaughter the miners of Killingworth. In those years the puzzle of its cause had never lost its hold on him. During his years in medical school, first in Newcastle and then at the Hunterian School of Medicine on Great Windmill Street in Soho, he had learned the prevailing medical beliefs about cholera. Those theories however did not seem to fit the disease that he had come to know with a chilling intimacy.