Cholera Notes

Cholera: Curse of Poverty and Early Industrial Cities

  • 19th-century cholera pandemics originated from India.
  • Cholera in Yemen (2017): Over 2.5 million cases and 4,000 deaths by the end of 2021 due to civil war.
  • IDs: The Hippocratic Epidemics, quorum sensing, Hecker’s The Black Death, Edwin Chadwick, contingent contagionism, William Farr

The Cholera Vibrio

  • Over 200 kinds, only a few cause disease.
  • Bacterial strains within serogroups O1 (‘classical’) and O139 (‘El Tor’) are associated with human disease.
  • Vibrio exist independently or in copepods (plankton), making eradication impossible.
  • Vibrio favors estuaries (mix of salt and fresh water) and may remain dormant until conditions are favorable.
  • Transmission: oral-fecal in the digestive system.
  • The vibrio uses its flagellum to move into the intestinal lining.
  • Cholera vibrio have a tail (flagellum) that enables them to move through water and are thus motile.

Quorum Sensing

  • Cholera bacteria secrete molecules (auto-inducers) sensed by other bacteria.
  • Sufficient molecules lead bacteria to act as a multicellular organism.
  • Used to ‘turn on’ group behaviors (e.g., bioluminescence, virulence).
  • Researchers are exploiting quorum sensing to develop antibiotics.
  • At low cell density, cholera vibrio turns on genes influencing virulence, causing violent diarrhea.
  • At high cell density, the vibrio turns off genes causing illness and turns on genes to detach from the intestinal lining for transmission to the next host.
  • Researchers are exploring using cholera’s auto-inducers to neutralize its effects.

Cholera Symptoms

  • Main symptom: Profound dehydration from vomiting and diarrhea, including “rice-water stools.”
  • Dehydration causes painful cramps in the abdomen and lungs.
  • Eyes become sunken, and skin can take on a bluish cast.
  • Death can occur within 24 hours of symptoms.

Historical Context

  • Cholera-like diseases noted since antiquity (Hippocratics, Sanskrit texts).
  • Traditional cholera spirits Olavedi and Olabibi in India.
  • Cholera worsened after 1817, possibly due to “distempered” weather after the Tambora eruption.
  • 1832: Railway and steamship pandemic.
  • Spread: Russia (fall 1830), Paris (spring 1831), Britain (fall 1831), The Americas (summer 1832) via railway lines and the Great Lakes.

Cholera in Canada

  • Montreal Gazette reported early cases on September 6, 1834.
  • 1832: Grosse Ile quarantine station created to hinder cholera spread.
  • Medical examiner screened ship occupants.
  • Quarantine measures were challenged by social and biological factors.
  • Incentive to conceal sickness; asymptomatic individuals and delayed symptoms.

The Conundrum of Cholera Quarantine

  • Cholera can spread violently or silently.
  • Symptoms appear 2-3 days after exposure.
  • Asymptomatic people and the recovered shed vibrios in stool for days.
  • Outbreaks are nearly impossible to stop without complete quarantine.
  • People with blood type O are more likely to experience severe symptoms.
  • Children aged about a year are especially vulnerable.
  • Swift rehydration treatment dramatically reduces severity/mortality.
  • Hoffman Island: an artificial island built near Staten Island, New York as a quarantine station (circa 1892).

Social and Class Tensions

  • Cholera aggravated social/class tensions.
  • Unrest among peasants and city dwellers.
  • Riot in Paris, April 1831.
  • Prussian “cordon sanitaire” of eastern border (60,000 troops).
  • Suspicion of elites: poison or medical collusion.
  • Religious responses emphasized personal habits/morality.
  • Immoderate living (drinking, dirty habits, overcrowding) deemed both unhealthy and immoral.
  • Less emphasis on divine action, more on the consequences of behavior deemed immoral.

Protests and Opposition

  • Cholera measures sparked protests for years.
  • In France (1832), protests merged with opposition to Louis-Napoleon Bonaparte.
  • In England (1832), riots targeted the medical profession and hospitals.
  • In New York (1858), riots targeted quarantine facilities and immigrants.

Cholera and the Black Death

  • J.F.C. Hecker’s book, The Black Death in the fourteenth century, according to the sources, written for doctors and educated non- doctors.
  • The idea of a Black Death in the Middle Ages gained traction in response to cholera in the 19th century!

Metaphorical Representations

  • “Death as a strangler—cholera’s first entrance into a masquerade ball in Paris, 1831” (A. Rethel, 1847).
  • Edgar Allan Poe, “Masque of the Red Death,” 1842

Industrial Cities: London and Manchester

  • Hazardous labor for adults and children.
  • Cloth: dyes, tanning chemicals, cotton fibers.
  • Smoke/fog, furnaces, mining and coal dust.
  • Contaminated water: old sewer pipes only draining from the surface.
  • Cess pools and pits emptied by “night soil men.”
  • Running water a few hours a day for some.
  • “Water closets” from the 1820s that emptied into the Thames.
  • Coexistence of humans and thousands of horses, chickens, stray dogs and cats, rats…

The Great Stink in the Thames

  • The Thames was notorious for its dirty water even decades before the “great stink.”
  • Sanitarian reformers considered “filth” to be the cause of disease.
  • The idea carried a moral overtone associated with lower-class people and less influential ethnic communities (e.g., the Irish).
  • The “great stink” during the hot summer of 1858 made the Thames unbearable and highlighted the harmful effects of contaminated water.

Nuanced Conceptions of Disease

  • Experts asked: “What are the sources of disease” rather than seeking isolated “causes.”
  • The older notion of humoral balance persisted in the concept of an individual’s ‘constitution.’
  • Belief in an interplay between the human body and the outer world.
  • Construction of various “exciting causes” that could trigger bodily responses/manifestations.
  • Miasmas penetrate/are inhaled.
  • Interaction of “seed” and “soil” both inside and outside the body.
  • Notion of predisposition that is either inherited or arising from one’s regimen.
  • Chemical models for processes that trigger disease: “fermentation” and/or “putrefaction” (like yeast).
  • Chemistry unified with concepts linked to ancient writer Galen.

Sanitarians and Social Reformers

  • Efforts to quantify: statistics for poverty, living conditions.
  • Efforts to map: identifying areas susceptible to disease, links to “filth.”
  • Efforts to standardize: ensuring investigators described the same thing.
  • Efforts to theorize: establishing causal relationships between disease, poverty, and living conditions.

Dr. Robert Baker (Leeds, 1833)

  • Observed that streets with the most severe cholera had the most imperfect drainage.
  • Advocated for a general and efficient system of drainage, sewerage, and paving.
  • Enforcement of better regulations for street cleanliness.
  • Edwin Chadwick’s Report on the Sanitary Conditions of the Laboring Population of Great Britain (1842) included a map indicating cholera incidence in Leeds.

William Budd (Bristol, 1842)

  • Paris-trained physician.
  • Aware of the insanitary quality of water.
  • In 1845, as a director of Bristol Waterworks, asked for water sources to be moved beyond the reach of sewage.
  • Distinguished typhoid and typhus, which William Wood Gerhard had done in 1836.
  • Bristol doctors conducted microscope examinations of water in the 1840s (possibly misled by non-microbial particles).

Influence of the Sanitarians (1830s-1910s)

  • Viewed disease through contaminating environments.
  • Believed in social reforms and the power of hygiene.
  • Medicine and health reform assumed health produced benefits for society.
  • The need to steer the poorer classes toward safer, more productive lives.
  • Highlighted the role of data (statistics) as a tool to shape health policy.
  • Believed other societies (under Western control) could be brought into modern sanitary health regimes.
  • British officials in India pointed to the role of climate in sapping social vitality and causing social differences.

William Farr

  • Trained as apothecary; worked at London’s General Register Office (GRO) after 1838.
  • Conducted mortality analyses and attempted to standardize disease names.
  • Focused on health policy as an adjunct to poor relief.
  • Edwin Chadwick: illness reduces productivity.
  • Relied on maps and statistics to justify social policy.
  • 1848: Parliament created a short-lived General Board of Health.
  • Growing influence of local health boards.

Contingent Contagion

  • Leading theory of the 1840s.
  • In 1839, William Farr coined the term “zymotic,” from the Greek term zumoûn (to ferment).
  • Farr thought cholera had a catalyst that sparked disease under the wrong conditions.
  • Piles of filth and noxious trades created putrid vapors.
  • No evidence that cholera spread by direct transmission as smallpox was known to do.
  • People who tended to the sick did not fall ill.
  • Some other diseases seemingly were contagious only under certain conditions.
  • Researchers expended tremendous energy considering factors contributing to increased incidence of disease.

William Farr's Statistical Study

  • Report on the mortality of cholera in England, 1848-49 (1852).
  • Plotted deaths from cholera and diarrhea against weather readings (barometric pressure, wind, rain, temperature).

Farr's Conclusions on Elevation

  • Intrigued by the link between elevation and cholera incidence.
  • Data suggested towns at lower elevations had higher cholera incidence, and lower neighborhoods within a town had higher cholera incidence.
  • In 1850, cholera remained a puzzling and frightening disease.