Some years ago I did a course in refugee health which had a strong focus on health care in the context of complex humanitarian disasters. One of the situations we discussed was how to handle a cholera epidemic. One thing I remember from that course is that cholera is an illness in which only about 5% of infected persons develop severe diarrhoea. According to the MSF textbook, Refugee Health, An approach to emergency situations (1997), “among infected persons 75% of them will have no symptoms, 20% will have mild or moderate diarrhoea and only 5% a severe clinical infection (or clinical cholera). Cholera is a bacterial infection that I have seldom, if ever, seen in my career as a doctor. This perhaps reflects the locations I have practiced, which have been mainly in developed countries. However, even during the year I spent in southern Africa, the two years working on a ship off the west coast of Africa, and shorter sojourns in the Himalayas and the South Pacific, I don’t remember seeing a single confirmed case of cholera. My main contact with the disease has been in providing vaccinations to people travelling to areas in which they might be exposed, but not one traveller that I have vaccinated has come back with stories to relate of cholera exposure.
Cholera infection is usually acquired by eating food infected with the bacteria. However, in overcrowded conditions where there is poor hygiene, direct transmission from person to person may also occur. Although cholera is quite treatable, an outbreak on a ship is a medical emergency. On a ship in the 1850s it was a catastrophe. This was what happened on the Caesar as it sailed south from Tenerife toward the equator carrying the Fischer family and hundreds of others, from Germany to Australia in December 1854. The feeling associated with the onset of the disaster is easy to discern in Dr Middendorf’s description of the first few cases:
I was called by a man to his child, who was said to have sickened suddenly. I came on deck; the air was humid and damp, the sails hung limp, flapping about the mast, the moon shimmered wanly through the ragged clouds. With a feeling of foreboding, I climbed down the stairway from the quarterdeck and felt a leaden weight in my feet. A wave of hot air came at me from the large hatch and took my breath away, and at the bottom, near the stair, where the air was freshest, sat a woman with a child, whose pallid face was lit by the wan light of the lantern. The child was dying, as I could see at a glance. The woman was crying, but the man was still calm. I couldn’t give them any hope, but I stayed with them, and two hours later the child was dead. While the mother was still bewailing the loss of this infant, she was suddenly alarmed by crying from her second child, who had been sleeping quietly until then. We went at once to the bed. The face of this child – quite healthy until now – was deformed, with sunken eyes and deathly white; there was terrible diarrhoea and continual vomiting. As the day broke, this child was dead too. The father, who was hitherto composed, now wailed, while the mother had no more tears but sat calmly.
Depressed, and in uneasy anticipation of what was to come, I was going towards the cabin when I was fetched by a sailor, who called me to one of his comrades. He was the leading sailor and had still been standing at the helm at 6 o’clock. He lay wrapped in his blanket and looked at me lifelessly with his eyes deep sunken in his head. His face had a deathly colour and was covered with cold sweat, his limbs icy cold and drawn together in a spasm. Every method of bringing him back to himself was fruitless. He died at 1 am.
I was no longer in any doubt as to our tragic fate. I went straight to the captain and informed him that we had cholera on board and that we would lose many people.
The passengers of the Caesar had been at sea for 11 days, and should by then have been getting used to the continuing rolling of the ship through the heavy swells. Dr Middendorf however comments that many were still weak from seasickness, making them more susceptible to illness. The weeks that followed were a depressing time of sickness and death, with sea burials a nightly event. The effect on the passengers was predictable:
The mood of the passengers passed through all the stages that occur in such circumstances: first alarm, then courage or desperation, and finally apathy. No-one knew whether he would be still alive the next day. On land one can protect oneself or flee, but on a ship several hundred miles from the nearest coast, one must have patience and resign oneself. The happiest were the children. They clambered about on the boat under which the dead were laid, and they had no inkling that in many cases they would be stowed under it themselves in a few days time…
Four of the children on the ship were my ancestors. The oldest of the Fischer children was my grandfather’s grandmother, Caroline. She was seven years old when they departed and she had three younger brothers, Charles 5, Heironimys 3 and William who was just one year old. Only Heironimys succumbed to cholera, but it is not unlikely that the rest of the family was ill too. Despite the comment by Dr Middendorf, I find it hard to believe that the children were happy and unaffected by the death and suffering around them. Perhaps the smallest ones, but certainly Caroline, at seven, must have been aware of how desperate the situation was. For their parents Gottfried and Viktoria, both in their early thirties, it must have been a nightmare, and they must have wondered more than once what they had brought their family to, and indeed whether any of them would ever see Australia.
In any such situation people react in different ways, as the doctor observed:
In general, there seemed little sense in their helping one another; no-one bothered about another, even though each could be soon in dire need of the other; that was somehow disputed, so everyone was on their own. In contrast, it was also gratifying that a few real Good Samaritan hearts were to be found, who, with the greatest self-sacrifice, helped where they could.
Perhaps it is wishful thinking to imagine that my ancestors were among the “Good Samaritans,” but what I have read of Caroline’s later life makes me think that though she was only seven she was likely to have been one of the helpers. Later in life, even after raising 11 children of her own, she ended up taking on five more children, one of which was my grandfather, when her first son’s wife died at an early age. She was clearly a strong woman, used to challenges, not shirking the responsibilities that were placed before her. Her earliest experiences as a girl at sea with sick and suffering all around her had been a baptism by fire in the art of caring for people.
The epidemic on board the Caesar eventually subsided, but not until some 66 lives had been lost and many more sick. The doctor’s relief is almost palpable:
On the morning of the 17th of December after sunrise we at last got the southeast trade wind, for which we had so ardently hoped. We were in latitude 5° North. From then on the epidemic was in a process of rapid decrease. At Christmas one more person died – the last; that was our Christmas present. There were now only convalescents. We were very happy that the pestilence had withdrawn from the ship… I breathed freely again, both physically and mentally, since I cannot deny that this beginning of my medical practice had somewhat depressed me.
I understand the feeling!
Quotes are taken from AAZ no.75 24 Sep 1855, p.298-9, translated from the German by Jenny Paterson. For those interested in medical aspects of cholera in the mid 1800s, especially at sea, there is an excellent article in the Journal of Public Health, which can be accessed online here.