Copyright © 1996 The Johns Hopkins University Press. All rights reserved. Bulletin of the History of Medicine 70.2 (1996) 233-265

Access provided by Columbia University

Edwin Chadwick, "Mutton Medicine," and the Fever Question

Christopher Hamlin

Edwin Chadwick's Report on the Sanitary Condition of the Labouring Population of 1842 is famous for launching the public health movement in Britain. It was the product of the so-called Sanitary (or Sanatory) Inquiry, an investigation begun in autumn 1839 by the Poor Law Commissioners (PLC), whose secretary Chadwick was. Using the rest of England and Wales as a laboratory, this investigation was designed to test a thesis about the environmental causes of fever developed in pilot studies in London done by Drs. Thomas Southwood Smith, J. P. Kay(-Shuttleworth), and Neil Arnott in May 1838. 1 The work of Chadwick and these associates has [End Page 233] been seen as reflecting a remarkable appreciation that the reform of social (and particularly of structural and environmental) conditions might prevent most infectious disease. It is seen as the manifesto of the desirability of a proactive rather than a reactive medicine, of prevention over cure. 2

The Commissioners explained their move into preventive medicine as part of their mission to lower the costs of poor relief. It had recently been discovered, they held, that dirt was the cause of disease. As disease was a common cause of dependency, it followed that "sanitary improvement" (removing dirt) could reduce disease and thus reduce the number of people requiring public aid. The inquiry would provide evidence to justify spending funds collected for poor relief on such sanitary improvement. As we know, its products were far-reaching. The environmental improvement it inspired probably did do much to diminish disease. Whether or not Chadwick's approach really lowered welfare costs, the sort of environmental conditions he championed have become standard expectations in industrial societies on grounds of amenity as well as health. Chadwick's move into public health has been seen as a major transition in his career, a move from poor-law disciplinarian and political economy zealot to benefactor of humanity. As to why he made the move, historians disagree: some suggest that he was finally settling into his true life's work, others that he was seeking public work that would bring gratitude, not calumny. 3 [End Page 234]

In this article I will suggest that public health was less a new policy initiative than a response to a developing crisis in poor-law management. Of more immediate concern to Chadwick and the three Poor Law Commissioners than lowering costs through preventive medicine was the political emasculation of aspects of medical theory--and worse, of medical practice--that was undermining the new poor law, and that would lead ultimately to the abolition of the Commission in the wake of the Andover scandal of the mid-1840s. 4 The move into public health was more a rhetorical means of damage control than an expansion into a new and less stormy area of social betterment.

The troublesome aspects of medical theory and practice arose most markedly in connection with continued fever (a distinction between typhus and typhoid was only beginning to emerge during these years). This disease had been the focus of the pilot studies and was the initial focus of the Sanitary Inquiry. It was, in effect, the "battle ground" for fundamental questions of social policy during the 1830s and 1840s--years of social and political turmoil, and equally of innovative social policy in Britain. 5 [End Page 235]

As is well known, the sanitarians' chief claim was that fever struck healthy people exposed to "insanitary" conditions, the most important of these being an atmosphere filled with emanations of decay. Embedded in this simple statement were at least five distinct claims bearing on key issues of fever etiology and prevention, which Chadwick and his

followers would advance more or less explicitly. Claim 1 was that decaying filth was a cause of fever. Claim 2, stronger, was that decaying filth was either the true "exciting" cause of fever, or at least the only necessary cause. Claim 3, a hidden antithesis, was that a debilitated condition of the victim (in particular, one due to destitution) was not a cause, or at least not an important cause. Chadwick insisted that fever struck primarily healthy people (i.e., employed, well-fed people), not those weakened by hunger, exhaustion, and exposure: "in the great mass of cases in every part of the country, in the rural districts and in the places of commercial pressure, the attacks of disease are upon those in full employment, the attack of fever precedes the destitution, not the destitution the disease." 6 Fourth and fifth were the preventive claims: (4) that improvement of the environment (chiefly by removing emanations of decay) would prevent fever; and (5) that other responses, particularly "employment . . . and abundant food," were not effective means to prevent or combat fever--or, as Chadwick put it, would not "guarantee" freedom from fever. 7 Of these, claim 1 was uncontroversial, and, depending on how strongly it was put, claim 5 was uncontroversial also: most medical men acknowledged some role for the environmental filth factor in the production of fever, and they acknowledged also that fever sometimes did break out among the nondestitute (although they regarded it as usually connected with destitution). 8 The fourth claim, too, was uncontroversial, so long as it was not [End Page 236] read as maintaining that sanitary improvement alone would eliminate all fever. For most (but not for Chadwick), the first claim, that insanitation contributed to fever, was itself sufficient to warrant the fourth, that sanitary improvement would help prevent fever. 9 The controversial claims were the second and third. They allowed Chadwick to transform what was usually regarded as a feedback cycle--disease caused poverty and destitution, which in turn caused further disease--into a unidirectional causal process: disease, an independent variable (at least with respect to economic condition), caused destitution. 10

I shall first consider the reasons why it was necessary to make stronger claims about the relation of poverty to fever than were necessary to show the utility of sanitary improvement, and shall then look at Chadwick's handling of the fever issue between 1838 and 1842.

When, in the spring of 1838, Edwin Chadwick and the Poor Law Commissioners initiated investigations into the "physical causes" of disease, the new poor law they administered was not even four years old. It remained controversial, and was vigorously resisted. During the period of the Sanitary Inquiry the survival of the Commission itself was precarious: it was on year-by-year reappointments. 11 Its main premise, and the source of much opposition, was the famous principle of "less eligibility," the attempt to discourage the election of pauper status by making sure that the pauper's life would be clearly less desirable--in liberty, diet, and [End Page 237] other "necessaries of life"-- than that of the person who remained independent. In principle, the pauper would be required to move into a local workhouse administered by a union of neighboring parishes. Family members would be sent to men's, women's, or children's wards, hard work would be required, and a minimal and tedious diet imposed.

To Chadwick, chief architect of the new law, the unpleasantness of the workhouse was to be a dam of disincentive, holding back the current of lazy people who would otherwise drift naturally into demoralizing (and costly) dependency. The provision of medical relief represented a hole in this dam, a sort of spillway to relieve pressure. Medical relief might be necessary, but it was potentially dangerous, for the faster it allowed people to bypass that dam of discipline, the faster the dam would erode until the entire structure was gone. Medicine had this effect for two sorts of reasons.

First, it seemed both practically and morally inappropriate to treat in the same way both the able-bodied laborer temporarily unable to work due to illness and the indolent laborer who would not do his utmost to find work to support self and family. Practically, it seemed wasteful to institutionalize an entire family whenever the breadwinner became ill; morally, it seemed wrong to treat the innocent disease victim in the same way as the wanton deviant. 12 Accordingly the law had provisions for providing emergency aid, in the form of both medical care and the "necessaries," to those who normally maintained their independence but who could neither pay for medical care nor sustain a loss of income for any significant period. Chadwick and his colleagues saw such provisions as an invitation to malingering, a way to circumvent the "workhouse test": through the excuse of illness, a laborer might obtain the benefits of poor relief without the penalties of pauper status. Medical aid was also a disincentive to saving money to provide for such contingencies. Chadwick tried to set up sick clubs and loan programs for medical care that would allow the independent poor to maintain themselves during illness, but none of these approaches worked well. He tried also, by establishing the office of relieving officer, to limit the freedom of medical officers to intercede. 13 [End Page 238]

Second, there were circumstances in which the workhouse system might itself cause disease. The chief focus here was the workhouse diet, for food was both the easiest medium for comparing independent life with life as a pauper, and the "necessary" whose insufficiency led most directly to disease. The deterrent principle required that the workhouse diet sustain life and (at some level) health, and yet be at best no more desirable than that available

outside. So long as the independent poor had enough to eat the approach might be viable, but during a depression (as in the late 1830s) maintaining credible deterrence became difficult as wages and diet (and access to medical care) fell. 14 Under such conditions it was deemed appropriate to suspend deterrent principles and provide without penalty the support needed to sustain life. Even more fundamental than "lesser eligibility," Chadwick insisted, was the principle that the poor law was to sustain those in need. 15

Yet there was no clear line between the normal regime of deterrence and the emergency situation where support was needed. Any starvation or malnutrition that undermined health, whether within or without the workhouse, showed that the line had been crossed. Starvation in the workhouse indicated a diet too low to sustain life and health; starvation outside showed that deterrence had worked all too well: fear of the "house" was so great that people would die avoiding it. 16 This line was defined in pathological and physiological terms, and how easy it was to recognize depended on physiological and pathological conceptions. On the hunger issue, Chadwick and the PLC took the view that starvation was an acute condition, quickly manifesting itself in the absence of food. They rejected the idea of a chronic exhaustion and malnutrition that slowly damaged health, eventually manifesting itself in some disease. In [End Page 239] assessing claims of starvation, the Assistant Commissioners would hold that if the deceased possessed money or any pawnable objects, death could not have been from starvation, since the person would have bought food. 17 Similarly, Chadwick assumed a clear demarcation between health and disease, in which disease, whether acute or chronic, had a clear beginning and end and struck more or less randomly. It might be that certain places were especially prone to disease, but this could be ascribed to exposure to environmental poisons rather than to the prevailing social and economic conditions. Thus both malnutrition and disease had to be seen as binary phenomena: a person was either healthy and adequately fed, or obviously ill and starving. For Chadwick, to have admitted a concept of disease as the product of slow decline under the totality of debilitating conditions would have been to portray the new poor law as ridiculous and unconscionable, as causing disease in the name of lowering costs and increasing efficiency. 18

For a number of reasons many medical men took the opposite view on these questions. They did so, first, because it was a prominent axiom of most contemporary medical theories that overwork, poor diet, and bad living conditions did continually undermine health and thus led ultimately to disease. Health and disease (sometimes synonymous with debility) were not binary opposites, but different areas of a continuum. One's place on this continuum was not the result of some random exposure to a poison but the product of an initial constitution, modified by place, occupation, passions, ingesta, and so forth--and it was always changing. Accordingly, many poor-law medical men found reason to sympathize with those applicants for medical relief whom Chadwick suspected of malingering. Equally, they recognized that the effects of overwork, cold, and hunger were manifest even in "normal times": the supposedly "healthy" workhouse inmate or independent laborer might not be very healthy at all. Robert Ceely, a leader in the movement for improved status for poor-law medical officers, described the inhabitants of the vale of Aylesbury as "a poor, sickly race of beings, which is partly attributable [End Page 240] to the soil, and partly to their insufficient diet and their generally depressed condition from the low rate of wages." 19

In attending the very poor, medical men frequently found that what was really needed was food, and despite pressure from local poor-law guardians and the PLC, that was what they prescribed--sometimes in substantial quantities, such as two to three pounds of mutton per week, along with bread and wine. Usually their orders of stimulants (chiefly meat and wine) were followed, but not always. Being "always reprimanded" for such orders, a Bethnal Green medical officer found that they were often not properly followed: "When I attend a case of fever I am often prevented from giving the quantity of relief the patient ought to have. They cannot get wine or porter ad lib., or animal food to the extent they ought to have. The Guardians do not refuse the certificates, but they give insufficient quantities." 20 Ceely told of spending £10 of his own money for such purposes; that course being "consistent with policy and economy, as well as in union with all my own feelings." 21 Edward Evans, medical officer of St. George the Martyr, in Southwark (and one of the informants in the 1838 inquiry) acquired such a reputation for prescribing food that people applied to him when they really wanted general relief. Initially, Evans's board had supported his orders in an effort to "subdue typhus." But as the cost of the "extras" seemed poised to rise indefinitely high, they found a need for restraint--he was "ruining half the ratepayers of the parish"; Evans's response was that "nearly every patient required support and nourishment. Whatever the disease, a large proportion of the illnesses he had to treat would never have arisen had the poor enjoyed a better diet." 22 [End Page 241]

Ironically, poor-law policies often encouraged this "mutton medicine." Many unions required their medical officers to pay for medicines from their own salaries, a move intended to control costs. As would be pointed out on numerous occasions in the next decade, it was impossible, given the salaries offered, to use first-class medication. Yet the "necessaries"--food, clothes, and fuel--that a medical officer ordered did not come under the heading of medication,

and were paid for by the union. Thus medical men found an additional incentive to medicate with food. 23

To Chadwick and the PLC, prescription of the basic commodities of life was unacceptable, a violation of the laws of political economy. Hunger was to spur work; here, under the ruse of illness, it was automatically, even luxuriously, being relieved by union medical officers. 24 The very provision of good medical care seemed incompatible with the deterrence principle; the inclusion of nourishment for the convalescing laborer (and family) was, according to Assistant Commissioner Edward Tufnell, "the avenue to all pauperism." 25 Indeed, some medical officers were openly espousing principles antithetical to Chadwick's political economy, among them the idea (later developed by Marx) that the laborer's health and body were his property and deserved the same legal protection as any other form of property; or the claim that gentry and poor should have the same medical practitioner and get the same medicine; and even that medical care was a right, like the spiritual care offered by the established church, and not a "commodity." Even the [End Page 242] otherwise orthodox Kay urged the establishment of a roster of the employed industrious poor who should be eligible to receive free public medical relief. 26

In the spring of 1838 these issues were already serious; they would only become more so in the next six years. In hearings held in June before a commons select committee packed with PLC supporters, questioners probed this medical exception to the rigor of the workhouse test. Kay was asked what legitimate medical rationale there could be for the fact that orders for meat and porter might be much greater in one union than in the union adjoining (he cautioned the questioner not to second-guess the judgment of professional medical men). 27 In the new Irish poor law (generally modeled on the English), the English custom of "medical 'orders' for mutton and porter, etc." would be explicitly forbidden. 28

All the while, an overwhelmingly hostile press held the PLC responsible for any death in which hunger was a significant factor. In part the prominence of the starvation issue was a function of economic depression: there were areas of significant hunger in 1837-43. Yet it was also being seized as a weapon in political campaigns, some of which only tangentially concerned poor-law administration: "starvation" figured centrally in the appeals to working- class hearts and minds of the growing Chartist movement (while the Charter was ostensibly concerned with constitutional issues of franchise, its popularity in the north came through its link to the anti-poor-law and factory movements) and of the Anti-Corn Law League, which was finding the sentimental issue of starving babes (the starvation being caused by import duties on food) to play [End Page 243] much better than its earlier appeals to abstract economics or scenarios of trade retaliation. In 1839, when William Farr's first official analysis of mortality attributed a tiny fraction of deaths to starvation, Chadwick acted immediately to discredit Farr. For the next several years he and the Assistant Commissioners monitored the returns Farr was receiving; they quickly investigated starvation claims, invariably finding them unsupportable. That the deterrent principle and the practice of pushing labor onto the market even when there were no jobs might generate hunger, disease, and death was a heresy to be vigorously suppressed wherever it appeared. 29

Thus there are strong reasons to think that what Chadwick sought from the Sanitary Inquiry was the basis to make a case for claim 3, that hunger did not cause disease and death. Fever was the key disease here because it, even more than consumption, was seen as the disease of misery. Many saw it as a general systemic response to debilitating forces. Such a view did not preclude fever's being a contagious or a miasmatic disease: "debility" simply identified those likeliest to succumb. 30 Chadwick claimed in the Report that few still took this "debilitationist" view. This is not the case. With regard to the circumstances in which fever arose, most [End Page 244] contemporary authorities (excepting Southwood Smith, whom many do not cite, and who often writes as if in an intellectual vacuum) agreed that fever was usually a contagious disease, though one in which predisposing factors were more important (and the radius of transmission larger) than in the classic contagious disease, smallpox. Crucial predisposers were dirt, damp, lack of ventilation, vitiated air, poor nutrition, cold, exhaustion, and anxiety. These were often seen as interchangeable: anxiety might compensate for lack of dirt. 31

In large part Chadwick and his associates made their argument without asserting claim 3 directly. They continued to recognize the influence of debilitating causes, but focused only on a subset of the usual list of predisposers: on vitiated air (including poisonous emanations), poor ventilation, damp, and dirt--but not on hunger, exhaustion, or anxiety, and only rarely on cold. Via the ancient concept of "malaria" they elevated emanations from the status of being one of many debilitating predisposers to that of replacing contagia as the exciting cause (while remaining an important predisposer). 32 In this move other causal factors, not just in fever but in most other diseases as well, were relegated to [End Page 245] insignificance. In essence the Chadwickians were arguing for claim 3 by suggesting that it was implied in claim 2. If the cause of fever were emanations from filth, it could not also be destitution.

Given this background, we can review Chadwick's handling of the fever issue. On 27 April 1838 he sent a questionnaire on fever incidence to the London parishes. The responses were the basis for the "pilot study" by Kay and Arnott, which they made in May. It and two independent reports by Southwood Smith on the east end of London were published as appendices to a "Report of the Poor Law Commissioners relative to certain charges which have been disallowed by auditors of unions in England and Wales," and then later in the Commissioners' fourth annual report.

The reports are usually seen as having been occasioned by the government auditors' disallowances of nuisance- removal measures undertaken by various unions. They were to provide a warrant for such activity by showing that lethal fever had removable "physical" causes. 33 Yet it is [End Page 246] worthwhile to consider the reports in the light of concurrent events. First, as we have seen, they were undertaken about six weeks prior to the first parliamentary review of medical provision under the new poor law. 34 Medical men were on the offensive in this inquiry, complaining of low salaries and precarious appointments, and noting incidentally that both the quality of public medical care and the health of the labor force had deteriorated under the new poor law. Second, the investigation followed almost immediately the transfer of James Phillips Kay from East Anglia to the London district. Kay was the most able social analyst among the Assistant Commissioners and the only one with medical training. His claim to fame was his 1832 work on the "Moral and Physical Condition" of Manchester operatives, in which he championed the political economy of Chadwick and Brougham against the humanitarianism of those who would interfere in the labor market to ease the factory worker's life. 35 A final factor was the area of Smith's study: Bethnal Green and Whitechapel, the last bastions of resistance to laissez-faire, where controls on prices in the cottage silk-weaving industry had produced a thriving community of educated and radical artisans. By the late 1830s the area was in decline, however, and its condition was seen as a test case between a managed and a free market. Against claims of locals that free trade was the source of poverty, crime, squalor, and starvation, a royal commission on handloom weavers (Chadwick's friend James Mitchell was the local investigator) was trying to make the case that the weavers' only hope lay in the rigor of the market. To show, as did Smith (and Kay and Arnott) that ill health in these areas was due to physical causes (and moral failure), and not to low wages, had a political importance it would not have had elsewhere. 36

The great Sanitary Inquiry launched in autumn 1839 would determine "the extent to which the causes of disease stated . . . to prevail [End Page 247] amongst the labouring classes in the metropolis prevail also amongst the labouring classes in other parts of England and Wales." 37 The mission statement implies that the London inquiry had determined which causes did in fact prevail--that is, that the sort of study needed to warrant claims 2 and 3 had been undertaken. In fact, the Kay-Arnott report made no effort to explore statistically which factors were most strongly correlated with fever; it was simply a compilation of medical opinion. That opinion certainly did not emphasize destitution as a cause of fever (a few correspondents mentioned it, though Kay ignored it in summarizing the responses), and one might infer that metropolitan poor-law medical men did not see destitution as an important factor. Yet neither Kay nor Arnott (who actually wrote separate reports) included the questionnaire to which the medical men had been responding. This actually reads:

"The Poor Law Commission have been informed that within many districts chiefly inhabited by the labouring classes fever and other diseases occur at regular intervals or are never absent. It has also been stated that such diseases arise in places where there is no drainage; where filth is allowed to accumulate, or where there are other physical causes of disease which are removable if steps be taken. It is further stated that where such causes exist the suffering of disease, often fatal, is extensively inflicted on the inhabitants, mostly of the labouring classes, and very heavy burthens are cast upon the ratepayers.--Instances have been given to the commissioners where setting aside the higher consideration, even regarding only the expenditure of the rates, it would be good economy to remove the causes in question at public expense if there were no other means for their removal. You will . . . describe to them the nature of any such places it may have been your duty to visit, and specify the number of cases of illness ascribable to such causes, which have become chargeable to the parish. 38

In no sense, then, was the inquiry an attempt to test rival hypotheses--namely, that filth causes fever, or that destitution causes fever. The questionnaire assumes what the study is usually taken to demonstrate, a causal relationship between filth and fever. At best, the answers might warrant claim 1, filth as a contributing cause in some fever; but they fell far short of warranting claims 2 and 3, that filth, and not destitution, was the cause of fever. Within the multicausal framework of contemporary medicine, the idea that bad drains were "physical" causes of disease was uncontroversial, standard in most accounts, and the possibility that government [End Page 248] might facilitate their removal was doubtless welcome. It did not follow that these were the chief or most remediable causes of fever. And though informants were asked only about physical causes, many were more concerned with social and economic

causes: unemployment, intemperance, the Irish, and so forth. 39

In fact, neither in the reports of Kay and Arnott, nor in Southwood Smith's reports of the same time and the following April, is there an attempt to test the destitution-fever hypothesis. Closest is Smith's claim that data on fever incidence among metropolitan paupers in 1837-38 showed a stronger correlation of fever with locale than with the percentage of paupers in the population. 40 For the most part, Smith, Kay, and Arnott simply took "malaria" to be the cause of the specific disease, fever (as well as of other diseases). 41 They either wrote as if a focus on "physical causes" exhausted the full domain of cause, or (less often) made that focus the excuse for ignoring other factors.

The investigation that would produce the Sanitary Report was commissioned by the House of Lords in August 1839. In November Chadwick sent copies of the Metropolis reports to union medical officers throughout England, who were asked to supply information of the sort requested of the London poor-law physicians. 42 Just as Kay and Arnott had "digested" the responses of the London officers, so too it was hoped that eminent provincial practitioners might provide (gratuitously) comprehensive reports on sanitation and health in their towns. When the inquiry was [End Page 249] extended to Scotland in early 1840, the reports were sent to Scottish practitioners identified as having substantial practice with the poor.

Thus the "Sanitary Inquiry" was not at all open-ended. Respondents were to limit themselves to "physical causes" and to be guided by the reports they received. These would inform them of both the state of the art in fever theory (as seen by Smith and Arnott) and the consensus view of London medical officers (as determined by Kay). Here too, they were not to test rival hypotheses, but only to confirm how far the "physical causes" identified in the metropolitan reports were also present in their districts.

The replies of the "eminent" English practitioners and some of the longer Scottish reports were printed as they came in and were subsequently published with the Sanitary Report as two volumes of "Local Reports," though in a smaller edition. And despite Chadwick's attempts to deflect the inquiry from embarrassing matters of exhaustion and starvation, several informants made a point of giving these factors a greater role than they gave to bad drains and so on. Moreover, unlike Chadwick and most laissez-faire political economists, they held that wages and prices, these key determinants of health, did not lie outside the sphere of matters properly remediable through legislation. 43

Most eloquent on this point was Richard Baron Howard of the Ardwick and Ancoats Dispensary in Manchester. In Howard's report the pathological effects of hunger formed a main theme:

So long as the poor are in a state of great destitution, and are not provided with adequate nourishment, clothing, and shelter, no sanitary regulations, with regard to the cleansing, draining, and ventilation of the streets, and the removal of the sources of malaria, will effectually check the spread of fever. Until the labouring classes are supplied with the common necessaries of life, and relieved from the state of extreme wretchedness and destitution with which great numbers habitually exist, fever and disease generally will continue to prevail extensively amongst them; and it must be equally the duty of a government to endeavour to devise means for insuring them these necessaries, whether their inability to procure them arises from causes which they [End Page 250] themselves might be taught, by ordinary prudence and forethought, to avoid, or from circumstances which they cannot control. 44

Thus for Howard the moral question so central in poor-law administration was moot. Similarly, he regarded the nature of fever and the mechanism by which destitution led to it as unimportant details. In Manchester, "whatever the essential causes of contagious fever may be, poverty and want are the most influential causes of its prevalence and extension." 45 Howard had published a short work on hunger as a cause of disease the previous year, so Chadwick might have known that he would not toe the sanitarian line; yet he was the only practitioner to offer a report from that city, was perhaps uniquely qualified for the job and enthusiastic, and produced a lengthy and detailed report. 46

Even more insistent on destitution as a cause of fever were Scottish medical men. Led by William Pulteney Alison, holder of the prestigious chair in the practice of medicine at Edinburgh, they had successfully campaigned in the winter of 1840 to have the Sanitary Inquiry extended to Scotland. The Scots hoped to use the inquiry for a quite different purpose than did Chadwick, however: they were campaigning for the establishment of a legal right to relief throughout Scotland--in effect, to bring to Scotland something like the English poor law. Alison's Association for Obtaining an Official Inquiry into the Pauperism of Scotland represented both medical and urban interests. Its argument (as expressed in reports that were largely Alison's pamphlets) was that the lack of any legal provision for feeding the hungry in Scotland led to an exodus of destitute people from rural areas into towns, where they overtaxed

the public and philanthropic social and medical services. 47 [End Page 251] These immigrants brought with them a contagious fever that thrived on their destitution and then spread among all ranks of society. Alison and his associates hoped that the English Poor Law Commissioners' investigation of Scottish sanitary conditions might demonstrate the need for wholesale poor-law reform in Scotland.

The Scots' request put Chadwick in an awkward spot. Here was Alison gushing about the health, morality, and stability that the new poor law had brought to industrial England, describing the infamous workhouses ("poor law Bastilles," the Lancet's Thomas Wakley called them) as happy havens for the aged and ill. 48 Yet Chadwick's admirer was calling for the adoption of Chadwick's poor law in Scotland with an argument that was anathema to Chadwick. Moreover, he was directly attacking Arnott, Kay, and Smith. 49 On the other hand, Alison's opponents, led by evangelical churchmen who saw voluntary charity as a vital function of the parish, began championing sanitarianism, though less for reasons of fever prevention than as a means of moralizing the Scottish poor to help themselves and thus overcome poverty and demoralization. Though they abhorred the secular and utilitarian solutions of those with no appreciation for native Scottish institutions, they were ready enough to take the [End Page 252] utilitarians' technology-- so long as that did not entail an actual utilitarian invasion by Chadwick's legions of inspectors. 50

In the Sanitary Report Chadwick dealt with this complexity by ignoring it. He wrote as if there were no Scottish poor- law controversy. (It would have been impolitic to address Scottish poor-law matters while the question was still sub judice, he later claimed.) 51 He did quote many of those who contested his fever-destitution claims--Howard, Edward de Vitre of Lancaster, William Duncan of Liverpool, and many of the Scottish reports--but drew from their reports only innocuous passages on uncontentious issues. On occasion he even enlisted their works to undermine their concerns. 52

During the inquiry itself, however, Chadwick was paying a great deal of attention to the controversy and, to a degree, playing both sides. He was present at the great clash between Alison and Rev. Thomas Chalmers, his chief opponent, at the Glasgow meeting of the British Association for the Advancement of Science in September 1840. 53 To the young Bath clergyman and newly appointed workhouse chaplain Whitwell Elwin he sent the pamphlets of Alison's opponents as models of poor-law administration, which confirmed Chadwick's view of the poor as feckless, dissolute, and dangerous--in need of the concentrated morality that only water and sewage and deterrent workhouses could bring. 54 At the same time, he welcomed the extension of the inquiry to Scotland and went so far as to adapt it to the needs of Alison's Association. In May 1840 he drew up a questionnaire to be sent to Scottish practitioners, based on the initial mission statement of the inquiry. Question 7 read:

Of the diseases described in question 1 ["various forms of continued fever, and other contagious febrile diseases"] are any or what proportion ascribable to other causes than those specified in questions 4, 5, and 6 [i.e., external conditions, including drains, internal structure, and cleanliness, and internal [End Page 253] economy, crowdedness, pigs, etc.]? If so, distinguish those other causes so far as you are able, and the extent of diseases resulting from them. 55

Soon after the questionnaire went off, Chadwick received a letter from Dr. P. D. Handyside of Edinburgh, the secretary of Alison's Association, asking that question 7 be amended to raise the destitution-fever issue directly. Chadwick accordingly revised question 7 to read: "Is the extension of the diseases described in question 1, ascribable in any or what proportion to want of any of the necessaries of life." 56 ("Necessaries of life," a semitechnical term of political economy, referred to food, shelter, heat, and clothing--the fundamental destitution indices.) The new questionnaires were quickly sent out with instructions to disregard the earlier version. The new wording surely accounts in part for the prominence of destitution as a cause of disease in the Scottish responses. 57

For the Sanitary Report to serve the needs of English poor-law administration, however, this collusion had to be hidden. The front matter of the Sanitary Report published in July 1842 included the questionnaires used to solicit information, but the Scottish questionnaire was present only in its first version, with no suggestion as to what the "other causes" of fever might be. It is possible that the first version was included in error, but considering the attention that Chadwick had given to the wording of question 7 two summers earlier, and given his sensitivity to the fever- destitution question, this is implausible: in all likelihood the substitution was deliberate. 58 Certainly it is of a piece with Chadwick's rhetorical strategy in the Report of alluding to the destitution-as-cause-of-fever view obliquely and disparagingly, never as a viable hypothesis to be tested. [End Page 254]

Despite fever's being the ostensible rationale of the Report, there is relatively little in it on fever. For all their

weaknesses, the Kay-Arnott and Smith reports deal far more substantively with fever theory than does the huge Sanitary Report. 59 Chadwick's most focused treatment is in the third section: "Domestic Mismanagement, a Predisposing Cause of Disease." There he argues that medical men are often deceived by rogues, who feign sickness to get relief in cash or exchangeable commodities like food and fuel (with which they then buy drink); 60 that there is no causal relation between either destitution or depressing passions and fever; 61 that medical men spend too much time squabbling about causal questions when they could be out stopping epidemics; 62 and that even if privation does cause fever it does so not through gradual debilitation, but through the inability to purchase things like soap, "and in various ways by inducing lax habits of life, [so as to] . . . increase the amount of exposure to and loss from the all-pervading cause [the malaria from filth]." 63 Finally, even if deprivation is a cause, it is not within the scope of the inquiry, which is the effect of "sanitary conditions," a domain that Chadwick is himself arbitrarily defining in the Report. 64 He also builds straw-man arguments, making the destitution-fever hypothesis appear a stronger claim (i.e., that fever is a necessary consequence of privation, or that privation alone produces fever) than were most contemporaries (the common view was that when fever occurs destitution is often, even [End Page 255] usually, a chief predisposing factor, and that one of the most practical ways to prevent fever or end an epidemic was to deal directly with privation through the provision of food, fuel, and shelter). 65 Further, he simply asserts epidemiological generalizations without citing evidence for them. 66 He ignored the many investigations of epidemics that had reached the latter conclusion, and ignored theoretical discussions of what fever was and how it was linked to both contagious and constitutional factors.

The only modern authority of whom Chadwick made much use was the Glasgow physician William Davidson, whose "Essay on the Sources and Mode of Propagation of the Continued Fevers of Great Britain and Ireland" had won the Thackeray Prize of the Provincial Medical Association in 1840. From Davidson, Chadwick took a study showing a lack of correlation between physiognomic stature and fever incidence, and a tirade that legislation to improve the sanitary condition of the poor was necessary to prevent fever. He also mentioned the Glasgow physician Robert Cowan, who was said to "assign the foremost place to these physical agencies as antecedents to fever." 67 In both cases Chadwick misrepresented the author's view. Davidson's stature-fever study was directed not to the question of destitution, but to the question of which physical types were most prone to fever. 68 On the destitution-fever question [End Page 256] Davidson had approvingly quoted Alexander Tweedie: "the connection of scarcity and privation with the occurrence of fever among the lower classes of the community, has been so often verified by the experience of epidemics, as now to be received as a general axiom." 69 The very passage Chadwick quoted included the assertion that "the evil [fever] will continue to assail us so long as . . . there is so much poverty and destitution." 70 Moreover, Chadwick was guilty of taking Davidson's work as a whole out of context. Among fever writers of the day, Davidson was furthest from the views of Chadwick and Southwood Smith in using smallpox as the closest analogue to fever. A staunch contagionist, he had devoted many pages to showing that emanations from decaying filth could not cause continued fever. 71 Even more brazen was Chadwick's misrepresentation of Cowan. Cowan had analyzed the vital statistics of Glasgow in detail for the better part of a decade and had concluded that the prevalence of epidemic diseases depends upon various causes; but it is demonstrable that their rapid and general diffusion must be aided by many concurrent circumstances, among which certain states of the atmosphere and contagion must be ranked; but the most influential of all is poverty and destitution. In every one of the epidemic fevers which have ravaged Glasgow, its progress has been slow, unless extreme destitution has existed. 72

[End Page 257]

He called contagious fever an "unerring index of destitution," and held that "food, fuel, and clothing are the best preventives of fever." 73 Cowan died before the Sanitary Report appeared; he could not reply.

Several factors help to explain the minimal status of fever in the final report, in contrast to its initial centrality. The investigation had been burdened at the outset with secondary objectives, such as cottage design and the setting of rates for working-class housing; all these were sucked into that catchall focus, "sanitary condition," and required consideration. In late 1841 and early 1842 Chartist revolution seemed imminent, and Chadwick became even more than normally preoccupied with social control. The protection of public order increasingly displaced the prevention of disease as the chief motive for sanitary improvement. 74 Nevertheless, the key factor must be that Chadwick had been forced to recognize that while medical men agreed that sanitary improvement was a fine idea and would surely help prevent disease, they would not remove destitution from the list of important causes of disease, and they found absurd the claim sometimes made by Chadwick that destitution might even be a positively healthy state. 75 Chadwick had not changed his mind on the issue; after the Report appeared he continued to view the "disproof" of the destitution-fever link as one of its great achievements. 76 One may assume he used the strongest independent

evidence available; it just was not very strong. 77

On their publication in 1838-39, the Kay-Arnott and Smith reports had been welcomed by the medical press. Even Wakley, whose Lancet regularly vented contempt for the Poor Law Commissioners (particularly for Chadwick), had nice things to say. 78 Owing to their massive distribution, [End Page 258] to Chadwick's representing them as the state of the art on fever, and to the political significance the inquiry was acquiring, especially in Scotland, the reports were being read more carefully (and judged differently) by the end of 1840. As its lead article the January 1841 issue of the British and Foreign Medical Review ran an anonymous essay review on fever (in fact by William Tait, an Edinburgh surgeon and an Alison ally). Tait considered the Kay-Arnott and Smith reports, the recent compilation of the work of Alexandre Parent-Duchâtelet, and Alison's main destitution-as-a-cause-of-fever pamphlet, Observations on the Management of the Poor in Scotland, which had appeared in the spring of 1840. For the latter authors he had profound praise, noting that Parent-Duchâtelet, a true empiricist, had begun his study believing that emanations from decay caused disease, yet had found that sewer workers and the knackers of Montfaucon were not particularly unhealthy. With regard to Kay, Arnott, and Smith, Tait did not merely dissent from their conclusions but accused them of incompetence and prejudice. Of Smith he gave what one might call the "what was he on when he wrote this" criticism: "It is astonishing to us who know Dr. . . . Smith's . . . acute and logical spirit, that he could have allowed such a passage . . . to drop from his pen. The only way we can account for this . . . is by supposing that the enthusiasms of philanthropy and a vivid imagination have secretly jumped to desired conclusions, while the cool and calculating eye of philosophy was closed in slumber." 79 It is the sort of review that no number of polite notices can overcome. The criticism is just. Whether in epidemiology or in theory, the standards of argument that Kay-Arnott and Smith display is well below what had been standard in the fever literature for at least a half-century.

In October 1842, shortly after the publication of the Sanitary Report, much the same arguments were made with regard to the report itself, but in quite a different context: the pages of the progressive-radical weekly, the Spectator, which published a multipart review both of Chadwick's Sanitary Report and of the two volumes of Local Reports of which it was ostensibly a "digest." Quoting from the medical reports, particularly those of Howard, of James Sym of Ayr, and of Somerville Scott Alison of Tranent--all of whom saw destitution as an important cause of fever--the reviewer accused Chadwick of violating a public trust: here was "a person clothed with an official character, collecting information in virtue of that character drawing up a Report which receives the sanction of his own and his superiors' public position, and is intended to lay the foundation of a legislative measure, suppressing opinions opposed to his peculiar [End Page 259] views." 80 The reviewer did not argue that Chadwick should accept the view that destitution led to fever, but only that as a public reporter he must not suppress a great body of opinion directly contrary to what he represented as a generalization from the evidence. Chadwick's excuses were many and conflicting--that to mention would be to endorse error, that because the opinions were printed in local reports they had not been suppressed, that the opinions were irrelevant to the "sanitary" question. 81 In a cover letter, according to the Spectator, he "vapoured about legal proceedings"; privately, he considered a trip to Scotland to undermine Sym's credibility. 82

The most open contempt for this sanitarianism came from the Times, which came close to accusing Chadwick and the PLC of cynical hypocrisy for an 1840 circular advising London vestries to take advantage of the powers for house disinfection provided by the new police act. The PLC's "attempt to erect themselves into a board of health for preventing or mitigating the evils of epidemics" was but another in a series of efforts of a temporary bureaucracy to invent new missions to sustain its existence. And while no one could object to "whatever is calculated to avert or diminish disease," this emphasis on sanitarianism was "the completest demonstration of the iniquity of their system that we have recently chanced to meet with." Had not William Farr, more impartial and authoritative than their own "medical hirelings," shown that hunger caused disease? Yet "the commissioners, carefully concealing the fact that the increase of disease among the poor is mainly attributable to starvation (a damning test of their workhouse comforts, seeing that the emaciated pauper will rather pine in his own damp cellar than submit to their infliction) are bold enough to assert . . . that the prevalence of disease [End Page 260] among the lower orders in close and crowded neighbourhoods is to be ascribed entirely to the want of cleanliness and ventilation." How the PLC could promote "cleanliness for the protection of health, while they pertinaciously refuse to prevent the diseases and deaths generated by their own miserable administration in starving their workhouse victims, and in refusing outdoor relief" was, the Times concluded, "a problem beyond the powers of divination." Even more audacious than the "pails of water . . . to flood their floors, . . . the chloride of lime . . . to saturate their walls" was the fact that "the wretched starvelings who endure such augmented suffering" were expected to pay for it. 83

Yet the Spectator's charges were not followed up. The Times greeted the Sanitary Report not with venom, but with mild praise. Medical men did not rise in outrage at Chadwick's misrepresentations of their views and contempt for their abilities. One can posit several reasons why they did not. The first is ignorance: Chadwick's report has been much more celebrated by historians than it was by his contemporaries. As a "condition-of-England" exposé it was swamped by the first report of the Children's Employment Commission, which had appeared a month earlier and caused a sensation with its pictures of naked children in mines. 84 Just as the press finally turned to the Sanitary Report, a long-awaited rebellion erupted in the plug plot riots, which commanded public attention for about a month. Of roughly 10,000 copies printed of the Sanitary Report, most were presentation copies to be sent to local poor-law officials regardless of their interest in the issues. 85 The Report was not widely reviewed and was probably not widely read; it began to be important only after the much-publicized Health of Towns Commission reports two years later.

Second, medical men were hesitant to complain lest they undermine the new public health movement. Both the Spectator and the British and Foreign Medical Review addressed the possibility that criticism of Chadwick [End Page 261] might be read as opposition to sanitation. Both reviewers (and the editor of the British and Foreign) went out of their way to avoid that imputation; they simply objected to Chadwick's ignoring of equally important avenues of prevention, and the Spectator worried that in claiming too much he damaged the credibility of sanitary reform. 86 There may have been unwillingness to air the dirty laundry of theoretical dispute just when it appeared that Parliament might act to facilitate substantial sanitary reform.

Third, the medical profession, particularly that portion of it most critical of Chadwick's rejection of the destitution-fever view, had little to gain and much to lose from a clash with Chadwick and the PLC. In March 1842 the PLC had decided that the law it administered forbade those with only Irish or Scottish medical credentials to serve as medical officers in English unions. Many had been serving in such posts; while Edinburgh had long been a center of medical education, the prospects for practice in Scotland were bleak. This ruling implied nothing about the relative merits of English versus Scottish or Irish medical certification; it was dictated simply by the letter of the law as understood by counsel. 87 The finding seemed obviously unjust, and within two years it would be set aside by the home secretary as groundless and contrary to the spirit of the law--but during the months following publication of the Sanitary Report it was in effect. Against the barrage of petitions from Scottish and Irish medical licensing bodies, the PLC calmly (and disingenuously?) protested that it was compelled by law and powerless to act. If any room was to be found for leniency it would not do to offend Chadwick. Might Chadwick himself have orchestrated the request for counsel's opinion to intimidate the Scots into silence? Possibly. On the one hand, the issue of the qualifications of medical officers was long-standing and legitimate; on the other, Edinburgh medicine, both through the pronouncements of the professor (Alison) and through the medical [End Page 262] practice of those he taught, did represent a challenge to the workings of the new poor law. Certainly Chadwick, a barrister, was trained to recognize such an opportunity. For Scottish medical men there was the additional complication of Scottish poor-law reform: support from the English poor-law establishment was vital if a similar system were to be established in Scotland.

A final factor is a change in the climate of opinion in both medical theory and public affairs. In the former, it was in precisely the years of the Sanitary Inquiry that both the zymotic theory of Liebig and notions of disease specificity (especially with regard to fever) began to take hold. Following the French, young practitioners like William Budd began to recognize typhoid and typhus as separate diseases. They became more interested in the causal questions that arose in respect to specific diseases like smallpox, rather than those appropriate to "constitutional" diseases. The search for transmissible zymotic agents was not incompatible with assigning a role to predisposing causes like hunger or other debility, but it did render the latter less important and less interesting. 88 At the same time, the sense of crisis was declining: Britain was emerging from the depression that had begun in 1837, and Chartism had peaked, its energy shunted into the ten-hours movement, or temperance, or the Anti-Corn Law League, or even sanitarianism.

Thus the hunger-or-filth dichotomy faded. In the sanitary investigations carried out in the early 1850s by inspectors from Chadwick's General Board of Health, one occasionally finds medical men taking the view that hunger is a key health problem. One finds this view too in the investigations that John Simon sponsored in the early 1860s. Along the main line of public health activity--in the doings of the Health of Towns Association and the Health of Towns Commission in the mid-1840s--the [End Page 263] issue does not arise; their agendas are carefully steered toward structures, what Chadwick regarded as "sanitary conditions" properly so called. Alison continued to insist that the lack of provision for the destitute led to an enormous amount of preventable fever, especially in Scotland and Ireland. Yet even during the great Irish famine he was unable to bring this issue into prominence on the public agenda. 89 How far that silence was a tense silence, with matters thought of but not spoken of, and how far the controversy had simply faded from attention, is not clear.

What I am suggesting in this article is the reverse of what is often entertained, which is that Chadwick rejected hunger, overwork, contagion, and other possible causes of fever in the process of building a case for the malarial cause of disease, which, he believed, could alone warrant sanitary improvement. A belief in these other supposed

causes would at best distract attention from sanitary improvement--and at worst, would subvert it entirely. On the contrary, I have argued that the Sanitary Report came about not as an opportunity to take on the new and useful project of urban improvement, but to meet the immediate political need of discrediting powerful enemies. For Chadwick and the PLC, the Sanitary Report was to be an ideological document, not a blueprint for sanitary engineering: it was less important that people actually build sanitary works than that they believe that in works, not mutton, was to be found the appropriate domain for the humanitarian's charity and the true path of progress. 90

If this is true, Chadwick was upholding the malarial cause precisely because it would, he hoped, permit him to reject other causes. The need was for an alternative to destitution as a cause of disease, and the main [End Page 264] merit of the view that the causes of disease were environmental was simply that it was a viable alternative to the view that they were economic. Of course, sanitary improvement did have other advantages: compared to the ten-hours movement, the Charter, and the Anti-Corn Law movement it was a politically innocuous remedy for social tension. And as Anthony Brundage suggests (and as subsequent events would show), it turned out to be a superb vehicle to further Chadwick's career, offering an arena for the kind of bureaucratic and legal minutiae in which he delighted and excelled. 91

Christopher Hamlin is Associate Professor of History and director of the Program in Science, Technology, and Values, University of Notre Dame, Notre Dame, IN 46556 (e-mail: [email protected]). He is completing a book entitled Public Health in the Age of Chadwick and working on a new edition of Chadwick's Sanitary Report. Notes

An earlier version of this article was presented at the sixty-seventh annual meeting of the American Association for the History of Medicine, New York, N.Y., 30 April 1994. I thank John Pickstone for comments on an earlier draft.

1. The standard account of the Report is M. W. Flinn's "Introduction," in Edwin Chadwick, Report on the Sanitary Condition of the Labouring Population of Great Britain, ed. M. W. Flinn (Edinburgh: Edinburgh University Press, 1965), pp. 43-58 (to be cited as Sanitary Report). The preliminary reports are Neil Arnott and James Phillips Kay, "Report on the Prevalence of Certain Physical Causes of Fever in the Metropolis, Which Might Be Removed by Proper Sanatory Measures," Fourth Annual Report of the Poor Law Commissioners, Supplement, Parliamentary Papers (henceforth P.P.), 1837-38, 28 (147.), pp. 67-83; Thomas Southwood Smith, "Report on the Physical Causes of Sickness and Mortality of Which the Poor Are Particularly Exposed; and Which Are Capable of Removal by Sanitary Regulations, Exemplified in the Present Condition of the Bethnal Green and Whitechapel Districts," in ibid., pp. 83-88; idem, "Report on the Prevalence of Fever in Twenty Metropolitan Unions or Parishes during the Year Ended March 1838," Fifth Annual Report of the Poor Law Commission, P.P., 1839, 20, (239.), pp. 100-6.

2. On Chadwick see S. E. Finer, The Life and Times of Sir Edwin Chadwick (London: Methuen, 1952); R. A. Lewis, Edwin Chadwick and the Public Health Movement, 1832-1854 (London: Longmans, Green, 1952); and Anthony Brundage, England's "Prussian Minister": Edwin Chadwick and the Politics of Government Growth, 1832-1854 (University Park: Pennsylvania State University Press, 1988). On Smith see Mrs C. L. (Gertrude) Lewes, Dr Southwood Smith: A Retrospect (Edinburgh: William Blackwood, 1898); and R. K. Webb, "Southwood Smith: The Intellectual Sources of Public Service," in Doctors, Politics, and Society: Historical Essays, ed. Dorothy Porter and Roy Porter (Amsterdam: Rodolpi, 1993), pp. 46-80. On Kay see Frank Smith, The Life and Work of Sir James Kay- Shuttleworth (London: J. Murray, 1923); Nicholas Coles, "Sinners in the Hands of an Angry Utilitarian: J. P. Kay (- Shuttleworth), "The Moral and Physical Condition of the Working Classes in Manchester (1832)," Bull. Res. Hum., 1985, 86: 453-88; and Frank Mort, Dangerous Sexualities: Medico-Moral Politics in England since 1830 (London: Routledge and Kegan Paul, 1987), chap. 1. On Arnott see the Dictionary of National Biography, 1: 593-94.

3. Brundage, England's "Prussian Minister" (n. 2), p. 79; Ursula R. Q. Henriques, Before the Welfare State: Social Administration in Early Industrial Britain (London: Longman, 1979), p. 126; Margaret Pelling, Cholera, Fever, and English Medicine, 1825-1865 (Oxford: Oxford University Press, 1978), p. 11. Certainly Chadwick felt himself (and probably was) a target of calumny in a way that his poor-law colleagues were not: see Edwin Chadwick, "Mr. Chadwick's Sanitary Report," Spectator, 1842, 15: 1002; and Chadwick's testimony in "Report of the Select Committee on Andover Union," P.P., 1846, 5 (pts. 1 & 2), (663.-I), qq. 20021 ff.

4. Henriques, Before the Welfare State (n. 3), p. 55. The thesis I develop below assumes a greater shared outlook between Chadwick and his superiors, the Poor Law Commissioners, than Finer and Brundage suggest. While the record of personality clashes, snubs, and disagreements on the management of particular cases and over administrative procedure is clear, Chadwick and the Commissioners shared a common view on how the new poor law ought to work. The PLC archives also suggest a closer involvement on the part of the Commissioners, particularly with the early stages of the Sanitary Inquiry, than is usually thought.

5. This article follows a line of march set out by John V. Pickstone, "Dearth, Dirt, and Fever Epidemics: Rewriting the History of British 'Public Health,' 1780-1850," in Epidemics and Ideas: Essays on the Historical Perception of Pestilence, ed. Terence Ranger and Paul Slack (Cambridge: Cambridge University Press, 1992), pp. 125-48; and Christopher Hamlin, "Predisposing Causes and Public Health in Early Nineteenth-Century Medical Thought," Soc. Hist. Med., 1992, 5: 43-70. In broader terms it takes up themes raised in William Coleman, Death Is a Social Disease: Public Health and Political Economy in Early Nineteenth-Century France (Madison: University of Wisconsin Press, 1982), and George Rosen, From Medical Police to Social Medicine: Essays on the History of Health Care (New York: Science History, 1974). See also Pelling, Cholera (n. 3). For a contemporary view on the significance of fever see W. P. Alison, Observations on the Management of the Poor in Scotland and Its Effects on the Health of Great Towns, 2d ed. (Edinburgh: Blackwood, 1840), p. 18: "the existence of epidemic fever in any great community, particularly if there be neither war nor famine to explain it, becomes a most important test to the legislator of the destitute condition of the poor, and . . . of the deficiency of the funds which, in a better regulated state, are applied to their support." Cf. Thomas Bateman, A Succinct Account of the Contagious Fever of This Country Exemplifed in the Epidemic Now Prevailing in London (London: Longman, Hurst, Rees, Orme, and Brown, 1818), p. vi. By contrast, Southwood Smith would argue that fever showed only the presence of malaria, its cause: see "Report on the Physical Causes of Sickness and Mortality" (n. 1), p. 88. On the state of the typhoid-typhus distinction see Dale Smith, "Introduction: Typhoid Fever Research and the Origin of William Budd's Thackeray Prize Essay," in William Budd, On the Causes of Fevers (1839), ed. Dale C. Smith (Baltimore: Johns Hopkins University Press, 1984), pp. 1-41.

6. Sanitary Report, p. 210. When challenged, Chadwick denied holding the view that destitution did not adversely affect health: "it may be necessary to declare, that the existence of destitution, or that absolute destitution, when it does occur, must aggravate diseases, is, so far as I am aware, questioned by no one" ("Mr. Chadwick's Sanitary Report" [n. 3], p. 1001).

7. Sanitary Report, p. 422. Chadwick also broadened the claim from fever to all epidemic diseases: "epidemic diseases . . . have been as frequent and as fatal in periods of commercial and manufacturing prosperity [as in periods of distress]" (ibid., p. 422).

8. Bateman, Contagious Fever (n. 5), pp. 2-11; Henry Clutterbuck, Observations on the Prevention and Treatment of the Epidemic Fever at Present Prevailing in the Metropolis and Most Parts of the United Kingdom (London: Longman, Hurst, Rees, Orme, and Brown, 1819), pp. 2-3, 32-36; Alfred Hudson, "An Inquiry into the Sources and Mode of Action of the Poison of Fever," in William Davidson and Alfred Hudson, Essays on the Sources and Mode of Action of Fever (Philadelphia: A. Waldie, 1841), pp. 104-5; Henry MacCormac, An Exposition of the Nature, Treatment, and Prevention of Continued Fever (London: Longman, Rees, Orme, Brown, Green, and Longman, 1835), p. xii; [William Tait], "Dr Alison, etc. on the Causes of Typhus Fever," Brit. For. Med. Rev., 1841, 11, no. 21: 33; A. Tweedie, Clinical Illustrations of Fever, Comprising a Report of Cases Treated at the London Fever Hospital, 1828-29 (London: Whitaker and Treacher, 1830), pp. 77-79.

9. W. P. Alison, Management of the Poor (n. 5), p. 11: "I have no doubt that vitiated air, like all other causes which weaken the constitution, favours the diffusion of fever--yet I cannot subscribe to their opinion, that this cause is of itself adequate to the production of contagious fever. And if, trusting to that opinion, the public authorities should think it sufficient, in any situation where contagious fever is prevalent, to remove all dead animal and vegetable matter, without attempting to improve the condition of the living inhabitants, I am confident that their labour will be in vain." See also W. P. Alison, "Illustrations of the Practical Operation of the Scottish System of Management of the Poor," Quart. J. Stat. Soc. London, 1840, 3: 230, 236-37; MacCormac, Fever (n. 8), pp. 193-94.

10. W. F. Bynum, Science and the Practice of Medicine in the Nineteenth Century (Cambridge: Cambridge University Press, 1994), p. 72.

11. John Knott, Popular Opposition to the 1834 New Poor Law (New York: St. Martin's Press, 1986); Nicholas C. Edsall, The Anti-Poor Law Movement, 1833-44 (Manchester: Manchester University Press, 1971).

12. And yet PLC staff sometimes took the view that all illness was blameworthy, and that the mere provision of public medical care amounted to an invitation to become ill; see Ruth G. Hodgkinson, The Origins of the National Health Service: The Medical Services of the New Poor Law, 1834-1871 (London: Wellcome Historical Medical Library, 1967), pp. 2-3, 5, 93.

13. The relieving officers were to help protect the medical officers from undue importunings of the poor, according to the PLC. See ibid., pp. 20-21, 23, 25, 38-39; M. W. Flinn, "Medical Services under the New Poor Law," in The New Poor Law in the Nineteenth Century, ed. Derek Fraser (London: MacMillan, 1976), pp. 45-66.

14. Hodgkinson, Origins (n. 12), pp. 8-9, 15, 60, 151-52. The Lancet editor and M.P. Thomas Wakley, among the most vehement opponents of the law, noted, however, that since the guardians of a poor-law union were likely also (especially in rural areas) to be the employers of labor, it was in their interest both as keepers of public funds and as employers to lower the workhouse diet, because thereby they could also lower wages, making sure to provide wages to sustain a quality of life only slightly above the declining workhouse standards. Given the laws of settlement, whereby the pauper could obtain relief only from the parish of legal settlement, the laborer would be unable to escape such a trap. See "Report of the Select Committee on Andover Union" (n. 3), testimony of Sir T. F. Lewis, qq. 22663- 75.

15. Hodgkinson, Origins (n. 12), p. 23; PLC to Metropolitan Police, 6 September 1837, PLC-Metropolitan Police Correspondence, PRO MH 19/173. Alison even quoted Chadwick on this point ("Illustrations of the Practical Operation" [n. 9], p. 252).

16. Hodgkinson, Origins (n. 12), pp. 38-40, 57; W. Cooke Taylor, Notes of a Tour in the Manufacturing Districts of Lancashire, 3d ed., with a new introduction by W. H. Chaloner (London, 1842; reprint, New York: A. M. Kelley, 1968), pp. 42, 79, 202.

17. Charles Mott, "Report on Starvation in Bolton," 24 September 1841, PLC-Bolton Union Correspondence, PRO MH 12/5594.

18. It has been appreciated that the moral justifications of the new poor law required a rejection of the destitution- causes-fever position, yet most have not seen that rejection as the raison d'être of the Sanitary Report. See Henriques, Before the Welfare State (n. 3), p. 126; Pelling, Cholera (n. 3), p. 42. For the politically explosive potential of such ideas see "Review of Kennedy, Medical Report of the House of Recovery and Fever Hospital, Cork Street Dublin," Brit. For. Med. Chirurg. Rev., 1840, 32: 171-73.

19. Robert Ceely in "Select Committee on the Poor Law Amendment Act, 44th-46th Reports (Medical Inquiry)," P.P, 1837-38, 18, pt. 3, (518.), qq. 15300-305; others quoted in Hodgkinson, Origins (n. 12), pp. 38-41. See also Henry Rumsey, "The Medical Care of the Poor in England, with Notices Relating to Ireland--Part II. Its Present Condition and Requirements; Its Relations to Political Economy and Sanitary Management," in his Essays on State Medicine (London: Churchill, 1856), pp. 259-60; M. A. Crowther, The Workhouse System, 1834-1929: The History of an English Social Institution (Athens, Ga.: University of Georgia Press, 1981), pp. 159-61. Such practice reflected more than altruism or the influence of theory. Many medical officers were local practitioners or hoped to acquire a local practice, and saw no gain in defending the guardians' tightfistedness at the cost of alienating potential patients.

20. Quoted in Hodgkinson, Origins (n. 12), p. 41.

21. Ceely, in "Select Committee on the Poor Law Amendment Act" (n. 19), qq. 15378-80.

22. Hodgkinson, Origins (n. 12), p. 40.

23. Henry Rumsey in Select Committee on Medical Poor Relief, "Third Report," P.P., 1844, 9, qq. 9157-58; Hodgkinson, Origins (n. 12), p. 120.

24. Hodgkinson, Origins (n. 12), pp. 35-41; Irvine Loudon, Medical Care and the General Practitioner, 1750-1850 (Oxford: Clarendon Press, 1986), p. 236. On the physician as advocate of the poor see George Rosen, "What Is Social Medicine: A Genetic Analysis of the Concept," Bull. Hist. Med., 1947, 21: 674-733. Among contemporary perspectives on this situation see "Review of E. T. Meredith, Parochial Medical Relief, considered in a letter to the Poor Law Commissioners, developing an entirely new system of Medical Remuneration, alike conducive to the interests of the rate-payers, the well-being of the poor, and the respectability of the profession," Brit. For. Med. Chirurg. Rev., 1840, 32: 168-69; E. C. Tufnell to PLC, 15 July 1842, Tufnell-PLC Correspondence, PRO MH 32/71; "Report of the Select Committee on Andover Union" (n. 3), testimony of Hugh Mundy, qq. 236-43, 1449-58, 1823-23; and of Sir Edmund Head, qq. 15272-81.

25. Quoted in Finer, Chadwick (n. 2), p. 245. Cf. E. C. Tufnell, "On Relief of Pauperism in Devon," 14 July 1842, Tufnell-PLC Correspondence, PRO MH 32/71: Tufnell complained that "every able-bodied applicant [for relief], if he labours under no ailment himself, has his wife or one of his children affected by some trivial complaint, which takes the case out of the Prohibitionary order [against providing relief outside the workhouse]; and thus practically relief is given in aid of wages."

26. ["New Poor Law Bill"], Lancet, 1833-34, 2: 667; Kay, Ceely, Elliotson, and Farr in "Select Committee" (n. 19), qq. 5160, 15397-99, 15880, 15787, respectively. Kay argued that "widows, with large families, I mean those supporting themselves, or men with large families, supporting themselves, or any other class, might be admitted into the class of persons who were to receive medical relief in the parish, the charge being borne by the parish" (qq. 5160). Something like this universality of access had been the case, it was argued, under the old poor law. Kay's approach was adopted in 1842. Cf. Henry Rumsey, "The Medical Care of the Poor in England, with Notices Relating to Ireland--Part I. Historical," in his Essays on State Medicine (n. 19), pp. 154-72; ibid, part II, pp. 259-61. Rumsey, while favoring universal coverage, agreed with the PLC that "the almost unlimited power . . . of recommending,--or as some call it, ordering--articles of diet, vinous and alcoholic stimulants, even fuel, flannel, and other personal comforts . . . [was a] direct temptation to the poor to make use of the doctor as the key to the parochial relief-chest" and "one of the main causes of the pauperizing effect of English medical relief" (ibid., p. 259). While acknowledging that food was in fact what many of these cases needed, he did not want public medical officers to be involved in the prescription of food.

27. Kay, in "Select Committee" (n. 19), qq. 5135, 5138-39, 5154.

28. Rumsey, "Medical Care of the Poor . . . Part I" (n. 26), p. 214.

29. Christopher Hamlin, "Could You Starve to Death in England in 1839? The Chadwick-Farr Controversy and the Loss of the 'Social' in Public Health," Amer. J. Pub. Health, 1995, 85(6): 856-66. On the view of the press see Finer, Chadwick (n. 2), p. 100. On starvation inquiries see "An Abstract of the Circumstances of Alleged Deaths from Want Occurring in the Year 1840 and of the Results of Inquiries Relating Thereto. In Mr Chadwick's of 22 Sept. 1841," Home Office-PLC Correspondence, PRO HO 73/56; "Alleged Death from Starvation: Singular Inquiry," Times, 26 August 1840, p. 7; William Farr to Times, 31 August 1840, p. 5e; "Examination in the Case of Elizabeth Friry," Lancet, 28 November 1840, pp. 348-49; "Starvation of Bridgit Berry," 29 August 1840, Leeds-PLC Correspondence, PRO MH 12/15225; "Alfred Power to Chadwick," 1 January 1840, PLC-Power Correspondence, PRO MH 32/64; Sir James Graham to PLC, 7 September 1841, PLC-Bolton Union Correspondence, PRO MH 12/5594. On the propaganda of the Anti-Corn Law League see Norman McCord, The Anti-Corn Law League, 1838-1846 (London: George Allen and Unwin, 1958), p. 91. On Chadwick's response to the depression see Finer, Chadwick (n. 2), pp. 94, 182-87.

30. Nor was it incompatible with the new localist-inflammationist pathology. It has been argued that by 1820 an old debilitation concept of fever associated with Cullen was replaced by a new inflammation-based conception. This is important, for it might be held that Chadwick, in challenging the claim of destitution-induced fever, was siding with the inflammationists (though he does not say that). Among those concerned with fever pathology (and, to a lesser degree, fever therapy) there was sometimes conflict with regard to the essential nature of the disease. But the view that fever was a local inflammation still did not dislodge the long-standing empirical association of fever with war, pestilence, commercial depression, and indigence; on the contrary, inflammationists, including Clutterbuck and Broussais, felt obliged to explain how inflammation might be a pathological product of destitution. See Pelling, Cholera (n. 3), pp. 14- 16, 21; E. H. Ackerknecht, "Broussais, or a Forgotten Medical Revolution," Bull. Hist. Med., 1953, 27: 330; Dale Smith, "Introduction" (n. 5); W. P. Alison, "Inflammation," in A System of Practical Medicine Comprised in a Series of Original Dissertations, ed. A. Tweedie (London: J. Whitaker, n.d.), pp. 69, 72. I differ here from Pickstone, "Dearth" (n. 5), pp. 139-44. 31. Pelling, Cholera (n. 3), pp. 6-7, 18, 25; Hamlin, "Predisposing Causes" (n. 5); Leonard G. Wilson, "Fevers and Science in Early Nineteenth-Century Medicine," J. Hist. Med., 1978, 33: 386-407; Anne Hardy, "Urban Famine or Urban Crisis? Typhus in the Victorian City," Med. Hist., 1988, 32: 401-25. For contemporary views, see William Henry, "Report on the State of Our Knowledge of the Laws of Contagion," in 4th Report of the British Association for the Advancement of Science for 1834 (London: John Murray, 1835), pp. 68-70; "Fever," in A Dictionary of Practical Medicine, ed. James Copland with additions by Charles Lee, 3 vols. (New York: Harper, 1855), 1: 1053, 1167-68; Alison, "Illustrations of the Practical Operation" (n. 9), p. 239; idem, "Inflammation" (n. 31), p. 69; John Armstrong, Practical Illustrations of Typhus Fever, of the Common Continued Fever and of Inflammatory Diseases, 3d ed. (London: Baldwin, Craddock, and Joy, 1819), pp. 294-95, 308; Thomas Bateman, Reports on the Diseases of London and the State of the Weather from 1804 to 1816 Including Practical Remarks on the Causes and Treatment of the Former; and Preceded by a Historical View of the State of Health and Disease in the Metropolis in Times Past (London: Longmans, Hurst, Rees, Orme, and Brown, 1819), p. x; John Reid, The Philosophy of Death, or a General Medical and Statistical Treatise on the Nature and Causes of Human Mortality (London: S. Highly, 1841); William Budd, "On the Causes and Mode of Propagation of the Common Continued Fevers of Great Britain and Ireland," in Budd, Causes of Fevers (n. 5), pp. 101-3, 117, 121.

32. Smith, more than Arnott and Kay, was the major theorist here. The claim that malaria was the key cause of fever was not new; the implication that therefore destitution was not a significant factor, was not a necessary concomitant. See Thomas Southwood Smith, A Treatise on Fever (Philadelphia: Carey and Lea, 1830), pp. 360-61, 372, 376-77, 381; Pelling, Cholera (n. 3), pp. 21-22. In earlier works, Smith had claimed that only the miasmatic or malarial hypothesis (rather than a contagionist view) could explain why fever preponderantly affected the destitute, rather than affecting all parts of the population equally; see, e.g., [Thomas Southwood Smith], "Contagion and Sanitary Laws," Westminster Rev., 1825, pp. 145, 515-16. Smith's miasmatist predecessors likewise had not seen an opposition between poverty and miasma, but simply held miasma to be the exciting, and destitution an important predisposing, cause. See Thomas Mills, A Comparative View of Fever and Inflammatory Complaints with Essays Illustrative of the Seat, Nature, and Origin of Fever (Dublin: Cumming and McArthur, 1824), p. 115; Francis Boott, Memoir of the Life and Medical Opinions of John Armstrong, M.D. to Which Is Added an Inquiry into the Facts Connected with Those Forms of Fever Attributed to Malaria or Marsh Effluvium, 2 vols. (London: Baldwin and Craddock, 1833), 1: 115, 165- 68, 172-73, and esp. 184. A key issue here was the interpretation of French experiments (chiefly by Magendie) investigating the effects on animals of the inhalation of atmospheres impregnated with emanations from decaying filth; while there was no doubt that these emanations were toxic, most writers held that the symptoms they produced were not consistent with fever. See Pelling, Cholera (n. 3), pp. 37-38; Southwood Smith, "Report on the Physical Causes of Sickness and Mortality" (n. 1), pp. 83-85, 92-93; William Davidson, "Essay on the Sources and Mode of Propagation of the Continued Fevers of Great Britain and Ireland," in Davidson and Hudson, Essays (n. 8), pp. 44-47; Hudson, "Inquiry" (n. 8), pp. 142-43; [Tait], "Typhus Fever" (n. 8), p. 10; Tweedie, Clinical Illustrations of Fever (n. 8), p. 85n.

33. Two (sometimes overlapping) stories are told: one stresses the disallowances; the other sees the reports as having been undertaken at the request of east London poor-law authorities on the occasion of severe fever in the winter of 1837-38. See Brundage, England's "Prussian Minister" (n. 2), p. 80; Flinn, "Introduction" (n. 1), p. 43; Finer, Chadwick (n. 2), pp. 155-57; Lewis, Chadwick (n. 2), pp. 34-37; B. W. Richardson, "Edwin Chadwick C.B.: A Biographical Dissertation," in The Health of Nations: A Review of the Works of Edwin Chadwick, with a Biographical Dissertation, 2 vols. (London, 1888; reprint, London: Dawson, 1965), 1: xlii.

34. Hodgkinson, Origins (n. 12), pp. 92-93; "Select Committee" (n. 19).

35. James Phillips Kay-Shuttleworth, The Moral and Physical Condition of the Working Classes Employed in the Cotton Manufacture in Manchester, with a new preface by W. H. Chaloner, 2d ed. (London: Frank Cass, 1970).

36. Paul Richards, "The State and Early Industrial Capitalism: The Case of the Handloom Weavers," Past Pres., 1979, 83: 110-15; Dr. James Mitchell, "On the East of England," in Royal Commission on Handloom Weavers. Reports of the Assistant Handloom Weavers' Commissioners, pt. II, P.P., 1840, 23, [43-I.], pp. 379-81. These appear also to have been areas of unusually generous provision of poor-law medical relief: see Hodgkinson, Origins (n. 12), pp. 23, 41-43, 135; Thomas Mackay, A History of the English Poor Law, vol. 1, From 1834 to the Present Time (New York: Putnam, 1899), pp. 244-46. A complaint of Spitalfields weavers was that even when they were in full employment they were starving; see William Hale, An Appeal to the Public in Defence of the Spitalfields Act: With Remarks on the Causes Which Have Led to the Miseries and Moral Deterioration of the Poor (London: E. Justines, 1822), pp. 43, 45. 37. Edwin Chadwick, Report on the Sanitary Condition of the Labouring Population of Great Britain (London: Clowes, 1842), p. iv.

38. Circular to greater London vestries, 1838 April 27, PRO MH 3/1.

39. See in particular the letters of James Appleton (quoted as evidence for stagnant drains as a cause of fever): "Considering the filthy habits of the people dwelling in this particular locality; considering the privation that many of them undergo with respect to food, and their intemperate use of ardent spirits; that they are huddled together in ill- ventilated rooms, and that this place is the rest of Irish lodgers, . . . it is exceedingly difficult to give an opinion how far these cases of fever have had their origin in such causes; how far they have had their origin in states of atmosphere equally affecting the crowded parts of this metropolis; and how far they have originated in the local causes above named" (Arnott and Kay, "Physical Causes of Fever" [n. 1], p. 73); Jordan Lynch (quoted in connection with slaughterhouse nuisances): "the majority attacked [by recent typhus] were those who were unable to procure adequate nutriment from want of employment during the past inclement winter, which predisposed them to the attack of the contagion, and deprived them of the power to resist its ravages" (ibid, pp. 75-76, and also Hatfull, Evans, Byles, and Mitchell (ibid., pp. 78-80). Kay makes it clear that he is quoting only a sample of the responses received. It seems safe to assume that he selected the most compatible responses--a criticism made at the time in [Tait], "Typhus Fever" (n. 8), pp. 5-9.

40. Southwood Smith, "Report on the Prevalence of Fever" (n. 1).

41. Arnott and Kay, "Physical Causes of Fever" (n. 1), p. 68.

42. Richardson, closest to the official biographer (i.e., writing at Chadwick's request during Chadwick's lifetime), held that these works became well known owing to great demand: "The reports became texts in sanitation, and were so much in demand that as many as seven thousand were distributed amongst the people--an unexampled edition of any previous medical or sanitary work outside the ranks of the medical profession" (Richardson, "Biographical Dissertation" [n. 33], p. xlii). On what Chadwick expected in the reports, see Alfred Power to Chadwick, 12 May 1840, PLC-Power Correspondence, PRO MH 32/64.

43. "Report on the Sanitary Condition of the Labouring Poor," Spectator, 1842, 15: 760-61; MacCormac, Exposition (n. 8), pp. 193-94.

44. Richard Baron Howard, "On the Prevalence of Diseases Arising from Contagion, Malaria, and Certain Other Physical Causes amongst the Labouring Classes in Manchester," in Sanitary Condition of the Labouring Population. Local Reports for England and Wales, P.P., H.L., 1842, 27, p. 330.

45. Ibid., p. 330.

46. Richard Baron Howard, An Inquiry into the Morbid Effects of Deficiency of Food Chiefly with Reference to Their Occurrence amongst the Destitute Poor (London: Simpkin, Marshall, 1839). On his recruitment see Charles Mott to W. Lumley, 7 December and 30 December 1839; Howard to Chadwick, 14 January 1840; PLC to Mott, 30 December 1839; Chadwick to Howard, 24 January 1840, Manchester-PLC Correspondence, MH 12/6039. On Howard see "Obituary--R. B. Howard, M.D.," Gentleman's Mag., 1848, n.s., 30: 323-25.

47. "Papers on Extension of Inquiry to Scotland," May 1840, Home Office-PLC Correspondence, PRO HO 73/56; Sir William Drysdale to Chadwick, 13 January and 6 August 1840, and to Mrs Chadwick, 24 January 1841, Chadwick Papers, no. 655, University College, London (UCL); "[First] Report of the Committee of the Association for Obtaining an Official Inquiry into the Pauperism of Scotland," 26 April 1841, Scottish Distress, 1840-1, PRO HO 45/160. For background see Christopher Hamlin, "Environmental Sensibility in Edinburgh, 1839-1840: The 'Fetid Irrigation' Controversy," J. Urban Hist., 1994, 20: 311-39. On Alison see "The Late Dr. Alison," Edinburgh Med. Surg. J., 1859- 60, n.s., 5 (1): 459-86; and A. Halliday Douglas, "The Harveian Discourse: On the Life and Character of Dr. Alison," Edinburgh Med. J., 1866, n.s., 11: 1063-76.

48. Alison, Management of the Poor (n. 5), p. 109; idem, "Illustrations of the Practical Operation" (n. 9), p. 243. Cf.

Wakley in S. Q. Sprigge, The Life and Times of Thomas Wakley (London: Longmans, Green, 1897), p. 481.

49. W. P. Alison, "Observations on the Generation of Fever," in Sanitary Condition of the Labouring Population. Local Reports for Scotland, P.P., H.L., 1842, 28, #2: 13-33; idem, Management of the Poor (n. 5), p. 11; idem, "Illustrations of the Practical Operation" (n. 9), p. 230; "[First] Report of the Committee of the Association for Obtaining an Official Inquiry into the Pauperism of Scotland" (n. 47) p. 7; W. P. Alison,"Reply by Dr. Alison to a Member of the Committee Opposed to the Official Inquiry, Appendix in Second Report of the Committee of the Association for Obtaining an Official Inquiry into the Pauperism of Scotland," 26 April 1841, Scottish Distress, 1840-1, PRO HO 45/160, p. 26. Arnott did reply: Neil Arnott, "On the Fevers Which Have Prevailed in Edinburgh and Glasgow," in Sanitary Condition of the Labouring Population. Local Reports for Scotland, P.P., H.L., 1842, 28, #1: 1-12; idem, "Remarks on Dr. W. P. Alison's 'Observations on the Generation of Fever,'" in ibid., #3: 34-39. White finds an antithesis between Scottish and English conceptions of public health during the period; this is probably correct, with the caveat that many English medical men (often those with Scottish training) held something like the Scottish view. See Brenda White, "Scottish Doctors and the English Public Health," in The Influence of Scottish Medicine: An Historical Assessment of Its International Impact, ed. Derek A. Dow (Park Ridge, N.J.: Parthenon, 1988), pp. 77-85. See also Hamlin, "Predisposing Causes" (n. 5), pp. 64-67; Pelling, Cholera (n. 3), pp. 44-45.

50. George Lewis, The State of St David's Parish, with Remarks on the Moral and Physical Statistics of Dundee (Dundee: R. Munsie, 1841), pp. 36-46; idem, "Prevailing Evils Examined in Detail: Physical Destitution," in Lectures on the Social and Physical Condition of the People Especially in Large Towns, by Various Ministers of Glasgow (Glasgow: W. Collins, [1842]), pp. 61-66; and John Forbes, "Introductory Lecture," in ibid., p. 28.

51. Chadwick, "Mr. Chadwick's Sanitary Report" (n. 3), p. 1001.

52. See, e.g., Sanitary Report (n. 1), p. 208, on the untrustworthiness of physicians' reports.

53. Arnott, "Fevers" (n. 49), p. 8; Chadwick to William Shuttleworth, 8 January 1847, Home Office Files Miscellaneous, PRO HO 45/1824. On the clash see Glasgow Saturday Post, and Paisley and Renfrewshire Reformer, 19 and 26 September 1840.

54. Chadwick to Rev. Whitwell Elwin, 22 October and 8 November 1841, Chadwick Papers, no. 694, UCL.

55. "Sanitary Inquiry. Request for information from Medical Men in Scotland," PLC Appendices to Minutes, 19 June 1840, PRO MH 3/2.

56. P. D. Handyside to Chadwick," 18 May, 6 June, 15 June 1840; Chadwick to Handyside, undated [May 1840], 13 June 1840 Scottish-PLC Correspondence, PRO MH 19/196.

57. It would appear also that Chadwick gave Alison prepublication access to the "Local Reports" he was receiving. Thus in the spring of 1841, more than a year before the publication of Chadwick's Sanitary Report, Alison was citing in print several reports on both England and Scotland that had been specially prepared for the Sanitary Report; some of these had been published locally, but Alison was also citing reports of Assistant Poor Law Commissioners, which are unlikely to have been prematurely published and more likely to have been sent to him by someone in the PLC. See Alison, "Illustrations of the Practical Operation" (n. 9), p. 226; W. P. Alison, "Further Illustrations of the Practical Operation of the Scotch System of Management of the Poor," J. Stat. Soc. London, 1841, 4: 293; idem, "Reply by Dr. Alison" (n. 49), p. 45.

58. The revised version does appear in the Poor Law Commission Circular for 1 September 1840 (Poor Law Commission, Official Circulars of Public Documents and Information [London, 1840-51; reprint, New York: Augustus Kelley, 1970], 1: 95).

59. Chadwick does not mention the Smith and Arnott-Kay reports, presumably in an effort to represent the Sanitary Report as independent confirmation.

60. Sanitary Report (n. 1), pp. 208, 214-15. "In general, medical practitioners and benevolent individuals are extremely liable to deceive themselves and to deceive others, by what they call the evidence of their own eyes" (ibid., p. 215).

61. Ibid., pp. 212-13.

62. Ibid., p. 214: "The medical controversy as to the causes of fever; as to whether it is caused by filth and vitiated atmosphere, or whether the state of the atmosphere is a predisposing cause to the reception of the fever, or the means of propagating that disease, which has really some other superior, independent, or specific cause, does not appear to be one that for practical purposes need be considered, except that its effect is prejudicial in diverting attention from the practical means of prevention." Cf. Pelling, Cholera (n. 3), p. 41.

63. Sanitary Report, p. 213.

64. Ibid., p. 218: "Evidence on the mismanagement of expenditure in respect to supplies of food, on mismanagement also in respect to clothing and fuel by the labouring classes, might also be added to complete the view of the principal causes of disease prevalent amongst them, but these do not come within the immediate scope of the present inquiry, which has been directed chiefly to the investigation of the evils affecting their sanitary condition, that come within the recognized provinces of legislation or local administration." Note that the privation will not come from low wages or unemployment, but from "domestic mismanagement."

65. Ibid., p. 210: "The more closely the investigation as to the causes of epidemic disease is carried the more have the grounds been narrowed on which any presumption can be raised that it is generally occasioned by extreme indigence, or that it could be made generally to disappear simply by grants of money." Cf. Alison, Management of the Poor (n. 5), pp. 10-11: "It is not asserted that destitution is a cause adequate to the production of fever (although in some circumstances I believe it may become such); nor that it is the sole cause of its extension. What we are sure of is, that it is a cause of the rapid diffusion of contagious fever, and one of such peculiar power and efficacy, that its existence may always be presumed, when we see fever prevailing in a large community to an unusual extent. The manner in which deficient nourishment, want of employment, and privations of all kinds, and the consequent mental depression favour the diffusion of fever, may be matter of dispute; but that they have that effect in a much greater degree than any cause external to the human body itself [i.e., emanations from filth], is a fact confirmed by the experience of all physicians who have seen much of the disease." See also idem, "Illustrations of the Practical Operation of the Scottish System" (n. 9), p. 235; MacCormac, Exposition (n. 8), pp. 48-49; [Tait], "Typhus Fever" (n. 8), pp. 23-24, 30. The writer who came closest to taking the view to which Chadwick objected, Thomas Bateman, had still recognized the need for "perfect ventilation and cleanliness" (Contagious Fever [n. 5], p. 156).

66. Sanitary Report, p. 210.

67. Ibid., p. 213.

68. Davidson, "Essay on the Sources" (n. 32), pp. 72-73. Chadwick acknowledged that Davidson was concerned with the "influence of delicacy of constitution as a predisposing cause of fever," but used it in the context of showing that destitution did not cause fever. See also his reiteration in "Mr Chadwick's Sanitary Report" (n. 3), p. 1002.

69. Davidson, "Essay on the Sources" (n. 32), p. 57. Davidson also cited the great study of Barker and Cheyne on the Irish fever of 1817-19 (pp. 14, 57), and quoted Bateman's statement that the 1817 fever epidemic in London was due to "'unparalleled distress among the labouring poor; when the loss of employment, occasioned by the termination of the war and the general suspension of manufactures, concurred with the failing harvest of 1816 to increase the difficulties of procuring subsistence'" (ibid., p. 14).

70. The full passage reads: "and the evil will continue to assail us so long as our cities contain so many narrow and filthy lanes, so long as the houses situated there are little better then dens or hovels, so long as dunghills and other nuisances are allowed to accumulate in their vicinity, so long as these hovels are crowded with inmates, and so long as there is so much poverty and destitution." Davidson goes on: "Why, then, should we not have a legislative enactment that would level these hovels to the ground--that would regulate the width of every street--that would regulate the ventilation of every dwelling-house--that would prevent the lodging-houses of the poor from being crowded with human beings, and that would provide for their destitution?" (Sanitary Report, p. 216n, quoting Davidson, "Essay on the Sources" [n. 32], pp. 65-66). 71. Davidson, "Essay on the Sources" (n. 32), pp. 4-5, 8, 17, 44-47, 49-51, 65-66.

72. Robert Cowan, "Vital Statistics of Glasgow, Illustrating the Sanatory Condition of the Population," Quart. J. Stat. Soc. London, 1840, 3: 288-89. Cowan did allude to a secondary cause: "the state of the districts which the poor inhabit . . . [the] lanes and alleys, in which the poor live, are filthy beyond measure; excrementitious matter and filth of every description is allowed to lay upon the lanes" (p. 290). As Davidson quoted this passage, it is possible that Chadwick inferred Cowan's views from Davidson. Davidson also quoted Cowan's views on destitution as a cause of fever, however; see Davidson, "Essay on the Sources" (n. 32), pp. 17, 58-59.

73. Cowan, "Vital Statistics of Glasgow" (n. 72), p. 288.

74. G. Kitson Clark, "Hunger and Politics in 1842," J. Mod. Hist., 1953, 25: 355-74; Stanley H. Palmer, Police and Protest in England and Ireland, 1750-1850 (Cambridge: Cambridge University Press, 1988), pp. 455-62; Sir James Graham, Life and Letters of Sir James Graham, 2nd Baronet of Netherby, ed. Charles Stuart Parker, 2 vols. (London: John Murray, 1907), 1: 333-36.

75. Alison, "Further Illustrations" (n. 57), p. 305.

76. Chadwick, "Mr. Chadwick's Sanitary Report" (n. 3), p. 1002; Chadwick to Sir R. Peel, 21 December 1843, BL. Add. MSS 40537, fol. 153; "Returns of Deaths from Fever during Periods of Distress," undated MS [probably late 1842] in "Sanitary Papers, 1843-46," Chadwick Papers, no. 47, UCL.

77. Few of the medical officers' returns have survived. Chadwick claimed that he had received reports from 1,600 medical men, and that the destitution-fever view was "the opinion of only a small minority" ("Mr. Chadwick's Sanitary Report" [n. 3], p. 1001). But see a series of eleven reports from Preston medical officers in "Sanitary Report-- Diseases," 1840, Chadwick Papers, no. 45, UCL.

78. ["Fever in London--Arnott, Kay, and Smith Reports"], Lancet, 28 July and 11 August 1838, pp. 630-33, 691-94.

79. [Tait], "Typhus Fever" (n. 8), pp. 10-13, quotation on p. 12.

80. "Local Reports on the Sanitary Condition of the Poor of Great Britain," Spectator, 1841, 15: 928-29. The reviewer did suggest as well that Chadwick had omitted not only views that were unpalatable, but also views that were more likely to be true than those included: "the person who attentively examines these [Local] Reports will draw conclusions different from those which he would gain from Mr. Chadwick's volume; for a fair proportion of the medical authorities as regards number, and we think a convincing proportion as regards weight, consider that poverty and its concomitants are the real cause of the infectious diseases which affect the poor; and that the action of dirt, bad drainage, and bad ventilation (though highly proper things to be remedied by legislation), is slight to the operation upon the human system, compared to the depressing effects of hunger, scanty clothing, and the mental anxiety of destitution" (ibid., p. 928). See also "Report on the Sanitary Condition of the Labouring Poor" (n. 43), pp. 760-61.

81. Chadwick, "Mr. Chadwick's Sanitary Report" (n. 3), pp. 1001-4.

82. Ibid., p. 1004; Sir Charles Shaw to Chadwick, 13 November 1842, Chadwick Papers, no. 1794, UCL.

83. ["Poor Law Commission and Public Health"], Times, 25 November 1840, p. 4b,c.

84. Angela V. John, By the Sweat of Their Brow: Women Workers at Victorian Coal Mines (London: Routledge and Kegan Paul, 1984), pp. 44-45.

85. "PLC Appendices to Minutes," 22 August 1842, PRO MH 3/3; Stationery Office to PLC, PLC-Stationery Office Correspondence, 25 July 1842, PRO MH 19/198. About 500 copies were reserved for sale. The chief source of the claim that the Report was a runaway best seller is Chadwick's letter to Lord Brougham of 24 July 1842, which refers to the sale of 20,000 copies. (See Flinn, "Introduction" [n. 1], p. 55.) Chadwick makes no explicit mention of the Sanitary Report in the letter (UCL Chadwick Papers, #378). I believe that the reference is to an earlier report on which he had collaborated with Brougham, the "extracts" from the report of the Poor Law Commission (Finer, Chadwick [n. 2], pp. 48, 98). It is not clear that the report signed on 9 July was even available by the 24th.

86. "Local Reports on the Sanitary Condition" (n. 80), p. 929; John Forbes in [Tait], "Typhus Fever" (n. 8), p. 36. Chadwick accused them of doing just that: "a fallacious opinion as to the extent of the operation of destitution as an extensively-operating cause of fever being interposed as an obstacle to measures of sanitary improvement, it became a duty not to pass by that opinion without indicating the evidence of its unsoundness" ("Mr. Chadwick's Sanitary Report" [n. 3], p. 1001).

87. "Minute of the Commissioners, Respecting the Admissibility of Scottish and Irish Medical Practitioners to Union Medical Officers in England," Ninth Annual Report of the PLC with Appendices, P.P., 1843, 21, app. B4, pp. 224-26. See also Hodgkinson, Origins (n. 12), pp. 67-71; Loudon, Medical Care (n. 24), pp. 113, 183; Rumsey, "Medical Care of the Poor . . . Part I" (n. 26), pp. 177-78.

88. Dale Smith, "Afterword: The Study of Continued Fever in Victorian Britain," in Budd, Causes of Fevers (n. 5), pp. 123-54. For the combination of new and old methods of explanation see Hudson, "Inquiry" (n. 8), pp. 124-25. Chadwick's associates quickly recognized the ideological advantages of the new views on fever. In November 1840 Kay-Shuttleworth, the only medically qualified Assistant Poor Law Commissioner, conducted on behalf of the PLC an investigation into the death of Elizabeth Friry, a London woman registered as having died from destitution-caused fever. Kay's strategy was to appeal to the latest French pathology: he claimed Friry had died of a specific disease entity, the new typhoid, an "idiopathic fever" in which cold and hunger need not be implicated. If it could be shown that there were the characteristic lesions on the Peyer's patches of Friry's intestines, the PLC would be acquitted of any blame, for then her death could be attributed to some real disease, rather than to the cumulative consequences of want and neglect. This argument Wakley rejected as beside the point: whatever the disease, if Friry had had food she would have lived. See "Examination in the Case of Elizabeth Friry" (n. 29), pp. 348-49.

89. W. P. Alison, "On the Effect of Poverty and Privation on the Public Health," Trans. Nat. Assoc. Promot. Soc. Sci., 1858, 2: 434-43; idem, Observations on the Epidemic Fever of MDCCCXLIII in Scotland and Its Connection with the Destitute Condition of the Poor (Edinburgh: W. Blackwood, 1844); idem, Observations on the Famine of 1846-7 in the Highlands of Scotland and in Ireland as Illustrating the Connection of the Principle of Population with the Management of the Poor (Edinburgh: N. Blackwood and Sons, 1847).

90. See "Report of the Poor Law Commissioners Relative to Certain Charges Which Have Been Disallowed by Auditors of Unions in England and Wales," P.P., 1837, 38, (539.), p. 4. This makes clear that at the outset the sorts of sanitary improvements that were under discussion were relatively small-scale--much more on the order of removing the occasional dungheap than of rebuilding water and sewage systems. On the basis of the evidence available at the time, it strains credulity to think that the PLC, for whom reducing rates was the key to whatever popular appeal it retained, had in mind the sort of massive public investment that the General Board of Health would undertake, though it is quite possible that Chadwick was thinking in this direction. It had been customary in many towns to expend poor rates on whatever public purpose seemed to require such funds.

91. Brundage, England's "Prussian Minister" (n. 2). This document was created with Win2PDF available at http://www.daneprairie.com. The unregistered version of Win2PDF is for evaluation or non-commercial use only.