Cholera Epidemic in 1831 in Zemplín County and Measures Against its Spread

The second wave of cholera, spreading from Asia since 1826, reached the borders of Hungary after five years of relentless progression. By 1830, reports emerged of the disease ravaging Moscow and Kazan, and within months, it became a reality in neighbouring Halych and Moldavia. Thus, the potential routes for the disease's entry into Hungary were either from the north, through Halych, or from the Romanian Principality via the Carpathian Mountains. As early as November 1830, Emperor Francis I issued a decree to close the Hungarian-Halych border and enforce strict boarder control, as this region was considered a high-risk area for the disease's transmission. In Hungary, health matters fell under the jurisdiction of the Local Government Council, which was responsible for monitoring the cholera outbreak and implementing preventive measures. Dr. Michal Lenhossék (20),²⁰ the chief regional physician, was a member of this council. On December 21, 1830, the Local Government Council issued instructions to the authorities on how to prevent the entry and spread of the cholera contagion. This directive was translated into German and other languages spoken in the country to ensure it was understood by as many people as possible (21).²¹

As the threat of cholera appeared to subside in the following months, and with troops needed to quell disturbances breaking out in Italy, border closures were relaxed in March 1831. Although these measures were soon reinstated, they were no longer effective in preventing the transmission of the disease. Since cholera was a new illness in Europe and doctors lacked experience in treating it, they initially resorted to methods previously used during plague epidemics (Pestis Verordnung) (4). Meanwhile, the Hungarian Governor's Council decided to appoint special royal commissioners to devise and oversee the implementation of protective measures against cholera. For the region spanning from Trenčín County to Ung County, this responsibility was assigned to County Mayor Anton Majláth, Count of Zemplín. For the Transylvanian border area, the mayor of Bereg and Uh Counties, Žigmund Perényi, was appointed (4). Based on the first cases of cholera and their geographical distribution, as well as contemporary reports, the prevailing opinion is that the disease was most likely introduced into Hungary by salt traders or rafters navigating the Tisza River. The first cases of cholera appeared in June 1831 in Bereg²², Zemplín, Ugoča, Satmár and Šariš Counties (21). However, early reports also surfaced in Turiec and Heveš Counties, and by July, cases had spread throughout the entire country.

In addition to the efforts of the royal commissioners, who were advised by doctors from the Faculty of Medicine at the University of Pest, Ľudovít Tognio and Pavol Bugát, the counties and their leadership played a crucial organizational role in combating the spread of the cholera epidemic (2). As previously mentioned, Count Anton Majláth served as the county mayor of Zemplín County. In May 1831, he reorganized key county positions, retaining Pavol Meczner and Martin Csermák as county physicians. In addition to them, the county employed seven surgeons: Jozef Fortmayer, Šimon Somogyi, Adam Bátor, Ignác Trefort, Jozef Csíky, František Szabó, and Andrej Fekete (22). The anti-cholera commission of Zemplín County met for the first time on 27 June 1831, and its minutes recorded the first case of cholera in the village of Trakany on 24 June (1). A letter from Mikuláš Kozma, the sub-servant of Michalovce, was also noted in the minutes, stating that he had taken all necessary measures: the village was placed under quarantine, and the army was dispatched there. All individuals suspected of infection were placed under strict surveillance. In addition to Trakany, the neighbouring villages of Agárd and Leányvár were also quarantined.²³

In Zemplín County, even before the first cases of the disease were discovered, general precautions for doctors and the public regarding the recognition of cholera and the subsequent care of the sick were distributed on 21^st December 1830. The document briefly described the origin of cholera and its gradual penetration into Europe. This was followed by an appeal to the authorities and the public to do their utmost to prevent the “spread of this terrible scourge” by taking necessary precautions (1). As a basic measure, a military cordon was established both on land and in ports. Doctors and officials were obliged to monitor all suspicious cases and report them immediately to the higher authorities, who, in turn, would notify the Local Government Council. The warning also applied to the receipt of mail from Russia, which, according to the instructions, was to be treated as if “it had come from the area most affected by the plague”. For this reason, smoking and quarantine stations were established, where individuals were required to remain for a period of 20 to 40 days. The aim of these stations was to control goods, people, and correspondence in order to prevent the transmission of the disease.

Much more space was devoted in the document to measures that should have already addressed the state of cholera's penetration into the country. First and foremost, it was essential that the disease be correctly identified, meaning its symptoms should be known not only by doctors but also by the general public. Weakness, chills, dullness, headache, loss of appetite, dizziness, strong heartbeat, sweating, hot flushes, and feeling cold were cited as the first symptoms. Following these symptoms, those infected would suddenly develop abdominal cramps, a feeling of vomiting, or an overfull stomach. Diarrhoea or vomiting then follows. Stools become progressively thinner and whiter. A sensation of dry mouth sets in, the tongue becomes blue or white, the tips of the fingers become cold, the pulse weakens, the face appears sunken, and the blood thickens to an almost black colour. The duration of the disease is very short; few patients survive more than two days; some die within twelve hours. If the skin shrivels, convulsions cease, and loses consciousness, it is evident that death is imminent. However, if, before the convulsions cease, bile begins to pass with the stool and the tips of the fingers no longer feel cold, there may be hope for recovery. If the symptoms described above appear, a doctor must be called, who is required to report the case to the Local Government Council. Concealment of illness will be punished very severely. Consequently, the isolation of such individuals must be carried out immediately.

Despite the detailed description of symptoms, it often happened that even the doctors themselves could not determine whether it was always cholera or some other form of infection or food poisoning. Such a case was reported to the Health Commission of the Zemplín County on 4^th July 1831, by the chief county physician, Martin Csermák. He provided a detailed description of a seventy-year-old tailor from Michalovce who, along with his family, had eaten mushrooms and stuffed cabbage leaves for dinner, all without lard, with only a small amount of salt, and washed it down with water. In the morning, while he was working, he became ill, started vomiting, had diarrhoea, and died at midnight that day. The doctor who was called stated that it was probably cholera, and that the family had been quarantined as a precaution. However, he expressed the opinion that an autopsy would conclusively prove this diagnosis. He did not wish to carry it out, though, because “he feared that people would be afraid to approach someone who had handled the body of a dead man with cholera.” (1).

The 1830 guideline for the population emphasized of taking measures to eliminate all factors from the environment that could contribute to an outbreak. Such factors included damp air, cold temperatures, closed and unventilated rooms, inadequate physical or mental activity, and insufficient clothing. The next paragraph enumerated specific practices to observe in combating the disease. It was especially important to keep the rooms clean and well-ventilated, maintaining a reasonable temperature of about 15° on the Réaumur scale. Every day, the patient's room was to be fumigated with vinegar or chlorine steam, or it should be doused with chlorine-lime water twice a day. Particular care was to be taken to remove all patients’ excretions thoroughly and promptly, which were to be poured into separate, more distant pits, then covered with lime and subsequently with earth.

Apart from environmental factors, food was also deemed important. An easily digestible diet was recommended, with the use of even common spices to be kept moderate. On the other hand, the consumption of fresh fruit, especially sour or unripe fruit, was to be avoided, and pumpkins, cucumbers, and grapes were to be completely excluded from the diet. Foods that were fermented or sour were also discouraged, while curd cheese, salty fish, and fatty foods were forbidden. A glass of brandy or liqueur was recommended before breakfast, particularly if it contained mint, caraway, aniseed, or juniper, with another glass of wine suggested during the day. However, it was strongly advised to practice utmost moderation, as it was literally stated that “nothing is worse for contracting cholera than drunkenness”. The guidelines also included a call for pub and inn operators, as well as bakers, to be mindful of these regulations and maintain cleanliness. People were admonished to observe good living habits, such as not working on an empty stomach, not staying overnight in unsanitary conditions, avoiding excessively strenuous work, and dressing appropriately. Among the recommendations was a call for preachers to help people find mental well-being. Doctors and preachers alike were admonished in a separate paragraph to follow these principles. They were to wash their hands, face, and the area around their mouths with vinegar or chlorine water whenever they visited a sick person. After leaving the sick, they were to wash their clothes thoroughly. Grave diggers were also urged to exercise similar caution. The last and most extensive part of the regulation concerned the care of the sick.

The first therapy suggested was venesection, with the amount of blood drained recommended to be no more than 12 to 15 ounces.²⁴ If the blood was very thick, the patient should be warmed up, preferably in a warm water bath. To relieve convulsions, it was recommended to administer calomel²⁵ and opium. Keeping the patient warm was essential, and the areas around the abdomen and heart should be rubbed with a soap, camphor, or ammonia solution; mint oil or sourdough could also be used. If the patient vomited, calomel or opium mixed in honey should be administered and rubbed over the mucous membrane of the mouth. Rice or barley gruel, or a decoction of hibiscus, with 3 to 4 ounces of opium added, could also be given to relieve stomach pain. Another soothing preparation could be made from crushed flax seeds mixed with 30 to 40 drops of laudanum, which is essentially an opium solution. To quench thirst, the patient was to be given a rice or barley decoction or a decoction of water and cloves. If the patient's condition improved and they had no diarrhoea, vomiting or cramps for 5 to 6 hours, they should stop taking their medication and instead have mint or lemon balm tea, or a sugar cube drizzled with mint oil. The drug therapy should be completed by the ingestion of a tincture of rhubarb or gum arabic²⁶ dissolved in spiced water (23).

If the vomiting stopped, the patient should be given soups to replenish strength, such as barley or rice soup, along with a glass of good wine to lift their spirits. If the patient was constipated, an ounce of castor oil, one drachma²⁷ of magnesium, or 10 to 15 grams of rhubarb powder diluted with water was to be administered (24). It is important for those in charge (pharmacists) to ensure that enough good-quality medicines are available in pharmacies.

The last paragraph was a directive to the authorities to have this document translated into a language understandable to every citizen²⁸ and disseminated to all areas of the country (4, 1).

It is clear from the medical reports submitted to the Medical Commission of the Zemplín County that the doctors tried to apply these recommendations when caring for patients. Doctor Jozef Fortmayer sent the commission a detailed report on the state of the disease in the village of Trakany. In his report, he described a patient, Maria Kalapos, who presented with burning pain in the stomach and severe cramps. In addition to administering calomel, he ordered that she be kept warm. The next day he prescribed mint oil mixed with Hofmann's liqueur (25)²⁹ and Sydenham's solution (26)³⁰. Another patient, named Mlynár, was given a laudanum solution; the following day, he was to receive rhubarb-honey tea. Fortmayer's report covers a period of five days, and on the last day, 6^th July, he again mentioned both patients, saying that they would probably survive, and the therapy should continue. However, he also noted several cases of both old and young individuals who died during that time. The doctor acknowledged a high mortality rate but was not convinced in all cases that the cause was cholera (1).

The anti-cholera commission of Zemplín County monitored the situation regarding the disease in its individual districts on a daily basis. In addition to information on the number of infected individuals, deceased people, and treatment status, the minutes also included detailed reports on the guarding of district borders within the county. Twelve men (listed by name in the table below) from the surrounding villages were continuously rotated in guarding the borders in the Papin district at two-day intervals during the month of June. A similar list was maintained for the landlord town of Stropkov, where four guards were also rotated at two-day intervals to watch over the bridge crossing the river flowing from the village of Bukovec at the northern end of the town (1). These precise records demonstrate that the leadership of the individual districts, as well as the county itself, took responsible measures to prevent the spread of the disease.

As early as the beginning of June 1831, reports of grain and food shortages in some villages began to appear in the reports of district servants. Wherever the infected were found, the villages were quarantined, preventing people from going to the fields to harvest their crops at the start of the harvest season, as well as from attending the markets, which were also prohibited. In addition to fears of contagion, there was also the threat of hunger. The county leadership had to address not only medical problems but also the supply of food to the affected villages in the region of the Medzibodrog (1). The neighbouring county of Sabolč was expected to assist with the food shortage. The Commission suggested specific locations³¹ where the passage of people and goods between the counties could occur. By mid-July, the first reports of medicine shortages began to surface. The chief physician, Martin Csermák, reported to the commission that the number of infections was rising in Michalovce and Lastovce, but the pharmacies were running low on supplies (1). However, as the doctor noted, "the need is man′s best teacher", so he experimented with a new medicine that had already helped four patients, though he did not elaborate on what the medicine was (1). Alongside the shortage of food and medicine, there soon arose ae shortage of doctors. Many either fell ill themselves, or struggled to cope with influx of patients under the travel conditions of the time. The problem was particularly serious in the district of Sečovce, where Anton Bekes, a sub-servant, reported a shortage of doctors. The landowners of Sečovce approached Zemplín County with a request to send a doctor (1).

During July 1831, the leadership of Zemplín County sought assistance from neighbouring regions to provide doctors. By the end of the month, doctors from Denmark had arrived. The royal commissioner, Count Majláth, informed the vice-mayor about the arrival of the doctors and requested a favourable reception. Two Danish physicians – Samuel Jakub Ballin and Ludovít Juraj Viliam Thune – were sent to familiarize themselves with the new disease and the possibilities for its treatment. However, the sources do not indicate how long they stayed or whether they assisted in the treatment of the sick (1). In addition to the shortage of doctors, there were isolated cases of issues regarding the doctors themselves and their practice of the profession. Dr. Csermák drew attention to the lack of patient care by surgeon Jozef Csíky in the Michalovce district. He wrote a letter to the vice-mayor complaining about Csíky, stating that he neglected his duties as a surgeon, did not comply with the ordered measures, approached his work very laxly, and lacked collegiality and empathy towards patients. In his letter, Csermák pleaded with the vice-mayor to address the situation with Csíky, and also requested that a new surgeon be sent to the district (1).

As more and more people became ill, the management sought to devise further measures against cholera. Count Anton Majláth, Royal Commissioner and Mayor of Zemplín County, ordered that in each village, as far as conditions permitted, the sick should be isolated in a single building, functioning as a makeshift hospital. In villages where this was not possible, the sick patients were to be separated and cared for by only one person.

As the number of deaths increased, the county had to issue guidelines on burials. Regardless of beliefs and burial traditions, those who died of cholera had to be buried, following the advice of doctors or surgeons, in special cemeteries away from roads and areas with larger concentrations of people. The excavated pits had to be at least 8 feet deep and spaced 4 feet apart. Due to the rising death toll, it was recommended that gravediggers excavate the pits in advance. After the dead had been examined by a doctor, the body was to be buried within 24 hours, with the stipulation that gravediggers were forbidden to touch the bodies or clothing with their hands, using special tongs instead.

Bodies were to be taken away for burial at night in closed coffins on wagons, without an escort or official burial ceremony, and even the ringing of bells was forbidden.³² The body was to be placed in a pit, the clothing burned, and the ashes also poured into the grave. The pit was then filled in, and soil had to be piled on top of it. After burial, the gravediggers were to be kept in quarantine for 42 days and were required to dispose of the clothes they had been wearing. Once the cholera outbreak had subsided, memorial pillars were to be erected at these sites (1).

In August, the situation did not improve regarding cholera or food shortage, eventually leading to the infamous cholera uprising, which became centred in the villages and towns of Zemplín County. At the beginning of August, reports came from Trebišov from the local military lieutenant Abrahám and the servant Tomsics regarding an outbreak of riots among the subjects, along with a request for instructions and, especially, reinforcements. A few days later, riots also broke out in the nearby villages of Sečovská Polianka, Plechotice, and Oborín. Reports of violence by subjects against landlords emerged from Vel’ké Ozorovice and Humenné. In addition to the relentless cholera epidemic, the deterioration of social conditions and widespread hunger among the population contributed to the rising tension. Various superstitions circulated, particularly the legend that landowners were deliberately poisoning wells to harm their subjects. Like cholera, attacks by subjects gradually spread to noble courts, local priests, and the neighbouring capitals of what is now eastern Slovakia. As a result of this situation, the management of Zemplín County had to address the rebellious subjects instead of focusing on combating cholera.