Part 26

The eighteenth century saw some of Petty’s principles put into practice. There was, as yet, but one section of public life in which scientific principles of preventive medicine could be applied. Only in the Army and Navy were the sufferers from disease under adequate control and observation, and only there were proper statistics of sickness and health available. Thus, many of the most important movements in Preventive Medicine during the eighteenth century, both in England and other countries, were initiated by naval and military surgeons.

Among military medical reformers an important place is taken by a Scottish pupil of Boerhaave, Sir John Pringle (1707-82). He had a large military experience in the British army, occupied a position of great influence, and was able to get many of his views and reforms generally accepted. Pringle was among the first to see the importance of ordinary putrefactive processes in the production of disease, and quite the first to apply these principles in hospitals and camps. Important conclusions on these matters were published in his Experiments upon Septic and Antiseptic Substances, with Remarks relating to their Use in the Theory of Medicine, which appeared in 1750. He identified ‘gaol fever’ or typhus with ‘hospital fever’. He laid down important rules for the hygiene of camps which involved avoidance of marshes, proper drainage, and adequate latrines. His most permanent service was probably his suggestion that army hospitals should be regarded as neutral, and be mutually protected by belligerents. This great physician is a good illustration of the ‘new humanity’ which came into public life in the eighteenth century. In much of that movement one may feel the influence of that most humane of physicians, Hermann Boerhaave (pp. 140-1).

Hardly less important than the work of Pringle for the Army was that of his brother Scot, James Lind (1716-94), for the Navy. Lind was a pupil’s pupil of Boerhaave. He had a long naval experience and in 1753 wrote an important work on Scurvy, then a very common and fatal disease at sea. He demonstrated how this might be prevented by the adequate use of fresh fruit or, when this was not available, of lemon juice. Fresh water had always been a difficulty of sea voyages. Lind arranged for sea-water to be distilled for the purpose. He introduced rules for the prevention of typhus on ships, and made great improvements in naval hygiene. His essay of 1757 On the most effectual means of preserving the Health of Seamen is a classic. He also wrote an important Essay on Diseases of Europeans in Hot Climates, which opened the campaign for the conquest of the tropics (p. 270).

Lind, like Pringle, is one of a type that is very fully represented in the eighteenth century. A worthy representative of that school was Captain James Cook (1728-79), the explorer, who adopted Lind’s principles. He established a record in one of his voyages to the South Seas. The voyage lasted three and a half years, and many hardships had to be endured, but out of 118 men only one died, and he was consumptive when he embarked from England. Of a different type was the Manchester health reformer, Thomas Percival (1740-1804), who worked to introduce the reforms of Pringle and Lind into civilian life. The work of Percival leads on naturally to Southwood Smith and Chadwick (pp. 193-5).

The eighteenth century was essentially a period of individual effort. The time was not yet ripe for public action on a large scale in matters of Hygiene. Pringle, Lind, and Percival had, however, their humanitarian parallels among prison reformers. Scientific attempts to improve the ventilation and sanitation of prisons had been instituted by the Rev. Stephen Hales (pp. 146-7). None brought greater devotion to the task than John Howard (1726-90), a native of London who spent his vigorous powers in investigating the prison system. His researches extended to the hospital, quarantine and prison systems of France, Flanders, Holland, Germany, Italy, Greece and Turkey (Fig. 88). His reports were directly instrumental in the improvement of the hygiene both of prisons and hospitals, as well as in the institution of special fever hospitals in many countries. Some aspects of Howard’s work were carried on by the great Quaker philanthropist Elizabeth Fry (1780-1845), others came within the field of activity of Southwood Smith and Chadwick (pp. 193-5).

The eighteenth-century humanitarian movement was active and had many able representatives in the United States. Foremost among them was Benjamin Franklin (1706-90), while in the ranks of Medicine none takes a higher place than Benjamin Rush of Philadelphia (1745-1813). Rush was particularly revolted by public punishments, to the abolition of which he devoted much energy. In matters of Hygiene Rush was ahead of his time. He wrote on the hygiene of troops and laid special stress on fresh air and cleanliness of body and mind as an aid to health. He had a peculiar horror and repulsion for alcoholic intemperance. He was responsible for the first systematic work on insanity published in America. He left a fine account of a Yellow Fever epidemic at Philadelphia, and he approached the truth in his view that the disease arose in Philadelphia itself and was not brought as an infection from without.

From John Howard’s An Account of the principal Lazarettos in Europe, Warrington, 1789.]

§ 11. The Industrial Revolution.

During the eighteenth century the character of English civilization became modified by a factor which has since profoundly influenced all civilized countries. There was a rapid increase in the number and size of the towns. The main cause of this was the transformation of Industry by the use of mechanical power. The change that resulted in the life and outlook of the people was very profound. These changes and the causes that gave rise to them are usually spoken of as the ‘Industrial Revolution’. That revolution had effects that were both wider and deeper than followed any other such single upheaval in history. With the mechanical elements that were at the back of the Industrial Revolution, such as the improvements in transport, the invention of industrial machinery (Fig. 90), the enclosure of common land, the new position of agriculture, we are not here directly concerned. What does affect our story is the increasing urbanization of the population, which began early in the eighteenth century, increased rapidly soon after the middle of the eighteenth century, and has progressed continuously ever since. In this matter England is but a type, for all other civilized countries followed in her wake, though at a somewhat later date.

Along with the growth of towns and the increased population there was an increased demand for food. The country became better cultivated and better drained, and there were many improvements in agriculture. Thus, certain diseases began to diminish, notably Malaria, essentially a disease of undrained and ill-cultivated lands. The expulsion of this disease, as of Typhus, was the work of the nineteenth century (p. 283).

It is often assumed that the physical evils of life became accentuated by the rise of the great towns. Nevertheless, investigation shows that the opposite has been the case. During the eighteenth century men and women began to crowd into the great towns from the country. They were, in fact, right in their choice, for their chances of life there were greater than upon the land. In the rural districts infamous housing conditions, an overcrowding beyond anything which we now encounter, exposure to weather, uncertainty and fluctuation in the prices of commodities, low wages, unpassability of roads in winter time, inaccessibility of medical aids, combined to render life, and especially child life, more precarious than in urban areas.

FIGS. 89 and 90 illustrate the passage of the textile trade from home industry to factory work with the consequent break-up of the family as the labor unit. Textiles were the first important articles of commerce to be thus affected, but others rapidly followed. The pictures are typical of the Industrial Revolution.

The improvement of hygienic conditions in the towns began in England soon after the middle of the eighteenth century. Westminster obtained an Improvement Act in 1762, Birmingham in 1765, the City of London in 1766, Manchester in 1776, and most of the other provincial towns soon followed. As a result of such Acts noisome streams which were but open drains were covered in, the streets were paved and lighted, and the sewers improved. There were still many glaring defects of sanitation which have occupied and still occupy reformers, but by the end of the eighteenth century the general appearance of a street in one of the more advanced cities was much what it now is. The change from the medieval conditions of a century before was at least as great as the changes that have since taken place.

FIG. 91 shows how the population of England and Wales started to increase rapidly about 1750, with the beginning of the Industrial Revolution. The chart covers a period in which statistics were not exact. The figures for it have had to be estimated, but they are probably accurate as round numbers. The census returns are available from 1801.

1910-12 Age 1730-9 1740-9 1750-9 1760-9 1770-9 1780-9 1790-9 Males Females 10 36·9 37·0 37·3 36·9 36·7 37·5 38·2 -- -- 20 29·1 28·9 29·2 29·3 29·4 29·9 28·4 42·35 46·71 30 23·7 23·5 23·8 24·1 24·1 24·9 24·4 33·87 37·94 40 19·6 19·2 19·4 19·6 19·5 19·5 19·5 26·03 29·67 50 16·1 15·8 15·7 16·1 15·9 15·7 15·8 19·09 22·17 60 12·2 12·4 12·1 11·9 11·9 12·0 11·9 13·09 15·39 70 9·4 8·6 8·7 8·5 8·3 8·7 8·5 8·17 9·57 80 5·9 5·7 5·7 5·7 5·7 6·3 6·2 4·79 5·39

Showing the expectations of life in London for each decade from 1730-1800, with recent data for comparison.

Age 1730-9 1740-9 1750-9 1760-9 1770-9 1780-9 1790-9 1911-12 10-20 6·5 5·9 5·9 7·1 8·2 7·1 6·5 -- 20-30 17·5 17·6 17·2 17·9 17·3 16·4 15·1 3·7 30-40 27·1 26·3 26·1 25·2 25·0 23·9 23·7 6·2 40-50 36·6 38·6 35·9 36·3 35·5 35·4 34·3 11·7 50-60 45·5 47·9 45·7 42·1 45·0 44·7 44·6 21·1 60-70 61·4 63·4 63·7 64·4 62·8 64·7 64·1 40·3 70-80 83·7 98·3 96·4 101·8 105·0 101·7 104·4 87·3 80-90 143·1 150·4 151·0 153·0 152·7 153·0 155·1 181·9

Showing the death-rates at Age groups in London for each decade from 1730-1800, with recent data for comparison.

FIG. 91A. TABLES showing that vital conditions in the eighteenth century did not deteriorate but improved with the Industrial Revolution. ]

But if the streets had improved there was much under and around them which would horrify us now. Water-supply, as in London, was usually drawn mainly from surface wells and rivers. In most towns a continuous water-supply was unknown. Even when water mains existed, the supply to the houses was limited. Thus, even in the early nineteenth century London houses had a water-supply only three times a week, and then only for a few hours at a time. The water mains were often defective, and there was not always that clear distinction between a water main and a sewer that we now regard as desirable. Floods were a constant trouble in all riverside towns. Cesspools were in use even in London as late as the middle of the nineteenth century, and water-closets did not become general, even in the better houses, until about 1828. The methods of disposal of sewage hardly bear relation. In London the sewage simply polluted the rivers.

The improvement of such conditions as these could only be made by State action. The eighteenth century did well where individual activity was concerned. It was reserved for Southwood Smith (p. 193) and Chadwick (p. 194) to introduce into the sphere of practical political action the truth, set forth by Bentham (pp. 190-2), that all factors which influence the health of the country must be the concern of the Legislature.

We gladly pass from this darker picture to the Hospital and Dispensary Movement which took its rise about the middle of the eighteenth century. Many of the great hospitals both in England and in Continental countries were either founded or rebuilt about this time. Thus, the London Hospital was rebuilt in 1752, St. Bartholomew’s in 1730-53. Between 1700 and

1825 no less than 154 hospitals and dispensaries were founded in the British Isles. Though defective from the modern point of view, yet under the influence of the sanitary reformers, Hales (p. 146), Pringle (p. 169), Lind (p. 170), and Percival (pp. 170-1), these were incomparably better equipped, better ventilated and better found than such institutions would have been at the beginning of the eighteenth century. The notes of the industrious Howard (p. 171) give us a very complete picture of them, and one that is more favorable than might, perhaps, have been expected.

A defect of the hospitals of the time was certainly the nursing. This, however, was somewhat better in the Lying-in-Hospitals, where the services of a higher type of woman were available and where ladies served on the committee of management. The general state of the hospitals remained much the same until transformed by the changes in surgery and nursing in the second half of the nineteenth century, though a number of special fever hospitals and pest-houses were established.

Something must be said of the more prevalent diseases of the Industrial Revolution. Stress is often laid on the effect of urban conditions on child life. Yet there can be little doubt that historically the movement has been beneficial to it. This comes out well in the death-rates. Thus, in England in the period around 1740, before the industrial revolution had begun, about 75 per cent. of children born died before the age of five. In the period around 1800, when the industrial revolution had set in, the percentage of deaths had fallen to about 41. In the period 1915-24 it was about 14. Among the most characteristic diseases of children is Rickets. It is very difficult to trace the early history of this disease, but its incidence seems to have been very high about 1700, and to have fallen progressively throughout the eighteenth century. This fall, it has been suggested, was due to agricultural improvements which led to better supplies of better-fed meat. It was these improvements and better supplies that, in their turn, made the big towns possible.

We have already spoken of Scurvy on ships. It was, however, well known on land, especially in winter when green vegetables were not to be had. Lind (p. 170) in 1753 found it common in the land population. The advances in agriculture removed it altogether from the land diseases during the eighteenth century.

§ 12. Control and Recognition of Epidemic Diseases.

Over one department of public health there was State supervision during the eighteenth century. The ports were guarded against the introduction of Epidemic Diseases, and especially against Plague. Throughout the eighteenth and early nineteenth century there was Plague in the Near East which extended at times to various parts of Europe. It was epidemic in Russia in 1709 and some 150,000 died of it. In 1719 it spread to Eastern Central Europe. One historic outbreak was at Marseilles and Toulon in 1720, when 90,000 died. The outbreak caused great alarm in England, but did not reach this country, nor has there since been any outbreak here. Quarantine is now regarded as antiquated, vexatious, inhumane, expensive, and ineffectual. It seems probable, however, that during the eighteenth century, when drastically enforced, as in France with the Marseilles epidemic, it had indeed the effect of keeping the disease within bounds. Incidentally, it led to the foundation of many plague hospitals or Lazarettos, of the conduct of some of which Howard (p. 171 and Fig. 88) speaks well.