Like so many of his time, Charles Dickens was intimately acquainted with the effects of illness and disease. Small for his
age and afflicted with spasms of renal colic, young Charles was no stranger to physical pain. By the time he was 12, he had
witnessed the close association of disease and poverty. The squalor of the Marshalsea prison, in which his father was detained
for debt, and the illnesses of its inmates, impressed him with a lasting horror. As an adult, Dickens was shocked by the mysterious
sudden sickness and death of his 17-year-old sister-in-law Mary Hogarth, who died in his arms. He nursed several of his ten
children through febrile illnesses, probably both typhus and cholera, and lost one infant daughter. His favourite sister,
Fanny, died an agonised death of consumption, or what we now call pulmonary tuberculosis. Later in life Dickens suffered from
high blood pressure and cerebral vascular disease. He died at the age of 58 of a cerebral haemorrhage.
This long list of illnesses was not untypical for a Victorian family. Members of all socio-economic classes were well acquainted
with consumption, which was endemic throughout Britain, causing a chronic, often bloody cough, intermittent fever, a long
wasting illness and early death. Cholera epidemics swept the country in 1831/2, 1848/9 and again in 1853/4. A particularly
terrifying illness, cholera provoked violent diarrhoea, rapid dehydration and circulatory collapse, killing about half of
its victims – often within days. Caused by ingestion of fecally contaminated water, cholera affected especially the overcrowded
slums of the urban poor. Typhus and typhoid, both endemic, produced frequent febrile illnesses, and again poor sanitation
contributed to their spread. Cases of typhus contracted in prison were so common as to acquire the title ‘prison fever’. Even
natural processes such as childbirth were hedged around with danger. Modern readers may be inclined to deplore Dickens’s frequent
and sentimental depictions of maternal and infant death, for instance, until faced with the Victorian statistics: fully 15
to 20 per cent of infants
died in their first year. As for mothers, nine died in childbirth every day throughout England and Wales. Orphans like Oliver
Twist, Pip or David Copperfield were not only symbolic of the Victorian ideal of individual self-definition, they reflected
a brutal reality of the era.
Grim as the Victorian experience was, Dickens’s treatment of disease often has a heightened, hallucinatory quality, as if
he delighted in dwelling upon the pathological or the morbid. But Dickens also worked energetically for healing, in art and
in life. When his daughter Katey was ill, she would take no medicine from anyone else’s hands, and Dickens took to calling
himself in letters, half-jokingly, ‘the physician’.
1 In his passion to expose social ills – especially by representing the material afflictions of individual bodies – Dickens
was not undeserving of the title. Later in his life he made his largest medical intervention in the form of impassioned journalism
on sanitation. Judging from his novels, it is not uncommon for the casual critic to assume that Dickens recommended individual
philanthropy alone, and that he mistrusted all centralised authority. But in a series of articles in
Household Words and in
All the Year Round, Dickens energetically supported the first physician activists in the new field of public health.
Victorian medics were largely enthusiastic readers of Dickens. Medical journals not infrequently carried articles on Dickens
adjacent to articles on pathology or diagnostics. Despite his many unflattering portrayals of doctors (usually minor characters
such as Jobling, the medical officer in
Martin Chuzzlewit, or Dr Lumbey of
Nicholas Nickleby) and nurses (more memorably,
Martin Chuzzlewit’s Sarah Gamp and Betsy Prig), Dickens numbered physicians, from the mesmerist John Elliotson to the public health reformer
Thomas Southwood Smith, among his personal friends. Attracted especially to the fantastic and pseudo-scientific, Dickens tried
his own hand at mesmerism, alternately admitted to and lampooned a belief in phrenology and, famously, defended the supposed
realism of the spontaneous combustion of Krook in
Bleak House. Yet his portrayals of various illnesses were so particular, so attentive to distinguishing signs, that he earned the respect
of the medical community. For instance, medics applied the name ‘The Pickwickian syndrome’ (for Fat Boy Joe’s sleeping malady)
to sleep apnoea long before the mechanism was well understood.
2 And the description of Smike’s ‘hectic fever’ (
Nicholas Nickleby) was quoted verbatim in a leading Victorian textbook, W. Aitken’s
Science and Practice of Medicine (1864). The
British Medical Journal credited Dickens with anticipating the neurology of Paul Broca and John Hughlings Jackson by associating right-sided paralysis
with
speech difficulty in his depiction of Mrs Gargery’s head injury (
Great Expectations).
3 On Dickens’s death, the
British Medical Journal lamented that he, with his powers of observation, had not ‘devoted his powers to the medical art’.
4As acute as his diagnostic eye could be, Dickens’s novelistic portrayals of illness often participate in dominant cultural
conventions. In Nicholas Nickleby, for instance, Smike’s consumption may be realistically described, but his wasting is attributed at least in part to disappointment
in love, as he languishes over the unattainable Kate Nickleby. This is part of the tradition described by Susan Sontag in
Illness as Metaphor, in which tuberculosis sufferers are romanticised as poets, unrequited lovers or passionate seekers who are then purified
and spiritualised as the flesh melts from their bodies. Dickens writes of Smike’s consumption:
There is a dread disease which so prepares its victim, as it were, for death; which so refines it of its grosser aspect, and
throws around familiar looks unearthly indications of the coming change – a dread disease in which the struggle between soul
and body is so gradual, quiet, and solemn, and the result so sure, that day by day, and grain by grain, the mortal part wastes
and withers away, so that the spirit grows light and sanguine with its lightening load and feeling immortality at hand, deems
it but a new term of mortal life … (Nicholas Nickleby, ch. 49)
Similarly, Richard Carstone’s illness in Bleak House, also probably consumption since he coughs blood, arises from his passion – not for Ada, but for the Chancery lawsuit Jarndyce v. Jarndyce. But as his flesh melts, his obsession is also consumed, and he is reconciled to his friends on his deathbed. We may not
be told explicitly what disease affects Paul Dombey and Little Nell, but their saintly suffering and ethereal deaths would
have marked them, to nineteenth-century readers well acquainted with the convention, as consumptive. Paul is borne out to
sea on a gently rocking boat, and Little Nell peacefully bids her friends goodbye before ‘fad[ing] like light upon a summer
evening’ (ch. 72).
As Miriam Bailin has shown, the sickroom, throughout Dickens’s novels, provides an opportunity for restoration of the sufferer’s
identity and reconciliation with his or her loved ones. The narrative reversal of illness from curse to blessing is of course
a traditional biblical theme found throughout Victorian fiction, but Dickens exploited it almost obsessively. Thus it is in
the sickroom that Oliver Twist is restored to Mr Brownlow and the Maylies, Pip is reconciled with Joe, Esther Summerson with
Lady Dedlock and Martin Chuzzlewit with Mark Tapley. In this setting, the women portrayed as loving, self-sacrificing nurses
are often united in matrimony to a grateful patient: Lizzie Hexam assumes the nursing of Eugene
Wrayburn, Little Dorrit cares for Arthur Clennam and the Marchioness revives Dick Swiveller. Bailin further notes that Dickens
often supplies a fever narrative, an account of the patient’s restless dreams in the grip of delirium, and uses this to recapitulate
and unmake his former life, restoring the sufferer to himself. The sickroom thus serves a narrative function, permitting a
removal from and redirection of the novel’s plot.
Dickens often uses illness artistically, as metaphor and as a narrative pivot, but contemporary issues, especially those of
social hygiene, are also pervasively present in the pages of his novels. The fog that descends on many of his novels, for
instance, represents a topical health problem. Dickens’s novels precede the modern germ theory of Koch and Pasteur, which
was not widely accepted until the 1880s. The leading theory of contagion of the time, miasmatism, held that disease was caused
by air poisoned by rotting animal or vegetable matter, which tended to settle, like fog, in low, damp places. Fog, for Dickens,
wraps his Londoners in a poisonous cloak, and those who live in crowded, muddy, garbage-ridden quarters are triply at risk
of infection. In chapter 47 of Dombey and Son, the narrator urges us to look into the ‘dens’ of the ‘outcasts of society’:
follow the good clergyman or doctor, who, with his life imperiled at every breath he draws, goes down into their dens, lying
within the echoes of our carriage wheels and daily tread upon the pavement stones … Breathe the polluted air, foul with every
impurity that is poisonous to health and life; and have every sense, conferred upon our race for its delight and happiness,
offended, sickened and disgusted, and made a channel by which misery and death alone can enter. Vainly attempt to think of
any simple plant, or flower, or wholesome weed, that, set in this foetid bed, could have its natural growth, or put its little
leaves forth to the sun as GOD designed it. And then, calling up some ghastly child, with stunted form and wicked face, hold forth on its unnatural sinfulness,
and lament its being, so early, far away from Heaven – but think a little of its having been conceived, and born, and bred,
in Hell! (ch. 47)
In this passage, Dickens not only describes the miasma threatening the lives of the poor, he reverses the traditional biblical
theme of illness as a retribution for sin. In this instance, it is the miasmatic environment that thwarts providential design,
producing wickedness. Raised in this socially produced hell, the child has no chance of moral uprightness. In fog-enshrouded
London slums, according to Dickens, poverty produces disease, which produces moral frailty – not the other way around.
Especially in his later fiction and journalism, Dickens insistently prioritises sanitation above any other kind of reform.
His growing interest in a strong central authority was clearly stimulated by local ineptitude and
irresponsibility in the face of cholera epidemics. In the Tooting disaster in January 1849, cholera struck a baby farm near
London. The owner, Benjamin Drouet, had failed to instate precautions recommended by the Board of Health, and refused, even
after the death of 150 children, to remove the uninfected children. Outraged, Dickens responded with a series of searing articles
in the
Examiner. The following year, Dickens founded
Household Words, which became his vehicle for a number of forceful essays on sanitation and housing reform, especially in response to the
next epidemic.
In his speech of 1851 to the Metropolitan Sanitary Association, Dickens claimed:
some of the first valuable reports of Mr Chadwick and of Dr Southwood Smith strengthening and much enlarging my previous imperfect
knowledge … made me, in my sphere, earnest in the Sanitary Cause. And I can honestly declare tonight, that all the use I have
since made of my eyes – or nose … – that all the information I have since been able to acquire through any of my senses, has
strengthened me in the conviction that Searching Sanitary Reform must precede all other social remedies.
5
The growth of his interest in sanitary reform was also inspired by his brother-in-law, Henry Austin, who was one of the founders
of the Health of Towns Association. Austin, a civil engineer, became interested in sanitation while working on the Blackwall
railway. During construction, Austin observed the squalid conditions of the slums through which the railway was built. Dickens
uses this connection to impressive effect in Dombey and Son. Austin also sent Dickens a report on a ‘General Scheme for Extramural Sepulture’, which found its way into Dickens’s description of Nemo’s gravesite in Bleak House: ‘a hemmed in churchyard, pestiferous and obscene, whence malignant diseases are communicated to the bodies of our dear brothers
and sisters who have not departed’ (ch. 11). In describing the putrefaction of the overcrowded urban graveyard, Dickens called
on his novel readers to uses their senses as well. ‘Come, flame of gas, burning so sullenly above the iron gate, on which
the poisoned air deposits its witch-ointment slimy to the touch! It is well that you should call to every passer-by “Look
here!”’ (ch. 11). This passage exemplifies the relationship between Dickens’s sanitary work and his fiction. He transmutes
his outrage into a powerfully sensate prophecy that demands his readers attend and see.
Although fog, mud, dust (or garbage) are effective symbols of unhealthy environments in many of Dickens’s novels,
Bleak House stands out as the novel that most explicitly takes on the issue of contagious disease. From
Nemo’s grave, Jo the crossing sweeper carries disease to his slum Tom All Alone’s, where, as Jo says, ‘they dies more than
they lives’ (ch. 31). In Tom All Alone’s the infection grows inexorably:
But [Tom] has his revenge. Even the winds are his messengers, and they serve him in these hours of darkness. There is not
a drop of Tom’s corrupted blood but propagates infection and contagion somewhere. It shall pollute, this very night, the choice
stream … of a Norman house, and his Grace shall not be able to say Nay to the infamous alliance. There is not an atom of Tom’s
slime, not a cubic inch of any pestilential gas in which he lives, not one obscenity of degradation about him, not an ignorance,
not a wickedness, not a brutality of his committing, but shall work its retribution, through every order of society, up to
the proudest of the proud, and to the highest of the high. Verily, what with tainting, plundering, and spoiling, Tom has his
revenge. (ch. 46)
Most readers agree that ‘Tom’s revenge’ must be smallpox, because, spreading from Jo to Charley to Esther, its scars disfigure
Esther’s face. Smallpox vaccination was not made compulsory until 1853, the year in which Bleak House was published, and the reading public would have been familiar with the malady and its scars, hyper-pigmented initially and
later fading somewhat. In asking ‘What connection can there be’ between ‘Jo the outlaw’ and the comfortable characters of
the novel, the narrator also hints that they will be ‘nevertheless, very curiously brought together’ (ch. 41). Smallpox functions
to make visible the necessary if hidden connection between people separated by socio-economic gulfs. But the pattern of contagion
also traces the sought relationship of moral responsibility that Jarndyce accepts when he takes Jo in, and which Esther accepts
when she nurses Charley.
By the time Dickens fashions Allan Woodcourt, there has been a deep change in his ability to imagine the fictional status
of professional healers. There are still inept, self-serving medics, such as Skimpole in Bleak House, but the world of this novel is one that almost demands a doctor as hero, one who can both make the ‘connections’ compassionately
and begin to understand the sanitary problems on a systemic level. Jarndyce describes Woodcourt as ‘generous’, ‘ambitious’
and yet willing to work doggedly at the task at hand, which, for much of the novel, is attending the diseased and outcast
of Tom All Alone’s (ch. 60). Although Woodcourt understands the connection between poverty and disease, he is not a governmental
reformer; but he is perhaps a character who begins to point in that direction, the direction that later Victorian medicine
will follow in the development of public health.
Dickens fails to represent centralised sanitary solutions in his fiction, but there is evidence that he saw his novels and
his journalism as differentiated in purpose. In a letter to Henry Austin, he reveals the gap he experienced between his role
as artist and that of activist. Excusing himself from a sanitary meeting, he writes: ‘I must get air and exercise in the evening – and think … If I get fierce and antagonistic about burials, I can’t
go back to Copperfield for hours and hours. This is really the condition on which I hold my creative powers, and I can’t get
rid of it.’ It seems that his activism inhibited his art – even if the art was aimed making his readers sense and see the
source of his outrage. Or perhaps he felt that his journalistic work for systemic reform simply required different mental
skills than his novelistic work for revolutions of the heart. Either way, it is impressive that he did both.