Defeating Diarrhea with Household Hygiene

In Birmingham, Alfred Hill followed a Chadwickian model that tended to eschew private interventions. He believed that minimizing the spread of diarrhea-causing microbes required large-scale sanitary engineering. When Hill considered all three of Ballard’s etiological categories, he concluded that “many infant lives are undoubtedly sacrificed through bad feeding, and this factor is no doubt accentuated in hot weather.”3Hill, Report on the Health of the City of Birmingham for the Year 1897, 23. Yet, Hill lamented that climatic and most social conditions were beyond his power or that of the sanitary authority to control. Instead, he urged the sanitary authority to improve “all insanitary [local] conditions it can” to mitigate the threat of summer diarrhea.4Hill, Report on the Health of the City of Birmingham for the Year 1897, 23. For example, in his 1893 report, Hill listed numerous municipal sanitary improvements that he believed might lessen diarrheal mortality. Among these, he supported the regular removal of liquid filth from residences by proper sewer drainage and the daily removal of the contents of ash pits (pit toilets in which in piles of human excrement were buried with ash to mask the odor and disinfect the waste), dustbins, and dung pits that not were not naturally cleansed by drainage. Hill believed that the consistent cleanliness of “the interior of domestic premises” and that sealing the ground around dwellings (ideally with cement or concrete) would maintain the cleanliness and dryness of the soil that would prevent microbial growth. He urged city planners to lay out streets and buildings to allow for the “free ventilation” of the air from both the front and back of houses. He ordered dairy farmers to pave cowsheds and regularly remove manure and filth from milking areas. He also discouraged families from storing milk on the ground floor or in the cellar of a dwelling, where it could be exposed to contaminants in the soil or air.5Hill, Report on the Health of the City of Birmingham for the Year 1893, 17–19.

Yet, when diarrheal deaths surged to their highest on record (1,444) in 1897, Hill reported that “a great deal of work has yet to be done before the town can be considered to be in a satisfactory sanitary state.”6Hill, Report on the Health of the City of Birmingham for the Year 1897, 5. Diarrheal death rates were especially high per capita in the oldest, poorest, and least sanitary wards of the city: St. Mary’s (16.9 per 1,000) and St. Bartholomew’s (18.6 per 1,000). From this data, Hill seemingly affirmed his conclusions that environmental conditions (such as atmospheric temperature) alone did not influence the spread of summer diarrhea; local conditions also had to be a factor. In these districts, flushing toilets were rare, many streets were unpaved, and poorly ventilated, back-to-back houses exacerbated ecological hazards.7Hill, Report on the Health of the City of Birmingham for the Year 1897, 22. In response to the surge in diarrheal deaths, Hill ordered a sanitary inspection of five hundred houses in which diarrheal deaths had occurred in just one month (August) – the worst month of the outbreak – to assess how domestic conditions had exacerbated the outbreak. Inspectors found that a majority (60.2 percent) of the deaths had occurred in small houses of three rooms or less. Inspections also found that many of these houses were poorly ventilated and lacked a back door or window (58 percent); a majority (60 percent) used pan privies – dry toilets commonly found in working-class housing which consisted of a seat over a bucket (the pan) into which one would defecate, which needed to be regularly collected and removed lest it became a haven for bacterial growth; and that 31.6 percent of diarrheal deaths had occurred in houses that had unpaved courts or yards surrounding them.8Hill, Report on the Health of the City of Birmingham for the Year 1893, 21.

Two years later, in another survey of another five hundred houses in which diarrheal deaths had occurred, Hill’s staff once again found that the majority (60.2 percent) had occurred in houses of three rooms or less, that many of these houses (56.4 percent) only had ventilation from the front, and that a substantial minority (47.6 percent) had pan privies rather than water closets. This data was deeply troubling for Hill, who believed that ash pit privies must be replaced, as they permitted the slow accumulation of filth over a long period of time, resulting in “fouling . . . both the air and the ground.”9Hill, Report on the Health of the City of Birmingham for the Year 1899, 26–27.

Hill’s suggestions for sanitary reform reflect his Chadwickian proclivities. Lamenting that Birmingham held an “increasingly unsatisfactory position . . . amongst the great towns” in 1897, he urged local authorities that “sanitary improvements should be pressed forward as quickly as possible.”10Hill, Report on the Health of the City of Birmingham for the Year 1897, 3. He argued that the city should bear the cost of paving streets and converting unsanitary waste receptacles like pan privies into water closets. With regards to ventilation, he argued that “the full healthiness of many parts of the town can never be adequately secured until more space is obtained around the dwellings,” which he believed required a space of at least twenty feet in front of them.11Hill, Report on the Health of the City of Birmingham for the Year 1897, 8. Thus, Hill went so far as to press for the demolition of overcrowded or ill-ventilated dwellings, where the poorest classes were forced to reside. However, he conceded that such a project would have to be small in scale to be affordable and supplemented by more modest sanitary improvements to existing houses.12Hill, Report on the Health of the City of Birmingham for the Year 1897, 25. In either case, municipal authorities would have to fund the work.

Given that the local authorities in Birmingham who first appointed Hill in 1873 favored public works as a matter of public health, it is not terribly surprising that in his annual reports Hill emphasized municipal sanitary and residential reforms as the key to mitigating diarrhea. This was what the local government in Birmingham would have been willing to fund. Curiously, though, in the opening of his 1897 annual report Hill also advocated for “increasing the number of inspectors and making some re-arrangements of their duties” so that much more “sanitary work [could be] accomplished during the year.”13Hill, Report on the Health of the City of Birmingham for the Year 1897, 3. In so doing, Hill asked the local government to pour more resources into public health, thus increasing the responsibility of the state for the protection of children’s health. As inspections often focused on assessing the sanitary conditions of individual households, this indicates that Hill might have been slowly developing an increased concern about the social conditions inside the English household as well. The appointment of the first professional health visitors in Birmingham two years later, in 1899 (which we will return to in the next chapter), was one important outcome.

All and all, in Birmingham, Alfred Hill’s focus on sanitary reforms surely would have begun to remove the refuse that gave flies a refuge in poor urban neighborhoods. This alone was an important feature of the campaign against summer diarrhea during its peak years in the 1890s. However, when we consider Hill’s efforts in comparison to those of his colleagues in Manchester and Liverpool, his seemingly sole emphasis on sanitary reforms as the most effective means of preventing summer diarrhea was comparatively narrow. In Manchester, by contrast, James Niven took far greater efforts to try to supplement municipal sanitary reforms with more intimate domestic interventions – and these more intimate interventions were really the key to meaningfully reducing infant mortality rates, especially from deaths due to summer diarrhea, by the outbreak of the First World War.

When Niven assumed his position as Manchester’s Medical Officer of Health in 1894, the lingering hazards of court housing still created a foul urban ecosystem, in which defective drains made “the air oppressive and malodorous.”14Niven, Observations on the History of Public Health Effort in Manchester, 4. In Hulme, Niven recalled, waste “collected in midden privies in the courts at the ends outside the houses, and in the narrow back passages behind houses. Often as many as six to eight houses were served by one privy.”15Niven, Observations on the History of Public Health Effort in Manchester, 2. As we saw in Figure 2.4, diarrheal deaths initially rose rather than fell under Niven’s tenure. In 1897, 933 deaths from summer diarrhea occurred in Manchester (1.19 per 1,000 living), which was nearly double the national average (0.64 per 1,000).16Niven, Report on the Health of the City of Manchester, 1897, 114. The following year, the diarrheal deaths rose to a level not seen since 1872 claiming 1,060 lives with a mortality rate of 1.96 per 1,000 living, which was again well above the national average (0.72 per 1,000).17Niven, Report on the Health of the City of Manchester, 1898, 107–9. By 1899, the death rate due to summer diarrhea rose higher still, claiming the lives of 1,121 residents of Manchester (2.05 per 1,000 living), including those of 840 children under one year of age.18Niven, Report on the Health of the City of Manchester, 1899, 92–93, 98.

In part, Niven attributed this surge in diarrheal deaths to a series of hot, dry summers, which resulted in fouling soil near ash pits and midden privies. Niven urged the sanitary authorities to rinse filth from streets and courtyards in warm, dry weather, a practice which he adopted from his colleague E.W. Hope in Liverpool.19Niven, Report on the Health of the City of Manchester, 1899, 95. In addition, like Hill, Niven argued that replacing privies with flushing water closets would more efficiently remove excreta and refuse from houses, courts, and alleys. This redevelopment was an ongoing process in Manchester in 1899 – and a step in the right direction in reducing summer diarrhea. He believed that when dust from filth (or excrement) became airborne, especially in ill-ventilated homes, this greatly increased the conduction of the microbes that caused summer diarrhea.20Niven, Report on the Health of the City of Manchester, 1899, 100. Niven grounded his arguments empirically and geographically, highlighting examples from Bradford and West Gorton, the two districts with the highest diarrhea death rates in 1899 (3.37 per 1,000 and 3.01 per 1,000, respectively), which disproportionately lacked a water-borne solid waste removal system, instead relying primarily on midden privies adjacent to houses to collect waste.21Niven, Report on the Health of the City of Manchester, 1899, 93, 101

Aware that piles of waste were a favorable ecological niche for flies, Niven understood their role as a likely vector. But he placed an even greater emphasis on social conditions as a cause of summer diarrheal deaths. Specifically, he focused his attention on foodstuffs that flies easily contaminated. Niven made his opinion quite clear in his first annual report, in which he wrote that “[d]iarrhoea is a disease eminently dependent on filth conditions, and also on careless feeding . . . If in any district the mortality from diarrhea is exceptionally high, it would be safe to assume that both causes are in operation.”22Niven, Report on the Health of Greater Manchester, 1894, 58. Niven argued that “with rare exceptions, breast fed children do not die of the condition,” because summer diarrhea was most often spread via contaminated milk. Therefore, he believed it was “a preventable disease” if milk supplies were properly attended to.23Niven, Report on the Health of the City of Manchester, 1895, 68.

Managing milk supplies became a central tenet of Niven’s efforts to combat summer diarrhea. He reasoned that exposure to the dust in air or filth-carrying flies were the main sources of contamination of milk supplies. Milk was also susceptible to contamination during transport from the dairy farm into the city, especially when a delivery was delayed, or on the farm itself if cowsheds were not regularly cleaned before milking. Thus, Niven insisted that milk imported into the city of Manchester should be regularly tested for quality and cleanliness, and that milk “unfit for the food of man” be seized by the city.24Niven, Report on the Health of the City of Manchester, 1899, 100. Monitoring the city’s imported milk supplies was well within Niven’s purview as the Medical Officer of Health, but monitoring milk supplies in the home was a much more “intrusive” act, to which we will return in the next chapter.

Liverpool’s Medical Officer of Health, E.W. Hope, adopted something of a middle ground. Hope’s approach to mitigating summer diarrhea began with an expansion of urban sanitation, building on the ideas of Hill in Birmingham. Yet, he also agreed with Niven that “infantile mortality from diseases of the bowels is very dependent on domestic conditions.”25Hope, Report on the Health of Liverpool during 1895, 14. Hope believed that “the manner of feeding is of the first importance,” suggesting in his 1895 annual report that infants fed with cow’s milk rather breastfed were fifteen times more likely to die than “infants reared . . . in the natural manner.”26Hope, Report on the Health of Liverpool during 1895, 14. This disparity was further influenced by social class. In upper-class families, the absence of breast milk was less problematic because these families often had the servants and resources to exercise care in the preparation of foodstuffs for children. Among working-class families, who fed their children whatever milk supplies they could afford and lived in housing conditions that created favorable ecologies for the growth and spread of pathogens, the risk of contaminated cow’s milk was substantially greater.27Hawes, “The Development of Municipal Infant Welfare Services in St Helens,” 168. Thus, Hope insisted that the utmost care had to be taken when providing a child with foodstuffs such as cow’s milk, to ensure that the milk was absolutely fresh, served at the natural temperature, and not exposed to airborne contaminants.28Hope, Report on the Health of the City of Liverpool during 1898, 41, 120. However, Hope lamented that sanitary authorities had little ability to actually manage foodstuffs and methods of feeding, because sanitary authorities had limited access to the English home.29Hope, Report on the Health of Liverpool during 1895, 14.

Hope believed that city-wide sanitation and in-home efforts like the careful storage of foodstuffs had to go hand in hand to prevent deadly infantile diarrhea. As Medical Officer of Health, he believed he could directly control only the former. Intervening in the household, however, was far more difficult. So, Hope sought to remind Liverpudlians that when food is exposed to dust or other particulates of fecal matter this could “give rise to fatal inflammatory diseases of the stomach and the bowels . . . and it is this kind of filth which of all others should be speedily and effectually washed away from the dwelling.” To do this, Hope annually distributed a memorandum among the poorest residents of the city (though it is unclear whether he considered their literacy). In his memo he advised residents on how best to feed and clothe infants to prevent exposure to deadly contaminants. Hope’s memo advised on matters of domestic sanitation as well: “the water-closet should be repeatedly and thoroughly flushed, and sinks and drains kept clean by frequent flushing each day. A free and unstinted use of water is far better than any disinfectant.”30Hope, Report on the Health of Liverpool during 1897, 43.

It is not possible to measure the impact of the memorandum directly. What is important to consider, though, is that Hope sought to intervene in the domestic environment by educating working-class parents about material dangers to their children’s health. But a memorandum was just a first step. As we will consider in the next chapter, in-home education conducted by health visitors would become a far more impactful component of the campaign to curb summer diarrhea and helped to seriously reduce England’s infant mortality in the first decades of the twentieth century.