​Shakespeare Cliff is the most visually distinctive of the White Cliffs of Dover, which stretch for eight miles, or thirteen kilometres, along the south-eastern coast of England, facing France across the Straits of Dover. The cliffs form part of the North Downs and are composed of chalk laid down in the Late Cretaceous period between 100 and 66 million years ago. Reaching a height of 350 feet (110 metres), Shakespeare Cliff has a sharp peak pointing skywards.

​During one of the earlier attempts to dig a tunnel in 1890, a seam of coal was struck 1,100 feet (340m) below the surface. Shakespeare Colliery opened in 1896 and by 1907 was producing 8 tons of coal a day. A railway line connecting Folkestone to Dover had opened in 1844. It was a remarkable feat of engineering with two single track tunnels passing through Shakespeare Cliff. They are exceptionally tall (28 feet/8.5m above the track) with distinctive Gothic arches. Following the opening of the colliery, the South Eastern and Chatham Railway opened a station at Shakespeare Cliff for the benefit of the miners.

When the mine closed in 1915, the station was used by the Admiralty to access their stores in the cliff, and by railway staff who lived nearby, but it never appeared in any public timetable: there was no reason for any member of the public to alight onto the small piece of land wedged between the sea and the cliff face. The British Army used the station during WW2 to serve a nearby military base, but it came into its own when work began on a new Channel Tunnel in 1973 (later aborted), and again during the construction of the current Channel Tunnel in the 1990s. Since the opening of the tunnel in 1994, Shakespeare Cliff station has again fallen into disuse.

​
​Standing on Shakespeare Cliff on a clear day, one can clearly see the French coast at Cap Gris Nez twenty-one miles (thirty-four kilometres) away. By the time Sarah was meeting Edwin on the cliff top in 1897, several people had attempted to swim across the Channel, but only one had succeeded. In 1875 Matthew Webb made the crossing in 21 hours, 45 minutes despite being stung by jellyfish. It was another thirty-six years until the next successful attempt. The first woman to swim the Channel was Gertrude Ederle in 1926, who also broke the record for the fastest time. She began her swim from the French coast at Cap Gris Nez and reached England in 14 hours, 39 minutes.

​Sources:
 
http://www.dover.freeuk.com/port/shakespeare_cliff.htm
The Dover Historian - A collection of historical articles from the town of Dover, England, by Lorraine Sencicle
BBC Shakespeare on Tour – Wherefore to Dover?
Dover Museum https://www.dovermuseum.co.uk
Disused Stations Site Record by Nick Catford
Wikipedia
 

​The first public libraries in the UK which allowed access to the general public were established in the first half of the seventeenth century. Possibly the earliest was one in the Free Grammar School in Coventry in 1601. The most famous is the Cheltham Library which opened in Manchester in 1653. It is named after its founder, Humphrey Cheltham, a textile merchant, who left money in his will for the purchase of the building. It currently houses over 100,000 volumes.

​The impetus for creating public lending libraries with no cost to the borrower came as a result of the industrial revolution. The middle classes worried that the working class who now congregated in towns and cities for work were passing their small amount of leisure time in unsuitable activities, namely drinking and fighting.

​Towards the end of the 19th century, pressure on the Dover council to open a free public library ratcheted up. A resolution was put forward on behalf of the Chamber of Commerce backed by the Dover Express newspaper. Objectors claimed the Chamber of Commerce was foisting a library on Dover ratepayers. A bookshop owner offered a large collection of books as a gift for a library opened in accordance with the Libraries Act, but the council declined the gift.
 
In 1902, a prominent Dover citizen applied to the philanthropist Andrew Carnegie for a grant to open a public library. He agreed to donate £10,000 on condition the council adopted the Libraries Act and provided a suitable building. The council rejected the offer. They were unwilling to dedicate taxes at the rate of a penny in the pound when plenty of libraries existed for those willing to pay a subscription. Councillor William Burkett argued that ‘a free library was a luxury that the ratepayers of Dover could ill-afford and that the ratepayers already contributed 1 penny in the pound towards elementary education, which many saw as a waste.’ 3
The Dover council’s attitude that people should pay if they wanted to read prevailed throughout the early part of the 20th century. Gradually, however, an increasing number of the town’s middle class became concerned at the lack of a public library. John Bavington Jones, owner of the Dover Express newspaper, stated: ‘Although it has to be recorded that Dover of to-day does not possess a centre of enlightenment, public opinion appears to be growing in favour of spending public money in a moderate way, not only for mental recreation, but for liberally furnishing the minds of citizens with information on public affairs to enable them to rightly exercise the duties of citizenship.’

​During the economic depression of the 1930s when unemployment reached its height and soup kitchens in Dover were doling out 1500 meals a week, several prominent Dovorians began taking concerted action on the library issue. Among them were the mayor, Frederick Morecroft, the headmaster of the Boys’ County School, Fred Whitehouse, and Lady Violet Astor, the wife of Dover’s MP. The Mayor set up a library committee, chaired by himself, and by 1934 the council had approved the establishment of a public library. The library, stocked with 7,600 books at a capital cost of £7000 opened on 13th March 1935. In the fortnight leading up to its opening, over 900 people had registered as readers. A year later, the long-overdue facility was being used by 29.5% of the population, compared to the national average of 16.7%.

Situated high on the North Downs, Chartham asylum fulfilled the requirements laid down by the Lunacy Commission for ‘a site on elevated ground with cheerful prospects and enough space to provide employment and recreation for inmates while preventing them being overlooked or disturbed by strangers’.1 High risk patients were looked after in single sex locked wards in the main building, while low risk residents lived in houses within the grounds and had the freedom to wander around.
 
By the 1920s it had become a self-contained village, with its own farm, workshops, baker, butcher, fire-brigade, church, graveyard, gasworks, cricket team, band, etc. Male patients worked on the farm, while female patients worked in the laundry or as seamstresses.2 It doesn’t sound too bad, does it? So why did Arthur dread the idea of living in an asylum so much?
That night Arthur lay awake, analysing the implications of the day’s events. Was he losing his mind? He could imagine no worse fate than ending up in a lunatic asylum.

Arthur’s idea of a lunatic asylum, like that of so many of the general populace, was based on the infamous ‘Bedlam’ asylum. Founded in 1247 as the Priory of St Mary of Bethlehem just outside the walls of the city of London, it was originally dedicated to the healing of sick paupers, but soon became England’s first hospital for the mentally ill. The name, ‘Bethleham Hospital’, was abbreviated to ‘Bethlem’ and later corrupted to ‘Bedlam’. Bedlam has entered the language as a word meaning uproar and mayhem, due to the disorder and chaos prevailing at the institution at the height of its notoriety in the eighteenth century. With its scandalous history, Bedlam came to represent all institutions of its kind in the public imagination.

The general public was able to gain an understanding of what life was like inside Bedlam due to a scheme, which began in the seventeenth century, of allowing casual visitors access to the inmates. This display of madness was a popular entertainment. In 1689, Thomas Tryon, a merchant and author, described the ‘swarms of people’ that flocked to Bedlam on public holidays, and César de Saussure wrote an account of his visit to the asylum on his tour of London sights in 1725:
 
​You find yourself in a long and wide gallery, on either side of which are a large number of little cells where lunatics of every description are shut up, and you can get a sight of these poor creatures, little windows being let into the doors. Many inoffensive madmen walk in the big gallery. On the second floor is a corridor and cells like those on the first floor, and this is the part reserved for dangerous maniacs, most of them being chained and terrible to behold. On holidays numerous persons of both sexes, but belonging generally to the lower classes, visit this hospital and amuse themselves watching these unfortunate wretches, who often give them cause for laughter.
 
During these visits the inmates were subjected to many kinds of abuse, being taunted, poked with sticks, even sexually assaulted.
 
Conditions for many patients at Bedlam during the worst phases of its history were undoubtedly shocking. A famous example is that of James Norris, an American marine, who spent twelve years shackled to an iron pole by means of a contraption which severely restricted his movement.

​Appalling as this is, there is no evidence to suggest that the majority of asylums were such awful places, and iron shackles and chains, once used to restrain mentally disturbed patients, were replaced by leather and strong cloth many years before the First World War. In fact, there seems to have been a wide variation in the type of care and practices administered. In her excellent work entitled Civilian Lunatic Asylums During the First World War, Claire Hilton writes that ‘different standards of care were experienced from patient to patient, ward to ward and asylum to asylum. There was no such thing as an average ward.’

There is little evidence of what life was like in Chartham hospital at the beginning of the twentieth century, but various studies of a range of different asylums throughout the country paint a complex picture. At one asylum in Northumberland, the Commissioners in Lunacy issued a yearly report. The report for 1867 claimed that ‘the state of the inmates was satisfactory, their person and clothing were very clean and in general their conduct was orderly with nobody in seclusion. On the day of the visit dinner consisted of baked meat, potatoes, bread and beer. The wards were clean and properly ventilated but were said to have a bare appearance.’ 3
 
On the other hand, the report for 1873 for the same institution commented upon ‘a male patient who had died due to a blow to the head but who was also found to have his breast bone and five ribs fractured.’3 It was never discovered how these injuries were inflicted. A female patient was also mentioned as when out walking with a party of other females she committed suicide by jumping in the river. Due to this incident walks outside of the asylum were terminated.
 
Records for one asylum in Hampshire show it to be professionally managed with male and female patients kept in separate wards. No male attendant, servant or patient could enter the female wards, nor any female enter the male wards except in cases where the superintendent deemed it advisable. Patients of both sexes were employed, men in the garden and women in the laundry and kitchen. Women also undertook sewing, knitting and mending work, and men were taught trades such as shoemaking, tailoring, plumbing and painting. Reading was encouraged and an ample supply of books and publications of a moral and cheerful nature were supplied in addition to the bible and prayer books.
 
‘Every Wednesday evening there was a dance interspersed with songs, and on two occasions a conjuring entertainment was kindly provided by Mr Shute, the assistant surgeon. In the summer months the men played cricket, bowls, quoits and football while the women played croquet. The patients also enjoyed picnics at the seaside.’ 4

Given the complexity of the evidence, it is difficult to reach a conclusion about the treatment in general that asylum inmates received in the late 19th and early 20th centuries. Perhaps it is reasonable to say that patients were not victims of physical brutality most of the time, but that standards fell far short in comparison with modern notions of acceptable care for the mentally ill.   

Footnotes:
1 1844 report of Metropolitan Commissioners in Lunacy, quoted in J. Taylor 1991 Hospital and asylum architecture in England, 1840-1914
2 J. Taylor 1991 Hospital and asylum architecture in England, 1840-1914
3 Northumberland archives
4 Civilian Lunatic Asylums During the First World War by Claire Hilton
5 Kathleen Jones, “The Culture of the Mental Hospital,” in 150 Years of British Psychiatry ed. Berrios and Freeman
6 The Cobb Inquiry, March 1922
7 W Sullivan, “Haematoma Auris in the Insane,” JMS 53 (1907)
 
Sources:
Historic England website.
Wikipedia
Northumberland archives
Allan Beveridge, Life in the Asylum: Patients’ Letters from Morningside, 1873–1908, History of Psychiatry 9 (1998)
 

​Welcome to blog post number six about childbirth in the early twentieth century.
 
Writing historical fiction involves a lot of research to uncover information which informs the novel but isn’t necessarily included in it. This blog is to share some of the interesting facts I’ve learnt during the course of my research for Shakespeare Cliff.

This subject does not always make for pleasant reading. Be prepared for some horrors.

A lot of children are born in the novel. The protagonist, Sarah, gives birth eight times between 1900 and 1914 (though only six daughters reach adulthood). Her daughters, Jane and Annie, also give birth in the 1920s. That they all survive is good going for the times, since childbirth was one of the major causes of death. Between 1850 and 1930, the rate of death in childbirth in the UK remained at between four and six deaths per 1,000 births. It is interesting that the risk of a mother dying in childbirth remained substantially the same for nearly a century despite improvements in medical care and standards of living during this period.1 With the advent of antibiotics and blood transfusions, maternal deaths reduced dramatically from the late 1930s onwards.
 
Because of the high mortality rates, childbirth was something to be dreaded. The risks were well-known:

Pictures in medical books covered it all: breech birth, stillbirth, the cord wrapped round the baby’s neck, its face blue and scrunched. Gracie had described the slow, dark-crimson soaking of bed sheets as one of her sisters-in-law died from blood loss.
Sarah’s own mother died giving birth to her. ‘Complications’ they said, without explanation.

Sarah’s mother died from one of the most common causes of childbirth deaths: puerperal sepsis, commonly known as childbed fever, an infection caused by a streptococcus bacterium. ‘Sepsis, due to casual use of sterile technique, remained the cause of half the total deaths until 1937.’ 1  With modern standards of hygiene and the discovery of antibiotics, the disease is rare nowadays.

Without access to transfusions and blood banks, severe haemorrhage was usually fatal in Sarah’s day. Often caused by a placenta previa where the placenta covers the cervix, the cervical dilations during labour can lead to severe bleeding. Nowadays with the aid of scans, the problem is diagnosed in advance and avoided by a caesarean section.

One of the dangers of childbirth not covered by Sarah’s list was eclampsia. In 1920, roughly 1,200 of the 6,000 maternal deaths each year in the UK were the result of this condition. Pre-eclampsia and eclampsia, the causes of which are not fully understood, are high blood pressure disorders. Left untreated, eclampsia can lead to convulsions, coma and death. Modern ante-natal care has greatly reduced rates of severe eclampsia.
 
Before WW1, antenatal care did not exist. Women called for a midwife or a doctor when they went into labour and most gave birth at home. Less than 5% of women went into hospital.
 
Most of Sarah’s deliveries are straightforward. Her sister-in-law, Elsie, who supports her through all the births, says:
 
“We’re old hands, you and me, and you pop out babies like shellin’ peas.”
 
But two of her labours are obstructed. The last time she gives birth in 1914, just after the outbreak of WW1, the baby suffers brain damage due to birth complications. Her nephew, Jack, tells this news to Bert, Sarah’s future son-in-law:

The birth was hard—I only discovered that recently—the cord tied round the neck, or somethin’ like that. Anyway, months afterwards, they found out…. Well, the boy wasn’t quite right.”
“What do you mean, not quite right?”
“Not sure, to be honest.” Jack struggled to describe the problem, as he understood it. “Not all there, you know—a shillin’ short of a pound. Anyway, he wasn’t three years old, and he died.”

At the beginning of the 20th century, over seventy-five per cent of births were attended by a midwife, usually working on her own. Up until the mid-1930s, the majority of working-class women, like Sarah, were attended not by a professional but by an unqualified local woman:
 
At four o’clock Elsie arrived with Granny Makey, who was younger than her title implied. A large-boned, no-nonsense woman, her experience qualified her for her role: she had given birth to a dozen children, and attended the deliveries of dozens more.
 
Only the better-off could afford a doctor, though doctors were not necessarily the better choice. The Medical Act of 1858 had instituted training and regulation for doctors, but it was not until 1886 that medical training had to include obstetrics. Often a midwife knew more about the birthing process than a doctor. When Sarah has a difficult breech birth, it is Granny Makey who knows what to do. Elsie tells Sarah:
 
“Listen, duck, when I looked just now, it weren’t the baby’s head I saw but its bottom. It’s a breech, so we’re goin’ to need Granny Makey’s help. She’ll know how to manage it.”
Sarah’s heart thumped so hard she was sure it was audible. What should she do now? The urge to push was overwhelming, but Elsie was right, she must try to hold back. No ingenue, she was aware of the dangers of a breech birth. If the baby’s head got stuck, it might die. So might she.
“Should we send for the doctor?” Her voice came out thin and high-pitched.
“No, duck, wait till Granny Makey gets here. She’ll know what needs doing better than any doctor.”

In 1902 Midwifery became legally recognised with the first Midwives Act, but many without formal training continued to operate as there were so few qualified midwives at the time. After 1910, uncertified midwives could no longer legally attend births without being under the supervision of a certified midwife or physician. In theory, an uncertified midwife could be prosecuted for attending a birth without the presence of a medical practitioner, ​but in practice a significant proportion of births nominally delivered by doctors continued to be largely or wholly managed by such women.

The choice of birth attendant was mostly determined by income, though the availability and reputation of midwives and doctors locally must also have been a factor:

Granny Makey, the neighbourhood’s unofficial mid-wife, assisted almost all the mothers in Tower Hamlets. She wanted payment, though. Sarah hoped Ed had worked a full day and earned a bonus.

The Insurance Act of 1911 and a payment of 30 shillings maternity benefit to the wives of employed men made it easier to pay for a birth attendant, but both doctors and midwives responded by raising their fees. ‘The average fee charged by independent midwives in 1917 was 15 shillings, with a higher charge for primagravidae than multiparous women’.2  At over 1£ per delivery, doctors were more expensive. Complicated labours cost more. When Granny Makey has employed her skills to good effect to safely deliver the breech baby, she says to Sarah:
 
‘Tell your husband it’ll cost a bit extra when he comes to pay my fee.’
 
Sarah knows that Granny Makey has likely saved her life and the life of her baby. Obstetric intervention in the case of difficult births has a long history going back to ancient times – the name caesarean section is said to derive, probably erroneously, from the birth of Julius Caesar. Most often this procedure was conducted to retrieve a living baby from an already dead or dying mother, though there are records, some as early as the Middle Ages, of successful operations performed on living mothers too.
 
If a foetus became stuck during delivery, for whatever reason, the dangers for both mother and baby were significant. Sarah sums it up when she first receives the news that the baby is in the breech position:

If the baby got stuck, there were few alternatives: cut her open to save the foetus, and risk her dying from blood loss. More likely they’d kill the baby in the womb and extract it piecemeal—an unimaginable horror, not without danger to her also. Was this it, then, her last day on earth?

During Jane’s difficult labour, her husband, Charles waits downstairs, no doubt listening to her screams.

When the mid-wife offered her the baby to hold, Jane turned away. Sleep was all she wanted. Annie took him downstairs to Charles, who was pacing the floor in the parlour.
“Congratulations! A big, bouncing boy, almost ten pounds.” She passed the bundle to Charles, who held him as though he might break.

Thankfully, childbirth today in the UK is a much less risky business. The latest statistics show neonatal deaths are 2.7 per 1000 live births, and the maternal death rate is 9.1 per 100,000, rather different from the four to six deaths in every 1000 of Sarah’s time. 

​Footnotes:
 
1 Deaths in childbed from the eighteenth century to 1935 by Irvine Loudon. National Library of Medicine.
2 Birth Attendants and Midwifery Practice in Early Twentieth-century Derbyshire, Alice Reid, Social History of Medicine, Volume 25, Issue 2, May 2012
3 Childbirth in the UK: suffering and citizenship before the 1950s, Joanna Bourke, The Lancet, April 2014.
4  From an article by Ellen Barry, New York Times, May 6, 2019.
 
Sources:
 
1. Midwifery in Britain in the twentieth century (Memories of Nursing website) 
2. Birth Attendants and Midwifery Practice in Early Twentieth-century Derbyshire, Alice Reid, Social History of Medicine, Volume 25, Issue 2, May 2012. J Drife, PubMed.gov May 2002 
3. Geoffrey Chamberlain, Journal of the Royal Society of Medicine, November 2006
4. A History of Childbirth in the UK, Tania McIntosh, The Conversation, January 2021

​Hello and welcome to post number five, this time about the condition known variously through time as war neurosis, combat hysteria, shell-shock, or PTSD.
 
Writing historical fiction involves a lot of research to uncover information which informs the novel but isn’t necessarily included in it. This blog is to share some of the interesting facts I’ve learnt during the course of my research for Shakespeare Cliff.

One of the characters in the novel, Sarah’s brother, Arthur, is seriously injured during the South African war, known at the time as the Boer War:

Rifle shots had injured his thigh and hand. The leg damage appeared severe, but the bullet must have passed through muscle and bone, not a major blood vessel, otherwise he’d be dead. After lying there an age, wondering how long he could endure, he noticed the stretcher-bearers in the near distance. To attract their attention, he waved a white handkerchief. A sniper shot away the handkerchief, taking with it two fingers.

Stories of the Boers’ rifle skills had circulated among the squadrons. Hunters, used to shooting both from a prone position and from horseback, they aimed quickly before the prey caught wind of them, and practised by firing at hens’ eggs a hundred yards distant. Now he had proof of their skills.

Invalided out of the army back to England, Arthur goes to stay with Sarah and Ed after living with his father becomes intolerable. But he soon realises he is disrupting their family life with his nightmares:
​
During the fortnight Arthur had stayed, he had woken the family for ten of the fourteen nights. He couldn’t prevent the nightmares, which had started in the field hospital and continued to become more frequent.

Arthur is suffering from what we would nowadays term Post Traumatic Stress Disorder (PTSD), but that designation was unheard of in 1902. The term PTSD was first used in 1980 in connection with veterans of the Vietnam War.(1) Even the name shell-shock had not been coined in 1902. It was first applied by Charles Myers in an article in The Lancet in February 1915 to soldiers of WW1 suffering from loss of memory, vision, smell, and taste.

The condition itself has long been recognised as an effect of war, and there are descriptions of it in ancient literature. The character of Gilgamesh in the Epic of Gilgamesh (Mesopotamia c. 2100 BC) suffers recurrent nightmares after witnessing the death of his closest friend. The ancient Greek historian Herodotus in his account of the battle of Marathon (440 BC) tells of an Athenian warrior who suddenly went blind in the midst of the fighting, not because of a physical wound but from fear after seeing his comrades killed.

The symptoms of PTSD are many and varied but can be grouped into three basic types: recurrent re-experiencing of the trauma in nightmares, thoughts, flashbacks or hallucinations; emotional withdrawal and avoidance of stimuli; a permanent state of increased arousal, of being ‘on edge’. Victims of shell-shock could suddenly be unable to speak or hear, to stand or walk. They could lose their memory or even undergo ‘personality loss, as in the case of one man who seemed to develop an entirely new identity, including a different accent, after he had been hit by a shell.’ (2)  Sufferers may experience headaches, episodes of loss of consciousness, tremors or convulsions. They may have problems sleeping or concentrating, are easily irritated or angered, and engage in reckless or self-destructive behaviour. Symptoms can be brought on by a sudden trigger which reminds the victim of the trauma he has undergone.

Arthur displays several of these symptoms, most notably nightmares and recurrent unwelcome memories of the war:

Arthur could not close his eyes without visions of the war: nightmares of lying wounded near dead and dying comrades, the sniper shooting off his fingers, the blindfolded deserter peppered with bullets. Even awake he remembered snippets he’d prefer to forget: a Boer woman wringing her hands and crying, as he took an axe to her piano; a young girl hiding her face in her mother’s skirts, as he shot the farm dogs; an old lady sitting in the dirt as he set the firebrands to her home.

In a scene where he is looking after his niece, Annie, he experiences a trigger which sends him back to the battlefield:

Annie stood on tiptoes, reached for the box of bricks and pulled it off the table. A resounding crack split the air as it hit the quarry-tiled floor.
​
For Arthur, it was the crack of a rifle shot. He leapt for cover under the rock overhang, dragging his mate out of the gunshot and shelling. Screams and cries engulfed him. With eyes closed and hands over his ears, he cringed at the sound of pom-pom shells whining towards him. Unable to stop shaking, he broke into a cold sweat, knowing any moment may be the last.

Rivers believed it was necessary to bring repressed memories into a patient’s consciousness to bring about a sort of catharsis and rid the memories of their potency. He pioneered a treatment based on talking to his patients to help them understand the nature of their illness, a process he referred to as autognosis. At a time when men were encouraged to keep a stiff upper lip, Rivers encouraged his patients to express their emotions. Many of his patients were ‘cured’ enough to be sent back to the front to fight again. The life of W. H. R. Rivers and his encounter with Sassoon is the subject of British novelist Pat Barker’s Regeneration Trilogy, made into a film in 1997 with Jonathan Pryce starring as Rivers.
 
My character, Arthur, in Shakespeare Cliff, is offered no treatment for his psychological problems and fears he is going mad:

That night Arthur lay awake, analysing the implications of the day’s events. Was he losing his mind? He could imagine no worse fate than ending up in a lunatic asylum. As it was, he dreaded nights, knowing they brought the inevitable nightmares. If he feared the day time too…

By the end of WW1 there were roughly 80,000 cases of shell shock in the British army. It was not until 1930 that the British government removed the death penalty for desertion and cowardice.

Survivors, by Siegfried Sassoon

No doubt they’ll soon get well; the shock and strain
Have caused their stammering, disconnected talk.
Of course they’re ‘longing to go out again,’--
These boys with old, scared faces, learning to walk.
They’ll soon forget their haunted nights; their cowed
Subjection to the ghosts of friends who died,--
Their dreams that drip with murder; and they’ll be proud
Of glorious war that shatter’d all their pride...
Men who went out to battle, grim and glad;
Children, with eyes that hate you, broken and mad.
 
Craiglockart. October, 1917
                                                                                                     

The Spanish flu does not figure at all largely in the novel. It is mentioned only once by Jane Marsh’s mother, Sarah, when she reports to Jane in March 1919 that she has found her a job with the butcher, Mr Coulter.
 
February was a miserable month of moping or searching for work, the loss of Jane’s income evident in the quality of the family meals. The atmosphere at home was gloom-laden with grief for Pa; outside was grey and wet. But in mid-March, when daffodils were blooming, Ma came back from her shopping and said: “I’ve found you a job, sweetheart.”
Jane looked up from her book. “Really? Where?”
“With Mr Coulter, the butcher. Do you remember his wife died of the Spanish flu last year? As you know, she helped in the shop, while he did the butchering, and….. Well, he’s employed a young lad to run errands and deliveries and sweep up and so on, but Mr Coulter says he needs someone else to serve in the shop, a more mature person, preferably a woman.”

The job has serious consequences for Jane but you will have to read the novel to discover what those are.

 
​​The Spanish flu was the most serious pandemic of modern times. Only the so-called Black Death caused by the bubonic plague during the fourteenth century caused a higher estimated death toll. But whereas the bubonic plague was caused by a bacterium, the Spanish flu was caused by an influenza virus of the H1N1 type originating in birds.
 
Spanish flu ravaged the world during 1918 and 1919, overlapping with ‘The Great War’ as WW1 was known at the time. The flu produced more fatalities than the war, causing upwards of 25 million deaths worldwide. It is impossible to arrive at a definitive number due to the lack of accurate record-keeping in many countries in that era, and some estimates put the death toll at more than 50 million. Whatever the exact figure, it far exceeds the current number of deaths due to Covid19.

The name Spanish flu is misleading as the disease did not originate in Spain. News of it was first broadcast from Spain. ‘All those countries that were combatants in World War I were not willing to mention that their troops might be decimated by an emerging pandemic and so were not talking about it. Spain was actually a non-combatant and because of that, they were ones that did not refuse to admit having cases and then got the moniker of Spanish flu' 1

I had a little bird
its name was Enza
I opened the window,
And in-flu-enza.”
(1918 children’s playground rhyme)
  

Footnotes:
​
1 Dr Daniel Jernigan, 1918 Pandemic Partner Webinar — Commemorating 100 Years Since the 1918 Flu Pandemic, CDC. 
2 1918 Flu Pandemic That Killed 50 Million Originated in China, Historians Say, by Dan Vergano, National Geographic.
3 Readiness for Responding to a Severe Pandemic 100 Years After 1918, Barbara Jester et al. July 2018
4 Why the Second Wave of the 1918 Flu Pandemic Was So Deadly, Dave Roos, December 2020. History.com
Sources:
1.  How some cities ‘flattened the curve’ during the 1918 flu pandemic, by Nina Strochlic and Riley D. Champine, March 2020 National Geographic
2.  In 1918 pandemic, another possible killer: aspirin, by Nicholas Bakalar, October 2009, New York Times
3. Coronavirus: How they tried to curb Spanish flu pandemic in 1918, May 2020, BBC News
4. The Deadliest Flu: The complete story of the discovery and reconstruction of the 1918 pandemic virus, by Douglas Jordan with contributions from Dr Terrence Tumpey and Barbara Jester, CDC

​

Welcome to the third blog about health issues referenced in my novel, Shakespeare Cliff.

Historical fiction involves a lot of research which informs the story but is not always included in it. This blog is for sharing some of the interesting and fun facts I discovered while researching the novel.

Illnesses covered in previous blogs have been childbed fever, duodenal ulcer, growths on the lungs and brain, measles, and consumption. Three more conditions this time.
 
SPOILER ALERT!! Contains extracts from the book and plot reveals.
 
 Bert Davies - Stomach flu

One of the characters, Bert Davies, gets offered a chance to do some moonlighting on a Saturday when he was supposed to be at work.

Jack’s dad knew a man contracted to demolish a row of dilapidated cottages in the Pier District where they were clearing slums. His workforce had succumbed to stomach flu, and the job had stalled. Desperate to meet his deadline, the contractor recruited labourers from the dockworkers’ line-up with the promise of a bonus, if they finished by the weekend. Jack recruited Bert.

The workers’ illness inspired the lie Bert planned to tell when he returned to work on Monday—stomach problems.
 
Gastroenteritis was common in the early twentieth century, caused either by a virus or bacteria. Both types of intestinal infection were commonly known as stomach flu. The symptoms of gastroenteritis are a watery diarrhoea, abdominal cramps, nausea or vomiting, and sometimes fever. The most common way to develop stomach flu was through contact with an infected person or by consuming contaminated food or water. It could be very unpleasant, but usually cleared up by itself within a week. Unfortunately, it spread very easily.

Stomach flu was common in summer and was believed to be brought on by heat. Treatments included castor oil, opium, brandy and hot baths. Soapsuds enemas were used to purge the intestines. The importance of restoring fluids and salt was largely unrecognised until the middle of the 20th century.
 
Since early times, diarrhoea has been associated with cowardice. In military conflicts, soldiers suffering from it were considered ‘gutless’, whereas diarrhoea-free soldiers had the ‘guts’ to keep fighting.
 
The saying ‘an apple a day keeps the doctor away’ has some validity when it comes to diarrhoea. During WW1, it was discovered that prisoners of war in a German camp who ate apples scrounged from a nearby orchard rid their systems of diarrhoea more quickly than the other prisoners. Research has proved it is the pectin in apples which has this effect.1

Jack Hill – Brain fever
 
Whilst not a sufferer of this illness himself, Jack suffers the consequence of an outbreak of brain fever at the naval training barracks at HMS Pembroke, Chatham in 1917.
 
Jack walked into the drill shed with his kitbag, searching for a place to kip. Close to nine hundred seamen, all trades and ranks, slept in crowded conditions in that hall. Some were there because the authorities had quarantined one barrack following an outbreak of brain fever.
 
Brain fever was the term used for any acute cerebral infection accompanied by fever. In this case it was epidemic cerebrospinal meningitis, otherwise known as spotted fever, caused by the meningococcus bacteria, Neisseria meningitidis. The bacteria produce inflammation of the meninges, or membranes, of both the brain and the spinal cord. It is highly infectious and often fatal, 50% if untreated.

​The symptoms of the disease are flu-like and include fever, headache and a stiff neck. Sufferers may go on to develop nausea, vomiting, sensitivity to light, a rash, and confusion.2

The bacteria are spread via secretions from the throat and respiratory tract. ‘Smoking, close and prolonged contact – such as kissing, sneezing or coughing on someone, or living in close quarters with a carrier – facilitates the spread of the disease’.3 It’s easy to see how a crowded barracks would be an ideal breeding ground for it.

Nowadays meningitis is treated with antibiotics and there are vaccinations against some forms of the disease. These were not available during WW1. Instead, patients were given emetics to induce vomiting, quinine wine, and the ubiquitous treatment of bloodletting. ‘It was believed that reducing the amount of fluid in the body by bloodletting and vomiting would relieve the pressure of inflammation.’4  From the late 19th century, lumbar punctures were also used to drain off excess fluid for the purpose of reducing pressure. Can’t have been fun without anaesthetic.

By the beginning of the 20th century immune serums were being developed using antibodies from animals injected with the meningitis bacteria. Injecting horse antiserum into the spinal fluid was the first effective treatment against meningitis and saved many lives during WW1. By mid-century this treatment was no longer recommended and penicillin was commonly used, heralding the start of the antibiotic era. Aren’t you grateful to be living in the 21st century?

Charles Kemp – Poliomyelitis

Charles suffered from polio as a child. It left him with a withered leg. He mentions it in the first conversation he has with Jane, his future wife.
​
Lost in her thoughts, she realised the man next to her had spoken.
“Oh, I’m sorry, sir. I didn’t catch what you said. I was absorbed in watching the dancing.”
He smiled. “That’s all right. I said if I could dance, I would ask you to take a turn with me, but I can’t, I’m afraid—gammy leg.” He knocked his leg with his cane.
“Oh, dear. Is it a war injury?”
“Sadly not.” A faint blush shaded his cheeks. “I’d have something to be proud of, if it were. No, a childhood disease left me with a withered leg.”
Jane noticed a metal calliper extending below his trousers and underneath his shoe. Unsure how to respond, she smiled.
 
            Unlike Charles’s previous girlfriend, Emma, Jane is not repulsed by his disability. She sees his withered limb for the first time on their wedding night.

“Would you like to see my leg, Jane?”
From her reaction, she had not expected that question. Without waiting for an answer, he rolled up his pyjama trouser leg to display the withered limb, his calf not much thicker than the bone within it, the foot misshapen and turned inwards. As Jane stared, he studied her face, and noted sadness and sympathy, not the revulsion he had seen in Emma’s expression.
“Oh, you poor thing,” she said. “It must have been awful for you, especially as a young child. When did it happen?”
“I contracted the disease when I was nine.”

Poliomyelitis is a highly contagious virus specific to humans. It is passed on through contact with faecal matter in contaminated food or water and invades the nervous system where it destroys nerve cells which control the muscles, especially the legs, causing paralysis. Death occurs in five to ten percent of cases when the disease reaches the respiratory system. It mainly affects children. There is no cure. It can only be prevented by immunisation but that had not been developed at the time Charles contracted the disease in 1903.
 
Although it is an ancient disease, outbreaks were relatively rare in the West until the late 19th century. Michael Underwood, a paediatrician in London, was the first to describe the disease in June 1894, but the first large-scale epidemic occurred in the United States in 1916.
There were no effective treatments, but a diverse range was attempted: baths using almond meal or oxygenated water, poultices of chamomile, slippery elm, arnica or mustard, doses of caffeine, quinine, radium water, and even chloride of gold.5

​In the 1950s an apparatus known as an ‘iron lung’ was invented to help polio victims whose breathing muscles had been affected. The patient was sealed inside the machine and air was pumped out of the casing, reducing pressure and making the chest rise to fill the lungs. When air was allowed back in, the lungs emptied.

It is not surprising that the vaccine, developed in 1955, was welcomed as a medical miracle. The injection was replaced in 1962 by a sugar cube vaccine. I have a vivid memory of eating my pink sugar cube, no doubt one of my more pleasant visits to the doctor’s surgery.
 
Thankfully polio has almost been eradicated worldwide. In 2015 there were only seventy-four reported cases, and in 2020 the WHO classified the disease as endemic only in Afghanistan and Pakistan.

​That's all for now. Stay healthy! Next blog: the Spanish Flu.

​References:
1The History of Acute Infectious Diarrhoea Management by Z.H.McMahan and H.L.Dupont
2 CDC – centers for disease control and prevention
3 WHO
4The History of Meningitis: Causes, Treatments and Vaccines – Confederation of Meningitis Organisations
5 A Monograph on the Epidemic of Poliomyelitis (Infantile Paralysis) in New York City in 1916 by John Haven Emerson
 
Sources:
The Independent newspaper
Britannica
Wikipedia
The history of polio, Action Medical research blog, October 2016.

​In the dim light, the poor woman lying in the enormous bed looked shrunken. Her gauntness emphasised her sharp features, softened only by the frills of her night-bonnet. A storybook illustration of a witch sprang into Sarah’s mind. Although supported by pillows, it appeared the effort of keeping her head upright exhausted Mrs Kesby and she kept closing her eyes.

She has called Sarah to her room to offer her a compromise. She will agree to her marrying Edwin – an unsuitable match in her eyes – on condition Sarah waits for a year:

It may have been Mrs Kesby’s common sense which made her accept the futility of further efforts to change Sarah’s mind. More likely, she had registered the imminent end to her span on this earth and death’s shadow lent her a clemency little in evidence during her hale and hearty years. The headaches which plagued her for several months worsened in frequency and intensity. Before the year ended, she was dead from a growth on the brain.

Mrs Kesby has been suffering from a brain tumour. Her symptoms apparent in the story are headaches, loss of balance, and fatigue. In 1898 there was little effective treatment for cancer other than surgical removal of the tumour. This was commonly attempted in cases where the tumour was visible, in breast cancers for example, but in the absence of CT scans, operating on a brain tumour was precarious to say the least. Nevertheless, it was attempted and ‘The first practical treatise on intracranial tumors was published in 1888 by Byrom Bramwell (1847 – 1931), an English surgeon who specialised in surgery for brain tumors.’ 1
 
Radiotherapy was developed too late for Mrs Kesby as X-rays were only discovered by Roentgen in 1896 and not used for cancer diagnosis or treatment until three years after that. All that was available to Mrs Kesby were adjustments to her diet and the ubiquitous bloodletting.

​Winnie Hill - Measles

When Sarah goes to her sister-in-law Elsie’s house to tell her she has gone into labour, she notices Elsie’s little girl, Winnie, is looking unwell:
 
Six-year-old Winnie sucked her thumb, staring at Sarah with glazed eyes.
 
The next day, Ed hears from his brother-in-law, Alf, that Winnie has the measles:
They shook hands. “How’re things?”
“Not bad, though Winnie’s come down with the measles, so Elsie’s busy. She won’t be goin’ round yours to help with the newborn, I’m afraid.”
“Crikey! Sorry to hear that. Hope poor Winnie gets over it soon.” Ed frowned in concern for Alf’s wife and daughter and his own. He had been relying on Elsie to help Sarah find her feet with the baby. “Hope the others don’t catch it.”

In 1900 when this conversation takes place, germ theory was still in its infancy, but thanks to the work of Louis Pasteur and Joseph Lister, most people knew that diseases like measles were infectious. British patent applications in 1900  included devices for avoiding infection from the communion chalice and the telephone. 2 Hence, Alf’s decision to send the other children away to prevent them catching it. But by no means everyone understood the mechanics of infection as this cartoon from 1915 indicates:

Measles was common and most people survived it, but it could have unpleasant side effects ranging from mild, such as diarrhoea and ear infections, to serious such as blindness, encephalitis and pneumonia leading to death. One of the treatments at this time was for the patient to stay in a darkened room as it was thought, erroneously, that light would increase the likelihood of blindness. Children lay in darkened rooms for two or three weeks until the infection had passed, a practice which continued well into the 20th century. I remember my mother telling me about her experience of this, and she was born in 1923.

Nowadays immunisation helps keep the incidence of measles down, although outbreaks of the disease occur in populations where the uptake of vaccinations is low. Measles is a virus and there are no antiviral drugs to treat patients once they’ve contracted the disease.

Edwin Marsh - Consumption

The first sign of this disease in Sarah’s husband, Ed, is a cough:
 
Ed’s coughing fit marred the walk to the park. He’d had a lingering cough for three weeks and couldn’t seem to shift it. Half way up Park Avenue he convulsed in a spasm lasting minutes, bringing up phlegm which he spat into a drain. As soon as they reached the park, he sat down on a bench close to the entrance.
            “You lot go and explore. I’m gonna sit here and catch my breath. I’ll wander along later and find you.”
            “Are you sure, Ed? We can wait with you.” Sarah tried to keep the anxiety out of her voice: the coughing fit had unsettled her. She would make certain they talked about it when they got home. Ed had to see a doctor.
 
The coughing is followed by a fever:
 
In the night, she awoke to find Ed trembling next to her. He had thrown off the covers and was exuding heat like a furnace, dampening the sheets with sweat.
“What is it, Ed? What’s the matter.”
“Don’t know. I can’t stop shivering. Must’ve got a fever.”
Sarah fetched a flannel wrung out with cold water to soothe his brow and lay awake worrying until he stopped shaking and fell back asleep.

Ed is suffering from tuberculosis commonly referred to as TB. The symptoms are a cough lasting more than three weeks which produces phlegm, sometimes with blood in it, fever, chills, night sweats, loss of appetite and weight loss, fatigue, sometimes swellings in the neck. Ed displays many of these symptoms:
Trembling and sweating from one of his night fevers, Pa’s voice shook, and he struggled to catch his breath. The handkerchief he clasped was speckled red. Jane wished she could help. She would trade everything she owned to make him better.

“It’s Jane, Pa. Annie’s in the cellar with Ma and the others. They’re all right, just scared. It was a loud bang.” 
     You can say that again.” Pa struggled to sit up and Jane propped pillows behind him, noticing the hard glitter of his eyes in the darkness.

And:
 
Bert had met him before and remembered him as a young, lively, athletic man. The change in his appearance shocked him: he had lost weight and muscle tone, looking gaunt and wasted. He must be mid- to late-thirties, yet looked older than Jack’s dad in his forties.

TB was widespread in the 19th and early 20th centuries, especially amongst the urban poor whose diets and unsanitary living conditions undermined their immune systems. ‘Causing as much as one-quarter of all deaths in Europe, arising with particular frequency among young adults between the ages of 18 and 35, and bringing on a lingering, melancholy decline characterized by loss of body weight, skin pallor, and sunken yet luminous eyes, tuberculosis was enshrined in literature as the “captain of death”, the slow killer of youth, promise, and genius.’ 3
 
Famous people who died of TB in the 19th and 20th centuries include Keats, Chopin, the Brontë sisters, Chekhov, Modigliani and Kafka.
 
It is caused by a bacterium, mycobacterium tuberculosis, identified in 1882 by the German physician, Robert Koch, for which he received a Nobel prize. It is not highly contagious and most people’s immune systems can overcome it. But in some people the bacteria lie dormant for years without the infected person showing symptoms of the disease.

​
Immunization was developed by 1921 but only became widespread after World War 2. In the early 1900s when Ed was suffering from this disease treatment options were limited. It was believed that fresh air was of benefit and sufferers were encouraged to rest and take the air in sanatoria located in the mountains or by the sea – a feasible course of treatment for the wealthy but not for the likes of Ed. He eventually succumbs to TB and dies aged forty:

Two weeks after Armistice Day, Pa neared his end. He surprised the doctor by lingering so long after so protracted an illness. At least he realised the war was over. For the final hours he slipped into unconsciousness, Jane took turns with Annie and Ma to hold his hand, listening to the gurgling breathing, as though his lungs were liquefying.
Ma smoothed the hair from his forehead. “Look how curly black his hair still is, Jane. Hardly any grey.” She ran her fingertips along the side of his face, tracing his jawbone in a loving caress. “We must give him another shave this evening. See how badly we did it before.”
Jane moved closer to study Pa’s gaunt, muscle-wasted face. Patches of tattered beard grew where the pockets of sunken flesh were too slack for the razor. The sight made her tearful.

Nowadays TB is treated by antibiotics and is only fatal if left untreated.

That’s this dose of medical facts done with, but there’s more to come next time. Thanks for reading.
 
Sources:
1. A note from history: Landmarks in history of cancer, parts 4 and 5 by Steven I. Hajdu MD and Farbod Darvishian MD, American Cancer Society Journals, 2013.
2. Health & Medicine in the 19th Century by Jan Marsh, Victoria and Albert Museum website.
3. Tuberculosis through history by the editors of Encyclopaedia Britannica.
​4. History of Cancer, Ancient and Modern Treatment Methods Akulapalli Sudhakar Journal of Cancer Science & Therapy, Vol.1 Issue 2
5. Wikipedia

A surgical operation to remove a malignant tumour from a man's left breast and armpit in a Dublin drawing room, 1817. Watercolour, 1817. [Power, Robert F. Credit: Wellcome Collection.]

For George, opiates to dull the pain were the only treatment. He dies a couple of months after this final meeting with his daughter and granddaughter in February 1920.

Enough of this gruesome topic for the time being - more characters and their illnesses in the next blog. Good health to you all!

Adrienne.
 
Footnote: 1. Emily Baumrin, William Corbett, and Amita Kulkarni, Dartmouth Medical School, 2010

Sources:
1.The Attempt to Understand Puerperal Fever in the Eighteenth and Early Nineteenth Centuries by Christine Hallett PhD.
2. Childbed fever: A Nineteenth-Century Mystery by Christa Colyer School of Science University of Ontario Institute of Technology
3. A comprehensive history of cancer treatment by Nigel Hawkes.