CHAPTER 4 Cholera

Like tuberculosis, cholera is a disease often associated with the nineteenth cen­tury and is likewise caused by a bacterium, in this case, the comma-shaped Vibrio cholerae that was identified by Robert Koch in 1883 after conducting autopsies on victims in Alexandria, Egypt, and Calcutta, India.¹ Cholera, whose name comes from choler or yellow bile, the humor often associated with digestive ill­nesses, made its impact not so much through its mortality as through its espe­cially dramatic symptoms.

Cholera has been a worldwide phenomenon but is said to have its endemic home in India, more specifically the Bengal region, where nearly every pandemic seems to have originated. (This is why the disease is sometimes known as Asiatic cholera.) Historians count seven separate pandemics of cholera to have occurred throughout history, the first beginning in 1817 in Bengal, India; earlier occur­rences of the disease no doubt existed, although it is hard to distinguish these in the record from other gastrointestinal diseases, such as dysentery or diarrhea. Last­ing until 1824, the first pandemic was largely confined to India, Southeast Asia, China, Japan, the Middle East, and southern Russia. It was not until the second cholera pandemic of 1827 to 1835 that the disease directly impinged itself upon the consciousness of Europe and the United States, particularly in the crucial year of 1832. The third pandemic from 1839 to 1856 brought the disease for the first time to South America, especially Brazil, and to much of North Africa as far west as Tunis. During the fourth pandemic of 1863 to 1875, much of sub-Saharan Africa was ensnared in cholera's worldwide net. By the time of the fifth and sixth pandemics of 1881—1896 and 1899—1923, greater understanding of the disease largely confined its worst mortalities to the east, including Egypt and the Arabian peninsula, Persia, India, and the Philippines, although some notable epidemics did occur in Europe and Russia, including an outbreak in Hamburg, Germany, in 1892 and in Naples, Italy, in 1910—1911.

Cholera, like tuberculosis, lends itself particularly well to a social interpreta­tion of disease. What exactly that interpretation should be, however, has been much debated by historians. Traditionally, cholera has been seen as dividing nineteenth-century European society into two camps, those who preferred to explain it as the product of person-to-person contagion and those who saw it as caused primarily by environmental factors, such as miasma, poverty, filth, and so on. Each explanation in turn produced its respective champions in terms of how best to combat cholera. Contagionism, typically associated with conservative members of the ruling class, advocated quarantine, while anticontagionism, also referred to as localism or infectionism, which was taken up by bourgeois captains of commerce and political liberals and free traders, recommended sanitation measures and better hygiene. Both had their antecedents in Europe's medieval and Early Modern past during the fight against plague. In reality, as more recent historians have argued, etiologic approaches to cholera did not always fall so neatly along these lines; often, in fact, the two might blur together within the same explanatory system, which perhaps best reflects the true epidemiology of cholera, and became known as “contingent contagionism.”⁶

Nineteenth-century cholera also presents historians with an opportunity to study the possible connections between disease and social conflict.

However, poison hysteria and riots did break out in 1832 in other countries, such as Russia, where the scapegoat was mainly foreigners, but there such up­heavals did not lead to any long-term social changes or reform, except perhaps in a blossoming of Enlightenment medicine along Western lines.⁸ In Britain, popular fears and suspicions in connection with cholera were directed, as in France, against hospitals and physicians, but for different reasons. Instead of ac­cusations of poisoning, there was concern that cholera victims were not receiving proper burial but instead were being diverted to anatomy schools for dissection, which was normally reserved only for criminals and those denied Christian burial. The disease just happened to coincide with a rash of “resurrectionists” or body-snatchers, gangs of criminal elements who robbed graves or even worse in order to supply subjects for anatomy students; the most notorious incident oc­curred in Edinburgh in 1827—1828, when two men, William Burke and William Hare, murdered a total of seventeen victims and delivered them to Dr. Robert Knox of the Edinburgh medical school. (Burke, the man who was hanged for these crimes on Hare's testimony, subsequently lent his name to “burking” and “burkers,” as body-snatching and its practitioners became popularly known from then on.) During the cholera epidemic itself, the body of a four-year-old boy who had died at the Swan Street cholera hospital in Manchester was discovered in his coffin with a brick in place of his head, which had been removed for dis­section purposes by the resident surgeon, Robert Oldham. Ironically, the boy's grandfather, who led an avenging crowd of three thousand that rioted in front of and inside the hospital, was another Irishman also named Hare.⁹

Once again, it is hard to argue for long-term trends in later cholera outbreaks, for popular discontent in Britain rapidly subsided after the passing of the Anat­omy Act by parliament in 1832, the same year that the Reform Bill greatly ex­panded the electorate and eliminated “rotten boroughs.” One study of a severe cholera outbreak in Hamburg, Germany, in 1892, which claimed over eight thousand lives (mostly among the working-class poor), has argued that the lack of any civil disturbances in the city, despite the panicked flight of some forty thousand middle-class citizens and a prior history of rioting during previous cholera epidemics, proves that by this time European populations had become “medicalized,” or resigned to authoritarian efforts to contain disease as necessary sacrifices of individual liberty and local customs on behalf of the general wel­fare.¹⁰ But the argument from silence here may be deceptive.

Yet another reason for historians to study cholera during the nineteenth cen­tury is that it is an irresistible case study of how disease can become a “tool of empire” or, in other words, the role that disease can play in the imperialist poli­cies of European powers in their colonies in the Americas, Africa, and Asia. This is particularly true of the British empire in India, the endemic home of cholera, where medical authorities (who adopted an anticontagionist line) mainly took a sanitary approach to combating the disease, as they were to do later during the Third Pandemic of plague beginning in 1896. However, even more so than in the case of plague, the British were hampered in their medical intervention in India and never seem to have seriously attempted to carry out what were consid­ered the necessary measures, such as restricting pilgrim traffic at Hindu shrines like the temple of Jagannath at Puri, due to the costs involved, fears of offending native sensibilities (particularly after the Sepoy Mutiny of 1857), and remaining uncertainties about the etiology of cholera. This was in spite of the fact that an international sanitary conference held at Constantinople in 1866 had declared pilgrimages to be “the most powerful of all causes” of cholera, an assertion seem­ingly backed up by the severe cholera outbreak that occurred in Mecca, one of the most popular pilgrimage sites in the world, in 1865, when fifteen thousand pilgrims died of the disease.¹²

An important difference between cholera and plague in terms of British poli­cies in India is that, when cholera first broke out in the Bengal region in 1817, native Ayurvedic and Western medical approaches were quite similar, both being based on humoral and miasmatic theories of disease; British doctors, despite maintaining the superiority of their medicine, were quite willing to borrow from local Indian practices. With later cholera outbreaks, however, the attitude of India’s imperialist masters began to change, as the disease was identified to be of Asian origin and became associated with lower standards of Asian hygiene (em­blematic, in Western eyes, of an inferior “civilization”) and greater Asian propen­sities toward superstition. By 1831, a Frenchman, Alexandre Moreau de Jonnes, connected Indian Hindu pilgrimages with the spread of cholera and greatly exag­gerated cholera deaths there (to as much as eighteen million), while a British sanitary commissioner remarked in 1868 that the Jagannath temple car at Puri presented a “tawdry and contemptible” spectacle.¹³ Yet, we have seen how Euro­pean populations, especially in 1831—1832, could likewise give in to irrational beliefs, such as that their own doctors were poisoning them, and resist, some­times violently, their own government’s attempts to “medicalize” them.

By the mid-nineteenth century, however, Britain and Europe, through the ef­forts of medical pioneers such as John Snow, were making great strides in under­standing the true causes of cholera, although differences of opinion still remained, so that it is hard to argue that “gentlemanly capitalist” interests behind the British Raj were solely responsible for keeping these advances from saving millions of lives in India.¹⁴ Rather, the very history of British policies toward cholera in India stood in the way of a drastic remolding of native medicine in line with the model provided by the colonial mother country, as was tried in response to plague at the end of the century. Britain therefore never had to learn the hard lesson that there were limits to what its superior medicine could do against the cholera in India, because it never really tested those limits where cholera was concerned. In turn, from the very beginning of cholera epidemics, native opinion in India tended to blame British violations of local Hindu customs and native acquiescence in colo­nial rule for its own susceptibility to the disease.¹⁵

By contrast, the United States did learn this hard lesson with cholera when, after the Spanish-American War in 1898, it took over the Spanish colony of the Philippines, where a terrible epidemic of the disease—killing an excess of one hundred thousand people—occurred in 1902, hard on the heels of a three-year­long war of independence or insurrection against U.S. rule. As with the British experience with plague in India, the United States discovered that its heavy­handed attempts to control cholera, such as isolating victims and their contacts in segregation camps and destroying or disinfecting their houses and possessions, were only counterproductive, inspiring Filipinos to flee or conceal victims of the disease, thus prolonging and even spreading the epidemic, and American au­thorities were forced to back down and make concessions to native sensibilities.¹⁶ The case of Tunisia in North Africa, however, demonstrates that native resistance to Western medicine against cholera did not always fall so neatly along colonial lines but perhaps more in the way of traditionalist objections to the forces of modernism. Since the eighteenth century, the local beys ruling Tunisia had cham­pioned Western medicine and science as superior to local Muslim custom. Quar­antine, for example, which was administered by a Sanitary Council dominated by Europeans, was held to be responsible for Tunisia being largely spared the cholera pandemic of the 1830s. But in 1848—1850, quarantine proved incapable of preventing the disease from spreading to Tunisia from Egypt and Arabia, and it was resisted by both European anticontagionists and local Muslims who, as in Europe, spread rumors of poisoning by foreign doctors. The fact that religious invocations by forty sharif named Muhammad—who all claimed descent from the Prophet—seemed to halt the epidemic in the summer of 1850, where medi­cal efforts had failed, only served to reinforce local Muslim prejudices that as­similated or privileged older, traditional concepts of disease, such as that the jinn, or demons, could pierce victims with their arrows and thus give them cholera. By the time of the next cholera outbreak in 1856, the new ruler, Muhammad Bey, expressly forbade quarantine or indeed any of the other measures recom­mended by the Sanitary Council that had been taken during the last epidemic; yet, in the long run this did not dislodge the continued influence and acceptance of European-style medical reforms in Tunisia.¹⁷

Finally, cholera demonstrates, like plague, that worldwide pandemics of disease are greatly facilitated by modern methods of transport, such as the railways and steamship travel that were coming into their own during the nineteenth century. But to my mind, one of the most important lessons of cholera, and it is a very heartening one, is how solutions were found for cholera—solutions that haven't been bettered even to the present day—even when society was decades away from the germ theory and the modern technology of antibiotic treatment. In 1854, for example, a Yorkshire surgeon practicing in London, John Snow, was able to map out a cholera epidemic in the city that proved conclusively that the disease was spread by “animaculae”-infected drinking water. (Snow was inclined to reject the dominant miasmatic theory through his work as an anesthesiologist.) Two com­panies that supplied water to the same districts from the River Thames, one site contaminated with sewage and the other not, resulted in dramatically different infection rates regardless of class or other factors. Most famously, Snow mapped out cholera infections that radiated out from the Broad Street pump in the Soho area where he himself had formerly lived, a pump that had been contaminated by a dead child's soiled nappies washed into a cesspool that leaked into the well. Those nearby who didn't use the well, such as the denizens of a workhouse and the employees of a brewery, remained free of the disease even though their moral or social status might make them ideal potential victims, while Susannah Eley, who lived four miles away from the city in Hampstead, nonetheless got infected and died because she had a nostalgic taste for the water from the pump just out­side her late husband's percussion cap factory in Broad Street. When Snow per­suaded the parish's Board of Guardians to remove the handle of the Broad Street pump, the epidemic disappeared.¹⁸ Snow's demonstration that cholera could be fought and conquered simply by altering the environment in which the disease was transmitted finds its parallel in twentieth-century efforts to eliminate yellow fever and malaria by targeting their mosquito insect vectors, such as was achieved in 1905—1906 by William Gorgas, chief sanitation officer during the completion of the Panama Canal by the United States.¹⁹ (Malaria's recent resurgence, which is particularly acute in sub-Saharan Africa, is partly due to the fact that pesticides used to keep down mosquito populations, such as DDT, have unintended harm­ful side effects that complicate their use.)

Yet, it has been observed that Snow's evidence published in his On the Mode of Communication of Cholera reads more convincingly to us than it did to his contemporaries—nor was cholera invariably the spur to public works projects, such as were taken up by local boards of health in England and New York City, that eventually eliminated the disease.²⁰ Authorities in London did not act upon Snow's water-borne theory until 1866, after his death, and sewage renovation in the city was as much inspired by the “great stink” that occurred in 1858, when private toilets overflowed the existing system.²¹ Not even Koch's discovery of Vibrio cholerae in 1883 proved decisive in all cases: during the cholera epidemic in Hamburg in 1892, Koch's personal presence in the city nonetheless did not ensure that all his recommended measures were effectively carried out, and the National Epidemics Law that he championed was not to be passed until plague threatened Germany in 19 00.²² Naples's cover-up of its cholera outbreak in 1910—1911, motivated largely by its desire to maintain its lucrative emigration traffic, undoubtedly hindered its low-key efforts to contain the disease and finds modern parallels in Bangladesh and the Philippines, which stopped reporting cholera cases in the 1980s over fears of trade embargoes and declines in tourism, and in China's initial silence about SARS (severe acute respiratory syndrome) when an epidemic broke out in the Guangdong province in 2002.²³

In the same way, the most effective therapy for cholera, direct injection of saline solution into the veins of the victim, was devised and successfully tested as early as 1832 by an obscure physician from Leith, England, Thomas Latta.²⁴ To this day, fluid replacement therapy is the most widely used treatment for cholera, especially as the bacteria develop resistance to antibiotic drugs, such as tetracy­cline.²⁵ Yet, because Latta's chemically based therapy did not fit easily into any existing medical tradition, such as the humoral theory, it was not widely adopted during his own lifetime. Meanwhile, some spectacularly unsuccessful, and in­deed quite harmful, treatments were being employed, such as bleeding (still practiced as late as the Hamburg epidemic in 1892) and administration of laxa­tives and other purgatives, which, while perhaps endorsed by long tradition go­ing back to ancient times, had exactly the opposite desired impact in a disease

Cholera $ 109 that was already draining the body's available fluids. Other “remedies” were sim­ply bizarre, such as bunging up the anus with beeswax in a futile attempt to stem the involuntary gastrointestinal flow.²⁶ All this demonstrates that, while the means of prevention and cure of a disease may be prematurely available to hu­man society, it does not always have the wisdom, foresight, or perhaps the mere psychological readiness to avail itself of them.