Epidemics in Western Society Since 1600

HIST 234 - Lecture 10 - Asiatic Cholera (II): Five Pandemics

Chapter 1. Asiatic Cholera as an Emerging Disease in the West [00:00:00]

Professor Frank Snowden: Good morning. We can continue with our subject of Asiatic cholera. And I thought we could perhaps frame that discussion by reminding you that in the 1990s the Nobel Prize winning microbiologist, Joseph Lederer, coined a term, “emerging diseases.” He used it to describe infectious diseases that are previously unknown, at least as sources of human infection, and emerge, as it were, for the first time to infect human beings. These are diseases — in our own day we can think of Ebola or Lyme’s disease, SARS, or of course, most importantly, HIV/AIDS.

Often the press — which seems, I would argue, to suffer chronically from historical amnesia — it often treats the appearance of new infections as something unprecedented, unnatural, that never happened before. But the reality is that Charles Darwin was correct. We live in the midst of a constantly evolving microbial world in which the microbes have an inherent advantage because of the frequency of their mutations, and the extremely brief length of a microbial generation, compared with a human one. So, new diseases have always been emerging and appearing. And Asiatic cholera is a good example of what we might — though let’s be mindful, it would be historically anachronistic — we might call it a great emerging disease of the nineteenth century.

There is a scholarly debate on whether cholera had long existed on the Indian subcontinent, and whether it went back for centuries or not. It clearly, by the early nineteenth century, had an endemic home on the Indian subcontinent, and particularly the area here in the delta of the Ganges and Brahmaputra Rivers. That’s that area. There are accounts of diseases in various writings that are suggestive of cholera well before the nineteenth century. But that particular debate is exotic for our purposes, and what we want to know is that by the early nineteenth century it was endemic in the Indian subcontinent. But it was unknown elsewhere in the world, until it burst into a major epidemic in 1817 that then escaped India and began its devastating international career, reaching Europe for the first time in 1830.

Cholera for the nineteenth century was something new, something never before experienced, and that helps to explain a good part of the reaction to the populations that were first afflicted by it, as the “great cholera,” we should remember, was the great feared disease of the nineteenth century. We’ve already seen that plague was the most dreaded disease, from the fourteenth century through the seventeenth. And we know that smallpox succeeded it in that role in the eighteenth. Cholera, though not the great killer of the nineteenth century, was the most feared affliction. It was feared for a number of reasons: its extremely sudden appearance; its exotic and unfamiliar character; the agonizing and gruesome nature of its symptoms; its high case fatality rate; and its predilection for adults in the prime of life, rather than children.

It’s revealing that a great deal of the discussion surrounding the early experiences with cholera revolved around the question of whether this was, in fact, the return of the plague. Some of the names that were given to cholera capture the fear it inspired. It was known in all kinds of ways. If you read the medical journals of the nineteenth century, and the press, you see it was called Asiatic cholera, cholera morbus, perhaps very scaringly cholera asphyxia; it was known as “the gypsy,” “the monster,” “blue cholera” and “King Cholera,” among other names as well.

Now, since the nineteenth century was an era of acute social tensions, it was, as you all know, marked by a series of revolutions, and is often dubbed the rebellious century for that reason. You know about the revolutions of 1830, the revolutionary wave of 1848 to 1849, across the continent, when there were something like fifty revolutions within a two-year period. Italian independence, the Paris Commune. One could go on. But due to the fact that cholera frequently accompanied those events, and indisputably did heighten social and political tensions, it used to be common to speculate about whether the passage of cholera across Europe was itself a contributory factor in the coming of revolutionary outbursts. By now it’s pretty clear that the causal chain actually worked the other way around. In other words, the outbreak of revolution, war and social order created conditions for cholera to thrive.

Cholera moved, I would argue, in the wake of revolution, rather than triggering it. So, cholera, if it didn’t cause the revolutions that marked the nineteenth century — there has been in recent literature a swing of the pendulum in a different direction, with a view sometimes expressed that cholera was dramatic, yes, but not a lasting influence on the history of the West after all. Some would say that it was dramatic, that it led to all sorts of short-term sound and fury, but in the long-term, that argument runs, its legacy was small, and clearly nowhere near the order of magnitude of plague and smallpox. Well, we’ll be deciding among those conflicting views. But before we can assess them properly, we should look in our usual way at the etiology of cholera, at its epidemiology, its symptoms and its course in European and North American history. Then we’ll be in a better position to judge its impact.

Chapter 2. Cholera Pandemics [00:07:37]

There were seven pandemics of Asiatic cholera, the first in 1817 to ‘23, which was an Asian event. The second pandemic was in the 1830s and affected Asia, but also Europe for the first time, and North America. The third pandemic of 1846 to ‘62, afflicting Asia, Europe, again North America. The fourth pandemic, from ‘65 to ‘75, again it was global. The fifth pandemic, from 1881 to ‘96, mainly a matter of Asia and Europe. The sixth pandemic of 1899 to ‘23, again primarily an Asian and European event. And then the seventh pandemic, from 1960 onward, that went through Asia, South America and Africa. The last pandemic, however, has been milder and less virulent, with a new biotype, the El Tor, which is less dramatic and less fatal than classic cholera, which is our subject, and which was the form of cholera from the first pandemic through the sixth.

The endemic home of cholera, as I’ve said, was the Indian subcontinent, in the delta, the Ganges and Brahmaputra Rivers. And it was confined there until a number of developments enabled it to spread. The bacterium that causes cholera is extremely delicate and doesn’t travel so easily. So, it required a number of factors that enabled the disease to move beyond its original area of endemicity. What were some of those? One was colonialism itself, which meant large-scale troop movements and increasing contact between the subcontinent and the outside world. The increase in trade did the same thing in terms of increasing contact. Then there was the transport revolution, which was very important. Because, as I said, cholera doesn’t travel so well over extended periods of time, and it was the railroad, the steamship and, later in the century, the Suez Canal, that radically reduced the traveling time from the subcontinent to other parts of the world.

Another major factor was religious pilgrimages and fairs in the Indian subcontinent itself. And very most especially, from the European perspective, a very important factor was the Hajj, the voyage of pious Muslims to Mecca. Now, that cholera afflicted Europe and North America in the nineteenth century wasn’t therefore a matter of chance. Epidemic diseases exploit features of societies that are social, political and economic and environmental. Cholera is spread, as we’ll see, exclusively by the oral fecal route; that is, it’s ingested by food and water contaminated by feces. And it requires, therefore — it clearly is among the diseases, certainly that we’ve examined so far, cholera is clearly different from plague and smallpox in that it’s much more a social disease; that is to say, a disease that has a clear predilection for poverty and for pathologies of social and economic life.

Cholera thrived on chaotic, rapid, unplanned urbanization, with its overcrowding and teeming slums, with inadequate and insecure water. This continues to be true with cholera in our own day. It thrives on substandard housing, on inadequate and inappropriate diet. It has a predilection for port cities, which are usually the first places to be affected. This reminds us perhaps of plague a little bit. Places in Europe, like Marseilles, Hamburg, Valencia, Naples were among the first and most frequently to be afflicted. Cholera thrives also on filth and the absence of sewage systems. Cholera is, among many things, a disease of poverty. Cholera also had a pronounced predilection for the poor, as I’ve said. And in that way it exacerbated social tensions.

Cholera, as I said, was associated with revolutions, though it followed rather than provoked them. You can see that in the revolt in Poland in 1830, the revolutions of 1848 to ‘49, when cholera is often part of the movement of troops to repress the revolutions, rather than being a factor in their cause. It was conditioned by the 1860s war between Austria and Prussia as well.

Chapter 3. Characteristics of the Disease [00:13:31]

Well, what about the disease itself? The pathogen is this, the Vibrio cholerae, which was discovered by Robert Koch in 1883, helping to establish the germ theory of disease. Now, this — we’ll note the flagellum or tail of the Vibrio, that plays an important role in the human gut, and we’ll talk about that in a moment.

Its transmission you know pretty well because of your reading for this week of John Snow, On the Mode of Communication of Cholera. You know that this is one of the foundational texts of epidemiology, where he did a brilliant epidemiological job of detective work by finding the famous Broad Street pump — that the people who drank the water from that particular pump were the ones who fell ill and took the disease back to their homes. Snow did a good job of establishing that cholera then was ingested in water, primarily; although it was also demonstrated later that shellfish and vegetables — that is food — contaminated with fecal matter can also play a role.

This was — that’s John Snow — and this is the famous Broad Street pump that made such an important moment in the history of medical science and epidemiology. Though it’s important to remember that — it may seem odd to you as you read this book and look at all of Snow’s evidence — to remember that in fact it failed to convince the medical profession at the time, by and large. There was a big debate about whether cholera was contagious or not. We’ll be coming back to that debate and the reasons for and against.

But one of the things was that John Snow was unable to demonstrate an actual mechanism. There was something in the water, but he wasn’t able to establish what it was, and therefore he didn’t provide a convincing mechanism. And for people who thought that probably it was some chemical factor, if it was anything — that Snow’s biggest chance of making an argument was that it would be something chemical. Well, if so — and remember this was London — if there was some sort of chemical in the River Thames, surely it would be infinitely diluted, and so how would it be possible that this chemical substance, if that’s what it was, was spreading the disease? So, there was a big debate about whether Snow was actually right. It was proved later in the century conclusively that he was. But it’s important to realize that for a long time his writing was very far from convincing the international medical profession. That didn’t happen until the 1880s and 1890s.

Well, what were some of the factors in the transmission of cholera in the West? We’ve talked about trade and the transport revolution. We’ve talked about pilgrimages. We’ve talked about the strategic role of seaports, where once again, as in the case of plague, it would be imported. The bacterium would gain access to the municipal water supply, and there would also be the danger of swimming, or of eating shellfish that fed on sewage, especially if the custom was to eat it raw. The disease would then spread along inland transportation networks. We’ve said too that cholera was a disease of urbanization, and of a defective urban infrastructure, without sewage systems. And remember, in the nineteenth century, waste in European cities was predominantly thrown into the streets, where there would be a seepage downward into tank wells; that people would then drink the water and its bacterial bounty.

Remember, too, that that many of the cities of Europe — Naples, that you’re reading about, but Paris too, and many others — were surrounded by vegetable gardens, and the vegetables would be brought into the city and consumed by the population. But in the growing of the vegetables, use was made of urban sewage, which was collected and transported to the vegetable gardens outside the city, and then the sewage was used as fertilizer — it was good not to waste anything — and the plants then grew in human sewage, and then the vegetables were brought back to town. So, we have a wonderful way for the bacterium to make an excellent roundtrip between the hinterland and the city itself. This was the practice of sewage farming, which was extensive throughout the West. And there was a good trick that market farmers knew very well, market gardeners, which was that if you had an open sewer — and there were many — if you dipped your head of lettuce, on the way to market, into the sewer, then the ammonia from human urine would make the vegetables look fresh, for sale in the market. So that was a good little trick that you might want to remember.

In any case, overcrowding was also another important factor in this. And I just want you to remember housing conditions. These are the fondachi in Naples that you’ve been reading about. And you can see that this is a place, if you use your imagination, that’s a wonderful place for a cholera epidemic. Not only the fact of lack of sewage and wells, but the fact that it’s really dark, and it’s overcrowded, and people, lots of people, live in a single room, and that single room is used as the sickroom, the sleeping room. It’s a place also where food supplies are stored, and with little opportunity to have clean hands. And remember that the Vibrio cholerae is spread through fecal matter. But the point is that in these conditions, and in the dark, it’s very difficult to see, and therefore it’s difficult to know when contamination was actually taking place.

Or, moving from Naples — these are streets in Nottingham, in England, where cholera also caused a couple of major epidemics, for similar reasons. And the waste matter was simply hurled into streets like this. And in the center of the street would be the gutter, which would carry human waste as well. Another source of contamination is flies, which carry the cholera bacterium with them. The clothing of victims — that is, the bed linen, the mattresses and so forth — were also sources of infection, and laundresses were people who were particularly likely to fall victim. And remember that cholera spread also by asymptomatic carriers. It was possible to be spreading- shedding the bacterium without exhibiting symptoms.

Chapter 4. Symptoms [00:21:47]

Well, how was the — what were the symptoms of cholera? And that I’m going to argue, the symptoms, the symptomatology, is an important factor in the social response to this dreadful disease, and it’s captured by such terms as “blue cholera,” “cholera asphyxia,” and “the monster.” This is a picture of a representation of a cholera victim in the agony of the disease, and this is an imaginative idea of how overwhelming it is. This is a cholera patient about to be overwhelmed by the disease itself. Well, the bodily defenses against cholera are numerous. The saliva in the mouth was an important defense. The digestive juices of the stomach are acidic and tend to kill the bacterium when it’s ingested. So, it’s quite possible to ingest cholera bacteria without falling victim to the disease itself. But there are a number of important variables that condition what happens next. One would be how great- extensive the infective dose actually was; how much did you swallow?

The diet that you’re living on is important because such foods that the poor, in particular, lived on in European cities, as ripe and overripe fruit and vegetables — in other words, the poor were likely to buy goods that were beginning to degenerate and deteriorate, because they’d be marked down in price, and those would be the goods that the poor would live on. And this meant that they often suffered from dire real illnesses, and those reduced the digestive time, and therefore deprived the stomach of its defensive capacity to protect you by the acidity of the digestive juices. And the consumption of raw fruit, for example, would be especially common in the summer months. Another factor would be the general health of the person who was exposed to the disease.

Let’s suppose that you’ve eaten a very large infective dose, and it passes successfully through your stomach, into the small intestine. What happens next? Well, there’s an incubation period. It can be as short as a few hours. And this too was important in the social history of cholera, and could last up to three days. The site of infection is the small intestine. There the flagellum, at the tail of the bacterium, that we’ve seen, propels the Vibrio, and it attaches itself to the intestinal wall. Ironically, there the immune system of the body is usually capable of killing the bacterium. But when it — as the bacterium dies, it releases a very powerful toxin, an enterotoxin, that’s one of the most powerful poisons in nature. And its effect on the intestinal wall is to cause it to work in reverse; that is, to drain fluid from the bloodstream into the bowel, and from there it’s expelled.

So, the mechanism by which cholera kills first of all, and predominantly, is a sort of hemorrhaging to death, in which the blood serum loses its fluidly massively — liters can be expelled in a matter of a few hours — and the patient hemorrhages to death, in effect, losing its blood plasma and excreting what are called the famous rice-water stools, and the patient goes into hypovolemic shock. Nineteenth-century physicians said — this is no longer a fashionable term today — but they described cholera as going through two major stages. The first was called the algid stage, which was the time of high drama and terror, which had a sudden onset, without warning.

This was part of the social tensions that were generated by cholera. In other words, you could be seized suddenly with this dreadful disease out in a public place — on a tram, in a marketplace, in the streets itself — where you would fall down and start writhing, vomiting and excreting rice-water stools. This was part of the high drama of the disease. And the algid state would last, if you survived, normally from eight to twenty-four hours. As a patient, you would lose — progressively your pulse would become fainter, or even almost absent. The body would turn cold and would have a livid appearance.

It looked, within a few hours — and this was another of the frightening aspects of this disease — within a few hours, someone who had been healthy that morning, by the afternoon looked cadaverized, like a person who had been wasting away from a long-term wasting illness. The breath would turn cold. The hands would look like dishwater hands. And very distressing, there would be a very severe cramping; terrible cramps, terrible abdominal pain, nausea, vomiting. And the blood itself — physicians who were trying to treat patients by bloodletting rapidly noticed that the blood itself, deprived of its liquid content, was transformed into a black tar that refused to circulate. This could lead to heart failure, to a terrible thirst that the patient suffered. And because the blood is no longer providing adequate oxygen, the patient suffers — has the sense of asphyxiating, a terrible effort to gasping for air. Those are a couple of pictures of contemporary — I said cholera is still with us, and so I just wanted to show you a picture of a patient, or another, a child patient today.

In any case, if the patient survived the algid stage, there was then the second stage, that nineteenth-century physicians called the reaction stage, that might last four or five days. The prognosis isn’t really better, but the symptoms are. At this time the cold body becomes warmer. There’s a fever usually. The patient suffers terrible headache and is often delirious. The problem is that there were terrible complications that overtook patients in the reaction stage. Pneumonia was a frequent complication. So was kidney failure, uremia, gangrene of the extremities; the ears, the nose, fingers, toes, the penis. And there was a case fatality rate then, from Asiatic cholera in the nineteenth century, of something like fifty percent. Today, as we said last time, there is an effective oral rehydration therapy, and the death rate with treatment is less than two percent today. That’s partly because of the effectiveness of the treatment, and partly because the El Tor biotype is less virulent than classic Vibrio cholerae, of the first six pandemics.

Chapter 5. Effects on Society [00:31:00]

In any case, then, what were the effects on a community, on a society, of an invasion of a disease of this type? Was this the return of the plague, as people speculated? This disease seemed a little bit to resemble that, in terms of the terror that it inspired, and the social chaos it caused during an outbreak. Now, an outbreak — let’s imagine a nineteenth-century city. You can pick your own, let it be London or Paris, or perhaps Naples. The outbreak would tend to begin with what the nineteenth-century medical community termed sporadic cholera. By that they meant a small trickle of cases. These would be transmitted in a neighborhood, a family, a house. The transmission might be by contaminated clothing or bed linen, contaminated food, hand to mouth transmission from tending a patient and then not washing the hands.

Let me give you an example from Venice in 1885. There was a particularly persistent outbreak, in a single street, before the disease became an epidemic in the city as a whole. And what happened was that this was traced to a single restaurant, and the proprietor was a lovely lady who happened to be tending to her own infant child who was sick with cholera in an upstairs bedroom. She would go upstairs and tend to him, and then she would go back downstairs, without washing her hands, and prepare food for her clientele. And that was how the disease was spread in a single street, for some time.

Now, in fortunate instances, the disease, this outbreak, this so-called sporadic cholera, would just fade away, and the community would escape a large-scale misfortune. But if the Vibrio gained access to the city’s water supply, then the disease would flare up with epidemic force, and this would be what the nineteenth century health authorities called epidemic cholera, instead of sporadic. And if you made a graph of cases and deaths, there’d be a sudden spike in mortality and morbidity. Well, what would be the likely magnitude of the disaster that would follow if, let us say, a major European city had its water supply contaminated with cholera? The order of magnitude would be different from that of the plague. Cholera was never responsible for the kind of demographic catastrophe that Europe experienced with the Black Death, or later invasions of bubonic plague.

In the nineteenth century, Europe experienced a major population growth, and cholera had little impact on the population surge. Let’s take again the example of Naples, a city famous for its overcrowding, its filth and its recurring epidemics of Asiatic cholera. Let’s compare it also with an earlier experience of bubonic plague. Naples experienced a terrible epidemic of plague in 1656. At that time the city had about a population numbering perhaps half-a-million people. The state wasn’t very good at knowing exactly how many people lived in the city, and its statistics for mortality are also to be taken with a grain of salt. But there were estimates that as many as 300,000 people died of bubonic plague in that single year. Let’s compare that with cholera in 1837.

I choose 1837 because that was the worst epidemic of cholera that Naples experienced. The population at that time was still round about half-a-million people, but in this worst year of Asiatic cholera, about 12,000 people perished. Now, I don’t — after our experience of bubonic plague — I don’t want that to be a basis for insensitivity. This epidemic in which 12,000 people died is a major disaster, but it didn’t have the same long-term cultural, philosophical and religious impact that the plague earlier had, and it didn’t seem to convince people that the end of the world had possibly arrived.

So, cholera, compared with plague, is less virulent. The bodily defenses of healthy adults are often effective. And it doesn’t have those efficient vectors, rats and fleas, that enabled the plague to reach every home. Also, unlike the plague, cholera didn’t endure for five centuries, returning every generation. Cholera first invaded Europe in the 1830s, and by the 1860s the history of cholera in the industrially advanced nations of Northern Europe was largely over. And for Western Europe as a whole, the 1890s mostly marked the end, and 1911 certainly did. So, cholera had only six pandemic waves that ever invaded Europe, and each wave was less widespread and claimed fewer victims than the ones preceding it. That’s a very different history than the history of bubonic plague.

How long would an epidemic last? It would normally last, in a great European city, for the length of the warm summer and perhaps the early fall. It would then recede and fade away with the onset of cool weather. Now, why would it fade away? Well, Robert Koch, who discovered the Vibrio cholerae, said himself that this was something, a question to which he couldn’t give a satisfactory answer. He said that this was one of the great cholera mysteries, as he called it. But we can speculate with regard to certain factors that seem important. One would be a change in weather. Cold dry weather is hard on the delicate Vibrio cholerae. Like plague, cholera too in Europe had a very pronounced seasonality. It struck during the warm months.

Another factor is that after the disease had struck those people who were most at risk because of their occupations, and their personal susceptibility and their living conditions, the epidemic was then like a fire that ran short of fuel. It ran short of people who were most susceptible and at high risk. And then communities, also — and this was probably important — adopted measures of self-defense, and those too helped to cut short the outbreak, especially later in the century when the disease was better understood. It’s now known too that the cholera can survive in a spore form, in algae blooms offshore of the great port cities, and so there is a possibility too that the disease was re-imported from the waters offshore.

Chapter 6. Community Reactions [00:39:33]

In any case, what were the reactions to cholera in a community? Here there was an analogy, possibly with plague, in that cholera too generated terror and fear. This is partly because of the agonizing nature of the symptoms of this disease. And the fact was that the symptoms of cholera suggested were analogous to something that people were already familiar with, and that is poisoning. The symptoms of cholera had symptoms that resembled someone who had taken strychnine, for example — rat poisoning. And, so, people were suspicious that perhaps this might be a crime, rather than a natural event. Let me show you some images that convey the sense of terror that people felt at the time. This is King Cholera; we’ve said that’s one of the terms that it was associated with. And you can see King Cholera astride the globe. This is clearly a sense of its pandemicity. Or we can look at — this is New York City, with cholera approaching. And again you can see the kind of terror that was associated with it. Or let’s look as well — and you can see cholera striding over the defensive bulwarks. Those are the kinds of — this is clearly one of the early pandemics, and what you can see is the attempt to control this disease with the plague measures. You can see the troops, sanitary cordons and all the rest, trying to keep out “the monster,” as it was called. But those in fact turned out, for reasons we’ll be coming to, to be entirely ineffective in dealing with cholera, unlike the plague.

Or we can see — and here the analogy in people’s minds that this might be the return of the plague is clear, because here we can see the Grim Reaper, with his scythe, mowing down the whole population. Or here we can see, once again in the nineteenth century, a revival here. This is the danse macabre, with death calling people. And there you can see again the Danse Macabre. Here’s the invitation of death to come dance. So, those are sorts of graphic illustrations of the kind of fear that this disease caused. Well it also caused scapegoating. Imagine, for example — let’s go back to the first arrival of cholera in the 1830s. In 1830, let’s think of the Russian Empire. When cholera struck St. Petersburg in 1830, at that time Russia was at war with Poland, and Russians believed at the time that the disease was an act of terror by Polish agents. So cholera gave rise to manhunts or witch-hunts, find — the search for scapegoats. Foreigners, gypsies, someone newly arriving in town could be suspicious and therefore could be set upon and attacked, as a scapegoat.

Cholera also led, because of its fear, to mass flight, and some cities experienced almost Biblical exoduses, with tens-of-thousands of people evacuating cities in fear for their lives. And just as in Defoe’s account, it was the wealthier classes who could afford the journey and had somewhere to go who went first. A consequence would be that the administration and public services, in the city that was being evacuated, were in chaos. Businesses shut down. There was mass unemployment. There was hunger and shortages of all kinds. There was also a new strain on class relationships. Cholera was a class disease, I would argue, in that it caused a sharply unequal burden of death and suffering. Unlike plague, unlike smallpox, cholera primarily chose the poor.

Now, there are reasons, in terms of risk factors, that explain that difference. There was normally by this time a pattern of housing segregation; that is to say, the poor and the wealthy didn’t live next to one another, and the poor suffered from overcrowding, filth, poor diet, lack of light, and the wells they drank from were not the same as those used by the wealthy. A good example of this difference, and one that caused sinister speculations. In time of plague, as you know, those who tended the plague victims — physicians and priests — perished in unimaginable proportions. During the time of cholera, however, doctors and priests moved among the most sordid slums, and yet mysteriously they managed to stay healthy, for the most part, while those around them fell ill and died.

There are good epidemiological reasons for this. Doctors didn’t eat and sleep in the sickrooms, as the poor did. They had better diets. They washed their hands. They drank different water. But to the urban poor, the immunity of the wealthier classes was highly suspicious. It suggested to some the idea of poisoning; particularly since the poor in the nineteenth century weren’t medicalized. That is to say, they had little contact and experience with medical attention. And, so, an effect, during the cholera years, was often violence. There were assaults on doctors. In some places crowds invaded hospitals and lazarettos. And the suspicions weren’t all in one direction. The wealthy, at this time in the nineteenth century, had a fear of those they called the “dangerous classes,” and they were thinking of the dangerous classes as dangerous politically — this was the rebellious century — dangerous morally and in religious terms. But also they now seemed to be dangerous medically. And I think this is a factor in some of the extreme violence that one sees in 1848, for example, or in the Paris Commune.

There was a strain on social relationships. Well, what happened in terms of public policy and organized effects? The first thing that happened was a tendency to revive the plague measures, to contain it. Cholera put unprecedented pressure on authorities to do something, to take some sort of effective action. And it was then that the states responded — first off, Russia, Austria, Prussia, for example — by reviving the plague regulations: land-based and maritime quarantine, sanitary cordons, lazarettos. One can see this in pictures. This is a cholera lazaretto. Or one can see here is cholera, theVibrio arriving, and you can see that the Board of Health is trying to stop it, and there are sanitary cordons and all the rest. This is a depiction of the early outbreak. Or the attempt — this is familiar to you from time of plague — to purify the atmosphere by burning sulfur and with fire.

These were — or there were funeral regulations. And you can see here again the people bring out your dead, and transporting the victims to the cemetery for rapid, hasty burial, the funeral regulations. The results then were to maximize terror, economic disruption and flight. The plague regulations against cholera caused political effects. But they were counter-productive in terms of the disease, for they taught a dangerous lesson, that outsiders could be dangerous. And so we see then, they don’t stop the cholera. They don’t stop the cholera because they’re asymptomatic carriers, because the flight of population causes — trying to escape the plague measures disperses the disease. Because cholera can flow in rivers and waterways, past the troops who are trying to contain it.

So, the plague measures weren’t effective against cholera. But I’m going to argue what were the long-term effects. And I’m running rapidly out of time, but just say that there were, I would argue, not just immediate drama, there were long-term effects. Cholera led to a big debate in the medical profession about contagionism, rapid or not. It led to the development of epidemiology as a medical discipline. It contributed to the coming of the germ theory of disease. In terms of public health, it led to a new set of measures of sanitary improvement, that we’ll be talking about next time, and even to the refitting and sanitary revolution in cities, and even the rebuilding of places like Paris and Naples; although cholera was not the only in fact in places like Paris. And it caused a mortality revolution in urban cities. We’ll be talking more about that.

There are reasons then to say that although cholera caused many of the immediate effects of terror, like the plague, it didn’t lead to the same kind of mortality, and it didn’t have the same long-term consequences. But it did have a number of long-term consequences that I think it’s well to bear in mind. This was the great dreaded disease of the whole of the nineteenth century.

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