Moral Cholera: Case Study of the Psychological Side of Epidemics
During times of epidemics, when everyone seems to be getting the same disease, it's easy to imagine we are feeling the symptoms.
"This type of cholera is produced by the apprehension or fear that takes over some people when they see they are close to the epidemic." With this statement, Dr. Benito Hordas y Valbuena—a Spanish physician*—described the symptoms of what he called "moral cholera" in 1833. When afflicted with this disease, patients believed they had contracted cholera and even felt the same symptoms.
Psychiatrists today would call this a psychosomatic or even a factitious disorder or hypochondria, depending on whether the patient was actually feeling the symptoms or faking them for other motives. During times of epidemics, when everyone seems to be getting the same disease, it's easy to imagine we are feeling the symptoms. I, for one, have felt COVID-like symptoms more than once, and only a negative test result has put me at ease.
The idea of psychosomatic illnesses and symptoms has been around for thousands of years, and physicians and psychiatrists have been well aware of them (see below). Emotions, in one way or another, influence the body. As described by Hordas y Valbuena, moral cholera was a mental problem and should have been treated as such. If someone was experiencing moral cholera—he emphasized—their doctor should provide some medication that was not particularly strong or useful but should do so with great pageantry and emphasis to reassure and comfort the patient. He added that the attending physician should convince the patient that their suffering would have a happy outcome.
As described by Hordas y Valbuena, moral cholera was a mental problem and should have been treated as such.
These ideas were published in London in a short treatise titled Curative Method of the Spasmodic Cholera and Means to Prevent It, when cholera epidemics were common in Asia, Europe and America. Back in the 1830s, physicians suspected that cholera had no direct communicable qualities, and over the latter half of the nineteenth century, scientists managed to understand the germ theory behind it. In 1854, English physician John Snow found that cholera's contagion was linked to water and not the air through an epidemiological investigation. But it was microbiologist Robert Koch who isolated the vibrio cholerae pathogen in 1884, leading to a better understanding of its contagion mechanism by water, feces, and food.
According to Hordas y Valbuena, when individuals see themselves surrounded by cholera, their level of excitement rises so high that they start to feel real symptoms. Sufferers of moral cholera begin to feel uncertain, to examine themselves constantly, and even believe they have all of "the imaginable predispositions" to the illness. They feel the symptoms of the disease and "see in front of their eyes the fatal consequences of it." Victims of moral cholera would "touch their gut and extremities, to frequently look themselves in the mirror; they think that they have pains, cold[…] and even feel the cramps." Hordas y Valbuena added that for these individuals "such phenomena may be repeated several times during the epidemic."
Hordas y Valbuena also discussed treatment for these types of afflictions. He wrote that the most crucial aspect when treating moral cholera was that sufferers maintained a "blind trust in [their] doctor and that [the doctor] knows the patient very well." He then prescribed a treatment to match the type of personality of the patient. First, those he described as willing to listen to reason should be convinced to go to the countryside for distraction, leading them to "believe that the best way to keep from cholera is to do exercise outdoors." A particular diet would have been enough for this group.
Second, for those he described as too stubborn to listen, Hordas y Valbuena said that he usually put "with great pageantry and ostentation a magnificent [and quite inconsequential, of course] internal and external curative plan [...] making them see that the disease was progressing well, and that it would have a happy ending by sweating it out." He would also give them a prescription for emulsionis amygdal (almond emulsion), syrupi gummi Arabic (gum syrup), or extracti opii (opium extract), the last of which suggests a calming purpose. By the end, he wrote, patients were usually delighted that they had survived their (perceived) cholera. That was probably the opium talking.
Two things stand out in Hordas y Valbuena's description and treatment of moral cholera: one, the understanding of a psychosomatic manifestation of cholera; and two, the use of the placebo effect to address it. The physician understood that moral cholera was the product of an active imagination and autosuggestion from his patients. His recommendations for treating moral cholera also aimed at convincing the patient of the treatment's quality; namely, he emphasized the treatment using "big pageantry" while carrying out a curative plan. Interestingly, Hordas y Valuena understood the role of the doctor in this process as well. He stressed that patients must trust their doctors, and physicians must know their patients, as talking to them was an essential part of the treatment.
Forbes Winslow's Take
Cholera epidemics brought special attention from doctors in several countries in the middle of the nineteenth century. Among several writings, one short book is called The Cholera Considered Psychologically by British physician Forbes Winslow, published in 1849. Winslow was a physician who specialized in insanity and had studied at Middlesex Hospital under Charles Bell, who is credited for discovering the difference between sensory nerves and motor nerves in the spinal cord.
Winslow published his book in 1849 in the midst of a cholera epidemic in London. At the beginning of this text, he stated that cholera had always been investigated in relation to its physical aspects and proposed to examine the disease from its psychological side. He said that persons who are exposed to a virulent contagion could go on with impunity so long as the mind remains in "a fearless, tranquil, and unanxious (sic) condition."
However, if fear was present, he continued, then the disease would manifest itself for sure. "'Fear is the predisposing cause of [the] plague.' The same remark holds true with reference to typhus fever, small-pox, and diseases which have a malarious origin," he wrote. If the person's mind was exposed to any "depressing cause," this could predispose them to get the disease.
Winslow also mentioned that the constant publication of reports and number of deaths was a harmful influence
About cholera, Winslow said, "I have no hesitation in asserting that the disease has been much aggravated, and extensively diffused by moral or mental agents. That the panic which existed both before and subsequent to the invasion of the disease has acted as a most powerful predisposing cause very few will doubt." He also mentioned that the constant publication of reports and number of deaths was a harmful influence, "increasing to an extraordinary degree the public apprehension, and engendering a fearful predisposition to the disease."
As for treatment, he wrote that the mind should be free from apprehensions. Specifically, "Every legitimate mode of inducing cheerfulness and serenity of mind should be as much as possible encouraged. Constant and agreeable occupation will do much good." He did not mention any formulas or recipes for treating cholera but echoed Hordas y Valbuena's ideas about distracting the patients and raising their spirits.
We have come a long way in how we understand epidemics and treat diseases, but managing the public's fear (or lack thereof) is not so easy. Contemporary doctors are well aware that as soon as a new epidemic hits the news, fear will take over their patients. The same idea was in Forbes Winslow's account of the psychological effects of epidemics when he discussed the constant publication of reports and the number of deaths.
Constant news of prevalent diseases has always overflown our media channels quickly and can get inside people's psyche just as fast. The current COVID-19 pandemic is the perfect example. Fear will always be present in such situations. But it's OK to feel a little scared and respect the gravity of the situation, and there are always ways to find support. Perhaps, part of living through a pandemic is to learn how to manage our personal stream of information to match our comfort level: to find peace in being adequately informed, enough to protect ourselves and those around us, without getting obsessed.
The ideas about the psychological aspects of epidemics have been around for quite some time. We find an early reference to the psychological aspects of plagues in the fifth century B.C. from the Greek historian Thucydides (c. 460–c. 400 BC) and his account of the Plague of Athens. Physician and botanist Paracelsus (1493–1541), for example, talked about fear as one of the three leading causes of epidemics. There were also some more extreme views, for example, those of German physician Augustus Rivinus (1652–1723), who said that fear was the “only cause” of a plague. Relating to fear of epidemics, Willian Falconer (1744–1824), a British physician, said that fear could weaken the body and produce diarrhea and tumours, while on the contrary, trust can cure intermittent fevers and plagues.
* I have not been able to find much about this doctor. It seems he was either born in Spain or Portugal and studied in Salamanca. Apparently, he had a good reputation as a doctor and was a prolific author. He wrote he was president of the Medical Academy of the University of Salamanca and a member of natural and medical societies in Brussels and Louvain. There are different spellings for his last names, e.g., Ordax, Balbuena.