The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856-1900.

With all the frightening headlines about various mystery illnesses and AIDS, the fear of any sexual contact, the demand for compulsory blood tests, it is easy to forget that only a hundred years ago infectious diseases killed millions of people. But Anne Hardy's study of death and disease in nineteenth-century Britain reminds one not only of the heavy toll of epidemics in history but also how much infectious diseases were until very recently just part of the ordinary experience of living, and of course, dying. Measles, whopping cough, scarlet fever, diphtheria, small pox, typhus, typhoid, and tuberculosis ravaged the urbane populace, and if a person went to a hospital at all, it was surely to die. Most of these plagues have became mere memories in the western world, although tuberculosis is making a comeback in the United States. As William H. McNeill has observed, killer viruses, bacilli, fungi, and other parasites are simply part of the ecosystem in which all animals and plants live. They merely carry out nature's call to reproduce. Hardy examines Victorian attempts to intervene in this natural course of events seeking an explanation for the reduction in morbidity from these infectious diseases in the last years of the nineteenth century.

Her statistical examination of the local (mostly London) epidemiological factors determining patterns of infectious disease leads her to the conclusion that preventative measures and the natural behavior of infections had a much greater impact on the reduction of death rates than the general influence of improved nutrition, a thesis held by Thomas McKeown. For Hardy social behavior rather than nutrition determines disease patterns. And the success of Victorian preventive medicine lay not at the national level, but at the local level where sanitary departments headed by dedicated medical officers of health (MOHs) quickly recognized the connection between disease and dirt. The beginning of the eradication of typhus and typhoid was closely linked to something as seemingly prosaic as the professionalization of the plumbing trade in the 1870s. Formal training courses in plumbing began to appear in the curricula of the London Polytechnic, and in 1885 the Worshipful Company of Plumbers of London instituted a registration system dependent on training certificates. By the 1890s the training of plumbers proceeded on a sound scientific basis. But more was going on here than the zealous work of doctors and plumbers, or of the staff of the new fever hospitals that were established to isolate infectious patients. Rather Hardy sees the beginnings of a profound shift in the British population's attitude toward disease from one of casualness, carelessness, and inevitability, to one recognizing sanitation, cleanliness, and prevention. For example, it had been customary to keep a corpse in the house for two weeks prior to burial, where large numbers of family members and friends crowded into a small room to pay respects. One health officer discovered the coffin of a child dead of small pox with its lid partly open, being used as a work-table by a family of four living in one room. Changing the intricate web of custom and popular belief surrounding infectious disease was at least partly the result of concerted efforts at education by medical officers and the government. But getting people accustomed to the idea of removal and isolation in hospital remained a problem well into the 1880s. If a death occurred at a certain hospital, there remained a great reluctance in the neighborhood to part with anyone who subsequently became ill. But by 1900, British men and women, more likely than not, did what the authorities told them to do, thus becoming Foucault's docile bodies. The declining death toll had another effect as well. It lessened the upper and middle class fear of dirt and disease among the poor, thus allowing for more Christian charity, where the poor would be made cleaner by example, by just being among their betters. It did not used to be fashionable to praise the Victorians for much, but the reduction in deaths from infectious diseases, particularly typhus and typhoid, through dedicated local activity and public health education, stands as a monument to enlightened, progressive, Victorian amelioration. Then as today epidemics tend to run their vicious courses, spreading death and misery, before they sink back into the ecosystem. And then as today, the changing of social behavior may at least lead to less death and misery.

The Epidemic Streets had its origins as a doctoral thesis for Oxford University - one can tell because the title is repeated in the last sentence of the book - so it contains some of the awkwardness of style associated with this genre. And then the subject matter hardly lends itself to a light read. Hardy handles her statistics well, including a useful appendix where she points out the problems and discrepancies inherent in using nineteenth century mortality statistics. She should be congratulated for bringing to the attention of social historians the importance of social intervention in changing the pattern of disease incidence and mortality in Victorian England.

Richard A. Voeltz Cameron University