Part Five (of ‘Don’t Count Your Children Until they’ve Had the POX!’ Series) – Cholera: The Disease that Inspired Bram Stoker to Write Dracula? & A Tale of Two Pathogens.

The Lancaster County Cholera Epidemic of 1854 …

Cholera, which was endemic to India, escaped the subcontinent in 1817, striking Moscow in September 1830. It then spread westward across Europe, reaching England in 1831 and North America in 1832. The pandemic would return to Europe and America in 1849, 1854, and 1866, each time filling the population with terror and revulsion; the mystery surrounding the cause of the disease only exacerbated the situation. Its effects were both rapid and devastating, and death was agonizing to those who succumbed to the disease…
Osborne, J.D., (2009)
[1]
http://www.edwardhandmedicalheritage.org/cholera.html
Link

A disease that becomes pandemic (impacts nations world-wide often with deadly impact) is obviously one that can be passed from person to person. And Ireland, on the edge of Europe, was certainly not immune to Cholera’s devastation as highlighted in the following excerpt:

Why does cholera have such a reputation?

Cholera was once one of the biggest killers in Irish society. The 1832 epidemic killed 30,000 people… Folk memories of the cartloads of bodies during the 1832 epidemic helped inspire Bram Stoker to write the novel ‘Dracula’.
MedMedia Group (2018)
[2]
http://www.irishhealth.com/article.html?con=246
Link

30,000 deaths in a single Cholera outbreak of the 1830s pandemic in Ireland (the first and seemingly, the worst), although not as major in terms of the death toll estimated for the initial impact of Typhus in the early days (which could have been well over half a million in a population of only 6 million), is still a massive impact to a community of several million at this time. Take, for example, just one well-documented experience within a single county in the whole country of Ireland, as outlined in the following:

The Sligo epidemic that stoked Bram’s interest in all things

Stoker’s mother, Catherine Thornley, came from Sligo town, and witnessed at first hand the devastating cholera epidemic that swept the county in 1832. Bram — or Abraham, as he was christened — would avidly listen to Catherine’s sobering accounts of what she had witnessed in Sligo before he was born…
And Stoker experts believe Catherine’s vivid descriptions of the suffering she had seen stayed with young Stoker and helped fuel his macabre novel later on in life…
It’s not known how it started but the first signs of the disease were noted shortly after a heavy thunderstorm. A market was being held that day and thanks to the large concentration of people in a comparatively contained space, it struck with a brutal swiftness.
A farmer was infected as he mounted his horse on one side of the town and was dead by the time he reached the other. Another man who attended the funeral of an employee in the morning became ill during the burial and was dead by evening. One family saw six of its members die in the course of a single night. The death rate was so rampant that carpenters ran out of wood for making simple coffins and the dead had to be wrapped in pitched sheets and rolled into mass graves.
Local legend has it that some people were buried alive, so great was the haste to dispose of the corpses. The scenes at night around Sligo only served to heighten the sense of dread in the town. Tar barrels were lit in the streets in a misguided attempt to purify the air…
Doctors valiantly attempted to stem the outbreak, and had to contend with widespread ignorance about the disease. There was also suspicion that the medics themselves may have brought the disease upon the town — they had conducted tests on the water to see if the epidemic had started there, and word spread that the water had been tampered with. Even when five of the doctors contracted cholera and died, the allegations continued.
Some 15,000 people were forced to flee the county and it is thought more than 1,500 people died from the epidemic. The events of 1832 would scar Sligo for generations, and the suffering of those who survived would be exacerbated by the Great Potato Famine, which struck just 13 years later.
John Meagher, J., (Independent, Apr., 22nd 2012)
[3]
https://www.independent.ie/entertainment/books/the-sligo-epidemic-that-stoked-brams-interest-in-all-things-26845703.html

The most revealing part of this narrative is perhaps the swiftness of the spread of Cholera – seemingly person to person – with no particular trigger such as the locals all drinking contaminated water (note that Cholera is supposed to be a waterborne disease). We have other historical documentation to support this very point as seen in the excerpt below. It relates to a later pandemic of 1854 as Cholera broke out in a small pocket of Columbia, U.S.

The Lancaster County Cholera Epidemic of 1854 and the Challenge to the Miasma Theory of Disease

September 6, 1854, when two German immigrants, sick with cholera, were left at the railroad terminus in Columbia while their party continued west. The men died the next day. Four Columbians who had tried to aid them came down with cholera and died shortly thereafter…
By September 9, cholera had spread to almost every section of the town, and 30 people had died, many of whom had visited the stricken immigrants. Physicians had no doubt that the disease that they were witnessing was cholera. The virulence of the epidemic that struck Columbia caused Jackson to observe that two-thirds of the victims died within five hours of showing symptoms of the disease…
Although only 127 victims died in Columbia—out of a population of five thousand—Dr. Wilson Jewell of the College of Physicians of Philadelphia and president of the Philadelphia Board of Health estimated that if a similar outbreak had occurred in Philadelphia, it would have killed 75 people an hour.
Osborne, J.D., (2009)
[4]
http://www.edwardhandmedicalheritage.org/cholera.html
Link

This third recorded Cholera pandemic of 1854 strongly suggests that no amount of cleaning up sewers could have stopped the disease in its tracks, at least not at a national and transnational level once it had found a means of jumping from person to person, as also implied by the title of article excerpt above. And supporting this concept, as noted at the beginning – the very nature of pandemics goes against the idea that Cholera was spread due to the level of hygiene within any of our far-flung and emerging nations.

 In other words,  although this goes against our commonly and firmly held belief that Cholera and other old diseases like it, came to prominence and ultimately declined due to our level of cleanliness, does not appear to fit the historical facts. A case in point is documented in the following:

No better example of this belief exists than in the now famous case of the Broad Street pump incident as outlined below:

John Snow and the Broad Street Pump: On the Trail of an Epidemic

The first cases of cholera in England were reported in 1831, about the time Dr. Snow was finishing up his medical studies at the age of eighteen…
Dr. Snow believed sewage dumped into the river or into cesspools near town wells could contaminate the water supply, leading to a rapid spread of disease.
In August of 1854 Soho, a suburb of London, was hit hard by a terrible outbreak of cholera. Dr. Snow himself lived near Soho, and immediately went to work to prove his theory that contaminated water was the cause of the outbreak.
“Within 250 yards of the spot where Cambridge Street joins Broad Street there were upwards of 500 fatal attacks of cholera in 10 days,”
…Officials contended there was no way sewage from town pipes leaked into the pump and Snow himself said he couldn’t figure out whether the sewage came from open sewers, drains underneath houses or businesses, public pipes or cesspools.
The mystery might never have been solved except that a minister, Reverend Henry Whitehead, took on the task of proving Snow wrong.
… Reverend Whitehead interviewed a woman, who lived at 40 Broad Street, whose child who had contracted cholera from some other source.  The child’s mother washed the baby’s diapers in water which she then dumped into a leaky cesspool just three feet from the Broad Street pump, touching off what Snow called “the most terrible outbreak of cholera which ever occurred in this kingdom.”
A year later a magazine called The Builder published Reverend Whitehead’s findings along with a challenge to Soho officials to close the cesspool and repair the sewers and drains because “in spite of the late numerous deaths, we have all the materials for a fresh epidemic.”  It took many years before public officials made those improvements.
Tuthill, K., (2003)
http://www.ph.ucla.edu/epi/snow/snowcricketarticle.html
[5]

Although the Broad Street outbreak may have greatly exacerbated the ongoing pandemic of 1854 at a local level within this tiny area of the London suburb, I think we can safely say that this episode cannot account for the pattern of deaths from Cholera – the same pandemic of 1854 – experienced simultaneously throughout our diverse nations.

Recalling that it took years for the contaminated sewer leak at Broad Street, London to be repaired, it is also worth noting that such hygiene measures and attempts to control the spread of Cholera were not always successful,  or, even necessarily viewed as a good thing as encapsulated in the excerpt from a letter to the ‘Times’ around the time of the 1854 pandemic.

Letter to the ‘TIMES’ 1854

‘ We prefer to take our chance with cholera than be bullied into health. There is nothing a man hates so much as being cleansed against his will or having his floor swept, his hall whitewashed, his dung heaps cleared away and his thatch forced to give way to slate. It is a fact that many people have died from a good washing.’
Child, J and Shuter, P. (1992, 101)
https://books.google.ie/books/about/Understanding_History.html?id=DsNKdbFrP7wC&redir_esc=y
[6]

Obviously, some people were willing to take their chances with the disease itself, which appears by all historical accounts to be becoming significantly less deadly as time went on – and certainly, from the time when Cholera first impacted our developing nations around the 1830s.

Perhaps that is why people were beginning to get a little irked by this zealous cleanliness as I am sure that many people on the ground knew quite well that the Cholera that had, not that long ago, swept across their homelands (certainly in living memory) was becoming relatively tame compared to the earlier days of the deadlier Cholera of plague-like proportions that swiftly spread devastatingly from person to person and the fact that people may have noticed that the limp corpses of entire families  being tossed unto cartloads of putrifying wretched bodies to be buried alive or dead amidst the tar filled sulphur piles, were not a common sight in the Cholera outbreaks of 1854.

An indication of this relative tameness of later Cholera pandemics, is already clear when we look to the preceding pandemic recorded a few years earlier dating to the late 1840s – generally known as Asiatic Cholera. What is interesting about this particular pandemic in the context of Ireland, is that it erupted on the heels of what is commonly referred to as the Great Hunger (or Irish Famine) of the 1840s.

One would think that this would have greatly increased the numbers dying from the disease, given our very poor nutritional status and overall dreadful living conditions, however,  as it turns out, seemingly, starvation, famines and overall impoverishment and squalid conditions do not appear to have played a major role in increasing the death toll as one might expect; although, it certainly didn’t help matters as indicated in the excerpt that follows:

History Ireland

Epidemic Diseases of the Great Famine

The arrival of Asiatic cholera as a pandemic in 1848-49 exacerbated the situation. This fearsome disease added to the physical and mental suffering of the beleaguered population and increased the overall mortality.
Greary, L., (1996)
[7]
https://www.historyireland.com/18th-19th-century-history/epidemic-diseases-of-the-great-famine/
Link

Instead, it actually looks like Cholera is losing its grip – even at the height of the Great Irish Famine of the mid-1840s, as indicated by the data recorded in the following excerpt based upon the national census over the course of the main famine years:

Famine Disease and Famine Mortality: Lessons from the Irish Experience, 1845-50

… the census reported a total of 1,376 cholera deaths in the years 1841-47 (plus a further 2,502 in 1848).
Mokyr, J., and Ó Gráda, C., (1999, 7)
[8]
https://pdfs.semanticscholar.org/498e/2d40caf5ebe67dfc422718a200112a488f79.pdf

Therefore, if we compare the Cholera pandemic of this Asian type of the late 1840s, with the first major and preceding Cholera pandemic of the early 1830s, we can clearly see that the estimated 30,000 deaths, in a single outbreak of Cholera in Ireland alone, compared to the incredibly reduced estimates – even with all its inaccuracies and difficulties – reported from the Irish census of a few thousand deaths from Cholera over the worst of the Famine years ever recorded in this small nation, we truly begin to see that starvation, poverty and dreadfully stressful conditions all round does not necessarily lead directly to increased mortality from Cholera circulating as part of a broader pandemic at the time.

Moreover, this significant taming of Cholera is clearly seen from statistics recording deaths from the final major pandemic of Cholera – which occurs simultaneously throughout our developing nations in 1866. This is the first Cholera pandemic captured by the official statistics of deaths from Ireland which began two years previously (Fig. 1). The death figures for the 1866 pandemic in Ireland shows a significant decline in the number of deaths for several decades when it re-erupts briefly for another decade – but is not as deadly, and is suddenly never heard of again (Fig. 1). 

Cholera deaths Ireland

Fig. 1: Chart of the annual number of deaths in Ireland from Cholera since records for this disease began in Ireland. Source: Chart generated using annual statistics reports since records began – “Annual Reports on Marriages, Births and Deaths in Ireland, from 1864 to 2000” courtesy of: An Phríomh-Oifig Staidrimh, Central Statics Office CSO, link. © Copyright dig-press.com

Once again, we may be looking at natural resistance to the disease over generations of exposure as indicated in a more modern assessment of the disease of Cholera as seen in the more recent excerpt given in the following.

Etiology and Epidemiology of Cholera

When cholera first appears in epidemic form in an unexposed population, it can affect all age groups. In contrast, in areas with high rates of endemic disease, most of the adult population have gained some degree of natural immunity because of illness or repeated asymptomatic infections.
CDC (1999, 39)
[9]
http://www.bvsde.paho.org/texcom/colera/etiology.pdf

In other words, Cholera, and such diseases that are typically viewed as hygiene preventable, appear to be marginally impacted by any of our regional hygienic responses and attempts at intervening in the natural circulation of this pathogen –  except perhaps at a local level.

The historical archives and the statistical data presented above indicate a very similar natural patterning over national boundaries for corresponding timeframes for the fate of Cholera. We see the near-simultaneous rise of Cholera to deadly prominence in pandemic proportions, rapidly spreading from person to person, but within a few short generations – the massive devastation  as epitomised by the macabre accounts of the initial pandemic of the 1830s, just as quickly lost its lethal grip on our fledgling nations to become a relatively benign disease once again.

Cholera, a waterborne pathogen still exists. It never went extinct, but instead, it seems that we have built up natural resistance and immunity to this pathogen via generational exposure and as such, this pattern is indicative of a natural biological interplay between the pathogen itself and us as its host.

This brings us to another interesting pattern as seen in the following section which lends further support for the ultimate demise of Cholera from its much deadlier impact in the earlier part of the 19th Century, which can be seen from the interplay between the pathogens themselves, attempting to compete with each other for us as their own particular host.

 

A Tale of Two Pathogens

Screen Shot 2018-08-15 at 04.35.28

Fig. 2: Chart of the annual number of deaths in Ireland from Cholera and Dysentery since records for this disease began. Note the large spike at the beginning, (from when records for both these diseases first began). These diseases decline somewhat thereafter, only to erupt again during the 1880s (Dysentery first, and then Cholera takes prominence from 1900 for almost a decade),– but both diseases stop abruptly with the first decade of the 20th Century. Source: Chart generated using annual statistics reports since records began – “Annual Reports on Marriages, Births and Deaths in Ireland, from 1864 to 2000” courtesy of An Phríomh-Oifig Staidrimh, Central Statics Office CSO, link. © Copyright dig-press.com

Notice from Figure 2, that there is a dramatic drop in deaths from Cholera (Dark Grey) just after the 1866 pandemic (shortly after official records began to record deaths from this disease). Note that deaths from Dystentery (Light Grey) since official records began, fill the space where Cholera seems suppressed somewhat by the predominance of Dysentery for a number of decades.  Note also, the slight gap in the graph that shows very few deaths from either Cholera or Dysentery compared to their loftier heights before records began as significantly more deadly diseases. As it turns out, this void of pathogen destruction appears to be filled by deaths from Typhus  (see the previous discussion on this disease) (Fig, 2).

Taking a closer look at Dysentery, we can see from (Fig.  2) that the deaths registered from this disease stop abruptly in 1900. Like Cholera, and all the other diseases discussed thus far in the context of our now developed nations, the historical records clearly show that Dysentery had a much deadlier beginning within our developing nations of the past.

Now, if we inspect the fate of Cholera (Fig. 2), we can now perhaps see what stopped Dysentery in its tracks. But even so, Cholera’s final reign only lasts a further decade before it too suddenly became an awful lot less deadly (note that these figures do not go beyond 1910, as there were simply no deaths officially being recorded annually in the register).

This interplay between the rise and fall of these two diseases is supported by the historical reference from the closing decade of the 19th Century as seen in the excerpt below. Note, however, that when this observation was written, little did the author know that even Cholera would also, like its older country cousin, be a thing of past just over a decade later.

A History of Epidemics in Britain, Volume II

Dysentery, the old ” country disease,” has steadily declined to about a hundred deaths in the year, while the considerable mortality from diarrhoea, nearly two thousand deaths in a year, is nearly all from the cholera infantum or summer diarrhoea of children in the large towns.
Creighton, C., (1894, 296)
[10]
https://www.gutenberg.org/files/43671/43671-h/43671-h.htm ]

As investigated in the previous sections on Typhus and Typhoid, a similar interplay of the rise and fall seen in the graphs as the predominance of one disease over the other presumably reflects their attempts to opportunistically colonise us as their hosts.  This pattern strongly suggests a biological cause – more to do with the vying for dominance between the pathogens themselves – than any hygiene measures that our particular developing nations may have (or not) implemented at any given time, within any particular region to try and prevent these pathogen’s bid for dominance.

Irrespective of this interesting interplay of pathogens fighting amongst themselves for top dog position, it seems that our own mighty immune systems won the day and managed to bring them all under control in the end. 

References to Part Five
[1] Osborne, J.D., (2009) The Lancaster County Cholera Epidemic of 1854 and the Challenge to the Miasma Theory of Disease, Edward Hand Medical Heritage Foundation [Available online at edwardhandmedicalheritage.org http://www.edwardhandmedicalheritage.org/cholera.html]
[2] MedMedia Group (2018) Why does cholera have such a reputation? Irish Health, [Available Online http://www.irishhealth.com/article.html?con=246 ]
[3] Meagher, J., (2012) The Sligo epidemic that stoked Bram’s interest in all things, Independent, (Apr., 22nd 2012) [Available online independent.ie https://www.independent.ie/entertainment/books/the-sligo-epidemic-that-stoked-brams-interest-in-all-things-26845703.html
[4] Osborne, J.D., (2009) The Lancaster County Cholera Epidemic of 1854 and the Challenge to the Miasma Theory of Disease, Edward Hand Medical Heritage Foundation [Available online at edwardhandmedicalheritage.org http://www.edwardhandmedicalheritage.org/cholera.html]
[5] Tuthill, K., (2003) John Snow and the Broad Street Pump: On the Trail of an Epidemic, Cricket Magazine, Cricket Vol, 31, [3], pp. 23-31, (Nov. 2003); Carus Publishing Company. [Available online republished with permission in full online: http://www.ph.ucla.edu/epi/snow/snowcricketarticle.html ]
[6] Child, J and Shuter, P. (1992, 101), Letter to the ‘TIMES’ 1854, Understanding History, Vol. 2, Heinemann [Available Online on Google Books https://books.google.ie/books/about/Understanding_History.html?id=DsNKdbFrP7wC&redir_esc=y ]
[7] Geary L., (1996) 18th – 19th Century History/Epidemic Diseases of the Great Famine.., History Ireland Magazine, Vol. 4. [1] (Spring 1996) [Available online historyireland.com https://www.historyireland.com/18th-19th-century-history/epidemic-diseases-of-the-great-famine/ ]
[8] Mokyr, J., and Ó Gráda, C., (1999) Famine Disease and Famine Mortality: Lessons from the Irish Experience, 1845-50. PDF, p. 7. [Available Online as PDF at semanticscholar.org ] https://pdfs.semanticscholar.org/498e/2d40caf5ebe67dfc422718a200112a488f79.pdf]
[9] CDC (1999) Etiology and Epidemiology of Cholera, in, Laboratory Methods for the Diagnosis of Epidemic Dysentery and Cholera, Centers for Disease Control and Prevention, Atlanta, Georgia, Chapt., 5, p. 39. [Available online as PDF http://www.bvsde.paho.org/texcom/colera/etiology.pdf ]
[10] Creighton, C., (1894) A History of Epidemics in Britain, Volume II, p. 296, Cambridge, University Press. [Available online at Gutenberg.org https://www.gutenberg.org/files/43671/43671-h/43671-h.htm ]

 

Next Episode: Part Six: Scarlet Fever Returns, but it is a lot less deadly.

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