The Great Filth E-Book

Stephen Halliday

• Herausgeber: The History Press
• Kategorie: Geisteswissenschaft
• Sprache: Englisch
• Veröffentlichungsjahr: 2011

Beschreibung

Victorian Britain was the world's industrial powerhouse. Its factories, mills and foundries supplied a global demand for manufactured goods. As Britain changed from an agricultural to an industrial ecomony, people swarmed into the towns and cities where the work was; by the end of Queen Victoria's reign, almost 80 per cent of the population was urban. Overcrowding and filthy living conditions, though, were a recipe for disaster, and diseases such as cholera, typhoid, scarlet fever, smallpox and puerperal (childbed) fever were a part of everyday life for (usually poor) town-and city-dwellers. However, thanks to a dedicated band of doctors, nurses, midwives, scientists, engineers and social reformers, by the time the Victorian era became the Edwardian, they were almost eradicated, and no longer a constant source of fear. Stephen Halliday tells the fascinating story of how these individuals fought opposition from politicians, taxpayers and often their own colleagues to overcome these diseases and make the country a safer place for everyone to live.

Leseprobe

Contents

Title Page

Introduction

One  The Pioneers

Two  A Nation of City-Dwellers

Three  Science, Scientists and Disease

Four  The Doctors

Five  The Public Servants

Six  The Midwives

Seven  The Engineers

Conclusion

Notes

Bibliography

Copyright

Introduction

In 1897 Queen Victoria celebrated her Diamond Jubilee, having ascended the throne in June 1837, less than a month after her eighteenth birthday. She was very proud of the fact that she was the longest reigning British monarch, having passed the record set by her grandfather George III, who reigned for almost sixty years. When she died in January 1901 she had reigned for almost sixty-four years.

Her reign was much less turbulent than that of her grandfather, which had witnessed the Seven Years War with France (1756–63) at its beginning; the Napoleonic Wars (1793–1815) at the end; and the disastrous American War of Independence (1776–83) in the middle. During Victoria’s reign there was no serious likelihood that the British Isles would be invaded, despite a few scares concerning supposed threats from the French or Germans. In the colonies the Indian Mutiny was suppressed and the Zulu Wars in Africa made some headlines, but neither represented a threat to the mother country. The Boer War cast its shadow over Victoria’s final years, but no one supposed that the Boers would march on London as Napoleon had intended to do.

But other battles were being fought in Victoria’s towns and cities that were concerned with saving lives rather than ending them. These were battles against disease, especially against epidemic diseases, which spread swiftly in the crowded urban communities that, by the end of her reign, had become the homes of most of her subjects. This book tells the story of those battles fought against squalor, poor housing, dirty water, sewage, ignorance and, ultimately, germs. Since its focus is Victorian England, most of the men and women whose achievements are recorded in this book are British, though two of the most important, Sir Joseph Bazalgette and Sir John Simon, were of French descent. However, the critical discoveries of Frenchmen like Louis Pasteur, Germans like Justus von Liebig, Dutchmen like Anthony van Leeuvenhoek and the Italian Filippo Pacini are also recorded, because of their impact on the understanding of the causes of disease.

By the end of Victoria’s reign some diseases, such as smallpox, typhus and cholera, had either virtually disappeared from the records or were in the process of doing so. Typhoid, scarlet fever and childbed (or puerperal) fever were following. Others, like whooping cough, measles, pneumonia and tuberculosis, were in decline but remained a very real threat. Another fifty years would pass before better living conditions and effective medication would provide successful remedies. The Victorians’ battles were fought by doctors, nurses, midwives, social reformers, scientists and engineers. Sometimes the professions overlapped. Sir John Simon was a doctor, but most of his achievements in the field of public health were made as a public servant, first as Medical Officer to London and, later, to the Privy Council. John Snow was also a doctor who practised in Soho, but he is remembered for his careful scientific study of the Soho cholera outbreak, so he is recorded in this volume as a scientist, as is Dr William Budd, who identified the mechanism by which typhoid is transmitted. Some of those whose achievements are described in the pages that follow were ridiculed in their lifetimes and even now are less well known than they should be.

But before the doctors, nurses, midwives and scientists could do their work, other battles had to be fought by politicians, social reformers and philanthropists. At the outset of Victoria’s reign the role of government was minimal. Its principal tasks were to defend the kingdom from foreign enemies and administer justice. The first of these was discharged by maintaining a powerful navy (though much smaller in peacetime, when many officers were put on half-pay, as Nelson had been) and a very small army, whose shortcomings were quickly exposed during the Crimean War. What later became the Victorian Empire largely consisted of trading posts in which government involvement was minimal. For the first twenty years of Victoria’s reign even India was largely the province of private enterprise in the shape of the East India Company, and it took the Indian Mutiny of 1857 to persuade the government to assume sovereignty over the ‘jewel in the crown’ of empire. The judicial system was the responsibility of central government, but even this was very small (there was not even a Court of Appeal until 1907), and it was mostly run by unpaid amateurs in the form of local magistrates who were also responsible for the affairs of local government, including the Poor Law and the maintenance of roads and bridges, outside the chartered towns. Trials were conducted in the minimum time and at minimum cost, one estimate being that in the 1830s Old Bailey trials took, on average, nine minutes. After the trial, those convicted were likely to be flogged, executed or transported, thus saving the state the costs of imprisonment. It was several years into Victoria’s reign before a prison building programme was instituted under the auspices of central government.

Transport was the responsibility of turnpike trusts for the main roads, canals built by entrepreneurs like the Duke of Bridgewater and, later in the reign, the railways, which in many ways exemplify the Victorian virtues: entrepreneurship, risk taking, high technology and, above all, the employment of private capital for the public good. Hospitals were dependent upon earlier philanthropists, such as John Addenbrooke at Cambridge, Thomas Guy in London and John Radcliffe in Oxford, and those who succeeded them and added to their bequests. The training of nurses at St Thomas’s Hospital was made possible because Florence Nightingale used the prestige she had gained from her work in the Crimea to set up a charitable fund, amounting to £45,000, to pay for it. Education, such as it was, lay in the hands of Dame Schools offering a rudimentary education to economically inactive children; private schools, often Tudor foundations, many of which had declined into a state of torpidity by the nineteenth century; and the ancient universities of Oxford and Cambridge, which were little more than Anglican seminaries.

One of the greatest of the achievements of the Victorians, therefore, was to accept that national and local government had a responsibility for the health, education and welfare of citizens, as well as for defence against foreign invasion and domestic injustice. With this went an acceptance that the authorities would have to raise taxes both centrally and locally. As late as the 1870s William Gladstone was still hoping to be able to abolish the income tax that had first been introduced during the wars against Napoleon, but by Gladstone’s time the cause was lost. A torrent of legislation regulated working practices; promoted the construction of sewers at public expense; instituted the inspection of factories, food and water supplies; built workhouses and the rudimentary hospitals they contained; laid down rules for the training of doctors and midwives; and reformed schools and universities. Big government had arrived and would not be going away. It was the most enduring legacy of Victoria’s reign. It was all necessary before the reformers could begin work.

The young Queen Victoria succeeded to the throne on 20 June 1837. Four days later the Manchester Guardian spokesman for the city, which, above all, represented the cause of laissez-faire and small government, expressed its hopes for the new reign: ‘The accession of our young queen is a circumstance full of hope and promise … government will be compelled to be more economical; a higher standard of civilisation will ultimately be adopted among us.’

By the time of the Queen’s death, in 1901, her subjects were better educated and better fed. More of them had access to clean water, effective sewers and medical practitioners who were trained and regulated. The population’s average life span had risen by almost 50 per cent. This is presumably what the Manchester Guardian meant by ‘a higher standard of civilisation’, but it had been achieved largely by the abandonment of the dream of ‘more economical’ government.

ONE

The Pioneers

The English are fools and madmen: fools because they give their children the smallpox to prevent their catching it; and madmen because they wantonly communicate a certain and dreadful distemper to their children, merely to prevent an uncertain evil.

(Voltaire, inveighing against the English practice of inoculation against smallpox)

Vaccination has been chiefly carried on by lady-doctors, wrong-headed clergymen, needy and dependent medicators and disorderly men-midwives.

(Dr Benjamin Mosley, inveterate nineteenth-century opponent of vaccination against smallpox)

VARIOLATION

In 1840, three years into Victoria’s reign, the Vaccination Act was passed. Vaccination of infants with ‘cowpox’ to protect them against the virulent, disfiguring and often deadly smallpox was made available free of charge as a public health measure. By the same Act the earlier practice of variolation, which involved infecting the recipient with a mild form of the disease itself, was made illegal. This was the first significant public health measure of the reign, the first stride along a long path towards recognition that government had a role in protecting its citizens against disease as well as against foreign enemies. The Act was not particularly successful. Ignorance about medical practices made many families unwilling to risk having their infants deliberately infected with a mysterious disease, albeit one that was supposedly harmless. Further legislation was necessary before the population was protected, often against its will, and smallpox ceased to be rife. Nevertheless the 1840 Act was significant as a symbol of future intentions, and, added to a developing understanding of the causes and nature of diseases amongst doctors, scientists, nurses, midwives and politicians, it represented a notable step in the battle against epidemic disease that was one of the achievements of the reign.

EARLY PLAGUES

The Anglo-Saxon Chronicle, which records the years 879–1154, has left accounts of many plagues, whose occurrence is normally preceded by intimidating accounts of such phenomena as comets, earthquakes and eclipses, though the precise nature of the diseases concerned is rarely clear. This did not prevent the early writers from speculating on the causes of the disorders, often in moralising tones that survived in some quarters into the Victorian period itself. In some cases, it was thought, the simple act of looking upon a disease was sufficient to contract it. The work Mabinogion, which was compiled in the thirteenth century from ancient Welsh legends, recorded that in about AD 550 one Maelgwn Gwynedd ‘beheld the Yellow Plague [probably jaundice] through the keyhole in the church door and forthwith he died’. St David (512–87) was thought to have escaped the plague by fleeing temporarily to Brittany.1

The moralising element is evident in the work of the Venerable Bede (673–735), who, in his De Natura Rerum, wrote that pestilence was ‘produced from the air when it has become corrupted (in accordance with the deserts of men) either from excess of dryness or of heat, or from rain. Inhaled in the process of breathing, the air generates plague and death.’2 His near contemporary Bishop Isidore of Seville (c. 560–636), in his great Etymologiae, declared that pestilence ‘is produced from a corruption of the air and it makes its way by penetrating into the inward parts’.3 Almost a thousand years later the Italian physician Girolamo Fracastoro (c. 1478–1553) attributed syphilis to foul air, which was no doubt a source of some relief to those who contracted it. In the absence of any knowledge of germ theory, the idea that foul air, in the form of a ‘miasma’, was the invariable cause of epidemics was to remain medical orthodoxy until well into the nineteenth century, when some bold spirits suggested that, in the case of cholera and typhoid, the real culprit was polluted water. In the meantime the idea that disease could be spread between people living in crowded communities prompted some authorities to take appropriate steps, albeit perhaps for reasons that were not fully understood. In 672 an outbreak of an unspecified disease among monks led Theodore, Archbishop of Canterbury, to decree at the Synod of Hertford that monks should not move between monasteries, the intention being to prevent the condition from spreading.

THE BLACK DEATH

The early writers may have had difficulty in identifying and attaching names to some of the pestilences that afflicted them, but when bubonic plague arrived in Europe it quickly acquired the name ‘The Black Death’ on account of its alarming symptoms: a blackening of the skin caused by haemorrhages beneath the surface and buboes, or swellings in the armpits and groin, followed by a swift and merciful death. It arrived in the port of Messina, Sicily, in October 1347 on a boat most of whose crew were already dead. Even now its precise origin is the subject of some controversy, but it is usually attributed to the bacterium Yersinia Pestis, transmitted by fleas that are found on black rats. It quickly spread throughout Europe, reaching England in June 1348 and eventually killing about a third of the population of Europe. Its progress had no doubt been assisted by the fact that the population was malnourished as a result of a series of poor harvests over the previous two decades, but the link between nutrition and health, which was eventually made in Victoria’s reign, was not made in the fourteenth century. Like Bede, contemporary writers favoured some kind of divine visitation as an explanation. In the church of St Mary’s, Ashwell, Hertfordshire, an anonymous villager carved a harrowing inscription in 1349: ‘Wretched, terrible, destructive year, the remnants of the people alone remain.’ The Jews, as usual, bore much of the blame and were the victims of many pogroms. The Black Death returned with less devastating consequences later in the century to a population whose previous exposure had presumably left it with some resistance. Its final onslaught on England occurred in 1665, though outbreaks occurred elsewhere in Europe until the early nineteenth century, Marseille being attacked in the 1820s, Russia at the end of the century and San Francisco, in the United States, in 1899–1900.

SMALLPOX

Epidemics of a disease that was probably smallpox were recorded in ancient Egypt and Mesopotamia (now Iraq) many thousands of years before the Christian era. The mummified remains of the pharaoh Rameses V, who died suddenly in 1157 BC, bear pustules characteristic of the disease. Europe seems to have escaped smallpox until it struck Athens in about 490 BC at the height of its prosperity. At this time such visitations were associated with the wrath of God or, in the case of Homer, gods. In the Iliad, book I, Homer describes a plague that falls upon the Greeks before Troy as ‘arrows of Apollo’, while in the Old Testament Job is afflicted by the ‘arrows of the Almighty’. Perhaps it is no coincidence that the martyred St Sebastian, who is normally shown as pierced by numerous arrows, is the patron saint not only of archers but also of places afflicted by plague, where shrines to him were commonly created during the Middle Ages.

Western Europe was evidently spared the scourge of the variola virus that causes smallpox until some time before AD 1000, but once it had become established, shortly after that date, it spread gradually, gathering pace from about the fifteenth century. In the eighteenth century the French writer Voltaire claimed that a majority of the population would contract smallpox at some time, with about a fifth of them dying of the disease and a similar number surviving with faces marked by the pustules it left behind.4 It was no respecter of persons. Among the more prominent English casualties was Queen Elizabeth I, who survived an attack in 1562 with a disfigured face, while Queen Mary II died of smallpox in 1694. Among foreign monarchs the Holy Roman Emperor Joseph I died of the disease in 1711, and his death was followed by those of Tsar Peter II in 1730 and Louis XV of France in 1774.

In the meantime the disease had become a weapon. The conquest of South America by the Spanish invaders in the sixteenth century was aided by the fact that the native population had no resistance to the variola virus, which they had never previously encountered. The first recorded outbreak occurred in the island of Hispaniola (Haiti and the Dominican Republic) in 1518, when half the native population was wiped out, but the problem became much more serious after 1520, when the disease reached the mainland through one of the soldiers of Cortés. A third of the Aztec population was killed, and when smallpox reached Peru the Inca emperor Huayna Capac was among its victims. It was also used as a threat. In 1728 the gaoler of the Fleet prison, Thomas Bambridge, demanded fees from one of his prisoners, a debtor called Robert Castell, in return for more comfortable accommodation. When Castell refused to pay the sum demanded, Bambridge, who had paid £5,000 for the office and was determined to gain a return on his investment, moved Castell to a part of the prison that was infected with smallpox. Castell died, and the matter became a cause célèbre when it was raised in Parliament by James Oglethorpe, who went on to found the colony of Georgia for discharged debtors.5 In the first recorded deliberate use of biological warfare, in 1763, British troops at Fort Pitt (later Pittsburgh) deliberately distributed smallpox-infected blankets to Indians who were thought to be allies of the French enemy. Consequently, during the American War of Independence George Washington ordered that his troops be protected against the disease by a process then known as variolation, which had been gaining in popularity since the early years of the century.

INOCULATION

The process of variolation, also known as inoculation, involved the deliberate infection of one person, usually an infant, by another. This was done by rubbing matter from an infected person’s smallpox pustule into a scratch on the arm of the recipient. The process was observed by Lady Mary Wortley Montagu in Constantinople while her husband was serving as British ambassador to the Ottoman Empire in 1717. Voltaire, who later wrote an account of her experiences, attributed the custom among Circassian families to a desire to obtain positions for their daughters in the harems of Turkey and Persia – opportunities that would be lost if the girls were disfigured by smallpox. The belief prevailed that, if one child were infected by another, the smallpox would be less virulent than if it were contracted later. Lady Mary had lost a brother to the disease and herself bore its scars. She persuaded the embassy surgeon, Charles Maitland, to inoculate her five-year-old, despite being warned by the chaplain that it was an un-Christian practice that would work only upon infidels. Following her return to England in 1721 she also had her four-year-old daughter inoculated, and the child became a medical curiosity who attracted the attention of the royal physician, Sir Hans Sloane. As a result, permission was obtained to test the process on six Newgate prisoners who were facing execution. The trial succeeded, the prisoners gaining their freedom as well as immunity to smallpox, and the practice received a powerful endorsement when, in 1722, the Prince of Wales’s daughters were inoculated. The Foundling Hospital, created in 1741 by the sea captain Thomas Coram to care for abandoned children, inoculated its children at the age of three from the time of its foundation.6

The process was more readily adopted in England than in many other European countries. Reference has already been made to the deaths of continental monarchs, and the attitude towards inoculation of many foreign observers was summarised by Voltaire in his Lettres philosophiques when he wrote:

It is inadvertently affirmed in the Christian countries of Europe that the English are fools and madmen: fools because they give their children the smallpox to prevent their catching it; and madmen because they wantonly communicate a certain and dreadful distemper to their children, merely to prevent an uncertain evil. The English, on the other hand, call the rest of the Europeans cowardly and unnatural. Cowardly because they are afraid of putting their children to a little pain; unnatural because they expose them to die one time or other of the smallpox.7

The most notable exception to the general European scepticism about inoculation was Catherine the Great of Russia. In 1768, faced by a severe smallpox epidemic sweeping through Russia, she contacted an English physician, Thomas Dimsdale (1712–1800), who had published a treatise, The Present Methods of Inoculation for the Smallpox, the previous year. Dimsdale visited Russia, inoculated Catherine and her son, the future Paul I, and was rewarded by being created a Baron of the Russian Empire.

Sir Hans Sloane (1660–1753) was born in County Down, Ireland, in modest circumstances and studied medicine in England and France. In 1687 he went to Jamaica as physician to the governor and began the collection of flora and fauna for which he is remembered. He returned to England and established a very successful medical practice in Bloomsbury Place, close to the site on which the British Museum was later built. His patients included Queen Anne, George I and George II. Upon his death he bequeathed his collection of over 70,000 objects, a herbarium and library to George II in return for a payment of £20,000 to his two daughters. The money was raised through a public lottery and formed the basis of the British Museum, which was consequently founded in the year of Sloane’s death and opened to the public in 1759. He was influential in promoting inoculation against smallpox and devised a drink for children made by mixing cocoa with cow’s milk, based on a practice he had witnessed in Jamaica, where mothers mixed breast milk with cocoa beans. It was marketed by Cadbury’s until 1885 as ‘Sir Hans Sloane’s Milk Chocolate’. He succeeded his friend Sir Isaac Newton as President of the Royal Society and has several London streets named after him, including Sloane Square and Hans Place.

VACCINATION

Edward Jenner (1749–1823) was a country doctor in the small town of Berkeley, Gloucestershire. The son of the local clergyman, he showed an early interest in natural history and was the first person to observe the habits of the young cuckoo in expelling other eggs from its nest. He trained as a doctor first with a local surgeon in Chipping Sodbury and later at St George’s hospital, London, under the great surgeon and experimenter John Hunter, of whom he became a lifelong friend. It was on Hunter’s recommendation that Jenner was employed by Sir Joseph Banks to prepare for examination specimens collected on Captain Cook’s expeditions to Australia and the South Seas, so his experience and connections were considerably greater than those of most country doctors. In 1772 he returned to Berkeley and set up a medical practice. His childhood interest in natural history had familiarised him with the tale that milkmaids (who were often represented by contemporary painters as icons of beauty) retained their good looks because their work rendered them immune to the disfigurements of smallpox. He had himself been inoculated, had been very ill as a result and knew that the process could, on occasion, lead to the full effects of smallpox itself.

He observed that milkmaids frequently developed blisters on their hands, known as cowpox, which resulted from contact with the udders of cows, and he reflected upon the possibility that this minor blemish might in some way protect them from the depredations of smallpox. He was consulted by a milkmaid called Sarah Nelmes, who had developed a particularly bad case of the characteristic blisters after milking a cow called Blossom, and he extracted some pus from the blisters. This he injected into an eight-year-old boy called James Phipps, the son of his gardener, gradually increasing the amount of pus over a period of several days. He then deliberately injected the boy with smallpox on several occasions. James remained immune from smallpox. Since cowpox was a relatively harmless disease that carried with it no risk of infection from smallpox itself, it offered obvious advantages over the alternative practice of inoculation. This experiment was repeated over the years that followed, Jenner vaccinating 100 children in further tests as well as trying the procedure on himself. In those days there were no ethical or regulatory constraints upon such experiments. Jenner named the new process ‘vaccination’ after the Latin word vacca for ‘cow’ and published his findings in a book titled An Enquiry into the Causes and Effects of the Variolae Vaccinae; A Disease Discovered in some of the Western Counties of England, Particularly Gloucestershire, and Known by the Name of Cow Pox.

He submitted his findings to the Royal Society, whose president was his acquaintance Sir Joseph Banks. However, he was advised that he had not carried out enough experiments to justify such revolutionary ideas. This discouraging judgement was influenced by the fact that cowpox was confined to a few areas, so that doctors who wanted to experiment with the new process were dependent upon Jenner to supply them with pus at a time when such a substance was difficult to transport over any but the shortest distance. This clergyman’s son also encountered resistance from churchmen, who thought it was profane to inject into human beings material from a diseased animal. James Gillray was one of the cartoonists who lampooned the practice by showing people growing cows’ heads. One of the fiercest critics of vaccination was a doctor called Benjamin Mosley (1742–1819), who described the arguments in favour of vaccination as ‘the ravings of Bedlam’8 and claimed that cow hair would grow on the scabs that formed after vaccination – scabs that in the early days could be unsightly. He later added that ‘vaccination has been chiefly carried on by lady-doctors, wrong-headed clergymen, needy and dependent medicators and disorderly men-midwives’.9

Despite such strictures, the prospect of escaping the dreaded disease was so attractive that criticism melted away. By the time that Mosley wrote, the great majority of medical practitioners were practising vaccination. Jenner developed ways of preserving cowpox microbes by drying them on to threads of glass and began to supply the material to doctors in Britain and abroad, calling himself ‘vaccine clerk to the world’. The process of vaccination was adopted more rapidly in other nations, often using material supplied by Jenner himself. Bavaria was the first nation to make vaccination compulsory, in 1807, while Denmark, Sweden, Prussia, Hungary, Romania and Serbia all imposed the practice before Britain did. In recognition of the value of his work, the British government awarded him the substantial sum of £10,000 in 1802 and a further £20,000 in 1807. He received tributes and presents from Napoleon, a man not normally noted for being well disposed towards the English, and from a delegation of North American Indian chiefs. His statue stands in Kensington Gardens. The 1840 Vaccination Act made the practice of inoculation with the disease itself illegal, free vaccination with cowpox being offered in its place, and in 1853 vaccination was made compulsory for all infants within four months of birth, a fine of £1 being imposed on parents who failed to comply. There were, however, no effective powers of enforcement, and the fine, once paid, put an end to the matter, which meant that reasonably wealthy families could flout the law, though poorer families, for whom £1 could amount to a week’s wages, were under greater pressure to comply.

The measure was fiercely resisted in some quarters by those who formed the Anti-Vaccination League and contended that it amounted to an unwarranted interference with the liberty of the subject. The 1867 Vaccination Act was more effective, again prohibiting the old practice of inoculation and imposing repeated fines for those who neglected to have their infants vaccinated. As late as 1871 the newspaper the Graphic praised one Anne Supple for refusing to ‘be a party to the poisoning of her baby’ when she was prosecuted for failing to have the child vaccinated during an epidemic that, over three years, claimed 44,000 lives. Local authorities like the London County Council gave further impetus to the vaccination movement by requiring a vaccination certificate from all citizens applying for public housing. Yet as late as 1898 the distinguished scientist Alfred Russell Wallace (1823–1913), who had shared with Charles Darwin the discovery of the mechanics of evolution, wrote a pamphlet entitled ‘Vaccination: A Delusion’.

SMALLPOX HOSPITALS

Outbreaks of smallpox continued to occur while the process of vaccination spread gradually through the population. In the meantime the disease was contained through the creation of isolation hospitals, to which sufferers would be sent in the hope that the uninfected population would thereby be protected. In the eighteenth century smallpox hospitals were set up by charities at places like Windmill Street, off Tottenham Court Road and Battle Bridge, on the present site of King’s Cross station, but as the population expanded these became too small. In 1867 the Metropolitan Asylums Board was established to care for London’s sick poor, and the board set about creating three hospitals funded by the ratepayers. They were constructed at Stockwell to the south and at Homerton and Hampstead to the north. The Hampstead site had a particularly interesting history. The site chosen lay just south of Hampstead Heath itself, which, by 1867, was becoming a fashionable residential area. The prospect of having as neighbours a multitude of highly infectious patients was very unattractive to the wealthy residents, whose opposition to the scheme was led by Sir Rowland Hill, inventor of the Penny Post, who lived nearby.

The site was nevertheless purchased in 1868, and was opened in 1870, using temporary buildings, to accommodate the victims of an outbreak of relapsing fever, transmitted by ticks, which had arisen in the East End of London. This condition, also known as ‘sweating sickness’, was characterised by a high temperature, nausea and severe headaches and about 30 per cent of sufferers died. It is now treated effectively by antibiotics but remains common in Ethiopia and the Sudan. The Hampstead hospital was, in effect, Britain’s first fully state-run hospital and could claim to be the first stirrings of the National Health Service that emerged eighty years later. By the end of 1870 the hospital was filled with smallpox victims who had been taken from workhouses and whose growing numbers caused further alarm to the local residents. In November 1871 The Times carried a report of a delegation to the Local Government Board in Whitehall led by the Hampstead MP Lord George Hamilton.10 The residents protested that the site was unsuited to such a use; that cases of smallpox had arisen among the local population that were attributed to the hospital; that holidaymakers frequenting the local pubs (including the celebrated Bull and Bush) were particularly vulnerable to infection and would carry the disease back to their own communities; that ‘property in Hampstead had deteriorated to the extent of £100,000 since the hospital had been there’; and that local traders had been adversely affected by the constant passage of ambulances and hearses. The residents even offered to pay the cost of having the hospital relocated elsewhere.

As a result of the petition a Parliamentary Select Committee examined the matter. It established that patients had communicated with local residents over the hospital walls and that ambulance men and relatives of the infected often stopped for refreshment at The George (which still stands on Haverstock Hill), thus providing opportunities for the local populace to become infected through contact. However, MPs concluded that these incidents did not amount to a reason for moving the hospital. The dispute rumbled on for several years, Rowland Hill’s part in the campaign being taken over by his son until the Metropolitan Asylums Board bought him off, literally, by purchasing his house and incorporating it in the hospital. After 1882 smallpox patients were accommodated on three ageing ships, Atlas, Endymion and Castalia, which were moored in the Thames near Dartford. The Hampstead hospital continued to be used to isolate and treat patients with infectious conditions like scarlet fever and was later used for polio victims. In 1948, with the creation of the National Health Service, the Hampstead hospital became part of the Royal Free Hospitals group, and in 1973 the Royal Free Hospital itself was moved from its site in Grays Inn Road to the Hampstead site, where it remains.

THE DEATH OF SMALLPOX

Smallpox was a long time dying. The mortality rate associated with the disease fell throughout the nineteenth century, the last major epidemic occurring in the late 1830s, when 2.3 persons per 1,000 contracted the disease: as many as 12,000 deaths per annum. Sir John Simon complained that vaccination rates fell away after epidemics and drew attention to ‘an appreciable amount of utterly incompetent vaccination’,11 which explains why, even in the last decade of the century, 30 per cent of smallpox deaths occurred among people who believed that they had been vaccinated. Nevertheless, by the 1870s the mortality amounted to less than one person in 2,000.12 In 1872 the Public Health Act established sanitary authorities in ports that could quarantine ships believed to contain passengers who were carrying infectious diseases, but as late as 1901–3 2,000 cases occurred in Liverpool as a result of unnotified cases arriving in the port. London’s final epidemic occurred in 1902. In October 1977 the last case of smallpox was recorded in an unvaccinated hospital cook in Somalia. In 1980 the World Health Organisation declared that smallpox had finally been eliminated from the population. Samples of the variola virus are kept in secure conditions in laboratories in Russia and the United States. The possibility of destroying them has been discussed, but they have been retained in case a new strain of disease emerges for whose cure an understanding of the workings of variola would be beneficial.

Other diseases were to prove more difficult to understand or manage.

TWO

A Nation of City-Dwellers

The stranger, during his visit, feels his breathing constrained, as though he were in a diving bell; and experiences afterwards a sensible and immediate relief as he emerges again into the comparatively open street.

(John Simon, London’s Medical Officer, describing a visit to a slum)

Of all the achievements of the Victorian era history will find none worthier of record than the efforts made to ameliorate the lives of the poor, to curb the ravages of disease and to secure for all pure air, food and water, all of which are connoted by the term ‘sanitation’.

(The journal Public Health on the occasion of Victoria’s jubilee, 1897)

THE MOVE TO THE CITIES

In 1801, at the time of the first census, Great Britain was primarily a nation of country dwellers. Of a national population of 10,686,000, about 30 per cent lived in towns and cities. London accounted for 959,000 of these. By 1851 the figure had risen to 54 per cent, and in 1901, at the end of Victoria’s long reign, 78 per cent of the population were town or city-dwellers. In the course of one century the average Briton had moved from being a countryman to a townsman.1 Moreover, in the same period the total population of Great Britain had almost quadrupled, so the move to the towns was further augmented by this unprecedented growth in numbers. London itself had experienced a sixfold increase in population by the time of Victoria’s death in 1901 and was by far the greatest metropolis the world had ever seen, but other cities, though smaller, had seen an even greater increase in population and in the consequent pressure on their resources. The figures in the following table speak for themselves.2

Population of

Census years

1801

1851

1901

Liverpool

82,000

376,000

704,000

Birmingham

71,000

233,000

522,000

Manchester

75,000

303,000

645,000

Glasgow

77,000

345,000

762,000

Sheffield

46,000

135,000

409,000

This movement of population did not proceed at a steady pace throughout the century. The great port cities of Glasgow and Liverpool were overwhelmed by waves of Irish immigrants during the potato famine of the 1840s. There was a further surge from the 1870s when the government’s free trade policies led to the importation of cheap food from America and the Empire, causing a serious depression in Britain’s farming sector and what one writer has described as a stampede to the towns by unemployed agricultural workers.3 The communities receiving this human tide were in no condition to accommodate the new arrivals who had come to work in Blake’s ‘dark, satanic mills’. Before the passing of the Municipal Corporations Act in 1835 most of the affairs of local government were conducted by magistrates, and the role of government of any kind in matters of sanitation, water supply or public health was barely recognised. In the disapproving words of G.M.Trevelyan, the first serious writer of English social history, the process of urbanisation was characterised by ‘a rampant individualism, inspired by no idea beyond quick money returns … Town planning, sanitation and amenity were things undreamt of by the vulgarian makers of the new world.’4 This is not to suggest that dwelling conditions in the countryside were ideal. William Cobbett, scourge of London, ‘The great Wen’, and of town-dwellers, described the village of Cricklade in Wiltshire as ‘that villainous hole’ and added that its agricultural labourers ‘seem miserably poor. Their dwellings are little better than pig beds and their looks indicate that their food is not nearly equal to that of a pig.’5 This is no rural idyll, but at least in the countryside fresh food was near at hand and the population could dispose of its relatively small quantities of human waste by depositing it on the surrounding fields of grateful farmers. The absence of fields and farmers from the great urban communities was to have fatal consequences for many of the century’s townsmen when the great cholera epidemics struck.

DEATH IN THE CITY

The urbanisation of the population was not accompanied by a corresponding improvement in the facilities for the new residents. It has been estimated that for about forty years after 1780 crude death rates fell and life expectancy increased,6 but the statistician William Farr, who campaigned for better public health measures,7 observed that this encouraging trend was reversed from about 1816. Nevertheless, at the outset of his career as Compiler of Abstracts (Chief Statistician) to the Registrar-General, he struck an optimistic note, writing in his second annual report: ‘There is reason to believe that the aggregation of mankind in towns is not inevitably disastrous.’8

The unwelcome upturn in mortality rates that Farr had observed coincided with a series of poor harvests, the release of many soldiers and sailors at the end of the Napoleonic Wars on to a market short of jobs, and the gathering pace of the movement to the towns and cities.9 Death rates were 22.4 per 1,000 population in 1838 as William Farr began his work as chief statistician to the Registrar of Births, Marriages and Deaths, and they remained above 20 until the 1880s, falling to 15 in the first decade of the twentieth century.10 Children were particularly vulnerable. An examination of Farr’s annual reports and those of his successors reveals the depressing fact that more than 15 per cent of children failed to reach their first birthday throughout the nineteenth century, and Farr’s attitude to this problem was at times fatalistic. Writing of the depressing levels of infant mortality, he commented that infants were ‘feeble; they are unfinished; the molecules and fibres of brain, muscle, bone are loosely strung together … It is not surprising that a certain number of infants should die.’11 Farr had worked as a surgeon’s assistant and qualified as an apothecary early in his career, though he never practised in either capacity, and one can only assume that these highly unscientific judgements were based on his own observations. The ‘certain number’ began to fall only in 1902, as new regulations governing the training of midwives began to take effect.12

The difference in death rates between rural and urban areas was remarked upon by many commentators, beginning with the Lancet, which in 1843 published the following information on the average ages at death of different social groups in rural Rutland and rapidly expanding Liverpool.13

Area

Ages at death (years)

Gentry

Farmers and tradesmen

Labourers and artisans

Rutland

52

41

38

Liverpool

35

22

15

William Farr seized upon the information he compiled to draw attention to the high incidence of premature death in towns and cities and published league tables of mortality with the intention of shaming municipal authorities into measures to improve public health. Preston in Lancashire was one of the most dangerous towns in the kingdom for infants, since more than 20 per cent of them failed to reach their first birthday. London was safer at just under 16 per cent, but Farr went further and showed that, within the metropolitan area, a child’s chance of dying was much greater if he was born in the East End than in Hampstead, while life expectancy for those fortunate enough to survive childhood was almost forty years in the wealthy parish of St George’s, Hanover Square, compared with thirty-four in the East End parish of Whitechapel.14 One of the most dangerous things that could happen to a sick city-dweller was to be sent to hospital. Upon her return from the Crimean War, Florence Nightingale reflected upon her experiences there and the effects of good hygiene upon the survival rate of the casualties for whom she had cared. In her book Notes on Hospitals she commented:

It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm. It is quite necessary nevertheless to lay down such a principle, because the actual mortality in hospitals, especially those of large crowded cities, is very much higher than any calculation founded on the mortality of the same class of patient treated out of hospital would lead us to expect.15

She was also acutely aware of the shortcomings of the system of Medical Officers of Health. She described the position as ‘a busy man with a private practice covering a very large area, who earns a pittance for doing a most important public duty’,16 and in her 1894 work ‘Health Teaching in Towns and Villages’17 proposed to supplement him with ‘a fully trained nurse for every district and a health missioner’. The ‘health missioners’ would be women of good character and education who would undergo a course of fifteen lectures by the Medical Officer and would visit people in their homes and give instruction on hygiene and sanitation to prevent illnesses from arising. In her own words: ‘Not Bacteriology but looking into the drains is the thing needed.’18 The first ‘missioners’ (later called health visitors) were trained in Buckinghamshire, where Florence Nightingale lived, and they began work in the 1890s.

In 1891 one of Farr’s successors compared the fates of 100,000 children born in the rural counties of Hertfordshire, Dorset and Wiltshire with a similar number born in the textile towns of Blackburn, Preston and Leicester. More than 90 per cent of the country-born children reached their first birthday, while only 78 per cent of the children born in towns did so.19 The Lancet further drew attention to the ghoulish fact that some parents were well prepared to benefit from the vulnerability of their infants. It cited one father who, in 1861, received the considerable sum of £34 3s by subscribing to numerous infant burial clubs.20