Hektoen International

A Journal of Medical Humanities

A Return to a Moralistic Perception of Disease: Prudence in the Time of Cholera

Lauren Lewis

During the 1830s, a critical shift in thinking occurred about the causes of disease as medical practitioners increasingly shifted their views of causation towards the environment and away from morality and the individual. However, not all followed this shift in thinking, as evinced by Sylvester Graham, a deeply spiritual Presbyterian minister and dedicated health reformer, who continued to stress the importance of morality and the individual in relation to disease.1 In his work on cholera, A Lecture on Epidemic Diseases Generally and Particularly the Spasmodic Cholera, Graham asserts that proper nutrition is the most effective defense against disease.2 As a result, Graham’s work proves interesting from the standpoint in that it deviates from the environmental interpretation of disease and stresses the importance of individual behavior as it relates to disease. While Graham did not provide a “magic bullet” to kill cholera, his general interpretation of disease gained many followers and encouraged Americans to lead a healthier and more sanitary lifestyle, which may have inadvertently saved their lives.3

Before Graham became interested in cholera and its causes, he worked as a Presbyerian minister. However, his career as a minister was short-lived because early on Graham demonstrated less of an interest in preaching the gospel and more so in preaching social reform.4 He joined the Pennsylvania Society for Discouraging the Use of Ardent Spirits as a lecturer in 18305 and in his lectures he claimed that a vegetable-based meatless diet would eliminate the desire to drink alcohol.6 Wanting to direct his attention to other substances that were damaging to the body, Graham left the Pennsylvania Society and moved to New York City to lecture on diet and hygiene.7 At first Graham’s lectures did not gain much attention, but in 1832 his lectures gained significant and critical attention because he discussed cholera within the context of his theories on diet and hygiene. During this time, Americans were desperately searching for advice on how to prevent cholera because they knew that it would soon make its way across the Atlantic.8 Thus, Graham was finally given the chance to share his health philosophy within a specific context, cholera, and with a large audience.

The specific symptoms of cholera—vomiting and diarrhea contributed greatly to why people flocked to Graham’s lectures. Many readily accepted Graham’s theory that cholera was caused by the “overstimulation of the stomach”9 because this seemed to make sense given the disease’s purging symptoms. In A Lecture on Epidemic Diseases Generally and Particularly the Spasmodic Cholera, Graham explicitly states that one’s whole physiological condition strongly correlates with the condition of one’s stomach: “When this organ [stomach] is in good health, and properly supplied with healthful food…then it is, that man has the greatest physical power for achievement and endurance; then has life the most complete victory over the causes which induce death.”10 While he overemphasizes the effectiveness of a healthy diet in defeating disease, the correlation he draws is important because it implies that the individual plays a significant and active role in determining his or her overall health.

For example, the individual’s dietary decisions determine what constitutes “properly” supplying the stomach. However, determining what food “properly” supplies the stomach can be difficult in an age increasingly defined by vice as revealed later in the text:

Unhappily for man, almost every circumstance and influence in civic life, tend to the development of preternatural irritability and diseased sensibility…All undue excitements and exercises of the mind, and of the passions; all excessive indulgences of the appetites; improper qualities and quantities of food…the various customs and circumstances of artificial life…and worst of all, the habitual use of artificial stimulants…more particularly the various narcotic and alcoholic substances; –all act upon the stomach to disturb its functions,…11

Here, the moralistic tone of Graham’s work becomes evident, as he attributes poor dietary decisions to the temptation to overindulge and use artificial stimulants. In the case of cholera, Graham argues that overindulgence weakens the body and transforms cholera from a non-fatal to fatal disease: “…when a long train of abuses has greatly impaired…or entirely destroyed the healthful susceptibilities…of the alimentary canal…if an irritation is induced which brings on cholera morbus, almost every thing concurs to increase the danger of a fatal result.”12 While his theory linking cholera-related deaths to immoral behavior was incorrect, his “physiological rationales for self-control”13 were important because they motivated people to actively pursue a healthy lifestyle by “moderating or avoiding certain forms of excitement.”14

Building on Benjamin Rush’s theory that “…an excess as well as an absence of stimuli…was the universal predisposing factor in disease,”15 Graham came up with three recommendations to help the body receive an ideal amount of stimuli. According to him, this ideal amount of stimuli would not only improve one’s general health, but also prevent cholera. His recommendations included cleanliness, exercise, and a strictly regulated diet.16 According to historian Ronald Walters, Graham wants us to read his recommendations within a moralistic framework: “The road to heaven was paved with restraint in food and sex; those who yielded to temptation were doomed. Salvation was freedom from illness and infirmity; the hellfire Graham preached for lechers and gluttons was the dissolution of their bodies.”17 While this is relatively easy to do considering he frequently reminds us what happens to those who are immoral, thinking about his recommendations within this framework also distracts us from what really caused certain populations to suffer from the disease more than others.

For example, Graham mentions that 1300 out of 1400 “lewd” women died of cholera and attributes these deaths to their lewdness, claiming that “excessive excitement” weakened their body and made them more susceptible to cholera.18 Given what we know about cholera today, how it is spread through feces-infected water or food19, it is likely that their cramped and dirty living conditions and not their “excessive excitement” facilitated the spread of the disease. While Graham discusses the importance of cleanliness early in his recommendations for prevention, his moral agenda and fixation on the principle of moderation likely distracted him from thinking about how a lack of physical as opposed to “moral” cleanliness contributed to why these women died. Also, it is interesting that Graham does not take into account how socio-economic factors often dictate an individual’s ability to make healthy decisions. Even at the end of his lecture when it seems like he is about to acknowledge how socio-economic factors may determine whether or not an individual can adopt his recommended regime, he reverts back to his moralistic mission:

Finally, those who can adopt the system I have recommended…should enter into it at once; but those who cannot, should get into it as soon as they prudently can. —Such, I say, would be my advice if the cholera were raging around you…but as it is not, my earnest entreaty now is, —remain not an hour in the Sodom of your pernicious habits and indulgences!20

Despite the shortcomings of Graham’s analysis on the causes of cholera, the public accepted his theories not only because they made logical sense given the purging nature of the disease, but also because of the way he presented them: “All one had to do was follow rational laws of health, easily understood by common people, without help from clergy or physicians.”21This notion of following the rules gave people a sense of security that if they followed the rules, they would remain healthy.

After discussing his three recommendations and rules to live by, he further elaborates on what he means by a strict diet because he considers this recommendation particularly important in preventing cholera. He stresses that people should avoid foods that have had their nutritious properties removed. To make his point, he compares superfine flour bread with unbolted wheat bread, saying that those who lived off of only the former and water would die, while those who lived off of the latter and water would thrive.22 According to him, unbolted wheat bread is the most important food item in his recommended regimen because no other food item keeps the stomach in a good and healthy condition like it does. Graham argues that the only way to ensure one gets this high quality bread is to make it at home because he claims that public bakers only care about making a profit and not the public’s health.23 This return to the home and self-sufficiency that Graham advocates for is a third reason why he gained so many followers. Those who followed him for this reason were reacting to the sense of insecurity created by the industrial revolution, more specifically when “the urban market economy replaced rural self-sufficiency.”24 Graham sought to create a health regimen, where one needed only minimal basic needs to survive. For him, this minimalist approach represented a form of “individual autonomy,”25 because one who followed such an approach did not become dependent on indulgences. Ronald Walters comments on this autonomy as well claiming, “Whatever Graham’s program cost a person in sensual pleasures, it repaid in autonomy. Mastery of the diet meant mastery of oneself and one’s destiny.”26 In Walters’ analysis of the autonomy Graham’s regimen granted, we see that people strongly believed that Graham’s regimen brought order to a time characterized by chaos and fear.

In conclusion, Graham’s focus on the individual and morality in relation to cholera came with pros and cons. While it encouraged many people to take an active role in improving their health, it may have also distracted people from the real causes of cholera by suggesting that they view the disease from a moralistic perspective. Also, his moralistic view of cholera did not take into account the fact that certain populations were economically constrained and thus, unable to take the time and effort to adopt his regimen. However, overall, his emphasis on moderation, nutrition, and self-sufficiency was useful in a time when there was little guidance on how to deal with a disease that Americans had never before experienced.


  1. Images:
    http://www.oberlin.edu/175/didyouknow-graham.html https://upload.wikimedia.org/wikipedia/commons/8/87/Graham-Cracker-Stack.jpg
  2. Winter, Thomas, “Graham, Sylvester.” American National Biography Online. Feb. 2000. Web. 26 Apr. 2014. <http://www.anb.org/articles/15/15-00283.html>.
  3. Graham, Sylvester. A Lecture on Epidemic Diseases Generally and Particularly the Spasmodic Cholera: delivered in the City of New York, March 1832, and repeated June, 1832, and in Albany, July 4, 1832, and in New York, June, 1833: with an appendix, containing several testimonials, and a review of Beaumont’s experiments on the gastric juice. Boston: David Cambell, 1838: p.11
  4. Winter, Thomas, “Graham, Sylvester.” American National Biography Online. Feb. 2000. Web. 26 Apr. 2014. <http://www.anb.org/articles/15/15-00283.html>.
  5. Verbrugge, Martha H. “Healthy Animals and Civic Life: Sylvester Graham’s Physiology of Subsistence.” Reviews in American History 9 (1981): p.359.
  6. Walters, Ronald G. American Reformers: 1815-1860. New York: Hill and Wang, 1978: p.136
  7. Winter, Thomas, “Graham, Sylvester.” American National Biography Online. Feb. 2000. Web. 26 Apr. 2014. <http://www.anb.org/articles/15/15-00283.html>.
  8. Walters, Ronald G., p.136.
  9. Walters, Ronald G., p.137.
  10. Walters, Ronald G., p.137.
  11. Graham, Sylvester, p.11.
  12. Graham, Sylvester, p.12.
  13. Graham, Sylvester, p.18.
  14. Verbrugge, Martha H., p.360.
  15. Verbrugge, Martha H., p.360.
  16. Verbrugge, Martha H., p.360.
  17. Graham, Sylvester, p.48-49.
  18. Walters, Ronald G., p.137-138.
  19. Graham, Sylvester, p.50.
  20. “Prevention & Control,” Centers for Disease Control and Prevention. 09 July 2013. Web 01 May 2014. <http://www.cdc.gov/cholera/prevention.html>.
  21. Graham, Sylvester, p.81.
  22. Walters, Ronald G., p.138.
  23. Graham, Sylvester, p.53-55.
  24. Graham, Sylvester, p.56.
  25. Verbrugge, Martha H., p.362.
  26. Verbrugge, Martha H., p.362.
  27. Walters, Ronald G., p.138.

LAUREN LEWIS, BA, received a double major in International Studies and English at Johns Hopkins University. She enjoys the historical side of medicine and is interested in learning more about the early developments of clinical pathology in 19th century Paris. She is currently applying to medical school.

Highlighted in Frontispiece Fall 2015 – Volume 7, Issue 4

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