In the Valley of the Shadow of Death: Life in the Time of Cholera

Depiction of cholera from Le Petit Journal, 1 Dec, 1912 (image from Wikipedia)

In circling dances so lightly swinging  

You follow wildly amusement's thread,
With myrtle blooming and music ringing ...  

But solemn I on the threshold tread:  

— The dance is checked

And the clang is wailing,  

The wreath is wrecked  

And the bride is paling:

The end of splendor and joy and might
Is only sorrow and tears and blight.

I am the mighty, who has the power,  

Till yet a mightier shall appear. 

In deepest pit, on the highest tower,  

My chilling spirit is ever near:  

Those plagues of night  

And of desolation,  

Whose breath of blight  

May annul a nation,  

They slay the victims, which I select,  

Whom shield and armor can not protect.

Johan Olof Wallin, 1834 (translation by A.W. Almqvist)

These lines were written during the first cholera epidemic ever in Sweden in 1834, by J.O. Wallin, minister, orator, poet and Archbishop, and the sentiment is echoed in thousands of accounts from across the world. Cholera struck quickly and fatally, and entire communities succumbed as if an avenging angel had walked from door to door.

Most likely originating in India, the first known pandemic began in the Bengal region of India in 1817and spread across Southeast Asia, China, Japan, the Middle East, and southern Russia. In 1827, the first epidemic occurred in Europe and America and lasted until 1835. After that, cholera, nicknamed "Jack Morbius" in English, was a recurring and deadly guest for most of the 19th century.

Initially, no one knew how it was caused or transmitted, and the advice given was therefore inadequate and erroneous. The New York Health Board advocated temperance in food and drink, while among the British troops in India, rumour had it that the men who went on drinking heavily had the best chance of recovery. Usually, ventilation was advocated since it was assumed that the disease was airborne. In Flora Anne Steel's The Complete Indian Housekeeper and Cook, first published in 1888, it is claimed that cholera is often "enveloped in damp clouds" why living on mountain ridges is not recommended. She also suggests cutting down "rank vegetation" as "it harbours dirt, and emits injurious gases".

In fact, Dr John Snow had established a connection between cholera and contaminated drinking water already in 1854, and suggested that contamination from human sewage had been the cause of the London epidemic in 1854. In 1883, five years before Flora Steel's book was published, Robert Koch identified the bacteria responsible, vibrio cholerae, through a microscope.

Vibrio cholerae can survive for extended periods in cold, clean water but rarely survives in foodstuff. Humans are usually the only living hosts for the cholera bacteria, and it is primarily spread through the contamination of drinking water by human fecies. The critical dose - ie the amount of bacteria required in order for the victim to be ill -  is fairly high, which means that any epidemic will have a fairly large amount of symptom-free carriers, which helps spreading the disease.

Undernourished people are more likely to catch the disease, as are people with low amount of acid in their stomach, since the bacteria is vulnerable to acidic conditions. Flora Steel claims that the acid treatment is the most successful, and she gives several recipes for different acidic cures - the most basic being the one she claims is used by tea coolies which consisting of a tablespoon each of vinegar and Worcester sauce.

The incubation time can vary from a few hours to five days, but in most cases it is 2-3 days. The symptoms start with acute bowel pains and profuse watery diarrhea (up to about 20 litres a day and sometimes described as "rice water"). Vomiting occurs occasionally, but is not common. Due to the dehydration caused by the diarrhea, circulation collapse frequently follows and untreated epidemics have a death rate of about 50%. The primary treatment is rehydration; i.e. replacing the lost fluid and salts. With the proper rehydration treatment, casualties may be brought as low as 1%.

Though such a frequent and efficient killer, cholera is rather under-represented as a killer in fiction (compare it with the frequent application of "the cough of death"in books and films, for example). I suppose the main reason is the complete lack of romanticism and dignity in voiding your body of 20 litres of diarrhea in a few hours. For realism though, it can hardly be beat as it was the cause of a staggering number of deaths over the 19th century, and it can be used as a handy little mors ex machina for anyone writing fiction set in the Victorian period. Also, the vast host of victims across the world deserves some sort of tribute I think, even if their deaths lacked cinematic appeal.

As consciousness of the importance of proper water hygiene grew over the 19th century, the cholera outbreaks grew less and less frequent, but mortality in the recorded cases remained high. Even today, cholera outbreaks cause a number of deaths around the world, most often in poor regions with severe water shortage. It also tends to appear following natural catastrophies, such as the earthquake in Haiti in 2010. A donation to an aid organisation for the purpose of supplying refugee camps and disaster areas with clean water is therefore strongly encouraged!


Special thanks to the Swedish Institute for Communicable Disease Control for great and precise information!