# Popular Science Monthly/Volume 43/September 1893/The Pilgrim Path of Cholera

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* THE PILGRIM PATH OF CHOLERA.
By ERNEST HART, F. R. C. S.,
EDITOR OK THE BRITISH MEDICAL JOURNAL; CHAIRMAN OF THE ENGLISH HEALTH SOCIETY.
WITH cholera steadily creeping toward our shores, and all Europe standing armed against the invader, it becomes a matter of the extremest interest to inquire how the disease escapes from its home in India, under what influences it becomes able to break its bounds, invade the outer world, and carry death and devastation into countries where not only has it no natural home, but where it is so far an exotic that even after repeated attempts it fails to become acclimatized.
India is the endemic home of cholera, and from some parts of that great country it is seldom entirely absent. In 1881 there were in India 161,000 deaths from cholera; in 1887, 488,000; in 1888, 270,000. The heat, the moisture, the necessity of drinking stored water, and the habits of the people which make that water foul, all combine to plant firmly in the district a contagium like that of cholera. For the living infection, the contagium vivum of this disease, enters man's body in the water which he drinks, while in return it enters the water by means of the sick man's discharges. A vicious circle is thus set up. Given a temperature and perhaps a condition of water in which this contagium can retain its vitality outside man's body, and a state of society in which the fouling of the water and the drinking of it when foul are daily habits, and we have before us the essentials necessary to render the disease endemic.
Whether this living contagious matter be a bacillus or a spirochæte is almost beside the present question, and under what circumstances of water and soil it grows and propagates, or merely rests, is again for our present purpose not of much importance. What is certain and what is of extreme importance is that incontestably within the human body it grows enormously; that every individual sufferer from cholera is constantly discharging an untold multitude of contagious particles, which are capable of again setting up the disease afresh in any one by whom they are swallowed; and therefore that if these contagious particles are swept by rain showers into streams or wells, or if the water in which linen soiled by them is washed percolates into tanks or ponds, the water so fouled is specifically poisonous and will produce cholera in those who drink it, just as arsenic mixed in water will produce arsenical poisoning.
It is a matter of surprise to many, who have the proofs of this vicious circle nakedly before them, that the truth so long lay hidden, and that even yet men who have lived much among ​era, and who have had large experience of it, should hesitate to admit the fact that the way in which the infection parted with by the one sufferer gets round to another is by the water which the one man fouls and which the other drinks. But, as a fact, those who dwell in the midst of an endemic area, although they may have exceptional opportunities for studying the disease itself, its symptoms, its treatment, and its pathology, are not always so well placed for the investigation of its mode of dissemination as those whose lot is cast in places where the disease is but of exceptional occurrence. In an endemic area the chances of infection are so various and complicated, the difficulty of eliminating other modes of access so enormous, that it is often hard in the extreme to prove the particular route by which the malady has reached its billet. In non-endemic areas, however, things are very different. The disease may not have appeared in the district for months or years; the source of the infection, the first in-carrier of the disease, may usually be known at once, and all his previous doings may be ascertained. With patience every mode of contact or communication between the first and subsequent sufferers may be traced out, free from the interfering influence of possible infection from other sources covert and concealed all around. Thus it happens that much of our most useful knowledge on the subject comes from the investigation of the disease as it has appeared in isolated epidemics rather than in endemic areas.
For Dr. Snow, of London, I must once more claim the great honor of being the first to recognize water as a medium of disseminating cholera. His deductions to this effect, from his observations of cholera in England between 1848 and 1854, were, as I have elsewhere shown, confirmed by the elaborate investigation of Farr and Simon; and in I860, following in the same footsteps, I placed the corner stone of the edifice by tracing the disastrous cholera epidemic of that year in East London to the distribution of polluted and partially filtered water from the river Lee, by the East London Water Company—the poisonous sewage of one family distributed unfiltered for forty-eight miles. Since that startling experience, I have been convinced that specifically polluted water is not merely an occasional or adjuvant cause, but the causa causans of almost every great epidemic of Asiatic cholera.
The earliest important instance in which the agency of water as a disseminator of cholera was clearly demonstrated was that of the Broad Street pump in St. James's, Westminster. The first death in the parish was recorded early in August, 1854, and throughout that month a few deaths occurred each week, but during the week ending September 'id, seventy-eight deaths were registered, in the next week there were two hundred and ​eighty-seven deaths, in the following week there were sixty-seven, and then the mortality as quickly subsided as it had arisen. No satisfactory solution of this mysterious outbreak presented itself until Dr. Snow was called in to examine the water supplies. His published report shows the clearly marked incidence of the disease on those who drank from the parish pump. The workers in one particular factory where the water was always used suffered severely from cholera, while those in an adjoining brewery, where the water was never touched, escaped, and numerous instances of fatal attacks of cholera following the use of the treacherously sparkling water from this pump are detailed. On the drains of the house adjoining the well being opened, it was found that there was a cesspool under a common privy, within three feet of the well, and at a higher level than that of the water in it; that the walls of the cesspool being rotten, the contents leaked into the surrounding soil; that the walls of the well were also rotten, and that there was distinct evidence of the cesspool contents having for a long time leaked into the well. Then came the startling fact that in the house itself a child aged five months had died on September 2d, of so-called "diarrha," but with distinctly choleraic symptoms.
In 1866 England was again invaded by cholera, and that epidemic is memorable for the terrible experiment which was unconsciously carried out by a water company at the expense of some four thousand lives in East London. Early in the outbreak I was struck by its incidence on the area supplied by the East London Water Company, and I felt confident that it could only be due to a sudden specific pollution of the water supply. Acting on behalf of a great medical journal, I dispatched the late Mr. J. Netten Radcliffe—who had not then become attached to the Medical Department of the Privy Council—to investigate the matter. After much trouble, the result showed that owing to changes having been made in their filtering apparatus, the company had sent out for a few days unfiltered water, or water in a very partially filtered state, direct from the river Lee, which had just at that moment become infected with choleraic discharges from a cottage, the sewers of which were connected with the river, and in which a family had come to reside who had reached Southampton infected with cholera and had been allowed to pass on after they were supposed to have recovered.
Fig. 1.—View of Tolly’s Nullah and One of the Ghats on the Morning of February 8, 1891. The nullah is crowded with boats carrying pilgrims. and pilgrims bathing in the sacred stream.
​they drink. The same was shown in Egypt in I880, in France in 1884, and again in the department of Finistère almost at the present time.
In Italy, Naples has afforded one of the most striking examples of the same thing. Commencing in August, 1884, the epidemic spread by rapid strides until September 11th, and then rapidly fell. Between August 23d and November 9th some 12,345 cases and 7,086 deaths occurred among a population of 402,908. At that period the water supply of Naples was mainly derived from trenches running from house to house underground, and was exposed to direct contamination not only by soakage of filth, but by the reckless practice of washing in the trenches linen soiled by choleraic discharges.
In the following year Naples was supplied with pure water from a distant mountain stream (the Serino), and there followed a marked immunity of the city from cholera, notwithstanding the presence of the disease in the neighborhood. In 1887, however, an injury to the Serino water conduit led to a temporary return to the old system, and two sharp explosions of cholera at once ensued, but ceased on the resumption of the purer supply. Even more demonstrative was the case of Genoa, a city provided by means of three aqueducts with an excellent supply of a naturally good water. After a few scattered cases a sudden and widespread explosion of cholera occurred between September 21st and 24th, the rich and the poor being indiscriminately attacked. It was soon found that of the first three hundred cases ninety-three per cent were in houses supplied by one of those aqueducts (the Nicolay), and on following that watercourse to its commencement near the village of Busalla, thirteen miles distant, a colony of workmen was found encamped. Cholera had broken out in Busalla on September 14th, and inquiry disclosed the fact that the clothing of the workmen, both of the sick and the healthy, was washed in the river Scrivia, which feeds the Nicolay aqueduct. The supply of this water to Genoa was promptly stopped on September 28th, and the epidemic at once rapidly declined.
Everywhere the same tale is told, but my present immediate object is to insist that also in India, the "home of cholera," it is now clear—to me at least—that water is the agent by which the infection is carried from one human being to another.
The experiences of Calcutta, as observed by Dr. W. J. Simpson, the able health officer of that city, show that those persons who have an abundant and pure water supply—namely, the Europeans and better-class natives—escape cholera epidemics, except in isolated instances which can generally be accounted for; while the natives who depend on tank water suffer severely when a tank becomes polluted by the excreta of a cholera patient.
​I think it capable of proof that it is on the scarcity of water, and on the habits and customs which have grown up during centuries of suffering from that scarcity, that the existence even of the "endemic area," the natural "home of cholera," depends. If this be admitted—and I think it can no longer be denied—the fact and necessary inferences from it are of vast and world-wide importance. The natives bathe and wash their utensils and clothes in the tank, because it is the only available place in which to do so, and they use the water of the tank, contaminated as it is in addition by soakage and sewage, for cooking and drinking, because it is the only water supply available for domestic purposes.
With these facts before us, and reading them in the light of our European experience, it can no longer be doubted by thoughtful and reasonable persons that the reason why, in India as in other places, some classes escape and others suffer, is that some drink pure water and others drink water contaminated with choleraic discharges.
Nor can we shut our eyes to the probability, growing stronger every year, that the true meaning of the term "endemic area," in regard to cholera, is a district in which the customs of the people sanction the drinking of fecally polluted water, and in which from temperature, and perhaps from other causes incompletely known, the cholera germ or contagium can easily keep alive and propagate itself in soil or water in the interval between its exit from one host and its entry into another.
Nothing seems more certain than that people can touch cholera patients, and rub them, handle them, and live with them, even in the midst of an endemic area, and not catch the disease so long as they take precautions not to swallow it.
This is the key to the position, the horrid truth, the dirty fact, that the bacillus, the contagium of cholera, lives two lives: one, in the human body, causing the disease, multiplying within the patient, and poured forth by him in abundance; the other, outside the body, waiting in damp ground, on soiled linen, in dirty water—waiting to be swallowed by some one else and to start again on its destructive course. How, then, does it get round? We know well enough that the outside of a cholera patient is not infectious; the infection comes from within, with the discharges; how, then, does it get into the alimentary canal? How can it get round except in what we drink?
Fig. 2.—Sacred pool at Hurdwar.
​the infection from its previous breeding ground within the body of a previous patient. We now can understand why, when cholera spreads and breaks its bounds, it follows the lines of human traffic and communication. Man, in fact, is the porter by whom the cholera is carried from place to place, and so the rate of diffusion depends upon the rate of travel. But, as no one porter can carry the malady further than he can go between the time of being infected and being struck down, the wide spread of the disease depends not only on the speed of the porter, but on the sanitary condition and social habits of the place where he is taken ill; for, if these are such that he can transfer his load to others, that the infection he deposits can take root and grow in the bodies of fresh patients, some of whom may travel to fresh places and set up fresh foci of disease, the epidemic spreads; but if, from cleanly habits or clean surroundings, or from plentiful supply of pure water, the infection fails to pass from body to body, the malady dies out, and there is an end of the matter. King Cholera is, in truth, a lazy and voluptuous potentate; unless he is carried by quick steamers, he will not travel far without a rest, and when he reaches his destination he declines either to advance or show his power unless he is nourished and pampered with his beloved luxuries of dirt and filth and fecally contaminated water.
The inhabitants of the Indian "endemic area" are a conservative race—the son lives like the father; one generation passes on like another, and centuries of intermittent pestilence and famine have till lately kept down the population to exactly tally with the means of sustenance. The village community has been for ages the unit which, multiplied by thousands, has made up the population. Each village has mostly kept to itself, and, except for the wars of their rulers, the passage of their traders, and their occasional pilgrimages, they have for time immemorial lived an isolated life. At times of pilgrimage, however, all this isolation is cast aside, and pilgrims from widely scattered districts rub shoulders in the bathing places, wash and cleanse their bodies and their clothes in the same water, which in turn they drink in an unsavory fellowship.
Disease may remain for long tied up in a single village; nay, a whole village may die of cholera, and do but little damage to their neighbors; but in times of pilgrimage cholera travels with the pilgrims, and, after the festival is over, is scattered broadcast through the land. Such fairs as that at Hurdwar, at the junction of the hills and plains, outside the endemic area, but attended largely by those who dwell within, have beyond doubt been the great gateways by which cholera has periodically escaped from its confines to ravage the world at large. Of this the historic ​records give abundant evidence, especially in the epidemics of 1867 and 1870.
But, spread all over the country, especially in its northern parts, there is a large Mohammedan population, from among whom there pours out an annual pilgrimage which wends its way to Mecca, the holy place which every faithful Moslem strives to reach—a pilgrimage which of late years has been a recurring danger to the Western world, having been the means of introducing to Egypt in 1866 that outbreak of cholera which carried off sixty thousand of its inhabitants in the course of three months; and of sending on to England the infection, which destroyed six thousand people in London; besides being the origin of the various epidemics which have fallen so heavily on the south of Europe, although they have not done great harm to our own more favored land.
The fairs and pilgrimages of the East constitute the danger of the West, and it is now recognized in every land that this danger is vastly aggravated by the, greater rapidity of communication in these latter days. When by weary marches, or sailing in small boats, tacking day after day against opposing winds, months, nay sometimes years, were spent in the journey, those who were taken ill died in the transit; whole caravans melted away, and ships with cholera-stricken crews were lost, together with their crowded cargo of holy pilgrims, and thus the outer world was saved. But with quicker means of communication, with railways and steamboats, and the general hurry of modern life, pilgrims also have quickened their pace, and, what is most important, have lengthened the stages and lightened the labor of their journey, so that the infected ones have lived through hundreds instead of tens of miles before they dropped, and have thus surmounted the barrier of desert and of sea by which Europe was formerly protected. No longer does cholera necessarily sneak round by Russia and the Caucasus, infecting the various resting places on its way, and setting out again as opportunity arises and as caravans and travelers may serve. At one bound it is in Jiddah. Mecca becomes a center of infection, and Red Sea ports distribute the disease to Egypt and the south of Europe.
Ordinary traffic can be watched, and by medical inspection cases of disease can be picked out and isolated; but with a sudden crowding of sixty thousand people devoid of all sanitary knowledge into a country ill equipped with sanitary appliances, governed by rulers whose chief principle and guide is a fatalistic trust in the will of Allah, the problem is complicated in a high degree.
It must not be forgotten that the spread of cholera is not entirely due to the infection carried by those who are attacked. No ​man can carry it more than one stage, and whether or not it starts again from the place where he deposits the infection depends on the sanitary conditions of the locality and the customs of the people. There is but little doubt that the danger caused by the Mecca pilgrimage to the health of Europe depends largely on the fact that from the recklessness of the people and the absence of adequate sanitary arrangements in the district, Mecca has become a great central fair for the exchange and distribution of the cholera infection.
In 1886 thirty thousand pilgrims died of cholera at Mecca. Nor can we wonder. Everything seems to be done to destroy their tone and their resisting power; everything seems to be arranged to spread the disease when the infection is once planted amid the host of pilgrims.
Fig. 3.—Approach to the Sacred Pool of the Hurdwar, with Pilgrims bathing.
​What is to happen to the crowd of pilgrims who close in on the spot that he has left, and who, each in turn, swallow in rapt fervor the fetid draught in which these thousands have been washed? Can we wonder, then, knowing the history of the Broad Street pump, that in 1866, within a few days of the ceremony, the road leading from Mecca was for twelve miles thickly strewn with dead bodies—a holocaust to be added to the account of perverted religious rites which has already so deadly a record?
Gradually England is undertaking the gigantic task of not only ruling India—a thing to which India has been accustomed for untold centuries—but of reforming and remodeling her habits and her customs, a thing hitherto quite unknown, untried, and thought by many to be impossible. A stolid mass of conservatism of habit and even of thought has to be moved, and has to be so moved as not to drift into anarchy and reaction. This is a long, slow, tedious process. The existence of the "endemic area," the "home of cholera," depends largely on the persistence of habits and modes of life which can hardly be rooted out. If they are to cease, they must probably die away or be slowly crushed out rather than be swiftly overturned. We may at once make up our minds that if the safety of Europe can only be attained by abolishing cholera in India, Europe will for long remain in danger. It is hard to say how long: the object of this essay is to abridge the period to the utmost. To those, again, who know best the condition of the towns in the south of Europe it seems an almost equally far-off hope to expect them within any reasonable time to reach such a condition of cleanliness and sanitary preparedness as to be able to look calmly on the approach of the dread disease. But this is a much less formidable and more hopeful task, when once it is courageously and persistently faced. Are we meantime to stand helpless? Can nothing be done to stop the infection on the way? Not so. In the matter of ordinary travelers isolation of the infected need not be insuperably difficult. The individual attacked may be sent to a properly equipped hospital, be surrounded by a true cordon sanitaire in the modern sense—not a ring of gendarmes or a circle of quarantine as of old, but an area of sanitation, within which cholera can not spread. Within this area the disease may expend its force with injury to no one and the crisis pass without danger to the country. But the case of the pilgrims is different. Fairs and pilgrimages of India differ from other means of spreading the disease in this, that not only do they draw people from all parts and thus increase the chances of receiving the infection, but the people attend them in such numbers that they support each other in carrying on their own customs, the very customs which have for centuries conduced to the spread of the disease in cholera's home. It is as if the fair or ​the pilgrimage were not only supplied with a proper dose of the infection, but were provided with a plot of the "endemic area" on which it could be grown. In bedding out a plant we do not put its naked roots into the new inhospitable soil, but we place in the new ground a portion of the mold in which it hitherto has grown, so that its tender rootlets may gradually get accustomed to their new surroundings. And the fairs and pilgrimages of India do much the same to plant the cholera in the new localities. The infection carried from the endemic area can not die out, even although it be but an exotic in a strange land, because the people carry with them also the habits and customs which are conducive to its growth, the willingness to use the same water for every purpose, the readiness to drink it when in its foulest state.
In a report in June, 1891, Dr. W. J. Simpson, of Calcutta, gave a picturesque and startling account of two large pilgrimages which he personally witnessed in that year—one in the endemic area of Bengal, and another in the non-endemic area, or north part of India. A pictorial presentation of one of their chief features, which I am able to give from private photographic plates that he has furnished me, will show the condition more effectively than merely verbal discussion.
The first of these was the Ardhodoya Jog, which comes round at rare intervals, happening only when the moon is in conjunction with the sun in a certain latitude of the Indian zodiac. This event, it appears, only occurs once in twenty-seven or twenty-eight years, and is then made the occasion for a great bathing festival. The purity to be obtained by bathing in the Ganges during this festival is exceptionally great, and therefore the gathering of pilgrims at the several bathing grounds was a very large one.
Kalighat, where the gathering in question took place, is the suburban area of Calcutta, on Tolly's Nullah, a small tidal creek which is held to be more sacred than the Hooghly, because it is believed to be one of the original beds of the Ganges which has gradually silted up. Sanctity, however, in these parts is no assurance of decency. Along its banks on both sides houses and huts are built, the drainage from the latrines of which finds an easy and convenient outlet into the streamlet. Soiled clothes of the sick and healthy are washed here; oxen, buffaloes, horses, goats, and other animals take their bath in the water; and as the nullah has frequently passing through it many country boats, the boatmen add to the general pollution.
Kalighat, like the other suburbs of Calcutta, also possesses a large number of tanks or ponds, round which the huts or houses of the inhabitants are built, and which are the drainage cesspools of the locality. Much has been said concerning the filthiness of ​these tanks. Their contents more or less resemble pea-soup in color, and their composition has been officially reported as similar to concentrated London sewage. Those conversant with the uses to which these tanks are put will not be surprised at this statement. And yet these ponds of filth are constantly resorted to for the cleansing of utensils and the soaking, maceration, and washing of the rice and dahl, and in the preparation of sweetmeats.
The nullah can be waded across at low tide, but it is the receptacle of unspeakable filth of all kinds. After describing the insanitary arrangements of the neighborhood. Dr. Simpson remarks that "without a good water supply, or drainage, or proper means of disposal of the excreta and sulliage, with crowding together of huts and houses irregularly placed, and with the filthy tidal nullah, which is practically the sewer of the district, and with numerous polluted tanks, Kalighat, it may be surmised, is at no time a healthy spot, and at all times a danger to pilgrims." On the occasion in question at least 150,000 people came into Calcutta in the first and second weeks in February. Great throngs came on foot whose numbers were not noted, 25,000 came by boat up the nullah, 90,000 came by the Eastern Bengal State Railway, and 32,000 by the East Indian Railway. Obviously the influence of railways in intensifying the danger of quick and wide diffusion of cholera after great festivals must not be neglected.
To describe the crowding which occurred in the nullah on the festival day is difficult. Perhaps the accompanying photographs will give some idea of the scene, and of the recklessness with which the filthy water was being bathed in and splashed over the head and even drunk. A large proportion of the pilgrims would not drink filtered water. They had come, they said, to bathe in and drink Ganges water, and they would have none from the standposts or the carts. Happily, the tube-well near the police station was not considered unholy, and was in lively requisition. The picture shows the crush to be very great, and it is marvelous that no accidents happened.
Fig. 4.—Pilgrims Swarming around the Sacred Pool at Hurdwar.
​To the pilgrims themselves the festival turned out a disastrous affair, but later investigation showed that in many villages to which they returned the residents also were affected, and that in at least three districts widespread epidemics were set up.
Such is a pilgrimage within the "endemic area" where perhaps it may be said that the danger in regard to cholera may be measured by the deaths, the dissemination of the infection through a population already charged with it not being of great importance.
But any Indian pilgrimage, even in a non-endemic area, has much the same characteristics. Dr. Simpson's description of the great Kumbh festival, which occurs once in twelve years at Hurdwar, outside the endemic area, is also very graphic, and the photographs (Figs. 2, 3, and 4) show the sacred pool and the approaches to it to be hidden by a mass of semi-naked human beings. The pollutions to which the sacred pool is exposed on these occasions are indescribable. There are not only the washing of the sacred fakirs, who cover themselves with wood ashes as their only clothing, and the general bathing of the pilgrims, who are not all in the cleanest of clothes—several, moreover, on the occasion in question being seen bathing with skin diseases upon them—but the ashes of deceased relatives brought from the different homes of the pilgrims, and the hair of widows who have been shorn, are also thrown into the water. The stream, usually so bright and pure, soon became a muddy one, offensive to the senses, and, although outside the endemic area, bacteriological examination of this defiled water showed it to contain the comma bacillus, which is looked upon as the true contagium of cholera.
With these pictures in our minds of what an Eastern pilgrimage means, and of what is done at the great festivals, whether of Hinduism or Mohammedanism, can we wonder that they are so constantly the means of lifting cholera out of its ordinary endemic character and spreading it over the world at large? In old times when cholera marched overland its route could almost be dotted out by the fairs which it infected. Now, with more rapid means of communication, Mecca, with of course Jiddah its port, is the half-way house, the halting place, the one spot at which it must be caught and stopped if Europe is to be protected. Hither tend pilgrims from all parts, including those from the infected area; here are performed rites which involve of necessity the wide spread of the infection among the visitors, if even perchance but one of them bring with him the disease; hence in a fortnight's time is scattered this great host, carrying with them the germs of pestilence to their homes in distant lands. Mecca is a peril to Europe, and at all cost Mecca must be made a sanitary area, in which cholera if it should arrive can play itself out, and from ​which no infection shall be allowed to be exported. It is, however, idle to expect a Government such as that of Turkey spontaneously to undertake the task. The affair is too expensive to be undertaken by a ruler to whom ready cash is worth more than prospective suffering. Nor would his people support him in such a crusade. To them Allah is great, and cholera is his will; nor perhaps does the evil seem to them so grievous as it does to us. To those who have to suffer Turkish rule a little cholera now and then may seem but a flea-bite.
It seems probable that no single nation can effectually interfere, although if any one nation could do so, it would be England or Russia. The danger belongs, however, to Europe; and if anything is to be done, Europe collectively should take action without delay, with the aim to cleanse the ports of the Red Sea, reorganize Mecca and its greedy crew, and supervise the pilgrims in all their course. With the increasing care, and the increasing intelligence with which that care is being exercised, in regard to cholera in Europe, and with the facilities given by the telegraph for watching the progress of cholera when it approaches via Russia, and the growing willingness shown by that great state to block the way when it invades her vast dominions, the Red Sea remains the route from which Europe and America have most to fear, and Mecca with its insanitary surroundings, its filthy rites, its crowds of devotees, stands as the half-way house between Europe and the home of cholera. Can we not for once think of the good of man rather than of nations? With railways and steamers linking us so closely in one family, we can no longer afford to fold our arms and look with indifference even at the strange