HY 150 BISK THE MODERNIZATION OF HEALTH http

HY 150 BISK
THE MODERNIZATION OF HEALTH
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This is crucial to answering the second question.

adapted from:
CHOLERA IN HAMBURG
adapted from
Richard J. Evans
Death in Hamburg: Society and Politics in the Cholera Years, 1830-1910. New York: Oxford University Press. 1987.

INTRODUCTION
Socially Unacceptable Disease
Cholera first visited the German port city of Hamburg in 1832 and reappeared serendipitously throughout the nineteenth century. Cholera was not the most deadly disease ravaging nineteenth-century Europe—tuberculosis, smallpox, typhoid, and measles killed more people—but it was the most vile. A seemingly healthy person who contracted the cholera bacillus, suddenly succumbed to diarrhea, fever, and vomiting. The body shriveled, the skin discolored, the extremities turned blue with cold, and the victim died a miserable though quick death. Unlike other diseases, cholera was socially unacceptable. Why was this the case?

Evans’ Interests
Social historian Richard J. Evans studies industrialization’s impact on social and political inequality. Using newspapers, letters, government documents, and medical publications, Evans describes the terror that cholera epidemics inspired, especially in bourgeois society. Having to be ingested, the bacillus spread through contaminated water, food, and clothes. Port workers and slum residents most easily contracted the disease. Thus, cholera affected the poor disproportionately.

TEXT
Origin of the Disease
In the early 1830s, a new and serious disease, Asiatic cholera, suddenly confronted Europeans. It came to Europe, an outcome of European mercantile and industrial enterprise. Once it arrived, it fastened on the industrial society that was then in the making. The disease exploited many of industrialization’s most prominent aspects, from urbanization and overcrowding to environmental pollution and social inequality. Long endemic on the Indian subcontinent, an expanding British Empire with its large-scale movements of goods and people plus the rapid growth in trade between India and Europe combined to export the disease to the rest of the world.

March of Cholera to Europe
By 1819, the major outbreak that had begun in Bengal two years before had reached Mauritius; by 1824, it covered all Southeast Asia. More ominously, traders carried it across Afghanistan before a military cordon sanitaire in Astrakhan halted it in 1823. After a brief respite in the mid-1820s, it returned to Persia and crossed the Caspian once more, making its way north to Orenburg, at the southwestern edge of the Urals, in August 1829. From this new center, merchants traveling to and from the great annual fair in Nizhni-Novgorod spread it. The disease also made its way independently up the Volga past Astrakhan, where this time the military cordon sanitaire failed to work. In September 1830, it reached Moscow. And in 1831, a major Russian military campaign against a rebellion in Poland rapidly spread it further west. By July, it had reached the port of Riga on the Baltic Sea. Reports of the horrifying and deadly effects of the new disease soon began to reach Western Europe.

The Pathology of Cholera
Cholera began to affect its victim through a vague feeling of not being well, including a slight deafness. Violent spasms of vomiting and diarrhea quickly followed. Vast and prolonged in their extent, observers described the evacuations as being like "rice-water." In this stage, a victim could lose 25 percent of his bodily fluids. This led to collapse in which, in effect, the blood coagulated and stopped circulating properly. The skin became blue and "corrugated," the eyes sunken and dull, hands and feet as cold as ice. Painful muscular cramps convulsed and contorted the body. The victims appeared indifferent to their surroundings, although they did not necessarily lose consciousness altogether. At this stage death would follow in about half the cases from cardiac or renal (kidney) failure, brought on by acute dehydration and loss of essential chemicals and electrolytes. In the other half, the victim would recover more-or-less rapidly. The whole progression of the symptoms could take as little as 5 to 12 hours, more usually about 3 or 4 days. Modern medical science would add that the incubation period lasts for a minimum of 24 hours and up to 5 days. Although the carrier state may last longer, it lasts roughly 24 hours to 8 days.

Causes of Cholera
The causative agent in the disease is a microscopic bacillus known as Vibrio cholerae. It thrives in warm and humid conditions, above all in river water, surviving up to 20 days. It multiplies rapidly when the water is warm, though it can survive in colder temperatures. Although water most easily transports the bacillus, it can also survive on foodstuffs, especially on fruit and vegetables washed in infected water. It can live in butter for up to a month. Milk also provides a hospitable environment. These facts are important because the disease strikes only if the bacillus enters the human digestive tract. In effect, a victim can catch it only by putting an infected foodstuff or other substance into his mouth. Touching the mouth with infected hands easily transmits the disease. This opens a further range of possibilities. The bacillus survives up to 15 days on feces and a week in ordinary earth dust. Infected clothes and linen, especially the bed linen of victims, are important sources of transmission should others touch them and then later unsuspectingly put hand to mouth. Person-to-person transmission usually occurs indirectly through infection of food or clothing or through bathroom and toilet facilities. Flies can also broadcast the bacillus as far as their limited range takes them.

Fighting Cholera
The best way to combat the bacillus is through scrupulous personal hygiene. Frequent hand washing, especially after contact with infected people and things, for example communal lavatories, is vital. During an epidemic, the heat of boiling or baking can kill bacilli in the water supply, milk, or foodstuffs. The bacillus cannot withstand acid. This includes some gastric juices and most disinfectants. It only lasts for a few minutes in wine or spirits, a few hours in beer. Sand filtration can prevent the bacillus from entering the water supply. This introduces bacteria into the water bacteria that quickly exterminate the cholera bacilli.

Conditions for Rapid Spread
It follows that cholera epidemics tend to break out in warm and humid weather. Infected water supplies, especially if allied to inefficient sewage systems, quickly spread the disease. Personal contacts also play a role. Dirty and overcrowded living conditions and shared toilet facilities are especially dangerous. On a wider geographical scale, victims and carriers as they move about the country spread the disease. Infected river water sometimes spreads the disease as it flows downstream. All this marked an unsanitary port city such as Hamburg as a major potential center if the disease continued to spread.

Nineteenth-Century Images of Death
For nineteenth-century sensibilities, cholera was a terrifying disease. Society had in many ways come to terms with infant deaths and with long-term, permanently present killers such as consumption (tuberculosis). Europeans had evolved a whole set of attitudes to help confront the reality of such everyday deaths. This was "The Age of the Beautiful Death." Literature was full of edifying deathbed scenes, in which death slowly and inexorably crept up on people, transformed their physical suffering into an ethereal beauty, and lent them a moral purity unattainable in everyday life. Death’s permanent presence in the family made its emotional costs easier to bear. Where death was sudden and violent, as on the battlefield, people usually dealt with it through an ideology of heroism, chivalry, or self-sacrifice. Even an ignominious death, by suicide or on the gallows, had its appointed rituals—the suicide note, often with its claim to a noble motive, the last meal of the condemned, the speech from the scaffold.

Death-Image of Cholera
Death from cholera was anything but beautiful.

a. It was a new disease, which people found hard to fit into the patterns established for coping with death that had evolved in the preceding centuries.

b. Cholera epidemics occurred sufficiently rarely for people to suppress consciousness of its visits. The threat which it posed was not permanent, and therefore not psychologically manageable.

c. Its impact was unpredictable, its causes unknown or disputed. It affected every population group. Thus, when a cholera epidemic did occur, it stamped itself on the public consciousness with all the force of a natural disaster. Tuberculosis, though a great killer, was usually a slow disease. It spread through the city’s population at a pace so leisurely that no one could notice whether it was increasing or decreasing in incidence. Cholera raged through the population with terrifying speed. People could be walking about normally, with no symptoms one day, and yet be dead the next morning. The mere onset of the symptoms could sometimes be enough to kill. The terrifying and unpredictable suddenness with which the disease struck appalled people. A businessman could leave his house in the morning and return from work in the evening to find a note on the door saying his wife and family had been taken to hospital after being stricken during the day. A woman could begin her supper in good health but not live to eat the pudding. The wide circulation of such stories during epidemics testified to the fear people found in the suddenness with which cholera attacked.

d. In addition, cholera symptoms were peculiarly horrifying to nineteenth-century, bourgeois sensibilities. Consumptives showed few symptoms that caused embarrassment or discomfort in the onlooker, and then only occasionally. On the whole, they merely became pale and interesting. Even typhoid, despite some unpleasant symptoms, was socially acceptable and claimed some prominent victims. It presented symptoms of fever that took some weeks to progress and people could understand it as a drama of life and death. Spectators were often present at the bedside to watch the whole performance and converse with the patient in his moments of lucidity. Not so cholera. The blue, "corrugated" appearance of the skin and the dull, sunken eyes of sufferers transformed their bodies within a matter of hours from those of recognizable friends, family, and relatives into the living dead. Worse, the massive loss of body fluids, the constant vomiting and defecating of vast quantities of liquid excreta, were horrifying and disgusting in an age which, more than any other, sought to hide bodily functions. Bourgeois society had taken increasing pains, as the century wore on, to make private the grosser physical acts of daily living and to pretend that they did not exist. Cholera broke through the precarious barriers erected against physicality in the name of civilization. The mere sight of its symptoms was distressing. That an uncontrollable, massive attack diarrhea might seize someone on the street or in a tram or restaurant, with scores hundreds of respectable people looking on, must have been almost as terrifying as the thought of death itself. It is telling that while writers widely used quiet diseases such as cancer and tuberculosis as literary metaphors, cholera’s appearance in the literature of the nineteenth century is rare.

Cholera Hits Hamburg
This was the disease that broke out in Hamburg on October 5, 1831, when a sixty-seven year-old former sailor called Peter Petersen, who mainly lived from begging, fell ill with "violent vomiting and diarrhea." Police surgeon Hauptfleisch found him on October 6 suffering from severe cramps, "the extremities ice-cold, hands and feet blue, and eyes sunken." At 6 P.M. on October 6, 1831, Petersen died. At this point, authorities learned of another case that had occurred on October 2 on board a barge that had traveled down the Elbe from Wittenberge. Most likely, the disease had entered the city by this route, through infection of the river water upstream from Hamburg where the barge lay in quarantine. Probably Petersen had come into contact with the river water or it had infected the sour milk which he often drank. Several of the 41 inhabitants of his cellar lodgings, who "consisted in their entirety of vagabonds and beggars" also fell ill with the same symptoms. So too did some of Petersen’s companions in the begging trade. Soon officials were reporting cases all over the city. Already on October 11, they reported 14 new cases. On October 16, there were 44, and on the 18th day the epidemic reached its height with 51 new cases. Thereafter, it declined rapidly. Hamburg breathed again. The epidemic had been a much less severe than many had feared.

But it had not yet disappeared from Hamburg. Authorities declared the epidemic as having ended in January, and they relaxed the various precautions they had ordered. No cases occurred in February or March. Already on April 1, however, officials reported a new case and then eight more, with five deaths in all. Only then did the Senate, on April 27, 1832, finally decided that cholera had broken out once more. The disease spread throughout May and June, reaching a first peak on June 16, when officials reported 92 cases in only a few hours. In July it declined, and toward the end of the month there were only half a dozen or so new cases reported each day. But in August, it grew in intensity once more, with 30 new cases reported on the 26th. Throughout September and October, it showed no signs of departing, with anything between 5 and 15 new cases occurring each day. In November, it finally began to let up. Officials reported the last case on December 17. All in all, 3,349 people in Hamburg fell victim to the disease in the epidemic of April-December 1832. Of them, 1,652 died.

What Caused Cholera? Contagion Theory
How the medical profession and the authorities dealt with the new disease depended on what they thought caused it. Here opinions divided. The obvious model to which cholera seemed to conform was the plague. Two Berlin medical men, writing in 1831, argued that it was "solely and exclusively caused and transmitted by an infectious material" which spread in people’s breath, clothing, excretions, and the things they touched. They drew optimistic conclusions from their theory. If a miasma (bad-smelling vapors) caused cholera, they declared, there was no way for the individual to protect himself. A contagionist theory (belief that diseases spread from one person to another) placed the means of prevention in everyone’s hands.

The doctrine of contagion was an old one. It went back at least as far as the plague writings of the sixteenth century, which postulated transmission by touch, infected clothing or goods, and (exceptionally) inhalation of an infected atmosphere. By the 1830s, however, many medical scientists seriously doubted the adequacy of the contagionist model.

What Caused Cholera? Miasmatic Theory
A second type of theory stressed instead the importance of local miasmas, in which causes special to certain localities under specific conditions polluted the air. This too was an old theory, with parallels in medieval plague medicine. Even before the disease arrived in Hamburg, the local medical profession was split over the issue. On June 21, 1831, the Doctors’ Club decided to meet once a week to study and discuss the reports of cholera coming in from further east and to prepare for its possible arrival. The doctors read aloud and debated letters from doctors in Königsberg, St. Petersburg, Warsaw, and other cities where the disease had broken out. Here the first battles took place between the "contagionists" and "miasmatists."

What Caused Cholera? The Debate Continued
What impressed the anticontagionists was the universal failure of quarantine. Time and again, this was the reason they gave for concluding that the disease was not contagious. When cholera again appeared in Hamburg, the idea of contagion fell further into disrepute because quarantine had failed to work. Doctors began to accept the idea that a miasma had produced cholera. F. Siemerling, writing in 1831, called it malaria animata or "animated swamp-air" released by rotting plants in marshy land.

If a local miasma caused cholera, then how did the disease move from place to place? One writer, Karl Preu, noting that it appeared to travel along waterways, hypothesized that "the strong airstreams that prevail along such great rivers" carried the miasma. From there it sank into the ground on the riverbanks. He denied that any particular type of weather produced the miasma. Dr. C. F Nagel, writing in Altona, went further toward a "contingent contagionism." He argued that the disease was in part the result of conditions in the ground, the nature of which scientists did not yet understand. It also seemed that "infection by people, perhaps also by goods and effects" also carried the disease. However, though he practiced in state-interventionist Altona rather than in free trade Hamburg, Nagel did not go so far as to argue for quarantine and isolation as preventive measures.

What Caused Cholera? Personal Failings
Nagel preferred instead to stress personal behavior. "Nothing encourages the outbreak of this disease more than excessive, persistent fear of the same." If people kept calm and avoided a "disorderly . . . way of life," they would be safe. In particular, dirt, damp, neglected living conditions, and, above all, the "abuse of alcoholic beverages" encouraged infection. "Old drunkards" were particularly vulnerable. Thus Nagel inserted his theory within a powerful current of opinion which ascribed disease to the moral weakness of the victims. The tendency to blame infection on moral failings or psychological disturbance in the victim was widespread. "Just don’t be afraid!" He advised people, "Be moderate and sober!" Fear, wrote Wilhelm Cohnstein of Glogau in a pamphlet circulating in Hamburg before the outbreak of cholera, had a "paralyzing influence on the nervous system."

In general, therefore, three basic explanations of cholera circulated in Hamburg in the early 1830s: the contagionist, the miasmatist, and the moral or psychological.

What Caused Cholera? Contagionists Losing the Debate
However, the experience of the first epidemic was enough to persuade most medical men in Hamburg—as in other parts of Europe—that whatever else cholera was, it was not a contagious disease in the accepted meaning of the word. As K. G. Zimmermann remarked in 1832, "a conviction that cholera is not contagious has become so fixed here, as everywhere, among the medical and lay public, that it would be difficult to bring them over to any other view." Importantly, the Chief Medical Officer of the city, Dr. Heinrich Wilhelm Buek (1796-1879), was from the outset a convinced anticontagionist. His influence doubtless contributed to the spread after 1831of anticontagionist views in the Hamburg medical profession. In his official report on the next major cholera epidemic to hit the city, in 1848 Buek repeated "that transmission from one victim to another, an assumption still found here and there, has not happened here." That the first cases to occur broke out in different parts of the city proved, he said, that they were not connected. Yet "how cholera spreads," he confessed, "is still a riddle. Nor has the present epidemic given us any clues to it." Indeed, so insoluble did the problem seem that the Doctors’ Club did not think it worth discussing at all in 1848-49. The medical profession remained anticontagionist in its majority. Its unity, however, was essentially negative: the doctors could agree on what cholera was not, but they could not explain what it was.

What Caused Cholera? Pettenkofer’s Localist Theory
By 1860, however, all this had changed. A new theory of cholera appeared and it seemed to answer to all these problems. Its author was the Bavarian scientist Max von Pettenkofer.

In his own day, and indeed in his own mind, Pettenkofer was the best known and most implacable of the contagionists’ opponents. His ideas evolved over the years, but the central ideas in his mature theory remained constant, and it is important to look at them for their practical and theoretical results.

Pettenkofer’s theories of cholera took for their starting point the ideas of his mentor, Justus Liebig. These ideas stressed the importance of fermenting, decaying matter as an influence on a given area’s receptivity to epidemic diseases. Pettenkofer began to apply these ideas in his account of the 1854 epidemic in Munich, published the following year. While accepting the existence of an infectious element which enabled cholera to move from one place to another, he denied that disease "contagion in the narrow sense of the word" spread the disease. Nor, he asserted, could drinking water carry it. Indeed, he wrote that "in my report in Munich, I have disposed of the idea of cause by drinking water." Nor, finally, did infected clothes or goods carry the disease. Human beings, even those who had not suffered the symptoms of cholera, probably carried it from place to place. But they could have no effect unless they infected the soil with their excreta.

Influenced by Liebig’s work on fermentation, Pettenkofer developed over the decade 1855-65 an elaborate theory of the conditions under which a cholera miasma could arise. It depended, he argued, on a series of changes in the water table. The water table would suddenly rise, and the moisture content of the soil increased. A dry season followed during which the water table dropped and the moisture content of the soil fell. This left a layer of soil above the water table and cholera would "germinate" in this soil, provided, of course, that the cholera germ had infected the soil. This would create a miasma which bore the disease through air polluted by the germination process. Thus people living on high ground, even on the upper stories of apartment blocks, could enjoy a relative immunity. Meanwhile, those living on low-lying or marshy land, in cellars, or in cramped and confined conditions, which restricted air circulation, were most at risk.

Pettenkofer thus became the self-appointed champion of the "localist" school, which stressed meteorological influences working through changes in the water table. Though he accepted a contagious element in cholera, he did not consider it important. He devoted most of his writings on the subject either to proving that drinking water did not pass on the disease or to refining his own "groundwater" theory and providing a statistical basis for its major assertions. On these fundamental points he did not change his mind over the decades. Pettenkofer’s theory achieved widespread currency, helped by his enormous influence in the field of hygiene, a discipline of which indeed he has some claim as the founding father.

Pettenkofer and Public Sanitation and Hygiene
In the 1860s and 1870s, therefore, there can be little doubt that Pettenkofer’s "groundwater theory," and his dismissal of the notion that cholera was a waterborne disease, dominated official and medical approaches to the cholera problem in Germany. Not all agreed with him, and many doctors continued to stress moral and other factors in the etiology (the causes of a specific disease) of cholera. But Pettenkofer’s influence is plain on medical writings and official policies. His influence would have been impossible without his tireless energy and endless flow of publications on cholera that streamed from his pen. Equally, it owed much to his enormous reputation in social hygiene, which all saw as having some intimate though hotly disputed connection with cholera. But there were also more general reasons for Pettenkofer’s influence.

Pettenkofer was a pioneer of preventive medicine. He promoted a broad approach and believed strongly in public education as a means of improving public health. Against some opposition from his own university, he determinedly popularized his own views. He recommended temperance, cleanliness, regular bathing, a "rational diet," warm clothing, and, above all, fresh air. Indeed, if anyone deserved to be called a "fresh air fanatic," it was Max von Pettenkofer. He opposed drinking not least because it took place in "the horrible atmosphere" of smoke-filled, overcrowded taverns. He argued that "our children’s health suffers when they sit exposed for many hours to the atmosphere of ill-ventilated schoolrooms." He poured well-deserved scorn on the Germans’ traditional horror of drafts. He admired the English habit of keeping an open fire in every parlor, because, "the English fireplace is a poor heating device but good for ventilation." Public education and propaganda could achieve these improvements, he thought. Legislation was not only largely unnecessary, it was also impracticable.

Pettenkofer spoke for state regulation and reform where he considered it necessary to reduce the possibility of creating an unhealthy miasma through soil contamination. He insisted that cities should supply adequate sewage and waste disposal. He believed that every dwelling, even a garret apartment, should have water supplied from a central source, because this meant people were more likely to wash often than if they had to fetch the water from a distance. The water, therefore, had to be clean, for if people repeatedly used foul water for washing, it could turn the surfaces into breeding places for disease. It was largely because of Pettenkofer that Munich built a slaughterhouse in 1878 and that the city got a new water supply from the mountains. Because of Pettenkofer, the city installed a new sewage system, channeling the waste into the river downstream from the city and preventing it from getting into the soil, where he thought it did so much harm.

Pettenkofer warned against thinking that sewage disposal and providing a fresh water supply was all that was necessary to improve public health. He asserted that a nutritious diet and fresh air were far more important. Moreover, he did not think it necessary to provide a filtration system for the water supply. It was enough for the water supply to avoid direct contamination by contact with groundwater in the soil. Thus spring water carried from the mountains was superior to water drawn from wells in the city. The water that he arranged for Munich get was unfiltered, and indeed, shortly after the water began flowing a massive typhoid epidemic hit the city, spread by the new supply system. Pettenkofer continued to believe, nonetheless, that epidemic diseases could not spread in water. He did favor reducing overcrowding in houses "partly by education and partly by regulations." But again he insisted, "We do not solve the problem by providing the poor with the most necessary food, housing, and clothing unless we at the same time educate them in painstaking cleanliness."

Pettenkofer sought to prove that prevention would result in massive savings in hospital costs by reducing disease. It thus offered municipal authorities a large return on their initial investment. He called hygiene, "health economics." Preventive measures as proper sewage disposal and drinking water were analogous to the minimal state intervention necessary to guarantee the smooth running of the economy, like standardizing weights and measures or—in Hamburg—building a harbor.

Once government had done these things, the real responsibility for health and well-being lay with the individual. In keeping with this voluntaristic approach to health, Pettenkofer opposed the massive state intervention favored by the contagionists. Prevention, he believed, was all. Once an epidemic had actually broken out, the state could do nothing to check its progress. In a major series of articles published in 1886-87, Pettenkofer declared that quarantine measures were useless against cholera. They would always be ineffective, he said, because state action could not affect the decisive factor, the soil conditions. Isolating cholera cases after the outbreak of an epidemic, he wrote, "is equally useless; and so is the special cholera hospital." Moreover, he added, "Obviously, I consider disinfecting the excreta of cholera patients to be as ineffective as is isolating cholera patients." This was because "cholera patients produced no effective infectious material." Flight was a reasonable precaution, because it removed people from the miasmatic local influences. Closing markets, fairs, and other gatherings would achieve nothing, unless they were in a locality where the soil factor was powerful. Finally, he continued to deny categorically that drinking water carried cholera. All measures during an epidemic to provide people with alternative supplies of pure or boiled water, therefore, were futile.

Pettenkofer’s Theory of Cholera and Liberal, Middle-Class Values
The parallels between Pettenkofer's theory of cholera and liberal theories of the state are obvious. Pettenkofer attracted medical opinion by offering a synthesis of many previous accounts and linking it to established scientific principles of fermentation. But his ideas also had a broader appeal. The German middle classes welcomed his emphasis on sanitation, cleanliness, fresh air, and a rational diet. They saw a rapidly deteriorating urban environment. Dirt, excrement, noxious vapors, and polluted or adulterated food offended them. His stress on temperance and regularity agreed with bourgeois values, as did his belief that hygienic improvement depended above all on the individual. But the seductiveness of Pettenkofer's theories went even further. They found a ready response not only because of the values which they expressed and the promise of environmental improvement which they held out, but also because of the direct appeal to bourgeois self-interest.

Failed Efforts to Control Cholera in Russia, Austria, and Prussia
When cholera first appeared on the European scene, governments everywhere went to great lengths to halt its progress. In Russia, the government threw up military cordons around infected areas. In the Habsburg Empire, the government introduced rigorous quarantine measures. These were almost always ineffective. Not only did they fail to stop the cholera, they also provoked widespread popular unrest. The military presence in the stricken areas, the isolation of hospitalized victims, and the sudden appearance of doctors, including foreigners who had come to observe the disease, convinced many Russian peasants that the government was trying to kill them off. Peasants killed several doctors and officials amid widespread rioting. In the Habsburg Empire, peasants sacked castles and slaughtered quarantine aid officers and doctors. When the disease reached Prussia, official efforts to control it met a similar response. Popular resentment against official interference in the livelihood of journeymen, peasants, traders, and many others found symbolic expression in the belief that the disease was the product of poisoning by doctors in a secret campaign to reduce excess population.

Hamburg’s Efforts to Control Its Cholera Epidemic
Public order was at the front of the minds of authorities as the cholera epidemic spread across Eastern and Central Europe in 1831. Even Hamburg did not escape; in September 1830, popular unrest in the city expressed itself in prolonged though minor anti-Semitic disturbances. Nevertheless, in common with the authorities elsewhere in Europe, the government of the city state in the summer of 1831 restricted the movement of people and goods to stop the approach of the cholera epidemic. Authorities subjected ships and river barges to medical quarantine from the summer of 1831 until the beginning of 1832. From October 8, the Senate refused to issue clean bills of health to ships leaving the port. During the 1831 epidemic, Hamburg was under medical quarantine with severe restrictions on trade.

The Hamburg Senate was no less energetic in the measures it took to combat the disease once it arrived. In July 1831, well before the outbreak of the disease, it issued an elaborate set of ordinances, to come immediately into force when the epidemic broke out, as it did in October. The city set up a General Health Commission, with special local commissions for the various city districts. Doctors were to report cases to these commissions as soon as they broke out. "Houses in which there are people stricken with cholera will be signified with a poster, on which the word ‘cholera’ is written, so that everyone knows that they are infected.” Authorities were to isolate and disinfect such houses. The city created a special commission to supervise disinfection work. This included chlorine fumigation in the streets, to clean the air. Five days after the first case, officials evacuated and fumigated the cheap lodging house where the disease had broken out. They similarly treated other affected houses. All these measures, of course, depended on the assumption that cholera was an infectious disease.

The Social and Economic Costs of Hamburg’s Efforts
But these measures met with increasing criticism as time went on. First, they did not prevent the arrival of the disease or its spread through the city and beyond. Second, in Hamburg as elsewhere, authorities saw the measures as posing a threat to public order. Like other German cities, Hamburg was walled in the 1830s, but its expansion with the growth of trade had already created in St. Pauli and St. Georg a substantial built-up area of urban settlement outside the walls. The inhabitants of these areas resented their exclusion from the city’s governing institutions and had been petitioning for equal rights for some time. With the founding of the General Health Commission in July, the Chief of the St. Georg Battalion of the Citizens' Militia demanded a seat on it and became a "troublemaker" for his pains. The incident led to a series of demonstrations in which the inhabitants of the suburb tried forcibly to prevent the nightly closure of the city gate, the symbol of their exclusion from equal participation in the city's affairs. Eventually city leaders solved the problem, but the Senate now decided that any further organizational measures against the epidemic might similarly offend popular sensibilities. Finally, the measures taken in 1831 were expensive. They involved, for example, employing some 700 workers to carry out the hospitalization, quarantine, and fumigation measures ordered by the Senate, as well as building the special hospitals and isolation wards to house the sick.

Middle Class Objections to Quarantine
Medical and bourgeois opinion in Europe now mobilized against quarantine and the other interventionist policies adopted in the face of the first cholera epidemic. Quarantine, argued a pamphlet published in Danzig in 1831, was not only useless but dangerous. It exhausted state finances, disrupted trade, and so increased poverty. It caused terror and panic flight in the population and prevented the support of the afflicted and isolated families by welfare agencies. There was thus ample support when the Hamburg authors decided to drop early in 1832 all the precautions they had taken against cholera the previous year. These precautions had contributed, they believed, to "fear and terror" among "the gentlemen who frequent our Exchange," and sealing-off the borders by the Prussian and Danish authorities had done untold damage to trade.

The Medical Profession Takes Over—The Privatization of Public Health
The Senate found support in its decision in the general swing of medical opinion against contagionism and that the epidemic had proved less severe than originally feared. The city did not renew the quarantine measures and it disbanded the state sanitary stations set up to deal with the disease. When cholera broke out with increased virulence later in the year, the burden of combating the disease fell entirely on the medical profession. The Doctors’ Club set up a sanitary station in its rooms, staffed by two doctors at a time, working shifts, during the day. There were no medical services available after 10 p.m. To the Doctors’ Club also fell the task of compiling lists of the sick and the dead. The medical profession, not the State, that hospitalized victims and supplied ambulance men and nursing staff, although doctors could claim expenses from the authorities. There were no quarantine measures and no isolation wards: cholera patients lay alongside the normal hospital inmates. Officials did not announce new cases, or even the epidemic’s presence. It was hardly surprising, therefore, that while the 1831 epidemic cost the authorities fully half a million Marks Courant (the standard monetary unit), that of the following year cost them only twenty thousand, even though it was considerably more severe.

Middle Class Values: The Answer to Cholera
The widespread concern with cholera as a problem of individual morality found its way into the medical handbooks on how to prevent the disease. Disease appeared here as the result not so much of immorality as of emotional disorder or excitement—the very thing which the bourgeoisie saw as at the root of the riot and rebellion with which cholera so often associated. Virtually all the early literature, including the official leaflet issued in 1831, prescribed personal cleanliness. It also offered dietary advice, such as avoiding "acidulous, watery foods and those which cool down the stomach and abdomen." Miasmatists stressed the need for fresh air, while the widespread belief that cholera was an extreme form of "the common cold" led many to urge people to keep warm. Most widespread and insistent of all was the advice to avoid physical or emotional excess. Many doctors in 1831 considered that fear of the disease was a sure invitation for it to strike. Correspondingly, they urged people to lead sober and moderate lives and to avoid upset. People were to avoid "passions," to trust in God, and to keep an "orderly way of life." The Prussian physician, Wilhelm Cohnstein, gave the classic formula. He declared that "unconditional trust in Divine Providence and in the orders of the authorities" best preserved a calm and positive frame of mind.

Revolutionary and Military Upheaval Associated with Cholera
Doctors and authorities associated cholera with individual immorality. They felt that emotional excess could lead to infection. But there was another reason to associate cholera with lack of self-restraint. Not only did cholera itself lead to public disorder, but cholera also appeared at moments of tension in European society. Social and international conflict led to large-scale troop movements that hastened the pace and scale of epidemic infection. In 1830, these troop movements were taking place everywhere in Europe. In Poland, the Russian army was putting down a major nationalist uprising. In the West, the revolutions of 1830 provoked massive military movements. During the revolutionary upheavals of 1848-49, there were even more extensive troop movements with the Russian army in Vienna and the Prussians marching as far west as Baden in the deep southwest of Germany. Similarly, Otto von Bismarck’s wars in1866 against Austria and in 1870-71 against France brought cholera to Hamburg and spread it to other areas as well. Because the disease was notoriously liable to appear at moments of acute political tension, it is hardly surprising that the first reaction of the authorities was to appeal for calm.

The Revolution of 1848 and Cholera in Hamburg
Authorities issued such appeals in the revolutionary year of 1848. Then, Dr. Friedrich Simon, a Hamburg medical practitioner, urged the early closing of inns and bars during the epidemic, and he told his readers to lead "a moderate, sober, and regular life-style" and "to avoid any excesses." This meant not just avoiding alcohol. It also meant, Simon explained, “altogether a state of mind that is as evenly balanced as possible is an essential and important means of protection .... Tiring intellectual exertions, especially deep into the night, have a disadvantageous effect; but strong and long-lasting spiritual excitements of other kinds, powerful passions and changes of mood, even exaggerated joy and sprightliness, are just as much to be avoided.”

In 1848, the priority for the Hamburg Senate was to preserve public order. In July, the medical representatives on the Health Committee held a meeting to discuss measures the city should take, given that after sixteen years cholera was once more approaching the city from the east. “The first thing we must say, before anything else, is the wish to alarm and disturb the public as little as possible. Therefore, we would like to avoid sensationalism during the preparations and right up to the actual outbreak of the epidemic. We do not want to release public notices calling attention to this widely-feared disease, nor, later, when the epidemic has broken out, do we want to take measures which make the disease appear dangerous or extraordinary.”

Such measures, they thought, would only cause panic and make things worse. The previous epidemic, they argued, had shown beyond doubt that cholera was not a contagious disease. So they decided not to set up a quarantine, not to isolate the sick, not to make any special arrangements for burying the victims. Such measures, the doctors warned, "are no help at all, but rather cause endless damage by getting people excited." All that was necessary was to print a pamphlet advising people what to do in the event of an epidemic. This plus arranging to feed the poor, control the quality of food in the markets, ensure the cleanliness and airiness of doss-houses" (cheap, overnight shelters for homeless men), and hospitalize any victims.

The unusually strong concern with public order reflected the political disturbances of the revolutionary year that reached their height in the first week in September, just as the cholera broke out. This concern led once more to a policy of inaction by the Hamburg authorities. Clearly they were anxious not to give further cause for lower-class discontent, which had already led to barricades and demonstrations in August. As in 1832, therefore, they did virtually nothing to cope with the epidemic.

CONCLUSION
The epidemics of 1832 and 1848 fixed a firm tradition in Hamburg, by which the state did almost nothing to prevent or combat the disease and took no steps to announce its presence. The burden of coping with cholera fell on the medical profession and voluntary organizations such as the Doctors' Club. Here too, anticontagionism reigned supreme. The Chief Medical Officer, Dr. Buek, had been an anticontagionist even before the arrival of cholera in 1831. He remained one in the epidemic of 1848. There were further minor epidemics in the 1850s and more serious ones in 1859 and 1866. Buek's successor as Chief Medical Officer, a "convinced supporter of Pettenkofer's views," strengthened the tradition of inactivity.

One of the most striking features of the history of medical administration in nineteenth-century Hamburg was the continuity of senior personnel. Dr. Buek, as closely involved in dealing with all the epidemics from 1831 to 1873. His successor; whose first experience of cholera came in 1873, was still in office in 1892.

Nothing between 1873 and 1892, not even Robert Koch's discoveries, made Kraus change his mind on the subject of cholera. In 1892, as in 1873, Kraus and the medical authorities were still working to a "definite plan" which obliged them to deny the existence of Asiatic cholera in Hamburg until after the disease had reached epidemic proportions. They could justify this policy by Kraus’ anticontagionist views, but doubtless that it had its origins in the fear of the quarantine measures that would immediately loom over the city if they made an official declaration.

The influence of Pettenkofer since the 1850s had diverted the attention of the medical profession to the soil factor. Many agreed in 1874 that "possible harmful substances in the soil” were “a direct cause." But Pettenkofer and his supporters never thought it was possible to eliminate these "harmful substances" altogether. Improved sewage disposal would help, they thought; and indeed great improvements had taken place in this area since mid-century. While the placed faith in a centralized water supply, uncontaminated by infected "groundwater," they did not believe in the importance of filtration. In most respects, the influence of Pettenkofer in Hamburg simply confirmed the existing way of doing things. In 1873, as in all previous cholera epidemics since the defeat of contagionism in 1831, the medical profession and the Senate did their utmost to avoid official confirmation of the disease's presence in the city. And once they had to concede this point, they made no effort to impose quarantine, isolate victims, or mount a campaign of disinfection. By 1871, at least the Senate agreed to undertaking a limited amount of state action, such as lending the police to collect the sick and the dead and providing funds to stop the contamination of the groundwater. But avoiding financial costs and preserving public order remained the highest priorities. Those who disapproved of this policy of state inaction remained a tiny minority.

JOURNAL 7 QUESTIONS
After reading the above and “What the Doctor Ordered,” please answer the following questions in your journal:
1. In the 18^th and 19^th centuries, how did medical techniques and instruments modernize? What is the role of improved medical care in the modernization process? How did the modernization of medical care change the relationship between doctor and patient?
2. How did the English handled the cholera epidemic that hit England in 1831 and after.
3. How did the medical profession and Hamburg’s leaders deal with cholera? What explanations did doctors offer for the spread of cholera in Hamburg and England? How did they advise the state and medical community to contain the epidemic? How did their opinions reflect bourgeois disgust with the poor of Hamburg? Why did scientist Max von Pettenkofer’s theory of cholera and a voluntaristic, individualistic approach to health and hygiene proved so attractive to the bourgeoisie and commercial elite that controlled the city government?
4. Can you think of examples today of the privatization of public (that is, the government’s) obligations? This is to say, in health care--or for that matter, other areas--where private entities provide services that in many other countries, government agencies provide.
5. What diseases today do many describe as caused by the moral failings of their victims? What diseases today do some see as a government-inspired effort to control or even to wipe out certain populations? How do such arguments hinder the effective control of disease?

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