SOURCE: Hamlin, Christopher. “A Political Medicine.” In Public Health and Social Justice in the Age of Chadwick: Britain, 1800-1854, pp. 52-83. Cambridge: Cambridge University Press, 1998.

[In the following essay, Hamlin provides the context for both Chadwick's Sanitary Report and for the issue of public health reform in general. Hamlin details the slow recognition of social factors that could lead to disease and the assumptions about class that had permitted unsanitary conditions to continue and flourish. At the point when Chadwick introduced his Report, Hamlin observes a tension between public health advocates who critique the fundamental systems of industrial society and those who felt that class differences, even at the level of health and happiness, were part of an unchangeable Providential plan.]

The great social issues of the first half of the nineteenth century—hunger, public order, population, and conditions of work—were stated as issues of health. It is almost inevitable that medical men would have been asked to comment on them, yet as we have seen, the profession made no effort to become public guardians of the people's health. There were good reasons to keep old client-based networks; moreover, medicine was ill-equipped to colonize. It was a crowded and divided profession: physicians, surgeons, and apothecaries (and increasingly those general practitioners qualified as apothecaries and in surgery) squabbled for status and practice. English qualifications vied with Scottish. Significantly, expansion into social policy occurred only after the medical reforms of 1858, and then quickly.

Understandable, yet nonetheless remarkable, this unwillingness, for just as the social issues of the day were significantly medical, so medical theory was significantly social, more alert to social causes of disease than any we have had since. One speaks with caution of the “medical theory” of the period, for it was a time of great competition among medical systems, of controversies on everything from proper fever therapy to the very essence of life. All the same, one can identify a broad framework of common concepts. For example, hygiene was central. Mind and body were seen as integrated. Each affected the other; both were affected by environment, broadly understood as the totality of physical, biological, hereditary, social, and psychological conditions of life. Because, in some way, most of these conditions could be altered, such a medicine was a source of great hope. With the rise of disease-centered pathology in the second half of the nineteenth century, this framework gradually faded, and it has been insufficiently understood or appreciated by most historians. I discuss first general concepts of physiology, pathology, and etiology. The second half of the chapter focuses on the application of this medicine to the social crises of industrializing Britain.

I

Eighteenth-century medical theory is deep water indeed, but it is necessary to wade in to clarify terms like “fever,” “miasm,” “contagion,” and so on. To immerse ourselves in its strangeness let us dive into what one might expect to be a treatise on public health, Charles Collignon's Medicina Politica, or Reflections on the Art of Physic As Inseparably Connected with the Prosperity of the State (1765). Collignon, Cambridge anatomy professor, argued that the healthy mind required the healthy body and that “the well-being, prosperity, and stability of empires [are] greatly dependent on the Health of Individuals.” The individuals he had in mind were not the poor but the wealthy, and in this humanitarian age one of the illnesses they might suffer was insensitivity to sentiment. By repairing the constitution, medicine could nurture appropriate feelings of pity and compassion; it could “destroy the acquired propensities, that inflame to an opposite behaviour: a behaviour found in pride or passion, arising … from reiterated fullness, provoking to peevishness, and not allowing a proper attention to human sufferings.” Jealously, ambition, pride were likewise expressions of humoral imbalance: “What is ambition,” asked Collignon, “but a more protracted paroxysm, of an existing mischievous insanity?” Religion could take root only in the healthy; irreligion was a sign of illness: “In proportion to the readiness with which some constitutions are inclined to sudden commotion of the blood beyond others, arises the propriety to more frequent offenses; against decency and duty. … The keeping in due temper the fluids, and solids of the Body … this I say has a natural aptitude to lay us open to the conviction of religious truths, and to make us pliant to be directed in our behaviour, by its laws.”¹ A powerful medicine indeed to gentle the Georgian rake!

Collignon's goal is clearly social: he will use regimen to regulate class relations, just as Chadwickian sanitarians would use water and sewers. Both believed that through expert management of the environment, health, outlook, and behavior could be utterly altered. Yet in the nineteenth century the focus would be the pathological poor, while Collignon will practice his art on the bloated and callous gentry.

Clearly, Collignon's conception of disease is different from ours. Legatees of the germ theory, we tend to see it as an invasion of the body's integrity. An uninvaded body may be declared healthy regardless of its owner's subjective view of its condition. We see disease as a narrow and specific entity, health a broad and vague range of unproblematic states of being. Collignon's notion of cause was equally far from the causes medical men would appeal to a century later in the early days of the germ theory: diseases arose from “baleful vicissitudes of heat and cold, moisture and drought; from internal Passions and external violence; from errors of Judgment, and excess of Indulgence.”²

Like most of his contemporaries, Collignon saw health as more than the absence of disease. He viewed disease physiologically, as an imbalance of some crucial internal commodity (e.g., vitality) or in some crucial internal process (e.g., circulation or elimination). The physician's job was the fine tuning of each individual's constitution to climate, diet, activity. Here health was narrow and disease broad. Not only was the “health point” different for each person, but it was always changing with season, age, accidents of circumstance. Since constitutions can be out of tune in greater or lesser degrees, one can be more or less diseased; there is thus a continuum between health and nonhealth.³ Since constitutions are integrated, one expects illness to manifest itself throughout the person, as much in mind as in bowels, muscles, and bones. Any state of unhealthiness might require medical attention; many delicate persons spent much of their lives at Bath and like spas under close medical management. In practice, of course, one did not speak of a “disease” until the deviation from health passed some vague threshold and took on some definite form or course.⁴

Within such a physiological approach, a disease exists only in the diseased individual. One may diagnose it as belonging to a species, but that in no way denies the inviolate individuality of this disease in this person. Its causes too were unique. Frequently they were events in the sufferer's personal history: what had she been eating; had he had bad news recently; was the family living in clean, airy conditions; were they working too hard? The many systems of disease classification were mainly ways of organizing knowledge for teaching and communication. “Systems are the work of our own minds,” wrote the medical lexicographer Parr: “nature advances by almost imperceptible shades.” To name a disease, even to talk of its seed or “germ,” did not necessarily imply that each disease was genetically unique, the consequence of a specific unique cause.⁵ Epidemics, it is true, were often seen as distinct entities, but the distinctiveness might lie in time or place (e.g., the plague of 1666) more than in assumptions of a mobile and persistent entity that periodically reappeared to engender the same effect.

While Collignon is evidently a Galenist (he talks of humors rather than fibers or ferments or vitality), had he drawn on Boerhaave's atoms, or written slightly later and emphasized nervous energy or vitality, he would have been addressing the same sorts of problems in similar ways. Even a pathology of lesions, physical injuries to tissues, such as would be imported from France in the early nineteenth century, could accommodate such a conception of disease.

Ancient Galenic conventions of causal explanation also suggested what strategies, public and private, might prevent such diseases. Contemporary textbook writers explained that a disease was the product of many different kinds of conditions or events, divided into two classes.⁶ The “proximate cause” of disease was the lesion or faulty process most closely associated with the disease itself.⁷ “Remote causes,” on the other hand, were further subdivided as “exciting” or “predisposing.” “Predisposing causes” were all the forces that could alter the constitution; one's predisposition was the summation of one's exposure to such causes. Writing in 1827, the Manchester obstetrician John Roberton explained the concept: “Previous to the commencement of any disease, there is a state of predisposition, which fits or prepares the system for being acted upon, by the morbific cause. This applies as well for diseases which operate by a specific infection peculiar to each, as to those which arise from incidental causes, as cold, intemperance, and the like.”⁸ Since high predisposition might exist for a long time without blossoming into disease it might be necessary to posit an “exciting” cause (Roberton's “morbific” cause) as an igniter of the fuel of predisposition. Many factors could serve as either exciter or predisposer, depending simply on when, relative to the onset of the disease, they acted.⁹

Well into the 1850s medical textbooks and dictionaries handled “cause” in this way.¹⁰ On one hand, such an agenda reflected the concern of a learned profession with adequate explanation; on the other it fit well a hygiene-centered medical practice because it provided long lists, both of actions people could take to prevent disease and of explanations for why they still sometimes became ill. In most of the physiological models of the period, predispositions, particularly those the poor were likely to suffer from, could be translated readily into a variety of metaphors signifying deficits of energy or vitality. “Causes act primarily on the vital endowment,” wrote James Copland in his Dictionary of Practical Medicine. Or according to Robert Thomas: “Every thing which has a tendency to enervate the body, may be looked upon as a remote cause of fever; and, accordingly, we find it often arising from great bodily fatigue.”¹¹ Because they all acted similarly on the same entity, such causes were interchangeable to a degree.

It should be clear how such a framework made poverty a pathological condition. “It has been determined, by exact observations and calculations,” noted Copland, “that those who enjoy easy or comfortable circumstances are much less subject to disease than the poor, the insufficiently clothed, and ill-fed. This arises not only from the former class being less exposed to its exciting causes, but also from the good effects of sufficient nourishment in supporting the energies of life, and thereby warding off the impressions of injurious agents and influences.” Joseph Ayre of the Hull Dispensary, writing in 1818, explained that while any individual component of poverty might not harm health noticeably, their combined effect could be strong: “The system, when weakened, is readily affected by agents, which, in a state of vigour, it would have resisted. Thus the cold, to which the children of the poor are subjected by their inadequate clothing, would have much less injurious effects if their food were nutritive and abundant; and for the same reason, the insufficient and watery diet, with which so many of them are fed, would be rendered less hurtful in a climate more temperate and congenial than ours.”¹²

It may seem that such explanatory conventions preclude epidemiological investigation. If anything can cause everything and everything can cause anything, it will be impossible to link discrete cause with distinct effect. Indeed, we can be pardoned for regarding all this as the doublespeak of equivocating charlatans.¹³ Yet for the hygienist's question of what ways of living are associated with health or disease, these conventions provided an excellent foundation for epidemiology. For example, C. T. Thackrah found dwellers of Lancashire cotton towns to be “small, sickly … pallid, thin … a degenerate race,—human beings stunted, enfeebled, and depraved.” In this holistic medicine it was futile to try to distinguish the effects of “bad habits” and “wretchedness of their habitations” from those of “long confinement in mills, the want of rest, the shameful reduction of the intervals for meals,” for all were causes of debility; the way of living in its totality was harmful.¹⁴

This debility might never manifest itself in an increase of any particular disease, yet still constitute a significant health problem. Thackrah looked for older workers in a trade. If there were few, he suspected the trade, and the life that accompanied it, were fundamentally destructive, however disease-free the current work force might be.¹⁵ Likewise, diet might best explain the disease experience of laborers in a northern climate. According to J. B. Davis, author of a popular health manual, heavy work in a cold place with too little food resulted in “a want of physical strength, a want of energetic action, and a proneness to all diseases of debility, as well as an especial liability to be affected with all kinds of epidemic diseases.” Indeed, lack of good food would be the “prime” factor in disease incidence. Similarly Thomas Bateman, following William Heberden, saw cold as the major factor controlling the London mortality rate.¹⁶

Not only did such a framework warrant a kind of epidemiology, it implied also that focusing on specific diseases might be counterproductive in obscuring general causes of illness. The very project of distinguishing diseases, which we now see as central to medical progress, might divert the researcher from recognizing the most readily remediable factors. So argued the Manchester dispensary doctor Richard Baron Howard, in An Inquiry into the Morbid Effects of Deficiency of Food Chiefly with Reference to Their Occurrence amongst the Destitute Poor (1839). The “starvation” Howard was studying was a combination of chronic malnutrition (“gradual and protracted starvation”) coupled with factory work and exacerbated by trade cycles. “Poverty and want exist largely at all times in populous towns,” he wrote: “A very large proportion of the mortality amongst the labouring classes is attributable to deficiency of food as a main cause.” Yet the postmortem effects of malnutrition were indistinct, for the lives of the malnourished might end in fever, scrofula, dyspepsia, dysentery, diarrhea, scurvy. So long as starvation was not a recognized diagnosis its extent would be unknown and it would be impossible to provide effective relief. Hence Howard wrote to teach medical men how to recognize starvation by its symptoms: apathy, a low fever, nervousness or inflammation of the brain, coldness, lack of appetite. Because lassitude was so common a symptom, those worst affected complained least.¹⁷

It may seem that the “physiological” perspective of Collignon and Howard works well enough for chronic illnesses, but what of the acute epidemic diseases that are usually seen as the main business of public health? Some diseases did indeed seem to reflect the specificity of a poison more than the uniqueness of the victim. By the mid-nineteenth century such diseases would become exemplars of a dominant “ontological” conception of disease, in which each disease was a species and for practical purposes the product of a single cause—exposure to its “germ.” Because diseases with similar symptoms—say typhoid and typhus fevers—might have different causal agents and routes of transmission and therefore warrant different preventive strategies, accurate diagnosis would be important.

There are striking differences between seeing diseases as imbalances and seeing them as invasions, yet the perspectives are not incompatible, and in the period they were usually complementary.¹⁸ Those studying acute epidemic diseases, like smallpox or typhus, had to explain why not all took the disease, and why it was more serious in some than in others. What distinguished those stricken? It seemed implausible to think exposure to the poison was the answer, for there were always some who must surely have been exposed, yet did not take sick. Strength of constitution (a “physiological” concept) evidently protected them: “Good diet, and good spirits, cleanliness, and fresh air, and proper clothing, and exercise, may all contribute to render the body less susceptible of disease; the seeds of which, like those of vegetables, will then only spring up and thrive, when they fall upon a soil convenient for their growth,” wrote Heberden.¹⁹

Often what appear incompatible explanations were answers to different questions. The character of that year's fever (i.e., that it responded to depletative rather than supportive therapy) might be ascribed to the character of the specific poison (contagion, miasm, or unusual state of atmosphere), while remote causes might explain who was stricken and who escaped, and proximate causes might integrate all these into an account of the disease that victims experienced and practitioners treated. While there was a slow shift from physiological to ontological conceptions of disease during the period, medical discussions often employed both, depending on what disease was being explained, what about it was at issue, and what the context of the conversation was: was one talking about unusual cases or urban populations?²⁰

The familiar terms “contagion” (the vehicle of person-to-person disease transmission) and “miasm” (a pathogenic emanation dispersed in the atmosphere) belonged to this larger system of causation. Often seen as anticipations of germs, the terms may seem to imply disease specificity. This was not always the case: contagia and miasms might simply be among the many malignant forces that harmed the constitution.²¹

The two terms were variously and vaguely defined and used. To those for whom they were alternative forms of disease-specific poison, they were still often not fully distinct, for both reached their victim through the air, though at greater or lesser distance from their source.²² But they were not necessarily alternatives. Sometimes they were synonyms and sometimes they were answers to different questions. In his 1799 Medical Dictionary, Richard Hooper saw no important distinction among “miasma,” “contagion” “effluvia,” “virus,” “lues,” “infection.”²³ Parr, in 1808, saw “miasm” as a kind of contagion: “Contagion, then, exists in the atmosphere; and we know distinctly but of one kind, viz., marsh miasmata.” He suggested also that jail fever arose from miasmata pervading the jail; the “human effluvium” would then be capable of giving “activity to the contagion.”²⁴ John Mason Good would have “miasm” refer to a state of being and “contagion” to the process by which that state of being was applied to a person, as in “contagious miasm.”²⁵ Sometimes “miasm” was used in its restricted sense for an unknown something “arising from stagnant water … from vegetable matter in a state of decomposition; from moist absorbent soils exposed to the sun's rays,” and similar environments. This was held to cause agues; enlargements of spleen, liver, and glands; rheumatism; and catarrh in cold climates, and remittents, bilious and gastric fevers, dysentery, choleraic diarrhea, and hepatitis in warm climates.²⁶ Yet some thought this thing from the swamp to be no more than deoxygenated air (resulting from the oxygen demands of decaying organic matter) or conversely to be one of the ordinary products of organic decomposition.²⁷ “Miasm” often referred simply to air vitiated in some unknown way.

II

Early-nineteenth-century etiological conventions did not imply particular social actions to prevent disease; they did, however, act as a fertile framework that encouraged medical men to recognize many social factors, more or less correctable, in their accounts of disease. The social possibilities of this etiology are especially apparent in two diseases: consumption and continued fever.

Though consumption was a generic term for a wasting disease, pulmonary consumption was a definite disease entity with recognized links to other “tubercular” phenomena (e.g., scrofula) and to diseases of malnutrition (rickets). In 1839 consumption was responsible for about a quarter of all deaths and more than 50 percent of deaths in older children.²⁸ The authority on consumption in 1839 was the Royal Physician Sir James Clark. Clark held the ancient view that tuberculosis struck “delicate” persons with a hereditary “cachexia” or “diathesis” for it. Far from taking a “blame-the-victim” stance, Clark, like many contemporaries, focused on the living and working conditions that determined whether that hereditary disposition ever developed into full-blown consumption.²⁹

The causes Clark identified were those being cited by various critics of industrializing Britain: poor food, clothing, infant care, ventilation; lack of light; and overwork. Inadequacy in only one of these might prevent the body's systems from making use of the others. Thus, impure air impaired digestion and hence led to malnutrition: “In the confined districts of large and populous cities … food … cannot be assimilated even though the supply be unexceptionable.” In the country that cachexia might be generated by thin clothes and lack of meat in the diet. Or it might arise from labor that “exhausts and debilitates,” or uncleanliness, drink, and dashed hopes. At risk was the body's ability to nourish itself: when predisposers lowered “the power of assimilation” sufficiently, “the tuberculous diathesis will be induced: Whenever … the nutritive functions are vigourously carried on, this disposition will not manifest itself.”³⁰ Clark found it impossible to distinguish causes which predisposed one to consumption from the exciting causes that initiated the disease. Long exposure to predisposing causes might finally trigger the irreversible decline that constituted the disease, but in a pathology that emphasized the cumulative effect of degrading forces, it was impossible to specify when that event occurred. He acknowledged that consumption might be contagious and that it was unwise to share a bedroom with a consumptive. But it was impossible to say, and pointless: the preventives were social.³¹

Consumption was incurable, Clark believed, but the physician could still help “by convincing the public of the comparative futility of all attempts to cure consumption, and of the signal efficacy of proper measures directed to prevent it.” The necessary measures were “simple, and … available”: airy workshops and apartments, regulation of indoor temperature, exercise, cleanliness, and abstinence from strong drink. Such an attack on predisposition would also “raise the standards of public health, and at the same time advance the moral excellence of man, augment his mental capabilities, and increase the sphere of his usefulness.”³²

It is easy to see how consumption might be linked with deprivation; it is a kind of exhaustion. But it was fever that was the central disease in public health discussions in the half century before 1840. Though it is often suggested that a focus on social and environmental preventives was a product of anticontagionist (miasmatic) explanations of disease (while contagionist explanations are presumed to limit responses to isolation), most medical men concerned with a social response to fever drew on concepts of contagia.³³

Typhus fever was not a new disease, but it was becoming increasingly prominent. Its competitors, ague, smallpox, plague, and dysentery, had declined. Moreover it seemed related to life in the new industrial towns: to mobility, crowdedness, and periodic unemployment and hunger (though typhus was as bad, if not worse, in the famine-ridden countryside, especially in Ireland).³⁴ That fever was contagious meant no one was free of risk, a fact reiterated by medical men seeking support for the new fever hospitals or “houses of recovery” they began to establish in the mid-1790s.³⁵ Fever was a prominent subject of controversy—on therapy (did one deplete or support?), diagnosis (was continued fever one disease or many, or was each outbreak distinct?), and proximate cause (what was happening in a fevered body—debilitation, inflammation, or both?).³⁶

The so-called fever contagion was clearly quite different from the smallpox—more volatile, yet weaker (in the sense of being effective only in a concentrated dose). Indeed, it was not clearly distinct from some miasms.³⁷ Thus there was a premium on one sanitary reform, ventilation. One might safely visit a fever victim so long as the space around the victim was well enough aired to disperse the contagion.³⁸ A crowded or confined atmosphere, however, would continually generate the poison, as in the Black Hole of Calcutta and many jails.

Because fever was only weakly contagious, predisposition figured centrally in explaining outbreaks. There was broad agreement, based on a large collection of reports of epidemics, that the most important predispositions were unusual deprivation and social crisis. Appealing both to ontological and to physiological conceptions of disease, to predisposing and exciting causes, contagia and miasms, and somatic and psychological factors, Robert Thomas, follower of the eminent Edinburgh professor William Cullen, wrote that nervous fever was “apt to attack those who are weakened from not using a quantity of nutritive food, proportionable to the exercises and fatigue they daily undergo; hence it is very prevalent among the poor.” Its “most general cause … [was] contagion, communicated through the medium of an impure or vitiated atmosphere, by concentrated effluvia arising from the body of a person labouring under the specific disease; but whatever debilitates the system or depresses the mind, may induce a state of predisposition more readily to be influenced by the operation thereof.” A calm and sober person, well fed, clothed, and housed, was less likely to fall into fever though by no means immune.³⁹ Since crisis, depression, anxiety, or poverty did not always bring on fever or produce contagion, some writers also invoked Thomas Sydenham's concept of an atmospheric “constitution”—a peculiar atmospheric change manifest only in the production of epidemic disease.⁴⁰ Indeed, the same atmospheric changes that blighted the crops and led to famine might also produce the fever contagion itself.⁴¹

Many held that contagion could generate spontaneously, either in a very debilitated body or from exposure to ordinary human effluvia in concentrated form. Wrote Parr: “If many men are confined in a comparatively small place, their health is gradually undermined; their complexions become sallow; their appetite and spirits fail. No real disease may be observable in them; yet, to others, they will some times in this state communicate fever, and fever will appear to arise spontaneously among themselves. … When the fever is actually formed, it is well known that it may be communicated by its effluvia.”⁴² Most believed spontaneous generation to occur rarely, but it explained how fever could arise when there seemed no other apparent contagion. Here the common character of the disease was due to the commonalities of human bodies, which could on occasion produce the same pathological processes usually triggered by exposure to a contagion or miasm.⁴³ The resulting poisons might be called “contagions,” but they were aspecific contagia, simply forms of pathological influence the products of a diseased body could acquire.⁴⁴ Such a view obviated the need to believe that God had created contagia and the need for arbitrary hypothesizing about transmission routes.

In most fever theories the nervous system was central.⁴⁵ It followed that the subjective state of the victim could be a cause of the disease. As James Copland explained it, “When mental energies are depressed … the powers of life are less able to oppose the debilitating causes of disease.” By contrast, with a positive mental state “the depressing causes make little or no impression upon the constitution.”⁴⁶ Reflection on the loss of liberty was a significant cause of prison fever, wrote Good. John Ferriar included “anxiety and depression of spirits … among the efficient causes, because it is not proved that the mere confinement of the effluvia of clean and healthy persons, free from mental uneasiness, can become poisonous; otherwise the close rooms of an elegant house might produce fevers as well as garrets and cellars.” Victorious armies were relatively immune to fever; defeated armies susceptible.⁴⁷ Terms like “depression” and “anxiety” recur in the literature, referring to a state both somatic and subjective. The sources of depression might be mental events themselves (fear and worry) or physical conditions that produce such outlooks: “low diet, fatigue, previous illness, excessive secretions and discharges, want of sleep, venereal excesses.”⁴⁸ Ferriar wrote of seeing “patients in agonies of despair on finding themselves overwhelmed by filth, and abandoned by every one who could do them any service; and after such emotions I have seldom found them recover.”⁴⁹

III

Medical theory suggested, then, that the living and working conditions of laboring people shortened life, impaired health, and distressed the soul. Yet that was not necessarily a public problem. Could the poor really expect health and ease of mind? Was not their lot poverty, and were not hardship and some misery concomitants of poverty? One certainly could regard the physical and psychological needs of the poor (and accordingly their justifiable expectations) as different from those of the wealthy (and, conveniently, commensurate with what society was willing to deliver). To adopt a physiological and moral universalism (all persons have similar physical and psychological needs), on the other hand was to acknowledge a problem of public health.

In Collignon's ancient régime of mutual dependency, physiological universalism did not apply: stations of life were rigid; health and happiness were functions of station. For the poor, security in the necessaries of life—food, shelter, warmth—was enough. It was clearly impossible (and therefore presumably unnecessary) to practice the same fine tuning of constitution that medical men practiced among the rich; the season in Bath or a choice of wine and food was not an option for an agricultural laborer. Accordingly, the keystone of successful social medicine was fulfillment of the duty of charity: Collignon would cultivate responsible landlordism by altering the constitution of those responsible for the poor; he would physick the poor by physicking the rich. There was, indeed, a long tradition that the sufferings of rich and poor were equal but different: the rich suffered from surfeit, the poor from deprivation. James Johnson, editor of the elite Medico-Chirurgical Journal, wrote that “the uncultivated boor glides along, unconscious of the pleasures and unacquainted with the sufferings which necessarily grow out of civic society and intellectual refinement.” “The balance of enjoyment,” he held, lay with “the lower classes of society, who have little susceptibility toward intellectual pleasures and pains.”⁵⁰

Yet even in Collignon's time, Locke and liberalism were threatening this stable harmony. With educability and liberty came notions of physiological equality: rich or poor, the human “machine” was the same; situations that led inevitably to shorter lives, more disease, and less happiness to poor than rich seemed to violate the possibility of liberty. Medical practice was changing too. In the mideighteenth century the medicine of regimen cultivation had been the stock in trade mainly of an elite of physician gentlemen with exclusive practices. By the end of century, their ranks were being diluted by middle-class doctors, from the new medical schools of Edinburgh and Glasgow. Heirs of Hippocrates by way of Boerhaave, many of these were dissenters, and many had practices among the poor.⁵¹

A flurry of manuals of health appeared, adapting the ancient art of hygiene to the new middle classes. They told what to eat and drink; how much to sleep and exercise; how to govern one's passions, choose a career, or raise children. Some of these popular hygienic works, like Bernhard Faust's widely translated Catechism of Health, were decidedly leveling: according to Faust, the healthy person felt “strong; full of vigour and spirits; he relishes his meals; is not affected by wind and weather; goes through exercise and labour with ease, and feels himself always happy.” The human body, wrote William Farr in 1839, was “framed to continue in healthy action 70 or 80 years.” Yet “soon after 40 years of age individuals of the labouring classes begin to suffer from stomach complaints, the consequences of poor diet, poor clothing, exposure to weather, and anxiety; and from these complaints … they seldom afterward become wholly free.”⁵² The historian T. B. Macaulay, earlier a champion of the market, became a ten hours' advocate in 1846: “The great masses of the people shall not live in a way that will abridge life, that will make it wretched and feeble while it lasts, and send them to untimely graves, leaving behind them a more miserable progeny than themselves.”⁵³

Concepts of liberty were often defined in terms of health: one could only be free to act if one were fit to act. Notions of fair markets in labor presumed physiological parity. Those who were not “able-bodied,” political economists generally agreed, were excused from the rigors of competition. But where lay the border between illness and health? And what was one to do if participation in the market for labor was itself the cause of illness? Some hoped that however hard their lives, the poor could and would follow the same hygienic rules as the rich. The Manchester fever authority John Ferriar advised the poor to avoid cellar dwellings: “They destroy your constitutions, and shorten your lives. No temptation of low rents can counterbalance their ill effects.” They were told, Wash your children “from head to foot with cold water, before you send them to work in the morning. Take care to keep them dry in their feet, and never allow them to go to work without giving them their breakfast, though you should have nothing to offer them but a crust of bread, and a little water.”⁵⁴ Whether it focused on churches, schools, or sewers, such a view was the premise of moral and sanitary reform of the 1830s and 1840s.

Among working people little of this optimism took hold, Thackrah found. Denial was the rule: artisans were unwilling to acknowledge that they led diseased lives. “Health is to most persons a disagreeable subject. … It implies a distrust of our sanity … most persons … will be inclined to admit that our employments are in a considerable degree injurious to health, but they believe, or profess to believe, that the evils cannot be counteracted, and urge that an investigation of such evils can produce only pain and discontent.” Lead miners drank heavily, he found, “not with the view of enabling them the better to sustain their unhealthy employment, but confessedly to drown the ever-recurring idea, that they are, from their occupation, doomed to premature disease.”⁵⁵

As well as being a precondition of liberty, health was also the readiest yardstick of injustice, and the most unanswerable justification for social change. All this fancy physiology only showed what “any cottager's wife” knew, wrote the surgeon and factory reformer George Kydd: that factory work exhausted and crippled people—“Selfishness and obstinacy could alone require so uncalled-for an exhibition of physiological knowledge—instinct itself … proved all that reason, humanity, and science, had contended for.”⁵⁶

But medicine held out a physiological as well as a moral rationale for reform. Disease was not just a currency of witness but an instrument of redress. Fever, we have noted, took root in desperate people and became contagious. The belief that subjective outlook affected the generation of fever meant that in a person's feelings (and the fragile constitution of her body) lay the power to generate a truly contagious disease. Thomas Bernard of the Society for Bettering the Condition and Increasing the Comforts of the Poor urged “indulgence” of the “prejudices” of the poor against ventilation, for “tho repressed by authority,” these “will operate secretly and forcibly on the mind; creating fear, anxiety, and watchfulness”—and possibly disease.⁵⁷ In this way fever theory empowered: the feelings of the poor person had political significance. Fostering a sense and (state) of well-being in others was critical to the success of that least altruistic task of public health, protecting oneself from epidemic disease.

Behind this modern psychophysical science was an ancient moral motif: plague is the oppressor's reward. Warnings of retribution via fever appear often, as medical writers sought support for their endeavors to prevent the disease. Fever was not a natural but an “artificial and accidental” occurrence, wrote MacCormac.⁵⁸ Ferriar warned that the “dwellings and persons [of the poor] continually breathe contagion,” and it was “hardly possible to prevent the communication of the disease to the families of the rich. … The poor are indeed the first sufferers, but … by secret avenues it reaches the most opulent, and severely revenges their neglect, or insensibility to the wretchedness surrounding them.” The “true danger[s] of luxury” were the “voluptuous habits” that led the rich to withhold charity. Thus “he contributes to the disease and destruction of thousands.” The moral: “The safety of the rich is intimately connected with the welfare of the poor … minute and constant attention to their wants is not less an act of self-preservation than of virtue.”⁵⁹ The argument parallels Chartist calls for justice though their retribution would come as revolution. It was also, both for Chartists and for fever doctors, embedded in Christian eschatology and natural theology: God is just; the creation embodies justice; injustice sooner or later triggers retribution.

IV

Admit that working-class human machines ran by the same laws as upper-class machines, that they required a sense of well-being, and would explode, spewing forth contagion if their “maintenance” were neglected, and you had a political medicine.⁶⁰ A medicine that granted everyone a “personhood” is not what one expects of the triumphant years of industrial capitalism and Ricardian economics, and one must ask how far it informed practice. Did social causes of disease imply a need for social changes to prevent disease or just for medicines to cure it? What parts of life were changeable? Given that hunger caused fever, was hunger preventable or only an indication of the disparity between population and food? Responses varied. In rural Ireland, where peasants survived by subsistence agriculture, famine and fever were acts of God. One might see the need for soup kitchens during an epidemic yet see no prospect of preventing future famines. Yet for urban workers, food seemed more to depend on the market and the corn laws than on nature. Fever writers of the 1830s and 1840s—Cowan, Davidson, MacCormac, Alison, Hudson—were generally unwilling to see falling wages or rising prices as “natural.” Instead, they were errors. Overproduction led periodically to unemployment, and on to hunger and fever. In general medical men did not take on industrial capitalism directly. They did, however, identify some of its features—the division of labor, trade cycles, and wages too low to support life—as medical problems. On occasion they interfered in the market, mitigating rigorous incentives with proclamations that a person or population was in a state of disease and required support.

In part they did so because at a basic level medical ideology was incompatible with political economy. One emphasized dynamism and maximization, the other stability and balance. By definition diseases were contranatural states. Since the human constitution reflected the state of its environment, the social conditions that caused disease must equally be contranatural. In part also they did so as healers. The goal of improving the state of health was independent of the question of why the person was ill. Usually medical men spoke of the economic causes of disease or their interventions in the market not in the charged language of the radical press but in the neutral language of epidemiological generalization or physiological law. One might identify cause and recognize remedy without indulging in blame. Perhaps medical men saw themselves as making medical, not political, statements; perhaps they knew that the best way to be political was to appear apolitical.⁶¹

A good illustration of this perspective is the Glasgow surgeon Robert Cowan's attribution of the fever of 1836-37 to a textile workers' strike. Unlike many contemporary social analysts, he did not denounce workers' combinations and would say only that the strike was “lamentable.” Cowan's problem was the misery of the strikers and their families. A medical problem existed; that the remedy—support for strikers and their families—had political implications, that it might seem to reward the blameworthy and interfere with the systems of incentives that made society work was beside the point.⁶²

A few years earlier, his colleague Andrew Buchanan had explained immorality and crime as physiological effects of desperate poverty.

The moral effect of an actual or apprehended privation of such necessaries, is to rivet [in] the mind the ideas immediately connected with them, and to create a physical impossibility of directing it to other subjects, however momentous. The moral condition of the poor, therefore, is in great measure, the necessary consequence of the privations, to which they are subject. It can excite no surprise, that, while they are completely and exclusively occupied, from day to day, in a struggle for mere existence, which demands not only their bodily exertions, but engages all their thoughts, they should become indifferent to everything else.⁶³

Thus, in highly moralistic Scotland, Cowan and Buchanan saw not evil or righteous persons, but only dangerous epidemiological situations arising from complicated combinations of human errors and natural circumstances.

Fever doctors need not be romantics or humanitarians: Ferriar spoke not of the noble poor, but of their “sullen indolence.”⁶⁴ But simply to practice effective public medicine, they had to admit that the power to affect the course of an epidemic lay with the poor. The fever hospital had to be much more than a place for isolating diseased bodies; it had to be attractive enough so that people would elect to go to it before the disease had been widely communicated.⁶⁵ They had to be persuaded to stay there for a substantial convalescence.⁶⁶ There had therefore to be support services for families to discourage wage earners from trying to work through a fever or from returning to work too early; and also to maintain the resistance of family members by providing sufficient food, warmth, and shelter to prevent new cases from arising. They had to recognize and try to manage perilous stages in the life course, such as the arrival of a child to a working couple, or the arrival of jobless newcomers to a manufacturing town, who might “sink under the pressure of want and despair.”⁶⁷

Fever thus became the warrant for a broad program of social welfare. Fever hospitals orchestrated subscriptions for general relief. A Miss Horner described the response to an 1803 fever epidemic at Hull:

Coals were provided for those, who had not the means to buy them. The sick and their families were supplied with arrow root, sago, or boiled milk, for their breakfast; and good mutton broth was made every day for dinner; each family, according to the number it contained, receiving two, three, or more quarts daily. … Good wheaten rolls, one day old, were distributed at the same time among the families, and in the same proportion; rice pudding, a little boiled mutton, or beef steak, with a half a pint of brisk small beer or ale, were allowed the convalescents. Milk sago, ale caudle, or arrow root, was prepared and given in the evening.⁶⁸

Under Bateman, the London Fever Hospital carried out a program of “white-washing, cleansing, and fumigating” the homes of their convalescing patients. Even such programs as these—hospital care, supplies of food, fuel, and clothing—seemed merely “palliative” to Ferriar. Since fever was generated in poor housing, the “best measure” would be “furnishing the poor with healthy habitations … erecting small houses, at the public expense … to be let at small rents.”⁶⁹

Even if an epidemic justified intervening in markets, indiscriminate charity was surely a brazen invitation to abuse. Surely people would pawn the clothes they were given, sell the food and fuel to buy drink (ironically, in Cowan's Glasgow, relief committees allotted funds precisely for “redeeming articles of clothing from pawn”⁷⁰). Abuses occurred. Ferriar told of a Manchester fever epidemic in which the usual “beds, clothing, nurses, and food” had been supplied. Yet “great numbers of the poor” had applied “to the Infirmary, under pretence of sickness, for the sole purpose of profiting by the subscription.” But the response to the abuse was to meet the request. Since “exposure to hunger and cold had always preceded the fever,” the proper response was “to promote subscriptions for the relief of the poor in general.”⁷¹

Actions like these were politically ambiguous. The protracted convalescence that protected the public was also a way to give a laborer rest and a statement that conditions of work were unacceptably exhausting. The provision of food, fuel, and clothing was a real redistribution, but equally a reification of the dependence of one class on another.⁷²

V

It should be plain that at the time of Chadwick there was an essential tension between medicine and political economy. To let the market swing free was to tolerate damage to health; to follow the lead of traditional medicine was to interfere regularly and profoundly in the market. All who were concerned practically or philosophically with the condition of England—philanthropic evangelicals, magistrates, poor law reformers—felt that tension and sought a viable middle ground. The exacerbation of this tension to the point of crisis in the middle to late 1830s is exemplified in the relations of three men who took these questions most seriously: William Pulteney Alison, James Phillips Kay (-Shuttleworth), and Thomas Chalmers.

Alison was from a comfortable Tory Anglican Edinburgh family and was nurtured in the Scottish enlightenment of the late eighteenth century. That Dugald Stewart, his godfather, celebrated his entrance into the world with a gift of a copy of the Rights of Man says much.⁷³ His brother Archibald became a historian and anti-Malthusian political economist of note and, as Lanark sheriff, Scotland's most important social administrator. W. P. held several chairs at Edinburgh, culminating in the prestigious “theory and practice of medicine,” and was an exemplary dispensary doctor, visiting the sick poor in their homes. In the early 1840s he led the campaign for reform of the Scottish poor law.

Kay, beneficiary of the new wealth of Lancashire cotton, had been one of Alison's prize pupils. Returning to Manchester, he sought a career in dispensary medicine and then medical journalism, as coeditor of the North of England Medical and Surgical Journal (1831-32). He would go on to become an assistant poor law commissioner and then secretary to the Privy Council's Education Committee.⁷⁴ Kay's pamphlet, The Moral and Physical Condition of the Working Classes Employed in the Cotton Manufacture in Manchester, was a product of his work during the cholera of 1832 for the quasi-official Manchester Board of Health. It is the apologia of a medical liberal and a decade later was a key source for Engels to defend views opposite Kay's.

Both Alison and Kay were responding to the optimistic Malthusianism of the Reverend Thomas Chalmers, political economist, mathematician, natural theologian, leader of the evangelical party in the Scottish church and of the breakaway Free Kirk in 1843. A charismatic minister, Chalmers held that demoralization, destitution, and disease could be overcome not by impersonal institutions of state but by a morally united parish community, through a mix of exhortation, market incentives, pervasive moral oversight, and, at last resort, minimal and carefully targeted relief in kind. With a cadre of deacons, Chalmers carried out his experiment in Glasgow's St. John's parish in the late teens and early twenties. What the St. John's approach accomplished was debatable—had pauperism really dropped or was relief simply being denied? Yet in the years prior to the 1834 new poor law, this Scottish approach was enormously popular in England. Chalmers seemed to represent a Christian political economy that merged the call to help the needy with a faith in the market. Indeed, the founders of University College, that “Godless College on Gower Street,” tried their best to persuade him to take their chair of moral philosophy (Chalmers took the Edinburgh divinity chair instead; an accomplished mathematician, he had earlier run second for the chair of natural philosophy).⁷⁵ Kay dedicated The Moral and Physical Condition (second edition) to Chalmers rather than to his teacher Alison; in September 1840 (with Chadwick in the audience) Alison, in glorious forensic combat with Chalmers at the Glasgow meeting of the British Association, overthrew the Chalmersian paradigm of social policy.⁷⁶ Yet he did so within Chalmers's terms, only adding medicine to the mix of Malthus, the market, and moral duty. Kay and Alison are both representative and immensely influential figures. They show us “public health” at the time Chadwick began his work and the cultural framework in which solutions were conceived and assessed.

Kay had become interested in political economy through his experience as Alison's assistant, during which he realized that the causes of disease were social. He gained “insight,” he later wrote, “into the grave questions affecting the relations of capital and labour, and the distribution of wealth, as well as the inseparable connection between the mental and moral condition of the people and their physical well-being.” His shift to Chalmers began after his return to Manchester.⁷⁷ In 1830 Alison was an established medical authority and a paragon of the quiet duty of charity, but not yet a social reformer. By contrast Chalmers led a noisy army of moral regeneration based equally in godliness and science. It is not hard to see the attraction for the dissenter, Whig, and evangelical Kay, himself inflamed with a religiosity so intense that it would lead to nervous exhaustion on several occasions.

Both Kay and Alison were unusual in their empathy for the poor about whom they wrote and whose outlook on the world they tried to imagine and explain. Their writings are thus difficult to categorize or dismiss: Kay, for example, was probably cited more often by supporters of factory legislation than opponents, though he opposed such interference.⁷⁸

Kay's pamphlet is often taken to typify early Victorian social discovery. Exploring the unknown land of the slum, Kay is aghast at what he finds: not just filth and poverty, but the self-destructive (and irrational) defiance of moral standards. In large part his response is typical too: to preach virtue, religion, education, and the free flow of capital. What makes the analysis unusually forceful is the extent to which it reflects a medical view of society. For Kay, as for most contemporary medical men, predisposing causes—“every thing which depresses the physical energies”—were central. These included “imperfect nutrition; exposure to cold and moisture … uncleanliness of the person, the street, and the abode; an atmosphere contaminated … extreme labour, and consequent physical exhaustion; intemperance; fear; anxiety; diarrhea, and other diseases.”⁷⁹ Because these were pathological forces, they necessarily caused harm, even if acute disease never arose. Because the nervous system was the medium of pathological action, they also had moral effects. “It is utterly impossible,” Kay wrote, “to separate any event which is witnessed by human intelligence, from a certain inevitable moral sequence; or that they who know that to drop a pebble on the surface of the world disturbs the planet, should not perceive how, of equal necessity, events acting on the human spirit, in proportion to their novelty and power, disturb, for good or ill, the constitution of society.”⁸⁰ That, explained Kay, was why cholera was coextensive with vice.

As the pebble analogy makes clear, Newtonian images of complex fields of force and delicate equilibria provided the master metaphor. The interacting physical, social, and moral forces of factory work, along with the rest of the Manchester environment, produced an accelerating degradation nearly irresistible to the soul of the mill hand.

Prolonged and exhausting labour, continued from day to day, and from year to year, is not calculated to develop the intellectual or moral faculties of man. The dull routine of a ceaseless drudgery, in which the same mechanical process is incessantly repeated, resembles the torment of Sisyphus. … The mind gathers neither stores nor strength from the constant exertion and retraction of the same muscles. The intellect slumbers in supine inertness; but the grosser parts of our nature attain a rank development. To condemn man to such severity of toil is, in some measure, to cultivate in him the habits of an animal.⁸¹

In a similar manner, brief mealtimes and poor food prevented adequate digestion; this, combined with dampness and other predisposing conditions, induced a form of bowel disturbance which exacerbated (and was exacerbated by) a “deep mental depression” that led directly to the gin shop. “The exhausted artisan, driven by ennui and discomfort from his squalid home … [strives], in the delirious dreams of a continued debauch, to forget the remembrance of his reckless improvidence, of the destitution, hunger, and uninterrupted toil.”⁸² It led also to crime, illicit sex, sedition, violence.

Kay's language leaves no room for acts of will. Manchester workers are victims of a social, moral, and physical disease which they no more choose than we choose the flu. Seeing disease as a consequence of environment might seem to absolve the victim of blame.⁸³ It did not for Kay. Though the interplay of forces led to an unfortunate result, yet it still did not constitute an error in a cosmic sense. For Kay as for Chalmers, natural events were not arbitrary, but the outcome of natural laws, which were the laws of God's Providence; one no more blamed Providence for the degradation of the operative than for the fall of heavy objects. Providence (not Malthus) was author of the principles of population and political economy. The actions a society took must not oppose Providence, but they could complement it. Poor laws, factory acts, revolution, or interference with markets would worsen matters. That these were the preferred solutions of the working classes did not matter. One could understand sympathetically why working-class people might be attracted to such solutions (just as one understands why two-year-olds throw tantrums), but since dehumanizing conditions had already deprived them of their full claim to humanity, their own analysis was no more credible than that of any ill person who cries out for something the doctor knows must be withheld.⁸⁴

Thus, the very attempt to take working-class experience seriously led Kay to discredit it. While dehumanized factory hands could not be blamed for their situation (on the grounds that they were not full moral agents), they, and not the conditions in which they lived, might still be the proper site of remediation—through countervailing forces, such as “spiritual discipline,” education, police, and sewers.⁸⁵

For Alison the need for medically informed social policy arose from the failure of Chalmers's effort to revitalize Scottish poor relief. Unlike the English poor law, the Scottish law denied public relief to the ablebodied. There was no official recognition of unemployment, increasingly common as a result of the fluctuations of an industrial economy. Even those with a right to relief, the disabled and the elderly, did not have a right to much. In most parishes there were no legal assessments for support of the poor and contributed funds were often too little. In St. Andrews the allowance was often a few pence per week and a bit of coal: a “system of protracted starvation,” wrote Alison.⁸⁶ There were many charities in Scottish towns, and also many beggars. Alison protested that medicine was being made to substitute for a proper poor law in a way that was both ineffective—by the time the indigent came to the attention of a medical charity or benevolent doctor little could be done—and unfair: displaced people, from Highland clearances or from Ireland, overloaded the medical charities in the larger towns or appealed to individual medical men, who often supplied them with the “necessaries” without hope of reimbursement. His solution was a Scottish version of the English poor law: it would recognize a right to relief, perhaps in conjunction with some needs test; would be administered by a professional staff, including a paid medical staff; and would be supported by rates.

Observations on the Management of the Poor in Scotland, and Its Effects on the Health of Great Towns, Alison's first and chief work on the subject, appeared in spring 1840, a response to a report on the Scottish Poor Law by the General Assembly of the Scottish Church. The church seemed unlikely to solve the problem. Unpopular ministers “intruded” by patrons into parishes were unlikely candidates to revitalize those parishes à la Chalmers; nor, in many places, did the public seem likely to endorse taxes to support the poor. Seizing on the opportunity provided by Chadwick's great Sanitary Inquiry, Alison quickly organized The Association for Obtaining an Official Inquiry into the Poor Laws of Scotland, preponderantly made up of medical men, which would try to broaden Chadwick's inquiry into a general investigation of the Scottish poor law.

For years, Alison explained, he had been “applying remedies to diseases which have obviously been the result of privations … [and] known that they could be only temporarily useful, simply because he had no remedy for the privations from which they originated.” He would undertake an epidemiology of the “grand evil of Poverty itself, and endeavour to apply to it the same principles of investigation, by which physicians are guided in determining the immediate causes and remedies of disease.”⁸⁷ The medical police tradition warranted this trespass of the usual bounds of medicine. Contagious fever was a far greater problem in Scotland than in England, Alison argued.⁸⁸ While destitution was rarely its direct cause, it was most common and most dangerous among destitute people.⁸⁹ Thus “a poor family wandering in search of employment, and infected with fever, who were driven from one part of the town to another … introduced the disease into three different districts, all inhabited by very poor people.” Fifty cases were traced to them; all could have been prevented by an effective poor law.⁹⁰ In practical terms, destitution was the public health problem. So strong was this relation that Alison would treat fever incidence as the “test to the legislator” of the adequacy of provision for the poor: “‘As the botanist can tell the quality of the soil from the flowers that spontaneously arise upon it, the physician knows the state of a people from the epidemics that mow it down.’”⁹¹

While medicine warranted Alison's involvement, he was equally adept making the case on theological and economic grounds. In Observations, Alison accused Chalmers of exegetical error, arguing that the command to charity was unqualified. All humans were a mix of good and bad; thus none was fully undeserving, and to punish sinful parents was also to punish innocent children. Yet behind the moral argument was the medical: those most in need (regardless of desert) were those “among whom fever and other epidemics are most apt to break out and to extend; and that this result can only be prevented by some improvement of their condition and comforts. … For the sake of the morals, but quite certainly for the sake of the health of the community, it is most important, that the wants (well ascertained by inquiry) of the vicious poor should be promptly relieved.”⁹² Alison rejected the prominent view that poverty implied sin, that, for example, a high mortality rate was the just reward of drink. Infant deaths were the chief component of higher than normal mortality rates, he noted; furthermore, the poor were too poor to drink themselves to death. And granting that intemperance was a problem, how was one to stop very depressed people from drinking heavily?⁹³

While Observations spoke to the Scottish church, “Illustrations of the Practical Operation of the Scottish System of Management of the Poor,” his address to the Statistical Section of the British Association in September 1840, targeted political economists. Alison accepted Malthus's views of the problems of poor relief, but argued that Malthusian policies were inconsistent, ineffective, and, by generating disease, dangerous. The Malthus-Chalmers approach was illogical because it presumed a clear demarcation between problems that stemmed from moral error (indigence, irresponsible reproduction, intemperance) and those resulting from “a visitation of Providence.”

Malthus and Chalmers had held medical relief to the sick pauper to be acceptable because it did not tempt one to become ill. Alison found this distinction illusory. How could it be right to assist when incurable disease disabled the able-bodied worker but wrong to assist those “disabled by that visitation of Providence which the mere advance of years brings upon all”? Admittedly destitution sometimes resulted from moral failing, yet many became destitute as a result of causes “over which they have had as little control as over the dispensations of Providence … the failure of any particular line of industry in consequence of improvement in art, the glut of markets, commercial embarrassments from failure of banks or other establishments, or the general increase of population.” Chalmers's error was the assumption that whoever was not a pauper was, in a meaningful sense, independent. Yet few were; the welfare of almost all was tied directly to the whims of landowners or the speculations of capitalists.⁹⁴

Either the Chalmersites had to be more rigid in their enforcement of social responsibility or one must disentangle public morality from public health, leaving the former to the church, treating the latter by the most effective means.⁹⁵ On empirical grounds Alison denied that either deterrent social policies or a fatalistic response to epidemics did anything to slow population growth. On the contrary, they exacerbated the problem: “In a country advanced in civilization, population makes the most rapid progress where least is done for the poor; … its tendency … to outstrip the means of subsistence, is most effectually restrained where a fixed and uniform provision, securing them against destitution and degradation, is known to exist.” Ireland, with (until recently) no legal provision for the poor, was the exemplar of Malthusian misery and regularly swept by epidemics.⁹⁶

Alison's writings in the early 1840s mark the epitome of a medical critique of industrialism and capitalism the like of which did not reappear until the twentieth century. He went further than others in exploring the possibilities of a supportive social policy. In his hands the deterrent workhouse of Chadwick became a hostel for the destitute and a fever-prevention institution. The invisible poor of Edinburgh, deserted elderly women who silently starved or froze in lodging houses, might live there “in comparative comfort, and, if they should take fever, would be prevented from communicating the infection.”⁹⁷ His critique was rooted, on the one hand, in eighteenth-century sentiment, on the other in practical experience. He realized that fever hospitals were ineffective if fever victims did not trust them and that the economists' theories of rational behavior did not describe the actions of the desperate people with whom he worked. Among the most eloquent of his observations was of three young mothers in Edinburgh:

During the inclement weather of spring 1838, I saw three young women with natural children on the breast, who were out of work, in a miserable state of destitution, and who were refused admission into the workhouses, and were very scantily relieved by the other charities here. After some weeks of severe suffering, the children all died, certainly of the effects of cold and imperfect nourishment. If anyone supposes, that the effect of this sacrifice of innocent life was to improve the morals of these women or their associates, I can only say, that he knows nothing of the effect of real destitution on human character and conduct.⁹⁸

What then of Kay, schooled in the same traditions of physiology and medical practice, likewise concerned with the condition of the people and adept in the scholasticism of political economy? Kay had gone far in wrestling with the question of what must be the effect on a person of a life in Manchester's mills. Yet his conclusion—that such a life bred monsters—only reinforced his belief in the need for invisible chains that would control them. He endorsed Chalmers. Unlike Alison, who held, in effect, that if destitution, fever, and overpopulation were consequences of the creation of the industrial proletariat, then there must be something wrong with that system, the providentialist Kay found himself trapped by what he, Chalmers, and many others saw as God's laws for the conduct of economic, moral, and social relations. One can of course attribute their differences to their upbringings, and the cultural climates they worked in. It is also well to remember that Edinburgh's problem (immigration of displaced people into a nonindustrial town) was not Manchester's (management of an “angry and alien” proletariat during a period of fluctuating trade and technological change). Would each have thought the same had he practiced in the other's town?⁹⁹

Their divergent analyses of the relations of public health to social policy are of great importance, however. For the early Christians the great question was “Athens or Jerusalem?” In public health it was “Manchester or Edinburgh?” Kay's approach led to the public health of Chadwick (according to Kay, he dumped the “sanitary idea” in Chadwick's lap when he took the post of secretary to the Privy Council's Education Committee). Outside Scotland the Alison approach disappeared, surfacing only briefly in the early 1860s, the first years of John Simon's reign over British public health. As we shall see in later chapters, Chadwick virtually ignored Alison; the reader of the Sanitary Report will not know of the Observations nor of the fireworks in Glasgow in September 1840, though both dealt centrally with the relation of fever to poverty, ostensibly the subject of the inquiry. Throughout the decade—which, after all, produced the massive fevers of the great Irish famine—Alison continued to produce analyses of the economic causes of disease, yet he was unable to halt the juggernaut of sanitarianism.¹⁰⁰ For Chadwick had conceived a policy far more innocuous than the redistributionism of a food-work conception of health, and one with a real treat for the dutiful middle classes: new porcelain water closets and ready water, for cooking, cleaning, even drinking.

Notes

1. Charles Collignon, Medicina Politica, or Reflections on the Art of Physic as Inseparably Connected with the Prosperity of the State (London: J. Bentham, 1765), 18, 28, 34.

2. Ibid., 8. DeLacy, following Riley, distinguishes between a neo-Hippocratic and a Galenical school in the eighteenth century. On this dichotomy Collignon is clearly a Galenist, as one would expect from his Oxbridge connection. Even if such a dichotomy can be demonstrated as reflecting distinct schools of thought and not merely different contexts of application and explanation, both positions still conceive the body as subject to environmental forces, behaving in a comprehensible and lawlike fashion, be they closer or more distant (Margaret DeLacy, “Influenza Research and the Medical Profession in Eighteenth-Century Britain,” Albion 25 [1993]: 37-63; James C. Riley, The Eighteenth Century Campaign to Avoid Disease [London: Macmillan, 1987]; Charles Rosenberg, “Medical Text and Social Context: Explaining William Buchan's Domestic Medicine,” Bulletin of the History of Medicine 57 [1983]: 22-42).

3. Parr defines “disease” as “that condition of the human body, in which the actions of life and health proper to it are not performed, or performed imperfectly. According to this definition the disease consists in disordered or impeded functions; and these form, in our view, its essence. By these it is defined; by these distinguished” (Bartholmew Parr, London Medical Dictionary; Including under Distinct Heads, Every Branch of Medicine, viz. Anatomy, Physiology, and Pathology, the Practice of Physick and Surgery, Therapeutics and Materia Medica; with Whatever Relates to Medicine in Natural Philosophy, Chemistry, and Natural History [Philadelphia: Mitchell, Ames, and White; 1819], s.v. “Causa,” 381). Cf. Copland's definition of “health” as “uninjured … vitality endowment,” with corresponding harmony of function and wholeness of structure. When disease occurs, “energies of the vital principle become depressed, excited, exhausted, or otherwise altered” (in James Copland, A Dictionary of Practical Medicine, Comprising General Pathology, 3 vols. [London: Longman, 1858], vol. I, 557; s.v. “Disease: the Causation and Doctrine of”). Significantly, Chadwick's mentor Bentham used a modern definition of health in justifying the deterrent workhouse: “Health being the mere negation of disease, if there be no disease in any instance … as far as health is concerned the smallest allowance is preferable as being least expensive” (“Outline of a Work Entitled Pauper Management Improved,” The Works of Jeremy Bentham Published under the Superintendence of His Executor, John Bowring, 11 vols. [Edinburgh: William Tait, 1843], vol. 8, 387).

4. Parr, London Medical Dictionary, s.v. “Hygidion.” Parr wrote that “many changes may take place, without inducing a lesion of the functions, and, of course, a disease.” On the social basis of this medicine see N. D. Jewson, “The Disappearance of the Sick-Man from Medical Cosmology, 1770-1870,” Sociology 10 (1976): 225-44.

5. Parr, London Medical Dictionary, II, 29, s.v. “Nosology”; I, 381, s.v. “Causa.”

6. The views both that scientific progress would lead to the recognition of a specific cause for each disease and that all cases of a given disease need have the same cause(s) seemed not only philosophically unwarranted, but implausible, and even downright erroneous. See Whitley Stokes, quoted by Alfred Hudson: “‘This supposition of a single cause of the effects we witness, is quite unsupported by nature. Every animal, every plant, every rock, requires for its production the co-operation of many causes that we know and most probably of many more that we have not yet discovered’” (Hudson, “An Inquiry into the Sources and Mode of Action of the Poison of Fever,” in William Davidson and Alfred Hudson, Essays on the Sources and Mode of Action of Fever [Philadelphia: A. Waldie, 1841], 108). Charles Williams argued that causation was fundamentally more complicated in medicine than in the “simpler” physical sciences: “In most cases there is not that uniform and constant relation between these as causes, and the diseases as effects, which we might expect from the analogy of causation in the simpler sciences” (Charles Williams, Principles of Medicine Comprising General Pathology and Therapeutics, edited with an introduction by Meredith Clymer (Philadelphia: Lea and Blanchard, 1848), 20-21.

7. With the advance of pathological anatomy and redefinition of disease as lesion, talk of proximate cause became redundant and confusing. Yet well into the nineteenth century disease was still an entity interpreted by the physician from the account and appearance of the patient and this hidden state was its most immediate cause. See Parr, London Dictionary of Medicine, s.v. “Causa,” 381. For a modern discussion see Lester King, Medical Thinking: A Historical Preface (Princeton, N.J.: Princeton University Press, 1982), ch. 9-10.

8. John Roberton, Observations on the Mortality and Physical Management of Children (London: Longman, Rees, Orme, Brown, 1827), 254fn. His description paraphrases Boerhaave (Dr Boerhaave's Academical Lectures on the Theory of Physic Being a Genuine Translation of His Institutes and Explanatory Comments Collated and Adjusted to Each Other, as They Were Dictated to His Students at the University of Leyden [London: W. Innys, 1746], 379-80).

9. Copland, Dictionary of Medicine, 559, 562: The analogy is apt because most theorists held that an exciter was not always necessary; something like a spontaneous generation of disease might occur if predisposing forces accumulated to a critical point: “Such is the state of the human frame, that no constitution can ever be pronounced free from predisposition. There is, in every one, some weak organ which requires only an exciting cause to blow the spark into a flame” (Parr, London Medical Dictionary, 381, s.v. “Causa”). See also Williams, Principles of Medicine, 22; George Wood, A Treatise on the Practice of Medicine, 2d ed. (Philadelphia: Grigg, Elliott, and Co., 1849), 126; C. Hamlin, “Predisposing Causes and Public Health in the Early Nineteenth Century Public Health Movement,” Social History of Medicine 5 (1992): 43-70.

10. Copland, Dictionary of Practical Medicine, I, s.v. “Disease,” 558; John Elliotson, The Principles and Practice of Medicine with Notes by Nathaniel Rogers (London: Butler, 1839), 11-31; J. M. Good, The Study of Medicine, 2d ed., 5 vols. (London: Baldwin, Craddock, and Joy, 1825), II, 42; Parr, London Medical Dictionary, s.v. “Causa,” 381; Thomas Watson, Lectures on the Principles and Practice of Physic, 4th ed., 2 vols. (London: Parker, 1857), I, 75-111. By around 1850 these terms were beginning to seem confusing and inutile (see Williams, Principles of Medicine, 18-67, esp. 21-23; Wood, Treatise, 126-43; Hooper's Medical Dictionary, 8th ed, revised, corrected, and improved by Klein Grant, M.D. [London: Longmans, Brown, 1848], s.v. “Aetiologia”).

11. Copland, Dictionary of Practical Medicine, I, s.v. “Disease,” 558; Robert Thomas, The Modern Practice of Physic, Exhibiting the Characters, Causes, Symptoms, Prognostics, Morbid Appearances, and Improved Method of Treating Diseases of All Climates, 6th ed. (London: Longman, Hurst, Rees, Orme, Brown, 1819), 27.

12. Copland, Dictionary of Practical Medicine, I, s.v. “Disease,” 561; Joseph Ayre, Practical Observations on the Nature and Treatment of Marasmus (London: Baldwin, Craddock, and Joy, 1818), 155. See also Henry MacCormac, An Exposition of the Nature, Treatment, and Prevention of Continued Fever (London: Longman, Rees, Orme, Brown, Green, and Longman, 1835), 40-41.

13. Parr complained of “causes without effects; effects without causes; opposite effects from the same cause; or the same effect from opposite causes” (London Medical Dictionary, s.v. “Causa,” 381).

14. C. T. Thackrah, The Effects of the Arts, Trades, and Professions and of the Civic States and Habits of Living, on Health and Longevity: With Suggestions for the Removal of Many of the Agents Which Produce Disease, and Shorten the Duration of Life, 2d ed. (London: Longmans, Rees, Orme, Brown, 1832), 144-46.

15. The idea of premature aging and death is linked to the theory of a quantity or reservoir of vitality that would be prematurely exhausted by those who worked too hard in youth (Thackrah, Effects, 35-37, 148-49).

16. J. B. Davis, A Popular Manual of the Art of Preserving Health (London: Whittaker, 1836), 144; Thomas Bateman, Reports on the Diseases of London and the State of the Weather from 1804 to 1816 Including Practical Remarks on the Causes and Treatment of the Former; and Preceded by a Historical View of the State of Health and Disease in the Metropolis in Times Past (London: Longmans, Hurst, 1819), 52-53, viii; see also William Heberden, Observations on the Increase and Decrease of Different Diseases (London: T. Payne, 1801), 46-49, 66-68; John Reid, The Philosophy of Death, or a General Medical and Statistical Treatise on the Nature and Causes of Human Mortality (London: S. Highly, 1841), 36. Bateman wrote to correct “a dangerous and fatal impression … of the salubrity of cold” (cf. James Johnson, The Influences of Civic Life, Sedentary Habits, and Intellectual Refinement, on Human Health and Human Happiness, Including an Estimate of the Balance of Enjoyment and Suffering in the Different Conditions of Society [London: Underwood, 1818], 30-31). There was an issue of class here—Johnson wrote for the wealthy, who didn't get out enough but had the means to get warm; Bateman, as a fever hospital doctor, saw those who could not get warm.

17. Richard Baron Howard, An Inquiry into the Morbid Effects of Deficiency of Food Chiefly with Reference to Their Occurrence amongst the Destitute Poor (London: Simpkin, Marshall, and Co., 1839), iii, 1-3, 19-29, 37-40. Howard would write the Manchester report for Chadwick's Sanitary Inquiry; Chadwick, finding Howard's views unacceptable, would virtually ignore it. A few years earlier in Glasgow, Andrew Buchanan, professor of materia medica at the Andersonian University, had raised the same issue even more directly: “In plain language, I am of opinion, that many of the poor in this city die of starvation,” which in turn was due to policies which “deprive one class of the community of the first necessaries of life, that another class may wallow in affluence.” The torpor of the starving was “perhaps, a blessing, as it prevents them from speculating on the causes of their own misery” (“Report of the Diseases Which Prevailed among the Poor of Glasgow, During the Summer of 1830,” Glasgow Medical Journal 3 [1830]: 446-47).

18. For recent discussions of these questions by philosophers of medicine see Science, Technology, and the Art of Medicine: European-American Dialogues, Corinna Delkeskamp-Hayes and Mary Ann Gardell Cutter, eds. (Dordrecht: Kluwer Academic, 1993), esp. Dietrich von Engelhardt, “Causality and Conditionality in Medicine Around 1900,” 75-104; Anne Fagot-Largeault, “On Medicine's Scientificity—Did Medicine's Accession to Scientific ‘Positivity’ in the Course of the Nineteenth Century Require Giving Up Causal (Etiological) Explanation?,” 105-26; and José Luis Peset, “On the History of Medical Causality,” 57-74. See also Riley, Campaign, 15.

19. Heberden, Increase and Decrease, 68. Cf. John Haygarth, A Letter to Dr. Percival on the Prevention of Infectious Fevers and an Address to the College of Physicians in Philadelphia on the Prevention of the American Pestilence (Bath: R. Cruttwell, 1801), 33-35. Haygarth experimented on susceptibility to typhus, calculating that from 1:23 to 1:33 were not susceptible. “It is not improbable that debility, or indisposition, or fear, or exposure to cold or fatigue, or, as some suppose, a difference of diet, may occasion a greater variety in the quantity of poisonous miasms necessary to produce an infectious fever.” See also MacCormac, Fever, 40-41.

20. Thus, most of the medical men explaining the Irish fever of 1817-19 gave an anticontagionist (mysterious alteration of atmospheric constitution) explanation of the origin of the epidemic, while appealing to standard contagionism as the primary means of its transmission within Ireland and invoking heavily physiological accounts of debilitation to explain why it struck those it did and affected those it struck differently (J. Barker and J. Cheyne, An Account of the Rise, Progress, and Decline of the Fever Lately Epidemical in Ireland, 2 vols. [London: Baldwin, Craddock, and Joy, 1821]). See also A. Tweedie, Clinical Illustrations of Fever, Comprising a Report of Cases Treated at the London Fever Hospital, 1828-29 (London: Whitaker and Treacher, 1830), 81. These were ancient questions (J. Ferriar, “The Origin of Contagious and New Diseases,” in Ferriar's Medical Histories and Reflections, 1st American ed., 4 vols. in 1 [Philadelphia: Dobson, 1816], I, 119-20).

21. Nor does “contagion” or “miasm” necessarily translate into “exciting cause”—a contagion might be equally understood as a predisposer, since not all who were exposed to the contagion acquired the disease. “The occurrence of the exciting cause may be, or may not be, accompanied by exposure to contagion” (Hudson, Fever, 124-25). See also Williams, Principles of Medicine, 36; Copland, Dictionary, s.v. “Disease,” 565-58.

22. What may seem the most important distinction—that a contagion could only be received from a previous human host, while a miasm could spontaneously generate under proper conditions of filth—was not completely accepted. Ontologist anticontagionists sometimes did imagine a permanent (i.e., nonlocal, non-spontaneously generated) aerial virus that periodically visited particular places—sometimes they even called it a contagion. See Thomas Mills, A Comparative View of Fever and Inflammatory Complaints with Essays Illustrative of the Seat, Nature, and Origin of Fever (Dublin: Cumming and McArthur, 1824), 111-15, 121. The range of contamination was an important issue: How closely could one safely approach a victim? (See Good, Study of Medicine, II, 66; Parr, London Medical Dictionary, s.v. “Miasm”; Haygarth, Letter to Dr. Percival, 6-7, 60).

23. R. Hooper, Compendious Medical Dictionary (London: J. Murray, 1799), s.v. “Miasm.”

24. Parr, London Medical Dictionary, s.v. “Contagio,” 482-84. Tweedie similarly held that contagious particles “originate, and spread, in consequence of a peculiar condition of the atmosphere” (Clinical Illustrations of Fever, 81-82).

25. Good, Study of Medicine, II, 64-65: “No great benefit, however, has resulted from endeavouring to draw a line of distinction between these two terms, and hence it is a distinction that has been very little attended to of late years. Miasm is a Greek word, importing pollution, corruption, or defilement generally; and contagion a Latin word, importing the application of such miasm or corruption to the body by the medium of touch. There is hence therefore, neither parallelism nor antagonism, in their respective significations: there is nothing that necessarily connects them either disjunctively or conjunctively. Both equally apply to the animal and vegetable worlds—or to any source whatever of defilement and touch; and either may be predicated of the other; for we may speak correctly of the miasm of contagion, or of contagion produced by miasm.”

26. Copland, Dictionary, s.v. “Disease,” 569. Or one could use the new term “malaria”: “a peculiar, invisible, and hitherto unexplained exhalation from the ground, supposed to be the consequence of either animal or vegetable putrefaction.” With predisposition it was a “powerful agent” (Tweedie, Clinical Illustrations, 82-84).

27. Parr, London Medical Dictionary, s.v. “Miasm”; Good, Study of Medicine, II, 64-65.

28. William Farr, “Vital Statistics,” A Statistical Account of the British Empire: Exhibiting Its Extent, Physical Capacities, Population, Industry, and Civil and Religious Institutions, ed. J. R. McCulloch, 2d ed., 2 vols. (London: Charles Knight, 1839), II, 574; Thomas, The Modern Practice, 497. Heberden reported much the same result in 1801 (Increase and Decrease, 42). For recent assessments see F. B. Smith, The Retreat of Tuberculosis 1850-1950 (London: Croom Helm, 1988); Sumit Guha, “The Importance of Social Intervention in England's Mortality Decline: The Evidence Reviewed,” Social History of Medicine 7 (1994): 96.

29. Sir James Clark, A Treatise on Pulmonary Consumption Comprehending an Inquiry into the Causes, Nature, Prevention and Treatment of Tuberculosis and Scrofulous Diseases in General (London: Sherwood, Gilbert and Piper, 1835), 200-202, 221. Cf. Davis, Hygiene, 51-53, 65, 274.

30. Clark, Treatise, 239, 12, 219, 230-35. Davis, who followed Clark, held that the “immediate” cause in nine of ten cases was “cold” (Davis, Hygiene, 89-95); cf. Thomas, The Modern Practice, 498.

31. Clark, Treatise, 238-40; cf. Thomas, The Modern Practice, 498. Occupation was a more central factor in explaining tuberculosis than in explaining most other diseases. Following Thackrah and drawing on the Paris clinicians, Clark saw irritation as the primary pathological process. Workplace atmospheres “loaded with pulverulent bodies or charged with gaseous substances of an irritating quality” were the exciting causes of consumption among stonemasons, miners, coal heavers, flax dressers, polishers of brass and steel, metal grinders, and needle pointers. Also deadly were sedentary occupations, especially those of cobblers, tailors, and dressmakers, because they prevented full expansion of the chest, and thus undermined the constitution (Clark, Treatise, 165-69, 186-93; cf. Thackrah, Effects, 201; Thomas, The Modern Practice, 497).

32. Clark, Treatise, iv, xiii-xiv, 202.

33. Cf. Erwin Ackerknecht, “Anticontagionism between 1821 and 1867,” Bulletin of the History of Medicine 22 (1948): 562-93; Riley, Campaign, x. For criticisms see Roger Cooter, “Anticontagionism and History's Medical Record,” The Problem of Medical Knowledge: Examining the Social Construction of Medicine, eds. P. Wright and A. Treacher, 87-108 (Edinburgh: Edinburgh University Press, 1982); Margaret Pelling, Cholera, Fever, and English Medicine, 1825-1865 (Oxford: Oxford University Press, 1987), passim; W. Coleman, Yellow Fever in the North: The Methods of Early Epidemiology (Madison: University of Wisconsin Press, 1987), ch. 7. Controversies did occur, but as Margaret Pelling has noted, more as concoctions whipped up for immediate political needs than as fundamental antitheses of theoretical medicine. Almost always, the practical response to epidemics included isolating the sick as well as scraping out the drains and hauling off the dung. This eclecticism in explanation was also true in the earlier campaign against plague (see C. Cipolla, Miasmas and Disease: Public Health and the Environment in the Pre-Industrial Age, trans. Elizabeth Potter [New Haven: Yale University Press, 1992], 4-5, 45-48, 60).

34. Reid, Philosophy of Death, 88-95; “Epidemic Fever,” Edinburgh Medical and Surgical Journal 14 (1818): 530, 534; Thomas Bernard, “An Extract from a Further Account of the London Fever Institution,” Report of the Society for Bettering the Condition and Increasing the Comforts of the Poor 5 (1808): 138.

35. W. F. Bynum, “Cullen and the Study of Fevers in Britain,” Theories of Fever from Antiquity to the Enlightenment, eds. W. F. Bynum and V. Nutton, Medical History, Supplement, 1 (London: Wellcome Institute for the History of Medicine, 1981), 135-47.

36. Dale C. Smith, “Medical Science, Medical Practice, and the Emerging Concept of Typhus,” in Bynum and Nutton, Theories of Fever, 121-34; Leonard Wilson, “Fevers and Science in Early Nineteenth Century Medicine,” Journal of the History of Medicine 33 (1978): 394; Good, Study of Medicine, II, 50-63, 240-42; Pelling, Cholera, 14-15; W. P. Alison, “Inflammation,” A System of Practical Medicine Comprised in a Series of Original Dissertations, ed. A. Tweedie, Library of Medicine, 1 (London: J. Whitaker, n.d.), 69-72; Robert Jackson, A Sketch, (Analytical) of the History and Cure of Contagious Fever (London: Burgess and Hill, 1819), 150: Robert Thomas, The Modern Practice, 4-60; MacCormac, Fever, 19-21.

37. Henry Clutterbuck, Observations on the Prevention and Treatment of the Epidemic Fever at Present Prevailing in the Metropolis and Most Parts of the United Kingdom (London: Longman, Hurst, Rees, Orme, and Brown, 1819), 37, 41; M. C. Buer, Health, Wealth, and Population in the Early Days of the Industrial Revolution (London: Routledge, 1926), 166-67; MacCormac, Fever, 54-57.

38. Thomas Bateman, A Succinct Account of the Contagious Fever of This Country Exemplified in the Epidemic Now Prevailing in London (London: Longman, Hurst, 1818), 14, 144; Haygarth, Letter to Dr. Percival, 70-75; cf. William Davidson, “Essay on the Sources and Mode of Propagation of the Continued Fevers of Great Britain and Ireland,” in Davidson and Hudson, Essays on the Sources and Mode of Action of Fever (Philadelphia: A. Waldie, 1841), 5.

39. Thomas, The Modern Practice, 44-46; cf. J. M. Good, A Dissertation on the Diseases of Prisons and Poor-Houses (London: C. Dilley, 1795), 25, 67; Wood, Treatise, 128-29.

40. Clutterbuck, Observations, 30; Jackson, Sketch, 148-50. Cf. Wilson, “Fevers and Science,” 388.

41. Clutterbuck, Observations, 35-36; MacCormac, Fever, 45.

42. Parr, London Medical Dictionary, 645.

43. I.e., “In a great number of instances, the disease has taken place where no contagion could be found, or even suspected, to which it might be referred” (Clutterbuck, Observations, 30); cf. Davidson, “Fever,” 4; Hudson, “Fever,” 104-8; MacCormac, Fever, 43-44; Haygarth, Letter to Dr. Percival, 45, 56, 110; Robert Graham, Practical Observations on Continued Fever, Especially That Form at Present Existing as an Epidemic with Some Remarks on the Most Efficient Plans for Its Suppression (Glasgow: J. Smith and Son; 1818). Among those for whom this was an explanation of first resort was Bateman (Succinct Account, 11); see also “Epidemic Fever,” Edinburgh Medical and Surgical Journal 14 (1818): 537.

44. The contagion might be merely “morbid exhalations and secretions … constituting a medium of infection capable of generating fever” (Bateman, Succinct Account, 13); MacCormac, Fever, 44-45; Tweedie, Clinical Illustrations, 82-86. This is the case even for Haygarth, a contagionist in a relatively modern sense (Letter to Dr. Percival, 129-32). See also Ferriar, “Origin of Contagious and New Diseases,” 118; cf. Pelling, Cholera, 15.

45. Christopher Lawrence, “The Nervous System and Society in the Scottish Enlightenment,” Natural Order: Historical Studies of Scientific Culture, eds. Barry Barnes and Steven Shapin, 19-40 (Beverly Hills: Sage, 1979); Gilbert Blane, Elements of Medical Logick, 2d ed. (London: Underwood, 1821), 46-47; Davis, Hygiene, 96; MacCormac, Fever, xi-xii; Reid, The Philosophy of Death, 35.

46. Copland, Dictionary, s.v. “Disease,” 562, cf. Williams, Principles of Medicine, 48; MacCormac, Fever, 36; Davidson, “Essay,” 72-73.

47. Good, Dissertation, 81-83; Ferriar, “Origin of Contagious and New Diseases,” 125; Thomas, The Modern Practice, 44-46.

48. Copland, Dictionary, s.v. “Disease,” 526; cf. Parr, London Medical Dictionary, s.v. “Causa,” 381.

49. John Ferriar, “Epidemic Fever of 1789 and 1790,” Medical Histories and Reflections, I, 78.

50. James Johnson, The Influences of Civic Life, 92-93, also 44, 11. See also Davis, Hygiene, 90-91. David Roberts finds this argument typical of paternalist social thought (Paternalism in Early Victorian England [New Brunswick, N.J.: Rutgers University Press, 1979], 152).

51. Anne Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (Cambridge: Cambridge University Press, 1994), 199-233; Anand Chitnis, The Scottish Enlightenment and Early Victorian English Society (London: Croom Helm, 1986), 135-46; Robert Kilpatrick, “‘Living in the Light’: Dispensaries, Philanthropy and Medical Reform in Late Eighteenth Century London,” The Medical Enlightenment of the Eighteenth Century, eds. Andrew Cunningham and Roger French, 254-80 (Cambridge: Cambridge University Press, 1990); Andrew Cunningham, “Medicine to Calm the Mind: Boerhaave's Medical System, and Why It Was Adopted in Edinburgh,” ibid., 40-66.

52. Bernhard Faust, The Catechism of Health, Trans. from the German and Carefully Improved by Dr Gregory of Edenburg [sic], 3d American ed. (Raleigh: Thomas Henderson, 1812), questions [qq] 7, 13-14; cf. Q 1: “Dear Children, to breathe, to live in this world, created by God, is it an advantage? Is it to enjoy happiness and pleasure?” A: “Yes. To live is to enjoy happiness and pleasure; for life is a precious gift of the Almighty.” In Q 23, we learn from psalm 90 that God promises long life (seventy to eighty years) to those who obey the commandments. It is noted (Q 15) that we have a duty to improve the health of one another, and that parents and schoolmasters do not sufficiently consider that—nothing is said of masters. Nonetheless Faust held most injuries to health to be hereditary (18-19). On Faust see Charles Rosenberg, “Catechisms of Health: The Body in the Prebellum Classroom,” Bulletin of the History of Medicine 69 (1995): 175-97. Also see Farr, “Vital Statistics,” 522, 557; Robert Cowan, “Vital Statistics of Glasgow, Illustrating the Sanatory Condition of the Population,” Journal of the Statistical Society of London 3 (1840): 270; “Epidemic Fever,” Edinburgh Medical and Surgical Journal 14 (1818): 529. On physiological equality see E. P. Thompson, The Making of the English Working Class (Harmondsworth, U.K.: Penguin, 1968), 90.

53. Quoted in Alfred [George Kydd], The History of the Factory Movement from the Year 1802, to the Enactment of the Ten Hours' Bill in 1847, 2 vols. (London: Simpkin, Marshall, 1857), I, 237-38.

54. John Ferriar, “Advice to the Poor,” Medical Histories and Reflections, Appendix 1, 403-6; cf. Ferriar, “Account of the Establishment of Fever-Wards in Manchester,” Medical Histories and Reflections, III, 337; Ferriar, “Of the Prevention of Fevers in Great Towns,” Medical Histories and Reflections, II, 233; Clark, Consumption, 268-95. Clark admitted, “I am well aware that many of my recommendations will unfortunately be found beyond the attainments of the public at large; but … I … state them, in order that they may be adopted when circumstances admit.”

55. Thackrah, Effects, 7, 90.

56. Alfred, Factory Acts, 56; see F. Engels, The Condition of the Working Class in England, trans. and eds. W. D. Henderson and W. H. Chaloner (Oxford: Blackwell, 1971), 111; MacCormac, Fever, 46.

57. Bernard, in Miss Horner, “Extracts from an Account of the Contagious Fever at Kingston-on-Hull,” Report of the Society for Bettering the Condition and Increasing the Comforts of the Poor 4 (1805): 105. The idea that mental outlook affected physical health was not new: “Passions of the mind” were among Galen's “non-naturals”; the art of physic included producing illusions of hope that might spur recovery.

58. MacCormac, Fever, 45, cf. “Epidemic Fever,” 539; Jackson, Sketch, 128.

59. Ferriar, “Origin of Contagious and New Diseases,” 125-27. These were central arguments in the campaign for fever hospitals. The tone varies from academic generalization—“wealthy people might get it too unless something is done”—to direct retribution—“the striking down of those who were given the opportunity to act justly, but didn't.” The former are more common. Cf. Ferriar, “Epidemic Fever of 1789 and 1790,” 77; idem, “Of the Prevention of Fevers in Great Towns,” 224-39. See James Kay-Shuttleworth, The Moral and Physical Condition of the Working Classes Employed in the Cotton Manufacture in Manchester, with a New Preface by W. H. Chaloner, 2nd ed. (London: Frank Cass, 1970), 7, 11. Cf. Richard Millar, Statements Relative to the Present Prevalence of Epidemic Fever among the Poorer Classes of Glasgow (Glasgow: John Smith and Son, 1818), 9-10; Thomas Bernard, “An Extract from a Further Account of the London Fever Institution,” 140. The best known version is not Ferriar's but Carlyle's, in Past and Present. Carlyle took it from the Edinburgh physician W. P. Alison, and it is at least implicit in nearly every fever writer of the period.

60. Ironically, the view of humans and machines as interchangeable was one of the vehicles of physiological universalism (Thackrah, Effects, 220-21).

61. Some did wonder why medicine did not have a greater voice in policy (Davis, Hygiene, 3-4).

62. Cowan, “Glasgow,” 269: “The rapid increase in the amount of the labouring population, without any corresponding amount of accommodation being provided for them; the density, and still increasing density of that population; the state of the districts which it inhabits; the fluctuations of trade and of the prices of provisions, and the lamentable ‘strikes’ in consequence of combination among the workmen, by which the means of subsistence have been suddenly withdrawn from large masses; the recklessness and addiction to the use of ardent spirits, at once the cause and the effect of destitution; the prevalence of epidemic diseases both among the adult and infantile portion of the community, have been the chief causes of the great mortality of the city of Glasgow.” Good, writing in 1795, described price inflation as a public health problem. Farmers and manufacturers were doing well, but not laborers: “I have made these observations, because the causes of almost all the diseases I am considering, and consequently the diseases themselves, are to be traced to this general source.” He wrote of a typical weaver's family, in which, “if even the strictest economy be made use of,” wages “will scarcely suffice to procure the bare necessaries of life.” “In such situations, little can be expected from the skill of the surgeon, if he have not influence enough with the chief parishoners to unite their efforts with his own to produce a complete reformation” (Good, Dissertation, 44-45, 52).

63. Buchanan, “Report of the Diseases Which Prevailed among the Poor of Glasgow, During the Summer of 1830,” Glasgow Medical Journal 3 (1830): 440. According to Brenda White, Buchanan got himself in trouble with this paper, though probably more for his ad hominem attacks on the patrons of local medical charities than for his political views (“Scottish Doctors and the English Public Health,” The Influence of Scottish Medicine, ed. Derek Dow, 77-85 [Park Ridge, N.J.: Parthenon, 1988]).

64. Ferriar, “Origin of Contagious and New Diseases,” 125.

65. W. F. Bynum, “Hospital, Disease, and Community: The London Fever Hospital, 1801-1850,” Healing and History: Essays for George Rosen, ed. Charles Rosenberg (New York: Science History, 1979), 102, 109. Cf. Buer, Health, Wealth, and Population, 200-201; J. R. Poynter, Society and Pauperism: English Ideas on Poor Relief, 1795-1834 (London: Routledge and Kegan Paul, 1969), 95. See the comments of Bernard in Miss Horner, “Contagious Fever at Kingston upon Hull,” 102, 108.

66. Ferriar, “Epidemic Fever of 1789 and 1790,” 77; Bernard, “Extract from a Further Account of the London Fever Institution,” 146; idem, “Extract from an Account of the Further Progress of the Fever Institution,” Report of the Society for Bettering the Condition and Increasing the Comforts of the Poor 6 (1815): 2; Ferriar, “Account of the Establishment of Fever-Wards in Manchester,” 323.

67. Ferriar, “Of the Prevention of Fevers in Great Towns,” 235, 237-38; idem, “Epidemic Fever of 1789 and 1790,” 79.

68. Horner, “Fever at Kingston upon Hull,” 100. She gives the ingredients of the broth as 15 pounds mutton, 3.5 pounds barley, 2 cow heels, 2 sheep's heads, 2 dozen turnips, 1/4 peck onions, 1/2 handful thyme, 1/2 pound salt, to yield 52 quarts broth. Great emphasis is also placed on warm clothes (Ferriar, “Account of the Establishment of Fever-Wards in Manchester,” 321; Bateman, Diseases of London, x). Also see John Pickstone, Medicine and Industrial Society: A History of Hospital Development in Manchester and Its Region, 1752-1946 (Manchester: Manchester University Press, 1985), ch. 1-3; Michael Durey, The Return of the Plague: British Society and Cholera, 1831-2 (Dublin: Gill and MacMillan, 1979), 84-85.

69. Bernard, “Extract from an Account of the Further Progress of the Fever Institution” (1815), 8; Ferriar, “Account of the Establishment of Fever-Wards in Manchester,” 322.

70. Cowan, “Glasgow,” 274.

71. Ferriar, “Of the Prevention of Fevers in Great Towns,” 228.

72. Ibid., 235. Roberts (Paternalism, 42) notes the centrality of this welfare of dependency among paternalist writers. Cf. R. A. Lewis, Edwin Chadwick and the Public Health Movement, 1832-1854 (London: Longmans, Green, 1952), 115-16; and Kilpatrick, “‘Living in the Light.’”

73. Chitnis, The Scottish Enlightenment, 23.

74. Frank Smith, The Life and Work of Sir James Kay-Shuttleworth (London: John Murray, 1923); R. J. W. Selleck, James Kay-Shuttleworth: Journey of an Outsider (Ilford, Essex: Woburn Press, 1994). Kay was the son of a Rochdale cotton manufacturer. He was Alison's principal clerk, practiced briefly in Dublin (1826), and by 1828 was senior physician at the Ardwick and Ancoats Dispensary.

75. Stewart J. Brown, Thomas Chalmers and the Godly Commonwealth in Scotland (Oxford: Oxford University Press, 1982), 156, 177. See also Anthony Brundage, The Making of the New Poor Law: The Politics of Inquiry, Enactment, and Implementation, 1832-1839 (New Brunswick, N.J.: Rutgers University Press, 1978), 70; Audrey Peterson, “The Poor Law in Nineteenth Century Scotland,” The New Poor Law in the Nineteenth Century, ed. Derek Fraser, 171-93 (London: Macmillan, 1976).

76. W. Hanna, Memoirs of the Life and Writings of Thomas Chalmers D. D., 4 vols. (Edinburgh: Constable, 1852), IV, 196-216; Brown, Chalmers, 288-96. Kay, Moral and Physical, 3, explains that he dedicated the second edition of the pamphlet to Chalmers after Chalmers had praised the first.

77. Smith, Kay-Shuttleworth, 13-14, 20, 26-30; Selleck, Kay-Shuttleworth, 56-61.

78. Nicholas Coles, “Sinners in the Hands of an Angry Utilitarian: J. P. Kay (-Shuttleworth), The Moral and Physical Condition of the Working Classes in Manchester (1832),” Bulletin of Research in the Humanities 86 (1985): 455, 462; Frank Mort, Dangerous Sexualities: Medico-Moral Politics in England since 1830 (London: Routledge and Kegan Paul, 1987), 22-23; Mary Poovey, “Curing the Social Body in 1832: James Phillips Kay and the Irish in Manchester,” Making a Social Body: British Cultural Formation, 1830-1864 (Chicago: University of Chicago Press, 1995), 55-72.

79. Kay, Moral and Physical, 27-28. I quote from the second edition; on the changes from the first see Selleck, Kay-Shuttleworth, 66-77.

80. Kay, Moral and Physical, 4 (italics mine). Chalmers's holding of such views verged on the unorthodox inasmuch as they seemed to threaten the doctrines of predestination and grace central to the Westminster Confession (Brown, Chalmers, 14).

81. Kay, Moral and Physical, 22.

82. Ibid., 23, 25, 43-44. See also James Phillips Kay, “Physical Condition of the Poor. I. Diet. Gastralgia and Enteralgia, or Morbid Sensibility of the Stomach and Bowels,” North of England Medical and Surgical Journal 1 (1830): 220-30.

83. But see Coles, “Sinners,” 475.

84. Kay, Moral and Physical, 9; [Kay], “Review of M. T. Sadler's Law of Population,” North of England Medical Journal 1 (1830): 105-26.

85. Kay, Moral and Physical, 6-7; see also 42-43, 45, 48-53, 78, 91-93, 94-97, 105-11; Smith, Kay-Shuttleworth, 46. In some sense Providence determined these social responses too, quite as much as it had originally determined the problems. That the solutions had not yet come was due to the slow action of the societal sensorium, or nervous system (Kay spoke of the need for a “natural faculty” to recognize the state of society). It was in this sense that the cholera epidemic was welcome—an indication of both divine “mercy” and divine “judgment”—as a pain stimulus strong enough to provoke preventive action. The task of the therapist Kay was then to invigorate the dulled nerves of society with the tonic of social statistics (Kay, Moral and Physical, 27-30, cf. Coles, “Sinners,” 465, 483, 486).

86. Alison, “Illustrations of the Practical Operation of the Scottish System of Management of the Poor,” Journal of the Statistical Society of London 3 (1840): 229. Cf. Ian Leavitt and Christopher Smout, The State of the Scottish Working-Class in 1843: A Statistical and Spatial Inquiry Based on the Data from the Poor Law Commission Report of 1844 (Edinburgh: Scottish Academic Press, 1979), 161, 220-21.

87. W. P. Alison, Observations on the Management of the Poor in Scotland, and Its Effects on the Health of Great Towns, 2d ed. (Edinburgh: Blackwood, 1840), x.

88. Ibid., 14; W. P. Alison, Reply to Dr Chalmers' Objections to an Improvement of the Legal Provision for the Poor in Scotland (Edinburgh: Blackwood, 1841), v. Thus fever accounted for 20 percent of mortality in Glasgow in 1837, 15 percent in Dundee in 1836, but no more than 8 percent in any English town during the century.

89. “It is not asserted that destitution is a cause adequate to the production of fever (although in some circumstances I believe it may become such); nor that it is the sole cause of its extension. What we are sure of is, that it is a cause of the rapid diffusion of contagious fever, and one of such peculiar power and efficacy, that its existence may always be presumed, when we see fever prevailing in a large community to an unusual extent. The manner in which deficient nourishment, want of employment, and privations of all kinds, and the consequent mental depression favour the diffusion of fever, may be matter of dispute; but that they have that effect in a much greater degree than any cause external to the human body itself, is a fact confirmed by the experience of all physicians who have seen much of the disease” (Alison, Observations, 10-11).

90. Alison, “Illustrations,” 240-41.

91. Alison, Observations, 18; idem, Reply to the Pamphlet Entitled “Proposed Alteration of the Scottish Poor Law Considered and Commented on,” by David Monypenny, Esq. of Pitmilly (Edinburgh: Blackwood, 1841), 46.

92. Alison, Observations, 80-83.

93. Ibid., xi-xii.

94. Alison, “Illustrations,” 246; idem, Reply to Dr. Chalmers, 17-20.

95. Alison, “Illustrations,” 212, 253-55.

96. Among many contemporary political economists the carrot of “artificial wants” that might be acquired through prudence was coming to seem a better motivator than the stick of misery, the punishment for imprudence (Alison, Observations, v-vi; “Illustrations,” 244-45; Alison, “Further Illustrations of the Practical Operation of the Scotch System of Management of the Poor,” Journal of the Statistical Society of London 4 [1841]: 290-93).

97. “Illustrations,” 243; Observations, 109. In general, Alison favored outdoor relief, arguing that “it never can be wise or useful, to break down those habits of comfort and cleanliness, and those artificial wants, which at present characterise the great body of the labouring poor, and even of the aged and disabled poor in England or to outrage the feelings of family affection” (Reply to Monypenny, 38).

98. Alison, Observations, 83fn.

99. Cf. Alison, Reply to Monypenny, 42-43. Alison emphasized the differences between Manchester and Edinburgh to highlight the contrast between a society with legal relief for the poor (England) and one without (Scotland). Accordingly he made working-class life in Manchester appear positively bucolic. For the handling of similar issues in America see Charles Rosenberg, The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: University of Chicago Press, 1962), esp. 40-64, 133-50.

100. Brenda White, “Scottish Doctors and the English Public Health,” 77-85. On the Irish famine fever see Joseph Robins, The Miasma: Epidemic and Panic in Nineteenth Century Ireland (Dublin: Institute of Public Administration, 1995).