Authors: Deborah Hopkinson
In the summer of 1854, when our story opens, London was a rapidly growing city of two million. Scavengers were the recyclers of Eel’s London: night-soil men emptied cesspools; mudlarks and other riverfinders recycled wood, coal, and other things from the Thames. There were ragpickers and bone collectors. Pure-finders collected dog waste and sold it to tanners, who used it in making leather goods.
But the scavengers could not keep up. London was a city without a sewer system capable of dealing with its animal and human waste. Much of it ended up in the Thames, especially as indoor toilets, which led to the river, became more prevalent.
London would have to wait until the Great Stink of 1858, a summer when the stench became so bad that laws were finally passed to authorize the construction of a modern sewer system. It took sixteen years and 318 million
bricks to build eighty-three miles of sewers, guided by the vision of the chief metropolitan engineer, Joseph Bazalgette. But that is another story!
Cholera is caused by the bacterium
Vibrio cholerae
. Although Robert Koch is usually credited with being the first to see the bacillus under a microscope in 1883, an Italian researcher named Filippo Pacini identified it in 1854, the same year as the Broad Street epidemic. In 1965, the name
Vibrio cholerae Pacini 1854
was adopted in honor of Pacini’s earlier, largely forgotten discovery.
As Dr. Snow theorized, cholera is spread primarily through contaminated water. According to the website of International Medical Corps:
Cholera is an acute diarrheal disease caused by an infection in the intestines that can kill even a healthy adult in a matter of hours. Symptoms, including severe watery diarrhea, can surface in as little as two hours or up to five days after infection, and can then trigger extreme dehydration and kidney failure. With such a short incubation period, cholera can easily explode into an outbreak.… Cholera is caused by ingestion of the bacterium,
Vibrio cholerae
. The infection is spread through contaminated fecal matter, which can be
consumed through tainted food and water sources or because of poor sanitation and hygiene, like unwashed hands. (
International Medical Corps. “Basic Facts on Cholera.”
http://internationalmedicalcorps.org/page.aspx?pid=475
)
It was Dr. Snow’s fervent hope that “the time will arrive when great outbreaks of cholera will be things of the past.” While this is true in many parts of the world, there are still tens of thousands of deaths from cholera every year. According to a 2012 fact sheet on cholera from the World Health Organization, there are an estimated three million to five million cases and 100,000 to 120,000 deaths every year.
Cholera struck in Haiti following the devastating earthquake of January 12, 2010. The disease had not been seen in Haiti in more than fifty years, but the conditions following the earthquake resulted in water contamination. As of 2012, there were more than a half-million cases of cholera, and seven thousand deaths from it since the earthquake.
The primary treatment for cholera today is relatively simple: reversing dehydration with an oral rehydration solution. Sometimes patients require IV fluids. Some residents of the Golden Square were able to survive the blue death by drinking lots of clean water.
Dr. John Snow is often called the father of epidemiology, the study of how and why diseases spread. The United States Department of Labor describes the work of these scientists this way: “Epidemiologists investigate the causes of disease and other public health problems to prevent them from spreading or from happening again. They report their findings to public policy officials and to the general public.” (
http://www.bls.gov/ooh/life-physical-and-social-science/epidemiologists.htm#tab-2
)
I have invented most of the dialogue for both the fictional and the historical figures in
The Great Trouble
. But I could not resist including Dr. John Snow’s own words, as quoted by Henry Whitehead:
“ ‘You and I,’ he would say to me, ‘may not live to see the day, and my name may be forgotten when it comes, but the time will arrive when great outbreaks of cholera will be things of the past; and it is the knowledge of the way in which the disease is propagated which will cause them to disappear.’ ”
MONDAY, AUGUST 28:
Five-month-old Frances (Fanny) Lewis, daughter of Sarah and Thomas Lewis of 40 Broad Street, falls ill with diarrhea and vomiting.
THURSDAY, AUGUST 31:
“Mr. G.,” a tailor who also lives at 40 Broad Street, along with nineteen or twenty other people, falls ill. Twenty-nine-year-old Henry Whitehead, assistant curate at St. Luke’s Church, is called out to several homes where people have been struck.
FRIDAY, SEPTEMBER 1:
Mr. G. dies of cholera. A yellow flag is placed on Berwick Street as a warning, and carts begin removing bodies.
SATURDAY, SEPTEMBER 2:
Baby Frances Lewis dies on Broad Street. Several miles away in Hampstead, Susannah Eley, a fifty-nine-year-old widow who has been drinking Broad Street water delivered by her sons, dies after a sixteen-hour illness. At Middlesex Hospital, the nurse Florence Nightingale begins seeing patients brought in every
half hour from Broad Street and elsewhere in the Soho district.
SUNDAY, SEPTEMBER 3:
Dr. John Snow, who lives a half mile away on Sackville Street, hears about the cholera epidemic. He goes to inspect the popular Broad Street pump and takes water samples for inspection.
MONDAY, SEPTEMBER 4:
Mrs. G., the widow of the tailor, falls ill with cholera. Dr. Snow returns to Broad Street and begins asking questions of the residents.
TUESDAY, SEPTEMBER 5:
Mrs. G. dies in the morning. Dr. Snow goes to the General Register Office in Somerset House to ask William Farr for records of recent deaths.
THURSDAY, SEPTEMBER 7:
Dr. Snow appears before an emergency committee of the board of governors of St. James Parish and convinces them to remove the handle of the Broad Street pump.
FRIDAY, SEPTEMBER 8:
The pump handle is removed. Thomas Lewis, father of Frances Lewis, develops symptoms of cholera.
TUESDAY, SEPTEMBER 19:
Thomas Lewis dies.
THURSDAY, NOVEMBER 23:
St. James Parish forms an inquiry committee to look further into the cholera epidemic,
which killed 616 people. Dr. Snow and Rev. Whitehead are invited to join.
MONDAY, NOVEMBER 27:
An inspection of the Broad Street well is conducted, but no holes are found.
MONDAY, DECEMBER 4:
Dr. Snow presents his cholera map at a meeting of the Epidemiological Society of London.
TUESDAY, DECEMBER 19:
The
Gazzetta Medica Italiana
contains an article by researcher Filippo Pacini, who reports microscopic findings from postmortem exams of cholera patients. His research will not become widely known until after his death.
SATURDAY, JANUARY 27:
The London publisher J. Churchill releases an expanded version of
On the Mode of Communication of Cholera
, a monograph by Dr. John Snow. Dr. Snow gives a copy to Rev. Whitehead, who is continuing to conduct interviews with Broad Street residents for his own report.
TUESDAY, MARCH 27:
While investigating death records in the General Register Office, Rev. Whitehead is drawn to the following entry: “At 40, Broad Street, 2nd September, a daughter, aged five months, exhaustion, after an attack of Diarrhoea four days previous to death.” Rev.
Whitehead finds that Mrs. Lewis emptied diapers into the cesspool, and he suspects this may be the index case and the cause of the well’s contamination.
MONDAY, APRIL 23:
A surveyor, Jehoshaphat York, excavates the cesspool at 40 Broad Street and the surrounding area.
TUESDAY, MAY 1:
York presents his report, showing that sewage was backing up in a drain and the cesspool’s bricks were decaying. Sewage from the cesspool had been seeping into the Broad Street well, less than three feet away.
WEDNESDAY, JULY 25:
The St. James Cholera Inquiry Committee completes its work, which includes reports from York, Dr. Snow, and Rev. Whitehead. The committee concludes that the cholera outbreak “was in some manner attributable to the use of the impure water of the well in Broad Street.”
WEDNESDAY, SEPTEMBER 26:
Based on a petition from residents, a decision is made to reopen the Broad Street pump.
This bibliography includes websites and books I used in researching my story. While some are for adults, I believe young readers who want to learn more would enjoy Steven Johnson’s
The Ghost Map
, as well as the books listed in the final section.
WEBSITES
DR. JOHN SNOW
The Department of Epidemiology at the UCLA Fielding School of Public Health maintains a website devoted to Dr. John Snow:
www.ph.ucla.edu/epi/snow.html
.
JOHN SNOW’S MAP
To view a large version of Dr. Snow’s map, you can go to the following link on the UCLA website:
www.ph.ucla.edu/epi/snow/highressnowmap.html
.
CHOLERA
To learn more about cholera, see
internationalmedicalcorps.org
.
EPIDEMIOLOGY
To learn more about epidemiology, visit
www.ph.ucla.edu/epi
.
To find out about epidemiology as a career, look at the United States Department of Labor’s Occupational Outlook Handbook:
www.bls.gov/ooh/life-physical-and-social-science/epidemiologists.htm
.
BOOKS ABOUT DR. JOHN SNOW, CHOLERA, AND LONDON
Hempel, Sandra.
The Medical Detective: John Snow, Cholera and the Mystery of the Broad Street Pump
. London: Granta Books, 2006.
Johnson, Steven.
The Ghost Map: The Story of London’s Most Terrifying Epidemic—and How It Changed Science, Cities, and the Modern World
. New York: Riverhead Books, 2006.
Mayhew, Henry.
London Labour and the London Poor: A Selection by Rosemary O’Day and David Englander
. Ware, Hertfordshire, England: Wordsworth Editions, 2008.
Mitchell, Sally.
Daily Life in Victorian England
, 2nd ed. Westport, CT: Greenwood Press, 2009.
Morris, Robert D.
The Blue Death: Disease, Disaster, and the Water We Drink
. New York: HarperCollins, 2007.
Picard, Liza.
Victorian London: The Tale of a City, 1840–1870
. New York: St. Martin’s Griffin, 2007.
Vinten-Johansen, Peter, Howard Brody, Nigel Paneth, Stephen Rachman, and Michael Rip.
Cholera, Chloroform, and the Science of Medicine: A Life of John Snow
. Oxford: Oxford University Press, 2003.
BOOKS FOR YOUNG READERS ABOUT EPIDEMICS
Anderson, Laurie Halse.
Fever, 1793
. New York: Simon & Schuster, 2000.
Barnard, Bryn.
Outbreak: Plagues That Changed History
. New York: Crown, 2005.
Farrell, Jeanette.
Invisible Enemies: Stories of Infectious Diseases
. 2nd ed. New York: Farrar, Straus and Giroux, 2005.
Lowry, Lois.
Like the Willow Tree: The Diary of Lydia Amelia Pierce
. New York: Scholastic, 2011.
Murphy, Jim.
An American Plague: The True and Terrifying Story of the Yellow Fever Epidemic of 1793
. New York: Clarion Books, 2003.
The Great Trouble
is a book about community and friendship, and I could not have written it without the help and support of many colleagues and friends. My editor, Allison Wortche, made me feel that bringing this story to life was possible, and I am grateful for all her hard work—her careful and thoughtful comments helped to shift this story in important ways. Thanks to Jenny Golub for her incredible copyediting expertise, which helped to make the manuscript better. Thanks to Jinna Shin for a wonderful design and Stephanie Dalton Cowan for her fabulous cover. I owe a longtime debt of gratitude to the entire team at Knopf and Random House, with special thanks to Nancy Hinkel, Adrienne Waintraub and her fantastic team, and Anne Schwartz and Lee Wade. Steven Malk, my agent, reminds me always to write from my heart. Thanks also to the staff at the Wellcome Library in London and to members of the John Snow Society, who keep Dr. Snow’s work and memory alive.
I am fortunate to be part of a professional community
at Pacific Northwest College of Art that encourages and values creativity. I am grateful to our board and our president, Tom Manley, and to my colleagues—especially the advancement team of Deanna Bredthauer, Deniz Conger, Jacquie Gregor, Killeen Hanson, Juliette Simmons, Melinda Stoops, Alisha Sullivan, and Luann Whorton—for their support.
I am profoundly grateful to my friends and family. My dear friend Michele Hill, to whom this book is dedicated, always encouraged me to write and was there when my first story was published. I miss her. Debbie Wiles reminds me every day that telling stories is important and inspires me to keep going. Thanks to Vicki Hemphill, Ellie Thomas, Teresa Vast, Michael Kieran, Sheridan Mosher, Kristin Hill, Bill Carrick, Cyndi Howard, Elisa Johnston, Maya Abels, Kathy Park, Greg and Becky Smith, Michele Kophs, and Nancy Barrows. I hope that my sisters, Bonnie Johnson and Janice Fairbrother, enjoy Dilly (modeled after our beloved Kona, whom we lost this year). Like me, they are dog lovers (perhaps we’re making up for a canine-deprived past). And finally, to my husband, Andy, and children, Rebekah and Dimitri—you give me joy every day and I love you.