The Burdens of Disease The Burdens of Disease Epidemics and Human Response in Western History Revised Edition J. N. Hays Rutgers University Press New Brunswick, New Jersey and London Library of Congress Cataloging-in-Publication Data Hays, J. N., 1938– The burdens of disease : epidemics and human response in western history / J.N. Hays. — 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN 978–0–8135–4612–4 (hardcover : alk. paper) — ISBN 978–0–8135–4613–1 (pbk. : alk. paper) 1. Epidemics—History. I. Title. [DNLM: 1. Disease Outbreaks—history—Americas. 2. Disease Outbreaks—history—Europe. 3. Western World—history—Americas. 4. Western World—history—Europe. WA 11 GA1 H425b 2009] RA649.H29 2009 614.4—dc22 2008051487 A British Cataloging-in-Publication record for this book is available from the British Library. Copyright © 1998, 2009 by J. N. Hays All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 100 Joyce Kilmer Avenue, Piscataway, NJ 08854–8099. The only exception to this prohibition is “fair use” as defined by U.S. copyright law. Visit our Web site: http://rutgerspress.rutgers.edu Manufactured in the United States of America For Roz Contents List of Tables ix Acknowledgments xi Introduction 1 One The Western Inheritance: Greek and Roman Ideas about Disease 9 Two Medieval Diseases and Responses 19 Three The Great Plague Pandemic 37 Four New Diseases and Transatlantic Exchanges 62 Five Continuity and Change: Magic, Religion, Medicine, and Science, 500–1700 77 Six Disease and the Enlightenment 105 Seven Cholera and Sanitation 135 Eight Tuberculosis and Poverty 155 Nine Disease, Medicine, and Western Imperialism 179 Ten The Scientific View of Disease and the Triumph of Professional Medicine 214 Eleven The Apparent End of Epidemics 243 Twelve Disease and Power 283 Notes 315 Suggestions for Further Reading 341 Index 357 vii Tables 7.1 City Populations: 1800, 1850, 1880 142 7.2 Average Ages of Death in City and Country, England, 1842 145 8.1 Deaths at an Early Age, 1776–1849 159 8.2 Percentage Rates of Urban Growth, 1800–1910 165 11.1 Death Rates in Selected Countries: Nineteenth Century and c. 1914 247 11.2 Deaths per 100,000 Population, 1871–1960: Diarrheal and Digestive Diseases 257 11.3 Deaths per 100,000 Population, 1871–1960: Pneumonia, Bronchitis, Influenza 257 11.4 Deaths per 100,000 Population, 1871–1960: All Infections 258 11.5 Deaths per 100,000 Population, 1871–1960: Diseases of the Circulatory System 258 11.6 Deaths per 100,000 Population, 1871–1960: Malignant Neoplasms 259 ix Acknowledgments In this revised edition of The Burdens of Disease I remain deeply indebted to those historians and other scholars whose works continue to inform my ideas about the history of epidemic disease. Since the first edition was published in 1998 that scholarship has grown steadily richer, deeper, and more enlightening. The updated “Suggestions for Further Reading” reflect some of that wealth, and I hope that the readers of this book will make use of them and so derive the same pleasures from them that I have enjoyed. Early in my historical training three distinguished scholars at the University of Chicago inspired me. Allen Debus introduced me to the history of science, still my bridge between C. P. Snow’s two cultures. William McNeill’s breadth of vision and imagination provided excitement and stimulus, even before his semi- nal Plagues and Peoples helped create interest in the history of disease. John Clive (later of Harvard University, and now deceased) constantly reminded me that history is a humanistic pursuit. My students at Loyola University Chicago, including undergraduate, gradu- ate, and medical students, persistently asked unanswerable and hence important questions. Loyola’s Department of History has remained a genial and stimulat- ing group of colleagues and friends; I could not have found a more congenial environment for my career. I must also thank Loyola University for the grants of two leaves of absence that facilitated the original conception and completion of the book. Since the appearance of the first edition, I have gained both ideas and encour- agement from a variety of readers and reviewers. And as have so many scholars, I have shamelessly exploited the professionalism and resources found in libraries, especially (in my case) those of the University of Chicago, Loyola xi xii Acknowledgments University Chicago, and the Wellcome Centre for the History of Medicine at University College London. At Rutgers University Press, senior editor Doreen Valentine has rendered invaluable professional counsel, and the whole Rutgers Press staff has made the production process a pleasure. And to my wife, Rosalind Hays, I still owe more than I can properly express, and certainly more than I can ever repay. She shares whatever merits this book may possess. The flaws and errors that remain are mine, all mine. The Burdens of Disease Introduction Disease and illness have obvious importance to human life. In recent years, popular awareness of them has sharpened with concerns about a new worldwide pandemic, perh aps of some form of Asian bird flu spreading to humans. More than ever some understanding of the workings of disease within Western (and world) history should inform our responses to present and future epidemic crises. This book, a second and revised version of the original, pres- ents a view that emphasizes alike the individual reality of sickness and death, the social responses to such physical illness, and the changing ways in which Western societies have constructed the meaning of disease. Disease is both a pathological reality and a social construction. Both material evidence for it and convictions about it exist; concentration on one to the exclu- sion of the other (as some earlier historical writing has done) has sometimes made a neater story, but an incomplete one. Especially during the period from the late nineteenth century through the mid-twentieth, disease seemed an objec- tive biological phenomenon, and those who combated it were scientific physi- cians. A large literature in the history of medicine resulted, one that focused on those figures from the past whose actions and thoughts most closely foretold the model of modern Western biomedicine. That literature usually said little about the effects of disease on social structures or on individual, everyday lives. More recently two other conceptions of disease complicated this positivist picture. Many social scientists and historians came to consider disease above all as a cultural con- struct, rooted in mental habits and social relations rather than in objective bio- logical conditions of pathology. Other writing saw disease as a force in its own right, an implacable product of a biological world in which humans are prey as well as predators. That view, associated with historians’ concern with the 1 2 The Burdens of Disease long-term conception of time and with environment rather than events, shifted attention from the medicine-centered approach to disease, but in doing so it may have reduced human responses to insignificance. The rich volume of scholarship in the last three decades on the history of particular diseases and disease episodes has shown the connections between diseases and social and political changes, the role of disease in the uncovering of social tensions, and the interactions of disease and changes in medical practice. It has explored the complex role of governments in the provision of health care, and the even more complex factors of professionalization that lay behind mod- ern scientific medicine. It has recovered both the variety and persistence of folk traditions and other responses to disease outside the realm of official medicine. This book aims to apply such approaches to the history of disease in Western civilization as a whole, while also insisting on the importance of the biological and pathological realities of disease and hence of the traditions of scientific medicine. Disease has affected Western civilization in a number of ways in different times and places. Some of its most obvious effects have been demographic: dis- ease has led to periods of stagnant or falling human population, for example, in Europe in the late fourteenth and early fifteenth centuries. In the last two cen- turies human responses (especially in the West) to disease have themselves affected demography, in ways still subject to historical argument. Disease has had social effects, as in the sharpening of class lines between immigrants and “natives” in nineteenth-century American cities. Its political effects have been numerous, and sometimes dramatic: it played a crucial role in the overwhelming of Native American polities by European invaders, and it has decided both bat- tles and the fates of European dynasties. Disease has affected economies, both by demographic pressure that has changed the supply and hence the price of labor and by its effects on the productivity of a particular region or social group. Disease’s intellectual and cultural effects have been far-reaching and profound; it has channeled (or blocked) individual creativity, and it may on occasion have set its stamp on the “optimism” or “pessimism” of an entire age. In perhaps less obvious ways, civilization has also affected disease. Some civi- lizations, by their very restlessness, have increased disease’s opportunities. European incursions in the tropics have meant contact with yellow fever; European contacts with Native Americans resulted in a complex interchange of microorganisms and diseases; the networks of medieval trade, both by sea and land, made the movement of plague easier, as did the steam transportation of the nineteenth century. Many cultures and civilizations, including the Western, have attempted to control disease or perhaps even eliminate it, although control and elimination are different goals that have been adopted for different reasons.