History and Geography

Consideration of the historical literature under the rubric “cholera” requires appreciation of what dis­ease is being treated. Literature on cholera in west­ern Europe and the Americas that was written prior to about 1830 and that described an endemic or sporadic disease called “cholera” is excluded from the following account.

Antiquity

There have been conflicting opinions concerning the possible references to cholera in the early Hindu literature. James Annesley (1825) stated: “I have not been able to obtain any information from those acquainted with the writings of the Hindoos, favour­ing the inference that cholera has prevailed in former ages as a wide-spreading epidemic.” Robert Pollitzer (1959) makes only a brief and doubtful ref­erence to the matter. Jan Semmelink (1885), for­merly principal physician of the army of the Nether­lands East Indies, in the French translation and condensation of his much more heavily documented Dutch edition of the same year, reviewed available English, French, and German translations very criti­cally and rejected all references to possible early epidemic cholera in the Far East.

Sixteenth Through Eighteenth Century Reference has already been made tn the explorer Correia, who stated that in the spring of the year 1503, 20,000 men died in the army of the Sovereign of Calicut, some of a “disease, sudden-like, which struck with pain in the belly, so that a man did not last out eight hours time.” Correia also met cholera in an epidemic form in Goa in the spring of 1543, called by the natives moryx, where the mortality was so great that it was very difficult to bury all of the dead.

The Netherlander Jan Huygen van Linscoten de­scribed what he called mordexijn in Goa in 1584, as did the Frenchman Vincent Le Blanc also in Goa in 1585. Reports followed through the rest of the 1500s and 1600s, including that of the well-known Jacobus Bontius in the earlier 1600s, who extended his obser­vations to Batavia, now Indonesia. Notices of the disease continued to appear into the eighteenth cen­tury when they were joined by those of Englishmen. Thomas Percival in 1788 reported that a ship sur­geon from Chester was treating cholera morbus with radix Columbo in the East Indies during the 1750s, and provided a fair description of the disease. The Scotsman James Lind described cholera throughout the East Indies and in India in the 1760s as a “con­stant vomiting of a tough white pellucid phlegm, accompanied by a constant diarrhea, [which] was deemed the most mortal symptom.” He used the term mordechin.

Macnamara (1870) recorded that the “earliest ac­count of the occurrence of cholera in India, from the pen of an English physician (Dr. Paisley), is dated Madras, February 1774, and is to be found in Cur­tis’s Works on Diseases of India, published in Edin­burgh in 1807.” Although nothing further seems to be known of this Paisley, his letter forms a corner­stone in the history of the disease in British India. Annesley (1825), in an early English classic on chol­era, quotes the following passage: “Thus,” Paisley wrote from Madras, in 1774, “there can be no doubt that their (the troops’) situation contributed to the frequency and violence of this dangerous disease, which is, as you have observed, a true cholera morbus.” In 1781, it ravaged the troops in the dis­trict of Ganjam, requiring the admission to the hospi­tal on March 22 alone of no less than 500 men of a division of 5,000.

This outbreak is reported to have reached Cal­cutta. In April of 1783, “cholera burst out at Hurdwar, and in less than eight days is supposed to have cut off 20,000 pilgrims.” Fragmentary observa­tions continued to appear, some from travelers, de­scribing the following:

[D]isease broke out with terrible ferocity, and destroyed an enormous number of people. During the month of October, 1787, epidemic cholera committed terrible ravages at Arcot and Vellore. With regard to this outbreak, Mr. Da­vis, a member of the Madras Hospital Board, remarks: “I found in what was called the Epidemic Hospital, three different diseases, viz., patients labouring under cholera morbus; an inflammatory fever with universal cramps; and a spasmodic affection of the nervous system, distinct from cholera morbus. I understood, from the Regimental Surgeon, that the last disease had proved fatal to all who had been attacked with it, and that he had already lost twenty-seven men of the regiment in a few days. Five patients were then shown to me with scarce any circula­tion whatever to be discovered; with their eyes sunk within the orbits; jaws set, bodies cold, and extremities livid.”

Nineteenth Century: The Pandemics

Cholera, or cholera-like disease, continued to be ob­served during the rest of the eighteenth and into the nineteenth century. Then, in the year 1814, out­breaks of cholera occurred in a number of Indian provinces, including the crowded barracks of Fort William at Calcutta among recruits just arrived from England.

Macnamara, who evaluated all these many re­ports of the appearance of the disease, concluded that “we are,... I think justified in arriving at the conclusion that it was nothing new for cholera to spread over India in an epidemic form prior to 1817 and 1819.” At this point, something drastically “new” did occur, as cholera escaped the bounds of India and initiated the waves of pandemics that were to engulf the world.

Incomplete or even fragmentary though the evidence brought forward... often is, it leaves no room for doubt that cholera, present in India since ancient times, not only continued to exist but was apt to manifest itself periodi­cally in wide spread conflagrations.

Dissenting views do, however, exist, including those of Annesley (1825) who, writing within a de­cade of the 1817 outbreak, states “[t]hat we have no proof of the prevalence of cholera in India, as a wide- spreading epidemic in former times.” Again the skep­tical Semmelink devotes a whole work to the obser­vations of cholera in the East before 1817, providing detailed criticism of what must be essentially every report in the European literature. And again he is vehement in his judgment that the accounts refer to other than the epidemic cholera of 1817 and after, although his nosology is sometimes archaic and diffi­cult to follow. It has also been suggested in this age of genetic engineering that a genetic modification in the microbe was responsible for this supposed change in cholera’s nature.

The First Pandemic. In any event, in March 1817, a death from cholera took place in Fort William, but because it was a solitary case no notice was taken of it. By July, however, outbreaks occurred in several districts in the Province of Bengal. The first notice of this in the Proceedings of the Bengal Medical Board was a letter from Robert Tytler, civil surgeon of Jessore, dated August 23, 1817. He wrote:

An epidemic has broken out in the bazaar, the disorder commencing with pain or uneasiness in different parts of the body, presently succeeded by giddiness of the head, sickness, vomiting, griping in the belly, and frequent stools. The countenance exhibits much anxiety, the body becomes emaciated, the pulse rapidly sinks, and the pa­tient, if not speedily relieved with large doses of calomel, followed by one of opium,...

In July and the following months, Calcutta was af­fected; 25,000 of its inhabitants were under medical treatment for the disease of whom 4,000 died. Thus begins the modern history of Asiatic or epidemic cholera, although none of the documents immedi­ately surrounding the event make reference to the name “cholera,” until a letter dated September 16 specifically refers to “cholera morbus.”

Within 3 months the disease had spread through­out the Province of Bengal, and in November it reached the camp of the Marquis of Hastings in Bundelcund. During 1818, it moved over the greater part of India including Delhi and Bombay, with estimated attack rates of up to 7.5 percent of the exposed population. It continued to rage through 1819 and 1820, extending into Ceylon and Burma, Siam, Malacca and Singapore, and the Phil­ippines. By 1821, it had invaded Java, Batavia, and China to the east and Persia to the west, reaching Baghdad with a besieging Persian army, and extend­ing from there to Aleppo. By 1823, it was in Egypt, Astrakhan, and the Caspian shores and throughout Syria along the shores of the Mediterranean. But it receded for a number of years, thereby terminating the First Pandemic.

The Second Pandemic. By 1824, cholera had re­treated to its endemic area in Bengal, where it re­mained active in the Ganges Delta through 1826. But in 1827, it spread out again in the so-called Second Pandemic into the Punjab, and by 1829 ex­tended through Persia to the shores of the Caspian Sea. In Orenburg in 1829 (August 26), it soon ex­panded north and west into Russia. By September of 1830, cholera was in Kharkov and Moscow, and be­gan spreading west into Bulgaria. During the winter of 1830-1, it persisted in the Russian army in Po­land, and then in the spring it invaded Warsaw and soon after, Riga. Meanwhile, cholera was also raging through Mecca and Turkey, reaching Constantino­ple and Alexandria by July and August. On August 3, it entered Berlin and Vienna, and reached Ham­burg by the beginning of October.

The opening of the year 1832 was soon followed by a reawakening of cholera. In February, it appeared in Newcastle, Edinburgh, and London, as well as places in between. Next it reached France, bursting on Paris on March 24, and soon engulfing all dis­tricts of the city. Within 18 days no fewer than 7,000 persons were dead. Next, cholera hurdled the Atlan­tic Ocean to appear on June 8 in Quebec and on Jime 19 in Montreal. Presumably, it arrived with emi­grants on the brig “Carricks,” which left infected Dublin in April and lost 42 of its 173 passengers before reaching Quebec on June 3. On June 23, chol­era invaded the United States, appearing in New York on that date and in Philadelphia on July 5. From these ports of entry, it marched westward across both North American countries.

Entry into Spain, Portugal, and the Caribbean and Latin America was delayed until 1833, and into Italy until 1835. Havana lost 8,253 persons in a population of 65,000 between February 26 and April 20, 1833, and by August no less than 15,000 had perished in Mexico.

Yet by 1834, the disease was beginning to recede, and while it persisted in a number OfMediterranean and Central American areas for a few more years, it retreated once again in 1837 to its Indian homeland. This pandemic has been described in detail, as it was the first modern experience with the disease for much of the world and because subsequent epidem­ics or pandemics were to follow much the same route. In addition, a great deal of popular and govern­mental response to subsequent appearances was based on experience gained during this pandemic.

The Third Pandemic. During the following decade, cholera continued to plague India, and it entered Afghanistan with British troops in 1839, and China in 1840 - again with troops from India - where it remained into 1841 and 1842. In 1844-5, it extended into Persia and Central Asia, reaching the Arabian coast as well as the Caspian and Black seas in 1846­7. Constantinople was attacked on October 24, 1847. In the spring of 1848, it broke out with renewed vigor, advancing as far as a line drawn through Arabia, Poland, and Sweden, reaching Berlin in July and Hamburg and Holland by September, and then London and Edinburgh in short order. After a short period of comparative rest, it renewed its activity in the spring, reaching Paris in March and by now was covering much the same ground of the earlier epi­demic. Meanwhile, in December 1848 cholera had crossed the Atlantic to invade New York and New Orleans, and spread rapidly across the continent from these centers. In 1850, it reached California with the wagon trains as well as by ships from Pan­ama. In that year it was reported in North Africa, Europe, and both North and South Americas. In many of these regions, it continued through 1851 and 1852.

There is some debate over the dates of the second and third pandemics. Most accept the worldwide spread of cholera during the decades of the 1840s and 1850s as constituting the Third Pandemic. How­ever, Pollitzer (1959) and a few others date the Third Pandemic at 1852 or 1853, and place the Second Pandemic within the mid-1840s to 1851, in spite of the obvious lull from the mid-1830s to the mid- 18408, at least outside the Indian subcontinent. It is true that cholera was present in eastern Europe in 1852, either because of persistent infection in these areas (i.e., continuation of the earlier pandemic) or because of a fresh wave of infection starting in India in 1849 (Pollitzer 1959). But in either case, it seems fairly unlikely that what for all appearances seems to have been a pandemic would break at mid-point.

The year 1854 found cholera widely spread in Eu­rope, England, Greece, Turkey, and North and South America. It was one of the worst cholera years on record. It was during this pandemic that John Snow made his observations in London that in 1855 led to the publication of his critical, if not immediately appreciated, study on cholera transmission by con­taminated water. In 1855 and after, the disease died down in much of the West, but it continued in a few spots there as well as in much of the East.

The Fourth Pandemic Pollitzer dates the Fourth Pandemic from 1863; it was to last about 10 to 12 years. In 1865, Macnamara estimated that a third of 90,000 pilgrims at Mecca succumbed. As before, it reached Constantinople and spread around the Medi­terranean, reaching northern Europe in 1866 and 1867, and the United States and the Latin Americas in 1866. It raged over its old grounds until 1874.

The Fifth Pandemic. According to Pollitzer, the Fifth Pandemic began in 1881, and lasted until 1896. It was during this epidemic that the studies of Koch in Alexandria and Calcutta in 1883-4 led to the isolation and identification of the causative mi­crobe. In addition to Egypt, the epidemic was at first largely limited to the Mediterranean shores of Af­rica and Europe, although it later became wide­spread in Russia, and in Germany where it was marked by the explosive outbreak in Hamburg in 1892. Importation into New York in 1887 was ar­rested, but outbreaks did occur in Latin America. The disease was also widely prevalent in the Far East - in China and Japan.

The Sixth Pandemic. The Sixth Pandemic ran from 1899 through 1923. It followed much the pattern of the fifth - largely affecting India, the Near and Far East, Egypt, western Russia, and the Balkan Penin­sula. Sporadic outbreaks occurred in southern Eu­rope and Hungary in the West and China, Japan, Korea, and the Philippines in the East. But this time cholera did not reach the Western Hemisphere.

The Seventh Pandemic. The Seventh Pandemic dates from about 1961 to the mid-1970s and followed

much the pattern of the previous epidemic. It is particularly important in providing an opportunity for the significant advances in studies of cholera pathogenicity and therapy extensively described by W. E. Van Heyningen and John Seal (1983), studies carried out in Egypt, India, Bangladesh, and the Philippines by several U.S. teams.

This brief sketch can provide only the barest outline of the nineteenth-century history of this significant disease. Pollitzer’s numbering of the pandemics is utilized here for the later ones, although, as has been mentioned, historians of the disease have not always agreed on this numbering. In fact, it is sometimes not entirely clear why or when one pandemic is said to have terminated and another to have begun.

Historical Considerations of Etiology, Control and Prevention, and Treatment

In addition to the history of the pandemics them­selves, the history of several other aspects of the disease seems significant to the overall history of medicine. Among these are the discovery of the etiol­ogy of the disease, concepts of contagion, develop­ments in sanitation and public health institutions, and developments in therapy.

Earlier thoughts on the causes of cholera were embedded in notions of disease causation going back to Hippocrates: weather, seasons, geographic envi­ronment, bad air and miasmas, and dietary indiscre­tions. If an infecting agent was referred to at all, it was likely to indicate an “infection” by a poison or miasma.

By the middle of the nineteenth century, however, ideas of a microbial etiology were gaining ground with the writings of such individuals as F. G. Jakob Henle. In 1849, William Budd and two associates described microscopic bodies in cholera excreta and published their findings with illustrations. The French botanist Charles Robin reproduced these il­lustrations in 1853, denying their “vegetal nature.” These were seen by the Gennan botanist Ernst Hal- lier, who rejected Robin’s rejection and set out to grow microbes from cholera excreta using bacterio­logical techniques that could not have produced suc­cess. He published his findings in Die Cholera- Contagium in 1867.

T. R. Lewis tried to confirm Hallier’s work in Cal­cutta in 1870, and in failing, became somewhat of an anticontagionist. In the meantime, as already de­scribed, Pacini made his correct but at the time largely ignored observations of the actual V. cholerae in 1854. Thus it was left to the genius, persistence, and technical elegance of Koch in 1883 to isolate and identify the microbe and to introduce the modern phase of the understanding of the disease. It was not, however, until 1959 that the toxin produced by the microbe was discovered along with its role in disease causation.

The question of the “contagiousness” of cholera was a matter of heated debate throughout most of the nineteenth century. It can be generally observed that the Contagionists were viewed by contemporar­ies as archaic, conservative, and even antisocial, whereas the anticontagionists were seen as modern, bourgeois, mercantile, and socially responsible. Most of the debate focused on the question of quaran­tine which, of course, was anathema to mercantile interests, and the anticontagionists gained ground as the nineteenth century progressed. The demon­stration of Snow of the waterborne nature of cholera was slow to gain acceptance, but this development, coupled with the discovery by Koch of the infective nature of the disease, finally proved the “contagion” of the disease, providing, of course, that one allows for the intermediary role of infected excreta and water or food, and that some individuals can act as carriers but do not develop the disease.

Sanitation has always played a major role in the thinking and in the efforts of those aiming to under­stand and control the propagation of cholera. As a consequence, a large body of literature has been generated on the role and influences of cholera epi­demics on the development of public health policies, public health organizations, and the development of sanitation procedures and techniques.

The earlier history of the treatment of cholera has been thoroughly treated by Norman Howard-Jones (1972) and Michael Durey (1979). Most of the thera­peutics employed were representative of the practice of medicine generally in and before the nineteenth century. Emetics, purgatives, and bleeding seem in retrospect to have been worse than ineffective. Calomel and opium were the standard drugs admin­istered, beginning with British physicians in India. Castor and croton oils, antimony, mustard, bismuth, arsenic, camphor, and quinine were among other drugs administered. A red-hot iron to the heel was widely employed in India, to the spine in Paris. Wa­ter hot or cold orally, per rectum, or as baths was sometimes recommended.

The definitive treatment - intravenous fluid and salt replacement - was a long time in developing. As early as 1830, the German chemist R. Hermann dem­onstrated in Moscow that the change in the blood’s fluid balance was reflected in the contents of the cholera excreta. A German colleague on one occasion injected 6 ounces of water into the terminally ill pa­tients, a treatment that produced a quick, temporary return of the pulse, although death nonetheless oc­curred 2 hours later. In October 1831, the Berlin surgeon J. F. Dieffenback took the premature step of injecting several ounces of whole blood into three patients. They died 6 minutes, 2 hours, and 6 hours later, respectively, the first during violent convul­sions. In Great Britain in late 1831 and early 1832, W. B. O’Shaughnessy published papers suggesting the intravenous replacement of salt and water. These suggestions led Thomas Latta of Leith, Scotland, and two associates to try the treatment on patients. They reported that 5 of 15 patients survived. Other spo­radic attempts followed, with some but not convinc­ing success during the 1830s. Sporadic trials contin­ued through the century in Britain and France, and in Calcutta in the 1890s, but the treatment was not successful until Leonard Rogers perfected it in Cal­cutta in the early 1900s. There were a number of technical problems to be solved first, not the least being sterility. But with these difficulties resolved, the definitive treatment of cholera was established.

Reinhxird S. Speck