Childhood, Illness and Disease
Lecture 5 From Cradle to Grave
Disease, mortality and the state
• Disease impacts on populations, but also
economy, state and cultural beliefs and
practices.
• State involvement in public health and disease
regulation – includes quarantine, vaccination,
public health measures, establishment of
infectious disease hospitals.
• Much positive (there is an improvement
narrative here), but also marks state
interference in individual rights with regard to
health – and often involves compulsion.
Topics
• Disease, morality and historical
interpretation
• Public health responses to disease
Lecture Outline
1. Disease, mortality and demography
2. Disease and its prevention
• Smallpox – inoculation and vaccination
• TB – sanatoria and nutrition
• Cholera – public health and sanitary reform
Definitions:
• Epidemic = prevalent in
waves, short-term; attacks
populations
indiscriminately.
• Endemic = regularly or
usually found among the
population.
• Pandemic = global
outbreak of disease in
limited time period.
L0032951 : Wellcome Library, London
"The Diagnosis of Smallpox", Ricketts, T. F,
Casell and Company, 1908
Plate XV, Young boy with smallpox showing the distribution of smallpox scabs
before and after falling from the body.
Smallpox
• Smallpox – major killer, and children
very vulnerable. Viral sickness – spread
by droplet infection. Also caused male
infertility as well as high mortality, so
major check on population.
• Smallpox endemic and epidemic –
vaccination only arena where significant
decline in death rates due to direct
medical intervention up until late 19th
century (McKeown thesis).
• Inoculation – Lady Mary Wortley
Montague (1720 son inoculated in
Constantinople).
Edward Jenner (1749-1823)
• Vaccination developed in 1796.
• Observed that milkmaids and
stockmen rarely developed smallpox.
• Inoculated James Phipps with
cowpox and 6 weeks later with
smallpox – proved immunity to
smallpox. Remarkable feat of
empirical medicine.
• Pamphlet An Inquiry into the Causes
and Effects of Variola Vaccinae
(1798). 1801 100,000 people
vaccinated. National Vaccine
Establishment 1808.
Edward Jenner vaccinating patients in the Smallpox and Inoculation Hospital at St.
Pancras: the patients develop features of cows. Coloured etching after J. Gillray,
1802
Vaccination implementation
• 1840 Vaccination Act –
first move into state
medicine
• Further legislation 1850s,
1860s
• 1853 Act vaccination of
infants compulsory before
age of 3 months
• Public Vaccinators 187071; fine of 25s if parents
refused to vaccinate
children
• Children refused
admission to school if not
vaccinated
Anti-vaccination
• Many of poor opposed
vaccination – objected to
compulsion, association
with Poor Law and to
procedure itself.
• Anti-Vaccination League
1866 – ‘conscientious
objectors’. Campaigns in
many towns e.g. Leicester,
Dewsbury, Brighton.
• However, opposition died
down and vaccination
widely introduced. Last
major outbreak smallpox
1902-03, and 1907 repeal of
compulsory vaccination.
Tuberculosis
• Major killer in the 19th century (endemic)
• 1839 TB was responsible for 17.6% of all deaths in England
and Wales
• 1848-55 largest single cause of death – 354,542
• In the early 20th century it remained the most prominent
chronic illness – 75,000 deaths per year
• Widely thought to be hereditary in 19th century and
associated with bad working and living conditions and vice
• Spread through close personal contact – important to
remove sufferers from their environment – TB sanatoria
and open-air school movement (1907)
• Shift to preventative approaches – health education also
important
• By 1950 death from TB greatly reduced – better hygiene
and nutrition and housing most likely cause, as well as use
of antibiotics
Sanatoria
CHOLERA
Edwin Chadwick (1800-1890)
1842, Report on the Sanitary
Condition of the Working
Population of Great Britain.
Emphasised the need for experts
to be employed by government
and believed the role of the
state should be regulatory rather
than directive.
His report cited disease as a
major cause of poverty –
reduced earning capacity of
the working classes. Broke
ground in relating sickness and
poverty.
John Snow (1813-1858) and cholera
• Cholera outbreaks 183132, 1848-49, 1853-54 and
1865-66
• 1855 ‘On the Mode of
Communication of
Cholera’
• Argued that cholera
water borne rather than
being based on miasmas
and insanitary conditions
Snow’s map of Broad Street
Soho district in London.
Called the ‘cholera field’
by Snow.
Over 500 people died in
10 days from 1 to 10
September 1854. Snow
linked the deaths to the
source of water.
Marked of shift from idea
of ‘miasmas’ causing
disease to ‘germ theory’
Public Health Legislation
• 1831 Central Board of Health – local boards set up in many
towns. Increasing recognition of state responsibility to
respond to public health problems caused by rapid growth of
towns.
• 1848 Public Health Act – piped water, removal of nuisances,
and local boards of health (permissive)
• 1855,1860 and 1863 Nuisance Removal Acts
• 1866 Sanitary Act – Sanitary Inspectors appointed to removal
nuisances and to review housing (compulsive)
• 1872 Public Health Act – appointment of MOHs compulsory –
marked rise of preventive medicine
• 1875 Public Health Act – councils compelled to build sewers
and supply clean water
• 1889 Infectious Diseases Notification Act
Notification of infectious diseases
• Calls for system of notification and isolation from
1860s (John Simon)
• Small number of towns set up infectious disease
hospitals – 1883 34 towns
• Infectious Disease Notification Act (1889) – notification
of infectious disease compulsory London, optional
elsewhere, but quickly adopted by local authorities –
by 1891 555 urban and 373 rural sanitary districts
(growing acceptance of germ theory)
• Also inspired by awareness after Education Act 1870
that infectious disease conveyed by school children
might become more widespread – in crowded
classrooms, diseases like measles and scarlet fever
more common
Infectious disease (isolation) hospitals
• Built on tradition of providing
fever hospitals during the 18th
and 19th centuries largely to
treat typhus (charitable).
Workhouses also treated fever
cases
• Provision of special hospitals
slow – opposition by local
inhabitants, funding
limitations (borough hospitals,
so local government
responsibility)
• Isolation Hospital Act 1893 –
county councils enabled to
provide hospitals
• Provision remained poor –
costly, and patients hated
compulsion
• Ca
Responses to disease and isolation hospitals
• Poor understood contagious diseases, fatalistic about
them. Terrified by smallpox, TB; other diseases, like
measles, seen as ‘ordinary childhood disease’, even
though death rate high.
• 1904 smallpox epidemic ‘There was a plague of
smallpox. On Moor Park they had to put marquees and
tents up and they had to put the children in there with
smallpox… They were dying like flies. Every Friday night
we would look in the paper and it took a great toll of
children in them days did the plague’
Lucinda Beier, For their Own Good (2008), collection of
oral histories – Barrow, Preston and Lancaster
Isolation hospitals
• Average stay 40 days or 6 weeks.
• Great reluctance on part of working class to admit children
– complete isolation from family
• 1898 MOH Barrow observed ‘It is impossible to get the
consent of parents amongst the working classes to the
removal of their children to hospital’. MOH Preston,
however, argued in 1909 that ‘invariably even the very
youngest soon settle down to their new surroundings,
enjoy the company of other children and benefit by the
more careful nursing, better food, and purer air than, in the
case of the majority, they would enjoy in their own homes’.
The hospital was made as attractive as possible to
overcome parents’ reluctance to allow children ‘to enter an
institution of a bright, cheerful, and ornamental character.
It does much to remove the prejudice and opposition
generally shown against the erection of an Isolation
Hospital…’
Children’s diseases
• Children particularly
vulnerable to smallpox,
measles, scarlet fever,
diphtheria, whooping cough,
croup, infantile diarrhoea and
also bronchitis and pneumonia
• Causes of death under 5,
1848-55
• Measles 44,003
• Scarlet fever 72,056
• Whooping cough 58,254
• Diarrhoea 76,660
• Pneumonia 107,831
• Registrar-General’s Office,
1857
Measles
• Deadly viral disease, spread by droplet infection or touch
• Peaks in summer and high case fatality in midwinter when
associated with coughs and influenza – reached epidemic
levels in many years
• Disease of poor – due to proximity of overcrowding
• F.B. Smith claims parents ‘stoical’ about measles – though
tried various kinds of domestic and patent remedies;
doctors struggled to treat it effectively
• Sanitary reform and isolation made little difference
• Broke out in schools – e.g. epidemics Coventry 1886, 1889
and 1894, but schools reluctant to inform authorities
• 1915 became notifiable disease following major epidemic –
1916 rate fell dramatically
• However, improved standard of living, improvements in
education and housing, and good nursing care could
improve survival rates
• See Anne Hardy, Epidemic Streets (1993).
Open-air schools
• To combat TB, but also to encourage hygiene,
fresh air, healthful practices more broadly
Polio
• Around 1900 epidemics of
polio appeared in Europe
and N. America
• Major outbreaks around
period of 2nd WW
• Salk and then Sabin
vaccination introduced mid
to late 1950s
Household and advice
• Also health initiatives in home – working-class
homes targeted by well-to-do visitors, and then
public health officials (health visitors, district
nurses, MOHs, sanitary inspectors) who
instructed on hygiene and domestic management
and management of illness
• ‘Domestic quarantine’ supplemented isolation
hospitals
• Parents increasing influenced by advice literature
– e.g. Pye Henry Chavasse and Thomas Bull
• And increasingly exposed to multiple sources of
professional advice via school, local/public health
authority
Nursing at home
• Parents own ideas on health – ‘strong’ and
‘delicate’ children – e.g. use of laxatives, patent
remedies, strengthening medicines, bolstered by
family and neighbours
• ‘To kill the germs and to make it easier for
breathing, pull the blinds downs if we had
measles so that we didn’t get the light in our
eyes. And on the whole she used to nurse us
through; I’ve had goose grease on my throat, that
was supposed to be good; I’ve had sulfur and
they put it in a white clay pipe and blow it down…
Liquorice sticks and cod-liver oil and malt and
Scott’s Emulsion…’
• Mrs Peel, born 1921 Barrow
Patent remedies
Conclusions
• Late 19th and 20th saw decline in diseases and diseases of
childhood, though some like TB and measles persistent
(major epidemic of measles e.g. in 2ndWW). By 2ndWW,
however, former killers, like measles and whooping cough,
minor childhood diseases.
• Initial decline largely due to major public health
interventions, but then into 20th century increasingly
associated with improved housing, diet and nursing care.
• By 2ndWW children immunised against many diseases,
including smallpox, diphtheria, whooping cough and polio;
antibiotics effective against TB and scarlet fever.
• Fighting disease involved considerable state intervention
e.g. vaccination, public health reform, regulation of housing
and compulsory notification of infectious disease – most
accepted as public good.
• However, also involved notification, surveillance, isolation,
disinfection and education.
Debate continues
The following slides contain the
images that were handed out in
the seminars as photocopies to
those of you who dealt with the
vaccination question. They are all
available online at Wellcome
Images: www.wellcomeimages.org
V0011399 Credit: Wellcome Library, London A health inspector dismayed to discover that a mother thinks her
child has been vaccinated because he has been butted by a cow. Wood engraving by C. Keane, 1877
1877 By: Charles Keene
Published: [London], 1877
Size: border 14.1 x 17.9 cm.
Collection: Iconographic Collections
Library reference no.: ICV No 11663
V0011390 Credit: Wellcome Library, London A well-to-do mother resistant to her daughter's doctor using a vaccine from their neighbour's child;
illustrating the narrow-mindedness of the petty provincial middle classes. Wood engraving by G. Du Maurier, 1872.
1872 By: George Louis Palmella Busson Du Maurier
Published: [London], 1872
Size: border 12.6 x 19.6 cm.
Collection: Iconographic Collections
Library reference no.: ICV No 11654
Full Bibliographic Record Link to Wellcome Library Catalogue
Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/
M0005398 Credit: Wellcome Library, London Collection: Iconographic Collections
Library reference no.: Slide number 2955
L0014798 Credit: Wellcome Library, London 'The Public Vaccinator'
Gouache circa 1895-1905 (?)
Collection: Wellcome Images
V0011450 Credit: Wellcome
Library, London
A skeletal death figure wielding
a scythe;
representing fears concerning
the Act of 1898
which made vaccination for
smallpox compulsory.
Wood engraving by Sir E.L.
Sambourne, 1898.
1898 By: Linley. Sambourne
Published: [London], 1898.
Size: border 24 x 18.1 cm.
Collection: Iconographic
Collections
L0028025 Credit: Wellcome
Library, London "The Future of
Innoculation."
Female customer enquiring
about the purchase of "a dose of
Yellow Fever" for her nephew
who is leaving for Sierra Leone.
From: Punch
Published: London 1881
Volume 81Page 230
Collection: General Collections