The effect of urbanisation It may be harsh to say so, but to the modern eye medical practice in the early 1800s looks pretty medieval. Harsh, because the 17th century had seen important breakthroughs in the fields of pathology, obstetrics and vaccination that would be built upon in the next century. The foundations were laid, but there was more to be done. Medicine in 1800 was a scary combination of chance and quackery that Blackadder would have found familiar. Macbeth-like medicines were overwhelmingly botanical, with preparations of mercury, arsenic, iron and phosphorous also popular. Doctors might recommend a 'change of air' along with vomiting and laxatives and those old favourites, bleeding or leeches. The power of prayer was regularly used. All in all, not ideal. Yet a century later medicine would be available in a form easily recognisable to anybody today: hospitals, stethoscopes, white coats and x-rays. What happened? Two things. Together, cities and science forced real progress in both prevention and cure. The Industrial Revolution was in full flow, and the invention of the steam engine meant that factories could go anywhere, not just near natural power sources. They went to the towns and cities. At a time when Britain's population was increasing rapidly (from six million in 1750 to nine million 50 years later), cities were expanding even faster as now redundant farmworkers migrated to the nearest town to find work. Preston grew sixfold between 1801 and 1851, Bradford and Glasgow eightfold. They were not alone. Overcrowding combined with poor sanitation and often grinding poverty to leave many vulnerable... This growth had enormous consequences. Death rates were high, and far worse in cities than in the countryside. Smallpox, typhus and tuberculosis were endemic, and cholera alarmingly epidemic. Overcrowding combined with poor sanitation and often grinding poverty to leave many people vulnerable to the latest outbreak of anything nasty. Luckily, the Victorians loved statistics, and these validated the emotive prose of Dickens, Gaskell and Engels. In 1832 Parliament agreed to an official inquiry into the operation of the Poor Laws. Sir Edwin Chadwick was energetic in establishing the links between poverty and disease, and the enquiry resulted in new Poor Laws in 1834. Yet these did not go far enough and continued work resulted in the Public Health Act of 1848, which set up local health boards, investigated sanitary conditions nationwide, and established a General Board of Health. Top

The appliance of science Another breakthrough came with the cholera epidemic of 1854. John Snow had experienced previous outbreaks in 1832 and 1848, and was convinced that it was a water-borne disease. This time he provided conclusive proof by mapping out the cases in Soho, central London, implicating a single, contaminated well. The epidemic subsided soon after the pump's handle was removed. Snow also analysed cholera's incidence in water that was bought from different suppliers, demonstrating that households buying from companies drawing water from the Thames downstream - after many sewers had flowed in - suffered a deathrate 14 times greater than those buying water from companies drawing upstream. Following on from this research, he recommended boiling water before use. The 1875 Public Health Act ... provided Britain with the most extensive public health system in the world. John Simon, who had replaced Chadwick to become chief medical officer to the General Board of Health, turned this work into action. He successfully diverted public funds into the investigation of communicable diseases - including diphtheria, typhoid and smallpox - and in the 20 years to 1876 oversaw the transition from the state's mere involvement in reform to a state system of medicine. Having gained some political influence, he found he was able to influence new health legislation. The 1875 Public Health Act comprehensively encompassed housing, sewage and drainage, water supply and contagious diseases and provided Britain with the most extensive public health system in the world. Prevention of disease had come a long way. Progress in this area was being matched by scientific breakthroughs in both diagnosis and cure. The stethoscope - invented in 1817 - was being widely used in Britain by mid-century, and microscopes had improved sufficiently to allow examination of micro-organisms. The practice of surgery also modernised with the invention of anaesthesia in the late 1840s. Although ether was initially used, chloroform soon became the anaesthetic of choice. Top

Breakthroughs Louis Pasteur's work from the late 1850s proved that the souring of milk was caused by living organisms and, by verifying the 'germ theory', changed pathology and surgery forever. Pasteur's work led ultimately to the introduction of antiseptic procedures into surgery via Joseph Lister. Infections and deaths fell sharply and, combined with anaesthesia, enabled surgeons to operate more slowly, carefully and confidently on patients, in turn reaping new discoveries. The end of the century saw yet more breakthroughs. Robert Koch built upon Pasteur's work and in 1882 identified the organisms causing tuberculosis, prompting extensive public health campaigns. But the sexy stuff was tropical disease, increasingly important with the ever-expanding Empire thrusting young Brits into unfamiliar climates. In 1898 Robert Ross proved the mosquito's role in transmitting malaria, and in the same year the Spanish American War prompted new research into yellow fever. Most dramatic, however, was the X-ray, discovered in Germany in 1895. Within days, the news had crossed the world. Sales of X-ray proof underclothing for ladies followed soon afterwards. In January 1896 the first X-ray was taken for clinical purposes, and they were soon used to diagnose fractures, locate foreign bodies and treat a variety of skin conditions. Radiation followed in 1896, and with it the promise of treatment for dreaded cancer. Medicine in 1900 was truly far removed from that 100 years earlier. Top

Medicine institutionalised It wasn't just prevention and cure that was changing, but also medical institutions. The 7th International Medical Congress in 1881 - with 3,000 delegates from 70 countries - gave medical practice a new pizzazz; a new big thing for a country that had had a crush on commerce and technology for the previous century. The death of Alfred Nobel in 1896 gave rise to the Nobel Prizes, with three of the five awarded for science: chemistry, physics and medicine. From the earliest stages Nobel prizewinners became big news. Institutes and prizes were the most glamorous face of a medical world that was becoming increasingly adult. Regulation of medical practice had begun with the establishment of the British Medical Association in 1856 and the General Medical Council in 1858. Medical training became more formalised with the establishment of medical schools, and the number of doctors rose considerably, from 14,415 in 1861 to 35,650 in 1900. Nursing ... became one of the few occupations a middle-class girl might contemplate. However, women remained largely unwelcome in the medical world. The exception to this was nursing. Although nurses had been active in hospitals long before she appeared on the scene, Florence Nightingale's exploits in the Crimean War (1854 - 6) gave the role a new respectability. Many of the nursing reforms she advocated already existed, but her training school at St Thomas's Hospital provided a model for many. Nursing enjoyed a reflected glory and, with teaching, became one of the few occupations a middle-class girl might contemplate. The emergence of modern nursing coincided with changes in hospitals. While initially hospitals just stuck in more beds, newer hospitals were being built. These were often more specialist in orientation, providing treatment for certain patients (eg children), body regions - like ear, nose and throat - or diseases, such as cancer. Funding became an increasing problem and hospitals began to take richer, fee-paying patients to subsidise others. Top

Significant changes ... psychiatry in particular proved very controversial, with many labelled as 'mad doctors'. Meanwhile there was increasing specialisation within the medical profession. This had happened in Germany for some time, but had been resisted by many in Britain as 'unnatural'. The growth of psychiatry in particular proved very controversial, with many labelled as 'mad doctors'. However, over time coherent professional psychiatric groups emerged and gained a certain level of respectability, helped by the work of Sigmund Freud at the end of the century. So medicine in 1900 had seen significant changes from a century before. Scientific discoveries had given medicine new impetus, and a patient seeking care around this time would have had access to new diagnostic procedures and new technologies. Surgery had undergone massive change, with practitioners now working in gowns, masks and the other accoutrements so familiar from TV today. Doctors had started wearing white coats and stethoscopes, and were able to bask in the reflected glory of scientific pioneers such as Marie Curie. However, it doesn't do to exaggerate. Death rates had decreased, but only marginally, from 20.8 per thousand in 1850 to 18.2 in 1900. All else being equal, however, increasing urbanisation would have been expected to increase these. For every disease on the wane - such as smallpox and cholera - another was on the up, including alcoholism and venereal diseases. Many inner city areas still experienced appalling conditions: a high percentages of potential recruits for the Boer War, and for the Great War of 1914 - 18, had to be rejected on medical grounds. Yet advances in public health, science and institutions had taken medicine into grounds of expertise and professionalism few would have expected 50 years earlier. You'd be a lot happier going to the doctor in 1900 than in 1800. Top

Find out more Read on Science and the Practice of Medicine in the Nineteenth Century by WF Bynum (Cambridge, 1994) A Social History of Medicine by FF Cartwright (Longman, 1977) The Epidemic Streets by Anne Hardy (Clarendon, 1993) 'The Victorian Vision', article by Jan Marsh (Victoria and Albert Museum, 2001) Top