And the Mystery of Cholera the Strange Case of the Broad Street

The Strange Case of the Broad Street Pump: John Snow and the Mystery of Cholera

Warren Winkelstein, Jr Online article and related content current as of September 8, 2010. JAMA. 2007;297(22):2532-2533 (doi:10.1001/jama.297.22.2532)

http://jama.ama-assn.org/cgi/content/full/297/22/2532

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Downloaded from www.jama.com at University of California - Los Angeles DCS on September 8, 2010 BOOK AND MEDIA REVIEWS organization. Accordingly, he also calls for change but taps of John Snow, presumably the “patron saint” of surgery. A into his past executive role to provide concrete advice. cursory inquiry would attest to the fact that Snow has tra- From patients’ narratives, the book takes the reader to per- ditionally been revered by surgeons because of his contri- sonal stories of health care professionals. Chapter 5 is a col- butions to pulmonary physiology and, more importantly, lection of conflictual experiences such as those of nurses B. his seminal role in the development of respiratory anesthe- Adams and R. Bingham, who narrate their stories of leaving sia. You might then wonder why Snow merits consider- nursing amid broken communications with supervisors or col- ation with regard to a major infectious disease, cholera. In leagues. Despite the unique elements of the nursing profes- fact, Snow is also revered as the “patron saint” of epidemi- sion in healing and saving lives, both of these stories seem more ology. In his introduction to Snow’s second edition of On like universal accounts of workplace disputes rather than nar- the Mode of Communication of Cholera,1 Wade Hampton Frost, ratives unique to the health care system. Also in this chapter, the first US professor of epidemiology, described Snow’s work D. Derksen carefully evaluates the state of postgraduate medi- in the following terms: cal education in the face of a resident-physician suicide. He is Epidemiology at any given time is something more than the total successful in not recommending simplified solutions. Chap- of its established facts. It includes their orderly arrangement into ter 6 covers the topic of drug companies’ darkest secret: their chains of inference which extend more or less beyond the bounds practice of buying our clinical allegiances. The essays are con- of direct observation. Such of these chains as are well and truly vincing arguments that regulation is needed to stop activities laid guide investigation to the facts of the future; those that are ill-made fetter progress.... sponsored by pharmaceutical companies. The final 2 chapters introduce stories of race, ethnicity, and ethical issues. These A nearly perfect model is John Snow’s analysis of the epi- are wide-ranging topics of varying quality, but all bring per- demiology of cholera, which led him to the confident con- sonal touches to issues of poorly defined policies. The topics clusion that the specific cause of the disease was a parasitic covered include race concordance, diversity among health care microorganism now known as the Vibrio cholerae.2 In The professionals, end-of-life decision making, and medical er- Strange Case of the Broad Street Pump, journalist Sandra Hempel rors. chronicles the saga of this remarkable medical scientist. This book takes the reader on a ride that is not always From humble beginnings in the north of England, he was smooth or consistent in quality but has a strong sentiment the eldest child of 9 born to a laborer’s family. Through hard of turning points and a profound call for change. The ma- work and an austere lifestyle, Snow rose to a position of promi- jorities of narratives are fascinating and touching and as such nence in London’s medical community. His 6-year appren- work as advocacy messengers. Each narrative is a single an- ticeship to a country doctor with extensive experience and re- ecdote, yet together they paint the story of the present health sponsibility to a mining community gave Snow a valuable basis care system. The narratives in this volume should be consid- for a special interest in respiratory disease. His medical edu- ered part of a curricular tool for medical students, adminis- cation and his introduction to research was accomplished in trators, and policy makers. Narrative Matters is a reminder London at the Westminster Hospital and the Hunterian School of the proper context of health and illness. To use an anal- of Medicine. In 1846, when news reached London of the dis- ogy from the closing narrative by Dr Richard Boyte, our na- covery of ether anesthesia in the United States, Snow imme- tion needs to open the curtain and expose the vulnerability diately turned his attention to the application of this technol- of its health care system. These stories open the curtain. ogy that revolutionized the practice of surgery. He devised Galit M. Sacajiu, MD, MPH instrumentation and procedures that promoted safety and ef- Department of Medicine ficacy for ether and chloroform anesthesia. In 1853, Snow ad- Montefiore Medical Center ministered chloroform to Queen Victoria for relief of labor pains Albert Einstein College of Medicine during the delivery of her eighth child. Bronx, NY In 1848, 2 years after Snow received his medical degree [email protected] and while investigating ether anesthesia, a major cholera epi- Financial Disclosures: None reported. demic decimated London. In a brilliant example of induc- tive reasoning, Snow concluded that the epidemic was propa- gated by drinking water contaminated by the causal agent contained in diarrheal discharges from patients. In a short THE STRANGE CASE OF THE BROAD STREET PUMP: pamphlet, Snow recommended washing hands after con- JOHN SNOW AND THE MYSTERY OF CHOLERA tacting a patient, avoiding drinking or using for cooking wa- By Sandra Hempel, 331 pp, $24.95. ter into which drains or sewers emptied, and, if these mea- Berkeley, University of California Press, 2007. sures were impractical, boiling water before use to prevent ISBN-13 978-0-520-25049-9. the disease. Hempel prefaces her description of Snow’s first edition of On the Mode of Communication of Cholera with ex- IF YOU WERE TO VISIT THE ROYAL COLLEGE OF SURGEONS IN tensive descriptions of the clinical manifestations of chol- Lincoln’s Inn Fields in London, you would find a portrait era and of previous epidemics and their spread.

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Figure. A London Board of Health Hunting After Cases Like Cholera. Courtesy of the National Library of Medicine. Lithograph by Robert Seymour (1798-1836). March 1, 1832. London. Permission to reprint courtesy of the National Library of Medicine.

In 1854, cholera was again epidemic in London. Snow ter companies to address this outbreak. By case interviews decided to test his theory of transmission by drinking and by mapping the location of infected residences, he in- water in what Hempel terms the “Grand Experiment.” The ferred that the outbreak was due to consumption of con- results were published in the greatly expanded second edi- taminated water from a public source, the Broad Street pump. tion of On the Mode of Communication of Cholera.2 Snow Snow recommended that the pump handle be removed, and knew that there was an area of London where water was it was. Snow got credit for aborting the epidemic but, in truth, delivered to homes on each street by competing distribu- the outbreak had largely ceased before that action. Never- tors, one of which, Southwarck and Vauxhall, derived its theless, Snow’s investigation of the Broad Street pump epi- supply from the Thames below major sewer outfalls and demic has entered the annals of medical classics. the other, the Lambeth Company, which derived its supply The Strange Case of the Broad Street Pump is an easy read. from the Themes above London. Using case incidence data Sixteen chapters and 294 pages of well-annotated text pro- obtained from the Registrar General and personal ascer- vide an informative insight into one of the great sagas of medi- tainment of water source for each household, Snow was cal history. able to compare attack rates for consumers of contami- Warren Winkelstein, Jr, MD, MPH nated water with those of consumers of relatively pure School of Public Health water. The results were impressive; the cholera rate in University of California, San Francisco houses supplied by the Southwarck and Vauxhall Com- [email protected] pany were 8.5 times greater that the rate in houses supplied by the Lambeth Company. Financial Disclosures: None reported. While collecting data for the experiment, a serious focal 1. Snow J. On the Mode of Communication of Cholera. 2nd ed. London, England: John Churchill; 1855. outbreak of cholera occurred in Snow’s home neighbor- 2. Frost WH. Introduction . In: Snow J. Snow on Cholera [reprint]. New York, NY: hood of Soho. He interrupted his investigations of the wa- The Commonwealth Fund; 1936:11-39.

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