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Coping with Cholera

Suitable for: Key stage 4, Key stage 5

Time period: Empire and Industry 1750-1850, Victorians 1850-1901

Curriculum topics: Medicine through time, Political and social reform, Victorians

Suggested inquiry questions: What do these documents reveal about treatment and attitudes towards cholera in the nineteenth century? What was the role of the Board of Health from the 1830s? Why was Dr John Snow significant in the history of medicine? What were the significance of the Public Health Acts of 1848 and 1875?

Potential activities: Students design their own advice leaflet for treatment of cholera from the perspective of the General Board of Health in Victorian times.

Download: Lesson pack

Tasks
Background
Teachers' notes
External links
Connections to curriculum

The purpose of this lesson is to explore sources which reveal something about the contemporary medical understanding of the disease, public attitudes and the role of the General Board of Health over a time frame of series of cholera epidemics in Victorian England. For some, the best advice against the disease was to improve ventilation, cleanliness and purge the body, keep it warm or change the diet. For others it required prayer and forgiveness from God. Again, it is interesting to consider why many of these ideas persisted after the breakthrough provided by Dr John Snow in 1854 that linked the presence of contaminated water to the spread of cholera at a time when the authorities and medical profession believed that the disease was spread by miasma, or bad air caused by pollution.

Tasks

Optional lesson starter:

‘A cholera patient experimenting with remedies’, coloured etching by Isaac Robert Cruikshank, c.1832 © Wellcome Collection. Isaac Robert Cruikshank (1789-1856), known as Robert Cruikshank was the older brother of caricaturist and illustrator, George Cruikshank.

How does the artist suggest the patient’s fear of the illness?
What cholera treatments can be seen in this cartoon?
Do you know why they were used?
What does this reveal about the scientific understanding of the causes of the disease?
Describe the starvation stool, can you explain why it is shown in the cartoon?
What points is the artist making in this cartoon, in the image and title about:
- Treatments for cholera
- The Board of Health

‘A cholera patient experimenting with remedies’

Plenary suggestions:

Teachers could hold a discussion after students have worked through the sources using the following questions:

Which sources were the most useful, interesting, or surprising?
What factors do you think ultimately meant that the work of Dr John Snow was accepted?
What light do these sources throw on the role of the Board of Health?
Can you think of other sources that could be used to research public health?
Are there any similarities or differences in the government response to cholera and Covid-19 today?

Source One

Extract from a letter from Charles Pearson, Chairman of the City of London Board of Health to Marquis of Landsdowne, Lord President of the Privy Council [group of advisors to the sovereign] concerning the need for separate burial grounds for those who had died from cholera, 16 July 1832, Catalogue ref: PC 1/114.

The Privy Council had set up the first Board of Health in 1805 to deal with the spread of fever. This letter is included in the correspondence and papers of the Central Board of Health, which was re-called to deal with a cholera epidemic in 1831.

Why has the chairman of the City of London Board of Health written this letter?
What does it suggest about:
- Understanding of the cause of the disease?
- How it spread among the population?
- How people regarded it according to language and tone of the letter?
What does the letter infer about the purpose of the Central Board and City of London Board of Health?

Source 1

Source Two

A letter sent to the Central Board of Health, during the first cholera outbreak from a surgeon in Devon, 17 February 1832, Catalogue ref: HO 44/25.

This is an example of many proposed cures for a disease that few in the medical profession understood and reveals the predominance of miasma theory.

How does this writer suggest that the air over London could be improved to reduce cholera?
Why do you think he makes this suggestion?
The writer also argues that infected households should be given a small amount of gunpowder to light in their homes. What was the purpose of this?
What are the dangers linked to these ideas to prevent cholera?
Does the tone or language used in the letter reveal anything about how the disease was viewed at the time?

Source 2

Source Three

This information table is included in the correspondence and papers of the Central Board of Health, which was re-called to deal with a cholera epidemic in 1831. Catalogue ref: PC 1/114.

Note: Calomel is a type of mercury chloride, used as drug to empty the bowels.

What is information is recorded in this table?
Why do you think the Central Board of Health collected this information?
Does the source tell us anything about the role of the Central Board of Health?
What are the limitations of this source for providing us with information about treatments for cholera?
Does this table show any understanding about the cause of the disease in 1830s?
Is the evidence provided by this document more or less valuable than the cartoon which is used at the top of the web page for this lesson?

Source 3

Source Four

Extracts from a printed copy of ‘Precautionary Hints on Cholera’ issued by the Central Board of Health, 9 May 1832. This describes different stages of the disease and other suggested treatments in addition to medication, Catalogue ref: PC 1/113

What other treatments for cholera patients are suggested here?
Are there any suggestions that could be considered poor advice for a cholera patient in particular?

Source 4

Source Five

Extract of a letter from Central Board of Health concerning advice to be circulated to civil hospitals on the disappearance of cholera, 16 November, 1832, Catalogue ref: PC 1/114

What does this letter reveal about the basic understanding of the cause of cholera and the spread of the disease?
How does the Central Board think cholera should be treated?
Can you suggest why cholera has not spread among hospital patients?

Source 5

Source Six

Letter from the Mayor of Plymouth, dated 21 August 1849, written to the Secretary of State at the Home Office. This was at the time of the second major cholera epidemic which prompted the first Public Health Act 1848, Catalogue reference: HO 45/2755.

What does the language used in the document infer about attitudes towards the disease?
Does the document reveal anything about treatment for cholera?
Does this letter suggest any change in the understanding of the causes of the disease as shown by the earlier sources from the 1830s?

Source 6

Source Seven

A petition from members of Clitheroe town council in Lancaster on behalf of local ratepayers saying that they do not want the Public Health Act of 1848 to be applied to their borough, December 1851, Catalogue ref: MH 13/53.

The government took responsibility for health for the first time, with the 1848 Public Health Act which set up a permanent General Board of Health in the light of the second cholera epidemic. The Board of Health did not have the power to force local boards to follow its recommendations. Again, local boards could only be established when more than one-tenth of the ratepayers agreed to it or if the death-rate was higher than 23 per 1000.

Why did the members of Clitheroe council send this petition to the Board of Health?
What does the petition suggest about the effectiveness of the Public Health Act in terms of combating cholera?
Can you explain why some rate payers might object to a local board of health for their area?

Source 7

Source Eight

Letter from a citizen of Ipswich to the General Board of Health, 21 September 1853, Catalogue ref: MH 13/100.

This is an example of a ‘nuisance letter’, many of these were written to the Board of Health in London at the outbreak of cholera, others outside the capital wrote too as fear of the disease spread. The authorities did fine offenders for not clearing away rubbish and waste, however not that harshly as they were unwilling to interfere with trade and business.

What is the writer of the letter complaining about?
What does this letter reveal common understanding about the cause of cholera in 1853?
What does this letter reveal about overcrowding in towns?
How does the writer expect the General Board of Health to deal with the problem?
What links can you see between this letter and Source 7?

Source 8

Source Nine

Extracts from a newspaper, the Chatham News, dated 10 November 1866, about an inquest held into a death caused by cholera near the Brook, (the renamed Old River Bourne), close to the River Medway in the Kent town of Chatham. Catalogue ref: MH13/47.

[Mr. Ely was the Medical Officer for the Medway Union who gave evidence at the inquest and Henry Hadlow was Assistant Surgeon at Chatham Dockyard whose letter to Mr. Ely was read to the jury at the inquest and is included here].

Why has this inquest been held?
What were the conclusions of the inquest?
Does this article suggest any difference in understanding about the origins of cholera from the first outbreak in 1831-2? Give your reasons.
What does the article infer about the relationship between the Chatham authorities and the General Board of Health?
Why is Henry Hadlow’s letter important evidence for understanding the spread of cholera?

Source 9

Source Ten

A design for a ‘’cholera belt’, 1882, Catalogue ref.: BT 45/30 (6563)

A ‘cholera belt’ was a wide cloth waistband made of flannel or wool worn around the stomach. The ‘belt’ was supposed to protect the person from the cold and damp, as it was thought that a cold abdomen would lead to cholera or diarrhea, and other stomach ailments.

Can you explain how this design for a ‘cholera belt’ was worn?
How different is this from the ordinary belt described in the caption?
What advantages are claimed for this design?
What does it reveal about the understanding of the causes of cholera in 1882 despite the discoveries of Dr John Snow?

Source 10

Background

Cholera in Victorian Britain represented fear of the unknown. It originated from Asia and many doctors were unfamiliar with its cause or treatment. It reached Europe in 1830 and Britain experienced its first epidemic in 1832 when 52,000 died. A second outbreak followed in 1848-9 and caused the death of 53,293 people. This, and pressure from the Health of Towns Association caused the government to introduce the Public Health Act of 1848. The new law set up the General Board of Health in London to give advice on disease prevention and set up local health boards to look into sanitary conditions across the country and appoint medical officers. Yet there was often little or no co-operation between the authorities, and many of the urban poor mistrusted the medical profession. The General Board of Health had no power to force the local boards to act. Nevertheless, the new law marked the beginning of the government taking responsibility for public health despite resistance from many ratepayers. The Public Health Act of 1875 later helped to eliminate this problem as local authorities replaced the local boards which became responsible for the provision of clean water, proper drainage and sewage systems.

Contemporary medical opinion was that cholera was caused by bad air or ‘miasma’ from dung heaps or ‘nuisances’, sewers, damp and dirt. Other doctors argued it was caused from contact with people who had the disease through overcrowding. Their treatments reflected these ideas. For example, isolation hospitals were set up, homes washed with lime and streets cleaned.

The disease seemed to spread most rapidly amongst the poor and they were often instructed to avoid alcohol and eat moderately. People were encouraged to purge the body (empty their bowels) to stop the persistent vomiting and diarrhoea that were the main symptoms of the disease. Patients were often bled with leeches. Overall, these treatments just weakened the bodies of those suffering from cholera and caused them to become even more dehydrated, hastening death in many cases.

Other measures included the wearing of flannel cloth “girdles”, as seen in one of the sources here, or woollen stockings to keep warm. Patients were frequently medicated with camphor and mercury. There were also petitions from across the country requesting, with Queen’s permission, a national ‘Day of Humiliation’ for fasting and prayer in order to ask God to deliver the country from cholera.

Unsurprisingly, there were a host of other “cures” for the disease, for example a surgeon from Chudleigh in Devon suggested gunpowder should be used to blast through the ‘miasma’ that supposedly caused cholera. Another gentleman wrote about the value of drinking brandy in cases of cholera. He suggested that the government should make it readily available for the ‘lower orders’ free of duty ‘until the cholera shall have ceased’.

However, the major breakthrough in understanding the cause of the disease came with the third cholera epidemic of 1854. Dr John Snow, having seen earlier outbreaks of the disease was convinced that it was caused by water contaminated by sewage. He had written a medical paper on this theory in 1849. In 1854 he proved it by mapping cases of the illness to the location of a particular water pump in Broad Street, Soho. The outbreak killed 127 people in three days and 616 within a month. On his suggestion, the Broad Street water pump was shut off and the epidemic receded.

Snow found that houses and public pumps supplied with water used by water companies taking water from where many of London’s sewers emptied downstream into Thames experienced much higher death rates from cholera. Those people whose water had been supplied upstream from Thames Ditton did not become ill. Dr John Snow was a significant pioneer in epidemiology, a branch of medicine which deals with the incidence, distribution, and possible control of diseases.

Britain faced a final cholera epidemic in 1866 in east London. Fewer people died, possibly as there was more acceptance of Dr John Snow’s suggestion of ‘the living organisms’ which contaminated drinking water. For example by Dr John Farr who was a supporter of ‘miasma theory’ and worked at the General Register Office, the government’s department for recording births, deaths and marriages. In subsequent advice, during this epidemic, people were advised to drink boiled water to reduce the risk of infection. However, it was not until 1883 a German doctor, Robert Koch, building on the important earlier work of Louis Pasteur, identified the bacterial causes of cholera (Vibrio cholera) with a microscope and theories about ‘miasma’ were replaced in medical thinking by ‘germ theory’. This provided the crucial evidence that better sanitation and improved water supply were essential to prevent future cholera epidemics.

Teachers' notes

Many teachers will be familiar with the cartoon the ‘Court for King Cholera’ by John Leech which was published in Punch Magazine in 1852. The cartoon reveals, with its punning caption, a poor area of the city demonstrating a range of health hazards. Whilst the cartoon can be regarded as an attack on the Board of Health for its failure to address these problems, it provides unwitting testimony to the lack of understanding of the root cause of cholera in the 1850s, a contaminated water supply following two earlier cholera epidemics.

Please note that this lesson contains a larger number of sources with linked questions. You may want to split the lesson for students working individually or use the sources in paired/group work. Students should be encouraged to think about the limitations of looking at this evidence to evaluate any understanding of health.

All sources are transcribed and difficult language defined in square brackets. We have also provided an optional lesson ‘starter’ and suggestions for a plenary below which you may also wish to use.

External links

Read the original reports on cholera epidemics in Victorian London recorded in The Gazette: https://www.thegazette.co.uk/all-notices/content/100519

Explore the Wellcome collections for original sources on Dr John Snow and public health https://wellcomecollection.org/works

More information on the work of Dr John Snow: https://www.ph.ucla.edu/epi/snow/broadstreetpump.html

Connections to curriculum

AQA GCSE:

Improvements in public health: public health problems in industrial Britain; cholera epidemics; the role of public health reformers; local and national government involvement in public health improvement, including the 1848 and 1875 Public Health Act.

Edexcel GCSE

C1700–1900: Medicine in 18th & 19th century Britain: fighting cholera in London, attempts to prevent its spread; the significance of Snow.

OCR GCSE

The Peoples’ Health: Industrial Britain C1750-1900: Responses to cholera epidemics.