by Sean Martin
It seemed as if the end of the world had come. The crowds assembled chiefly at the corners of the streets, where the red-painted wineshops are situated, and it was generally there that men who seemed suspicious were searched, and woe to them when any doubtful objects were found on them. The mob threw themselves like wild beasts or lunatics on their victims. Many saved themselves by their presence of mind, others were rescued by the firmness of the Municipal Guard, who in those days patrolled everywhere; some received wounds or were maimed, while six men were unmercifully murdered outright. Nothing is so horrible as the anger of a mob when it rages for blood and strangles its defenceless prey. Then there rolled through the streets a dark flood of human beings, in which, here and there, workmen in their shirt-sleeves seemed like the white caps of a raging sea, and all were howling and roaring – all merciless, heathenish, devilish. I heard in the rue Saint-Denis the well-known old cry, ‘À la lanterne!’320 and from voices trembling with rage I learned that they were hanging a poisoner. Some said that he was a Carlist,321 and that a brevet du lis had been found in his pocket; others declared he was a priest, and others that he was capable of anything. In the Rue Vaugirard, where two men were killed because certain white powders were found on them, I saw one of the wretches, while he was still in the death-rattle, and at the time old women plucked the wooden shoes from their feet and beat him on the head till he was dead. He was naked and beaten and bruised, so that his blood flowed; they tore from him not only his clothes, but also his hair, and cut off his lips and nose; and one blackguard tied a rope to the feet of the corpse and dragged it through the streets, crying out, ‘Voilà le cholera-morbus!’
… It appeared the next day by the newspapers that the wretched men who had been so cruelly murdered were all quite innocent, that the suspicious powders found on them consisted of camphor or chlorine, or some other kind of remedy against the cholera, and that those who were said to have been poisoned had died naturally of the prevailing epidemic.322
Heine was also in no doubt as to what caused the cholera to spread. It was not suspicious-looking people in the street. Rather, it was the
vast misery prevailing here… the incredible filth, which is by no means limited to the lower classes, to the excitability of the people and their unrestrained frivolity, and to utter want of all preparation and precaution whatsoever, the cholera laid hold here more rapidly and terribly than elsewhere.323
Europe’s politicians and religious leaders responded in like manner. There was a sense of clamping down, of getting ready for a siege. Whether the pandemic was the work of God or not, it couldn’t be allowed to stoke simmering political tensions. An ‘us and them’ mentality prevailed: the pandemic was interpreted as a menace from Asia, a pestilence that Asians were most susceptible to. That Europeans died of it too was merely an inconvenience that could be overcome through carefully co-ordinated responses from government, and putting a brave face on things. Some commentators came out with semi-Malthusian arguments, pointing out that the cholera was only affecting members of the lowest social classes in Bengal, and ‘was particularly prevalent among the abandoned class of women.’324
In Britain, the prospect of an impending pandemic not only inspired days of national prayer and penitence, but also political action. The Central Board of Health was established in June 1831 in anticipation of the pandemic reaching Britain. Fear that densely populated slum areas might spread disease led to the formation of a Royal Commission to investigate the need to reform Britain’s Poor Laws which, it was hoped, might then lead to the cleaning up of ‘fever districts’, the lessening of infection, and any possible unrest. The last thing the government wanted were revolting peasants who also had cholera.
In the shape of Edwin Chadwick (1800–90), appointed to assist the Royal Commission, the government got more than it bargained for. Chadwick and his team meticulously studied urban living conditions, and incidence of infectious diseases. (In addition to cholera, there was also a typhus epidemic in London in 1838, while Chadwick was at work.) The result was a document that would have repercussions far outside the sphere of British public health and Poor Law reform. The Report on the Sanitary Condition of the Labouring Population of Great Britain (1842) unambiguously demonstrated the link between overcrowding, filth, pollution, lack of adequate sanitation and infectious disease and low life expectancy. The report also pointed out how the loss of the family breadwinner could lead to crime, prostitution and the poor being led astray by ‘anarchist fallacies’. Although Chadwick ascribed the spread of disease to miasmas – he believed that ‘all smell is disease’ – it was perhaps the threat of ‘anarchist fallacies’ and other unthinkable horrors that galvanised the British government into action. His biographer was to comment that Chadwick ‘drew his respectable hearers to the edge of the pit and bade them observe the monsters they were breeding beneath their feet.’325
The Public Health Act of 1848 was one of the report’s first major achievements. With another cholera epidemic looming, and fear of political unrest increasing – it was the year of revolutions in Europe – the British government passed a piece of legislation that not only began the long, slow process of cleaning up Britain’s cities and towns, but would also inspire action abroad. Chadwick’s ‘disciples’ included the Bostonian Lemuel Shattuck (1793–1859), whose Report on the Sanitary Condition of Massachusetts (1850) paved the way for American public health (and Shattuck himself was to inspire the later work of John Shaw Billings in the US). In Germany, the Bavarian chemist Max Pettenkofer designed a new sewerage system for Munich.
Ironically, ‘Mr Chadwick’s Report’, as it was known, also had a direct influence on the kind of political agitators that the British establishment feared – the propagators of ‘anarchist fallacies’. The Condition of the Working Classes in England (1845) by the German political theorist and philosopher Friedrich Engels (1820–95) was based on research Engels conducted in Manchester in 1842. The book described the overcrowded, dirty and squalid conditions of working people, whose houses were mere ‘kennels to sleep and die in.’ Piles of offal and refuse clogged the streets; ordure oozed from outside privies.
That Engels had been in Manchester at all was itself an irony. His father, an industrialist, had sent him to work in a mill owned by the family firm in the hope that hard graft would cure the young Friedrich of his ‘anarchist fallacies’. Unfortunately for Herr Engels, and conservatives everywhere, it had the opposite effect. Three years later, Engels junior co-authored The Communist Manifesto with his friend Karl Marx. 1848 was a year of revolutions across Europe: governments tottered and fell, people flocked to the barricades, and streets echoed with the spirit of ‘À la lanterne!’ The same year, Rudolf Virchow managed to light the fuse of another, perhaps more significant revolution: the publication of his Report on the Typhus Epidemics of Upper Silesia helped lay the foundations of public health in Germany.
It was among the lower classes of Britain that progress was made against cholera. A young Yorkshire doctor, John Snow (1813–58), treated patients during the 1831–2 outbreak, and came to believe that a miasma could not be the cause of the pandemic. He published his theories in 1849 in a pamphlet entitled On the Mode of Communication of Cholera, by which time the third, and probably worst, cholera pandemic, had reached Britain.326 Snow’s ideas fell on deaf ears. Around 14,000 people died from cholera in London alone, twice as many as in the 1832 epidemic. After that, cholera mortality decreased, but did not disappear. Then, in 1854, the pandemic renewed its intensity, becoming ‘one of the worst cholera years on record’.327 It was also the year that Snow made his breakthrough.
Snow had been in London since 1836, working for the Westminster Hospital, where he was able to study the incidence of cholera in Soho. The central London district suffered from the usual litany of urban collapse and decay, when, in August 1854, people began dying from cholera in alarming numbers. The families most affected were drawing their water from the pump in Broad Street; those drawing their w
ater elsewhere suffered fewer cases. In the case of monks from the nearby abbey, there were no casualties at all: the monks only drank small beer they brewed themselves. Snow concluded that cholera must be a waterborne disease, and got the authorities to remove the handle of the Broad Street pump. The death rate dropped significantly. The pump was found to have been built just three feet from a cess pit. Further research found that other affected areas were served by the Southwark and Vauxhall Waterworks Company, a utility company that drew water from polluted downriver sections of the Thames. However, cholera cases were far fewer in neighbourhoods served by the Lambeth Water Company, who drew their water upriver at Thames Ditton, which was uncontaminated by London’s sewage.328
Snow published his findings the following year in a revised version of On the Mode of Communication of Cholera. Medical – and political – opinion remained sceptical, and the handle on the Broad Street pump was put back. By then, the third pandemic had largely run its course, and the government no doubt heaved a sigh of relief that it didn’t have to offend public sensibilities by explaining faecal-oral transmission. But cholera remained a problem for politicians as much as the residents of Broad Street: by the time Snow presented his findings to the Houses of Parliament in 1855, Britain was in the process of losing nearly 18,000 troops in the Crimean War (1853–6), almost all to cholera. By contrast, only 2,700 were killed in action, with another 1,800 dying of wounds.329 (All the belligerents in the war were to suffer heavy losses to cholera and other diseases such as dysentery; disease casualties far outnumbered deaths in action.)
Despite the reluctance of politicians in Britain and elsewhere to accept Snow’s findings, Snow was not working on cholera alone. 1849 also saw the publication of Thomas Shapter’s study of the 1832 outbreak in Exeter, a pioneering piece of work that inspired Snow during the 1854 epidemic. William Budd and others published their findings on microscopic bodies in cholera excreta, contributing to the emerging discipline of microbial etiology. In 1851–2, the First International Sanitary Conference took place in Paris, which focussed on cholera. More conferences were to follow, and international cooperation in the field of public health began in fits and starts (wars and diplomatic spats permitting). In 1854, the cholera bacillus was first observed by the Italian scientist Filippo Pacini (1812–83) although, like Snow, Pacini was faced with peers who believed in the miasma theory of disease, and his work did not achieve recognition straight away.
Meanwhile, cholera was not idle. Two further pandemics followed. The fourth (c.1863–79) was the most widespread yet, reaching Europe, Africa and the Americas. It was particularly bad in the Near East, where 30,000 pilgrims died from cholera in Mecca. 90,000 died in Russia.330 But the pandemic marked another turning point in the battle against the disease: New York City authorities acted on John Snow’s findings and supplied clean drinking water and mounted a disinfecting campaign; the result was a significant drop in cholera deaths. The fifth pandemic (1881–96), however, saw major breakthroughs that would change humanity’s relationship to cholera forever.
Receiving news that pilgrims returning from Mecca had introduced cholera into Alexandria in 1883 – 5,000 were dying each week – the powers that be in Europe feared another epidemic reaching them. Britain, France and Germany dispatched teams in a competitive attempt to try and find the cause, and cure, of cholera, before it was too late.
However, the British had a vested interest in keeping the Suez Canal open. By 1880, four-fifths of the tonnage passing through the Suez Canal was British. Journey time to India was halved. While this brought economic advantages, it also meant that diseases could travel to Europe in half the time. The British decided to deny cholera was an infectious disease – i.e. deny germ theory – and instead espouse miasma and tainted soil theory. This would protect British financial interests, and also India. And so the British team comprised men who would find evidence in favour of the miasma and tainted soil theory. As medical historian John Waller noted, ‘the government panel that appointed the British medical team was careful to avoid including anyone already sympathetic to the germ theory of cholera. The team selected also lacked experts in microscopy, so that in Egypt it carried out totally inadequate microscopical studies of water supplies and made no attempt to isolate specific microbes.’ The British team decided that cholera was due to unusual weather patterns reactivating cholera poisons that were dormant in the soil of Egypt. Therefore, it did not come from India, was not a microbial disease and Britain had every right to continue trading with India (or exploiting it, depending on your point of view). The head of the British team, Dr Guyer Hunter, was honoured with a KCMG. It was, as Waller notes, ‘a travesty of investigative science’.331
The French behaved more honourably. Louis Pasteur helped organise the expedition, although he remained behind in Paris and did not participate in field work. The team was led by key Pasteur collaborator Émile Roux (1853–1933). The French team struggled to find bodies fit to dissect, as the epidemic was on the wane by the time they arrived in Egypt. Things went from bad to worse when one of the team, Louis Thuillier (who also worked on anthrax vaccines), contracted cholera and died. The French went home. The German team, led by the epidemiologist Robert Koch (1843–1910), had the good grace to attend Thuillier’s funeral.
The Germans then got on with the business of performing autopsies on the bodies of some of the pilgrims. Koch was convinced germs, not miasmas or tainted soil, caused cholera, and his team’s results were encouraging: in the intestines of the victims they found a bacillus, the comma-shaped Vibrio cholerae. But Koch didn’t have enough evidence to suggest that V. cholerae was the cause of cholera. The following year, Koch and his team were in Calcutta when cholera flared up there, and they found the bacillus again, this time in tanks drinking water was drawn from, and also in victim’s stools. The discovery of V. cholerae seemed to support John Snow’s theory that cholera was a water-borne disease. It was also a major advance for germ theory, as the bacillus now appeared to be present wherever there was an outbreak of cholera. The eminent British medical journal, The Lancet, fumed that ‘It seems probable that the discovery of the true nature of the virus of cholera will be effected in England’s greatest dependency, but not by an Englishman.’332
The Lancet’s indignation was slightly premature, as Koch’s discoveries were still not conclusive proof, but nonetheless, it was a major blow, not only to British pride but also to miasma theory which, even at this late stage, still had adherents. Perhaps the most colourful of them was the Bavarian chemist Max von Pettenkofer (1818–1901), who also believed that contaminated soil played a key role in the spread of cholera. He clashed frequently with Koch over the latter’s new-fangled germ theory. Despite this, Pettenkofer felt that contaminated water probably was involved in the spread of cholera, and campaigned for clean water supplies. One of his great achievements in this area was building a modern sewerage system for Munich, the state capital of Bavaria. At the height of his dispute with Koch over the cause of cholera, Pettenkofer went to almost lunatic extremes to prove that germs did not cause cholera: he drank a glass of water containing the cholera bacillus. Remarkably, he survived. This is thought to have been because V. cholerae can be killed by stomach acids before it gets a chance to take root in the wall of the gut. Pettenkofer must have been extremely acidic.
While such theatrics were going on, a Spanish doctor called Jaime Ferrán (1851–1929) produced a cholera vaccine. He tested it on himself before inoculating 30,000 people. Independently of Ferrán, Russian scientist (and would-be revolutionary) Waldemar Haffkine (1860–1930) developed a vaccine in Paris while working under Pasteur’s assistant Émile Roux. In an echo of Pettenkofer publicly drinking cholera laced water, Haffkine got Roux to inject him with cholera to prove that the experimental vaccine worked. This was nothing if not an age of heroic derring-do in medicine. Haffkine survived after a spell of what John Waller described as ‘only moderate discomfort.’333 When an epidemic of cholera broke out in India in
1894, Haffkine knew this was an ideal opportunity to test his vaccine. Lord Dufferin, the former Viceroy of India, enabled Haffkine to begin vaccinating, perhaps hoping to save some British embarrassment after The Lancet’s fear that the cure for cholera would be found, but not by an Englishman. Perhaps Dufferin was hoping that, if Haffkine succeeded, a certain amount of face could be saved. As it turned out, Dufferin’s hunch was right. Haffkine worked in a suburb of Calcutta, vaccinating 116 out of 200 residents. All of them survived. He then moved on to work in Assam, where 20,000 people were vaccinated. Of those Haffkine had treated, the death rate fell to only two per cent, compared with 22 to 45 per cent for the unvaccinated.
When Robert Koch heard about this, he said ‘the demonstration is complete’.334 The cure for cholera had been found, proving right Koch’s 1883 discovery that the comma-shaped bacillus, Vibrio cholerae, was indeed the causative agent of cholera.
The Age of Breakthroughs
The last major European outbreak of cholera occurred in Hamburg in 1892, a city whose port had played a prominent role in spreading the disease during the second pandemic. But the sixty years between the two outbreaks had seen a paradigm shift of almost unimaginable proportions when it came to the understanding – and treatment – of disease. What had started with virtually mediaeval responses – the day of penance in Britain and Ireland, the Paris mob lynching anyone thought to be spreading cholera through ‘powders’ – had ended with modern: the disease had been shown to be caused by the bacillus V. cholerae, spread by water.
The medical, political and social effects of cholera were immense. The likes of Chadwick, Shattuck and Virchow had made an indelible mark on public health, whose development would contribute to a significant drop in disease in the developed world as the nineteenth century turned into the twentieth. In identifying the bacillus, the new sciences of epidemiology and bacteriology had played decisive roles, aided by developments in laboratory technology such as better microscopes, the introduction of solid substances in culture media and the use of industrial dyes to better identify microbes.