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The Medical Detective: John Snow and the Mystery of Cholera

Article  in  BMJ Clinical Research · May 2006

DOI: 10.1136/bmj.332.7551.1220-a · Source: PubMed Central

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BOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGS

Frantically he bathes his

eyes in the shower, but already
he can feel his sight weakening.
We see a kaleidoscope of blur
and tunnel vision. At hospital
he asks the doctor if it is
Ways of seeing serious, and the doctor says
yes, very. And the next day, de
A documentary about going Montalembert is blind. He’s not
in darkness, though—rather
blind offers a powerful study golden light “like falling into a
in adaptation pot of dark honey.” Over the
next few days his brain creates
Black Sun, a film directed by Gary Tarn vivid, erotic, and disturbing
Cinema 1, ICA, The Mall, London images.
SW1Y 5AH, until 25 May; Silverdocs People start to treat de
Documentary Festival, outside Washington, Montalembert differently—now De Montalembert uses his blindness to try to understand
DC, 13-18 June; Nantucket Film Festival, nurses, doctors, and visitors what it means to be able to see
Massachusetts, 14-18 June; UK-wide bare their souls to him. He fears
other people’s reaction to his blindness. One and a half years later, De Montale-
theatrical distribution and screenings on
“When will you be able to see again?” a taxi mbert tells no one and leaves New York for
BBC and HBO television to be confirmed
driver asks him. De Montalembert learns to Indonesia. He depicts Bali in dazzling multi-
Rating: ★★★★ play the piano with one hand, the other coloured thermograms, noisy red and green
hand reading the Braille score. He equates faces. Here he finds catharsis in writing.

H
ugues de Montalembert was losing his sight with losing his masculinity, to Sometimes, unwittingly, he keeps writing
attacked and blinded in 1978, aged castration. He grieves his loss as an artist and after his pen runs out. One time he
36. The French artist and dedicated as a human being. continued for 12 pages, until his cook
traveller describes his new life without Initially he wants his blindness kept noticed.
sight—in film. Black Sun is a vibrant and secret from his friends, family, and girlfriend. A man in a bar tells him he looks like a
moving impressionistic documentary that He thinks he wouldn’t be able to console painter. “Yes. How did you know?” de
follows the next 20 years of his life, in an them. But they find out, and he has to ask his Montalembert asks. “The way you look at
amazing journey around the world. And it’s mother not to visit because he needs more things.” Travelling gives him new confidence
a personal and open portrayal of loss and and helps him to reaffirm his identity as an
time. His lover leaves him, as do other
grief, and an insight into what sight means artist. He shares adventures from his travels
friends. “People don’t like tragedy,” he says.
to a blind person. The ultimate impression, with new optimism. Thieves steal all his
He tortures himself that without eye contact
though, is of an artist determined to possessions when he arrives in New Delhi,
there cannot be love. And he despairs: “You
continue his life as before.
never think it’ll happen to you.” But he’s not but they return his bags unopened when
De Montalembert narrates Black Sun,
prepared to accept a sedentary life. they realise that he is blind. In another
but his story includes visual narrative
He also fears having to give up his inde- anecdote, de Montalembert has to be
too—scenes inspired by those constructed in
pendence, to need help. “If I want convinced that he’s never really seen one of
his brain as it tries to interpret the impaired
something I know it will be difficult.” And he his friends, because they met after the attack.
input. He reasons that the existence of these
manmade “visions” proves that sight is associates blindness with a body defeated However, de Montalembert claims to know
created internally, and is not a perception. through age. Despite doctors’ protests that exactly how he looks.
The lens pans soft focus across aerial he is not ready, encroaching depression Black Sun is a sensitive account of
views from high above New York: a million spurs him to enrol in a rehabilitation centre. personal loss set to stunning visuals—a study
lights twinkle in the hazy purple dusk. “How Upbeat footage shows white sticks, sight in frustration and adaptation that occasion-
many blind people have you met? Where are charts, Braille lessons, and obstacle courses ally exposes genuine bitterness. Although de
they?” he calmly asks. The camera zooms in in hospital corridors. He recalls in colour as Montalembert would like to see again he
on a crowded avenue, and then the edges of he describes in delight the rush of says he’s completely happy being blind.
the streets and buildings become outlined in excitement at sneaking out of the centre Black Sun is uplifting because rather than let
white, as if they’re in a giant computer and walking seven blocks down Madison his blindness confine him, de Montalembert
graphics program. White annotations line Avenue late one night. uses it to try to understand what it means to
up neatly with the wire frames. Buildings change into clouds that be able to see.
He relives the attack. Two drug deprived change into cratered grassy wasteland in a
addicts force him at knifepoint into the flowing montage. At times the photography Richard Hurley technical editor, BMJ
New York flat that he’s borrowed from a evokes nostalgia for summer holidays shot rhurley@bmj.com
friend. Because he has nothing of value— on super eight and at others is garish and
and because he fights back—the intruders synthetic. Computer enhancement trans-
become angry. One throws paint stripper at forms shots into technical drawings and Items reviewed are rated on a 4 star scale
him, and the noxious liquid burns his eyes. thermal images, intense bursts of contrast- (4=excellent)
His screams scare off the attackers. ing colours.

BMJ VOLUME 332 20 MAY 2006 bmj.com 1219

reviews

is spreading among the Chinese in a market Gripping stuff, mostly very well done.
town soon to be visited by an American busi- Particularly effective visual scenes include a
nessman. He catches it from a coughing vast temporary hospital set up in a New York
factory worker and then begins shedding subway station and a huge burial pit into
virus as he travels home. In dramatically which trucks dump hundreds of wrapped
effective microscopic close-ups now common bodies. And likely problems—such as a
Hollywood fights on television shows such as CSI: Crime Scene
Investigation, a graphic portrayal of forensic
shortage of medications, the time lag until a
vaccine is developed, and the problems of
bird flu police work, viral particles are shown being rationing both—are realistically portrayed.
passed to unsuspecting people via serviettes, There are some scientific inaccuracies. It
An entertaining worst case martini olives, hot face towels, and hand- makes no sense to quarantine people
shakes. beyond influenza’s four day incubation
scenario The hero of the story is, of course, a beau- period, so the Virginia governor’s prolonged
Fatal Contact: Bird Flu in America, a film tiful blonde, an Epidemic Intelligence Service quarantine of portions of Richmond with
on ABC television, aired in the United (EIS) officer played by Joely Richardson, who fences and barbed wire seems unlikely.
States on 9 May 2006 is rather wooden and has traces of her Migrating wild birds are made out to be the
English accent remaining. She is called away
big villains, although we’ve now learned that
from a tryst to fly to China to confirm that the

S
o what’s bird flu going to be like, they don’t, in fact, seem to be transmitting
assuming that it comes? In this televi- virus has mutated. She then breaks the news
the virus. But these are rather minor slips.
sion movie we get to see all the scary to the US health secretary and they convene a
What the movie does very well is to
things the writers have learned about a pos- meeting of state governors to inform them
entertain and get people thinking. I watched
sible avian influenza pandemic crammed that bird flu is on the way.
it with two teenagers who paid rapt attention
into two hours: a highly virulent, rapidly The rest of the movie follows the
and kept asking whether this could really
transmissible virus, inept attempts at con- pandemic through three major story
happen and what we would do about it if it
tainment, overwhelmed medical facilities, threads: the death of the index case and the
grief, quarantine, emotional paralysis, recov- did. Good questions.
mass graves, food and water shortages, and
looting and rioting. ery, and subsequent community leadership
Douglas Kamerow US editor, BMJ
The programme begins with a solemn of his widow; the mistakes made by the gov-
dkamerow@bmj.com
disclaimer telling us that the H5N1 virus has ernor of Virginia and his redemption after
not (yet) been transmitted from person to losing his son and realising that quarantine The US Centers for Disease Control has
person. Cut to geese flying over the ocean is not the answer; and the everyday heroism prepared a viewer’s guide to provide answers:
and chickens being slaughtered by the of a New York City emergency room nurse http://pandemicflu.gov/news/birdfluinamerica.
million in China. The virus has mutated and and her National Guard husband. html[guide.

The Medical Detective: Southwark and Vauxhall Company, which in an appropriate socio-political and scientific
still pumped its water in a polluted area of environment. He had the opportunity to
John Snow and the Mystery the Thames in the heart of London. We team up with William Farr, medical registrar
of Cholera know a great deal about Snow’s large scien- for England and Wales, whose offices
Sandra Hempel tific heritage because he was a prolific writer. collected death certificates and reported their
But very little written testimony exists about aggregated numbers weekly.
Granta Books, £18.99, pp 304
his personal life and psychology beyond an A key figure of Victorian medicine, Farr
ISBN 1 86207 842 4
www.granta.com
expanded obituary. played a crucial role in Snow’s success, which
Given the limited biographical material is not appreciated as much as it should be by
Rating: ★★ available, it seems that everything that might Hempel. In December 1853, the registrar-
be written about Snow has already been said general had first noticed that the districts par-
by other authors, or collected by Frerichs on tially supplied with the improved water from
a website devoted to Snow (www.ph.ucla. the Lambeth Company suffered much less
edu/epi/snow.html). Indeed, Snow’s fans than the other districts from cholera,
will not learn anything new about him in The although, previously, these same districts suf-
Medical Detective. Still, Sandra Hempel has fered about as much as those supplied
succeeded in drawing a three-dimensional entirely by the Southwark and Vauxhall
portrait of Snow by abundantly describing Company. Farr provided Snow with the
the place, time, and society in which he lived. names and addresses of the dead and made
The Medical Detective reads like a well

J
ohn Snow is perhaps the only doctor Snow’s demonstration possible. Farr did not
ever to be considered the founder of two informed novel featuring Chadwick and share Snow’s views on the role of polluted
medical disciplines: epidemiology and Dickens, Queen Victoria and Florence Night- water, but he was instrumental in the success
anaesthesiology. An early believer in the ingale, and digressions on the history of Vic- of Snow’s endeavour.
theory of contagion, he grasped the oppor- torian medicine, of ether and chloroform, Snow is already the hero of an excellent
tunity of a peculiarity in the water supply in and of cholera. A mythical image of Snow as children’s book (The Blue Death: The True Story
London to gather quantitative evidence sup- a brilliant doctor with a penetrating intuition of a Terrifying Epidemic. London: Hodder
porting his theory that cholera was transmit- about the cause of cholera and who Children’s Books, 2001). Hempel has now
ted by polluted water. ingeniously found a way to test it emerges. staged him as a brilliant detective and paved
In 1853-4, when a cholera pandemic hit However, in contributing to Snow’s mythol- the road for a popular movie, which will
London, one of the two major water supply ogy, Hempel fails to address some basic ques- finally let Snow enter the pantheon of great
firms, the Lambeth Company, had moved its tions any detective would ask. Why Snow? doctors.
Thames intakes upriver, above the tidal (and Why London? After all, many bright physi-
therefore sewage) reach. Snow showed that cians in Europe and elsewhere were tracking Alfredo Morabia professor of epidemiology,
most of the cholera deaths occurred among the causes of cholera at the same time. Many City University of New York, United States
clients of the other major water provider, the shared his contagionist views. But Snow lived am52@columbia.edu

1220 BMJ VOLUME 332 20 MAY 2006 bmj.com

 reviews

PERSONAL VIEW SOUNDINGS

Which patients with which needs are Souls in cages

leading the patient-led NHS? “Some are like souls in cages. Like, you
can see they’re there, but they look like

I
t was the summer of 1992 when we first practice where everyone knew her was they don’t want to be.” He tries to
met. She was a retired nurse, aged 76, infinitely more important than “instant elaborate, can’t take it much further,
recovering from a heart attack. I was access for routine care at anytime” that but—for a 17 year old on work
new to the practice, and we talked at some seems to drive the white paper. But then she experience in a nursing home and
length. She told me about her work in the was not middle-aged, middle class, and wanting to be a doctor—perhaps he’s
hospital, her children and grandchildren. living in middle England. She rated the done quite well already.
And we talked about my experiences on the quality of her personal care very highly— Where do they come from, these
same wards and my growing family. She was from the reception team to the visiting souls in cages? Not sure, but I see too
checking out the new doctor, while I was nurses and general practitioners. I don’t many of them: too often and too easily
putting into practice the “bio-psychosocial” think her view would have changed even if we fail the souls and build the cages. In
approach drummed into us as we prepared she had known that her care fell short in the rush and glamour of acute care, in
for our college membership exams. many areas of the Quality and Outcomes the busy system that is designed to cure
A few months later I was called to see Framework (QoF)—indicators for which GPs and doesn’t like to lose, there are
her at home. She was short of breath and receive payments as part of their contract. priorities that may take insufficient
showing the first signs of heart failure. We A few weeks ago she suffered another account of the worse-than-death
talked about medication, investigations, or heart attack followed by a stroke, and never outcome—the helpless, stabilised,
outpatient referral. She wanted as little returned home. She died peacefully this week damaged survival—that so many of us
“interference” as possible—preferably never in a local “continuing care” bed, at the age of dread. And too often families are
to go near hospital again. 90. We had been on life’s summoned for the grimly absurdist
We worked our way through journey together over 14 routine: “We’ve saved your father’s life . . .
various treatments and her We had been on years—the epitome of what I But now he’s blocking a bed.”
symptoms improved a little. life’s journey had hoped and believed The sorrows can endure for months
But gone were the daily general practice would be or years. The death averted is a
walks to the baker or the together over 14 about when I began my bereavement suspended, the caged soul
newsagent—a few steps years training at medical school. lingers, and people remain upset. Is it
down the path became all Last night I opened her about regrets, or a strange injustice, or a
she could manage. Never- computer notes to record a wider and far more worrying
theless, she remained invariably cheerful, final entry: “Goodbye to a true friend— RIP dysfunction? Who knows, but it seems to
playing host to several groups of medical [rest in peace].” There are no longer any happen quite a lot.
students, helping them with their “chronic flashing alerts highlighting our failure to con- Yesterday my mother was well. This
disease” projects. I called in every now and trol her blood pressure, her ischaemic heart morning her neighbour rang me to say
then to monitor her progress on an ad hoc disease, or her diabetes. But then a smile she was not: “She kent me, but she
basis, yet she always managed to have a plate overtook my tears. It was in true character couldna talk, and she couldna get up.” I
of sandwiches waiting. that this generous spirited woman turned all speak some Scots and know some
Over time her symptoms gradually the red entries green by dying just before the neurology. It’s very bad. Three hours
worsened. Later she developed diabetes, end of the QoF year, when figures count later, in the emergency department of a
predictably difficult to control. We control- towards GPs’ payments under this scheme. decent district general hospital, I see her.
led her blood pressure with tablets, which I am not sure, as I approach retirement Everyone has been kind and efficient,
worsened her renal function. A statin in another 14 years’ time, whether we will but she is now, in her grandson’s words, a
lowered her cholesterol, but her liver still be delivering this kind of care to our soul in a cage.
function went haywire. Her blood sugar rose patients—quality that is very much appreci- She was 90 in October and greatly
inexorably, despite triple therapy, so we ated but so hard to measure. Quality that enjoyed her birthday bash. Yesterday she
switched to insulin. She lived with her means patients are looked after by “my doc- logged yet another great grandchild into
beloved grandson who took over adminis- tors and my practice.” Sections of the popu- her fearsomely well organised birthday
tration of her injections, but her HbA1c lation quite understandably want a very book, and had ordered but not yet
remained stubbornly high. Beta blockers different model of access and availability. collected her first walking stick. She had
But this focus may end up seriously eroding ticked all her boxes—two careers,
made her breathing worse and her warfarin
the delivery of long term continuing care to bringing up her children, burying her
had to be stopped after a gastric bleed. I
the elderly and chronically sick. We are husband—and since then has greatly
continued to call in every month or
building our patient led NHS. However, enjoyed her bowling, her voluntary work,
two—there always seemed to be a new symp-
sometimes I do wonder exactly which and a lively extended family. She cannot
tom or drug side effect to deal with. We tink-
patients with which needs are actually in the move her right side and cannot speak.
ered with medication; introduced a neb-
lead. She is dying but she is lucky: no
uliser; and always had a good chat together,
catching up on each other’s families, nasogastric tube or PEG (percutaneous
Diana M Jelley general practitioner, Collingwood endoscopic gastrostomy) feeding for her.
exchanging photos. She ended up in hospi- Surgery, North Shields
tal a couple of times but returned home A few months ago she tidied up her life,
di.jelley@nhs.net
after each admission full of determination to perhaps anticipating eternity, and made
her wishes clear. I pass them on and a
remain independent.
We welcome submissions for the personal view wonderful district general hospital team
She is not the kind of patient who had
section. These should be no more than 850 words respects them, cares lovingly for her, and
the opportunity to fill in the “Your health,
and should be sent electronically via our website. will not cage her soul.
Your care, Your say” survey (www.nhs.uk/
For information on how to submit a personal view
yoursay) to inform the recent white paper online, see http://bmj.com/cgi/content/full/325/
on community care. But if she had been Colin Douglas doctor and novelist, Edinburgh
7360/DC1/1
asked, I feel sure continuity of care from a

BMJ VOLUME 332 20 MAY 2006 bmj.com 1221

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