NOTES

page 2 Beside them fluttered the mud-larks Mayhew, p. 150.

page 2 Above the river, in the streets “The pure collected is used by leather-dressers and tanners, and more especially by those engaged in the manufacture of morocco and kid leather from the skins of old and young goats, of which skins great numbers are imported, and of the roans and lambskins which are the sham morocco and kids of the ‘slop’ leather trade, and are used by the better class of shoemakers, bookbinders, and glovers, for the inferior requirements of their business. Pure is also used by tanners, as is pigeon’s dung, for the tanning of the thinner kinds of leather, such as calf-skins, for which purpose it is placed in pits with an admixture of lime and bark. In the manufacture of moroccos and roans the pure is rubbed by the hands of the workman into the skin he is dressing. This is done to ‘purify’ the leather, I was told by an intelligent leatherdresser, and from that term the word ‘pure’ has originated. The dung has astringent as well as highly alkaline, or, to use the expression of my informant, ‘scouring,’ qualities. When the pure has been rubbed into the flesh and grain of the skin (the ‘flesh’ being originally the interior, and the ‘grain’ the exterior part of the cuticle), and the skin, thus purified, has been hung up to be dried, the dung removes, as it were, all such moisture as, if allowed to remain, would tend to make the leather unsound or imperfectly dressed.” Mayhew, p. 143.

page 2 “What world does a dead man belong to?” Dickens 1997, p. 7.

page 3 “It usually takes the bone-picker” Mayhew, p. 139.

page 4 “the most disagreeable in the whole range of manufacture” Mayhew, p. 143.

page 5 “The removal of the refuse of a large town” Mayhew, p. 159. “Now the removal of the refuse of London is no slight task, consisting, as it does, of the cleansing of 1,750 miles of streets and roads; of collecting the dust from 300,000 dust-bins; of emptying (according to the returns of the Board of Health) the same number of cesspools, and sweeping near upon 3,000,000 chimneys.” Mayhew, p. 162.

page 5 the Colosseum served as a de facto quarry Rathje and Murphy, p. 192.

page 7 But if the bacteria disappeared overnight “In fact, so significant are bacteria and their evolution that the fundamental division in forms of life on Earth is not that between plants and animals, as is commonly assumed, but between prokaryotes—organisms composed of cells with no nucleus, that is, bacteria—and eukaryotes—all the other life forms. In their first two billion years on Earth, prokaryotes continuously transformed the Earth’s surface and atmosphere. They invented all of life’s essential, miniaturized chemical systems—achievements that so far humanity has not approached. This ancient high biotechnology led to the development of fermentation, photosynthesis, oxygen breathing, and the removal of nitrogen gas from the air. It also led to worldwide crises of starvation, pollution, and extinction long before the dawn of larger forms of life.” Margulis, p. 28.

page 8 No extended description of London Punch (27, September 2, 1854, p. 102) even captured the stench of the metropolis in verse:

In every street is a yawning sewer;
In every court is a gutter impure;
The river runs stinking, and all its brink
Is a fringe of every delectable stink:
Bone-boilers and gas-workers and gut-makers there
Are poisoning earth and polluting air.
But touch them who dares; prevent them who can;
What is the Health to the Wealth of man?

page 9 drowned in human shit Halliday 1999, p. 119.

page 10 “I found whole areas of the cellars” Halliday 1999, p. 40.

page 10 “a heap of dung” Picard, p. 60.

page 10 “We then journeyed on to London-street” Mayhew, London Morning Chronicle, September 24, 1849.

page 11 The visitors no doubt marveled Halliday 1999, p. 42.

page 13 “The corpses [of the poor]” Engels, p. 55.

page 13 “up to my knees in human flesh” Picard, p. 297.

page 14 “a hemmed-in churchyard” Dickens 1996, p. 165.

page 14 “There is no document of civilization” Benjamin, p. 256.

page 16 Eventually, the city’s inexorable drive Summers, pp. 15–17.

page 17 Another Blake brother opened a bakery Summers, p. 121.

page 17 “In that quarter of London” Charles Dickens, Nicholas Nickleby (London: Penguin, 1999), pp. 162–63.

page 18 “[The flat] has two rooms” Quoted in Summers, p. 91.

page 21 Sometime in the late 1840s Vinten-Johansen et al., p. 283.

page 22 Plagues and political unrest The radical democrat James Kay-Shuttleworth described cholera as an opportunity to explore “the abodes of poverty… the close alleys, the crowded courts, the over-peopled habitations of wretchedness, where pauperism and disease congregate round the source of social discontent and political disorder in the centre of our large towns, and behold with alarm, in the hotbed of pestilence, ills that fester in secret, at the very heart of society.” Quoted in Vinten-Johansen et al., p. 170.

page 26 “Mind you, the man” Rawnsley, p. 4.

page 26 “One does not realize” Rawnsley, p. 32.

pages 27–28 In some cases, cows were lifted Picard, p. 2.

page 28 defining the region that the “gentleman” Rawnsley, p. 34.

page 28 forced to perform arduous labor Workhouses had existed in one form or another for centuries, but the Poor Law Amendment Act of 1834 had greatly increased their number, and the severity of the “punishment” they dealt out to the pauper classes of the day. “Under the new Act, the threat of the Union workhouse was intended… as a deterrent to the able-bodied pauper. This was a principle enshrined in the revival of the ‘workhouse test’—poor relief would only be granted to those desperate enough to face entering the repugnant conditions of the workhouse. If an able-bodied man entered the workhouse, his whole family had to enter with him. Life inside the workhouse was… to be as off-putting as possible. Men, women, children, the infirm, and the able-bodied were housed separately and given very basic and monotonous food such as gruel, or bread and cheese. All inmates had to wear the rough workhouse uniform and sleep in communal dormitories. Supervised baths were given once a week. The able-bodied were given hard work such as stone-breaking or picking apart old ropes.… The elderly and infirm sat around in the day-rooms or sick-wards with little opportunity for visitors. Parents were… allowed limited contact with their children—perhaps for an hour or so a week on Sunday afternoon.” See http://www.workhouses.org.uk/.

page 29 “the noisy and the eager” Charles Dickens, Little Dorrit (London: Wordsworth, 1996), p. 778.

page 33 “burst forth… with extraordinary malignity” London Times, September 12, 1849, p. 2.

page 34 The epidemic of 1848–1849 Koch, p. 42.

pages 34–35 “While the mechanism of life” London Times, September 13, 1849, p. 6.

page 35 “countenance quite shrunk” Shephard, p. 158.

page 36 With the exception of a few unusual compounds “Louis Pasteur, who proved the microbial origin of such devastating diseases as foot and mouth disease, plague, and wine rot, set the tone of the relationship from the start. The context of the encounter between intellect and bacteria defined medicine as a battleground: bacteria were seen as ‘germs’ to be destroyed. Only today have we begun to appreciate the fact that bacteria are normal and necessary for the human body and that health is not so much a matter of destroying microorganisms as it is of restoring appropriate microbial communities.” Margulis, p. 95.

page 37 A glass of water could easily contain Most of the information on the size, visibility, and replication rate of Vibrio cholerae comes from an interview with Harvard’s John Mekalanos. The Centers for Disease Control have an excellent overview of cholera, available online at http:www.cdc.gov/ncidod/dbmd/diseaseinfo/cholera_g.htm.

page 38 “Those animal species that fully adapted” Margulis, p. 183.

page 41 “We are living at a period” Quoted in Picard, p. 215. While the Great Exhibition is more famous than the Broad Street epidemic, in a strange sense the two events have a comparable, if inverted, symbolic value: the Exhibition marking the emergence of a truly global culture, with all the dynamism and diversity that suggests, and Broad Street marking the emergence of a metropolitan culture, with all the promise and peril that offered. The twentieth century would ultimately be the story of increasingly large cities increasingly connected to one another; the Great Exhibition and Broad Street each in their separate ways helped make that a reality.

page 43 “All the world’s bacteria essentially” Margulis, p. 30.

page 45 Thomas Latta, hit upon Shephard, p. 158.

page 46 “among the first to recognize” Standage, p. 234. “The Elixir of Life sold by a Dr. Kidd, for example, claimed to cure ‘every known ailment.… The lame have thrown away crutches and walked after two or three trials of the remedy.… Rheumatism, neuralgia, stomach, heart, liver, kidney, blood and skin diseases disappear as by magic.’ The newspapers that printed such advertisements did not ask any questions. They welcomed the advertising revenues, which enabled the newspaper industry to expand enormously.… The makers of St. Jacob’s Oil, which was said to remedy ‘sore muscles,’ spent five hundred thousand dollars on advertising in 1881, and some advertisers were spending more than one million dollars a year by 1895.”

page 47 “FEVER and CHOLERA” London Morning Chronicle, September 7, 1854.

page 47 “Sir—I have observed” London Morning Chronicle, August 25, 1854.

page 48 “Will you… kindly allow” London Times, August 18, 1854, p. 9.

page 49 “Sir—Induced by” London Times, September 21, 1854, p. 7.

page 50 “It really is nauseating” Punch, 27 (September 2, 1854), p. 86.

page 51 “Having at length emerged” London Morning Chronicle, September 1, 1854, p. 4.

page 52 Overnight, Henry Whitehead’s sociable rounds Henry Whitehead’s experiences and thoughts presented here are drawn almost entirely from four overlapping accounts of the epidemic authored by Whitehead himself: The Cholera in Berwick Street, his original pamphlet published shortly after the outbreak’s conclusion; his official report for the Cholera Inquiry Committee, published the following year; an essay recalling the outbreak published in Macmillan’s Magazine in 1865; and the transcript of an astonishingly long speech delivered at a farewell dinner on the eve of his departing London in 1873, published in H. D. Rawnsley’s biography in 1898.

page 54 All but one would perish Whitehead 1854, p. 5.

page 58 But one Soho resident The details of John Snow’s investigation of the Broad Street outbreak are drawn primarily from his account of the outbreak and its aftermath, in his report published in the Cholera Inquiry Committee report of 1855, and in his revised monograph, On the Mode and Communication of Cholera.

page 59 He would largely avoid meat Details on Snow’s life up to his cholera investigations are drawn from four primary sources: Richardson’s hagiographic “Life of John Snow,” published shortly after Snow’s death; David Shephard’s biography John Snow: Anaesthetist to a Queen and Epidemiologist to a Nation; the superb Cholera, Chloroform, and the Science of Medicine; and Ralph Frerichs’ invaluable John Snow Web archive hosted by UCLA’s School of Public Health.

page 60 A university degree opened “With a consulting practice and beds in one of the London teaching hospitals for his patients, a man of the right character and background could achieve fame of a sort treating high society. The lure of beds in a private hospital or a nursing home where they could treat wealthy feepaying patients tempted not a few physicians. For them a university degree—the M.A. as well as the M.D., perhaps, especially from Oxford or Cambridge—was important not so much for its academic kudos as for its social cachet, because if one wished to practise in fashionable circles it was as important to be seen as a gentleman as much as a well-trained doctor. A knowledge of Latin and Greek was as much an entree to this type of practice as a knowledge of medicine itself.” Shephard, p. 21.

page 61 His first published paper “The arsenic candles investigations show Snow as a collateral scientist in keeping with the new scientific approaches to medicine that were part and parcel of his training. His approach to these investigations also reveals a model that would recur in his anesthesia and cholera research. At an early stage in his career he demonstrated an ability to set up a series of experiments that traced an agent as it circulated in a medical school dissection room, in rooms where arsenic candles were burned, and in the bodies of everyone who entered them. That is, he was already concerned with chemical analysis, employing animal experimentation, and asking questions about what he would later term modes of communication—the pathways by which a specific poison was introduced into a community and where and how it lodged in the body.” Vinten-Johansen et al., p. 73.

page 61 “Mr. Snow might better employ himself” “[Lancet editor] Wakley’s statement can be read as a snub: Snow was an upstart trying to make a name for himself by finding fault with his elders. It can also be read as the reaction of a prickly editor who thought Snow was criticizing him for including flawed articles in his journal, and it can be read as a gentle, if ham-fisted, warning by a senior colleague that Snow should temper himself at so early a stage of his career. Whatever Wakley’s intent, his comment was patently unfair to Snow. His first letter to the editor had detailed arsenic experiments, and the Lancet had reported on Westminster Society meetings at which Snow had read several papers on his research activities. He appears to have taken offense, for he found a friendlier reception in [the London Medical Gazette].” Vinten-Johansen et al., p. 89.

page 63 “When the dreadful steel was plunged” “Elective surgery was performed very infrequently prior to the advent of effective anesthesia. From 1821 to 1846, the annual reports of Massachusetts General Hospital recorded 333 surgeries, representing barely more than one case per month. Surgery was a last and desperate resort. Reminiscing in 1897 about preanesthesia surgery, one elderly Boston physician could only compare it to the Spanish Inquisition. He recalled ‘yells and screams, most horrible in my memory now, after an interval of so many years.… In one of these operations, performed by the hospital’s senior surgeon, John Collins Warren, M.D., the cancerous end of a young man’s tongue was cut off by a sudden, swift stroke of the knife, and then a red-hot iron was placed on the wound to cauterize it. Driven frantic by the pain and the sizzle of searing flesh inside his mouth, the young man escaped his restraints in an explosive effort and had to be pursued until the cauterization was complete, with his lower lip burned in the process.” Sullivan 1996.

page 65 He reaches for his pen Snow’s first biographer, Richardson, reported that Snow had investigated the following agents: “carnoic, acide, carbonic oxide, cyanogen, hydrocanic acid, Dutch liquid, ammonia, nitrogen, amylovinic ether, puff-ball smoke, allyle, cyanide of ethyle, chloride of amyle, a carbo-hydrogen coming over with amylene.” He went on to note: “If the agent seemed to promise favourably from these inquiries, he commenced to try it on man; and the first man was invariably his own self.” Richardson, p. xxviii.

page 66 “Thursday 7 April” Snow and Ellis, p. 271.

page 67 “The Consilience of Inductions,” Whewell wrote Quoted in Wilson, p. 8.

page 68 His mind tripped happily Vinten-Johansen et al. make this point with typical eloquence: “Snow was a systems-network type of reasoner. He seldom dealt with linear chains of cause and effect but rather with interacting networks of causes and effects. He viewed the human organism, and the world it inhabits, as a complex system of interacting variables, any one of which, isolated temporarily for careful study, might provide a useful clue to the clinical-scientific problem—but only when seen in its proper context, and only when the variable, having once been isolated for study, was then put back into its place in the system and restudied in its natural environment. Vinten-Johansen et al., p. 95.

page 69 “We can only suppose the existence” “History of the Rise, Progress, Ravages etc. of the Blue Cholera of India,” Lancet, 1831, pp. 241–84.

page 70 By the time the epidemic wound down Nearly all the details of cholera outbreaks—and Snow’s investigations of them—leading up to the Broad Street affair are drawn from Snow’s own accounts, published in the various editions of “On the Mode and Communication of Cholera.”

page 74 it didn’t include the false leads J. M. Eyler, “The Changing Assessments of John Snow’s and William Farr’s Cholera Studies,” Sozial- und Präventivmedizin 46 (2001), pp. 225–32.

page 75 “The experimentum crucis would be” London Medical Gazette 9 (1849), p. 466.

page 83 The papers of the day were filled In the Central London area, postal deliveries could sometimes take only an hour to reach their destination. Each residence could expect twelve regular deliveries on a weekday. Picard, p. 68.

page 83 “It is said that Friday night” Observer, September 3, 1854, p. 5.

page 84 The 1842 study found Picard, p. 180.

page 85 “Jo lives—that is to say” Dickens 1996, p. 475.

page 86 “The roads, in all directions” Quoted in Rosenberg 1987, p. 28.

page 88 “The infinite number of Fires” Quoted in Porter, p. 162.

page 89 “the houses will become too numerous” Porter, p. 164.

page 91 The unplanned… engineering of ant colonies For more on the connection between the bottom-up organization and intelligence of ant colonies and the collective development of cities, see my 2001 book Emergence. The extended Wordsworth quote reads: “Rise up, thou monstrous anthill on the plain / Of a too busy world! Before me flow / Thou endless stream of men and moving things! / Thy every-day appearance, as it strikes— / With wonder heightened, or sublimed by awe— / On strangers, of all ages; the quick dance / Of colours, lights, and forms…”

page 91 “monster city… stretched not only” Quoted in Porter, p. 186.

page 93 The Londoner enjoying a cup of tea For a thorough—and thoroughly entertaining—overview of the sociohistorical impact of tea (along with other beverages) see Standage’s A History of the World in Six Glasses.

page 93 A collection of water molecules Iberall 1987, pp. 531–33.

page 94 In a sense, the Industrial Revolution “If the steam-powered factory, producing for the world market, was the first factor that tended to increase the area of urban congestion, the new railroad transportation system, after 1830, greatly abetted it. Power was concentrated on the coal fields. Where coal could be mined or obtained by cheap means of transportation, industry could produce regularly throughout the year without stoppages through seasonal failure of power. In a business system based upon time-contracts and time-payments, this regularity was highly important. Coal and iron thus exercised a gravitational pull on many subsidiary and accessory industries: first by means of the canal, and after 1830, through the new railroads. A direct connection with the mining areas was a prime condition of urban concentration: until our own day the chief commodity carried by the railroads was coal for heat and power.” Mumford, p. 457.

page 95 One mechanic who provided Picard, p. 82.

page 95 Largely freed from waterborne disease Standage, p. 201.

page 99 John Snow would go to his grave A comprehensive overview of the discovery of the cholera bacterium, including a biographical sketch of Pacini himself, is available online at the UCLA John Snow archive athttp:www.ph.ucla.edu/EPI/snow/firstdiscoveredcholera.html.

page 101 By the mid-1840s, his reports “He approached the Presidents of the Royal Colleges of Physicians and Surgeons and the Master of the Society of Apothecaries and persuaded them to write to their members throughout the kingdom, urging them ‘to give, in every instance which may fall under our care, an authentic name of the fatal disease,’ to be recorded in the local register books from which Farr compiled his statistics. At the same time, Farr compiled a ‘statistical nosology,’ which listed and defined 27 fatal disease categories to be used by local registrars when recording causes of death. Thus dysentery (‘bloody flux’) was distinguished from diarrhea (‘looseness, purging, bowel complaint’). Farr also gave the ‘synonymes’ (sic) and ‘provincial terms’ by which the diseases might be known locally. Letters were drafted in the name of the Registrar-General setting the qualifications which were necessary for local registrars, and instructions were also issued to ships’ captains concerning their responsibilities.” Halliday 2000, p. 223.

page 102 “To measure the effects of good or bad” Quoted in Vinten-Johansen et al., p. 160. The authors offer this instructive commentary on the phrase itself: “Farr’s usage of the same Baconian term that Snow had employed in his first publication indicates the importance of the hypotheticodeductive method to some medical men of this generation. In the laboratory one can conduct a ‘crucial experiment’ in which two samples are treated in identical fashion except for the factor in dispute. The results of the experiment then tell one with certainty whether the underlying theory is correct, but London was not a laboratory.”

page 103 To digest large quantities of it Ridley, p. 192.

page 104 One provides the fizz, the other the buzz Margulis, p. 75.

page 105 S&V chose to delay its move In many ways, Snow’s “grand experiment” with the metropolitan water supply stands as a more impressive—and, arguably, more convincing—example of medical sleuthing than the Broad Street case. For a detailed account, see Vinten-Johansen et al., pp. 254–82.

page 106 “The experiment… was on the grandest” Snow, 1855a, p. 75.

page 109 “In Broad-Street, on Monday evening” Observer, September 3, 1854, p. 5.

page 112 “The Guardians are acting” London Times, September 6, 1854, p. 5.

page 114 This is the great irony of Chadwick’s life For more on the life of Chadwick, see Finer.

page 114 “All smell is… disease” Quoted in Halliday 1999, p. 127.

page 115 One in twenty had human waste Halliday 1999, p. 133.

page 116 “According to the average of the returns” Mayhew could also wax philosophical on these issues, in language that was strikingly ahead of its time: “Now, in Nature everything moves in a circle—perpetually changing, and yet ever returning to the point whence it started. Our bodies are continually decomposing and recomposing—indeed, the very process of breathing is but one of decomposition. As animals live on vegetables, even so is the refuse of the animal the vegetable’s food. The carbonic acid which comes from our lungs, and which is poison for us to inhale, is not only the vital air of plants, but positively their nutriment. With the same wondrous economy that marks all creation, it has been ordained that what is unfitted for the support of the superior organisms, is of all substances the best adapted to give strength and vigour to the inferior. That which we excrete as pollution to our system, they secrete as nourishment to theirs. Plants are not only Nature’s scavengers but Nature’s purifiers. They remove the filth from the earth, as well as disinfect the atmosphere, and fit it to be breathed by a higher order of beings. Without the vegetable creation the animal could neither have been nor be. Plants not only fitted the earth originally for the residence of man and the brute, but to this day they continue to render it habitable to us. For this end their nature has been made the very antithesis to ours. The process by which we live is the process by which they are destroyed. That which supports respiration in us produces putrefaction in them. What our lungs throw off, their lungs absorb—what our bodies reject, their roots imbibe.… In every well-regulated State, therefore, an effective and rapid means for carrying off the ordure of the people to a locality where it may be fruitful instead of destructive, becomes a most important consideration. Both the health and the wealth of the nation depend upon it. If to make two blades of wheat grow where one grew before is to confer a benefit on the world, surely to remove that which will enable us at once to do this, and to purify the very air which we breathe, as well as the water which we drink, must be a still greater boon to society. It is, in fact, to give the community not only a double amount of food, but a double amount of health to enjoy it. We are now beginning to understand this. Up to the present time we have only thought of removing our refuse—the idea of using it never entered our minds. It was not until science taught us the dependence of one order of creation upon another, that we began to see that what appeared worse than worthless to us was Nature’s capital—wealth set aside for future production.” Mayhew, p. 160.

page 116 He also entertained an aquatic version Another visionary named William Hope thought that these new sewage farms might attract visitors as a kind of excrement-themed spa: “London beauties might come out to recruit their wasted energies at the close of the season, and… would perhaps at times listen to a lecture on agriculture from the farmer himself, while drinking his cream and luxuriating in the health-restoring breeze.” Halliday 1999, p. 133.

page 118 “[Any] Dwelling House or Building” Nuisances Act, September 4, 1848, p. 1.

page 119 the sewers themselves began to clog Halliday 1999, pp. 30–34.

page 120 “The Thames is now made” Halliday 1999, p. 35.

page 121 “On entering the precincts” “A Visit to the Cholera Districts of Bermondsey,” London Morning Chronicle, September 24, 1849.

page 122 “How is the cholera generated?” London Times, September 13, 1854, p. 6.

pages 122–23 “telluric theory”… “failed to include all the observed phenomena” London Times, September 13, 1849, p. 6.

page 123 “The very first canon of nursing” Florence Nightingale, Notes on Nursing (New York: Dover, 1969), p. 12.

page 124 “If the tell-tale air test” Nightingale, p. 17.

page 125 “It might be supposed” Mayhew, p. 152.

page 127 “Whoever wishes to investigate” Hippocrates, p. 4.

page 127 “the atmosphere, all over the world” Whitehead 1854, p. 13.

page 128 The brain scans in the 2003 study Royet et al., pp. 724–26.

page 132 For every sewer-hunter living happily Tom Koch offers a precise and articulate survey of some of the statistical and cartographic studies offered in defense of the miasma theory during this period, including work on elevation authored by Farr. In most cases, Koch observes, the studies were thorough and internally consistent, even if they were ultimately supporting an incorrect hypothesis. “While the miasmatic, contagionist conclusion was wrong, the inverse relationship that was used to argue it was accurate. That Acland and Farr missed the meaning of the relation is a fault neither of the researchers nor the mapping they did. In contention were different theories of disease, different perceptions of the city, and different assumptions about the data required for a disease study. One cannot blame a scientist for being limited by the science and knowledge of his time.” Koch, p. 126.

page 133 “The probability of an outburst” Quoted in Vinten-Johansen et al., p. 174.

page 142 Snow noticed another telling absence There is some ambiguity about the timing of these investigations in the historical record. Snow’s investigation of Broad Street unfolded in two primary phases: a rapid survey of the neighborhood as the outbreak was still raging, and then a longer study that commenced a few weeks after the outbreak subsided, based partly on secondhand accounts from other surgeons and physicians in the area. Snow may in fact have uncovered information about the brewery and the workhouse in his later investigation, though the prominence of both operations, in terms of number of employees and proximity to the pump, makes it more likely that Snow paid them both a visit during the outbreak itself. In his published account Snow merely reports: “There is a Brewery in Broad Street, near to the pump, and on perceiving that no brewer’s men were registered as having died of cholera, I called on Mr. Huggins, the proprietor.” This appears several paragraphs after his description of requesting theWeekly Returns from the Registrar-General’s Office shortly after September 2.

page 145 Snow was naturally inclined to view the theory “Perhaps his research into the nature and mechanisms of anesthesia by inhaled gases made him certain that gaseous vapors alone, whether general or local, could not cause specific epidemic diseases, as miasmatic theory posited. Moreover, his investigation of arsenical candles had suggested that when a body inhaled a specific poison, it showed the specific effects of that poison, not the generalized fevers typically claimed for miasmatic and local effluvial poisoning. Contrary to the older generation of medical men who dismissed the law of the diffusion of gases as armchair theorizing, Snow’s training and daily experience administering anesthesia made him believe that careful attention to the chemistry and physics of gases could have practical benefits. It was precisely that which permitted him to use otherwise dangerous medicinal agents with safety and with exact application to the peculiar needs of each patient and each surgical operation.” Vinten-Johansen et al., p. 202.

page 145 “I have arrived at the conclusion” Lilienfeld, p. 5.

page 146 For Snow… an obvious etiology “A consideration of the pathology of cholera is capable of indicating to us the manner in which the disease is communicated. If it were ushered in by fever, or any other general constitutional disorder, then we should be furnished with no clue to the way in which the morbid poison enters the system; whether, for instance, by the alimentary canal, by the lungs, or in some other manner, but should be left to determine this point by circumstances unconnected with the pathology of the disease. But from all that I have been able to learn of cholera, both from my own observations and the descriptions of others, I conclude that cholera invariably commences with the affection of the alimentary canal. The disease often proceeds with so little feeling of general illness, that the patient does not consider himself in danger, or even apply for advice, till the malady is far advanced. In a few cases, indeed, there are dizziness, faintness, and a feeling of sinking, before discharges from the stomach or bowels actually take place; but there can be no doubt that these symptoms depend on the exudation from the mucous membrane, which is soon afterwards copiously evacuated.” Snow 1855a, pp. 6–9.

page 149 He delivered chloroform to two patients Snow’s casebooks report the full range of his professional activity for the week: “Saturday 2 Administered Chloroform at Mr Duffins to a little girl three years old from the neighbourhood of Blackheath whilst Mr D. performed amputation of the great toe together with its metatarsal bone. Monday 4 Administered Chloroform at Mr Cartwright’s to a lady whilst he extracted two [?] teeth. Wednesday 6 Administered Chloroform to Mr Jenner, Linen draper, Edgware Road whilst Mr Salmon operated by ligatures on some haemorrhoids. The patient was extremely blanched from loss of blood from the past and had a bounding haemorrhagic pulse. No faintness or depression from the chloroform. Administered Chloroform at 16 Hanover Square whilst Mr A. Rogers extracted 2 teeth. Thursday 7 Administered Chloroform to a gentleman on King Street Covent garden patient of Mr Edwards whilst Mr Partridge operated for haemorrhoid. No sickness &c. Friday 8 Administered Chloroform at 46 Wigmore Street whilst Mr Salmon operated for fistula in ano. No sickness.” Snow and Ellis, pp. 342–43.

page 152 But the most likely scenario I am grateful to Harvard’s John Mekalanos for suggesting this scenario.

page 154 “No one but those who knew him” Richardson, p. xix.

page 154 St. Bartholomew’s Hospital had received Lancet, September 16, 1854, p. 244.

page 160 And so… the Board voted Snow’s own description of the exchange is taciturn: “I had an interview with the Board of Guardians of St. James’s parish, on the evening of Thursday, 7th September, and represented the above circumstances to them. In consequence of what I said, the handle of the pump was removed on the following day.” This last sentence is now memorialized on a pin worn by members of the John Snow Society. Snow 1855a.

page 160 “Owing to the favourable change in the weather” Globe, September 8, 1854, p. 3.

page 161 “We regret to announce” Globe, September 9, 1854, p. 3.

page 162 These were real achievements Richardson probably did more than anyone to build the story that the pump handle’s removal had single-handedly brought the outbreak to an end. “The pump handle was removed,” he triumphantly announced, “and the plague was stayed.” The popular version of the Broad Street story conventionally follows this appealing narrative line. Snow identifies the perpetrator, and brings its reign of terror to an immediate end. In my research, nearly half of the shorthand accounts of the outbreak tell the story along these lines.

Snow did not demonstrate the link between the pump and the cholera by removing the handle; he demonstrated the link through statistical analysis of data accumulated via door-to-door interviews. And of course, the pump was not the neighborhood’s only water source, merely the most popular. In fact, the existence of the other water sources was crucial to Snow’s case. But the biggest—and most common—distortion is the notion that closing down the pump single-handedly brought the outbreak to an end. Removing the pump, in all likelihood, had little impact on the course of the outbreak. New attacks were already on the wane before Snow had the handle removed, and it’s entirely possible that the water had ceased to be dangerous by the time the authorities did anything about it.

The final statistics for the Broad Street outbreak suggest that the removal of the pump handle likely played a minor role in the ultimate trajectory of the outbreak. The most dramatic decline in deaths falls between the 4th and 5th of September, while the second-most dramatic drop occurs between the 10th and the 12th. The timeline of attacks, not deaths, has a more dramatic spike at the beginning of the week, followed by a steady leveling-off. The number of new attacks reaches the statistical norm for the neighborhood only by the 12th. If you assume a twenty-four-to-forty-eight-hour incubation period between ingesting V. cholerae and the first onset of symptoms, it would appear that the closing of the Broad Street pump well may have extinguished what was left of the outbreak, like a fire department arriving to snuff out the last embers of a building that has already burned to the ground. The plague may well have been stayed by Snow’s intervention, but it was already on its last legs. However, as we will see at the end of this chapter, there might well have been a renewed epidemic after John Lewis contracted the disease had Snow not convinced the authorities to shut down the pump.

page 163 “Structural peculiarities of the Streets” Committee for Scientific Inquiries, pp. 138–64.

page 169 “Dufour’s Place… Five houses escaped” Whitehead 1854, p. 4.

page 170 “There were no less than 21 instances” Whitehead 1854, p. 6.

page 170 “God’s ways are equal” Whitehead 1854, p. 14.

page 172 “principally on the ground” Cholera Inquiry Committee, p. v.

page 175 As much as he had resisted Whitehead described his response to Snow’s theory in his 1865 memoir: “When I first heard of it, I stated to a medical friend my belief that a careful investigation would refute it, alleging as one proof of its inaccuracy the fact of several recoveries from collapse having taken place, at least in spite of, if not actually by reason of, the constant use of the Broad Street water. I added that I knew the inhabitants of Broad Street so well, and had occasion almost daily to spend so much time among them, that I should have no great difficulty in making the necessary inquiries. Accordingly I began an inquiry, which ultimately became very elaborate; at an early stage of which, however, one day meeting the same friend, and being asked by him what way I had made towards clearing the character of the pump, I was obliged to confess that my opinion on that matter was less confident than when we had last talked about it.” Whitehead 1865, p. 116.

page 176 Whatever agent had caused the cholera Whitehead 1865, p. 116.

page 179 “abominations, unmolested by water” Whitehead 1865, p. 121.

page 181 “You and I may not live” Rawnsley, p. 206.

page 182 “The weight of both positive and negative” Cholera Inquiry Committee, p. 55.

page 183 “In explanation of the remarkable intensity” Committee for Scientific Inquiries, p. 51.

page 184 “That such local uncleanliness” Committee for Scientific Inquiries, p. 52.

page 185 “Atmospheric Pressure” Committee for Scientific Inquiries, p. iv.

page 186 “The water was undeniably impure” Committee for Scientific Inquiries, p. 52.

page 192 If some noxious effluvium Koch, pp. 106–8.

page 194 It was not the mapmaking technique Koch, pp. 75–101. Vinten-Johansen et al. also have a superb chapter on Snow’s cartographic legacy that addresses many of these topics.

page 196 it measured how long it took Koch, p. 100.

page 198 copies of copies began appearing in textbooks The original redrawing appears in Sedgewick’s public-health textbook from 1911. For a meticulous investigation of the Broad Street map’s convoluted history, see Koch, pp. 129–53.

page 204 Snow responded to these papers “SIR,—I did not until to-day, read the important and interesting Address of Sir J. K. Shuttleworth, Bart., in The Lancet of the 2nd instant. I find that he alludes in complimentary terms to my conclusions regarding the propagation of cholera, as modified by a suggestion of Drs. Theirsch and Pettenkofer, but he erroneously attributes these views, so modified, to Dr. W. Budd.… A few weeks after the first edition of my essay on Cholera appeared in 1849, Dr. W. Budd published a pamphlet on the subject, in which he adopted my views, and made a full and handsome acknowledgement of my priority.” Lancet, February 16, 1856, p. 184.

page 205 “Why is it, then, that Dr. Snow” Lancet, June 23, 1855, p. 635.

page 205 “What a pity” Quoted in Halliday 1999, p. 82.

page 206 “DR. JOHN SNOW—This well-known physician” Lancet, June 26, 1858, p. 635.

page 208 “It was certainly a very troublesome job” Quoted in Halliday 1999, p. 183.

page 211 Ninety-three percent of the dead This account of the East London outbreak is drawn largely from Halliday 1999, pp. 137–43.

page 212 “The final report of the scientific committee” Parliamentary Papers, 1867–1868, vol. 37, pp. 79–82.

page 215 to reverse the flow of the Chicago River http:www.sewerhistory.org/chronos/new_amer_roots.htm.

page 216 The main road in… Sultaneyli Neuwirth, pp. 1–11.

page 218 A service called GeoSentinel http:www.istm.org/geosentinel/main.html.

page 221 “Towns and suburbs… are natural homes” Jacobs 1969, pp. 146–47. The current buzzword for this trend is “long tail” economics; instead of concentrating exclusively on big mass hits, online businesses can target the “long tail” of quirkier fare. In the old model, the economics dictated that it was always better to sell a million copies of one album. But in the digital age, it can be just as profitable to sell a hundred copies each of a thousand different albums. Urban information mapping systems offer an intriguing corollary to the long-tail theory. As technology increasingly allows us to satisfy more eclectic needs, anytime those needs require physical presence, the logic of the long tail will favor urban environments over less densely populated ones. If you’re downloading the latest album from an obscure Scandinavian doo-wop group, geography doesn’t matter: it’s just as easy to get the bits delivered to you in the middle of Wyoming as it is in the middle of Manhattan. But if you’re trying to meet up with other fans of Scandinavian doo-wop, you’ll have more luck in Manhattan or London. The long tail may well lead us away from the dominance of mass hits and pop superstars toward quirkier tastes and smaller artists. But it may also lead us to bigger cities.

page 225 The public spaces and coffeehouses “‘The coffee-house was the Londoner’s home, and those who wished to find a gentleman commonly asked, not whether he lived in Fleet Street or Chancery Lane, but whether he frequented the Grecian or the Rainbow.’ Some people frequented multiple coffeehouses, the choice of which depended on their interests. A merchant, for example, might oscillate between a financial coffeehouse and one specializing in Baltic, West Indian, or East Indian shipping. The wide-ranging interests of the English scientist Robert Hooke were reflected in his visits to around sixty London coffeehouses during the 1670s, recorded in his diary. Rumors, news, and gossip were carried between coffeehouses by their patrons, and on occasion runners would flit from one coffeehouse to another to report major events such as the outbreak of war or the death of a head of state.” Standage, p. 155.

page 226 “In the Broad Street outbreak” Quoted in Rawnsley, p. 76.

page 227 “that in any profession the highest order” Rawnsley, p. 206.

page 232 Two-thirds of the women living in rural areas Statistics from “State of World Population 1996.” See http://www.unfpa.org/swp/1996/.

page 233 “Virtually any service system” Toby Hemenway, “Cities, Peak Oil, and Sustainability.” Published at http://www.patternliteracy.com/urban2.html.

page 234 If we’re going to survive as a planet Much has been made of the staggering size of the environmental footprint of today’s modern city, the area of land required to support sustainably the energy intakes of the city’s population. London’s environmental footprint, for instance, is practically as large as the entire United Kingdom. The sheer magnitude of such a footprint has been invoked as part of antiurban environmental arguments, but the primary objection is in fact industrialization not urbanization. However large London’s footprint might be today, it would be many times larger if the city’s population were scattered at suburban or exurban densities. Unless we renounce our postindustrial lifestyle altogether, cities are environmentally preferable to other, lower-density forms of living. The United Nations’ Global Environmental Outlook describes it this way: “The relatively disproportionate urban environmental footprint is acceptable to a certain extent because, for some issues, the per capita environmental impact of cities is smaller than would be made by a similar number of people in a rural setting. Cities concentrate populations in a way that reduces land pressure and provides economies of scale and proximity of infrastructure and services.… Urban areas therefore hold promise for sustainable development because of their ability to support a large number of people while limiting their per capita impact on the natural environment.”

page 235 “All the apparatus of surgery” Jacobs 1969, pp. 447–48.

page 238 “The most devastating damage” Owen, p. 47. Owen describes the environmental impact of his family’s move from Manhattan to rural northwest Connecticut: “Yet our move was an ecological catastrophe. Our consumption of electricity went from roughly four thousand kilowatt-hours a year, toward the end of our time in New York, to almost thirty thousand kilowatt-hours in 2003—and our house doesn’t even have central air-conditioning. We bought a car shortly before we moved, and another one soon after we arrived, and a third one ten years later. (If you live in the country and don’t have a second car, you can’t retrieve your first car from the mechanic after it’s been repaired; the third car was the product of a mild midlife crisis, but soon evolved into a necessity.) My wife and I both work at home, but we manage to drive thirty thousand miles a year between us, mostly doing ordinary errands. Nearly everything we do away from our house requires a car trip. Renting a movie and later returning it, for example, consumes almost two gallons of gasoline, since the nearest Blockbuster is ten miles away and each transaction involves two round trips. When we lived in New York, heat escaping from our apartment helped to heat the apartment above ours; nowadays, many of the BTUs produced by our brand-new, extremely efficient oil-burning furnace leak through our two-hundred-year-old roof and into the dazzling star-filled winter sky above.”

page 240 But we don’t have that option One “third-way” solution to this problem would be to adopt the medieval system of distributed density, still visible in hill towns of northern Italy: a network of tightly packed mixed-use nodes of finite size, separated by large stretches of low-density vineyards and farms. This is not the decentralized approach of edge-of-city sprawl; the towns in the medieval system were not as dense and economically diverse as most modern city centers, but they had a ceiling on their overall growth, usually defined by the walls that outlined the town limits. A post-9/11 city could be built along similar lines: the density of traditional metropolitan space in distributed nodes limited to 50,000 to 100,000 people each, separated by expanses of low-density development: parkland, nature preserves, sports facilites, even vineyards where the climate allows. Such a model would reverse the Olmsted vision of urban greenery: rather than carve out a park in the middle of an immense city, the new model builds a space for nature on the edges of the city center—Peripheral Park, instead of Central. In medieval times, the walls protected the town population. In these theoretical settlements, the open spaces separating the nodes would keep the city safe. Imagine a city of 2 million people, built out of twenty nodes. In a worst-case scenario, a terrorist with a backpack full of smallpox might well be able to do extensive damage to a single node, perhaps killing tens of thousands in the process—not millions. The remaining nodes would be largely unaffected, not unlike the Arpanet and its now folkloric skills at routing around damage. An attack like those on the Twin Towers could still do a lot of damage, but there wouldn’t be a centralized, symbolic node to target. Life in such a metropolitan complex would not feel suburban, by any means: the generative force of sidewalk culture and urban density would be preserved, possibly even enhanced.

page 243 In September 2004, health officials in Thailand “Asian Shots Are Proposed as Flu Fighter,” New York Times, October 13, 2005.

page 246 It needs the CTX phage to switch over Mekalanos et al., pp. 241–48.

page 253 but detection is hardly a fail-safe option I described some of the latest advances in radiation detection—and speculated on how they might be employed to defend large metropolitan areas from nuclear terrorism—in the essay “Stopping Loose Nukes,” published in Wired, November 2002.

page 254 But if the trends of asymmetric warfare continue The one thing we can do now to prevent such a dark future is to radically reduce, if not eliminate, the current stockpiles of nuclear weapons in the world. The United States alone has around 10,000 weapons in its active arsenal. This is madness in an age of asymmetric warfare, where mutually assured destruction is meaningless. (It was madness in the cold war too, but for different reasons.) If all the nuclear powers agreed to limit their stockpiles to no more than ten weapons per country—thereby reducing the total number of weapons in the world from 20,000 to less than a hundred—we would reduce by more than an order of magnitude the risk that a weapon would fall into the wrong hands. We would still retain the ability to kill 100 million people and do untold environmental damage with those ten nukes, but at least we would be making significant progress against the growing menace of proliferation. It would be an epic undertaking, yet history shows we are capable of projects on this scale, if we apply ourselves. We eliminated smallpox from the wild, after all. If we can rid the world of a microscopic virus, we can eliminate weapons the size of tractor-trailers. We hear a lot of war-on-terror rhetoric cajoling us to be realistic about the threats that face us, to confront those threats without pity or foolish idealism. That’s why we have elective wars and unauthorized wiretapping: because we’re realists now, or so we’re told. But wherever each of us stands on the wars and the wiretaps, we need to agree that maintaining a stockpile of 10,000 nuclear weapons is the very opposite of realism. It is, in fact, an idealism of the most starry-eyed sort: the ideal that says we’re better off spending billions of dollars maintaining devices that would, were they all detonated, potentially end life as we know it on planet Earth. We are, as a species, sleeping with a gun under our pillow. It may make us feel safe to know that we have all that firepower so close at hand, but someday it’s going to go off.

page 255 Angola is suffering through the worst outbreak “Angola is suffering its worst outbreak of cholera in more than a decade, recording 554 deaths and 12,052 cases in just over two months, according to Doctors Without Borders. The disease has spread unusually fast, even for Africa, where cholera epidemics are common and often hard to control, said Stephan Goetghebuer, an operational coordinator for the organization. It has set up eight clinics in Angola to treat the sick and plans to open more.” “Angola Is Hit by Outbreak of Cholera,” New York Times, April 20, 2006.