Infectious and Epidemic Disease in History

Department of History
University of California, Irvine
 Instructor:    Dr. Barbara J. Becker

Lecture 15.  Cholera.

Cholera's clinical features:
  • diarrhea
    • early stages:  fecal and malodorous
    • later stages:  "rice water stool"
    • painless, non-straining, and often involuntary
  • vomiting (in early stages)
  • dehydration (massive diarrhea can remove more than 20% of victim's body weight in a single day!)
    • sunken eyes and cheeks
    • slow "pinch response"
    • rapid and weak or missing pulse

Dehydrated cholera victim
  • death
    • caused by dehydration
    • can occur in 12 hours or less
    • can be prevented by aggressive rehydration

Cholera was unknown in Europe until the late 1820s

Its home was India--and remained confined there until Europeans, particularly the British, increased their routine contact with the subcontinent.

Vasco da Gama (1460-1524) reaches Calicut.
Portuguese establish trading ports along India's western coast.
British East India Company is formed.
British establish trading posts and forts in Bombay, Madras, and Calcutta.

French establish trading site in Pondicherry (India's southeast coast).
Dutch establish trading sites in Java and Spice Islands.

Death of Emperor Aurangzeb ends period of strong Mogul rule.
  • Persians raid north India
  • Sikhs found their own kingdom
  • Maratha tribesmen conquer central and western India
British East India Company competes with other European traders for control.
  • develops great political power 
  • obtains right to collect taxes
  • turns Indian princes against each other
  • wages wars against princes who refuse to give in peacefully to its rule
British East India Company becomes leading power in India.
First Cholera Pandemic (1817-1823)
Marquess of Hastings launches military campaign against the Maratha
  • loses 3,000 of his 10,000 troops to disease including cholera
Second Cholera Pandemic (1826-1837)
Trade fairs in major cities help cholera spread from India to Afghanistan to Persia to Russia.
Feb 1831
Russian troops introduce cholera into Poland.
Oct 1831
Cholera reaches England by ship from Hamburg.
Apr 1832
Cholera reaches Paris.
Jun 1832
Irish immigrants carry cholera to Quebec.
Cholera arrives in the US.
Jul 1832
Cholera reaches Illinois and New Orleans.
Cholera reaches the Pacific coast and enters Mexico
Third Cholera Pandemic (1841-1859)
Cholera reaches England and crosses the Atlantic to Canada and the US (via New York and New Orleans).
Cholera travels with 'Forty-niners and other pioneers to the Pacific coast and into Mexico.

Infant victim of 1849 Cincinnati cholera outbreak:
Samuel Charles Stowe, sixth child of Harriet Beecher Stowe

Cholera reaches the East Indies, China, Japan, Korea, and North Africa
Aug 1854
Outbreak in London neighborhood near Golden Square:  over 500 deaths in ten days.  Attracts the attention of physician, John Snow.
Cholera hits Central America
Fourth Cholera Pandemic (1863-1875)
geographically, the most widespread pandemic
Fifth Cholera Pandemic (1881-1896)

Robert Koch (third from the right) on a cholera research expedition in Egypt in 1884, one year after he identified V. cholerae, the microbe responsible for cholera.

Sixth Cholera Pandemic (1899-1923)
no impact on western Europe; didn't reach Americas; mostly affected Asia
Seventh Cholera Pandemic (1961-)
new strain of V. cholerae--El Tor strain; first observed among Indonesian emigres to Egypt in 1905; emerges as pandemic in 1961
Eighth Cholera Pandemic (1991-)
new strain of V. cholerae--Bengal strain; first observed in Bangladesh and India in 1991

Miasma vs. Contagion:

  • If cholera is contagious, why do doctors and attendants not catch the disease at a higher rate than others?
  • If cholera is the result of miasma, why does its spread seem to follow along trade routes and military campaigns?
  • What are the special circumstances that make an outbreak occur in a particular place and affect only certain individuals?
  • How can future outbreaks be prevented?
Cholera in Paris


The topographical situation of France is so advantageous that there is little to fear in this country from cholera morbus or any other pestilential epidemic.

As for the plague's entering by way of our seaports, I find little probability of such an occurrence, particularly in the Atlantic ports, where sanitary measures have been so carefully observed that it would seem to me quite difficult for the disease to infiltrate our borders.  And in any event, the disease would quickly be confined to the ports and treated with such success by rational medicine, known to all French physicians, that there need be no fear of its spreading to the interior.

Throughout France, the felicitous application that has been made since the Revolution of 1789 of rules of hygiene and health measures has redounded to the benefit of the country's inhabitants.... 

By contrast, recall that, so far as we know, the disease has proved devastating only in fetid, marshy areas in certain parts of Asia Minor, Russia, and Poland....

Today in no other country of the globe have civilization, industry, and commerce achieved a higher degree of perfection [than in France] and in no country but England are the rules of hygiene more faithfully observed.  Cleanliness and above all sobriety, prophylactics against every sort of disease, are the leading traits of the French Citizenry...

Enlightenment has spread so widely through all classes of society that everyone is well aware of the precautions to be taken against the causes of disease:  We are blessed with a superb and healthy population....

What country, moreover, is richer than ours in enlightened physicians who contribute so powerfully to the maintenance of public health?

--Dominique Jean de Larrey (1831)
    surgeon and inspector of the army health service


Should poisoning, pestilence, and death be the watchwords of the government of France, the world's premier nation?

...The admirable people of Paris, who are so heroically confronting the cholera of poverty, which in eighteen months has tripled the death rolls--the people of Paris were not made to serve as fodder for the cholera of Asia and to die like slaves in pain and terror.

There is one true protection against cholera; it is to remain, in the presence of this new and ubiquitous enemy, courageous and invincible.

There is ... an important lesson to be learned in the midst of public calamity:  namely, that man is in part the author of his own destiny.  For in the external world man may not always be master, capable of preventing nature from encroaching in ways often destructive to his own work; but he is almost always capable of stopping, and energetically repelling, these invasions of evil, by means of a moral reaction that stems from within....

Paris--that center of civilization and progress, a city where such vast resources are sacrificed on the altar of public welfare--should have demonstrated the power of the social state by triumphing over the most terrible scourge to afflict the human race.

Instead, Paris has succumbed to this new invasion; the disease has proved more lethal here than elsewhere; and no quarter of this great city is nowadays so populous as its cemeteries.

What good, then, are all its hospitals, its doctors, its science, and its public administration?  Are all the resources of civilization worthless?  Is civilization incapable of compensating mankind for all the harm it has done through its laws, its institutions, its errors, and its injustices?

No:  the blame should not be laid at the door of the social state itself.  Instead, the finger of accusation should point at those who exploit the state and corrupt it, at those who see civilization merely as a more sophisticated servant of their luxury and pleasure, at those who view a great city as a factory in which all hands labor for their benefit and all space is arranged for their convenience.

The city is a city of palaces and hovels:  a few splendid quarters with colonnades and huge gardens closed to the man in work clothes and, in the center of this sumptuous enclosure, a sewer of narrow streets and dark, unhealthy buildings, as dank as dungeons, where those who toil come to catch their breath in fetid air....

So, an epidemic arrives, preceded by cries of terror from two continents, and finds its prey ready-made, its victims huddled together and weak.  It opens its charnel house in the artisans' district, whereupon the philanthrophists say that the public should take heart, for the scourge seems willing to claim as its victims only the ill-clad, ill-housed, and ill-fed, which is to say, the working people of Paris.

--Michel Chevalier (1832)
    economist and liberal theorist
Cholera in England
West-ham Union.
Notes to the Poor on CHOLERA

EXPERIENCE having proved that "CHOLERA" is not contagious, let no one fear to render assistance to his Neighbour, or any Fellow-Creature who may be attacked with it.

Keep the mind at rest, trusting in God, and "fear not the Pestilence though it walk in darkness, nor the Destruction that wasteth at noon-day."

"CHOLERA" in its early stages is easily curable.  When more advanced, is not only difficult to cure but almost defying the power of Medicine.

Preventive measures and prompt attention to the earliest symptoms are chiefly to be relied upon.

The Causes predisposing to "CHOLERA," and therefore to be avoided as much as possible, are--want of Cleanliness of Person,--Intemperance in the use of Spirits--of fermented Liquors--or of Tobacco,--Debauchery, or excess of any kind,--Irregular Habits,--excessive Fatigue,--Sitting in wet Clothes,--or indeed exposure either to wet--cold--damp--or sudden Chills.

The great preventive of "CHOLERA," is--Pure Air and Cleanliness.  Every House ought therefore to be kept perfectly clean and thoroughly ventilated.  Lime-washing is particularly recommended, and persons whose Work is out of doors should wear a flannel belt round the body, next to the skin.

The symptoms of "CHOLERA," which should act as a warning, are--Looseness of the Bowels or Diarrhoea--Nausea or Sickness--in which stage it is easily curable or preventible.  If neglected, the Blue Stage or "ASIATIC CHOLERA" comes on, in which little help is derivable from Medicine.

Let none therefore neglect the slightest signs of Looseness or Diarrhoea, or any other irregularity in the system, as there is a tendency, during the prevalence of "CHOLERA," for all Diseases to merge into this Complaint.

The Guardians are prepared to issue "CERTIFICATES" to the Poor generally, entitling them to Medical Relief gratuitously, should "CHOLERA" break out, or its symptoms prevail in the Neighbourhood.  They recommend such persons as cannot afford to pay for Medical attendance to apply forthwith to the Relieving Officer, who will lay the application before the Board.  It is important for the Poor to be put in possession of these "CERTIFICATES" before they are actually required.

By order of the Board,
29th September, 1848.
Edwin Chadwick (1800-1890)
  • pioneer in "sanitary awakening" in England
  • wrote Sanitary Condition of the Labouring Population of Great Britain (1842)
    • principal cause of disease is miasma
    • disease cannot be cured
    • must rely on prevention
    • government can and must remove the causes of disease
    • need for ceramic water pipes
    • need for straightline water and sewer networks
    • need for water-closets for private homes and public places
    • need to end practice of storing night-soil in cellars

Chadwick's sanitary sewer plan
John Snow (1813-1858)
  • anesthetist
  • wrote On the Mode of Communication of Cholera (1855)
    • cholera is contagious
    • humans become sick with cholera by ingesting "morbid matter" possessing a cellular structure and the capacity to reproduce its own kind
    • cholera can be prevented by purifying the water supply
Edmund Cooper, an engineer for the Metropolitan Commission of Sewers, also studied the outbreak of cholera in the vicinity of Broad Street.  His investigation was prompted by public fears that recent sewer line construction in the area had disturbed old plague pits thereby releasing harmful material into the air.  Some residents worried that the gully holes, through which sewer gases were vented to the surface, were especially dangerous sources of cholera.

Edmund Cooper's "spot map" showing cholera deaths in the Broad Street area.

On September 26, 1854, the Commission held a special public meeting to address these concerns.  According to The Times of London:  "Mr Cooper had prepared a plan which accompanied his report, and on the plan a distinguishing mark was affixed, showing the houses in which death had occurred."  Cooper's "plan" was the first so-called "spot" map made to show the geographical distribution of cholera deaths in the neighborhood.  In December, John Snow created a similar spot map to illustrate his own views on the cause of the severity of the outbreak in Golden Square.

John Snow's "spot map" showing cholera deaths in the Broad Street area.

After analyzing his map, Edmund Cooper drew the following conclusions:

  • houses near gully-holes had no greater number of deaths than those farther away
  • sewers in the area where most deaths were clustered were in reasonable condition.
  • drains of affected houses were in generally bad condition
    • many cesspools
    • deteriorating brickwork
    • most had not taken advantage of opportunity to connect drains to recently constructed sewers
  • Broad Street served by two non-connecting sewers:  one old and one new
    • deaths appeared to be equally divided between areas served by the two different sewers
  • few deaths occurred near the old plague-pit
    • sewers that drain the plague-pit area flow northward where there had been few, if any, cases of cholera

Cholera epidemics struck Europe in a period of economic growth, material progress and scientific achievement.

Affected the healthy as well as old and infirm.

TB killed more people, but cholera killed swiftly and horribly.

Was the psychological and social impact of cholera powerful enough to override the fact that--in terms of the absolute numbers of people affected--its impact was relatively minor compared to that of tuberculosis or various forms of infant mortality?
Traveled at the speed of moving people.
What role did advances in transportation technology play in the spread of cholera?
Did not strike rich and poor in equal measure.
Did cholera epidemics play a part in fomenting the political upheavals of the nineteenth century?  Who or what did people blame?  How was state policy affected?
Cholera Mortality as a Function of Elevation*
by Dr. William Farr (1807-1883)

Elevation above
Sea Level
Cholera Deaths per 10,000

*Based on data gathered during the 1848-1849 epidemic in London

Cholera in Germany

Hamburg, Germany is situated on the Elbe River where it enters the Baltic Sea.  In 1892, it was a self-governing city-state embedded in the Reich of the new kaiser, Wilhelm II, and one of the principal points of departure for millions of Europeans on their way to new lives in the New World.

Hamburg provided few public services to its citizens, relying instead on private investors to supply what was needed and people were willing to purchase.  Hamburg's water came directly from the Elbe River.  By that time, water filtration was recognized as an effective deterrent to the spread of cholera.  Reich-ruled cities like Berlin had long since taken steps to make filtered water available to their residents.  Even Altona, a small town immediately downstream from Hamburg, and which also took its water from the Elbe, had its own public filtered water system.  Unfortunately, the high cost of installing and maintaining such a system had delayed Hamburg's plans for twenty years.

In August 1892, a trainload of hopeful emigrés arrived in Hamburg.  Before they could depart for America, the travelers were held in quarantine in a special facility near the dock.

The passengers were subjected to medical inspection.

Some of the new arrivals were infected with cholera.

That year Hamburg paid a high price for its lack of a water filtration system.
Cholera cases
Hamburg    580,000    19,891      34
Altona    143,000        572        3.9

Mass grave for Hamburg's cholera victims, 1892

Go to:
  • On the Mode of Communication of Cholera (1855), by John Snow, M.D. (1813-1858);
  • "Observations on the Filth of the Thames," a letter to the Times of London (July 7, 1855) by Professor Michael Faraday (1791-1867);
  • "Monster Soup commonly called Thames Water, being a correct representation of that precious stuff doled out to us..." (ca. 1828) by William Heath (1795-1840);
  • News articles from the Chicago Tribune:
    • "They Deal in Death...," August 20, 1893;
    • "Caused by Microbes...," November 23, 1893; and
Weekly Readings
Lecture Notes