College of Humanities
78 “Epistolary Quackery:” 19th Century Cholera Discourses and Medical Professionalization
Natasha Pagel-Aprill
Faculty Mentor: Nadja Durbach (History, University of Utah)
Abstract
In 1832, cholera appeared in London for the first time. This caused social upheaval and various actors with differing and often conflicting agendas competed for authority over the distribution of information to the public. Editorials and correspondence published in the Lancet and the Times, a medical journal and a major newspaper, reveal these conflicts. In the absence of medical licensing, the editors of the Lancet sought to resolve issues of the legitimacy of medical knowledge within the journal’s pages so the emerging profession could present a united front to the public. These efforts were undermined by practitioners who published their opinions on contagion or the results of therapeutic trials directly in the pages of newspapers such as the Times. The Times portrayed itself as a mediator of medical knowledge, but also used the discord that existed within the profession to advance its own political agenda. By the final major cholera outbreak in London in 1866, however, greater consistency existed between the medical information presented in both the Lancet and the Times. This is largely due to the integration of medicine into the government and the medicalization of public health.
Introduction
Cholera first arrived in London in 1832, in the midst of momentous social and political upheavals for Britain. The 1832 Reform Act, which received royal assent in June of that year, marked the culmination of campaigns for parliamentary reform throughout the 1820s and resulted in the extension of franchise to men who owned or rented land with a £10 yearly value or more. This expanded the vote from about twelve percent to twenty percent of the adult male population, including many members of the urban, middle class businessmen who had previously not met property qualifications. With the passage of the act, many seats from rotten or pocket boroughs were transferred to manufacturing cities, leading to an influx of Members of Parliament who were invested in urban manufacturing and a laissez-faire labor market. While wealthier men benefited under the 1832 Reform Act, lower middle class and working class individuals continued to advocate for further expansion of suffrage and reform to electoral systems, which would eventually coalesce into the Chartist movement in the later 1830s.1
The struggle for democratization and deconstruction of old aristocracies apparent in the general political realm was also reflected within the medical profession. The regular medical profession consisted of physicians, surgeons, and apothecaries – these groups will be collectively referred to as “medical practitioners” in this paper. Prior to 1858, there was no centralized licensing system for medical practitioners in Britain. Instead, practitioners were licensed by corporate bodies for their respective professions; in London, these were the Royal College of Physicians, the Royal College of Surgeons, and the Worshipful Company of Apothecaries.2 Physicians practiced primarily among the rich and portrayed themselves as gentlemen, while surgeons and apothecaries were tradesmen whose skill lay primarily with their hands, not their minds.3 In the early nineteenth century, divisions within the hierarchical tripartite system were beginning to break down with the rise of ‘general practitioners’ who practiced in all three areas.4 The medical colleges had reputations for being highly exclusive, with the College of Physicians and the College of Surgeons both being reluctant to recognize qualifications from provincial medical schools.5 In response to this, a medical reform movement began to emerge that sought to challenge the dominion of elites in the Royal Colleges within the profession and raise the status of medicine in the eyes of the public through regulation of unlicensed practice. Thomas Wakley, the editor of the Lancet, played a prominent role in this movement and was himself a political radical and Chartist supporter, though medical and political reform did not always go hand-in-hand for many medical practitioners.6
While changes were afoot within the medical profession, the same was happening in regard to medical knowledge. The rise of hospitals in the eighteenth and early nineteenth century helped develop the idea of localized disease pathology. Working in hospitals, practitioners were able to observe symptoms of disease in large numbers of patients, compare these cases, and observe the natural history of a disease with less obligation to demonstrate the effects of their treatments than when working for private patrons. In this approach, the patient as a whole and as a person became increasingly obscured and diseases were viewed as afflicting particular organs or tissues.7
By the 1840s, this view of pathology would also influence disease etiology with zymotic theory. Detailed by Justus von Leibig in 1839-40 and adopted by William Farr of the General Register Office as an official disease classification in 1842, zymotic diseases were believed to be caused by specific poisons that caused ferment in the body which manifested as specific diseases. For example, the disease state of smallpox was said to be caused by transformations caused by varioline matter.8 Poisonous matter, or “zymes,” acted as catalysts for disease processes that could become active under certain environmental and bodily conditions. The zymotic theory of disease represented a chemical turn to older miasmatic theories. In miasmatic theories of disease, which date back to the Middle Ages, diseases were caused by foul air arising from putrefying or decomposing organic matter. Zymotic theory posited that zymes could arise from rotting organic matter and endure in the environment or be spread through human contact. According to Farr’s 1854 classification of zymotic diseases, miasmatic diseases diffuse through air or water and arise from either human/animal matter or earth/plant matter while contagious diseases are transmitted through contact between people.9 However, though miasmatic and contagious interpretations of diseases like cholera could be at odds, they were not necessarily contradictory. A disease could be both miasmatic and contagious, initially arising from the environment and, under certain conditions, being transmitted from person to person. This “contingent contagionist” view became the most common interpretation of cholera by the time the disease settled into England in the mid-century.10
It is within the context of political, professional, and scientific change that various agents with differing agendas would compete for authority over information during the oncoming cholera epidemics. In a period of medical professionalization and reform, the Lancet medical journal sought to increase the credibility of the profession in the eyes of the public by discouraging practitioners from engaging in medical discourse in the public sphere, thereby creating the appearance of accord and establishing an exclusive knowledge base. The Times initially acted as a foil to the Lancet, sometimes exploiting medical discord to further its own goals.
Methods
This paper will examine material published on the subject of cholera in the Times newspaper and the Lancet medical journal during three outbreaks of cholera in London: 1832, 1854, 1866. These were not the only years in which cholera epidemics occurred, with 1848-49 also constituting a major period of cholera in Britain. However, 1832 was the first year that cholera appeared in London and 1866 was the last major outbreak in the metropolis. 1854 is the best known cholera outbreak, perhaps of all time, as it was during this period that John Snow traced a local outbreak to the Broad-street pump. Along with this, it represents a mid-point between the 1848 Public Health Act and the 1858 Medical Act, two important pieces of legislation that impacted public health and medical professionalization. The specific timeframes examined were February through August of 1832, August through September 1854 (April through October 1854 for the Times), and June through September 1866. Each of these periods begins before cholera was declared epidemic in London, often before cases were even being counted, and ends once the cholera outbreaks subsided, though lower case counts continued to trickle in after some of the periods surveyed. A shortcoming of this approach, therefore, is that it does not include publications reflecting on the outbreaks from months or years later. As the Lancet noted in 1866, “the time of the actual outbreak of cholera is often a season of panic, unfavourable to careful observation and dispassionate reasoning, and fertile with wild hypotheses and puerile suggestions.”11 However, this can also be beneficial as the heat of cholera outbreaks was a time when medical knowledge was most hotly contested and most urgently needed.
Newspapers and Medical Periodicals
The Times and the Lancet were among the most widely circulated publications of their respective types during the 19th century. However, neither the Times nor the Lancet can be viewed as “typical” public or medical periodicals (if such a thing exists). The Times was able to gain supremacy over news periodicals by the 1830s in part due to its exploitation of non-union labor and, by 1832, was given the epithet “the Thunderer” for its vocal support of the 1832 Reform Bill. The paper represented the rising power of the commercial middle class and held such sway that its role was vital in government turnovers in 1834 and 1855. By 1855, however, the Times’ dominance over the public press was ended with the abolition of stamp duty, allowing other publications to undercut its price; it also no longer was the leader in news-breaking, with other papers outpacing it in the latter half of the 19th century. As Andrew Hobbs has noted, the extensive focus on the Times in many nineteenth century histories has often obscured the vital roles played by local and regional publications as well as non-daily publications.12 One cannot assume that beliefs presented in the Times reflect those of other newspapers in London, let alone the rest of Britain. The same can likely be said about the correspondence contained in the Times, which came from a specific portion of the country’s population which was largely middle class, professional, and male (though there are exceptions).
The Lancet was also an exceptional publication in the 19th century. In contrast with other medical journals, it was published weekly (not quarterly), was relatively cheap, and was more widely circulated than its competitors. From its first issue in 1823, the Lancet positioned itself as subverting the established medical hierarchy, stating that it would shunt the language of the Colleges in favor of “plain English.” As Brittany Pladek has argued, this was less an invitation to lay readers than an emulation of radical populist tactics for challenging exclusionary governing practices – in Wakley’s case, aristocratic medical colleges.13 Early in its run, the Lancet published lecture series by the surgeons Astley Cooper and John Abernethy (without the speakers’ consent) with the respective aims of increasing accessibility of valuable information within the profession shedding a light on incompetence and nepotism. Abernethy decided to pursue legal action against the Lancet, something with which the publication was intimately familiar as it was involved in ten legal proceedings, mostly libel, during its first ten years of publication.14 The Lancet was notable among the emerging genre of medical periodicals for its radical perspective, dramatic and often theatrical editorials, and its combative style.
In the late 18th century, medical journals in which practitioners could publish case histories, courses of treatment, and more began to emerge. As Roy Porter discusses, these publications arose in an age when questions related to medical knowledge and authority propounded. Practitioners questioned whether medical information should be freely communicated or kept behind a veil of privacy, with reformers like Thomas Beddoes arguing that medicine could only progress through fact-sharing. He advocated the systematic collection of medical facts and increased medical publication. Questions also arose relating to how accessible medical knowledge should be to the public: “Was the publishing doctor a public benefactor? Or was he a self-serving publicist? […] how far should the public be au fait with medicine, with a view to self-help and informed decision making?”.15 There were also issues relating to medical authority and authenticity in a world in which practitioners themselves were debating what constituted orthodox medicine and what was deemed quackery or empiricism. In early medical periodicals such as the Medical Transactions Published by the Royal College of Physicians in London, all authors were members of the titular professional organization; however, even then, the journal included a disclaimer stating that the College did not vouch for the truth of any papers published therein. Porter contrasts the conditions of medical publishing in Georgian England with those of the Victorian era, which was characterized by “a heightened sense of professional esprit de corps and exclusiveness”.16 However, as will be shown, the discourses surrounding 19th century cholera outbreaks demonstrate that many of the questions identified by Porter in relation to 18th century publishing continued well into the 19th century, with professional periodical editors decrying practitioners who published in newspapers as quacks and trying to harness contradictory practices into some semblance of medical orthodoxy.
Public periodicals, like the Times, were also undergoing a period of change throughout the 19th century. The average length of the Times quadrupled from about 4 pages in 1832 to 16 pages in 1866. The newspaper transitioned from reporting international news in a section titled “Private Correspondence,” indicating that these correspondents were not backed by the Times to having a large network of “Our Own Correspondents” as well as “Special Correspondents” that the Times dispatched to the Crimean War of the Atlantic telegraph expedition. In 1866, the Times published a reflection on the reporting of the Napoleonic Wars sixty years before; it observed that “The sources of information were often of a very doubtful description in those days, and the Government received no better or safer intelligence than came by private hands” – the Times had reported the British capture of Flushing two days before the news reached England by any other means .17 Similar statements could be made about military intelligence during the Crimean War when the Times editorial stated that, if the government relied on official dispatches rather than newspaper correspondents, “the worst informed men in Europe would have been the English Ministers.”18 Stephanie Markovitz notes that the Times functioned as a public forum in reality, not only appearance, because it provided a space where private experiences were freely expressed and co-mingled with public voices.19 However, as indicated by the Times’ statements about the “rapidity and accuracy” with which intelligence from the Austro-Prussian War was reaching the country in 1866, official dispatches were becoming more reliable. The mix of public and private correspondence persisted through this period, but the Times’ editorial stance, at least in respect to medicine, was shifting to favor centralized and official governmental reports over private correspondence.
Cholera Discourse in 1832 and 1854
When cholera arrived in England in 1832, no consensus existed as to its etiology and most therapies adopted by medical practitioners were experiential or drew from older practices. It was generally agreed that “Asiatic” cholera was distinguished by vomiting and “rice-water” diarrhea, diminished pulse, and cold, blue skin. However, controversy existed as to whether these symptoms set the new cholera apart from “English” cholera or whether fecal diarrhea ought to be considered part of the disease proper or a premonitory symptom. In the 21st century, it is accepted that cholera is an infectious disease caused by Vibrio cholerae that is generally transmitted through ingestion of water or food that contains the bacteria, often through contamination by feces. It is primarily treated through oral or intravenous rehydration therapy that aims at restoring lost fluids.20
The discourses that formed around 19th century cholera outbreaks reveal an aspect of medical professionalization sometimes passed over: the desire for consensus and uniformity of opinion presented to the public. This is repeatedly betrayed by Lancet editorials. In the 1832 outbreak, no agreement existed within the medical profession as to cholera’s contagiousness or lack thereof – medical practitioners airing on both sides of the dispute were published on the pages of both the Times and the Lancet. However, the editors of the Lancet strongly believed that cholera was contagious, and branded practitioners who expressed anti-contagionist views in the public press as attention seekers, chasing after ephemeral fame. It balked at men who leave their “proper spheres and exhibit their grotesque movements to the gaping public”21 – discussion of technical matters should occur within the medical sphere and should not be visible to the public. The Lancet’s concern was partially caused by the harm that could be caused by public dismissiveness of the threat posed by cholera, but it was also motivated by the desire that the medical profession present a united front to the public. The inclusion of the public in medical discourse also perpetuated the notion that lay people were as qualified to pass judgement as practitioners, a notion harmful to the cause of professionalization which necessitated the creation of an exclusive knowledge base.
Throughout the period, the Lancet also advocated for the establishment of commissions or governmental inquiries to conduct large scale studies which, it hoped, would put an end to the “epistolary quackery” found in public papers and settle medical disputes.22 The editors disparaged medical “empiricism” characterized by individual practitioners developing therapies and theories of disease based on their personal experiences, rather than large scale trials. This perpetuated a network of medical knowledge that contained diverse and often conflicting ideas, decreasing the credulity and authority of any information issued by medical practitioners.
The Lancet’s attitudes toward medical empiricism and pluralism were both borne out and informed by the Times to some extent. In 1832, the Times seized the lack of agreement among practitioners about contagion to push an anti-contagionist agenda favorable to its mercantile disposition. Similarly, the Times promoted the use of castor oil because of the lack of a clearly effective treatment for cholera and the myriad treatments advocated by medical practitioners. In both instances, the Times’ approach provoked the Lancet to respond by calling for unity among medical professionals and separation of the spheres of medical and public discourse. The following case studies will provide further illustrations of these dynamics.
Case Studies
1. The Cholera “Humbug”
Throughout the 1820s, cholera traveled from the Indian subcontinent to Europe and Russia, with Britain watching every step of its progress. To prepare for the threat, the Office of the Privy Council gathered cholera intelligence from abroad and sought advice from the Royal College of Physicians. The President of the College deemed cholera contagious and recommended quarantine measures for cholera under the 1825 Quarantine Act. However, the College also gave a collective opinion that the disease was not contagious. To settle the issue, the Privy Council asked the President of the College to recommend members to sit on a board of health that would advise the government. This temporary Central Board of Health was established in June of 1831 and was expressly aimed at addressing cholera. It recommended the formation of local boards of health to enact sanitary measures. Over the summer of 1831, the contagion debate raged. Contagionists won a victory when the government declared a fourteen day quarantine for vessels; however, anti-contagionists were fueled by testimony from medical practitioners who had seen cholera in India that it was not contagious. The debate about whether or not cholera was contagious was not just about medical theory, but also (and oftentimes primarily) about regulating commerce and labor through quarantine. Despite the initial enforcement of quarantine measures, cholera cases started to appear in northern England in October and November. From its initial appearance in Sunderland, the epidemic began to spread throughout Britain and would soon make its way to the capital.23
The Times reported London’s first cholera cases on February 14, 1832.24 The same editorial in which the newspaper announced that cholera was present in London also directed the readers’ attention to a letter by “Theta” published in that day’s issue. This letter asserts that the cholera currently spreading in London and throughout England was not a new disease that originated in Asia, but was native to England and existed in the country in a milder form due to differences in climate. In the letter, Theta also accuses the Board of Health and the medical profession of exaggerating the cholera cases and exciting public fears, stating that “The profit derived from cholera-phobia by the profession at large, who have obviously no interest in exposing the groundless nature of the alarm” explained medical practitioners’ support for the “hoax.”25 At this point, the Times still presented itself as neutral on the cholera question, stating that people should apply themselves to following healthful habits and leave “the men of science and political economists to dispute those matters which peculiarly appertain to their studies.”26 The paper still placed some degree of credence and trust in official reports and the conduct of medical and scientific professionals. In fact, in an ironic twist, the Times published a letter describing how “mischievous” periodicals in the north had persuaded their communities that cholera was not contagious, with fatal consequences. The writer imagines what “indescribable horror” could occur if anti-contagionism took hold of London and says that it therefore “behoves you (the press) therefore to continue to put forth all your energies in enforcing the means of suppressing and averting this calamity.”27
The Times would do exactly the opposite. The following day, the editorial puts forward the paper’s official view that the cholera present in England was neither new nor Asiatic and cites correspondence from Dr. David Uwins and an unnamed Indian surgeon to support this claim.28 A day later, the Times printed a note in its “To Correspondents” section stating that “We cannot publish specifics for cholera sent by our numerous medical correspondents: no two of them agree.”29 The newspaper utilized this lack of consensus and the support of a few practitioners to advocate for the preservation of laissez faire trade and commerce in the face of cholera. The editors state that they support cleaning and sanitary efforts, but not any course of action that would interfere with trade. They justify this by arguing that curtailing trade would leave people unemployed and inactive, making them more susceptible to the disease, which was caused by “poverty, bad living, insufficient clothing, dirty streets and dwellings, united to occasional excess.”30 As the Times was known for representing the interests of the commercial middle class, this opinion would have been popular among a substantial portion of its audience, many of whom were more directly involved in trade that would be affected by quarantine than in the lives of the poor who were the primary victims of cholera. However, the notion of a cholera “humbug” was also popular among the working class as it accorded with commonly held notions of governmental and professional corruption, with officials inventing cases to keep jobs paid by public taxes.31
The newspaper’s editorial stance became more conspiratorial as the month advanced. Fears over cholera were not just exaggerated, they had been maliciously stirred up by interested parties. The Times’ editorial also argued that cholera had been “got up” to distract from the reform bill before Parliament.32 It alleged that the medical profession “has been brought into utter contempt by the system of charlatanism to which truth and common sense, and the comfort and welfare of society, have within the last three months been made victims.”33 By the end of the month, the Times stated that “Official announcements have long ceased to be gospel with us.”34
On the pages of the Times from early 1832, one witnesses a landscape in which no official knowledge could go uncontested. The Times’ editorial and correspondents pointed to the similarities between the Central Board’s description of the new Asiatic cholera and descriptions of “cholera morbus” described in publications like Dr. Buchan’s Domestic Medicine decades earlier. Both describe vomiting and purging, a low pulse, cramps, cold extremities, and urinary obstruction (though it should be noted that Buchan describes vomiting and purging of bile while the Central Board expressly states that evacuations are not bilious).35 Medical practitioners and laypeople alike frequently visited, or attempted to visit, hospitals or the homes of reported cholera cases to ascertain whether individual cases had been falsely reported.36 Medical practitioners frequently wrote in pointing out individual cases of under their treatment which they believed to have been misreported by overzealous colleagues.37 People who were suspicious of overreporting of cholera in certain areas would also write to the paper to request that someone investigate and ascertain whether the reported cases actually had cholera.38 Another common theme was individuals with chronic conditions, such as “windy spasms,” being wrongly reported as having cholera.39 This practice did not go uncriticized in the Times – Alex Tweedie wrote to the paper complaining that people “who, from their obscure station in the profession, would in any ordinary circumstance hardly be entitled to a medical opinion at all” making pronouncements after cursory visits to cholera wards.40
However, the Times framed its medical correspondents very differently, saying that the “ablest and most estimable physicians in London and in other parts of England have […] declared the official manifestoes, assertions, injunctions, precautions, reports, and so forth, to be one mass of humbug.”41 The Times, therefore, was the purveyor of estimable medical information in publishing reports of the cholera “humbug.” In resolving that anti-cholerists and anti-contagionists are the most respectable medical practitioners, the newspaper decided that their medical views were accurate while those of other medical practitioners were not. It created a dynamic in which the Times was not choosing a side in a medical debate but was rather just conveying the opinions of the most established and reputable practitioners (a group which happened to exclude governmental officials). This framing was necessary because, even though the editors very obviously had a stance on this medical issue, it was still a public paper with no pretense of possessing technical medical knowledge. Various correspondents lauded the Times for being “properly reluctant” to admit technical papers or expressed reluctance at writing to a public paper rather than a medical one.42 This demonstrates that medical practitioners who wrote to the paper still viewed it as occupying a separate sphere from a professional publication like the Lancet and that it was improper for its editors to become embroiled in professional disputes. Unlike the editors of the Lancet, the editors of the Times did not make an argument based on their own authority and knowledge; rather, they did so based on the authority of the medical correspondence they curated. This dynamic is perhaps most clearly articulated in the Times’ statement that “We again commend to public notice the Report of the ‘Central Board of Health’ and at the same time other documents by which that report is contradicted. […] We are not medical people, and our concerns are in no way whatever affected by the existence or non-existence of the cholera.”43 The Times portrayed itself as a neutral arbiter of medical information, only relaying the views expressed by the respectable majority of the profession. A person reading only the Times during early 1832 could easily have assumed that it was a widely agreed-upon fact that cholera was not a new or contagious disease in England.
The Times’ easy course into the realm of conspiracy is indicative of the status of the medical profession at the beginning of the 19th century. As Roy Porter has argued, the 18th century was a time of great medical plurality, with “regular” practitioners practicing alongside a wide variety of “irregular” practitioners in a medical marketplace. There was little differentiation in status between regular and irregular practice and “quackery” abounded in both groups. Regular physicians’ cures “were experienced as tediously protracted, expensive and disgusting, […] their demeanor often loathed as pompous, and patients commonly doubted their competence.”44 This, combined with the facts that there was no governmental regulation of medicine and medical colleges did little to police the profession, meant that licensed medical practitioners were not viewed as holding status or authority that set them or their ideas apart from the myriad others found in newspapers. Their participation in a medical marketplace, characterized by self promotion and rife with quackery, would have primed the Times to identify self-interested motivations in practitioners’ assertions that cholera was a serious threat. The Times did not view medical knowledge as authoritative or all of its practitioners as particularly noble parties, and, therefore, took it upon itself to dispute and critique the actions and beliefs of medical practitioners when they clashed with the Times’ interests.
While the Times sought to dispute medical knowledge, the editors of the Lancet attempted to consolidate it and argued that the rhetoric the Times engaged in was an insult to the medical profession. At the beginning of February, the Lancet published an editorial tracing the progress of cholera through England and Scotland. In it, they identify several cases clearly attributable to human communication and conclude that there is “irrefragable proof” that cholera can be spread via contagion.45 The Lancet editors, unlike the Times, were willing to “stake our professional and literary character on the assertion, that numerous cases of the malignant Asiatic cholera have occurred in London.”46 This, they state, can be established through consistency in cause, symptoms, and pathology, with any two coexisting being sufficient to prove the presence of Asiatic cholera. With the cause of the disease still unknown, they go on to examine individual cases that have been reported as cholera, finding at least one case in London where both the symptoms and morbid anatomy coincided perfectly with Asiatic cholera (the body was also examined by a doctor who had served in India, lending credence to his judgement).47 This prime example of a cholera victim is described as having been afflicted with “a loose, irritable state of the bowels,” vomiting, cramps and spasms in the extremities, sunken and blueish features, oppressed respiration and pulse, and a cold tongue and skin. Upon dissection, he had a “whitish turbid fluid” in the intestines and his blood was dark and often congested, among other features.48 According to the positive burden of proof that the Lancet had established for itself, this was enough to demonstrate that malignant Asiatic cholera existed in London.
The Lancet’s editorial position on the rhetoric surrounding cholera did not end with firmly asserting that Asiatic cholera was present in London and likely contagious. Rather, the editors set out an exhaustive critique of the positions taken by public papers, like the Times, and many of the medical men who decided to publish in their pages. The journal viewed this as its duty to both the public and the medical profession, stating that “never was a portion of the public more successfully, more dangerously, deluded, and never, in our sincere belief, was there a more scandalous bolt flung upon the dignity of British medicine.”49 In examining the make-up of the “anti-cholera party,” the Lancet identified “The Times and its tail, all that is notorious for stupidity and venality in the metropolitan press,”50 indicating that, while the Times was not the only purveyor of anti-cholera rhetoric, it was certainly an important one. The editors counter the Times’ arguments with historical data showing that the plague death counts mimicked those of cholera early in the epidemic and with a list of the emoluments ofmedical inspectors and members of the Central Board of Health, based on Parliamentary papers, to prove that the Times had grossly exaggerated the pay of these officials.51 The Lancet concludes that, “we trust we need say no more either of the erudition of the veracity of the journal in question, or of the right it has to direct the minds of rational and honest men.”52 In this statement, the Lancet is commenting more on the Times’ journalistic integrity than its ability to make statements claiming medical authority, largely because the Times was doing no such thing. However, the same could not be said for medical practitioners publishing in its pages.
The editorial goes on to address the “more disagreeable topic” of medical practitioners who denied the existence of cholera in London and aired these opinions in papers like The Times. The Lancet viewed itself as a defender of the medical profession, stating that, up until its founding, “the bulk of English medical practitioners were destitute of the protection afforded by an independent journal; the press, up to that day, had never been employed for them, but always against them.”53 Protecting the medical profession often meant policing (or at least commenting on) which of its members functioned as emissaries to the public and what the public perceived of the inner functioning of the profession. The paper was concerned with having “eminent” and “reputable” medical opinions conveyed to the public and, in its judgment, most anti-contagionists were neither.
The Lancet characterizes anti-contagionist medical practitioners as individuals who, in their false statements, had fallen from grace in the profession or only rose from obscurity through notoriety. The theme of medical practitioners unrightfully using the public press to gain fame and credence was one often repeated in its pages. While the “Times and its tail” characterized anti-cholerists they cited as “eminent men,” the Lancet responded by describing them as “those persons whom the cholera has had the effect of calling into ephemeral existence which vain and weak, but busy men sometimes obtain by the publication of their names in the columns of a newspaper.”54 These statements reveal a distrust of obscure medical professionals who decided to publish in the public sphere rooted in 18th century notions of quackery. These practitioners were not publishing in newspapers for the good of the public, greater accessibility of information, or faster dissemination of findings, but to garner unwarranted fame and attention. Despite the fact that anti-contagionists were not selling nostrums and some did not even provide their names in the Times, their actions were reminiscent of quacks who “proclaim their medical abilities in public places.”55 It also seems likely that certain practitioners receiving special editorial attention from the Times which would function to raise their public personas.
The Lancet editors did not believe that this type of behavior was appropriate and advocated for a separation of spheres of medical and public discourse. When the formation of an Association to Investigate the Cholera was announced, the Lancet commented that “if men will leave their proper spheres and exhibit their grotesque movements to the gaping public, who is to be blamed for the disgrace consequent upon the offence?,”56 indicating that debates among members of the medical profession should not occur in public forums. The “grotesque movements,” once visible to the public, served only to discredit the profession. The editors added that their reaction would have been very different had the association included prominent chemists like William Brooke O’Shaughnessy and pathologists like Charles Bell. Correspondence from individuals whose “renown is of that quality which is created by an ephemeral puff, or a paragraph in a morning print” was more likely to be self-promoting quackery.57 Furthermore, they were more likely to shape their medical opinions to fit the beliefs of their clients to ensure further patronage, a common practice in Georgian medicine.58 In the case of the Times, practitioners might proclaim themselves as anti-contagionists to fit the well-established editorial position of the newspaper, which was likely shared by its readership, some of whom might have been looking for a new physician. However, people like O’Shaughnessy and Bell already had established reputations and were therefore more impervious to this type of influence. It likely helped that O’Shaughnessy was a relatively frequent correspondent in the Lancet – endorsing him as a reputable practitioner was also the Lancet endorsing itself as the proper forum for intra-professional discussion.
However, the Lancet was not completely opposed to the dissemination of medical discourse in public papers. It supported the publication of medical society discussions in public papers as these had become the only means through which both sides of the contagion debate were available to the wider public.59 While some members of the medical profession viewed publication of these proceedings in widely disseminated papers as “puffing” and a form of extravagant promotion and advertisement, the Lancet argued that “it is the manner and the object of publicity, and not publicity itself, which constitute that art, at which some of the objectors themselves, by the way, are the most thorough adepts.”60 The editors believed that publishing medical discourse in public papers, in and of itself, did not constitute “puffing.” In fact, it was necessary for the public to have access to balanced medical information. The true puffery was individuals of little repute seeking notoriety in the public papers.
It is notable that the Lancet, critical of elitist medical societies and nepotism, advocated for the publication of surgical and medical proceedings to encourage professional criticism and challenge the authority held by exclusive colleges early in its run.61 As a champion of medical reform, the Lancet advocated for increased transparency within the profession and allowing general practitioners to have access to the same information and opportunities as members of elite medical societies. In shedding light on these types of proceedings, the lay public would also be let in on the inner workings of the profession. The object of this publicity was not the aggrandizement of individual practitioners or advocacy of a particular nostrum or pathology; therefore, it did not constitute puffery. It also differed from the actions of groups like the Association to Investigate the Cholera in that the members of medical colleges and societies like the London and Westminster Medical Societies had established reputations and the publication of their proceedings was not a means of creating ephemeral fame. Despite the Lancet’s opposition to the elitism of many medical societies, it relied on their reputation to legitimize medicine to the public while also opening them up to scrutiny from within the medical profession.
The Lancet seemed certain that once the upheaval of the outbreak died down, practitioners seeking fame in the pages of newspapers would be revealed as attention-seeking falsifiers.62 However, at present, they were not necessarily considered persons of ill-repute in the wider medical sphere. In fact, Dr. James Johnson, who the Lancet identified as one of the leaders of the anti-contagionist party, was the editor of Medico-Chirurgical Review and a prominent member of the Westminster Medical Society whose correspondence the Lancet often published.63 One can infer that the Lancet was more concerned with the image of the medical profession in the public eye than restricting the discourse on its own pages. Even during the height of the cholera controversy in February and March, the Lancet published correspondence that argued that the disease was not new in England and that it was definitely not contagious.64 Outside of the Lancet’s editorial section, these views were not even in the minority. This demonstrates that individuals who did not agree with the Lancet’s editorial stance still sent correspondence to the paper and that the Lancet did not refuse to publish correspondence that did not accord with its views. It also shows that the Lancet was not concerned about contradictory statements within its pages, though the same could not be said for medical discussion in public papers.
While it seems likely that the Lancet exercised relatively little editorial discretion in publishing correspondence related to contagion, it is unclear to what extent the Times engaged in such activities. Based on the Times’ statement that “We continue to receive more letters on cholera than would fill our paper daily […] We shall publish none, except such as contain some curious and well-established fact, or are written by some person of established reputation,”65 one can ascertain that the newspaper could exercise a large degree of choice in which correspondence to publish and which not to. The editors state that they will only publish correspondence with well-established facts or from reputable persons and, given that they already decided that anti-contagionists were the most reputable medical professionals, this creates the perfect groundwork for an echo-chamber in which the Times only included correspondence that repeated “facts” already established in the paper. However, the Times’ published correspondence was not unanimously anti-contagionist and grew increasingly heterogeneous as the year progressed.66
The spring of 1832 was marked by a decline in both cholera cases and discussion of its contagiousness in the Lancet and the Times. When cases began to climb again in the summer, both publications’ partisanship on the question of contagion softened. When commenting on the people being released from a prison affected by cholera, the Times editorial entertained the possibility of the disease being contagious and voiced concern about it spreading through infection.67 The Lancet editorial, in turn, voiced the opinion that cholera was both epidemic and infectious and that “it is principally in places free from the epidemic that the disease can, under ordinary exposure, spread from person to person.”68 While the shift in the Times’ tone can be ascribed to its desire to not see prisoners released, the Lancet’s strong contagionist stance was undermined by patterns of cholera infection. There were simply instances in which no person could be traced who could have transmitted cholera from one place to another, leading the Lancet to adopt a contingent-contagionist view. According to modern understanding of cholera, the reason for the Lancet’s softening in tone can be attributed to the fact that Vibrio cholerae is generally vector-borne, rather than being transmitted directly from person to person, circumventing the need for direct contact.
2. The Saline Treatment
By the time cholera reached London in February 1832, various treatments had emerged among British medical practitioners, many of them informed by the experiences of colonial surgeons and physicians who had experience with the disease in India. Most agreed on various aspects of cholera pathology. One of the primary aspects of the disease is decreased circulation marked by coldness of skin and a weak pulse in the appendages – some descriptions expand on this by detailing how blood is coalescing in the center of the body, diminished energy from the heart, or through thickening of the blood.69 Those who focused on changes in the circulation of the blood mainly prescribed bleeding or external applications of heat to draw the blood back towards the skin.70 Bleeding was by far the less common of these treatments, with most practitioners prescribing some form of external heat or poultice regardless of the other therapies they pursued (one recommended wrapping patients in the skin of freshly slaughtered sheep).71 Many medical practitioners also ascribed many of cholera’s symptoms to disruption of the function of the liver. The cholera poison either increased the bile secretion of the liver, resulting in vomiting and purging which eventually led to collapse; or it suppressed bile secretion.72
The course of treatment that received the most attention in the Lancet was based in a pathological interpretation that viewed the evacuations as the cause of exhaustion associated with the final state of “collapse” in cholera. While many sought to treat this through the use of astringents, the “saline method” advocated for treating the effects of evacuations was based on analyses of the blood of cholera patients conducted by the Irish chemist and physician, William O’Shaughnessy. He found that, in comparison with normal blood, the blood of those afflicted with cholera showed decreases in the amounts of water and soluble salts, which were instead found in patients’ “rice water evacuations.”73 Similar results were found by others who conducted analyses of cholera patients’ blood. Based on this, various saline treatments emerged, which functioned as precursors to both modern oral rehydration therapy and intravenous therapy. Dr. William Stevens and Henry Wakefield, working in the Coldbath-Field Prison developed a treatment in which “the main reliance is upon the following powder, to be administered every hour in half a tumbler of cold water, viz: – Carb. Of soda half a dram; common salt 20 grains: oxymuriate of potash 7 grains.”74 This is closely reminiscent of modern oral rehydration therapy (ORT) which involves oral administration of water combined with sugar and salts to treat dehydration due to diarrhea. In cholera, Vibrio cholerae disrupt the body’s ability to reabsorb Na+ ions in the digestive tract. This changes the osmotic pressure of the intestinal tract, causing water to diffuse out of cells in the intestines and leads to diarrhea and dehydration. Modern oral rehydration therapy restores lost sodium and water to cells by using glucose to facilitate Na+ transport into cells.75 Given that Stevens’ treatment did not include glucose, it would likely not have been as effective as modern ORT, but it likely would have helped restore depleted sodium and water to some extent. Stevens, based on the blood pathology provided by O’Shaughnessy, reasoned that administering water and salts would restore the substances missing in the blood. Following a similar line of reasoning, Dr. Thomas Latta, joined by Robert Lewins and Thomas Craigie, advocated the use of copious injections of saline fluids into the veins. He observed that deficiency of water and saline matter in the blood caused “the thick, black, cold state of the vital fluid” which produced many of the effects of cholera and often directly resulted in death.76 This method of treatment has given Latta the epithet “the father of intravenous infusion therapy.”77 In the present day, intravenous therapy is also considered an effective treatment for cholera, though less accessible than ORT.
The Lancet viewed these “saline treatments” as highly promising. To the editors, the saline treatments represented medicine based on an innovative combination of chemistry, pathology, and clinical trials and “teaches us how boldly we may proceed when certain and scientific data are before us.”78 However, this optimism and excitement would not last. By June 23rd, the Lancet editorial threatened that, if Stevens et al. continued to conduct their experiments in the present manner, “the whisper of detraction will doubtless be heard in many corners […] that Dr. Stevens and Mr. Wakefield exaggerated trifling cases in order to enhance the value of their efforts.”79 While the editors do not immediately indict the reputation of Stevens, they do urge him to call for the government to appoint a commission to investigate the treatment. The change in tone is due to reports in other journals that Dr. Stevens’ treatment was only used on prisoners exhibiting premonitory symptoms; this is substantiated a few weeks later by a letter from Sir David Barry observing that he had seen no cases of cholera in Coldbath-Field Prison.80 In 1832, “premonitory diarrhea” was not viewed as a part of cholera. Only “rice water evacuations,” as opposed to fecal diarrhea, constituted the disease. This view would shift in later outbreaks as treating premonitory diarrhea became viewed as the most effective way of halting cholera. Stevens responded to Barry by arguing that there were no cases of cholera collapse in the prison as his treatment prevented people from reaching the state of collapse (though 12 people still died of cholera during the month of July).81 However, the Lancet editors ended up concluding that “the Coldbath-Fields Prison epidemic has been most reprehensibly exaggerated by Dr. Stevens and the magistrates” and withdrew their call for further investigation into the saline treatment.82 This incident provides an early example of the Lancet’s desire for large-scale, governmental investigations of medical treatments. The Lancet was weary of individual medical practitioners exaggerating the efficacy of their treatments to garner attention or merely through their implicit biases. While they do not accuse Stevens of doing so, they intone that other members of the medical profession would shunt him as a “quack” if his results were not replicable. It likely did not help that Stevens had published his findings in the Times. Furthermore, investigation by a government commission would provide governmental endorsement to the saline plan if adopted, a factor which would legitimize the treatment in the eyes of the public, as the government was still likely more trustworthy than the medical profession.
Latta’s intravenous version of the saline treatment was also not without controversy. Dr. Craigie, another proponent of saline injections, published a piece of correspondence related to this treatment in the Courant, an Edinburgh public paper, in which he portrayed himself as the sole originator of this practice. In response to this, Latta wrote a letter to the Lancet, railing against the practice of publishing on medical subjects in public newspapers.83 In his letter, Latta states that practitioners writing about medical subjects in newspapers is “a crime for which they have no excuse” and that “no respectable practitioner can possibly be guilty of such empiricism, for, certainly, quackery it is, in the humblest sense of that degrading term.”84 Given the context, it is likely that Latta used the term “empiricism” as a synonym for quackery, rather than to refer specifically to the practice of medicine based on personal experience and observation. Latta believed the practitioners publishing outside of the medical sphere primed them for self aggrandizement as they vied for potential patronage from readers of public papers. This was an issue to be taken very seriously in the medical marketplace. In this particular instance, Mr. Mitchell, a friend of Latta’s wrote a letter to the Edinburgh Observer, calling Craigie out for stealing credit. After this “an interview took place, casually, in the street, when a trifling assault with a child’s whip was believed by Dr. Craigie to have been committed on him by Mr. Mitchell.”85
3. Castor Oil Controversy
Between the 1832 and 1854 cholera epidemics, the 1848-49 cholera epidemic occurred in England. This epidemic was the deadliest wave of cholera to sweep England and spurred the passage of the 1848 Public Health Act, which created the first permanent, centralized General Board of Health tasked with advising the public on sanitary matters and disease prevention and administering local boards of health.86 This institution was headed by Edwin Chadwick from its inception until 1854, when it was dissolved and re-formed under Benjamin Hall. Chadwick and his successors in the General Board had backgrounds as civil administrators, not medical practitioners. Christopher Hamlin has argued that Chadwick’s leading role in sanitary efforts during the 1830s-50s shaped the evolution of public health as a field. While many medical practitioners in the early nineteenth century identified issues such as poor diet and living conditions as threats to health, Chadwick adopted an approach to public health that centered on external disease eradication through modern sewers, constant water supply, and cleaning. In turn, Victorian public health measures after the 1832 epidemic placed greater focus on technical and civil engineering issues than social problems or addressing poverty and its effects.87
While changes were afoot in the realm of public health, little changed in terms of cholera treatments by 1854. During this outbreak, the Times received correspondence on a variety of cholera treatments that tended to echo treatments used in previous epidemics. For example, one surgeon wrote in suggesting a course of treatment including small, frequently repeated doses of calomel, a mixture of rhubarb, ammonia and peppermint water, and half pint draughts of salt and water.88 This prescription demonstrates the eclectic courses of treatment described by most medical practitioners who did not subscribe exclusively to one school of treatment but rather borrowed from modes of treatment advocated by individuals like Dr. Stevens and Dr. Ayre. Medical correspondents in the Times also generally did not publish the pathological theory behind their treatments, merely aiming to publicize therapies that had proven effective in their personal experience. Several practitioners also wrote the newspaper expressing “the danger of giving by your publicity weightly prescriptions from non-medical men” specifically in reference to excessive doses of laudanum.89 This shows that practitioners believed the Times carried a burden to censor treatments that had been deemed dangerous by the profession at large. The Times sometimes did this, as in the case of laudanum and also in the case of a “Angostura bitters” which was itself safe but contained components that were often substituted with strychnia bark.90
The discourse surrounding cholera therapies would be disrupted by the emergence of a relatively novel treatment into the public eye: George Johnson’s castor oil. The treatment was first mentioned in the Times on September 6th in a piece describing Johnson’s hypothesis that purging in cholera was the body’s effort to expel the poisonous matter causing the disease and that, therefore, the purging ought to be aided using evaculants like castor oil. Castor oil was an “eliminative” treatment aimed at eliminating poison from the body, rather than an “astringent” aimed at reducing diarrhea. The letter adds, “what method of treatment could be more simple than this?.”91 The correspondent cites the previous week’s Lancet for this information, however, their excitement over the treatment did not reflect the attitude of the Lancet, which merely stated that most cases treated with castor oil had done well and that it left its readers to judge.92 However, at this point, the excitement over castor oil was probably already growing as the original correspondent to the Times mentions druggists inflating the price of the product in response to increased demand. A few days later, the Times published a piece by George Johnson and editorialized that they were glad at the amount of correspondence they were receiving and that “the rational system of treatment is attracting the attention which it deserves; but we are at the same time sorry to see the jealousy with which the profession at large seem to regard the threatened downfall of the old obstructive system of astringents, opiates, and stimulants.”93 The Times viewed existing medical treatments as largely ineffective and challenged medical practitioners to put castor oil to the test instead of blindly dismissing it. It seems that the appeal of castor oil to readers of the Times was that it had simple and clear reasoning behind it: cholera was an external poison, and it had to be expelled from the body. Unlike other therapies in which disease agency was obscured or convoluted, in which symptoms were treated rather than addressing the root cause, Johnson presented a simple story with a simple solution. For members of the public frustrated with decades of ineffective therapies that addressed complex pathological processes, imagining the “cholera poison” as an invader that need only be removed would have been enticing.
In the following weeks, the Times received letters from many individual practitioners who attested to the efficacy of castor oil in their practices.94 Of these, the only to cite specific statistics was R.H. Bradley, who stated that he attended 26 cholera cases, of which 15 recovered and that all recovered cases and all the cases that recovered were treated with castor oil (he does not state what the other cases were treated with, meaning that castor oil was effective in 58% to 100% of cases).95 Apart from Dr. Ayre, who dismissed Johnson’s hypothesis as “wholly untenable,”96 the only voice that spoke against castor oil on the pages of the Times was the surgeon George Sutherland. He conducted a trial of castor oil in eight cholera cases and seven of cases he treated with the remedy died. Sutherland went so far as to include a table featuring the names and ages of the patients, the time and date admitted to the hospital, and the times and date of death.97 This was met with a letter expressing regret at seeing “an attempt to impugn the efficacy of castor oil.”98
The General Board of Health soon followed suit in investigating castor oil as a treatment for cholera and conducted a meta-analysis of the reported findings of various practitioners employing the treatment. They found that, out of 89 cases treated by 14 different practitioners, 68 concluded in fatality, 15 recovered, and 6 were still under treatment.99 In this study, at least 76% of cases treated with castor oil terminated in fatality. The next day, a letter appeared in the paper wondering how the successful results reported in the newspaper could be reconciled with the overwhelmingly negative results of the General Board of Health and intoned that the medical profession closed their minds to “anything that appears contrary to the preconceived notions.”100
For the Lancet, the Board of Health’s announcement around September 16th that it would begin collecting a systematic record of cholera cases, as well as their treatments and results, beckoned in a new era in which treatments could be assessed on a large scale with the hope of finding the most effective treatment for cholera. With this came the acknowledgement that all current treatments of the disease, “howsoever loudly some of them may be vaunted as rational, are, in truth, empirical, experimental, and tentative.” People were prone to rush into theories “according to accidents of observation and accidents of hobbyism.” Every new theorist felt compelled to advertise their ideas in “epistolary quackery” and George Johnson was but another such individual.101 According to the Lancet, he asked the profession to adhere as blindly to his system of treatment as he accused them of adhering to others. Johnson also asked his readers to assume a pathology from his authority alone, with his treatment being a corollary of this pathology. The Lancet cautioned the public to be wary of such “posts and propters,” the profession already being aware of their real value, and stated that “The condemnation of castor oil and the system of purging, by the profession, is almost universal.”102 This statement would have come as a surprise to anyone reading the Times alone, where the vast majority of medical correspondents sang the praise of castor oil. By describing a consensus against castor oil, the Lancet was again delineating medical discourse in professional journals from the puffery of the public press. It was also separating experiential, empirical medicine from medicine based on large-scale, systematic approaches like the meta-analysis conducted by the Board. Despite the fact that the majority of the Lancet’s correspondence was based on the experiences of individual practitioners, the editors placed greater credence in the surveys conducted by the Board of Health that focused on the replicability of results among practitioners.
The next week, the Lancet took an even more forceful stand based on reports that hundreds of people put off seeking medical treatment and instead placed their faith in castor oil, often terminating in fatality. The editors stated that the “history of this delusion offers a memorable example of the evil of medical prescribing in the newspapers.”103 Medical practitioners who published “certain cures” in the public press lost sight of professional decorum and duty to the public, their behavior only explained by “the supposition that they think medical science is likely to be advanced by public discussion in the newspapers. This is tantamount to advocating universal suffrage in Medicine.”104 This is perhaps the most strident stand the Lancet took on medical publishing in relation to cholera. The editors believed that discussing medical science in public papers allowed every unqualified individual to have an equal say in a field in which a bedrock of specialized knowledge and training was required to participate. Medical discussion should, instead, be restricted to the pages of professional journals, after which a consensus finding could, presumably, be transmitted to the public. If this discussion initially occurred in the public sphere, people illiterate in the field of medicine could be misled by untested treatments and, moreover, the authority and exclusive knowledge base the medical profession was attempting to establish would be challenged by pluralistic and conflicting opinions.
The Situation by 1866
As the Lancet observed in the 1832 epidemic, times of cholera were characterized by a “turmoil of rashness and excitement” that obscured facts and did not allow for thorough investigations.105 However, in the aftermath of the 1854 epidemic, more thoroughly developed theories about cholera etiology began to gain publicity. The 1854 outbreak in London was unique from its predecessors as it primarily struck the respectable and relatively more affluent neighborhood of St. James. Previous epidemics had been mostly centered in poorer areas in east and south London, contributing to the perception of cholera as a disease of filth and poverty. As illustrated earlier, the appearance of cholera among middle and upper class individuals in the summer of 1832 may have contributed to a softening of the Times’ anti-contagionist stance. Pamela Gilbert has argued that the outbreak of cholera in St. James lent credibility to John Snow’s theory that cholera was transmitted through water contaminated by human excrement in 1854. Water had been identified as relating to cholera since the disease first appeared in England and Snow had forwarded his hypothesis as early as 1849. However, it was only the prevalence of cholera in an area defined by “whiteness, lightness, Englishness, and cleanliness” like St. James rather than one of “racial degeneration, darkness […], Irishness, and filth” that allowed cholera to be disentangled from place, visible filth, and moral degeneracy in the minds of English officials.106
Apart from the growing acceptance of cholera as a disease transmitted via contaminated water between 1854 and 1866, this period also saw increases in medical professionalization and the integration of the medical profession into the state apparatus. By mid-century general practitioners’ struggles for professional reform were reaching their height. After 1840, seventeen bills advocating for various forms of professional regulation were presented before Parliament; the last of these passed as the 1858 Medical Act. This act created a national register held by the General Medical Council of medical practitioners who were licensed by one of the twenty-one licensing bodies in existence at this point. It also extended the licensing authorities of all these bodies to cover the entirety of the United Kingdom and allowed licensed practitioners to practice in any of the three areas of medicine. The act did not, however, outlaw unlicensed medical practice.107 The passage of the act brought the medical professional under the purview of the government, lending the government’s tacit endorsement to medical practitioners.
By 1866, medical practitioners and medical knowledge were beginning to find their place within government as well. In 1858, the General Board of Health was dissolved and its duties were assumed by the Medical Department of the Privy Council, which was led by John Simon as its Medical Officer. John Simon was a surgeon and had worked as the first Medical Officer of the City of London since 1848. In 1855, the appointment of Medical Officers of Health became compulsory for all London’s districts, signaling further integration of the profession into the governmental bureaucracy. Simon is credited by Margaret Pelling with “eliminating the gap between [official] doctrine and the opinions of the profession as a whole.”108 He aimed to create a scientific basis for sanitation and public health and conducted similar epidemiological investigations to John Snow following the 1854 epidemic as well as repeating experiments on mice by the German surgeon Karl Thiersch that tested the possibility of fecal-oral transmission of cholera. Combined, these investigations by Simon convinced him that cholera was capable of being transmitted fecal-orally through contaminated water, though he did not believe this was exclusively true.109
The General Register Office also played a key role in the 1866 epidemic. Official registration of causes of death had begun in 1837, largely in response to the 1832 cholera epidemic. From 1838 onwards, William Farr, a trained apothecary, held the position of “Compiler of Abstracts” in the office. In this position, Farr developed methods for predicting the rise and fall of epidemics and conducted studies into the epidemiology of cholera, the first of which centered on the 1848-49 epidemic. In this, he identified “cholera fields” where the disease hit hardest and found correlations between income and elevation in relation to cholera mortality. While this could be linked with miasma theory, Farr also entertained Snow’s ideas and noticed that the cholera fields also correlated with areas serviced by specific water companies. He tested this again during the 1854 outbreak and came to the conclusion that “cholera matter” was largely diffused via water.110
In short, by the time cholera reemerged in 1866, the medical profession was becoming increasingly integrated into the British government and medical professionals occupied high-level, highly public positions within the bureaucracy. The Times published the first reports of the General Register Office, including discussions from Farr, weekly, and gave prime billing to statements from the Medical Officer of the Privy Council. Due to how the 1854 cholera outbreak upset conventional thinking on the disease and their own scientific studies, the public mouthpieces of these two offices were in agreement that cholera was often transmitted through water contaminated by human excrement. This was the first time that this type of agreement existed among highly visible medical practitioners who were endorsed by the government going into an outbreak, a set of circumstances which would shape how discourse surrounding the epidemic evolved.
Cholera Discourse in 1866
In previous epidemics, the Lancet had decried the old Board of Health for its lack of representation of medical professionals,111 and attributed the lack of authority of the profession to the fact that “they do not hold high and commanding lucrative offices of state.”112 However, in 1866, it took pleasure in the integration of the medical profession and the government, commenting that the Office of the General Register was closely connected with the profession and that the Registrar’s main collaborator (Farr) “is one whose sympathies would naturally be with a body of which he himself is an esteemed member.” They add that the recommendations of Dr. Farr would be shared by the journal.113 The Times also endorsed the views of these offices. The newspaper had published reports from the Registrar General every Wednesday under the heading of “Public Health” since the commencement of registration and had printed recommendations from the General Board of Health when it was in operation. The appearance of this governmental medical knowledge was not new to the Times. However, it would take on a new significance in 1866.
In July of 1866, the Times published a report from Dr. Simon to the Privy Council stating that a person traveling from a place under epidemic influence may convey the infection to other locations through discharges that underwent decomposition. Furthermore, discharges from a cholera patient could seep into drinking water supplies, with the potential to infect a large population.114 Three days later, the Times editorial reiterated these views, saying that Simon’s statement “give distinct account, on the highest authority, of the principle facts ascertained respecting the nature and contagiousness of Cholera.”115 The Times ascribing “highest authority” to the Privy Council Medical Officer is a far cry from 1832, when the newspaper gave anonymous correspondents about the same degree of authority in swaying its editorial opinions. This is indicative of both the standardization of medical knowledge through the filter of governmental officials and the Times’ turn away from pluralistic knowledge generation in the later part of the nineteenth century. Having one medical opinion echoed throughout the government rather than a cacophony of discordant ones from private practitioners lent great credibility to official medical knowledge. Furthermore, as discussed previously, the Times relied on a loose network of correspondents for virtually all its information in the 1830s as these could often ensure faster apprehension and dissemination of knowledge. However, by the 1860s, governmental dispatches were becoming faster and more reliable, surpassing unofficial correspondent networks.116
Just because the Times’ editors agreed with governmental medical authorities on the transmission of cholera did not mean that all its correspondents were in accord or that old theories were completely gone. For example, some correspondents, including those with medical credentials, complained of public nuisances or other hazards cited foul airs as risks for cholera.117 The connection between cholera and atmospheric conditions also continued to prevail, with the meteorologist James Glaisher writing to the paper to report an unmovable blue mist that he observed hanging over London which had also been present during previous cholera outbreaks.118 A few correspondents wrote to confirm the existence of this mist, with one connecting it with the presence of a comet.119 Despite the coexistence of atmosphere related beliefs in 1866, these beliefs did not come into direct conflict with the idea of water-based transmission in the pages of The Times. It is therefore possible that individuals expressing such observations were either not informed on the new developments in cholera etiology or that they simply merged these into their pre-existing views on disease. This demonstrates the proliferation of contingent-contagionist thought in the 1860s, as even Simon and Farr did not believe that cholera was exclusively transmitted from person to person through water.
While the Privy Council’s reports informed the public of the method of cholera transmission, information regarding the distribution and the root cause of the 1866 outbreak came from the Office of the General Register. Based on the developments in thought in the aftermath of 1854, reports from the office in 1866 were far more conscious of the geography of cholera than ever before and, beyond that, made inferences based on the disease’s geographic distribution. At the beginning of August, the Registrar’s report in the Times stated that the areas affected by cholera all derived their water from the East London Waterworks Company, which drew its water supply from the Lea River. The report went on to argue that filtration did not guarantee the purity of water and that London’s water supply needed reform, beginning with the abolition of tanks and butts and their replacement with a constant water supply. The report concluded that local authorities had been largely paralyzed throughout the outbreak and that “The people of East London want help.”120 Unlike in previous epidemics, the Registrar was not only reporting statistics and geographic distribution of disease, but investigating the causes connecting cholera cases and adopting an advocacy stance. The Times editorial reiterated the statements of the Registrar a few days later while also critiquing the claims by the engineer of the East London Waterworks Company, published in correspondence the day before, that water derived from a rural district would necessarily be clean. The editors went on to express happiness at the fact that the Privy Council would be conducting a public inquiry into the epidemic, adding that “Medical men who are in the heat of the epidemic have no time for careful observations and experiments, still less are they able to collect general statistics, and they often do not possess the authority which is requisite for a complete prosecution of their investigations.”121 The Times believed investigations by private medical practitioners into the epidemic were not a desirable mode through which to obtain information given their small scale and limited resources. Similar to the Lancet’s conclusions about cholera treatments in 1854, the Times decided that only large-scale investigations could produce generalizable results; furthermore, these investigations should be conducted by medical officials in the government. With some exceptions,122 the time of personal, empirical observations germinating myriad different theories of disease was giving way to a single, officially endorsed narrative of cholera transmission.
Despite the increasing role of the government in investigating and generating knowledge related to cholera, the Lancet still felt that the majority of the burden to research these issues fell on regular medical practitioners, who also had to spend their time treating individual cases on top of recording and trying to make sense of all the circumstances surrounding them.123 Underlying this statement is the Lancet’s enduring frustration with the empiricism prevalent in cholera literature. Practitioners in the midst of treating cholera were necessarily so involved in their cases that these would shape their opinions and judgements, leading to a mass of medical literature that was merely an assortment of disparate and often conflicting personal experiences. What the Lancet believed was needed instead was a commission that, unclouded by the biases of personal experience, could reach generalizable conclusions. The journal called for the appointment of a government commission to fulfill these duties and when this did not happen, it decided to form its own commission to investigate to what extent the water supply caused the spread of cholera.124 The formation of “Lancet Sanitary Commission on the Epidemic of Cholera in the East End of London” came right on the tail of the “Lancet Sanitary Commission for Investigating the State of the Infirmaries of Workhouses,” whose work dominated the public press earlier in the summer. The Commission was followed by an investigation by H.B. Farnall, the Commissioner of the Poor Law Board, who was described by the Lancet as being appointed to follow in the footsteps of their commission.125 By establishing commissions like these, the Lancet was taking an active role in generating the type of public health information it asked for. The journal also found that the government was receptive to its investigations, starting their own based on those of the Lancet. Through this, the journal could nudge the government into conducting investigations into public health and create the broad, large-scale data for which it had been advocating.
Apart from itself taking steps to counter empiricism in public health, the Lancet also called on the medical profession at large to do the same. The 1866 Sanitary Act made the removal of nuisances and improvement of sanitary conditions compulsory for local authorities, creating stricter standards than the Public Health Act of 1848. With the passage of this act, the Lancet called the medical profession into action, urging “our professional brethren” to “avail themselves at once of the opportunity now afforded them of assuming their rightful place as conservators of the public health.”.126 This phrasing is interesting as the abilities endowed to medical practitioners under the Act were the same ones given to the public as a whole, namely the ability to appeal to the government to compel local authorities to make sanitary changes. However, the Lancet attributed special power to the medical profession through their shared understanding of sanitary science and their ability to unite as an influential group. They state that “the united application of respectable practitioners of a town or district” would have a powerful influence on sanitary authorities, even more so with the backing of the Home Secretary.127 Therefore, the Lancet implored “our brethren to unite in one great effort to raise the tone of public spirit throughout the profession to such a level as shall render it impossible for any medical men, with the slightest regard for his reputation, to offer factious assistance to the enemies of sanitary improvement.”128 Once again, the Lancet called for the medical profession to unite and warned against the threats of pluralism in issues of public interest. They were afraid of medical practitioners being swayed by the state of their employment to ignore sanitary threats. Because of this, they called for the formation of sanitary associations among practitioners so that they could act as a united front. Similar to how the Lancet had attempted to restrict medical discussion from the pages of public newspapers so that the profession could present a united front of knowledge in terms of treatment, they also advocated for practitioners to reach agreements about sanitary issues amongst themselves before petitioning publicly to give the impression of uniformity of medical opinion. The Lancet was aware of how a plurality of medical opinions could be used by public officials or publications to equivocate and push their own agendas. The journal’s appeals for the abandonment of empiricism were not confined to public health; in fact, they were most plaintive in regard to treatment.
Despite the seemingly conclusory reports from the Board of Health in 1854, the craze over “eliminative” treatments for cholera continued on the pages of the Times in 1866. By this time, most medical practitioners recognized treating the “premonitory diarrhea” as the most effective means of arresting cholera and this idea was also supported by the Privy Council .129 However, the question remained as to what the best way to treat these symptoms was, and, more importantly, how to treat cholera once it progressed past premonitory symptoms. The Times, once again, decided to endorse the work of George Johnson, printing excerpts from his pamphlet which now focused specifically on the “bilious diarrhea” that marks the onset of the disease. The Times comments on these excerpts that “The acknowledged failure of the repressive system, […] renders it at least as possible that the opposite system may be both theoretically and practically sound” and argues that Johnson’s treatment deserves a trial.130 The fact that the Times was still advocating for a trial of Johnson’s treatment after the 1854 debacle implies that they held the General Board of Health’s findings as inconclusive and were unfazed by the Lancet’s chiding. While the medical profession may have reached general consensus about cholera’s mode of transmission and means for preventing it, the same could not be said for treatment. As a result, the newspaper still felt qualified to conjecture about which treatments might be sound.
In the coming weeks, medical practitioners provided the newspaper with a variety of treatments; some endorsed the eliminative treatment and favored purgatives,131 while several advocated variations of the astringent treatment.132 One advocate of the astringent treatment was Waller Lewis, the medical officer for the post office, who supplied postmen with opium confections to be taken with the first appearance of diarrhea.133 Lewis’ remarks provided the foundation for a heated debate that raged for about a week in mid-August in which advocates of the eliminative and astringent treatments argued about what exactly the stance of the College of Physicians was on the use of laxatives.134 The debate culminated in a letter from Johnson himself in which he stated that “the time has come when those who put forth their opinions must be prepared to give reason for them, and defend them before the world.”135 Prior to this, nearly all of the parties involved in the debate went out of their way to disclaim that the Times was not an appropriate forum for this type of discussion, yet proceeded to use the public paper as a forum. Johnson, on the other hand, was clearly in favor of the public airing of disagreements between medical practitioners as well as public explanation and justification of therapies that were pursued.
The astringent versus eliminative debate played out quite differently on the pages of the Lancet. At the beginning of June, the Lancet editorial devoted a section to discussing the “peculiarities” of Johnson’s theory. It argued that “choleraic collapse” due to “exhaustion” was common and that, therefore, Johnson’s method of exciting diarrhea would worsen the severity of collapse. Furthermore, the Lancet pointed out that “there is a discrepancy between Dr. Johnson’s experience and that of the profession. His treatment was largely tried in 1854, and generally and strongly disproved.”136 In the coming weeks, the Lancet editorial grew increasingly disconsolate about the medical profession’s refusal to abandon treatments that had proven ineffective, describing this as “a libel on medicine.”137 The editors firmly believed that no therapy presently employed could successfully treat cholera and urged practitioners to rather not administer any treatments than ones that had no effect, as this could at least elucidate the natural progress of cholera.138 Still, every week, its pages were filled with the specifics of practitioners’ therapies that all utilized the same rotating gallery of common cholera treatments, leading the editors to bemoan the “current blind empiricism.”139
These editorials demonstrate the Lancet’s growing dissatisfaction with empirical treatments, in which every physician based their prescriptive plan on their own observations and experience, rather than large studies and trials. Johnson’s beliefs may have been borne out in his experience, but larger bodies of evidence tended to disprove them. However, the same went for virtually all practitioners – Johnson just had the poor decorum of parading himself in public papers. In September, the Lancet published an editorial highlighting the pitfalls of the current method of reporting and developing therapies. It states that conclusions are quickly adopted and that “there is hardly any remedy that can be mentioned for which triumphant success has not been claimed, either on the basis of the collected results of a long series of cases, or the individual experiences of some one practitioner.”140 The editorial goes on to compare two sets of data received from Liverpool, one from Dr. M’cloy, an individual physician who claimed that castor oil was highly effective for him, and one from the Liverpool Workhouse Hospital. While M’cloy reported a 34% mortality rate while using castor oil, the Hospital experienced a 50% mortality rate with the same treatment. However, the Hospital treated more than three times the number of patients with castor oil. This leads the Lancet to conclude that statistics dealing with small figures, like those of M’cloy are of very little value.141 This editorial represents the solution the Lancet posits to the problem of empirical treatments. With the current format of data dissemination, practitioners would continue to report their individual experiences, clouded by individual biases, with no means of assembling all this information into anything larger and more meaningful. However, through large statistical studies of the efficacy of treatments, practitioners would be able to take a step back and view the issue unclouded by personal biases. While the Lancet’s goal of creating consensus among the medical profession had largely succeeded in terms of thought on cholera etiology by 1866, the same could net be said for cholera treatments, which remained an area that the journal was desperately trying to mold into a coherent, uniform approach.
Conclusion
Throughout the nineteenth century, the authority of medical knowledge was constantly in contention. In the 1830s-1850s, no consensus existed about the etiology or treatment of cholera and a myriad of opinions were propounded in public and medical publications. At this time, the Times seized upon the discord to implicitly forward an anti-contagionist agenda by endorsing and providing a platform to medical practitioners who agreed with them. However, the Lancet, convinced that cholera was contagious, decried these practitioners as attention seekers, chasing the “ephemeral puff” of notoriety in the daily press. These sentiments were also shared by members of the medical profession who viewed practitioners who published in newspapers as ruthless self-promoters. In discouraging medical practitioners from publishing in public newspapers, the Lancet was also attempting to carve out separate spheres for medical and public discussion, which would allow medical practitioners to achieve a consensus amongst themselves before exhibiting these findings to the public. The Lancet, in attempts to generate medical consensus, called for large-scale investigations into the efficacy of treatments like saline fluid and castor oil. By 1866, the medical profession had grown increasingly integrated into government bureaucracy, which both served to medicalize public health and legitimize practitioners. Through the mouthpieces of the growing medical bureaucracy, an official, government endorsed consensus began to emerge regarding the etiology of cholera. This was readily accepted by the Times and praised by the Lancet. However, disagreement about cholera treatment persisted amongst medical professionals, much to the chagrin of the Lancet, which continued to advocate for large, governmental inquiries into treatments. Despite a significant amount of change over the century, some of the Lancet’s goals continued to evade it.
Issues of medical consensus, spheres of discussion, and the authority of medical knowledge are by no means confined to the nineteenth century. Cholera, upon entering Britain in 1832, was met with many of the characterizations that accompanied the beginning of the COVID-19 pandemic in 2020: denial, incredulity, and conspiracy. However, the circumstances defining both events are very different: in 1832, there was virtually no regulation of the medical profession; most treatments were highly ineffective; no medical consensus existed as to the disease’s infectiousness, let alone its fundamental cause; and the government played a minimal role in public health. Given these circumstances, it is relatively easy to understand an anti-contagionist’s skepticism or a castor oil advocate’s hope in a novel therapy. Similar analysis of the circumstances surrounding current medical controversies could shed light on why people respond in the ways they do and inform new approaches to medical communication, journalism, and public health.
Bibliography
Primary Sources:
The Times
The Lancet
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[1] Sean Lang, Parliamentary Reform, 1785-1928, (London and New York: Routledge, 1999), 26-66.
[2] Noel and José Parry, The Rise of the Medical Profession, (London: Croom Helm, 1976), 104
[3] W.J. Reader, Professional Men, (New York: Basic Books, 1966), 17-18, 33-43
[4] Parry & Parry, 1976, 104-117.
[5] Reader, 1966, 16-17, 62.
[6] Michael Brown, “‘Bats, Rats and Barristers’: The Lancet, libel and the radical stylistics of early nineteenth century English medicine,” Social History, 39, no. 2 (2014): 182-83, 206
[7] Michael Worboys, Spreading Germs, (Cambridge: Cambridge University Press, 2000), 28-29
[8] Margaret Pelling, Cholera, Fever, and English Medicine, 1825-1865 (Oxford, Oxford University Press, 1978), 101-104
[9] Worboys, 35-37.
[10] Pelling, 76-79.
[11] Lancet, 14 July, 1866, p. 44.
[12] Andrew Hobbs, “The Deleterious Dominance of The Times in Nineteenth-Century Scholarship,” Journal of Victorian Culture, 18, no. 4 (2013), 473-476.
[13] Brittany Pladek, “‘A Variety of Tastes’: The Lancet in the Early-Nineteenth-Century Periodical Press,” Bulletin of the History of Medicine, 85, no. 4 (2011), 569.
[14] Brown, 188-192.
[15] Roy Porter, “The rise of medical journalism in Britain to 1800,” in Medical Journals and Medical Knowledge, ed. William Bynum, Stephen Lock, and Roy Porter, (London: Routledge, 1992), 12.
[16] Porter, 13.
[17] Times, 10 July, 1866, p. 8.
[18] Times, 12 May, 1854, p. 6.
[19] Stefanie Markovits, “Rushing Into Print: “Participatory Journalism” During the Crimean War,” Victorian Studies 50, no. 4 (2008): 561.
[2] Richard L. Guerrant, et al., “Cholera, Diarrhea, and Oral Rehydration Therapy,” Clinical Infectious Diseases, 37, no. 3 (2003): 398-405.
[22] Lancet, 17 March, 1832, p. 865.
[23] Lancet, 23 September, 1854, p. 261
[24] R.J. Morris, Cholera 1832, (London: Croom Helm, 1976), 21-32.
[25] Times, 14 February, 1832, p. 2.
[26] Times, 14 February, 1832, p. 3.
[27] Ibid, p. 2.
[28] Ibid, p. 3.
[29] Times, 15 February, 1832, p. 2-3.
[30] Times, 16 February, 1832, p. 4.
[31] Times, 16 February, 1832, p. 4.
[32] Morris, 97.
[33] Times, 18 February, 1832, p. 3.
[34] Times, 20 February, 1832, p. 2.
[35] Times, 21 February, 1832, p. 4.
[36] Times, 15 March, 1832, p. 1.
[37] Times, 17 February, 1832, p.3; 20 February, 1832, p. 3; 15 March, 1832, p. 3; (for example)
[38] Times, 15 February, 1832, p. 3; 20 February, 1832, p. 3; 23 February, 1832, p. 4.
[39] Times, 29 February, 1832, p. 1.
[40] Times, 20 February, 1832, p. 3; 23 February, 1832, p. 3.
[41] Times, 26 March, 1832, p. 3. Tweedie, in turn, was accused of trying to stir up alarm over cholera three days later
[42] Times, 20 February, 1832, p. 2.
[43] Times, 15 February, 1832, p. 3; 7 March, 1832, p. 3.
[44] Times, 25 February, 1832, p. 4.
[45] Roy Porter, “Before the Fringe: ‘Quackery’ and the Eighteenth-Century Medical Market,” in Studies in the History of Alternative Medicine, ed. Roger Cooter (New York: St. Martin’s Press, 1998), 4.
[46] Lancet, 4 February, 1832, p. 669-684.
[47] Lancet, 18 February, 1832, p. 735.
[48] Lancet, 25 February, 1832, p. 775-776.
[49] Lancet, 18 February, 1832, p. 739-740
[51] Lancet, 25 February, 1832, p. 774.
[52] Ibid, p. 776.
[53] Lancet, 25 February, 1832, p. 775-778. Many members of the Central Board received no payment and medical inspectors who were not military officers received seven shillings and sixpence per day plus lodging expenses, a far cry from the twenty guineas a day the Times had quoted.
[54] Ibid, p. 776.
[55] Lancet, 17 March, 1832, p. 861.
[56] Lancet, 4 March, 1832, p. 806. (The Lancet website dates this issue as March 3)
[57] Porter, “Fringe,” x.
[58] Lancet, 17 March, 1832, p. 865.
[59] Lancet, 17 March, 1832, p. 865.
[60] Porter, “Fringe,” 7.
[61] Lancet, 25 February, 1832, p. 768
[62] Lancet, 25 February, 1832, p. 768
[63] Brown, 189.
[64] Lancet, 25 February, 1832, p. 778.
[65] Brown, 192; Lancet, 19 May, 1832, p. 209-210; 7 July, 1832, p. 441. In the period surveyed, Johnson published three letters in the Lancet, including one containing his views on cholera contagion and one siding with the Lancet about a lawsuit in which it was involved. Johnson and Wakley had a contentious relationship. In 1826, they were involved in a libel suit after Johnson made insinuations about a fire at Wakley’s house which resulted in Johnson paying damages to Wakley.
[66] Lancet, 25 February, 1832, p. 767-768; 4 March, 1832, p. 795-798; 19 May, 1832, p. 209-210; among others
[67] Times, February 23, 1832, p. 3.
[68] Times, 17 March, 1832, p. 1; 26 March, 1832, p. 3.
[69] Times, 11 July, 1832, p. 2.
[70] Lancet, 28 April, 1832, p. 124.
[71] Lancet, 4 February, 1832, p. 653-654; 18 February, 1832, p. 744-745.
[72] Lancet, 4 February, 1832, p. 652-653.
[73] Lancet, 21 April, 1832, p. 94-95.
[74] Lancet, 14 April, 1832, p. 43-46
[75] Lancet, 26 May, 1832, p. 225-232
[76] Times, 4 May, 1832, p. 2.
[77] Richard L. Guerrant, et al., “Cholera, Diarrhea, and Oral Rehydration Therapy,” Clinical Infectious Diseases, 37, no. 3 (2003): 398-405.
[78] Lancet, 2 June, 1832, p. 275.
[79] Neil MacGillivray, “Dr Thomas Latta: the father of intravenous therapy,” Journal of Infection Prevention, 10, no. 1 (2009): 3-6
[80] Lancet, 2 June, 1832, p. 284.
[81] Lancet, 23 June, 1832, p. 378.
[82] Lancet, 14 July, 1832, p. 455-456.
[83] Lancet, 21 July, 1832, p. 492-293.
[84] Lancet, 21 July, 1832, p. 503-506.
[85] Lancet, 7 July, 1832, p. 428-430.
[86] Lancet, 7 July, 1832, p. 428.
[87] Lancet, 4 August, 1832, p. 574.
[88] Morris, 159-173
[89] Christopher Hamiln, Public Health and Social Justice in the Age of Chadwick: Britain 1800-1854, (Cambridge: Cambridge University Press, 1998), 8-15.
[90] Times, 16 August, 1854, p. 9.
[91] Times, 17 August, 1854, p. 10.
[92] Times, 25 August, 1866, p. 9.
[93] Times, 6 September, 1854, p. 4.
[94] Lancet, 26 August, p. 178.
[95] Times, 9 September, 1854. It was not uncommon for the Times to find publications advocating various treatments for cholera and to publish them, but they were generally relegated to the lower portion of the page, without a noticeable heading. However, this is the second time that the Times decided to publicize Johnson’s work and to give it noticeable billing within its pages.
[96] Times, 12 September, 1854, p. 10; 14 September, 1854, p. 6; 20 September, 1854, p. 8.
[97] Times, 20 September, 1854, p. 8.
[98] Times, 15 September, p. 9.
[99] Times, 18 September, 1854, p. 9.
[100] Times, 20 September, 1854, p. 9.
[101] Times, 21 September, 1854, p. 7.
[102] Times, 22 September, 1854, p. 8.
[103] Lancet, 23 September, 1854, p. 261-262.
[11am 04] Ibid.
[105] Lancet, 30 September, 1854, p. 282.
[106] Lancet, 30 September, 1854, p. 282.
[107] Lancet, 25 February, 1832, p.778.
[108] Pamela K. Gilbert, “‘Scarcely to Be Described’: Urban Extremes as Real Spaces and Mythic Places in the London Cholera Epidemic of 1854,” Nineteenth Century Studies, 14 (2000): 149-172, 151.
[109] Reader, 66-67.
[110] Pelling, 231
[111] Ibid, 229-249
[112] John M. Eyler, Victorian Social Medicine, (Baltimore: Johns Hopkins University Press, 1979), 111-120.
[113] Lancet, 19 August, 1854, p. 151.
[114] Lancet, 21 April, 1832, p. 88.
[115] Lancet, 21 July,1866, p. 77.
[116] Times, 20 July, 1866, p. 5.
[117] Times, 23 July, 1866, p. 8.
[118] See discussion in Times, 10 July, 1866, p. 8.
[119] Times, 6 August, 1866, p. 5; 9 August, p. 6.
[120] Times, 7 August, 1866, p. 12.
[121] Times, 9 August, 1866, p. 6.
[122] Times, 1 August, 1866, p. 11.
[123] Times, 3 August, 1866, p. 7.
[124] The 1866 outbreak saw the reemergence of correspondence from an individual going by the pseudonyms of ‘Investigator’ or ‘S.G.O..’ This person had written to the newspaper in 1854 to report their personal experiments in identifying a fungal cause for cholera. In 1866, they again wrote to the paper to chime in on a debate about whether boiling water was effective at eliminating cholera matter from water. They investigated this question using similar methods of fungal cultivation. ‘Investigator’ was, by all indications, an hobbyist investigator and the continued presence of their correspondence in the Times indicates that, while knowledge generation was becoming more homogenized, there was still pluralism to be found. See Times, 11 September, 1866, p. 9.
[125] Lancet, 28 July, 1866, p. 97.
[126] Lancet, 11 August, 1866, p. 157-160.
[127] Lancet, 21 July, 1866, p. 71.
[128] Lancet, 18 August, 1866, p. 187.
[129] Ibid.
[130] Lancet, 18 August, 1866, p. 187.
[131] Times, 25 July, 1866, p. 5.
[132] Times, 31 July, 1866, p. 4.
[133] Times, 7 August, 1866, p. 12; 11 August, 1866, p. 10.
[134] Times, 3 August, 1866, p. 7; 9 August, 1866, p. 6.
[135] Times, 9 August 1866, p. 6.
[136] Times, 13 August, 1866, p. 12; 14 August, 1866, p. 14; 15 August, 1866, p. 7
[137] Times, 17 August, 1866, p. 4.
[138] Lancet, 2 June, 1866, p. 609-610.
[139] Lancet, 11 August, 1866, p. 153.
[140] Lancet, 4 August, 1866, p. 125-126.
[141] Lancet, 11 August, 1866, p. 153.
[142] Lancet, 1 September, 1866, p. 238
[143] Ibid.