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.