Plagues and Peoples (38 page)

It was otherwise, however, beyond India’s borders. Moslems had long been resigned to plague and found European
quarantine efforts rather amusing. But the unfamiliar, dreadful, and sudden nature of cholera deaths created among the population of Egypt and other affected Moslem lands almost the same alarm that prevailed in Europe. Neither Moslem medical nor religious traditions were able to cope. The popular fright cholera aroused helped to discredit traditional leadership and authority within the Moslem world, and opened the way for reception of European medicine.
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In Europe, to be sure, there were a few localities where memories of former visitations by the plague remained sufficiently vivid that public and private responses to the emergency could find fitting if somewhat archaic expression. This was the case in much of Mediterranean Europe, where a combination of religious supplication and medical quarantine had been built into public law ever since the sixteenth century. Thus in Marseilles, where annual commemoration of the plague of 1721 had kept memories of that disaster very much alive, the cholera became an occasion for renewal of Christian piety.
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In northern Europe, however, traditional guidelines for behavior in time of epidemiological crisis were less well defined. To be sure, chronic tensions between social classes tended to find overt and even ritualized expression in places as diverse as St. Petersburg and Paris; but such symptoms of social strain did not easily convert into concrete and definite programs of action.
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People had therefore to improvise, argue, and flee, as well as plead, threaten, and pray. In other words, there was a wide spectrum of behavior from which to choose the most effective way to cope with what everyone agreed was a real and present threat to life and society. From these perturbations, refreshed at frequent intervals during the rest of the nineteenth century, came the major impetus to improvements in urban sanitation and public life regulation.
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To begin with, cholera added new urgency to long-standing debates between rival schools of thought about epidemics. Since the days of Hippocrates, some European doctors had held that sudden outbreaks of disease were caused by a mi-
asma, emerging perhaps from dead corpses or other rotting matter in the earth. When the miasma encountered appropriately weakened constitutions, these theorists believed, disease resulted. Wherever encounters with malaria and other insect-borne diseases remained important, the miasmatic theory had a firm and satisfactory empirical basis—or seemed to.

The rival germ theory of contagion had been clearly advanced as early as 1546 by Girolamo Fracastoro. This provided the theoretical justification for the sort of quarantine regulations that had become standard in the Mediterranean against plague. But early in the nineteenth century the germ theory was put on the defensive. The occasion was the disaster that came to French troops sent to Santo Domingo in 1802 to suppress rebellion led by Toussaint L’Ouverture. Within a few months, yellow fever and other tropical diseases utterly destroyed a force of 33,000 veterans, and the resulting setback to Napoleon’s imperial ambitions (among other things) made him willing to sell the Louisiana Territory to the United States in 1803. This dramatic demonstration of the power of disease to blunt European military force overseas gave a special fillip to study of tropical diseases among French doctors; and when yellow fever broke out in Barcelona in 1822, they seized the opportunity to make a definitive test of the against the miasmatic school of thought. French experts, led by Nicholas Chervin, organized systematic and careful study of how the disease occurred. They concluded that there was no possibility of contact among the different persons who came down with yellow fever in Barcelona. Thus contagionism seemed to have been fully and finally discredited.

For the next fifty years medical reformers set out to dismande the long-standing quarantine regulations of Mediterranean ports, arguing that they were mere survivals from a superstitious age. Lacking any empirical base—for no one as yet imagined that insects might be carriers of disease—the germ theory seemed destined for the scrap heap of history.
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British liberals, in particular, saw quarantine regulations as an irrational
infringement of the principle of free trade, and bent every effort toward the eradication of such traces of tyranny and Roman Catholic folly.

Yet in 1854 a London doctor, John Snow, neatly demonstrated how cases of cholera that broke out in a district of central London could all be traced to a single contaminated source of drinking water. But Snow’s argument was merely circumstantial; and since contagionism had been so recently and so definitively discredited by Europe’s most meticulous and celebrated medical experts, Snow’s interpretation of his data commanded little attention.
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Then in the 1880s the microscope abruptly reversed the balance of medical opinion with the dramatic discovery of disease-causing “germs.”

The first such germs to be detected were the bacilli of anthrax and tuberculosis, discovered respectively by Louis Pasteur, between 1877 and 1879 and Robert Koch in 1882. Since neither of these infections spread in a dramatically epidemic fashion, their identification did not upset the miasmatic theory, which had come into existence to account for epidemics. It was otherwise when in 1883 Robert Koch claimed to have found a new bacillus responsible for cholera, for if Koch was right the miasmatic theory was wrong—at least in explaining cholera.
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Since many learned and respected doctors had committed themselves to the miasmatic theory as explanation of epidemic, it is not surprising to find that Koch’s explanation for the cause of cholera met stout resistance among experts.
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As late as 1892, a famous German doctor drank a beaker full of cholera bacilli to prove the falsity of the germ theory—and gleefully informed his professional rivals that he had experienced no ill effects.
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No doubt he was lucky; but his act dramatized the uncertainties that still surround the question of what factors affect transmission of cholera infections. Perhaps in the professor’s case, anger and nervousness provoked an extra charge of stomach acids which sufficed to kill the bacilli he swallowed.
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Long before Koch’s microscope thus provided doctors with
an empirical base for the modern view of how cholera spreads, the alarm it created in American and European cities provided essential leverage for those reformers who sought to improve urban sanitation, housing, health services, and water supply. Models of what to do and how to do it were readily at hand, for during the eighteenth century European governments discovered that soldiers’ and sailors’ lives were much too valuable to squander needlessly, when simple and not overly expensive measures could check the ravages of disease.

The most famous and significant of these health measures was the use of citrus juice to ward off scurvy. This disease haunted European ships on long voyages, when crews for weeks or months on end ate food that lacked essential vitamins. Its peculiar pattern of incidence provoked an abundant medical literature; and as early as 1611 the use of lemons and oranges as a cure was recommended in print, and repeated thereafter by respectable and important medical writers. But other cures were no less warmly recommended, and a supply of citrus fruit was often hard to come by. Hence the superior effectiveness of the cure was not clearly recognized until the end of the eighteenth century.

Indeed, even after a British naval surgeon, James Lind, published the results of his carefully controlled experiments that proved the efficacy of fresh lemons and oranges in curing scurvy (1753), the Admiralty did not act. The reason was partly pecuniary: citrus fruit was expensive and scarce and could not be stored for very long. Partly too, the naval authorities believed other cures were suitable, e.g., the sauerkraut Captain James Cook fed his crews in the Pacific. Moreover, when in 1795 the Admiralty did decide on citrus juices as the best preventative for scurvy and prescribed a daily ration for all sailors on shipboard, the result was imperfect. The species of limes grown in the West Indies lacked the essential vitamins; but it soon proved that West Indian limes were cheaper than Mediterranean lemons, with the result that the British navy soon was drinking the almost valueless lime juice that gave them the nickname, “Limeys.” As late as 1875,
therefore, outbreaks of scurvy occurred on British naval vessels, despite the daily dose of lime juice prescribed by regulations.
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In spite of such confusion and inefficiency, James Lind and other medical men in the British navy pioneered a number of other significant improvements in health administration during the latter decades of the eighteenth century. Lind was instrumental, for instance, in installing sea-water distilleries on board ship to assure a supply of fresh drinking water. The adoption of the practice of quarantining new recruits until they had been bathed and equipped with a new set of clothes was another simple procedure that reduced typhus dramatically. Use of quinine against malaria, and rules against going ashore after dark on malarial coasts, were also introduced under Lind’s direction.

Parallel improvements in army health administration, with conscious attention to water supplies, personal cleanliness, sewage, and the like met with larger obstacles, inasmuch as soldiers were never so well insulated from external sources of infection as sailors aboard ship could be. Yet there, too, eighteenth-century European armies, being the pets and playthings of Europe’s crowned heads, were both too valuable in the eyes of authority and too amenable to control from above not to benefit from a growing corpus of sanitary regulations. From protection of soldiers to medical regulation of the public at large was an easy step which had been made on the Continent, in principle if not fully in practice, by systematically minded servants of German monarchs. The most influential was Johann Peter Frank, whose six volumes on medical policy, published between 1779 and 1819, attracted wide and favorable attention among rulers and government administrators who recognized that the number and vigor of their subjects was a fundamental component of state power.

Interaction between Europe’s political history and the health of professionalized standing armies and navies deserves more consideration than historians have commonly devoted to the subject. Obviously, the rise of absolutism on the European
continent hinged on the availability of well-trained armies to do the sovereign’s will; and the preservation of such armies, in turn, rested on the development of rules of sanitation and personal hygiene that reduced losses by epidemic disease to relatively minor proportions, winter and summer, in the field and in cantonments. “Spit and polish” and ritual attention to cleanliness was, of course, the way European armies achieved this goal, and the eighteenth century was clearly the time when such practices became normal, altering the experiential reality of soldiering in far-reaching ways. But no one seems to have investigated the intersection of high medical theory, as expressed by doctors like Johann Peter Frank, with the routines that inconspicuous drill sergeants and junior officers invented to occupy soldiers’ time, keep them healthy and train them to battle efficiency.

As in most matters of military administration, the French were pace-setters. Early in the eighteenth century, the French royal administration set up military hospitals and medical training schools. In the 1770s a medical corps of a modern type was established. The key innovation was that doctors served their entire careers in the new corps, and could aspire to ascend a ladder of rank just like regular officers, instead of coming, as before, into military service from civilian practice at the invitation of a regimental colonel when some emergency or impending campaign required it.

The benefit of the professionalization of the French military medical corps was demonstrated during the wars of the revolutionary and Napoleonic period. Young men conscripted from remote farms and from the slums of Paris mingled in the ranks of the new and vastly expanded armies of the French Republic. Yet despite the fact that the recruits brought widely different disease experience and resistances into the army, the medical corps was able to prevent massive epidemic outbreaks, and took swift advantage of new discoveries, like Jenner’s vaccination (announced in 1798), to improve the health of the soldiers in their charge. The expanded scale of land warfare, characteristic of the Napoleonic period, could not have oc-
curred otherwise. Equally, the capacity of the British navy to blockade French ports for months and years on end, depended quite as much on lemon juice as on powder and shot.
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In view of the achievements of military medicine, therefore, the problem as it presented itself to sanitary reformers of the 1830s and 1840s was less one of technique than of organization. In England, at any rate, a libertarian prejudice against regulations infringing the individual’s right to do what he chose with his own property was deeply rooted; and as long as theories of disease and its propagation remained under dispute, clear imperatives were hard to agree upon. In this situation the fear of cholera acted as a catalyst. To do nothing was no longer sufficient; old debates and stubborn clashes had to be quickly resolved by public bodies acting literally under fear of death.

The first outbreak of cholera in Britain (1832) promoted establishment of local boards of health. Being unpaid and locally elected, the personnel of these boards often lacked expertise as well as legal power to alter living conditions; indeed, not everyone agreed that filth and ill health went together. Far more significant was the reaction to the reappearance of cholera in 1848. In that year Parliament authorized the establishment of a Central Board of Health exactly one week before cholera appeared in England for a second time. The dreaded approach of Asiatic cholera had been a matter of public notice for more than a year, and there can be no doubt that it was the expectation of its return that precipitated Parliament’s action.