5: The Historiography of Social Medical Improvement
Until recently the historiography of social medical history had been dominated by a nutritional interpretation of Britain's mortality decline. McKeown demonstrated the central importance of gradually rising living standards, as expressed through increases in per capita nutritional consumption, as a means of understanding declining patterns of disease.77 For such nutritionists the impact of the local public health movement was strictly limited, leading only to nominal decreases in the waterborne diseases of cholera, typhoid and diarrhoea. The decline in the incidence of mortality from airborne diseases, such as tuberculosis and scarlet fever, was considered to be beyond the beneficial effect of nineteenth-century sanitary improvement, and that such a decrease could only have been the result of improvements in the population's nutritional intake.78
Recently a revisionist interpretation has emerged.79 Szreter has stressed that McKeown's emphasis on the fall in airborne diseases as the leading epidemiological feature, both as fact and as a primary product of dietary standards, needs reassessing. Others have noted that the declining incidence of the airborne diseases scarlet fever and smallpox was more a response to inoculation and variations in the virulence of the pathogen itself than to changing nutritional habits.80 Szreter points out that deaths through the airborne diseases of pneumonia and influenza actually increased until the 1930s: this is confirmed for Bristol by Figure 4. More importantly Szreter attacked McKeown's belief that the fall in the incidence of tuberculosis was already occurring before the sanitary improvements of the mid to late nineteenth century.81
Figure 4 does indeed seem to support McKeown, with a general decline of the disease in evidence for Bristol from at least the late 1830s, thirty years before the city's major sanitary reforms in sewerage and water supply. However, as both Szreter and Hardy make clear, the use of the Register General's figures for tuberculosis in this early period should be used with some caution.82 Problems of diagnosis and certification led to the aggregation of both phthisis (respiratory tuberculosis) and bronchitis in the Registrar General's figures for this crucial mid-century period. For Szreter, McKeown's mid-nineteenth century decline of mortality through tuberculosis was simply a statistical aberration or blip. Hardy goes further:
This, together with the counter-trend for the mortality rates for bronchitis, influenza and pneumonia, has led Szreter to reinterpret the epidemiological events of the late nineteenth and early twentieth centuries. With the central theory of declining airborne diseases disparaged, Szreter claims that it was the decline of the waterborne diseases, cholera, typhoid and diarrhoea, through the implementation of local sanitary reform that stands out as the most striking epidemiological feature of the period.84 Through such a re-evaluation, the nineteenth-century public health movement now became a significant and integral component of improving mortality rates.
An understanding of the impact of sanitary reform within urban environments requires analysis of developments at that level - a task that this Abstract goes some way to achieving. For Szreter the achievements of the public health movement were impressive and sustained. The increasing powers handed over to local authorities from the 1860s onwards allowed them to deal effectively with some of the most pressing sanitary issues confronting the urban environment, leading to the almost complete eradication of typhoid, cholera and smallpox by the end of the century.85 However, the limits of this improvement were clearly delineated, as much of the nineteenth-century reforms did little to alleviate the condition of housing or reduce the incidence of food-borne and airborne diseases such as diarrhoea and influenza. These improvements only came during the early years of the twentieth century, but were again achieved through the auspices of local government as municipal town-planning initiatives, and the growth of local health and maternity services. Coterminous with this was a growing awareness of the significance of personal hygiene, especially in regards to infant mortality, an approach influenced strongly by the work of Sidney and Beatrice Webb, and actively taken up by local authorities.86 For Szreter then, local government was the central component in the sanitary improvements exhibited throughout the last quarter of the nineteenth century and into the inter-war period.
However, it is apparent that studies of local areas reveal a greater degree of complexity and variation in approaches to sanitary reform than Szreter has recognised. As has already been shown, the separation of authority between the Urban Sanitary Authority, MOH, GRO and central government could produce real tension as each operated according to their own specific agenda.
Conclusions drawn from Figure 6 suggest that Bristol's mortality rate from the seven principal infectious diseases was highly favourable relative to the national experience, especially for the nineteenth century. However, as this Abstract shows, Bristol's own medical history was far more complex than might be supposed from Figures 1, 2 and 3. Figure 7 shows the incidence of mortality from six principle 'diseases of poverty', smoothed using a moving average with a periodicity of three years. Since certain data for London could not be found, tuberculosis is not included. Again the lower rate of mortality for Bristol is evident, although the three distinct peaks associated with outbreaks of scarlet fever in Bristol in 1863, 1869-79 and 1875-6 push the average well-above that registered for the capital. It is this particularly high incidence of scarlet fever in Bristol which forms the core of this case study.
Of course, Bristol did have its own industrial quagmires - fever nests in industrially-scarred areas of the city such as parts of the parishes of SS. Philip's and Jacob's and Bedminster which appeared beyond the assistance of the MOH. As has been alluded to, by the beginning of the twentieth century Bristol's housing policy was in dire need of reform. Pressure was growing on the Sanitary Authority to implement the powers of the Artisan's and Labourer's Dwelling Act to remove the slum areas of Bedminster, St. George and central Bristol, a policy option that remained largely ignored until the 1930s. Thus it would be wrong to assume that Bristol's health record was particularly benign. The city suffered from a series of epidemics - outbreaks that were helped by a particularly obscurantist local government, and a consequently emasculated MOH who appeared unwilling to accept the social and economic dynamic underpinning much of the disease prevalent in the city.
Bristol's abnormally high mortality rate in the years 1863, 1869-70 and 1875-6 was primarily due to the impact of a single disease, scarlet fever. As a disease of the young scarlet fever is rarely fatal today but it remained one of the major killers throughout much of the nineteenth century. The Registrar General always counted scarlet fever as one of the major 'zymotic' diseases, and deaths from the disease were consistently recorded in the RG's Reports. It was also one of the first diseases to be classed as compulsorily notifiable after 1889. The cyclical nature of the disease has been studied by Duncan, Duncan and Scott who found an interval of 5-6 years between each national epidemic, closely correlated to the price of wheat two years before, a lag which they suggest indicates a link between foetal health and development and subsequent reduced resistance to infected illness on the part of the young child.87
The local impact of this disease is clearly shown in Figure 8, particularly in the years 1863 and 1870 when Bristol repeatedly suffered a far higher mortality rate from scarlet fever than did either London or the country as a whole. In the outbreak of 1869-70, for instance, over 500 people per 100,000 of the population were dying from the disease annually in Bristol; this compared to less than 200 per 100,000 in London. Conversely between these epidemics the incidence of scarlet fever in Bristol fell dramatically to levels lower than those in London.
Scarlet fever was to haunt Bristol just as the city's fathers were drawing attention to the sanitary improvements which they felt had been achieved since the 1840s. The most severe outbreak of scarlet fever occurred in 1869 and 1870, a mere four years after the appointment of the city's first MOH, Dr David Davies, in 1865. Such was the ebullience of local opinion at that time that the editorial of the Western Daily Press boasted on 28th September 1869 that 'Bristol has been converted from one of the most unhealthy to one of the healthiest towns in the world'.88 Within a week, on 2nd October, the Western Daily Press was to return to this congratulatory theme, stating that 'we now enjoy a comparative immunity from diseases to which we were formerly incident, and to which sundry other large towns in the Kingdom, whose tactics do not assimilate to ours, are still painfully liable'.89 It concluded that Bristol might be 'justified in appropriating to herself the title of the Hygienic Metropolis of Great Britain'. Combined with financial stringency, such self-satisfied complacency on the part of the city's bourgeoisie was to prove a major hindrance to sanitary progress. The Western Daily Press not only ignored the major scarlet fever epidemic of 1863 but its glowing editorials appeared on the eve of the worst recorded outbreak of the disease which was to kill at least 925 individuals, mostly children, before the end of 1870.
What is apparent however is the highly cyclical incidence of approximately six years for scarlet fever in Bristol and London, and the consequences of this characteristic on the national picture. It seems evident that each epidemic seriously depleted the cohort of susceptible infants, after which the disease remained endemic within society, only reappearing as an epidemic again after the augmentation of that most susceptible age cohort.
The incidence of death from scarlet fever was generally uniform across the three unions of the city. Only in the 1869-70 outbreak was there a marked disparity when over 1,000 per 100,000 of Clifton's population died from the disease. By contrast the two other unions of Bristol and Bedminster recorded levels at less than half this rate. Although all three unions contained areas stricken by poverty, data for individual districts is harder to find. Disaggregation for the 1875 outbreak reveals that the wards of St Philip, St Paul, Bedminster and St Mary Redcliffe suffered the highest mortality. In 1887 it was St Philip, St Augustine, St Paul, Ashley and Bedminster which suffered most.
The successful prevention of scarlet fever remained beyond medical science until the early twentieth century, by which time isolation and hospital treatment for the disease had become common place. Although the incidence of the disease was to decrease markedly in the last years of the nineteenth century, to Bristol's MOH the situation in February 1885 remained bleak:
Davies was not alone in his pessimism. The MOH for the Privy Council, Dr John Simon, if anything, went further in his pessimism:
Bristol's variable mortality record had not gone unnoticed among the nation's medical profession. The Lancet of 29th January 1870 noted that mortality in Bristol had been 'remarkably high' for some time, and that its death rate had been higher the previous week than in any other of the large towns.92 Although a direct reference to scarlet fever had not been made, The Lancet of November 1875 reported that scarlet fever had been 'remarkably fatal' in Bristol, noting the high incidence among the most crowded districts of the city such as St Mary Redcliffe and St Philip.93 Finally in the 1887 scarlet fever outbreak, Bristol was again made noteworthy by having a higher rate of mortality from the disease than any districts in London.94
Yet Bristol's local authorities and the press appeared reluctant to recognise the extent of fatality from the disease. Not one local contemporary source has been found which highlights the seriousness and regularity of scarlet fever in Bristol. These repeatedly significant outbreaks seriously undermined the efficacy of Dr Davies's own work as the MOH. Perhaps it is not surprising then that his reports contain little detail about such appalling epidemics. Perhaps it is more surprising that historical analysis appears to have taken these reports at face value rather than provide an investigation of the mortality statistics recorded by the RG's Reports.95 However, this omission by Dr Davies provides clear evidence of the political agenda followed by Bristol's MOH, at least until the 1880s. This link between the MOH and local government was further highlighted in August 1878 when an outbreak of scarlet fever in Napier Street, Clyde Road, Grafton Street, Doveton Street and adjoining parts in St. Philip's led the MOH to respond with surprising conviction that the outbreak was certainly not due to the water supply, the water from Bristol Water Company being 'above suspicion and from a source above human contamination'.96 Before the isolation of the 'common bacillus' of cholera by Koch in 1883, certainty about the spread of any disease was misplaced. However, as Hamlin has shown for London, the ownership of the water supply could be a highly politicised issue on which expert medical opinion was used tendentiously.97 What is certainly true is that Dr Davies's comments of 1878 came as the Town Council was engaged in heated debate over a proposal to acquire the Water Company.98
In fact Dr Davies's reports of the previous year were the subject of direct criticism from a contemporary national sanitary journal, the Sanitary Record, which was reprinted in the Western Daily Press. In particular the article noted that Bristol's death-rate was stationary, rather than declining.
Interestingly the two localities isolated by the Bristol Board of Guardians were not included by the Western Daily Press in their report and there was no direct response by Dr Davies himself in any subsequent report.
It may well be that the Sanitary Record was a mouthpiece of the GRO. If so, then its conclusions should be closely scrutinised, as Szreter has argued. Until the 1880s the GRO was particularly keen in pushing its own doctrine of sanitary improvement at the local level and felt no compunction in utilising the full weight of its statistical records to manipulate local authorities.100 The article in the Sanitary Report, so critical of Dr Davies, may be an example of such attempted manipulation.
Clearly then the progress of sanitary reform in Bristol by the 1880s needs careful evaluation. Although historians such as Large and Round have explicated some of the basic sanitary reforms conducted by both the Local Board of Public Health and the Sanitary Health Authority, it is also apparent that the alarming incidence of scarlet fever identified in this Abstract speak of a city far removed from that described by the complacent bourgeois descriptions of the day. That this complacency excited the interest of a national journal such as Sanitary Record, and that the MOH appeared complicit, are important although hitherto neglected aspects of Bristol's sanitary history.
By the early 1880s it is clear that Dr Davies was asserting a level of independence hitherto missing from his reports. In 1883 his quarterly report to the Town Council on scarlet fever criticised the ignorance of the population in their belief that the spread of the disease was simply the 'Lord's Will' and that it was caused singularly by sanitary defects.
The growing confidence of Dr Davies is evident from this attack upon the press, a medium that had previously been a most useful ally, as examples from the editorials cited above testify. However, it is also clear that by 1883 the pro-Liberal Western Daily Press had begun a concerted campaign against what it saw as the iniquities of the prolonged Conservative dominance of the Council Chamber. In the 1880s inadequate sanitary reform therefore became a sensitive political issue that the Liberal Party was able to deploy with some success among the expanding ranks of the late-nineteenth-century municipal electorate.102 His Report continues with a recognition of the problems of isolating sufferers of scarlet fever within working class areas of the city:
Although the issues of overcrowding and slum clearance were beginning to enter the political debate by this time, Dr Davies remained decidedly uncritical of the city's working-class housing conditions; and even as late as 1906 his son, as MOH, was to question the link between preventable disease and overcrowding.103
However it appears that Dr Davies was less than happy with the number of isolation beds available to him to combat such infectious diseases as scarlet fever. During the 1881 epidemic of scarlet fever Dr Davies openly linked the issue of isolation wards within the city to the issue of compulsory notification.
In effect this amounted to a thinly-disguised attack upon the Sanitary Authority itself. Davies's direct linking of notification with full preventive powers was an attempt to increase the city's medical facilities at his disposal, and in particular to increase the number of isolation and fever hospitals to which scarlet fever patients could be sent. Similar pressures were also building in London, as the limited number of isolation hospitals and a need for compulsory notification was continually raised by the city's medical officers. Bristol Sanitary Authority ignored Dr Davies's Report, and the subsequent reports by his son, and notification was only enforced after the implementation of national legislation in 1889, the Notification of Infectious Diseases Act. This was also true for London, despite that fact that by 1880 many provincial towns such as Leicester, Nottingham, Huddersfield and Norwich had already introduced the measure.105 However, whereas the Metropolitan Poor Act of 1867 led to the increase of isolation hospitals in London, Bristol did little to augment its limited provision. Until 1872 Bristol's only fever hospitals were the separate institutions run by the three Poor Law Boards of Guardians. According to Dr Davies, Bristol Board's hospital at Stapleton had room for 60 patients; Barton Regis Board's hospital in Fishponds Road had accommodation for 24; while Bedminster Board's hospital on Bedminster Down had beds for 20 patients.106 Thus until 1872 the MOH had at his disposal a maximum of 104 beds to be used during the outbreak of an infectious disease. These beds would have been limited to paupers. However, when one remembers that in the scarlet fever epidemic of 1863 925 deaths alone were reported, excluding the unreported numbers of those contracting the disease, it can be appreciated just how overwhelmed must have been the sanitary authorities during the horrific scarlet fever outbreaks of the 1860s and 70s.
In 1872 the newly appointed Bristol Urban Sanitary Authority built two small isolation hospitals close to the River Avon in St. Philip's Marsh, one providing 14 beds for fever cases and the second providing 14 beds for cases of smallpox. However, funds from local government were limited: the two buildings were constructed from wood and packed sawdust and were located in one of the most industrialised parts of the city, close to the gas works, cattle market, several chemical works including an acid and manure works, and the engine sheds of the GWR. In the winter of 1887-8 two huts were added, providing additional temporary accommodation for a further 16 cases. A charge of not move than £1 per week could be made, although this was rarely enforced.
By 1888 the three Poor Law hospitals could accommodate 246 patients, while the two small non-pauper hospitals could house just 44. As the new MOH, Dr D. S. Davies, noted in his Annual Report of 1888:
Thus by the 1880s scarlet fever outbreaks were putting considerable strain on the relationship between the MOH and the Sanitary Authority under which he served. The absence of compulsory notification before 1889, despite the suggestions of the MOH, and the shortage of isolation facilities indicate a lack of confidence in the MOH himself and the degree of emasculation from which the position could suffer. It was after 1899 that relief was forthcoming with the construction of an isolation hospital at Ham Green, providing 185 beds.
Evidence of the tension between the local authorities and the MOH was shown dramatically in February 1886 when Dr Davies resigned after holding the position of MOH for almost 21 years.108 Although the exact reasons for his resignation have gone unrecorded, it is clear that criticism of his performance was growing, not only from sanitary journals such as the Sanitary Report but also from within the BSA Committee itself.109 The insistence that the new MOH should only be appointed to serve full time suggests that the BSA Committee was more than aware that the job had become far too complex to be performed effectively on a part-time basis. Yet despite recognition of the position's added responsibilities, a characteristically involved debate ensued concerning levels of pay, in which the Committee attempted to secure the payment of half the MOH's salary by the Local Government Board, because of 'extra' duties undertaken for Bristol Port Sanitary Authority.
Yet despite this rather ignominious inception, the new MOH began with enthusiasm and a palpable level of dynamism which, by implication, casts some suspicion on the perceived efficacy of his own father. The impression of a fresh start was clear from the front cover of the Annual Report for 1886, which contained the misleading subtitle 'First Annual Report'. It was first only in the sense that it was the earliest report fully conducted under the procedures of a MOH who had been trained in contemporary understandings of sanitary science through a Diploma in Public Health and a Certificate of Sanitary Science. Whereas Dr Davies Snr. could only melodramatically bow out:
His son immediately proclaimed the beginnings of a new approach to the use of statistical data in the furtherance of sanitary reform in Bristol, though a rider indicated his less than favourable assessment of the data collection undertaken by his predecessor:
At the end of the Report Dr Davies Jnr. included a detailed breakdown of incidences of disease at street level, at last answering the earlier criticism of the Sanitary Report in 1881 for the dissaggregation of mortality rates into 'convenient statistical blocks of streets'. However there was one important aspect of continuity with his father: his demand for enforced compulsory notification of scarlet fever:
He then quotes from his father's original 1881 Report which explicitly demanded notification, and further urged the Authority to purchase a 'rapid and efficient disinfector' which the city still lacked. Compulsory notification of scarlet fever in Bristol had to wait a further three years until stipulated by national legislation.
Scarlet fever was one of the major diseases discussed by Dr D. S. Davies's Report of 1886. The high incidence of the disease among certain schools was noted, and the suggestion was made that 'where this happens, the question of school closure at once calls for serious consideration'.113 However, of equal concern was his attempt to overcome the assumption that scarlet fever and scarlatina were different diseases, with the latter existing as a milder and less dangerous form of scarlet fever. Should a member of a household fall ill, then Dr Davies recommended the patient should be given the room at the top of the house. This should be stripped of all carpets and curtains, and isolated from the rest of the household by a sheet soaked in carbolic acid solution. After the fourth day the patient's skin should be rubbed twice a day with camphorated oil, or carbolised oil, or carbolised vaseline; and oiling should be continued until the patient could take a warm bath when the skin should be scrubbed with carbolic acid soap. Finally on recovery, all floors, walls and ceilings should be fumigated, scraped and cleaned. Any patient not observing these conditions, and unnecessarily bringing themselves into contact with the public could be liable for a fine of £5.114
Despite this initial dynamism from the new MOH, the issue of slum clearance remained unchallenged, although the issue of isolation and the allied subject of inadequate housing for the poor was to appear again in the MOH Report for 1906:
On a previous occasion in 1896 the MOH had described Bristol's collection of courtyards as particularly unhealthy places to live. By 1906 however, both the political and social character of the city had changed. The Tories had just lost their 70 year domination of the Council Chamber after the local elections of 1904, and the nascent influence of the Labour Party was beginning to be felt. It was one of the Labour Party's earliest stalwarts, Frank Sheppard, who repeatedly linked the issue of sanitary reform to the issues of housing and over-crowding. Despite the MOH's rigorous denials that overcrowding remained a problem and that it could be linked to high incidence of preventable disease, the growing strength of the Labour Party in the early years of the twentieth century ensured that slum clearance and housing reform remained a prominent issue. Figure 9 shows annual residential construction between 1898 and 1967, as well as the density of residential occupation in Bristol as indicated by the average number of persons per house. The city's first municipal housing was built in 1901, although it was not until after the First World War that a serious programme of municipal housing was begun, and the city's problem of over-crowding addressed.116 According to Floud and McCloskey, in England and Wales the number of occupants per dwelling fell from 5.3 to 5.0 between 1871 and 1911.117 In Bristol, excluding the war period, an average density of five persons per dwelling was not attained until 1927, although this ratio continued to decline until the late 1950s. An unsympathetic Council had not helped the issue of over-crowding in pre-1914 Bristol and as Dresser states: