Chapter Two Flies and Feces

On the most basic level, “summer diarrhea” (sometimes also called cholera infantum) was a disease state defined by its symptoms: cramps, body aches, and fluid loss due to vomiting and diarrhea that resulted in rapid dehydration and potentially renal insufficiency (kidney failure). In adults, rehydration typically made diarrheal diseases treatable, but in infants this rapid dehydration could be fatal.3Buchanan, “Infant Feeding, Sanitation and Diarrhea in Colliery Communities,” 149. For those children who contracted summer diarrhea and survived, infection often resulted in enfeebled growth or a weakened immune system, increasing their susceptibility to further infections.4Biehler, Pests in the City, 48. George Buchanan, Chief Medical Officer of the Local Government Board, described summer diarrhea in 1887 as “habitually the most fatal disease of all the so-called ‘zymotic diseases’” and “the most frequent cause of death out of all designated causes” excluding convulsions and bronchitis, despite many years of important sanitary work.5Supplement in Continuation of the Report of the Report of the Medical Officer for 1887: Diarrhoea and Diphtheria, iii. Following only premature birth and respiratory infection, summer diarrhea perennially ranked as the third leading cause of death among British infants.

In our three case-study cities, Birmingham, Liverpool, and Manchester, summer diarrhea claimed the lives of 23,689 children in the last decade of the nineteenth century alone, exceeding cumulative measles deaths (9,688) for the same period by 14,001, and was a major contributing factor to the rising infant mortality rate. Then, over the first three decades of the twentieth century, as shown in Figure 2.1, despite the special attention public health administrators paid to this disease, it still claimed the lives of over another 50,000 children across the three cities.

While the particular pathogen(s) responsible for summer diarrhea, which likely encompassed a range of intestinal bacteria (such as Salmonella, B. dysenteriae or E. coli) and viruses (likely rotavirus or norovirus), remained unknown to contemporaries, late nineteenth-century epidemiology led the Medical Officers of Health to believe that a range of environmental and human behavioral factors contributed to the ebb and flow of cases and mortality rates from year to year.6Hardy, Salmonella Infections, 72; Webb, The Guts of the Matter also provides an excellent overview of the history of intestinal diseases, including those that likely caused infantile diarrheal mortality. This is historically significant. As the Medical Officers of Health came to realize this, they began to annually collect data on the environmental conditions that influenced the spread of summer diarrhea. Considering their own ecological data invites us to consider the importance of the local ecologies that influenced the spread of pathogens and reinforced the importance of localized, targeted sanitary reforms.

Conventionally, the Medical Officers of Health thought that the pathogen(s) responsible for summer diarrhea inhabited fouled soil, and that its annual severity was based on local climatic conditions.7Tatham, Report on the Health of Greater Manchester, 1891–1893, 70. Yet, while annual climatic conditions ranging from fluctuations in temperature and rainfall could be used as a predictor of the severity of summer diarrhea from year to year, human ecological factors were equally influential, if not more so, on summer diarrhea mortality. Once the mysterious microbe reached the surface it could become airborne, carried on the feet of flies that carried the microbe into the micro-environment of the English home.8Otter, Breyfogle, and Brooke, “Forum Introduction,” 718, makes the powerful argument that we must consider the built environment itself as an ecological niche: they argue that the “human built world . . . provides an elaborate set of networks within which a range of disease agents emerges and circulates. Human health is now maintained or disturbed within the complex niches we have constructed for ourselves.” I want to suggest that the Victorian working-class home is one such niche that we should historicize because it was the epicenter of the threat of summer diarrhea. When flies landed in food, especially milk, in badly ventilated pantries, they passed the pathogen on to children. As the Medical Officers of Health came to this realization, they began to extend public health into the Victorian home, especially in the most densely populated, economically poorest districts of their cities, where the prevalence of summer diarrheal mortality was often highest.9Hill, Report on the Health of the City of Birmingham for the Year 1898, 27. In tracing how the Medical Officers of Health increased public health efforts to combat summer diarrhea, we will see how they began expanding “the providence of public health” and “the guardianship of [local] government” into the English household.10Hardy, “Public Health and the Expert,” 132. As a result, the case study of summer diarrhea allows us to consider all three aspects of my argument: the importance of place in the history of public health, the ways in which public health systems were expanding in the last decades of the nineteenth century, and the slowly increasing role of the state in directing the scope and aims of public health.