Before modern vaccines transformed public health, childhood infectious diseases like measles and mumps were a pervasive reality of everyday life. Because millions of children contracted these infections, they were viewed almost as childhood milestones or rites of passage. Reflecting the times, children’s literature from the late 19th and early 20th centuries featured realistic and relatable depictions of these illnesses as central plot points. These books offer an interesting lens into public perception and experience of childhood infectious diseases as we face a resurgence of these same illnesses today. In this first of a series, Gretl Lam looks at examples of children’s literature in which infectious disease plays a key role.
Five Little Peppers and How They Grew by Margaret Sidney is an early example from 1881. This book describes the daily life of the hardworking Pepper family and how they remain cheerful and loving despite challenges associated with 19th century poverty. The Pepper family consists of widowed Mrs. Pepper or “Mamsie,” 11-year-old Ben who voluntarily takes on the mantle of “man of the house,” patient and selfless 10-year-old Polly, impulsive and food-loving 9-year-old Joel, gentle and conscientious 7-year-old Davie, and beloved baby of the family 3-year-old Phronsie.
Children’s literature during this era was heavily instructional and used relatable characters and stories to teach morals and values to young minds. Illness was rarely just a biological event; it was a test or demonstration of character. In a chapter aptly titled “Trouble for the Little Brown House,” the first challenge that the Pepper family faces is measles.
Notably, this book highlights the ophthalmologic symptoms and sequalae of measles, as first Phronsie, then Ben, Polly, and Joel all catch the infection. Common early symptoms of measles include conjunctivitis and photophobia, which occur before the obvious rash. Ben and Polly, the hardworking older siblings who earn money for the family by chopping wood and sewing respectively, are each in initial denial of infection because they understand the financial repercussions this will have on the family. But the historic reader understands the warning signs when Ben and Polly report visual complaints. Ben tries to reassure Polly by saying, “I’m all right; only my head aches, and my eyes feel funny,” alluding to the itchy and gritty sensation of conjunctivitis, before he becomes bedridden. The narrator describes Polly’s struggles more vividly, “An awful feeling made her clutch the back of a chair, but she managed somehow to get into her clothes, and go groping blindly into the kitchen. Somehow, Polly couldn’t see very well. She tried to set the table, but ‘twas no use.” Polly’s initial visual impairment can be attributed to severe photophobia, leading to blurry vision.
Modern day readers may not know that the measles virus can result in serious vision-threatening complications. It can cause deeper structural damage starting with keratitis – a painful inflammation or infection of the cornea, the clear front surface of the eye, which manifests as blurred vision and intense tearing. If keratitis is left untreated or a secondary bacterial infection occurs, corneal scarring can permanently impair vision. In rare instances, measles can also cause retinopathy and optic neuritis leading to blindness. The severity of eye damage from measles is heavily linked to nutrition. The virus actively depletes body stores of vitamin A. In low-income populations where Vitamin A deficiency is already common, measles is more likely to cause permanent childhood blindness.
The Peppers live in poverty and hunger. Mrs. Pepper makes a meager income sewing “sacks and coats” for a local store and “had hard work to scrape together money enough to put bread into her children’s mouths, and to pay the rent of the little brown house.” There is never enough food to go around. Their main source of calories are coarse brown bread and unappetizing cornmeal mush, neither of which contain meaningful amounts of vitamin A. However, the generosity of the parson’s wife, Mrs. Henderson, helps protect some of the Peppers from blindness. Mrs. Henderson gives the Peppers “a little pat of butter,” which Phronsie and Ben put on their bread. Dairy, like milk and butter, is an excellent source of vitamin A. And later, Mrs. Henderson sends over “a little bird delicately roasted,” which Joel consumes with delight. Poultry and gamebirds are another good source of vitamin A.
However, selfless Polly saves the butter and bird for her siblings and ends up being most at risk for permanent vision loss. She develops very painful eyes, suggesting keratitis, and the doctor pronounces that “her eyes are very bad” and warns, “You will be blind!” if she doesn’t take care. Although the author attributes Polly’s illness severity to eye strain from sewing to earn money for the family, it is medically more likely due to vitamin deficiency. The therapeutic value of vitamin A in treating measles was not discovered until 1932 – 51 years after the publication of this book – when British physician Joseph B. Ellison found that administering vitamin A extracts roughly halved the death rate of hospitalized children suffering from measles [1]. Studies establishing the role of vitamin A in reducing blindness in children with measles did not occur until the 1980s [2,3].
Because moralizing 19th century children’s literature rewards the virtuous, Polly ultimately makes a full recovery. However, reality is not so kind. Even today in the 21st century, an estimated 15,000 to 60,000 children are blinded by measles every year globally [4]. The World Health Organization recommends that children in low income and developing regions diagnosed with measles receive immediate, high-dose oral vitamin A [5]. This simple, low-cost intervention protects the cornea and has successfully saved the eyesight of millions of infected children [6]. And, those who are vaccinated against measles are spared the risk and need for intervention completely.
[1] https://pubmed.ncbi.nlm.nih.gov/20777111/
[2] https://pubmed.ncbi.nlm.nih.gov/8486934/
[3] https://pubmed.ncbi.nlm.nih.gov/3492298/
[4] https://pubmed.ncbi.nlm.nih.gov/14998696/
[5] https://www.who.int/news-room/fact-sheets/detail/measles
[6] https://pubmed.ncbi.nlm.nih.gov/24407830/
Original Publication: The story was originally serialized in an 1880 edition of Wide Awake, a children’s magazine and later published in a hard cover edition.
Dover Publications, 2006. 224 pages
Web image by Medhum.org
