The Transformation of the World (43 page)

Unlike dysentery, typhoid, or malaria, cholera is an itinerant disease; it travels from one continent to another and through village after village, it is borne on ships and in caravans. Like the plague, it came from Asia and was often described by people at the time as “Asiatic cholera.” It therefore conjured up old fears of an invasion from the East, an Oriental menace. Its symptomatology underlined its horrifying nature: it appeared suddenly and could theoretically strike anyone, leading with plague-like probability (more than 50 percent of cases) to death in a time that might be as short as a few hours. Unlike smallpox, which causes a high fever, cholera is always described as a “cold” illness; unlike tuberculosis or “consumption,” it is ill suited to any romanticism. Patients neither become delirious nor slip into a coma; they remain fully aware of what is happening to them. Diarrhea, vomiting, a bluing of the face and limbs: the symptoms resemble those of acute arsenic poisoning. Cholera, says the medical historian Christopher Hamlin, “was not a disease that a person lived with.”
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The distribution of cholera can be clearly plotted.
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European visitors to India drew a picture of the disease as long ago as the early sixteenth century. In 1814 it became more common in several parts of the country, and from 1817 there was a spectacular rise in the number of reported deaths in Bengal. With a speed unparalleled in people's experience, it then left the geographical confines of South Asia to become a global phenomenon. Medical historians identify a number of pandemics: six between 1817 and 1923, and a seventh after 1961. Their abrupt end is striking in each case. Cholera vanished as suddenly as it had appeared, and it might be another half-generation before it became visible again. In 1819 it arrived in Ceylon, and from there much-traveled shipping routes carried it west to Mauritius and East Africa and east to Southeast Asia and China. In 1820 it struck Siam and Batavia, and shortly afterward, moving simultaneously by sea via the Philippines and by land via Burma, it reached mainland China; by the following year it had moved two thousand kilometers north to Beijing. In 1821 it marched to Baghdad with an Iranian army and had already reached Zanzibar off the East African coast. In 1823, cases were reported in Syria, Egypt, and the shores of the Caspian Sea. Siberia was infected from China. It reached Orenburg in 1829, Kharkiv (Ukraine) and Moscow in September 1830, Warsaw and Riga in spring 1831.
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Summer 1831 saw it reach Istanbul, Vienna, and Berlin; and in October it appeared in Hamburg, from which it spread to England and four months later to Edinburgh. In June 1832 it leaped across the Atlantic, probably in an immigrant ship from Ireland to Quebec, and by the twenty-third of the month it was in New York. In spring 1833 Havana lost 12 percent of its population. In Mexico City 15,000 people died in the space of a few weeks.

Later waves gave fresh vigor to local epidemics and added new localities to the list. Aggressive though this first wave certainly was, its devastating impact was later exceeded on several occasions. The third cholera pandemic (1841–62) raged during the Opium War in China, where British troops carried it from Bengal. In Paris, where the first attack occurred in 1832, as many as 19,000 people lost their lives in 1849. At the same time (1848–49) a million died of the disease in the Tsarist Empire.
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Further outbreaks, each one weaker than the last, followed in Paris in 1854, 1865–66, 1873, 1884, and 1892. After 1910 France was free of cholera.
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London had no more instances after 1866—doubtless because of the exemplary measures taken to improve sanitation. New York too escaped the epidemic of 1866 thanks to sensible preventive action, while other parts of the United States were severely affected. The last time that cholera invaded the country was in 1876.
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In the Crimean War (especially during the winter of 1854–55), the ravages of cholera among unprotected troops living in catastrophic hygienic conditions were the main impetus that led reformers such as Florence Nightingale—not only a ministering nurse but one of the great political and administrative talents of her age
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—to call for radical changes in army health policy. Of the 155,000 British, French, Sardinian, and Ottoman soldiers who perished in the war, more than 95,000 succumbed to cholera and other diseases. In 1850 Mexico again suffered terribly, as did East Africa from 1865 to 1871; there were particularly severe outbreaks in Japan in 1861 and in China in 1862.
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In Munich, an ill-famed hotbed of disease, the epidemic of 1854–55 was worse than that of 1836–37, and another major visitation would follow in 1873–74.
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In Vienna cholera claimed nearly 3,000 lives during the world's fair of summer 1873. Hamburg was to some extent spared by the early pandemics, but in the 1892–93 outbreak (which was more severe than anywhere else in western Europe) more of its citizens died than in all previous ones combined. Since this happened at a time when statistical techniques had already made great advances, the records make it possible to analyze its social impact in greater detail than in the case of any other late-nineteenth-century public health crisis.
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The Philippines suffered epidemics in 1882 and 1888; in 1902–4 (when vegetables from Hong Kong and Canton probably imported the bacillus) it saw as many as 200,000 deaths from cholera in a population weakened by the American war of conquest.
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In Naples, three decades after the outbreak of 1884, cholera arrived again in 1910 from Russia (where it had claimed 101,000 lives), and US officials kept a close eye on the large numbers of Italian emigrants who were arriving at the time. Uniquely in the European history of the disease, the Italian authorities (under pressure from Neapolitan shipping interests) made a major effort to cover it up.
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The total number of people who died from cholera cannot be even approximately calculated. In India, probably the most seriously affected region, a figure of 15 million has been suggested for the period from 1817 to 1865 (when reasonably useful statistics began), with a further 23 million for 1865 through 1947.
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The suddenness of a cholera outbreak, which in one day can infect thousands of people in a large city by means of contaminated water, added to the drama. In 1831–32, and again in 1872–73, Hungary was hit harder than almost any other European country; its mortality rate in the 1870s was 4 percent higher than in the decades before and after. More generally, deaths from the disease varied from an upper limit of 6.6 per thousand in London to more than 40 per thousand in Stockholm or Saint Petersburg and 74 per thousand in Montreal (in 1832).
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The great pandemic of 1830–32, in which Georg Wilhelm Friedrich Hegel lost his life, made a particularly deep impression on people's minds in Europe. The speed with which it spread from Asia, suggestive of a Mongol-style microbial invasion, and the helplessness of its victims led to a veritable demonization of the “new plague.” Among the rich it fueled fears of the lower classes as carriers of death, while among the poor it aroused fears that the authorities were poisoning them to solve the problem of unemployment. The “primitive Orient,” to which the “civilized world” had felt so superior for decades, seemed to be providing proof of its continuing subversive power.
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In Britain, France, and Germany, medical people tried to prepare for the future after the first disturbing reports came in from Russia, at a time when nothing was known about the likely extent or conduits of the disease or the efficacy of any countermeasures. The most precise descriptions of cholera came from British doctors in India, but these had received little or no attention in continental Europe.

Many sources tell of the first appearance of cholera in France and its social impact on the capital. The first cases, on 14 March 1832, afflicted doctors who had recently returned from Poland; cholera, unlike the plague, did not enter via Mediterranean ports but through the Rhineland or across the Channel. There were ninety deaths in March, but already 12,733 in April. Public places emptied, as anyone able to flee the city lost no time in doing so—a perennial type of response (the viceroy of Egypt in 1848 fled as far as Istanbul).
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The problem of corpse disposal was almost insoluble. Rumors, reminiscent of a previous age, spread about the causes of the epidemic.
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Revolts broke out, claiming at least 140 lives. On October 1 it was established that the outbreak had come to an end. As in all epidemics, the lower classes were hit disproportionately hard. The first waves of cholera rolled over societies that, in some cases, were passing through a stormy period of their political history. France had just experienced the Revolution of 1830 and had not yet adjusted to the new routines of the July Monarchy; the newly “emancipated” bourgeoisie was seeking fresh tasks for the state apparatus it had taken under its control. Cholera thus became a test for new forms of state regulation of civil life.
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Cholera appeared in India in 1817, at a point when the British had militarily defeated their strongest rival in the region, the Maratha Federation, and were moving to consolidate their own rule; the recent troop movements connected with this contributed to the spread of the bacillus. Moreover, India had just been opened up for the first time to Protestant missionaries. A link between
conquest and epidemic therefore suggested itself to ordinary Indians: there was a widespread view that the British, in violating Hindu taboos, had called down the wrath of the gods. So, in their different ways, both British officials and Indian peasants saw cholera as more than a health crisis but as a danger to “order” in general.
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All through the century, the British authorities adopted a laissez-faire attitude to the disease. The kind of massive health measures taken in the 1890s to combat the plague never applied to cholera; there was scarcely any quarantine, isolation, or even a slight tightening of controls on Hindu pilgrim flows. The events of 1865 in Mecca, when pilgrims from Java introduced cholera and triggered a global domino effect that began in Egyptian ports, had confirmed that pilgrimages could be a factor in the spread of the disease.
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So long as the nature of cholera was unexplained, doing nothing could seem as good as any other response. A doctrinaire liberalism and the penchant of the colonial state for cheap solutions thus bolstered the dominant medical opinion in both British India and London: that expensive health measures were not warranted, because there was no proof that cholera was infectious.

In continental Europe the main reflexes were those associated with earlier battles against the plague, so that sealing off affected areas seemed to be the most promising course of action. Russia, Austria, and Prussia established
cordons sanitaires
around themselves: the Tsarist Empire in Kazan against Asia, Prussia on the Polish frontier against everywhere to the east of it. Prussia alone deployed some 60,000 soldiers along a line of 200 kilometers, subjecting travelers to a rigorous quarantine and new cleansing measures, and even washing banknotes or fumigating letters they had on their person.
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Here, too, there were medical authorities and lobbies that represented various theories concerning the transmission of cholera—by air, water, or direct contact. States such as Pettenkofer's Bavaria that did not share such views did not impose
cordons
or quarantines either. The effectiveness of such measures was, of course, called strongly into question by the almost unstoppable dynamic of the various outbreaks. Indeed, one wonders whether the ritual incantations to ward off evil spirits, which the king of Siam ordered to be chanted, were essentially less appropriate. Yet the whole of Europe, pulled this way and that by the competing theories, again gave itself over to a quarantine approach in the 1890s.
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Quarantines remained a feature of international travel during the great age of the steamship: ports reassured passengers and merchants when they built functioning, but not too irksome, quarantine facilities. The rise of Beirut as “gateway to the Levant,” for example, began in the 1830s with the opening of a modern sick bay and quarantine station.
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Countries unable or unwilling to halt the flow of immigrants faced special problems, but they had to adopt protective measures even if a strict quarantine had proved early on to be of little use.
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Smallpox, plague, cholera, and yellow fever are mobile diseases suited to globalization, enemies of human beings with truly military properties: they attack, conquer, then withdraw. Sometimes physical defenses such as quarantines and
barriers remain the last hope. The growth of world trade and shipping in the nineteenth century increased the speed of transmission; humans and animals, but also goods, could become infected and disseminate deadly pathogens.
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It should be added, however, that other, more localized epidemics also brought suffering and death.

In the nineteenth century the main one was typhoid or enteric fever, a good indicator of special historical problems. The classic description of this disease, which strikes an undernourished population living in conditions of “appalling misery,” has come down to us from Rudolf Virchow, who in February and March 1848 was sent by the Prussian Ministry of Religious, Educational and Medical Affairs to Upper Silesia and sketched a powerful social panorama of one of the poorest regions in central Europe.
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Industrialization and urbanization turned many large European cities into breeding grounds for typhoid. But it was also a soldier's disease, pointing to a failure to reform conditions in the army. It accompanied the Napoleonic armies, after they were infected by the waters of the Nile in 1798. It was especially grave during the Peninsular War in 1808, and even worse during the Russian campaign. In 1870–71 it was endemic in the Metz region during the Franco-Prussian War, and some of its worst ravages occurred in the Russian-Turkish war of 1877–78. At the turn of the century, a typhoid crisis could still bring the army medical service of any state to the brink of collapse.
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