Cholera

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CHOLERA

The traditional ecological cradle of cholera was Bengal. Because of the intensification of geographical mobility in India, as well as occurrences of colonization wars and more active merchant activities, the epidemic expanded first to the whole of India (1817–1818), and then to Ceylon (1819), to the eastern coasts of Africa and to Asia (1821–1822), and also to the northwest to Astrakhan (1823). This first pandemic ended, and in 1829 a second one began (lasting until 1837), the first to reach all the continents and affect all European countries as well as the United States. Cholera followed the merchants' routes and arrived in Europe via the Russian Empire, Poland, Germany, the Baltic Sea, Denmark, and England. In some months, several hundred thousand deaths occurred, with huge effects on the economy, social cohesion, and political regimes. During the nineteenth century, cholera was the first broad epidemic imported since the time of the last plague in the south of France in 1720 to 1722. Moreover, each generation experienced several pandemics: the third one spanned from 1840 to 1869, the fourth one followed from 1863 to 1875, and the fifth one lasted from 1881 to 1896. In France (out of a total population of 32 million) more than 100,000 people died because of cholera in 1832 and 150,000 in 1854, while in England (with a population of 17 million) 54,000 died over several months in 1849, which created a shock. Cholera's symptoms were spectacular: severe vomiting and diarrhea, cold sensation, trembling, and dehydration, sometimes leading to a blue-colored face; some victims died within a few hours or a couple of days, while others survived following a long convalescence.

Western European medical doctors assessed this new threat with confidence when the epidemic was still limited to eastern Europe. But very quickly a division manifested itself between those who tried to show that it was a contagious disease, like smallpox or plague, and those who thought, as neo-Hippocratism emphasized, that it was a noncontagious disease linked to specific climate changes, the growth of large cities, and "miasmatic" emanations (that is, that people were infected by bad air). As the traditional plague regulations enforced in Russia and eastern Europe led to social tensions, violent riots broke out. Because these regulations contradicted the new ideology of free exchange and trade, and because there was no medical consensus, governments decided to enact controls. Cholera occasioned a new "English" system. Instead of sanitary cordons and quarantines, medical controls were set up to monitor those arriving and to follow them at least during the succeeding weeks. Fever hospitals were established to shelter poor patients, while middle-class people were allowed to stay at home, another fact that heightened social tensions. But to make such a new system efficient, the western European countries placed considerable pressure on the Turkish and Egyptian governments to enact measures to keep cholera from entering the Mediterranean Sea. (After the opening of the Suez Canal in 1869, the danger was seen to be Muslim pilgrims going to Mecca.) The less-controlling system in western Europe was possible because of greater controls on the eastern frontiers of Europe.

cholera causes and treatments

Different methods to try to cure patients followed contemporary medical theories. On one side, followers of the French physician François-Joseph-Victor Broussais (1772–1838) and his inflammation theory of the intestine believed that the body could be "calmed" with leeches and bleeding. In contrast, followers of the French physiologist François Magendie (1783–1855) argued that the body was really weak and thus had to be helped to fight against weakening with exciting drinks (including punch), blankets, and steam to keep it warmer. Others were aware of the necessity of giving lots of water to their patients (which was the right thing to do when confronted by dehydration symptoms). In London and Paris some doctors tried to give intravenous or anal injections of water and salt. Furthermore, some drugs (e.g., ipecacuaha, laudanum de Sydenham) were used to stop the symptoms.

All over Europe, the "miasmatic" explanation for the cause of cholera remained paramount among officials and doctors until the 1860s. During the 1854 cholera epidemic, however, the English physician John Snow (1813–1858) noted particularly high mortality among users of a water pump on Broad Street in London's Soho district. He showed that the number of deaths from cholera among customers of the Southwark and Vauxhall Water Company was six times higher than among customers of the Lambeth Waterworks Company, and he emphasized that the latter was pumping water from the Thames far from sewage, and the former drew water at the most polluted place in the river. This evidence did not change the view of a select parliamentary committee, which continued to believe that cholera was carried in the air. Finally William Farr (1807–1883), an English epidemiologist, acknowledged the committee's error upon studying the last London epidemic in 1866. He was impressed by the fact that the epidemic had been confined to a small area of Whitechapel. Farr demonstrated that the East London Waterworks Company's reservoirs had been contaminated. It was precisely this company that served the White-chapel district.

Throughout the century, but particularly in the early decades, each cholera epidemic had been seen to pose an immense political threat to governments. The poor accused the rich of trying to poison them; doctors were suspected of carrying out experiments on poor people. The political opposition also tried to use the epidemic to criticize governmental policies; many newspaper caricatures linked political issues to the epidemic. The cholera epidemic reflected a destabilization of contemporary societies. Even if the official thesis remained that the epidemic was not contagious, the population at large believed the contrary and fled large cities, stores, workshops, and markets. Social and economic life ground to a halt for some weeks. In France, in 1832, Casimir Périer, the prime minister, died, as did the leader of the republican opposition, General Jean-Maximilien Lamarque. This led to riots in Paris because republicans suspected that the latter's death was not the result of cholera but of someone on the government's side having poisoned him. Cholera epidemics also brought to light tensions in Russia, Poland, Austria, the German states, and England, as well as in France. René Villermé (1782–1863), a pioneer of French public health, demonstrated that following the 1832 epidemic, the poorest districts of Paris were those most affected by the epidemic, and that the number of cholera deaths in these areas was higher than in the wealthier districts.

The wealthy and the doctors criticized the way in which the poor ate, drank, and generally behaved in daily life, suggesting that they were responsible for their own misfortune. Such views influenced the social representation of cholera. The first epidemics had even been used by authorities in an attempt to obtain greater conformity of behavior in the general population. The Catholic Church organized special relief efforts for families struck by cholera, attempting to recapture popular support.

In 1883 the German physician and bacteriologist Robert Koch (1843–1910) finally identified the Vibrio cholerae bacterium as the cause of cholera. Henceforth, it was no longer possible to argue that a cholera epidemic was not contagious. Yet in Hamburg in 1892, leading citizens of the municipality decided to adopt a thesis more compatible with their own commercial interests, ignoring Koch's discovery from the previous decade, which had led to restrictions on emigration from Hamburg, one of the major activities of the bustling harbor. Hamburg's most serious epidemic followed. A vaccine had even been available since 1885, purified by the Russian bacteriologist Waldemar Haffkine (1860–1930) at the Pasteur Institute in Paris in 1892. But medical progress was not sufficient to convince local politicians, nor did it prevent the spread of the disease. Nevertheless, Hamburg was an exception in Europe. Outbreaks of cholera declined in gravity after the 1860s. In most countries the last attack occurred in 1884 and 1885, with fewer deaths than during the previous epidemics.

As has been seen, relevant theories on the spread of cholera existed before the epidemics but were in some cases ignored. Despite this, accumulated knowledge led to better prevention and care. After each pandemic, improvements in both public sanitation, especially the improvement and the extension of sewage systems, and water supply systems accelerated. And because of political considerations, the cholera epidemics also tended to focus public health policies more on sanitation than on attempts to improve the lives of the poor.