Chapter 9: Epilogue

by R. J. Morris

in Cholera 1832 -- The Social Response to An Epidemic, 1976.

Cholera Returns

When cholera returned in 1848 and 1849 there were many features of the epidemic which were familiar to those who had witnessed 1832. It visited the same places and found the same state of unpreparedness. Treatments and preventative measures all failed, and imperfect evidence suggests that the death rate was higher.

But there was a change in the dominant public mood which reflected greater changes in attitudes to health, government, religion and science, 

...there is an improved condition of the public mind since 1832. The vague but intense alarm which preceded the former visitation of the epidemic, has been exchanged for a calm and rational view of the real amount of danger.[9]

After the epidemic there was none of the sudden loss of interest in cholera which had taken place in 1832. The Edinburgh Review and the Christian Remembrancer both reviewed the government reports on the epidemic, whilst the medical journals showed none of the 'boredom' they had expressed in 1832. The Edinburgh Medical and Surgical Journal, the Medical Times and the Lancet continued to review books on cholera well into 1850, discussing new theories on its origin, printing letters on treatment as well as looking at the government publications.[10] There were several reasons for the change. During 1847, thousands of starving Irish people had fled from potato blight and brought typhus to the large cities of Britain. Those who had seen 'famine fever' in the crowded centers of Glasgow, Manchester and Leeds could not view cholera as an unprecedented horror.[11] The public health reports of the 1840s were slow to produce practical results in terms of government action, but through the many articles, pamphlets and public meetings they provoked, these reports gave public and government opinion a thorough education in science-based, especially miasma-based, attitudes to public health problems.[12]

Although they had little more to offer in 1849, the medical and scientific community were much more assured than they had been in 1832. Many doctors had seen cholera in 1832 and there were fewer disputes over the identity of the disease. The government was better informed. It had its own network of local agents, the local Registrars of Births, Deaths and Marriages, who were able to check reports by simple reference to death certificates. In addition, the General Board of Health employed two medical inspectors of their own, Drs Sutherland and Grainger, who were also able to check local reports and conditions. The new railway network meant they were able to do this with a speed impossible in 1832. The regular publication of weekly tables by the Registrar-General replaced the rumor and counter-rumor of the first epidemic. The profession itself was better organized for carrying out and discussing research. There was a network of journals which exchanged information across Europe. Most of the provincial hospitals had medical schools attached to them, and in the 1830s many towns had formed provincial medical societies which were a base for research. In addition the medical and scientific resources of London were greater, and included the increasing government interest in statistics.

There was the same confusion over treatment. The most important change was one of emphasis. The profession had 'discovered' in 1832 that nearly all cases of cholera were preceded by premonitory diarrhea.[13] Searle explained the logic of this. Cholera, dysentery, diarrhea and typhoid all had the same basic cause and were modifications of each other. It was natural that under certain conditions one form of the disease would develop from another. Many thousands of cases of diarrhea were treated through house-to-house visitations, upon which boards of health confidently congratulated themselves that they had prevented many cases of cholera. Novelties were tried. Chloroform used by Simpson in Edinburgh as a pain-killer during childbirth was tried. A bed with anti-static legs was proposed to counter electrical influences. There was a dim memory but little interest in Latta's method, and Dr George Johnson, physician at King's College Hospital, achieved some notoriety by his 'eliminative' treatment in which he assisted the natural course of cholera with huge doses of castor oil.[14]

The real sign of assurance came over etiology. The old contagionists still held their views, but miasmatic thinking dominated official medical and government statements. When the Royal College of Physicians asked for the views of members they had 84 replies: 32 rejected contagion and only 7 gave unqualified support. The others were uncertain or held that both modes of diffusion could operate under different conditions. The recently created General Board of Health, like its secretary Edwin Chadwick, was aggressively miasmatic.[15] The ready acceptance of this theory was helped not only by the public health campaigns of the 1840s but also by the methodology of an increasing number of statistical studies of disease. These depended on figures gathered by geographical area. Hence attention was directed to localized influences which in turn, with the help of the nauseating smell of many of these areas, was related to miasma.

It is tempting to attribute the dominance of miasmatic thought to the increasing influence of the middle class. Whilst this paradigm had gained influence through middle-class groups and research sponsored by commercial interests, it now had a logic of its own, which gave the paradigm an authority with all manner of governments and social groups quite independent of class or sectional interest. By 1848, miasma had been accepted by autocratic Russia as well as bourgeois Britain.[16]

By contrast, whether as cause or effect, the religious response was more muted. There was no official day of fasting, prayer and humiliation, though many churches appointed their own individual day. Such rituals had by no means been rejected. A few months after the 1854 epidemic, the nation went to prayer for success in the Crimea. The God of cholera had become the God of battles. Hugh Miller in his Free Church paper the Witness saw the ritual with almost anthropological clarity. It was unwise, he said, to rely on 'natural laws' alone. 'Society is a moral being and demands something more'.

A whole people prostrate at the footstool of the Supreme, owning their sins and acknowledging that they have received merited chastisement, yet casting themselves upon the clemency and grace of the Majesty they have offended. . .Nor will such an act be unproductive of the happiest results for society itself.

These acts of worship confirmed the values and unity of the community. Indeed, the very existence of that community depended upon the acknowledgement of their collective awareness of God. The day of prayer was 'an outward and visible sign' of their relationship to God's moral government. 'It tends to conserve order and good government.' [17]

God the Avenger was not dead but in retreat. He survived among the Wesleyan Methodists who had their only cholera revival at Redruth in Cornwall. Christ the Mediator played a more important part. Sentimentality replaced savagery, 

...only one in our circle has been thus removed as yet; and of her eternal gain, by death, no-one who knew her has even the shadow of a doubt. Her class in the Sunday Schools cannot think of heaven now without thinking of her. Oh, copy, so far as you are teachers her lovely example and sweet spirit.[18]

All denominations, and even the evangelicals were much less confident and clear about the relationship between sin and cholera. Drink still had a central place in such thinking. The epidemic was obviously another call to prayer. But the sins of the individual were being replaced by sins of omission on the part of the nation. By 1848 Providence and public health went very nicely together. As the United Presbyterians said in Scotland, 

there is reason to hope that, under the blessing of God, attention to sanitary regulations issued by the national Board of Health will prove effectual in mitigating greatly if not in arresting this awful judgment.[19]

The Bishop of London represented the change in religious mood as neatly as any one individual. In 1832, he had taken care to place Providence in both Cholera Acts. In the intervening years he had come to see material poverty as a major barrier between the Church and the working classes and had given special attention to housing and sanitation. In November 1849 he preached in St Paul's. He began with Providence and the Psalms, with Nineveh, the destroying angel, reaping in the whirlwind and chastising the sinner for his worldliness. God the legitimator was called on as guardian of the social order. The epidemic was 'the surest antidote to the poison of infidelity, disloyalty and anarchy.. .let us endeavor to show our thankfulness by supplying the people with increased means of education and public worship'. He went on in a new mood, that of God the reformer,

The most suitable and I believe the most acceptable mode of acknowledging the goodness of God in withdrawing the scourge of pestilence, and preserving to us the kindly fruits of the earth, will be by a larger measure of charitable consideration for the physical evils which affect our poorer brethren... Want of decent cleanly habitations is one of the chief evils that affect the poor... At present neatness order and comfort are unknown in their miserable overcrowded dwellings; modesty is impracticable, delicacy of feeling destroyed, and coarseness of language and manners prevail, and prepare the mind for vicious intercourse in future years. None of the comforts of home are there -- none of its softening purifying influences; and can we wonder if in such sinks of immorality, if spared by disease, the scandals and pests of society, the mendicant, the drunkard and the thief are produced?[20]

This change in religious mood took place before medical science had produced any convincing account of cholera. The God of cholera represented the social and metaphysical attitudes of those who were dominant in forming the religious consciousness of Britain, and was not primarily a God of the gaps.

Continue to The Public Health Acts of 1848