Dickens: Social Class and Early Victorian Medicine


Elizabeth Negus M.A., Barking and Dagenham F.E. College, Essex

17 January 2012


The year 2012 marks the bicentenary of Charles Dickens’ birth.  The time which shaped him and catapulted him to greatness is so far behind us, as to have become a matter of historical study for this generation.  We can regard Dickens from the standpoint of posterity; to consider his career, to review his literary work, and to estimate his total activity, as belonging to an age clearly distinguishable from our own.

First, why did Dickens write novels like Pickwick Papers (1836-37), David Copperfield (1849-50), Bleak House (1852-53), Little Dorrit (1855-57) and Great Expectations (1861).  In his letter to Henry Carey of 24 August 1854, Dickens, in ‘Writing for These Times’, wrote:

To interest and affect the general mind in behalf of anything that is clearly wrong - to stimulate and rouse the public soul to a compassionate or indignant feeling that it must not be, without obtruding any pet theory of cause or cure, and so throwing off allies as they spring up - I believe to be one of Fiction’s highest uses.  And this is the use to which I try to turn it.

The modern public health movement began in the nineteenth century. It was built on earlier political, social and medical structures, but the form in which we relate to it emerged only a couple of centuries ago.  If the relationship between patients and their doctors is about hospital medicine, public health is about the state and the individual.

Indeed, the relationship between the individual and Dickens’ London was plagued with abject poverty, child labourers, crime, prostitution, sickness and disease and where one’s social class determined whether you lived or died. Therefore, we ask the question – ‘Did Dickens want better treatment for child labourers, shut down the workhouses, better schools, better hospitals, and a swifter, fairer system of justice for all, cleaner cities, healthier houses, kinder prisons?’ Did he want more dedicated, less dishonest politicians?  Certainly, the failing institutions and abominable conditions were not wrong in themselves; they just needed better work ethics. Dickens’ observations and attacks on the system by which the claims of individual human beings are trampled in a melee all found its expression in his publicised novels, speeches, letters, journals and newspaper articles.  One of his central concerns had to do with social class and the effects of class division on the working class. He understood that there was a direct link between poverty and health and directed his interest towards medicine and medical discourses. We grasp this from his well-documented personal acquaintance with a range of doctors, like John Connolly, Sir Charles Bell, Dr Ernest Hart, whom he worked with on improving workhouse infirmaries. He possessed several signed copies of works by other surgeons and physicians; in particular, his library boasted a medical dictionary and a dictionary of practical surgery. Dickens was even cited in medical works of his time.  His description of Smike’s hectic fever in Nicholas Nickleby (1838-39) was reprinted word for word in both Aitkin’s Science and Practice of Medicine and Miller’s Principles of Surgery.

This wealth of medical information made clear to Dickens that many disorders, sicknesses, diseases, and ailments during his time were not easily cured. Medicine in the nineteenth century was hardly the enlightened profession it is today. Medical practices were often barbaric, employing methods that had been used for centuries, yielding little or no results and often killing patients with a different affliction from the original ailment. Medical training, research and education in the UK were relatively poor and in some instances deplorable compared to other western European countries. As such, during the 1830s and 40s a number of deadly diseases including influenza, typhoid, smallpox and cholera swept through Britain, killing hundreds of thousands of people.  The worst affected were inevitably the poor, in towns and cities.

Before the Victorian era medical knowledge was largely bound up in magical and religious ideologies, incorporating spells, voodoo, witchdoctors and herbalism.  What caused diseases ranged from the wrath of God and sloth, bad air, and marginal human groups such as witches.  Astrological causes were also frequently invoked. Despite the range of supernatural explanations on offer, the world struggled through several periods of alternating education and ignorance. Diagnosis might involve prayer, interpreting animal entrails, or determining how the patient had digressed. The belief was that, you did not get sick because you caught a virus; you got sick because you offended a spirit.

However, these forms of medical treatment were gradually overtaken by a greater sophistication at the dawning of the Victorian era. Britain in the nineteenth century was the first country in the world to undergo the changes that became known as the Industrial Revolution. For the first time, religion started to lose its grip on many people. While science was developing and saw the industrial revolution as a gift, the downside was that it gave rise to urban fog and the miserable masses of child labour required to run the factories.  London was the centre, home and heart of the Victorian era, and thousands and thousands died in terrible conditions brought about by factories and lack of knowledge or wisdom regarding public health.

In short, the Victorian era was a time of incredibly rapid change, advancement and experiment. It improved the lives of many with its inventions and its new philosophies but it had a dark side of oppressed people.  The burgeoning populations meant that row upon row of poor quality terraced slums were erected around factories.  In Bleak House, Dickens describes the slum, Tom-all-Alone’s “As on the ruined human wretch vermin parasites appear, so these ruined shelters have bred a crowd of foul existence that crawls in and out of gaps in walls and boards and coils itself to sleep, in maggot numbers, where the rain drips in”. (Bleak House, Chap XVI, Penguin Books, 1996)

Tom-All-Alone’s is characterised chiefly by creeping moisture and resultant disease. There is a close relationship between the vermin breeding in the wretches in the slum and the wretches themselves who infests its tenements. In brief, living conditions amongst the poor were appalling and disease was rife, particularly water-borne disease such as cholera and typhoid.  As with Dickens, Friedrich Engels, in his Condition of the Working Class in England, 1844-45, gives a detailed description of Manchester, being one of the many slums in England. He comments:

In one of these courts there stands directly at the entrance, at the end of the covered passage, a privy without a door, so dirty that the inhabitants can pass into and out of the court only by passing through foul pools of stagnant urine and excrement”.

Dickens’ writing in the wake of Carlyle’s Signs of the Times and Chartism makes absolutely clear the responsibility of politicians for the downfall of Britain.  The slums in London are a case in point:

The filthy and miserable appearance of this part of London can hardly be imagined by those... who have not witnessed it.  Wretched houses have broken windows patched with rags and papers: every room let out to a different family and in many instances to two or even three-fruit and “sweet stuff” manufacturers in the cellars, barbers and red-herring vendors in the front parlours, cobblers in the back, a bird fancier in the first floor, three families on the second, starvation in the attics, Irishmen in the passage, a musician in the front kitchen, and a charwoman and five hungry children in the back one - filth everywhere - a gutter before the houses and a drain behind, clothes drying and slops emptying, from the windows; girls of fourteen or fifteen , with matted hair, walking about barefoot...; boys of all ages, in coats of all sizes and no coats at all; men and women, in every variety of scanty and dirty apparel, lounging, scolding, drinking, smoking, squabbling, fighting, and swearing...” (Boz on Slums).

His graphic descriptions of Victorian England give his readership a good idea of what life was really like, particularly for the poor, and it is not surprising that he became extremely hostile to the 1834 Poor Law Amendment Act, and wrote several articles on the workhouse system, showing his concern with public health and the need to reform the legal system. This is succinctly challenged in Pickwick Papers, Great Expectations, Bleak House which show a direct and indirect link between the working class, illnesses and diseases – many of his characters suffer from mental disorders such as depression, dementia, neuropsychiatric disorders,  and illnesses such as fever, stroke, epilepsy, sleep disorders, smallpox, fever, tuberculosis, cholera, polio and diphtheria.   Dickens knew that in a crowded city like London, diseases such as smallpox and cholera were bound to spread. With limited medical treatment available to the poor, it was this social group that suffered the most.

It was believed that people caught smallpox from being contaminated by animal material.  In an article for Household Words in March 1851 Dickens describes the environmental impact of having live cattle markets and slaughterhouses in the city:

In half a quarter of a mile`s length of Whitechapel, at one time, there shall be six hundred newly slaughtered oxen hanging up, and seven hundred sheep but, the more the merrier proof of prosperity. Hard by Snow Hill and Warwick Lane, you shall see the little children, inured to sights of brutality from their birth, trotting along the alleys, mingled with troops of horribly busy pigs, up to their ankles in blood but it makes the young rascals hardy. Into the imperfect sewers of this overgrown city, you shall have the immense mass of corruption, engendered by these practices, lazily thrown out of sight, to rise, in poisonous gases, into your house at night, when your sleeping children will most readily absorb them, and to find its languid way, at last, into the river that you drink”.

A hospital in Leicester

For most part of the nineteenth century, following ground breaking work by London Physician John Snow (1813-58), cholera was recognised as a disease that spread through the consumption of contaminated water, emerging when war or some other crisis brings large numbers of people together in unsanitary conditions.  Dickens was well aware of this and in his speech on Sanitary Reform in London on 10 May 1851, having read Chadwick’s report on the sanitary condition of the labouring population of Great Britain, Dickens observed:

I can honestly declare that the use I have since that time made of my eyes and nose have only strengthened the conviction that certain sanitary reforms must precede all other social remedies, and that neither education nor religion can do anything useful until the way has been paved for their ministrations by cleanliness and decency”.

These strong sentiments are echoed in Little Dorrit.  Dickens had abhorred the once used- to-be great River Thames, which had become a "deadly sewer" (Book 1, Chapter 3); “Miles of close wells and pits of houses, where the inhabitants gasped for air, stretched far away towards every point of the compass. Through the heart of the town a deadly sewer ebbed and flowed, in the place of a fine fresh river.” (Little Dorrit, Wordsworth Classics, 1996).

In like manner, the River (David Copperfield, Chapter 46) appears to evoke repulsive images based sharply on the tidal flats at Westminster, and the assertion that a cesspit dating from the last great visitation of the Black Death was once located in the vicinity:

There was a story that one of the pits dug for the dead in the time of the Great Plague was hereabout; and a blighting influence seemed to have proceeded from it over the whole place. Or else it looked as if it had gradually decomposed into that nightmare condition, out of the overflowing of the polluted stream.” (David Copperfield, Odhams Press, London).

Physical sickness and disease were not Dickens only concern.  In many other novels he showed how poverty in itself was the cause of many forms of mental disease. In David Copperfield we analyse Mr Dick’s social class and his mental breakdown, in terms of nineteenth century and we get to understand Dickens’ negative view towards the incarceration of mad people. Records show that in 1851 Dickens visited St Luke’s Hospital and described his impression in Household Words.  His accounts revealed a combination of anxiety and deep concern for the sufferers. For Dickens, insanity is a “terrible calamity” and represents the loss of “…the greatest of the divine gifts”.  Such misfortunes should be treated with humanity and kindness and consequently opposed the increasing dominance of asylums that were gaining ground all over England.

This is illustrated in the caring and dignified relationship between Mr Dick and aunt Betsey. Dickens tells his readership of Mr Dick’s “bursts of laughter”, he is “mild” and “pleasant”, he is presented as a harmless person, simple, yet there is something of the “idiot savant” in him, so that he makes wise decisions which allows aunt Betsey to rely on him.

Similarly, the novel Little Dorrit presents us with another patient, when we encounter Maggy through the eyes of Arthur Clennam, outside the Marshalsea Prison:

“She was about eight-and-twenty, with large bones, large features, large feet and hands, large eyes and no hair.  Her large eyes were limpid and almost colourless; they seemed to be very little affected by light, and to stand unnaturally still.  There was also that attentive listening expression in her face, which is seen in the faces of the blind; but she was not blind, having one tolerably serviceable eye.  Her face was not exceedingly ugly, though it was only redeemed from being so by a smile; a good-humoured smile, and pleasant in itself, but rendered pitiable by being constantly there.  A great white cap, with a quantity of opaque frilling that was always flapping about, apologised for Maggy's baldness, and made it so very difficult for her old black bonnet to retain its place upon her head, that it held on round her neck like a gipsy's baby.  A commission of haberdashers could alone have reported what the rest of her poor dress was made of, but it had a strong general resemblance to seaweed, with here and there a gigantic tealeaf.  Her shawl looked particularly like a tea leaf after long infusion.” (Little Dorrit, Wordsworth Classics 1996,p.97).

The collective description of Mr Dick and Maggy’s disorder suggests that Dickens had considerable insight into the socio-medical climate.  

Mr Dick exhibits some general features of a mania which was pointed out by Dr John Connoly.  Connoly, in his observation of mentally ill individuals, noted that: “…there is often a great violence in physical movements; the whole frame of the body and mind is in commotion; the eyes have an unnatural brightness and prominence, and the pupil is dilated or contracted”.

Whilst early Victorian treatment for the insane was a form of brutal dominance with restraint, and in some ways supported Foucault’s argument that discipline creates “docile bodies” ideal for new economies, politics, and warfare of the modern industrial age, Dickens had a different opinion. Dickens’ stance on psychosis was that of moral treatment. He was more in favour of moral treatment as a form of medicine and in David Copperfield, he allows Aunt Betsey to rescue Mr Dick from a private asylum where he is ill treated, takes him to her home where he is cared for, humanely. Chapters I to XIV of this work are not only an autobiographical dramatisation of Dickens’ life, but also of the sense of desolation in his early life. He understands that character and environment are mutually interconnected this is demonstrated in his seriousness to reform asylums’ living conditions.

Dickens’ imperative of liberty and hostility to confinement is highlighted in Great Expectations.  Satis House, the abode of Miss Havisham, one of the novel’s protagonists, is represented as a symbol of power: power that comes from wealth, status, and the freedom to live as one pleases. The simple fact is that Miss Havisham was jilted on what was to have been her wedding day. Her eccentricities are directed not only at herself but against the world. Nonetheless, the community encourages her self torment and see her weird clinging to the past as justifiable. Had Miss Havisham been merely insane, with no narrative in her past to explain her insanity, or had she been poor, like Magwitch's jilted wife or Mr Dick, the community probably would not have been so tolerant. Miss Havisham is the one character among these examples who could be classed as insane, even by today's standards; yet, she is not ostracised or chastised in any way. She successfully detached herself from engaging with the community, and therefore relieves them of the burden and responsibility of having to reject her. Since they welcome her company, they are not to blame for her withdrawal from them. Without the albatross of blame, they can allow her the right to be eccentric.

The lunatics and eccentrics that occupy Dickens’ novels are never (apart from the early exception of a madman in the Pickwick Papers) shown in asylums.  In the nineteenth century, affluent patients who experienced mental disorders were desperate to avoid confinement in asylums because they were increasingly seen as workhouses for the unwanted and poor. Andrew Scull in Museums of Madness regarded workhouses as nothing more than “dumping grounds for the decrepit and dependent of all descriptions”.

In the early modern period the cure for the insane was left to the family, one reason being that public institutions specialising in handling the mad were limited. In cases where the families could not afford the costs, they wanted re-assurance that these high walled, prison like buildings were places of treatment and not punishment. 

In Idiots an article in Household Words written in 1853, Dickens praises the care and education of ‘idiots’ who were placed in a properly designed and humane building, as opposed to the old wretched asylums:

Most of our readers know that one of our best achievements of the present century is a complete reversal, in the treatment of madness, of opinions, and practice which had previously been in force for five-and-twenty-centuries at least... The blessing of the change has been secured to England and by the example of England, more widely and certainly diffused among civilised nations - mainly by the help of the wise energy of Dr John Conoly, who claims that “after all mechanical restraints were abolished, the patients began to behave with decency and quietness, to become cheerful, and to acquire the habit of cleanliness.””

A hospital in High Street, Southwark built for poorer sections of London society.

Although there were improvements, Dickens’ moral approach to social reform in the medical world was still somewhat limited. Whilst the asylums were built in the name of humanity and treatment, they hardly did any justice to the patients in producing cures. Instead, the asylums grew larger and silted up with incurable patients; they became, in the words of Andrew Scull “…mere museums of madness”.  The special nature of these institutions reinforced the distance between psychiatry and ordinary medicine and surgery, a breach that still exists, despite modern knowledge of the brain and how it functions.  Dickens knew very well that crime, drunkenness, violence, despair, sickness and many other social problems were caused by ignorance and poverty and were predominant among the lower class.  He knew that unless there was greater equality of wealth, power, education and opportunity, things would not improve.

Whilst the Pickwick Papers testifies to this, it also highlights Dickens’ opposition to abstinence.  In a letter to Lydia Maria Child (1842) Dickens openly confessed that he was a “…great foe to abstinence”.  His letters and journalism suggests that he did not believe in total abstinence, but rather he advocated moderation.  He admitted that he was a “…great friend to temperance” and alcohol “moderately used” is undoubtedly a cheerful, social, harmless, pleasant thing.  In another letter to Mrs Charles Wilson in 1847 Dickens openly attacked those who were “prone to make a beast of themselves by irrational excess in these things” i.e. alcohol and claimed:

I would endeavour, in my poor way, to teach people to use such goods of life, cheerfully and thankfully, and not to abuse them.  I am not sure but that this is the higher lesson, and that the principle will last the longer in the better ages of the world.”

In Pickwick Papers, famous for its realistic descriptions of the detrimental effects of alcohol abuse on both the mind and body, Dickens charted the effect of both acute and chronic drunkenness on his characters with remarkable medical detail and accuracy.

The drunkard in the Stroller’s Tale is described as “restless” and he suffers from “the tortures of a burning fever”; he is haunted by frightful spectres and other “…hideous crawling things with eyes that stared upon him, and filled the very air around...The walls and ceiling were alive with reptiles.” (Pickwick Papers, Penguin Popular Classics 1994).  Dickens’ description of the drunkard’s hallucinations is remarkably similar to several case studies recorded by the early nineteenth century medical professionals like George Mann Burrows (1828).  The physician Isaac Ray similarly reported that the patient often sees “devils, snakes, vermin, and all manner of unclean things around him and about him”.  It is not uncommon, the medical profession maintained, for these patients to die suddenly in a convulsion. Similarly, the drunkard in the Stroller’s Tale grasps Dismal Jemmy’s “shoulder convulsively...and he falls back...dead.” (Pickwick Papers, Penguin Popular Classics, 1994).

These interpolated tales are saturated with alcohol. Whilst Dismal Jemmy narrates The Stroller’s Tale, the Pickwickians sit idly by and enjoy their brandy and water.  Similarly The Bagman’s Story is narrated while “Mr Tupman and Mr Snodgrass were smoking and drinking.’’  The story of the bagman’s uncle is told while Pickwick was mixing his brandy and water.  The contrast between the Pickwickians’ convivial moderate drinking and the excessive alcohol consumption of the protagonist in the interpolated tales can be explained in class terms.  The Pickwickians are financially independent; they are representatives of the settled middle class: “…retired, and of considerable independent property”. In other words, they shine as an example of what every good rich man should be: defiant to villains, courteous to ladies and magnanimous to enemies. On the other hand, the anonymous pantomime actor of the Stroller’s Tale and the Bagman’s uncle respectively are all working class men reduced to catering for their most basic needs, that is, alcoholic drink.  Both the medical and the temperance literature of the first half of the nineteenth century consistently emphasised the different drinking habits between the working class and the middle and upper class. The general view was that the middle and upper classes could moderate their alcohol intake, whereas members of the working class were notorious for their drunkenness.

Sick people with more money were often tended at home

Finally, Dickens’ Bleak House is portrayed as a microcosm of England decaying, stressed through the medically infected ‘bleak house’, where doctors possess good bedside manners but are unable to cure diseases. This is demonstrated through the effortless movement of infection from Jo to Charley to Esther, coupled with the terminal nature of most of the ailments detailed in the novel.

Curing disease was not always possible in either the fictional world of Bleak House or the real world of Victorian England.  Although there are many diseases present in Bleak House, the problem of smallpox is clearly Dickens’ main device for arguing for social change.  Smallpox was known to be one of the few contagious diseases that could be transmitted from person-to-person, and one of the few illnesses that could cut across social class.  Dickens used it as a device to argue for sympathy towards suffering in general.

In dwelling on urban poverty as represented by the slum of Tom-All-Alone’s, a site of moral decay, misery and disease and the Chancery which is embroiled in greed and corruption, Dickens shows the ultimate effect of society's corruption and neglect of the poor; both cause suffering and death irrespective of class, thus exacting justice of a different order. He knew that unless there was greater equality of wealth, power, education and opportunity, the huge injustices of social class division would not improve.

Elizabeth Negus, revised by Robert Blackburn