Medicine in Modern Britain 1780-1950 (Seminar Studies) [1 ed.] 1138784222, 9781138784222

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Medicine in Modern Britain 1780–1950

Medicine in Modern Britain 1780–1950 provides an introduction to the development of medicine – scientific and heterodox, domestic and professional – in Britain from the end of the early modern period and through modern times. Divided thematically, each chapter within this book addresses a different aspect of medicine, covering diseases, ideas, practices, institutions, practitioners and the state. This book centres on an era of rapid and profound change in medicine and gives students all they need to establish a solid understanding of the history of medicine in Britain, by offering a clear and coherent narrative of the changes and continuities in medicine, including names, dates, events and ideas. Each aspect of medicine discussed within the book is explored and contextualised, providing an overview of the wider social and political background that surrounded them. The chapters are followed by a documents section, containing important primary sources to encourage students to engage with original material. With a selection of images, tables, a who’s who of all the key people discussed and a glossary of terms, Medicine in Modern Britain 1780–1950 is essential reading for all students of the history of medicine in Britain. Deborah Brunton was a senior lecturer in the History of Medicine at The Open University. Her previous publications include Health and Wellness in the Nineteenth Century (2014), The Politics of Vaccination. Practice and Policy in England, Wales, Ireland and Scotland, 1800–1874 (2008), Medicine Transformed: Health, Disease and Society in Europe 1800–1930 (2004) and Health, Disease and Society in Europe 1800–1930: A Sourcebook (2004).

Introduction to the series

History is the narrative constructed by historians from traces left by the past. Historical enquiry is often driven by contemporary issues and, in consequence, historical narratives are constantly reconsidered, reconstructed and reshaped. The fact that different historians have different perspectives on issues means that there is often controversy and no universally agreed version of past events. Seminar Studies was designed to bridge the gap between current research and debate, and the broad, popular general surveys that often date rapidly. The volumes in the series are written by historians who are not only familiar with the latest research and current debates concerning their topic, but who have themselves contributed to our understanding of the subject. The books are intended to provide the reader with a clear introduction to a major topic in history. They provide both a narrative of events and a critical analysis of contemporary interpretations. They include the kinds of tools generally omitted from specialist monographs: a chronology of events, a glossary of terms and brief biographies of ‘who’s who’. They also include bibliographical essays in order to guide students to the literature on various aspects of the subject. Students and teachers alike will find that the selection of documents will stimulate the discussion and offer insight into the raw materials used by historians in their attempt to understand the past. Clive Emsley and Gordon Martel Series Editors

Medicine in Modern Britain 1780–1950

Deborah Brunton

First published 2019 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 711 Third Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 Deborah Brunton The right of Deborah Brunton to be identified as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data Names: Brunton, Deborah, author. Title: Medicine in Modern Britain 1780-1950 / Deborah Brunton. Description: Milton Park, Abingdon, Oxon ; New York, NY :   Routledge, 2018. | Includes bibliographical references and index. Identifiers: LCCN 2018003943| ISBN 9781138784222 (hbk : alk. paper) | ISBN 9781138784239 (pbk : alk. paper) |   ISBN 9780429488504 (ebk) Subjects: LCSH: Medicine—Great Britain—History—18th-20th centuries. Classification: LCC R486 .B78 2018 | DDC 610.941—dc23 LC record available at https://lccn.loc.gov/2018003943 ISBN: 978-1-138-78422-2 (hbk) ISBN: 978-1-138-78423-9 (pbk) ISBN: 978-0-429-48850-4 (ebk) Typeset in Sabon by Apex CoVantage, LLC

Contents

List of figures and tables Chronology Who’s who

viii ix xii

PART I

Introduction

1

1 Introduction

3

Part II

Narrative

7

2 Disease in modern Britain Death and disease  9 The epidemiological transition  14 Measuring morbidity  21 Why did patterns of disease change?  23

9

3 Medical ideas The emergence of hospital medicine  28 Laboratory medicine  33 Laboratory and clinic  38 Beyond the biological  40 Heterodox medicine  42

27

4 Medical practices The pursuit of health  45 Domestic medicine  49 Medical practitioners  53 Consuming medicine  59

45

vi Contents 5 Medical care in institutions Voluntary hospitals and dispensaries  63 Poor Law hospitals  70 Fever hospitals and tuberculosis sanatoria  72 Hospitals and dispensaries in Ireland  75 Asylums 76

63

6 Medical practitioners Making a medical living  82 Excluding competitors  88 Nursing 91

81

7 Health and the state Sanitary reform  99 Public health  102 Welfare 105 Government medical care  109

99

PART III

Assessment

115

8 Medicine in modern Britain: change, continuity, variation

117

PART IV

Documents

121

1  2  3  4  5  6  7  8  9  10  11  12  13  14  15 

123 123 124 125 126 127 127 128 129 130 131 132 132 133 134

Description of fevers Victims of cholera The Spanish Flu The increase in cancer Variations in mortality The health of working class women The action of fever Pathological changes in the lung The technical language of medicine The physiology of the kidney The benefits of physiological research A holistic view of the body The benefits of exercise Health and sunlight Domestic remedies

Contents  vii 16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37 

Patent medicines Hydropathic treatment Treatment of heart disease The experience of surgery An appeal for funds Rules from Huddersfield Infirmary Hospital design The patient’s experience Asylum design Medical training in London Setting up in practice Unity in the profession Opposition to the Colleges Opposition to homeopaths Opposition to women doctors Nurse training Insanitary conditions in cities Public health in central and local government Health education The work of the Medical Officer of Health The cause of infant mortality The new National Health Service

136 136 137 138 139 140 142 142 144 145 146 146 147 148 149 150 151 151 152 153 154 155

References Glossary Further reading Index

157 166 169 173

Figures and tables

Figures 2.1 3.1 4.1 4.2 5.1 5.2 6.1 7.1

Cholera victim, 1832 Engraving of diseased kidney, 1799 Advertisement for lung tonic, c. 1918 Charing Cross Hospital; Stanley Boyd in the old operating theatre, 1900 Plan of Royal Infirmary, Edinburgh, 1893 The Henry Quinn Ward, Great Northern Central Hospital, Holloway Road, London, 1912 Luke Fildes, ‘The doctor’, 1891 ‘Express panel doctor’, Punch, 1913 vol. 144, p. 138

16 30 52 58 66 68 87 110

Tables 2.1 Selected causes of death in Carlisle, 1779 and 1781–1787 2.2 Percentage of deaths from selected causes, London 1760 and 1770s 2.3 Most common causes of death, England and Wales, 1851–1860 2.4 Selected causes of death by age 1851–1860, females only 2.5 Death rates from selected infectious diseases per 1,000 population, 1891–1930 2.6 Selected causes of death, 1951

10 12 13 15 18 19

Every effort has been made to contact copyright-holders. Please advise the publisher of any errors or omissions, and these will be corrected in subsequent editions.

Chronology

1782

Founding of York Retreat, an asylum which pioneered moral therapy. 1793 Publication of Matthew Baillie’s Morbid Anatomy of Some of the Most Important Parts of the Human Body. 1808 Passing of Lunacy Act allowing, for the first time, the use of local rates to fund asylums for the poor. 1809 First operation to remove a cyst on the ovary. At this time, operations on abdominal organs were risky and rarely carried out. 1815 Apothecaries’ Act sets minimum requirements for licensing in line with changes in medical education. 1816 Rene Laennec invents the stethoscope, which allowed better diagnosis of lung and heart diseases. 1823 Founding of The Lancet, campaigning medical journal, by Thomas Wakley. 1828 First British teaching post in pathological anatomy established at University College London. 1832 Anatomy Act allows medical schools to use the bodies of paupers for dissection. 1832 Founding of Provincial Medical and Surgical Association, the first national medical society. 1831–32 First cholera epidemic in Britain prompts the creation of Central and local Boards of Health. 1835 New Poor Law Act passed for England and Wales, reorganising relief around workhouses. 1837 Founding of Registrar-general’s office for England and Wales. The equivalent agencies for Scotland and Ireland were founded in 1854 and 1864. 1838 Irish Poor Law Act passed. 1842 Publication of Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population. Poor Law Act for Scotland passed. 1845 1845–49 The Great Famine in Ireland, caused by repeated failures of the potato crop, which caused over a million deaths and high levels of disease.

x Chronology 1847 1848 1848–49 1852 1853 1858 1860 1866–67 1867 1869 1869 1871–73 1875 1888 1895 1899 1902 1905 1906 1910 1911 1912 1913 1913 1914–18

Both ether and chloroform first used as surgical anaesthetics. Chloroform was more generally used in Britain. First Public Health Act for England and Wales, and the establishment of the General Board of Health, the first central government agency dedicated to medical matters. Second cholera epidemic in Britain. Founding of Great Ormond St Hospital – the first children’s hospital in Britain. Vaccination Act for England and Wales introduced compulsory smallpox vaccination for all infants. Medical Reform Act establishes General Medical Council and the Medical Register of all qualified practitioners. Opening of Nightingale Nursing School at St. Thomas’ Hospital, London. Last major cholera epidemic in Britain. Joseph Lister publishes on his system of antiseptic surgery. Chloral hydrate, the first chemical drug, discovered. A group of women, led by Sophia Jex-Blake, begin studying medicine at Edinburgh University. Major outbreak of smallpox, reversing the trend of declining incidence since the introduction of vaccination in 1798. Public Health Act for England and Wales passed, requiring the appointment of Medical Officers of Health. Founding of British Nursing Association, which campaigned for nurse registration. Discovery of x-rays by Wilhelm Roentgen. Aspirin first marketed. Midwives’ Act sets minimum standards of training for licensed midwives. Ernest Starling names a group of chemicals capable of provoking secretion ‘hormones’. Education Act establishes School Medical Service responsible for inspecting all children. Discovery of Salvarsan, a drug for the treatment of syphilis. It was the first ‘magic bullet’ targeting only the disease organism and not effecting healthy cells. Passing of the National Insurance Act, which provided general practitioner care and sickness benefits to many workers. Isolation and identification of the first vitamin. Founding of Medical Research Council. Founding of Highlands and Islands Medical Service, supporting practitioners in remote areas of Scotland. First World War, causing around 723,000 deaths to British combatants. Many more were left disabled.

Chronology  xi 1919

Nurses Registration Acts passed for England and Wales, Scotland and Ireland. 1919 Creation of Ministry of Health and Scottish Board of Health 1918 Maternity and Child Welfare act allowed local authorities to set up infant welfare centres. A similar act had been passed in Scotland three years previously. 1918–20 Pandemic of ‘Spanish’ influenza, which killed around 250,000 people in Britain. Local Government Act, which passed control of poor law 1929 infirmaries to local government. Founding of Women’s League of Health and Beauty. 1930 Discovery of Prontosil, the first sulphonamide drug. The sulpha 1935 drugs were effective against some, but not all bacteria, including those responsible for puerperal fever. 1939–45 Second World War, which killed around 460,000 combatants and civilians. Penicillin available in sufficient quantities to treat sick and 1944 wounded Allied combatants. 1946 Passing of National Health Service Acts.

Who’s who

Bevan, Aneurin (1897–1960) Minister for Health in the 1945 Labour Government and architect of the National Health Service Acts. Anderson, Elizabeth Garrett (1836–1917) The first British woman to qualify as a practitioner. She established the New Hospital for Women and the London School of Medicine for Women. Baillie, Matthew (1761–1823) Teacher at the anatomy school at Windmill St., London, Baillie was one of the first researchers into pathological anatomy. Bayliss, William (1860–1924) Physiologist, who worked on the nervous control of blood flow, and the role of enzymes. He is most famous for the discovery (with Ernest Starling) of the first hormone, secretin. Chadwick, Edwin (1800–1890) A lawyer and public health reformer, who led the first General Board of Health. Chadwick advocated the installation of better water and sewerage systems as a means of controlling disease. Cullen, William (1710–1790) Lecturer in medicine at the universities of Glasgow and later Edinburgh. Cullen was one of the most distinguished teachers, authors and practitioners of his day, particularly known for his work on fevers, and on the classification of diseases. Dale, Henry (1875–1968) Physiologist who worked on the role of chemicals in stimulating smooth muscle, and in carrying impulses between nerves. He shared the Nobel Prize for Medicine for this work in 1936. Farr, William (1807–1883) Medical practitioner and first statistical analyst at the Registrar-general’s Office for England and Wales. Farr helped to drive public health reforms in the mid-nineteenth century. Fenwick, Ethel Bedford (1857–1947) Founder of the British Nurses Association in 1887, she campaigned for the reform of nurse training and the creation of a register of qualified nurses. Foster, Michael (1836–1907) First professor of physiology at Cambridge, he established the new research school and trained many eminent physiologists.

Who’s who   xiii Hopkins, Frederick Gowland (1861–1947) First Professor of Biochemistry at Cambridge University, he worked on metabolism and nutrition. He was awarded a share of the Nobel Prize for Medicine in 1929 for the discovery of vitamins. Jex-Blake, Sophia (1840–1912) A pioneer of medical education for women and one of the first women students at Edinburgh University. She founded the Edinburgh Hospital and Dispensary for Women and Children and the Edinburgh School of Medicine for Women. Lister, Joseph (1827–1912) Lister developed the use of antiseptic techniques to prevent wound infection. His use of carbolic acid as an agent was unpopular with some surgeons, but was widely adopted until superseded by aseptic surgical techniques. Nightingale, Florence (1820–1910) Nightingale famously reorganised and administered the military hospital at Scutari. A public fund, raised in recognition of her efforts was used to found the Nightingale nurse training school at St. Thomas’ Hospital. As well as helping to reform and raise the status of nursing, Nightingale was also a pioneer in the use of statistics in medicine. Sanderson, John Burdon (1828–1905) Professor of Physiology at University College, London and at Oxford University, he worked on the relationship between respiration and the circulation, and the communication between nerves and muscles. Sherrington, Charles (1857–1952) Physiologist who worked on different aspects of the nervous system, including the inhibitory action of the reflex and the communication between nerves. Simon, John (1816–1904) At the Medical Office to the Privy Council and later the Local Government Office, Simon shaped public health policy and practice in the nineteenth century. Simpson, James Young (1811–1870) Simpson specialised in obstetrics and from 1840 was Professor of Midwifery at Edinburgh University. In 1847 he began searching for an alternative to ether as an anaesthetic agent and discovered that chloroform provided the same insensibility with fewer drawbacks. Stark, James (1811–1890) First Superintendent of Statistics at the Office of the Registrar-general for Scotland, responsible for producing data on disease and death. Starling, Ernest (1866–1927) Starling worked on the control of the action of the heart, the production of lymph and other body fluids, and discovered (with William Bayliss) the first hormone, secretin. Wakley, Thomas (1795–1862) Surgeon and founder of The Lancet, which provided a platform for his efforts to sweep away the old professional institutions and recognise the role of general practitioners. He also pursued these issues in parliament, where he served as an MP for seventeen years.

Part I

Introduction

1 Introduction

This book aims to provide an introduction to medicine in Britain between 1780 and 1950 – or, to use the historian’s terminology – from the end of the early modern period through the modern period. (Events after 1945 are usually designated as ‘contemporary history’.) This is a significant era: it saw the emergence and establishment of scientific (or Western) medical ideas, practices, and institutions in Britain, alongside other and older systems of medicine. The book assumes no prior knowledge of the subject. Each chapter addresses one basic aspect of medicine in the past – diseases, ideas, practices, institutions, practitioners and the state – and sets out to explain what happened, where and why, as well as introducing some of the central figures associated with the topic. Even though it is not intended as a historiographical essay that analyses the scholarship on the topic, this book inevitably reflects the literature on the history of medicine in the early twenty-first century. History of medicine as an academic discipline is relatively young: it was only established in the 1970s. Since that time, researchers have moved away from a traditional concern with those great steps forward, such as the development of anaesthetics or antiseptics, which seemed to lead to modern medicine. Historians began to explore much broader fields of medical experience. They grappled with making sense of medical ideas and practices in the past that now seem irrational, showing how the use of medicines that caused patients to vomit, sweat, or urinate were a rational response to illness, when understood within the framework of humoural medicine. Instead of dismissing heterodox and unqualified practitioners as medical frauds, historians explored the reasons for their continuing popularity. In recent years, the scope of the field has continued to expand to cover topics on the borderline of medicine and other aspects of society, such as the relationship between health and beauty. Researchers now use medical issues to analyse broader historical questions: for example, the development of public health initiatives has been used as a means to analyse the shaping of nineteenth-century government administration. Research papers, once found only in specialist journals such as Medical History or Social History of Medicine are now published in a wide range of history journals. As historians’ approach to medicine has shifted, so has their focus of research and the scope of the field. The strong interest

4 Introduction in eighteenth-century medicine and the patients’ experience of illness that dominated in the 1980s has given way to studies of nineteenth and twentieth century medicine, including explorations of the role of government in health, of the work of charities and voluntary bodies, practitioners’ experiences of working within medicine, and medicine practiced within the home. Much research in the history of medicine is underpinned by a common approach. In the 1970s, developments in medicine were seen to be driven by the internal logic of ideas and the work of doctors. From the 1980s, historians of medicine have sought to locate change within its social, political and cultural context. In this reading, developments in medicine were not inevitable, but emerged, were taken up, dropped and shaped within a particular set of circumstances. For example, efforts to control cholera were not motivated simply by a desire to help poor victims of the disease, but rather to protect local economies which always suffered during epidemics. Similarly, the desire to exclude women from the medical profession reflected widely held ideas about their inability to study and to deal with the difficulties of medical practice, but it was also informed by a concern that the medical profession was overcrowded, with too many practitioners chasing the fees of too few patients. In such circumstances it made sense to male practitioners to marginalise a new group of rivals. Some historians have gone beyond seeing social factors shaping medicine, and have argued that medicine is socially constructed. In this reading, diseases are not constant biological entities but products of a particular time and place. Practitioners, they argue, created illnesses by noting certain phenomena and fitting them into frameworks of theory, which explains why diseases have appeared and disappeared within the historical record. While most historians shy away from the notion that diseases have no biological reality, it is widely acknowledged that understandings of disease have changed significantly over time. ‘Heart attacks’ only appeared in medical records in the late nineteenth century, although undoubtedly people had suffered from this condition for hundreds of years. However, their symptoms were understood and labelled in different ways. Historians’ focus on the factors shaping medical practice has helped to highlight variations in experience across different populations – between rich and poor, urban and rural, and between different geographical areas. It also meant that ideas of progress lost their central position: medicine was no longer a succession of great improvements, usually attributed to the work of great men. Historians of medicine continue to have a slightly uneasy relationship to the concept of progress. Few academics would frame their work as tracing a shift from bad to better knowledge and practice, but notions of progress and improvement cannot be written out of history. While medicine continues to have a 100% failure rate – we all die – there has been a huge improvement in life expectancy, in the chances of surviving illness, and reductions in the levels of discomfort that patients suffered between the early modern period and the present day.

Introduction  5 A shared approach which emphasises social factors does not, of course, mean that historians always agree on the interpretation of the past: the history of medicine has its fair share of historiographical debates. Researchers have disagreed over many topics, including the usefulness of the concept of professionalisation when analysing changes to medical occupations, the impact of public health measures in reducing incidence of infectious disease, to what extent there was a decline in infectious disease, and the relationship between clinical and laboratory medicine. Historians of medicine have devised a number of schemas to characterise change over time. One of the most widely used is that of Nicholas Jewson, who divided medicine from the eighteenth to the twentieth century into three phases. Bedside medicine dominated in the eighteenth century, with patients and practitioners collaborating and negotiating over diagnosis and therapy. Practitioners took control of the medical encounter in the nineteenth century with the emergence of hospital medicine, with its new theories of disease and new methods of diagnosis. Their authority was further consolidated in laboratory medicine, as they possessed increasingly technical information on patients’ physiology and pathology. Jewson’s overview emphasises the relationship between knowledge and the division of power between patients and practitioners. John Pickstone’s schema of twentieth-century medicine emphasises the role of the state and political interests. Productionist medicine, associated with the expansion of welfare in the early twentieth century sought to improve the health and strength of the workforce. Mid-century medicine was communitarian in character and featured collective action, most notably the founding of the NHS (the National Health Service). The late twentieth century (which falls outside the scope of this study) Pickstone characterised as ‘consumerist’ medicine, where patients were increasingly free to choose from a range of public and private medical services. While each chapter of this book explores a different aspect of medicine, all address a common theme of change and continuity. Between 1780 and 1950 there were significant developments in all areas of medicine, but the rate of change varied significantly: compared to the rapid adoption of new theories there was much greater continuity in the use of therapeutics. Each chapter also attempts to give some sense of the variations in medical practice and patients’ experience of illness across class, age and gender, and in different geographical areas within Britain. Comparisons of medicine within the different nations provide a useful tool to tease out the working of social and cultural factors on medicine, although they are limited by the available literature. The bulk of British history of medicine deals with England: medicine in Wales remains under-researched, although there is a growing body of material on both Scotland and Ireland. For much of the period from 1780 to 1950, the whole of the island of Ireland was part of the United Kingdom, and for the sake of continuity, material on both parts of Ireland after partition in 1921 is included where appropriate. Only lack of space has prevented the inclusion of material on medicine in the Empire.

Part II

Narrative

2

Disease in modern Britain

The landscape of disease forms the context for any history of medicine: the prevailing diseases at any time defined the experiences of patients and how long they lived, and shaped the work of practitioners, institutions and the state. However, mapping disease over time is a complex process. Different generations of doctors understood illness in different ways. Late eighteenth century practitioners identified diseases by their pattern of symptoms but by the mid-twentieth century, practitioners defined illnesses by their causative agent such as a specific bacteria or virus or a malfunctioning organ or tissue. Thus diseases changed their identity over time. Complaints labelled ‘fever’ in the eighteenth century had, by the twentieth century, been re-categorised as typhus, typhoid fever and other infections that caused a high temperature. Nevertheless, it is possible to draw a general picture of illness in Britain between 1780 and 1950. Records of mortality – of causes of death – show that from the late eighteenth until the early twentieth century, most people died from infectious diseases such as tuberculosis, fevers, pneumonia, smallpox, and measles. Vast numbers of infants died from diarrhoea, convulsions and ‘teething’, all of which were linked to dirty living conditions. In the middle of the twentieth century the pattern of deaths shifted to one similar to the present day, with more people dying in later life from heart disease, strokes and cancer. Figures on disease taken from mortality records inevitably give only a partial picture – they tell us what diseases people died from but not the much greater numbers of illnesses that they survived. Records of morbidity – of all forms of illness – are available from the nineteenth century and present a more stable and familiar picture of diseases, dominated by cases of colds, stomach upsets and bad backs.

Death and disease Data on causes of death in Britain for the late eighteenth century is patchy. There is a comprehensive set of records available for London, where, from the sixteenth century, parish officials compiled and published bills of mortality to alert residents to the presence of plague and other diseases. Outside the capital, some (although by no means all) parish registers reported the

10 Narrative cause of death of those buried in their churchyards. In addition, a number of medical practitioners collected and analysed data on causes of death for their local town (Rusnock, 2002). Table 2.1 gives figures on the causes of death in Carlisle, collected by John Heysham, a local practitioner. In many ways these are typical of the eighteenth-century mortality data, and reveal the difficulties of understanding what diseases were prevalent in the past. Many of the causes of death listed here appear very strange to modern eyes. In medicine in the twenty-first century, each disease has a specific biological basis – they are caused by infection with a micro-organism, a malfunction in an organ or tissue, or some genetic mutation. In the eighteenth century, diseases were categorised by their pattern of symptoms and the sensations experienced by patients. For example, fever is now a symptom, defined by a raised body temperature; in the eighteenth century it was a disease diagnosed by the experience of feeling hot or cold, excessive sweating, flushed skin and delirium (Hamlin, 2014). Fever was divided into different types: ‘putrid’ fever, for example, produced blotches on the skin and was associated with groups living in crowded conditions such as prisoners, sailors and soldiers [Document 1, p. 123]. Putrid fevers probably included cases of what would now be diagnosed as typhus, but we should not assume that every case of putrid fever was in fact typhus. Similarly, consumption – a disease associated with wasting of the body – is often equated with modern tuberculosis, but deaths from consumption could well have resulted from other diseases such as cancers. Table 2.1  Selected causes of death in Carlisle, 1779 and 1781–1787

Smallpox Decay of age Consumption Weaknesses of infancy Thrush Nervous fever Dropsy Putrid fever Scarlet fever Apoplexy Measles Asthma Worm fever Cancer

Number of deaths

% of deaths

238 226 214 204 65 59 49 43 39 32 31 27 27 5

14.7 13.9 13.2 12.6 0.4 0.4 0.3 0.3 0.2 0.2 0.2 0.2 0.2 0.03

Source: Taken from H. Lonsdale (ed.) (1870) The Life of John Heysham, M.D., pp. 53–54. The data for 1780 was omitted in the original table.

Disease in modern Britain  11 Despite the problems of understanding many disease categories, mortality data combined with contemporary accounts of disease allow historians to construct a picture of death and disease in the late eighteenth century. Deaths were predominantly caused by illnesses that we would categorise as infections – fever, smallpox, measles, whooping cough, scarlet fever and consumption. Smallpox was a particularly deadly disease at this time. Almost everyone caught smallpox, usually during childhood. It was highly dangerous: around one in ten victims died, while survivors were often left scarred by the rash or ‘pocks’ but were left immune to further attacks (Mercer, 2014). Some groups within the population suffered particularly high levels of mortality. Large numbers of infants died from convulsions and ‘teething’. Neither of these condition are now believed to be dangerous, but in the late eighteenth century, the period when infants cut their first teeth was seen as a perilous transition from helpless infancy to more independent childhood. Historians have suggested that many of these deaths were caused by weaning and the shift to eating solid food, often contaminated by microorganisms, which caused diarrhoea, and, in severe cases, dehydration and convulsions. The elderly also suffered from high mortality: their deaths were often recorded under vague categories such as ‘decay’ or simply ‘aged’. The Carlisle data gives a picture of mortality in a substantial town, with a population of around 8,600 people at the end of the eighteenth century. Townspeople experienced a rather different pattern of disease to those living in rural areas. They were exposed to frequent outbreaks or epidemics of infectious diseases. For example, in Carlisle, smallpox was present in most years, but the numbers of deaths varied widely, from the 90 victims of a major outbreak in 1779 to just one in 1786 (Mercer, 1990, pp. 59–67). More extreme patterns were observed in isolated communities: when smallpox arrived on the remote island of Foula in Shetland in 1720, the population was all but wiped out. By contrast, in major centres of population such as London, which had a population of around 700,000 in the middle of the century, infectious diseases were endemic: they were present at all times and caused roughly similar numbers of deaths each year (see Table 2.2). Compared to the snapshots of mortality in specific locations available in the eighteenth century, there is a vast and comprehensive amount of data on cause of death from the middle of the nineteenth century, when the government began to collect records of births, marriages and deaths as part of a wider movement to accumulate data on social issues. The Registrar-general’s office (RGO) for England and Wales was created in 1837, while the equivalent offices in Scotland and Ireland were established in 1854 and 1864 respectively. In each nation, a network of local registrars recorded births, deaths and marriages, and the information was analysed in the central offices, combining it with data on the population from the census. Compared to earlier

12 Narrative Table 2.2  Percentage of deaths from selected causes, London 1760 and 1770s

Convulsions Consumption Fevers Smallpox Old age Teething Dropsy Asthma and tissick1 Whooping cough Measles

1770s

1780s

26.5 21.4 12.4 10.2 6.1 3.5 4.3 1.7 1.5 0.9

24.2 24.5 12.7 8.8 6.6 2.4 4.6 1.7 1.5 1.2

1  Tissick – coughs, especially associated with difficulty breathing. Source: Adapted from Appendix 2a, Percentage of deaths attributed to different causes in the London Bills of Mortality, in Alex Mercer (1990) Disease, Mortality and Population in Transition Epidemiological-Demographic Change in England Since the Eighteenth Century as Part of a Global Phenomenon. Leicester: University of Leicester Press, p. 227.

mortality records, the data from the Registrar-generals’ offices was much more comprehensive and was subjected to increasingly sophisticated analysis by location, age and gender. Reports compiled from this data included information on local and national mortality rates – the number of deaths within a given number of living over a set period – which gave a measure of the relative healthiness of the population. It is tempting to see this numerical information as an objective and accurate picture of mortality, but it needs to be approached with a critical eye. The data was not complete: although all deaths were required to be certified before burial, in remote rural areas many deaths went unregistered. As many as a quarter of the deaths in Highland Scotland went unrecorded as late as 1906. There were also inaccuracies and inconsistencies in reporting the cause of death. Certificates were signed by medical practitioners who were not required have attended the patient in his or her final illness, so the diagnosis of cause of death relied on information from relatives or neighbours. Doctors sometimes collaborated in covering up the cause of death: there was persistent under-recording of venereal disease (associated with immorality) or suicide (linked to mental illness) (Scottish Way of Birth and Death, accessed 2017). Inconsistencies in the recording of cause of death were produced by the Registrar-general’s offices own lists of recognised causes of death, which were revised over time to take account of developments in medical knowledge. A sharp rise in the numbers of deaths from diabetes from the 1890s was a result of adding this disease to the list of official causes of death. Political agendas informed the analysis of mortality data. William Farr (1807–1883), the superintendent of the statistical department of the RGO

Disease in modern Britain  13 in London, was a strong supporter of the new public health movement. He used data on cause of death to identify links between mortality, population density and unhealthy environments. By publishing the numbers of deaths in each location, Farr hoped to shame the local authorities in particularly unhealthy places into taking greater action. James Stark (1811–1890), Farr’s counterpart in Scotland, placed a greater stress on the link between disease and poverty. While the two offices recorded similar patterns of disease, in the 1860s and 1870s their annual reports presented diseases in different groupings and offered different interpretations of how best to improve the health of the population (Higgs, 2004). Table 2.3, showing causes of death in England and Wales in the middle of the nineteenth century, presents a rather more familiar appearance to modern eyes. Complaints such as ‘tissick’ have been replaced by categories such as ‘lung disease’. The new terminology reflects a change in the understanding of diseases which was moving towards one used in the present day, although the transition was far from complete (see Chapter 3). However, understanding disease in the 1850s still requires some knowledge of contemporary Table 2.3  Most common causes of death, England and Wales, 1851–1860

Total deaths Lung disease Diseases of brain Phthisis2 Heart disease and dropsy Cholera, diarrhoea Diseases of stomach and liver Typhus Scarletina3 Other zymotic4 Whooping cough Measles Scrofula5 Hydrocephalus6 Cancer Smallpox

Number of deaths

Percentage of total deaths

4,210,715 573,826 520,728 439,923 236,977 205,172 190,722 172,458 166,433 158,138 95,624 78,211 77,354 75,500 60,175 42,071

13.7 12.4 10.4 5.6 4.9 4.5 4.1 4.0 3.8 2.3 1.8 1.8 1.8 1.4 1.0

2  Another name for tuberculosis. 3  Also known as scarlet fever. 4  Infectious diseases, which Farr believed were spread by ‘zymes’, an unknown biological agent. 5  Swelling of glands, some of which was due to TB infection. 6  Excess fluid in brain. Source: Supplement to the twenty-fifth annual report of the Registrar-general of Births, Deaths and Marriages in England. Parliamentary Papers, 1865, vol. 13 (3542) pp. 2–3.

14 Narrative medicine. For example, the cholera deaths listed in tables of mortality are often assumed to refer to Asiatic cholera, a disease that was endemic in India but which periodically swept across Europe in the nineteenth century. However, practitioners also recognised ‘British cholera’, a disease similar to dysentery, which was endemic in Britain, causing deaths every year. Although the names of diseases may have changed, the prevailing causes of death presented in Table 2.3 have many continuities with those in the late eighteenth century. Infectious diseases continued to claim the greatest number of lives. Children died from scarlet fever, whooping cough, measles and smallpox – so much so that these were often referred to as ‘childhood diseases’ which everyone was expected to experience early in life. Adults were killed by typhus, phthisis (a wasting disease previously known as consumption) bronchitis, pneumonia and influenza. But there are differences too; the percentage of deaths from smallpox dropped markedly between the late eighteenth and mid-nineteenth century – from over 10% to 1%. However, the table also suggests an increasing number of deaths from non-infectious, chronic diseases such as cancer, diseases of the brain and heart.

The epidemiological transition The data in Tables 2.1 and 2.3 hint at changes in the causes of death between the late eighteenth and mid-nineteenth centuries. This was part of a longer term change known as the epidemiological transition, first described in 1971 by Abdel Omran (1925–1999) professor of epidemiology at the University of North Carolina. The epidemiological transition was a global shift from mortality dominated by infectious disease to one where chronic diseases caused the greatest proportion of deaths, although the timing of the change varied between different economies and regions. For northern Europe, Omran identified a pre-modern phase of pestilence and fever, when large numbers died as a result of widespread epidemics. This was followed by an age when these mortality crises declined in frequency and severity with a general reduction in deaths from infectious diseases. The third age was one when mortality was predominantly caused by chronic and degenerative diseases such as cancers and heart disease associated with old age (Omran, 1971). In Britain the second phase of this transition began in the late seventeenth century, with the end of a series of plague outbreaks, and continued through the eighteenth and much of the nineteenth century. The third phase began around the end of the nineteenth and beginning of the twentieth century and continues to the present. The annual publication of mortality statistics by the Registrar-generals’ offices has allowed historians to analyse patterns of death, and compare them to Omran’s model of the epidemiological transition. The data confirms that there was a decline in mortality from infectious diseases beginning in the late eighteenth century. The most significant reduction in deaths was due to a decline in smallpox mortality, which fell from between 10% and 14% of all deaths in the late eighteenth century, to just 1% by 1850. The proportion of deaths rose

Disease in modern Britain  15 temporarily during a major epidemic in 1871–73, but smallpox had ceased to be a major killer by the end of the nineteenth century. Such a dramatic reduction in deaths was the exception, not the rule. Among other childhood diseases patterns of mortality varied markedly. Scarlet fever deaths declined rapidly in the late nineteenth century. The disease caused around 10,000 deaths each year in England and Wales at mid-century but by 1900 the death rate had fallen by almost four-fifths. Mortality from whooping cough, however, fell only very slightly, from 2.1% of all deaths to 1.8% over the same period while the proportion of deaths from measles hardly fell at all. Deaths from diphtheria actually increased over the last decades of the century (Hardy, 1993; see also Table 2.4). Among those diseases which effected both adults and children, the most significant decline in mortality occurred in respiratory tuberculosis (the disease previously known as consumption or phthisis). In the eighteenth century, consumption has been reckoned to have caused around 15% to 20% of all deaths, with some reduction in mortality over the early nineteenth century. According to the tables produced by the Registrars-general, the mortality decline then accelerated, with deaths from phthisis falling from 12.4% of all deaths around 1850 to 7.5% in 1900. However, this figure has to be treated with some caution: over the same period, deaths from respiratory diseases such as bronchitis (like tuberculosis, a chronic lung complaint) Table 2.4  Selected causes of death by age 1851–1860, females only. Age

0-

5-

Smallpox Measles Scarlatina Diphtheria Whooping cough Typhus Cholera, diarrhoea Other zymotic Cancer Scrofula Phthisis Diseases of brain Heart disease and dropsy Lung disease Diseases of stomach and liver Childbirth

12,854 34,597 51,242 5,416 50,387 18,052 61,650

2,694 3,191 22,107 3,100 2,379 11,923 2,476

1,507 576 6,695 1,644 163 18,290 2,024

2,278 252 1,795 529 19 23,314 9,836

273 30 236 135 5 10,396 9,164

49 5 47 55 5 6,363 14,694

30,940 291 22,320 16,125 119,300 4,186

5,018 102 2,802 6,856 6,171 2,378

3,359 258 3,883 44,955 7,258 5,990

7,787 9,085 3,133 15,5195 21,833 14,272

7,023 20,792 1,669 39,383 35,554 42,922

9,328 11,309 648 5,624 52,304 70,284

119,559 14,100

6,712 2,715

5,571 4,787

24,391 22,876

45,556 30,130

63,782 227,34

1,336

29,135

588

-

-

10-

20-

45-

65-

Source: Supplement to the twenty-fifth annual report of the Registrar-general of Births, Deaths and Marriages in England. Parliamentary Papers, 1865, vol. 13, pp. 2–3.

16 Narrative and pneumonia increased, and it is probable that some of the reduction in phthisis mortality was due to deaths being shifted into these categories of lung disease (Hardy 1993). There was significant geographical variation in the fall in phthisis deaths: in Scotland the reduction began rather later – in 1870 not 1840 (Jenkinson, 2002). In mid-nineteenth century Britain, epidemics loomed very large in the contemporary consciousness, but deaths from the classic epidemic diseases – fever and cholera – declined over the century. Cholera was unique in the nineteenth-century list of diseases. It was endemic in India and unknown in Britain until 1831, when the population was struck by the first of several pandemics that swept around the globe. Thereafter, epidemic cholera appeared again in Britain in 1848, 1853 and 1866. Cholera generated terror and panic. It was an unfamiliar illness with a frighteningly rapid course: victims could be well in the morning and dead by nightfall. The symptoms were equally distressing: patients suffered from violent vomiting and diarrhoea which dehydrated the body, causing the skin to take on a bluish tinge, followed by convulsions, stupor and death. No remedies could cure cholera, or even alleviate the suffering of its victims, and around one third of all cases ended in death [Document 2, p. 123]. While cholera caused widespread concern, and sometimes panic, in terms of overall mortality, it was relatively unimportant. The epidemic of 1848–49 was the worst, causing around 5% of all deaths in that year. In total, cholera is estimated to have killed over 100,000 people in Britain across the four epidemics.

Figure 2.1  Cholera victim from Sunderland, 1832. This image of one of the first British victims of the cholera epidemic of 1832 exaggerates the discolouration of the skin for dramatic effect, although the sunken features were typical of cholera cases. Credit: Wellcome Library, London.

Disease in modern Britain  17 In terms of mortality, fever – from the 1840s split into typhus and typhoid – was a far more significant cause of death. Both diseases were associated with poor living conditions. Typhus, which was spread by body lice, flourished in dirty, overcrowded housing while typhoid was communicated through contaminated water and food. Fever flourished in times of upheaval and social dislocation: epidemics occurred in towns and cities when large numbers of unemployed rural labourers made their way into cities each winter and during major strikes or downturns in the local economy. However, the worst outbreak of typhus occurred in rural Ireland during the Great Famine between 1845 and 1852. The potato crop that sustained most of the population failed, resulting in over a million deaths from starvation, fever and other diseases. In England and Wales, fever was responsible for around 12% of all deaths in the early 1850s, but the disease was already in decline. Typhus epidemics in cities had largely disappeared by the 1870s, although minor outbreaks of typhoid fever continued to cause deaths among all classes. The decline in deaths from infectious diseases continued into the twentieth century, with an important turning point in 1914, when, for the first time, non-infectious diseases caused the majority of deaths (Hardy, 2000). In the twentieth century, smallpox became rare. Mortality from childhood diseases – measles, scarlet fever, whooping cough and diphtheria – plummeted, reaching levels in the 1930s that were just one-third to one-eighth those of the 1890s. The decline of infectious diseases among adults was similarly dramatic. Levels of deaths from typhoid fever(now relabelled enteric fever) in 1930 were less than 10% of that in 1890. Deaths from tuberculosis fell, both from respiratory TB, which damaged the lungs, and non-respiratory tuberculosis, where the infection lodged in the joints or in the skin (a condition previously known as scrofula). The numbers of deaths from all forms of TB declined by around a third and the mortality rate (which corrects for population growth) shows that deaths from both forms of the disease declined by around one half. Nevertheless, tuberculosis continued to be a major killer (see Table 2.5). The exception to the picture of declining deaths from infectious disease was influenza. It was not a new disease – flu had been recorded in Britain from the eighteenth century, and its incidence rose in the nineteenth century, especially among urban populations. The high mortality in Table 2.5 for the period between 1911 and 1920 is a consequence of the pandemic of ‘Spanish flu’ that hit Britain in 1918–19. Flu was normally a fairly mild disease, but in 1918 a particularly virulent new strain appeared. It acquired its name as the first reports of large numbers of deaths came from Spain, although the actual source of the disease is still the subject of debate. Initially, the disease was a typical form of flu, causing headaches and fever, which was cured by a few days in bed. However, the second wave of the disease, which began in the autumn of 1918, was very different. In addition to the usual symptoms,

18 Narrative Table 2.5  Death rates from selected infectious diseases per 1,000 population, 1891–1930

Smallpox Measles Scarlet fever Whooping cough Diphtheria Typhoid and paratyphoid fevers Typhus Diarrhoea and enteritis Respiratory TB Other forms of TB Influenza

1891–1900

1901–1910

1911–1920

1921–1930

0.01 0.41 0.16 0.38 0.26 0.17

0.01 0.31 0.11 0.28 0.18 0.09

0.00 0.27 0.05 0.18 0.14 0.03

0.00 0.37 0.03 0.11 0.08 0.01

0.00 n/a

0.00 n/a

0.00 0.49

0.00 0.21

1.39 0.63

1.16 0.50

1.05 0.34

0.81 0.20

0.36

0.21

0.58

0.37

Source: Report of the Ministry of Health for the year ended 31 March 1946, Table IX, p. 136. Parliamentary Papers, 1946–1947 (Cmd 7119).

the infection caused serious damage to the lungs. Victims struggled for breath and many died from asphyxiation or heart attacks brought on by trying to breathe. This strain of flu was also unusual in that it killed mainly adults, not the young or the elderly [Document 3, p. 124]. The flu epidemic caused huge disruption: factories and businesses were left short of staff, transport was disrupted and hospitals had to create temporary wards to accommodate flu victims. The epidemic caused around 250,000 deaths across Britain, and it is estimated that 20 to 50 million people died worldwide (Quinn, 2008). While there is a large body of research on the decline of infectious disease, much less has been written about the rise of chronic illness. However, it is clear that by the late nineteenth century, deaths from non-infectious, often chronic diseases associated with old age, such as stroke, heart disease and cancer, were increasing. Heart disease emerged as a major killer in the first half of the twentieth century. Mortality rose sharply from 2.9% to 9.9% of all deaths in England and Wales between 1851 and 1901, then leapt to over 35% in 1951 (see Table 2.6). Death rates from cancer doubled in the late nineteenth century from a fairly low starting point, mainly among those aged 65 and over, and mainly among women – in the nineteenth century cancer was a female disease. This increase continued over the early decades of the twentieth century, with death rates almost doubling from just over 1,000 to over 1,800 per million living between the 1910s and 1940s. By 1951 the disease accounted for 16% of all deaths in England and Wales

Disease in modern Britain  19 Table 2.6  Selected causes of death, 1951

Heart and circulatory diseases Cancer Respiratory disease Cerebrovascular diseases Congenital/premature/perinatal Respiratory TB Old age/senility Kidney disease Nervous disease Peptic ulcers

Death rate

% of total

4,495 1,965 1,839 1,562 412 275 217 200 136 128

35.6 15.6 14.6 12.4 3.3 2.2 1.7 1.6 1.1 1.0

Source: Adapted from A. Mercer (2014) Infections, Chronic Disease, and the Epidemiological Transition: A New Perspective. Rochester, NY: University of Rochester Press, pp. 234–235.

(Mercer, 2014) [Document 4, p. 125]. In both diseases, the rise in recorded deaths was partly due to more accurate diagnosis. Heart attack, for example, was only recognised as a cause of death at the end of the nineteenth century: previously such deaths were recorded under other categories (Mercer, 2014). Although rates of heart disease and cancer were increasing, and there was a good deal of public concern about the latter, overall, British practitioners did not see chronic disease as an important problem. Chronic diseases were thought to effect the elderly and their increase was the inevitable consequence of an aging population. It was not until after the Second World War that limited efforts were made to establish specialist facilities for the care of elderly patients (Weisz, 2014). The data from Britain fits Omran’s concept of an epidemiological transition, with successive phases each characterised by a particular pattern of diseases. While his thesis has been generally accepted by historians and demographers, some have sought to modify it. It has been suggested that a model of three stages is too broad and that the second phase – that of declining deaths from infectious diseases and increasing deaths from chronic disease – should be subdivided into two overlapping phases, the first running from 1750 to around 1890 when there was a decline in the large numbers of deaths of infants and children from infectious diseases, and the second occurring between 1850 and 1950, a period characterised by a reduction in adult mortality, with significantly fewer deaths from respiratory diseases (Riley, 2001). Other historians have pointed out that Omran’s theory requires historians to categorise diseases in the past using modern concepts of infectious and chronic diseases. Although some diseases, especially smallpox, were acknowledged in the past to be transmitted from person to person, the

20 Narrative infectious nature of many other diseases was not recognised until the causative bacteria were identified in the late nineteenth century. For example, phthisis was believed to appear in those with a particular physical makeup or ‘constitution’. Some historians have suggested that if contemporary categories are applied, then only around one-fifth of deaths in England and Wales in 1853 were understood at the time as being the result of infections (Condrau and Worboys, 2007; Mooney, 2007). Recently, Alex Mercer has pointed out that even modern divisions between chronic and infectious disease are not clear cut. Some cancers are linked to infection by viruses and non-fatal infections are now known to predispose individuals to chronic or degenerative disease in later life (Mercer, 2014). The decline in infectious diseases caused an overall decline in mortality – the number of deaths each year within a given population, usually presented as a number per thousand or per million living. In England and Wales, the number of deaths per 1,000 population stood at 22.4 in 1838 – the first year for which statistics are available. It fell to 20.8 by 1850 and to 17.3 per 1,000 around the turn of the century. By the late 1940s, the figure was just 6.6 per 1,000 (Mercer, 2014) Not all parts of Britain benefitted to the same extent. Mortality levels in Scotland were persistently higher, standing at 18.5 per 1,000 in 1900 (Mitchell, 1988, pp. 57–58) and 12.4 per 1,000 in 1950, almost double the rate in England and Wales. Mortality rates in Ireland were also higher than the rest of Britain at 19.6 per 1,000 in 1900 but improved more rapidly, falling to the same level as that in England and Wales by 1950. Mortality rates also varied between different groups within the population, with infants particularly susceptible to dangerous infections. Infant mortality – the number of deaths among children under 1 year per 1,000 live births – remained high through the nineteenth century. The Infant Mortality Rate (IMR) stood at 155 per 1,000 live births in mid century [Document 5, p. 126]. As deaths from teething, convulsions and diseases including scarlet fever, diphtheria and TB declined, the survival of infants improved. In the 1900s, the IMR stood at 128 per 1,000 in England and Wales. This figure had halved by the early 1930s and, following a temporary rise in the early years of the Second World War, it fell again to 45 per 1,000 in 1944 (Hardy, 2001). As with overall mortality, Scotland had higher levels of infant deaths. In 1922 the IMR stood at 101 per 1,000 live births over the country as a whole and in industrial towns, such as Glasgow and Paisley, the IMR was even higher (Jenkinson, 2004). With the overall decline in mortality came an improvement in life expectancy – the average number of years that anyone could expect to live. In the mid-eighteenth century, life expectancy in England and Wales was around 39  years. In the first decades of the nineteenth century it increased slowly to around 41, before levelling off or declining in the middle decades, especially in cities (Harris, 2003, p. 120). There is some debate about how far urban life expectancy declined, with some authors

Disease in modern Britain  21 suggesting a low point of less than 30  years in rapidly growing cities such as Manchester (Szreter and Mooney, 1998). Life expectancy began to creep up again from the 1860s and by the 1900s had reached 50 years. The figures for overall life expectancy are slightly misleading, as the total was greatly reduced by the huge numbers of deaths of infants and young children. In 1851, life expectancy at birth was around 40 years, but the life expectancy of infants who had survived to their first birthday was 48 years. Those who reached their mid-twenties were likely to live to 61 and those who reached 65 years could expect to survive until their midseventies (Mercer, 2014, Appendix F). The rise in life expectancy continued in the twentieth century. From an average life expectancy of 50 years in 1900, by the early 1930s it had shot up to over 60 years and by 1950 had reached 69. The decline in mortality among infants and children meant that the steep change in life expectancy over the course of life seen in the nineteenth century flattened out. In 1951 life expectancy was 66 years at birth, but had only increased to 76 years by age 65 (Mercer, 2014 Appendix F). A larger proportion of the population lived to old age. In England and Wales, those aged 60 and over made up over 7% of the population in 1911: by 1951 this had risen to around 16% (Anderson, 1990). In Scotland the equivalent figures were 5.4% and 9.9% (Anderson, 2012).

Measuring morbidity Mortality data tells the story of only a small proportion of the cases of illness that effected people in the past. Then as now, episodes of illness very rarely ended in death; minor ailments and injuries were far more common. Morbidity – the level of illness within the population – was far less well recorded than causes of death. Late eighteenth and nineteenth century diaries, letters and doctors’ case books provide an insight into individual experiences of illness. They reveal a population deeply concerned with their health, constantly fearing that a minor ailment could transform into a more serious complaint. Letters between friends and relations regularly reported on family illnesses and suggested remedies or treatments that might prove effective. While letters give a very selective account of illnesses, they show that people frequently suffered from colds, from indigestion, constipation, painful joints and the consequences of injuries – complaints that rarely appeared in mortality records. Historians have built up an overview of the diseases that were prevalent within the general population from the mid-nineteenth century using the records of friendly societies. These institutions provided insurance for working men and women: in return for a small weekly payment, members were entitled to receive medical care and money to cover lost wages when they were ill, and funeral costs at their death. Their records still give a partial account: they cover particular groups of workers and show when members

22 Narrative were sufficiently incapacitated that the friendly society doctor certified them as unfit to work. Consequently, very mild ailments are not recorded. The friendly society data shows a very different pattern of illness to that of mortality statistics: working men and women predominantly suffered from minor respiratory and muscular complaints. Most claims were for injuries caused by accidents at work (especially back pain resulting from heavy manual labour), and illnesses such as colds and bronchitis. Relatively few claims were made for serious ailments such as tuberculosis or heart disease and these were mostly from older workers. Workers suffering from tuberculosis appear to have managed to stay at work until the disease was well advanced (Riley, 1997). Morbidity changed very little in the twentieth century. The findings of a number of studies from Scotland, England and Wales for the 1930s and 1940s found remarkably similar patterns of disease to those in the previous century. People regularly suffered from colds, flu and other respiratory diseases, rheumatism and upset stomachs. Large numbers took time off work to recover from work related injuries such as backache (often called ‘lumbago’ at this time), hernias, sprains, infected cuts and abscesses (Digby, 1999). Working class women often suffered from the long-term consequences of frequent pregnancies and births including backache, painful legs and displacement of the uterus [Document 6, p. 127]. The continuity of the types of illness suffered across the British population has prompted the historian James Riley to suggest that we should think of a ‘sickness transition’ distinctive from the epidemiological transition (Riley, 1997). Whereas mortality declined significantly in the nineteenth century, the friendly society records suggest that there was no decline in time spent off work due to infectious diseases. The pattern of morbidity changed more slowly than that of mortality: the diseases that caused workers to be absent from work in 1940 had changed very little since 1890. However, there was a distinct increase in the amount of time spent off work due to ill health, which increased from 7 days per year in 1870 to 15 days in 1914. Analysis suggests that this was partly due to the increasing age of those covered by friendly society schemes: while younger members were fairly healthy and tended to suffer from less serious ailments, older members made claims for chronic complaints such as rheumatism that required longer periods off work. Ironically, as workers no longer died young from infectious diseases and lived longer, they spent a greater proportion of their lives being ill (Harris et al., 2012). It has been suggested that the increasing time taken off also reflected a change in cultural attitudes to sickness: in the twentieth century workers were quicker to decide that they were too ill to work than previous generations, who struggled on despite feeling unwell. However, there is no evidence that workers made an increasing number of claims for very minor ailments (Gorsky et al., 2011).

Disease in modern Britain  23

Why did patterns of disease change? The factors responsible for driving changes in the pattern of disease in Britain between the late eighteenth and mid-twentieth centuries are complex and the subject of much debate. Social and economic developments undoubtedly had a major impact on health, both positive and negative. The expansion of global trade was responsible for introducing Asiatic cholera to Britain: the disease moved from India to Europe and Britain along shipping routes. Within Britain, rapid urbanisation and the growth of industries in the early and middle decades of the nineteenth century provided conditions in which infectious diseases flourished. As large numbers of people moved from the countryside into towns in search of work, the population of cities such as Manchester, Glasgow and Liverpool expanded; all grew from around 100,000 in the 1830s to reach half a million by 1871. Rapidly growing cities were notoriously insanitary, as local government struggled to establish systems for the removal of ever-growing quantities of industrial and domestic refuse and to provide an adequate water supply. The quality of housing also suffered, with increasing numbers of people packed into existing houses or cramped new dwellings. Consequently, the general environment and water supplies became contaminated with wastes and urban residents suffered from regular outbreaks of filth diseases such as cholera, diarrhoea and fever. The poor, living in insanitary conditions were the main victims but the wealthy were not immune: the Prince of Wales caught typhoid fever in 1871. While urban living conditions did improve from the late nineteenth century, poor quality housing, high population densities and insanitary living conditions persisted in slum areas well into the twentieth century. The economy of many towns and cities was based on factory production. Steam-powered factories generated large volumes of smoke, causing air pollution over whole towns, which rendered their populations susceptible to respiratory diseases and created generations of children stunted by rickets, as the smoke blocked out sunlight. Factory work also undermined health. Many workers were exposed to dangerous chemicals such as lead and mercury. Lung diseases were common among workers in the dusty environments in textile mills or in metal workshops. A Sheffield doctor described the symptoms of workers suffering from ‘grinders’ asthma’. They suffer from shortness of breath at the slightest effort . . . Their complexion becomes dirty yellow, their features express anxiety, they complain of pressure upon the chest. Their voices become rough and hoarse, they cough loudly, and the sound is as if air were driven through a wooden tube . . . Spitting blood, inability to lie down, night sweat, colliquative [liquid] diarrhoea, unusual loss of flesh, and all the usual symptoms of consumption of the lungs carry them off. (Engels, 1845 (1952), pp. 203–204)

24 Narrative There is good evidence for the effects of urban living conditions in reduced life expectancy: in the 1830s, city dwellers lived on average ten years less than their rural counterparts, although this low figure was largely the result of very high urban infant mortality. Studies of the height of children who survived to adulthood also show the persistent impact of urban living conditions. Children who have a poor diet in childhood, and experience a number of non-fatal infections grow less than those who enjoyed a healthier life with a better diet. Studies of boys who joined the military show that those born in the second quarter of the nineteenth century, and especially those from cities, were shorter than those born in later or in rural areas (Floud et al., 1990). Until the 1970s it was widely assumed that infectious diseases were brought under control by public health reforms, especially the introduction of clean water supplies and improved methods of sewage disposal (see Chapter  7). However, this was challenged by demographers who argued that the decline in infectious disease came about through improved standards of living in the late nineteenth century, with higher wages allowing the poorer classes to enjoy a better diet (McKeown, 1976). The effect of standards of living on health also been the subject of considerable debate. It is hard to capture the impact of rising wages in the nineteenth century. Efforts to track the impact of unemployment and declining standards of living during the depression of the 1930s – a period with much better statistical data – produced heated debates. Government statisticians presented a positive picture of national improvement in health, especially the health of women and children. However social reformers reported that in areas where unemployment was highest, the numbers of women dying as a consequence of pregnancy and childbirth rose to levels not seen since 1900, while poor nutrition and rickets were common among children (Webster, 1982). Cultural factors also contributed to mortality. The rise in cancers from the 1920s, and especially after 1945, were largely a consequence of the spread of cigarette smoking. The mass production of cigarettes from the end of the nineteenth century and a new perception of smoking as a fashionable activity increased the popularity of the practice, first among men and later among women. The consequence was increasing mortality from lung cancer after 1945 (Mercer, 2014). The first report linking lung cancer and smoking appeared in 1950, followed three years later by another showing the link between heart disease and lack of exercise. British involvement in two world wars might be expected to have a serious impact on health and mortality. The conflicts obviously caused a huge number of deaths. In the First World War between 1914 and 1918 around 723,000 combatants were killed and over a million were left disabled; in the Second World War of 1939 to 1945 there were 400,000 military casualties and around 61,000 civilian deaths caused by bombing, although higher figures are given in some sources. The First World War in particular brought new types of injury and disease for combatants. In addition to combat

Disease in modern Britain  25 injuries and diseases linked to insanitary conditions such as ‘trench fever’, soldiers suffered from shellshock – at first thought to be due to the physical shock caused by explosions but later seen as a form of mental collapse caused by the strain of exposure to long periods of artillery fire. Soldiers also suffered from the effects of poison gas, which injured the eyes and lungs. Better medical care in the Second World War meant that illness was less common among the armed services, although soldiers serving abroad suffered from unfamiliar infections such as malaria and amoebic dysentery (Hardy, 2000). The impact of war on civilian health has been the subject of debate among historians. Some have painted a positive account of health during the First World War. Despite the strains put on food supplies, the loss of medical staff to the military and the mobilisation of women and older men into the workforce, they point to the continued decline in mortality during the war. The poor benefited from higher employment during the war, and higher wages and better nutrition resulted in a decline in diarrhoea among infants and deaths among pregnant women (Winter, 1985). These conclusions have been challenged by other historians, who point out that not all workers benefited from high wartime wages, that there was a significant rise in tuberculosis deaths among women, as well as increased overall mortality among the elderly, probably as a result of poor housing and nutrition (Bryder, 1987). Claims that the British population had never been healthier than when living under rationing during the Second World War are exaggerated, but the conflict did not produce a major decline in health. There was a temporary increase in deaths from tuberculosis and a brief rise in infant mortality during 1940–41 in England and Wales (and a more persistent increase in Scotland), while death rates among the elderly remained high throughout the conflict. Fears about infectious disease spreading rapidly though the large numbers of people crammed into communal air raid shelters failed to materialise, although there was a sharp rise in cases of sexually transmitted diseases (referred to as venereal diseases or VD in this period). The evacuation of children from the inner cities to the countryside revealed the continuing health problems among the urban poor – despite efforts to improve welfare many were dirty and had head lice and skin complaints. A final factor in changing disease patterns were natural variations in the severity of diseases. In the twenty-first century we know from genetic analysis that disease-causing micro-organisms mutate over time. Historians can only speculate that similar changes may have occurred in the past mortality. The Spanish flu epidemic of 1918–19 is perhaps the best known example, with high death rates resulting from a particularly virulent strain of the virus. Similarly, scarlet fever was a fairly mild disease until the early nineteenth century, when it became a major cause of death among the under-5s, probably through the emergence of a new strain of the causative bacteria. Diphtheria had been present from the eighteenth century as a relatively mild disease but a more severe form spread across the country

26 Narrative in the late 1850s, causing widespread concern among doctors and parents (Hardy, 1993). Some historians have suggested that the tuberculosis bacillus also went through changes, resulting in variations in mortality over time, although the evidence is not clear cut. This brief survey of disease in Britain reminds us that ill-health is always with us. In the past, just as in the present day, the most common episodes of illness were brief, self-limited ailments such as colds and muscular pains. Many people must have carried on their normal lives despite feeling unwell, while others took to their beds for a few days. For successive generations of the elderly, such minor ailments became increasingly common – the price of living longer was that some of that extra time was spent in poor health. In the eighteenth and nineteenth centuries, minor ailments co-existed with much more dangerous complaints such as tuberculosis and typhoid fever, which are now rare, or, in the case of smallpox, completely eradicated. Such major illnesses were potentially fatal and prompted more active intervention – calling in a doctor or seeking admittance to hospital. The role of practitioners in understanding, preventing and treating these illnesses is the subject of much of the rest of this book.

3 Medical ideas

Between the late eighteenth and mid-twentieth centuries, understandings of the body and of disease were revolutionised. Theories in which health and disease was governed by a balance of energy over the whole body and influenced by environment and lifestyle were replaced by the concept that disease was located in malfunctioning organs or tissues and caused by specific agents such as bacteria. In the past these changes have been presented as a series of discoveries by a succession of brilliant individuals. This sort of account has its attractions – the story of progress and the successes of heroic researchers fills the reader with optimism about future developments, so it is not surprising that it persists in popular accounts of medical history. Since the 1960s, academic historians have developed a more complex account of the development of medical ideas, identifying a series of significant shifts in medical theory and setting the production of ideas within their intellectual, social, political and institutional contexts to explain why they emerged at particular times and specific places. A useful framework for this development of medical ideas is provided by the sociologist Nicholas Jewson. In the strikingly titled article ‘The disappearance of the sick-man’ (Jewson, 1976) described three phases of medical thinking between the late eighteenth and late nineteenth centuries. In ‘bedside medicine’, the dominant late eighteenth-century understanding of the body, each patient was an individual and disease effected the whole body. Information about the each case was obtained largely through the patient’s account of the progress of his or her symptoms. In the nineteenth century, ‘hospital medicine’ dominated: disease was located in specific parts of the body and doctors no longer saw a ‘sickman’ but a diseased lung or heart, to be scrutinised through physical examination. By the end of the nineteenth century, ‘laboratory medicine’ located disease within cells and tissues, to be analysed through tests conducted in the laboratory. Although Jewson did not invent these categories – both bedside and hospital medicine had been described by earlier historians – he was the first to present them as medical cosmologies – ‘conceptual structures . . . within which all questions are posed and all answers are offered’ (Jewson, 1976, p. 225). Jewson’s analysis has proved extremely durable. However, his account of three distinctive medical cosmologies emphasises change over continuity.

28 Narrative More recent work by historians has blurred the boundaries between bedside, hospital and laboratory medicine, showing how apparently incompatible ideas and approaches co-existed.

The emergence of hospital medicine In the eighteenth century, many of the fundamental concepts of health and disease looked back to humoural medicine, a theory devised in ancient Greece, in which illness reflected an imbalance in four types of fluids (or humours) within the body – blood, phlegm, yellow bile and black bile. While practitioners had abandoned the idea of humours as a cause of ill health, later ideas preserved other aspects of humoural theory. They understood disease to be holistic: although symptoms might occur in a specific part of the body, such as a gouty foot or the collection of fluid in the abdomen, this was an expression of a more general malfunction of the body’s systems. Disease was also malleable: one ailment could transform into another. A  neglected cold could become bronchitis, a chill could transform into a fever. Each case of illness was in some ways unique to each person, a product of their constitution – weak or strong, nervous or placid – which varied with age and gender, and was often inherited. This rendered individuals susceptible to particular illnesses and shaped their severity and outcome. There was no single dominant theory of the underlying cause of disease. In the seventeenth and eighteenth centuries, practitioners had proposed that ill health was the result of blockages in the flow of body fluids, changes in the chemical nature of the blood, hydraulic forces within a disrupted flow of blood, or spasms in the body’s fibres. In the late eighteenth century, practitioners turned their attention to the role of nerves in health and disease, inspired by research into the responses of muscles and nerves to electrical stimulation, phenomena which seemed to distinguish living bodies from inanimate material. Practitioners produced competing theories in an effort to best explain disease (Lindemann, 1999). William Cullen (1710–1790), one of the foremost medical authorities of the day and a leading light of the Edinburgh Medical School, argued that diseases such as fevers arose from weakness in the nerves, which in turn produced a ‘spasm’ within the arteries. This forced the blood away from the surface of the body, causing sensations of chills and shivering, and a counter reaction that pushed the blood outwards resulting in sweating and the sensation of heat (Hamlin, 2014) [Document 7, p. 127]. His pupil, John Brown (c.1735–1788), saw disease as different degrees of over- or understimulation of the nervous system. Eighteenth-century practitioners agreed that disease was triggered by environmental factors. Bodies were influenced by every aspect of the environment and lifestyle. Sudden changes in temperature, gorging on particular types of foods, excessive physical activity, or too much or too little sleep could all predispose the body to certain forms of sickness. For example,

Medical ideas  29 leaving a warm and stuffy room for the cold air outdoors could result in colds or even fevers (Jankovic, 2010). The influence of climate and lifestyle on the body meant that some diseases were associated with particular places. The migration of British people to the Americas or Antipodes, or to serve in the army in India, inspired a large number of works discussing the effect of foreign climate on European bodies, and the particular dangers of life in low-lying, hot, swampy lands. As well as the physical environment, state of mind had a strong influence on the body: violent emotions could result in physical disease. While each case of illness was a unique product of constitutional and environmental factors, eighteenth-century practitioners broadly agreed on a catalogue of diseases, each with their typical pattern of symptoms. They sought to devise classifications, similar to those devised for plants and animals, which reflected the fundamental character of illnesses and their relationships to other complaints. Diagnosis was based on close observation of symptoms at the bedside, combined with information from patients’ accounts of their bodily sensations. Practitioners paid particular attention to any changes in the normal pattern of excretions. Vomiting, diarrhoea and constipation were all signs of disease processes at work, and of the body’s spontaneous efforts to restore a healthy state (Conrad et al., 1995). The late eighteenth century saw developments within medical theory that presaged the shift to hospital medicine. Anatomy was increasingly seen as one of the fundamental aspects of medical knowledge. Since the Renaissance, anatomists had described the bones and organs of the body; by the eighteenth century, practitioners had turned their attention to analysing the more minute structures, such as the nerves and lymphatic vessels. Researchers also began to explore the effects of disease on the structures of the body. In 1761, the Italian Giovanni Morgagni (1682–1771) published the first major work on pathological anatomy – the study of how structures within the body were effected by diseases. De sedibus and causis morborum (On the seats and causes of disease), consisted of a catalogue of cases correlated with the pathological changes observed at post-mortem examination. In the late eighteenth century, a group of British researchers, led by Matthew Baillie (1761–1823) and John Hunter (1723–1793) developed a more sophisticated account of the pathology of tissues. In 1793 Baillie first published The Morbid Anatomy of Some of the Most Important Parts of the Human Body, a systematic account of a wide range of pathological changes including inflammation, collections of fluid and tumours. Baillie’s work provided a more comprehensive account of pathology than Morgagni’s book and a new interpretation of pathological changes: where Morgagni saw pathological change as the cause of disease, Baillie argued that changes were the product of a disease process [Document 8, p. 128]. Hunter combined observations of cadavers with experiments to explore disease processes, especially inflammation, in the different tissues of the body.

Figure 3.1  E  ngraving of a kidney from Matthew Baillie, The Morbid Anatomy of Some of the Most Important Parts of the Human Body, 1799. This very detailed drawing of a diseased kidney epitomised the new idea that disease is located in specific organs. Credit: Wellcome Library, London.

Medical ideas  31 Large scale research and teaching into the localisation of disease within specific parts of the body was first carried out in Paris in the years following the outbreak of the French Revolution. Paris provided a particular set of political and institutional circumstances that allowed these new ideas to flourish. In 1794, faced with a demand for army surgeons to treat soldiers engaged in the revolutionary wars, the government created new medical schools in Paris, Montpellier and Strasbourg. Training in the new schools combined lectures with clinical teaching in hospitals. In Paris, students and staff were able to observe hundreds of patients in the wards of the city’s huge hospitals, and conduct post-mortem examinations to analyse how symptoms observed in life related to changes within the body. Practitioners working in Paris used these facilities to publish on normal anatomy and pathological anatomy. From data collected in hundreds of post-mortem examinations, Marie François Xavier Bichat (1771–1802) developed the theory that tissues – similar structures found in different parts of the body – rather than organs were the building blocks of human anatomy. In his books he described 21 types of tissue, including connective tissue, skeletal muscle and cartilage. Jean-Nicolas Corvisart (1755–1821) published the first study of diseases of the heart, describing pathological changes in the valves and muscle. Gaspard Laurent Bayle (1774–1815) showed that tuberculosis was a single disease that affected different organs in various ways. He made similar findings for cancer, revealing how the disease took various forms in different parts of the body (Ackerknecht, 1967; Maulitz, 1987). With the theory that disease was localised within specific parts of the body came a new emphasis on physical examination. Practitioners had previously conducted very basic examinations – feeling the body for lumps and listening for sounds within the body by pressing an ear to the chest. In 1816, René Théophile Hyacinthe Laennec (1781–1826) devised the stethoscope – essentially a simple wooden tube – which made these sounds much clearer, and allowed practitioners to diagnose lung diseases with much greater accuracy. John Forbes (1787–1861), who translated Laennec’s work into English, captured the significance of this new diagnostic technology: Laennec ‘may be said to . . . have placed a window in the breast through which we can see the precise state of things within’ (quoted in Jacyna in Bynum et al., 2006, p. 43). The historian Michel Foucault in his Naissance de la clinique: une archéologie du regard médical (1963, translated into English in 1973 as The Birth of the Clinic) argued that Paris researchers produced an entirely new way of seeing patients which he called the ‘clinician’s gaze’. Practitioners no longer observed patients’ outward symptoms and questioned them about their ailments. Instead, using their knowledge of morbid anatomy and new techniques of physical examination, they were able to visualise the processes of disease within the body of the living patient. They devised a new, technical language to describe disease, one which was not shared by patients

32 Narrative [Document 9, p. 129]. As a consequence, patients were no longer suffering individuals, but clinical objects – no longer a person, but a diseased kidney or heart (Foucault, 1973). Recently, historians have questioned the significance of the Paris school in the development of hospital medicine. Some have pointed to the importance of research into pathological anatomy carried out in Britain. Others have argued that early historians of the Paris school over-emphasised the significance of pathological researches. Not all teachers in the Paris schools worked in this area: François-Joseph Broussais (1772–1838), one of the most highly regarded staff, focused on therapeutics (Hannaway and La Berge, 1998). Studies of the letters and diaries of British and American students who travelled to France to study show that they came not to learn new ideas associated with pathological anatomy, but to take advantage of the opportunities to hone their skills in dissection, to attend clinical classes, and observe medical and surgical treatments (Warner, 1998). British students were particularly interested in attending Laennec’s teaching in the use of the stethoscope. The Paris school undoubtedly offered a new model for teaching and research. British practitioners drew unfavourable comparisons between the teaching facilities in Britain and France, and called for better systems for the provision of cadavers for anatomical training, a greater recognition of the value of science and research in medicine and the appointment of hospital staff who would use their positions to engage in research. Pathological anatomy was gradually incorporated into the curriculum of medical schools. The first teaching posts in the subject were established at University College London (UCL) in 1828 and at Edinburgh University in 1831. A number of British students chose to spend some time studying in France and on their return spread word of the new ideas and techniques taught there. Thomas Hodgkin (1798–1866) studied in Paris with Laennec and on his return gave a talk on the stethoscope to the Physical Society at Guy’s Hospital in London (Brunton, 2004). Robert Carswell (1793–1857) and William Thomson (1802–1852) used their studies in France to inform their pathology teaching at UCL and the Edinburgh Medical School. There was an exchange of ideas between researchers in Britain and France. Works by the staff of the Paris school were translated into English, while books by British practitioners – including Matthew Baillie – were translated into French (Hannaway and La Berge, 1998). News of medical developments also spread through medical journals founded in the mid-nineteenth century, such as the British and Foreign Medical Review. Despite the lack of large hospitals and a plentiful supply of bodies for dissection, British practitioners produced original work on pathological anatomy. John Forbes published his Original Cases With Dissections and Observations Illustrating the Use of the Stethoscope and Percussion in the Diagnosis of Diseases of the Chest (1824) based on 39 cases from the Chichester Hospital. Richard Bright (1789–1858) researched into cases of dropsy – the accumulation

Medical ideas  33 of fluid within the body. He related these symptoms to structural changes in the kidneys and the presence of albumin in the urine, which could be detected by chemical analysis. Thomas Addison (1793–1860), a physician at Guy’s Hospital, published on diseases associated with changes in the adrenal glands.

Laboratory medicine Laboratory medicine emerged in the middle decades of the nineteenth century, and encompassed not only a set of ideas about the body and disease, but also the techniques by which these theories were developed and the physical spaces where research was conducted. It applied a range of techniques used in physics and chemistry to the study of the body, and reconceptualised disease as a set of processes occurring among cells and tissues. Laboratories were not new: dedicated spaces in which to carry out medical or scientific experiments had existed from the seventeenth century but they were usually small and with limited equipment, located in the homes of researchers. From the mid-nineteenth century, laboratories moved into institutions, expanded to accommodate a range of ever-more sophisticated instruments to observe and measure the structure and function of the body, and were used for teaching as well as research. A number of biomedical sciences emerged from research conducted in nineteenth-century laboratories. Among the first was histology, the study of minute structures within the body. This new field of research was made possible by improved microscopes. Originally invented in the seventeenth century, from the 1830s major technical improvements including the manufacture of high quality lenses allowed researchers to observe ever smaller structures within the body. In 1839, Theodor Schwann (1810–1882), professor of anatomy at the University of Louvain, Belgium, established that cells were the building blocks of all living tissues. Two years later Jacob Henle (1809–1885), anatomy professor at Zurich University, published an atlas of microscopic anatomy describing the cellular structures found throughout the body. Researchers also examined the structure of diseased cells. Rudolf Virchow (1821–1902), professor of pathological anatomy at Wurzburg, argued that all disease was rooted in abnormal changes at the level of the cell, and described the cellular changes associated with a number of diseases, including leukaemia, in tumours and in thromboses (blood clots formed within veins). The microscope was also fundamental to bacteriology, the study of microorganisms responsible for causing disease. The idea that some sort of chemical or biological agent was responsible for spreading infectious disease had existed as early as the sixteenth century, and by the late nineteenth century, the germ theory was widely accepted, even though the identity of ‘germs’ was unknown. In the 1870s, the French researcher Louis Pasteur (1822– 1895) had shown that micro-organisms were responsible for a number of

34 Narrative animal diseases (Worboys, 2000). In 1876, Robert Koch (1843–1910), a German practitioner, showed that a bacterium was responsible for anthrax. From 1882, Koch and his followers identified the bacteria responsible for many important human diseases, including tuberculosis and cholera (see Chapter 2). These discoveries were made possible by developing and carefully honing new methods to isolate, grow and stain bacteria (Gradmann, 2009). Although the presence of viruses – very small infective agents responsible for plant and animal diseases – had been deduced in the late nineteenth century, it was not until the development of the electron microscope in the 1930s that they could be observed and identified. The most important of the new medical sciences was physiology – the study of body function. Research into the processes of life began long before the nineteenth century – William Harvey (1578–1657) conducted experiments on animals in the seventeenth century to prove that the blood circulated in the body. However, systematic research into the functioning of the organs and tissues within the body, using instruments to measure and record dynamic processes, began in the mid-nineteenth century [Document 10, p. 130]. New instruments such as the kymograph, developed in 1847 by Karl Ludwig (1816–1895), professor of anatomy at the University of Marburg, allowed researchers to record changes in blood pressure or the movement of muscles. Techniques from organic chemistry were used to analyse the composition of body fluids such as blood and urine, and to demonstrate changes in their composition caused by disease. Animal experiments (a practice that was deeply unpopular with many of the British public) were devised which isolated and measured biological processes such as the release of secretions from glands, the role of nerves in controlling blood flow and the transmission of nervous impulses. Physiology gradually divided into a number of specialist branches, including biochemistry and immunology. Just as hospital medicine has been closely associated with the Paris medical school, so nineteenth century laboratory medicine is closely linked to German universities. (Before 1871, the area occupied by modern Germany consisted of a number of separate states. In this chapter they will be referred to as Germany as a matter of convenience.) The curriculum in German universities was the first to include medical sciences as the foundation of knowledge, and to emphasise practical work in laboratories as the best means of learning. The administrators of the universities in the 28 German states engaged in fierce competition to appoint staff with a distinguished record of research, and thus to attract students to study at their institutions. In large, well-equipped laboratories, students learned the basics of histology and physiology, while advanced students and staff worked in teams carrying out original research. By the end of the century, Germany had become the acknowledged world leader in research and teaching: ambitious medical students from the rest of Europe and America increasingly chose to go to Germany rather than Paris to complete their education.

Medical ideas  35 However, laboratory research was not confined to Germany. In France, Louis Pasteur worked on micro-organisms and developed the first vaccines, and Claude Bernard (1813–1878) made a number of fundamental contributions to physiology. Despite having very limited space and equipment, Bernard conducted experiments that revealed that animals were capable of regulating the internal environment within the body (a set of processes later named homeostasis) and analysed the action of drugs on nerves, the control of blood flow, and important aspects of the processes of metabolism and digestion. The new model of combined laboratory teaching and research developed in Germany was widely copied across Europe and North America, although British hospitals and universities were slow to adopt new methods of teaching medical sciences (see Chapter  6). Pioneering teachers had to begin with small classes and very basic facilities. For example, histology was first taught in Edinburgh by a group of practitioners who had studied in France and Germany. With no laboratories, and with a limited number of microscopes (which were very expensive), they developed methods of teaching using illustrations and shared microscopes. Smaller groups were trained in the skills of using the microscope, and of interpreting their observations. Students were encouraged to carry out their own research to contribute, even in a small way, to the growing body of knowledge (Jacyna, 2001) Posts in the biomedical sciences were first established in university medical schools. Cambridge University and UCL led the way and became the leading centres for research in Britain. From 1867, physiology at UCL flourished under the leadership of Michael Foster (1836–1907). Foster later moved to the chair at Cambridge in 1870, where he established an important research group. Posts in physiology at Edinburgh, Oxford, Manchester, Leeds and Liverpool universities were created shortly thereafter (Butler, 1988). The first full-time chair in pathology was established in Cambridge in 1891, and Frederick Gowland Hopkins (1861–1947) was appointed as the university’s first lecturer in chemical physiology in 1898 and became professor of biochemistry in 1914. Medical schools based in hospitals, rather than universities, where teaching was geared to imparting clinical skills, were slower to adopt laboratory teaching and research. Administrators feared that potential donors might be put off by the association between laboratories and experimentation on animals. The teaching of biomedical sciences required elaborate new facilities and considerable financial investment. Often new staff struggled with poor facilities, as universities authorities were unable or unwilling to fund expensive new laboratories. At Cambridge, new laboratory buildings were paid for partly through a public appeal (Weatherall, 2000). At Oxford, too, researchers in pathology and biochemistry had to make do with limited space in existing buildings and had to persuade the university administrators to fund additional support staff and equipment. Staff appointed to these new posts often had to spend most of their time in teaching, and had limited

36 Narrative opportunities to conduct original research (Butler, 1988). It was not until the 1920s that chairs in university medical schools were routinely held by staff with record of research. Laboratory medicine was also supported by funding from charities. Large grants to Cambridge University funded the establishment of the Sir William Dunn School of Biochemistry and the Dunn Nutritional Laboratory. The Imperial Cancer Research Fund, established in 1902, had its own laboratories and supported researchers conducting research into the possible causes and the incidence of cancer (Austoker, 1988). Philanthropy also funded Britain’s first independent research institute. The British Institute of Preventative Medicine (later renamed the Lister Institute) was founded in 1891 and paid for by grants from a variety of individuals, particularly the Guinness family. Research there focused on microbiological research and the production of vaccines. By contrast, the British government played a limited role in promoting laboratory research. The Medical Research Council (MRC) was founded in 1913 (as the Medical Research Committee) to investigate various aspects of tuberculosis. Within a few years it had switched to funding pure research on a range of topics. By 1920 the MRC had its own research facilities in Hampstead, with departments of physiology, medical statistics, biochemistry and pharmacology. It provided fellowships to individual researchers and funded research units within other institutions. The MRC tried to co-ordinate the funding of medical research within Britain, with committees to address specific areas of research such as the cause of rickets and the function of vitamins (Austoker and Bryder, 1989). By the late nineteenth century, the biomedical sciences had an established place within British medicine. New specialist medical societies and medical journals provided a forum for researchers to publish and to exchange ideas. The Physiological Society was founded in 1876 and the Journal of Physiology in 1878. A research-oriented Pathological Society of Great Britain was established in 1906 to complement the older and more clinically oriented Pathological Society of London. The first journal dedicated to biochemistry appeared in 1906 and a society was founded in 1911. In the late nineteenth century British practitioners pursued many lines of research. In Cambridge University’s physiology department Michael Foster co-ordinated a research programme on the physiological processes causing the heart to beat. Elsewhere, individual researchers were free to pursue their own path. At the Cambridge Biochemistry department, research workers explored a range of topics – nutrition, photosynthesis, muscle contraction, and the metabolism of microbes. At UCL, John Burdon Sanderson (1828– 1905) pursued his own work on the physiology of nerves but encouraged his students to follow their own interests, working on topics including the internal secretions produced by the body’s glands. In the early twentieth century British researchers made significant contributions to the understanding of chemical communication within the body.

Medical ideas  37 William Bayliss (1860–1924) and Ernest Starling (1866–1927), working at UCL, discovered the first agent responsible for communicating between a gland and the rest of the body. They showed that stimulation of the intestine provoked the secretion of fluid from the pancreas, a substance they named ‘secretin’. In 1905, Starling named this class of substances ‘hormones’. By 1915, hormones were understood to be chemicals produced in tissues, which travelled through the bloodstream and influenced the action of cells in another part of the body and helped to co-ordinate body function. The exact chemical identity of many hormones was discovered in the 1920s and 1930s, including the sex hormones, and insulin and cortisone. Nutrition was another important field of research. From 1906, Frederick Gowland Hopkins at Cambridge University showed that when rats were fed a restricted diet, they grew ill and died, even though they were not starving. Only a group of animals receiving small amounts of milk survived. Hopkins concluded that very small qualities of some chemicals, which he called accessory food factors (later renamed vitamins) were necessary for life. He was awarded the 1929 Nobel Prize for Medicine for this work. In 1912 Casimir Funk (1884–1967) isolated a compound which prevented beri-beri, a disease caused by dietary deficiency, later named vitamin B3 (niacin). British researchers worked within an international research culture. In the twentieth century, laboratory research was conducted across Europe (although German research lost its pre-eminent position after the First World War) and expanded rapidly in North America. Researchers across the Western world worked on similar questions, exchanging findings through visits to laboratories and in published papers. For example, important discoveries in the function of cells were made across Europe. The basic structure of nerve cells was initially described by workers in Germany. The Spanish researcher Santiago Ramon y Cajal (1852–1934) argued that each cell was independent and not physically connected to other cells. British workers made important contributions to understanding the communication between nerve cells and between nerves and the brain. In Britain, Charles Sherrington (1857–1952) put forward the thesis that the nervous reflex was the fundamental unit of nerve function, with messages relating to involuntary movement (such as blinking) carried by nerves to the spinal cord. Sherrington’s work on reflexes was taken up by Ivan Pavlov (1849–1936) in Russia, who, using his famous experiments on dogs, proved that reflex responses could be learned. In 1921, another British researcher, Henry Dale (1875–1968) showed that impulses were carried between nerve cells by the chemical acetylcholine. In the past, it was assumed that laboratory medicine became the dominant medical theory because it led to improved ways of treating illness [Document 11, p. 131]. However, in practice, the impact of new ideas was very slow. While hospital and laboratory medicine provided new methods of diagnosis, new therapies did not emerge for many decades (see Chapter  4). Historians have suggested that the adoption of laboratory science

38 Narrative was driven by other factors. Practitioners sought to increase their power and authority by linking their discipline to the new biomedical sciences. Science therefore had an ideological as well as technical function (Warner, 1995). Historians have also pointed out that laboratory science fitted with a drive for greater organisation and efficiency within medicine: for example, bacteriology allowed practitioners to identify infected persons, and hence enforce more effective forms of quarantine to halt the spread of disease (Sturdy and Cooter, 1998).

Laboratory and clinic In the past, historians tended to see an inherent conflict between laboratory medicine and the clinical practices of hospital medicine, with their different methods and understandings, and their very different cultures. Under laboratory medicine, disease was seen as a specific set of processes, provoking patterns of clinical symptoms and changes in the body’s physiology that could be measured in numbers – the temperature recorded on a thermometer or the concentration of chemicals in blood or urine. The individuality of each case of disease, and its fluid and changeable nature, so central to medicine in the eighteenth century had vanished. Cases which did not fit the idealised pattern of a specific ailment were labelled ‘atypical’, or a form of ‘complication’ (Rosenberg and Golden, 1992) However, in the early twentieth century, many practitioners continued to favour the older clinical art, which used the techniques of both bedside and hospital medicine to identify disease through a range of signs. By combining physical examination, observation and questioning the patient, clinicians aimed to understand each case and to capture its unique aspects. They also continued to use lifestyles as an explanation for ill health. Although bacteriological research had identified the agents responsible for infectious disease, practitioners looked to the patient’s inherent constitution, and his or her lifestyle to explain why, in a germ-laden environment, one person fell sick while others remained healthy. The stresses of modern life in the late nineteenth and twentieth centuries – the physical speed of transport, the deluge of news emerging from the press, and, among women, their demands for a more physically and intellectually active life – were regularly cited as a cause of diseases including cancer, diabetes, and heart conditions (Cantor, 2002). Thus both practitioners who favoured the ‘bedside’ approach of clinical medicine and those who preferred the ‘bench’ of laboratory medicine claimed to have a superior understanding of disease and competed for authority, status and resources within medical institutions. Researchers in the medical sciences saw clinical medicine as old fashioned and uninformed: clinicians criticised laboratory medicine for being overly reductionist, focusing on one small part of the body and losing the bigger picture of the patient as an integrated body living in a particular environment (Lawrence, 1999; Sturdy, 2011).

Medical ideas  39 In research, too, the application of the different approaches of bedside and bench to a single problem could produce quite different conclusions. There was considerable debate around the cause of rickets, a disease common among the poor in industrial towns in the late nineteenth century, resulting in impaired bone growth and deformed limbs. Studies of patients with rickets conducted by researchers at Glasgow University concluded that the disease was the result of a lack of exercise and poor living conditions. Around the same time, laboratory experiments by researchers in London suggested that a food factor was responsible. Rickets could be induced in dogs by feeding them on a restricted diet, then cured by giving them cod liver oil. The debate was not resolved at the time: only later was it shown that vitamin D deficiency was responsible for rickets, and could be treated both through diet and by exposure to sunlight, which allowed the body to produce the vitamin (Smith and Nicolson, 1989). More recent research points to co-existence and collaboration between the laboratory and the clinic. For many practitioners, especially among the medical elite, clinical medicine was at the heart of good medical practice: the key to diagnosis was observation of symptoms. However, they did not reject the new medical sciences, but argued that pathological anatomy and laboratory science supported the clinician by explaining the processes behind the observed symptoms. The laboratory should not lead the diagnostic process, but be at the service of the clinician, giving additional information when required (Lawrence, 1999). Laboratory equipment and techniques brought to the bedside could also bring new insights into clinical conditions, such as heart disease, which was becoming increasingly common (see Chapter 2). Hospital medicine had linked heart conditions to structural change, with deformities in the valves seen as the underlying cause. In the late nineteenth century, researchers began to explore the action of the heart, thinking of it as a dynamic organ, characterised by its ability to pump blood around the body, and capable of changing its action to compensate for defects in its structure. The action of the heart was captured though new instruments such as the sphygmomanometer which measured the constantly changing pressure in arteries and veins and the electrocardiograph to trace the heart’s movement. As a result, by the early twentieth century, heart disease was no longer understood to be the result of abnormal structure but of different forms of dysfunction which prevented the heart from pumping enough oxygenated blood around the body to cope with physical effort. Textbooks described a range of diseases of function such as arrhythmias (Lawrence, 1985). The ability to resolve the tensions between new ideas and traditional forms of teaching practice can be seen in the American Rockefeller Foundation’s efforts to introduce a German model of laboratory work into Edinburgh University. The Foundation sought to establish a biochemical laboratory as the first step to reform teaching at one of the most important medical schools in Britain. However, the university authorities and medical staff

40 Narrative feared a wholesale introduction of ‘American medicine’ which ran counter to the institution’s traditional hierarchies and practices. Although the laboratory was built (after long negotiations), the staff at the medical school incorporated it alongside their more clinically oriented approach to teaching and practice (Lawrence, 2005). Recent work has also shown how blurred the boundaries between clinical and laboratory medicine could become. A case study of work in a small laboratory in Edinburgh shows that it was used by both clinicians and scientists, and that there was no clear division between using the facility for ‘clinical puzzle-solving’ – uncovering an explanation for anomalous cases by microscopic studies of tissue or bacteriological tests – and the production of new, generalised knowledge. Many practitioners published the results of findings from their clinical work in academic journals (Sturdy, 2007). Further research has also challenged the idea that laboratory medicine was always reductionist – locating disease within small structures. A  strong strand within laboratory research was concerned with different forms of communication within the body, and thus how it functioned as a closely integrated system and a holistic unity. Research revealed the multiple mechanisms co-ordinating body function: work in neurology, endocrinology and biochemistry showed that the body was constantly changing in response to stimuli from the environment [Document 12, p. 132] (Cantor, 2002).

Beyond the biological It is often assumed that diseases are stable, biological entities that have always existed, although their prevalence and their names have changed over time (see Chapter 2). This is far from the truth: to quote the historian Jacalyn Duffin (2005, p. 3), ‘diseases are ideas’ related to the culture and knowledge of specific times and places. In the past, disease was understood to have social or cultural components. Cholera, the ‘shock disease’ of Victorian Britain was widely believed to strike preferentially at the poor, the immoral and the heavy drinker. It seemed to be a divine punishment striking the irreligious, the feckless and the criminal. Similarly, venereal diseases, especially syphilis, were not just a serious infection, but a sign of sexual licence, loose morals and vice. As a consequence, sufferers of VD were often treated harshly by practitioners and by a state anxious to clamp down on such behaviours. Under the Contagious Diseases Acts, in operation between 1864 and 1886, prostitutes believed to have spread VD among soldiers and sailors were forced to undergo regular medical inspections and, if found to be infected, to undergo treatment in hospital (Walkowitz, 1980; Mort, 2000). In the twentieth century, governments offered free VD therapy in an effort to reduce the incidence of these diseases. Married women, who were seen as innocent victims, infected by their husbands, were offered discreet care to protect their reputation. By contrast, infected single women were portrayed as ‘amateur prostitutes’, with loose morals and little social

Medical ideas  41 conscience who were unlikely to submit to a full course of treatment (Davidson and Hall, 2001). While cholera and venereal disease carried negative connotations, other diseases had more positive meanings. In the delirium of a high fever, it was believed that reason and self-control were lost, allowing intense creativity. Fever patients recalled composing music or writing poetry. The naturalist Alfred Russel Wallace (1823–1913) reported suddenly lighting upon the idea of evolution by natural selection while in a high fever. Tuberculosis was also associated with creativity as well as emotion, frailty and redemption, especially among women. It is no coincidence that the plots of a number of operas and novels revolved around heroines (rarely heroes) dying of consumption. An episode of fever was another handy plot device: characters emerged from the sick room with their characters fundamentally altered as, for example, in Jane Austen’s Sense and Sensibility (1811). In the 1980s, a number of historians questioned whether diseases had any fundamental biological identity, and suggested that they were concepts constructed by medical practitioners. By selecting a group of signs and symptoms and giving them a name, practitioners created diseases. This explained why some complaints appeared and disappeared from the historical record. Miner’s nystagmus, for example, was a condition that caused spasms of the eyelids, dizziness and inability to cope with bright light. The disease was first described in the early nineteenth century, and by the 1930s over 10,000 cases were reported and huge sums paid out in compensation to miners unable to work as a result of the condition. Miner’s nystagmus was believed by contemporary practitioners to be caused by nerve damage as a consequence of working with the poor illumination produced by safety lamps. Later, it was interpreted as a psychosomatic complaint, similar to shell-shock. The historian Karl Figlio has argued that the disease was a product of an industrial power struggle between miners unhappy about their working conditions and mine owners in pursuit of greater profit in a competitive market (Figlio, 1978). The fluid nature of diseases is illustrated by the history of ‘green sickness’ – an illness that effected girls around puberty, with symptoms including a very pale skin, lack of menstruation and feelings of depression. Emerging in the early modern period, green sickness was widely reported in the eighteenth century and was associated with the uterus. In the nineteenth century, the disease was renamed ‘chlorosis’ and its seat shifted to the liver. In the twentieth century, laboratory science was applied in an effort to define the cause of chlorosis, and blood tests and X-rays used in attempts to devise a reliable test for the condition. The disease disappeared in the 1920s when it was probably re-labelled as anorexia nervosa (King, 2004). Most historians of medicine found the notion that diseases were wholly constructed ideas with no biological bases hard to accept. In response, the American historian Charles Rosenberg developed the concept that practitioners and patients ‘framed’ disease: diseases had a biological reality

42 Narrative that produced consistent patterns of symptoms, but over time, doctors interpreted these in different ways. For example, the concept of a ‘heart attack’ – now a familiar concept in modern medicine – came into being very slowly. Until the 1920s, cases of acute chest pain were diagnosed as forms of angina, and as a sign of a malfunctioning heart that was failing to pump sufficient blood around the body. Sudden death was the most extreme final outcome of this malfunction. Gradually, practitioners specialising in heart diseases put together the concept of a heart attack as a means to explain the range of forms of angina. The creation of the heart attack emerged from existing observations – there was no sudden insight or new information but rather a new way of interpreting well-known symptoms (Rosenberg and Golden, 1992).

Heterodox medicine While the nineteenth century is often portrayed as the dawn of scientific medicine (and a great improvement on earlier forms of medicine), from mid-century, a variety of different medical theories were introduced to Britain. All used very different principles to explain the causes of disease from those in scientific (or orthodox) medicine, and are usually described as heterodox or alternative medicine. Many of these systems looked back to old ideas of a natural balance within the body as the key to health and to disease as a phenomenon effecting the whole body. Thomsonian medicine was a system of medical practice devised by Samuel Thomson (1769–1843) in early nineteenth-century America, which was brought to Britain by the rather unfortunately named Albert Coffin (1790–1866). Dissatisfied with conventional medicine, Thomson devised his own theory. In his system, all disease was the result of exposure to cold, which caused an imbalance of heat within the body. Healthy functioning was restored by a small number of herbal drugs, including cayenne pepper and lobelia (to induce vomiting) and steam baths. Other forms of heterodox medicine sought to mimic or stimulate an innate healing response within the body. Hydropathy, or the water cure, was developed by Vincenz Priessnitz (1799–1851) in Germany in the 1820s. A combination of baths, showers and being wrapped in wet sheets plus a simple diet and plenty of exercise caused the body to throw off the ‘morbid matter’ which caused disease. Later hydropathic practitioners claimed that these treatments worked by simulating the body’s natural healing processes. Hydropathy was later incorporated into naturopathy, a form of alternative medicine or ‘drugless healing’ which combined diet and exercise with new forms of alternative medicine such as osteopathy and chiropractic (Adams, 2015a and b). Homeopathy arrived in Britain in the 1830s. The system was devised by Samuel Hahnemann (1755–1843), a medical practitioner working in Saxony (now Germany) in the 1800s, who noticed that many drugs induced symptoms similar to those seen in disease. He devised a system of

Medical ideas  43 giving drugs in the smallest possible dose to mimic the symptoms of disease, and thus to stimulate the body’s own healing response – the principle of ‘like cures like’ (Nicholls, 1988; Bivins, 2007). The mid-nineteenth century also saw a vogue for more exotic forms of medicine. Mesmerism or hypnosis was derived from a form of treatment practised in the eighteenth century, which claimed to manipulate natural forces running through the body. By the nineteenth century, the practice had become similar to modern-day hypnosis, with practitioners able to induce an altered state of mind that could cause sleep, ease discomfort, cure chronic disease and anaesthetise patients during surgery. However, the trance state was also believed to heighten patients’ awareness of their own body and disease, and to give practitioners insight into the patient’s condition. Mesmerism, introduced from Europe in the 1840s, was absorbed into psychoanalysis in the 1870s (Winter, 1998). Acupuncture and moxibustion, techniques taken from Chinese medicine, also enjoyed a brief vogue in the nineteenth century. In Chinese medicine, these treatments were applied at very specific points on the skin to stimulate the flow of ‘chi’ or energy through the body. Practitioners in Britain struggled to understand this, so shorn of their theoretical rationale, these therapies were used for the treatment of chronic pain, gout, sciatica and nervous diseases (Bivins, 2007). Historians have suggested that the popularity of heterodox medicine was a reaction against laboratory medicine. Where scientific medicine emphasised the localisation of disease and justified the use of chemical-based drugs, the various heterodox systems used simple ‘natural’ remedies that claimed to work with the body’s own healing processes. Heterodox medicine appealed to a particular section of the population – those who opposed many aspects of mainstream culture. Its followers were drawn from dissenting religions, from groups opposed to the power of the state, such as the anti-vaccination movement, and from those who sought ‘natural’ lifestyles such as vegetarianism, total abstention from alcohol and ‘rational’ dress (which favoured light, loose clothing rather than the stiff corsetry and formal dress worn by most Victorians). Participation in any of these groups required a certain independence of spirit, and many alternative systems of medicine encouraged patients to take responsibility for their health into their own hands and devise their own forms of treatment, rather than submitting to the prescriptions and directions of medical practitioners (Durbach, 2005). However, there were considerable points of overlaps between the heterodox and orthodox medicine. Many practitioners saw the two as perfectly compatible, offering different ways of diagnosis or treatment (Bradley and Dupree, 2003). John Elliotson (1791–1868), professor of medicine at UCL and one of the senior staff at University College Hospital, was a strong advocate of the use of mesmerism. Many forms of heterodox medicine initially claimed an alliance with orthodox medicine. Close clinical observation was at the heart of homeopathic practice, with practitioners carefully observing the effect of remedies on their patients. An 1865 guide to a hydropathic

44 Narrative establishment appealed to hospital medicine when it claimed that ‘A visit to a “Water Cure” Establishment gives rest to those organs that have been overworked – and active play to those organs which have not been duly exercised’ (Bradley and Dupree, 2001, p. 435). It is often assumed that the general public adopted the medical theories used by orthodox and heterodox practitioners. However, studies of popular medical ideas show that while most people consulted practitioners when ill, they also continued to hold ideas about the causes of illness that harked back to humoural theory. Well into the twentieth century, people explained that they fell ill due to exposure to cold. Mothers warned their children against going outside with wet hair, not wrapping up in coats and scarves, and wearing damp socks and shoes. Notions of a healthy balance of excretions also survived into the twentieth century, with children regularly dosed with laxatives to avoid constipation. While Jewson’s three medical cosmologies provide a lucid and thoughtprovoking overview of medicine in Britain between 1780 and 1850, there are some disadvantages to his scheme. Jewson presents bedside, hospital and laboratory medicine as different ways in which practitioners and their patients came to understand disease, and it is all too easy to read them as separate systems, each eclipsing the previous theory, forming stepping stones towards a better, more effective medicine. As later research has shown, new ideas of disease did not displace older theories; rather, they at least partially co-existed, with information from the clinical setting making use of, and in some cases helping to further advance, the biomedical sciences. Jewson’s account does not capture the complexity of ideas about diseases, and how a mix of biological, social and cultural explanations lay behind every episode of illness. How these fed into ideas of cure is the subject of the next chapter.

4 Medical practices

While medical theories went through a period of radical change between the eighteenth and twentieth centuries, the history of medical practice is one of greater continuity. Very few medical ideas persisted from the 1780s to the 1950s, and those that did moved from the realm of orthodox medicine into that of popular or folk medicine. By contrast, many treatments for minor ailments remained in use from the eighteenth to the twentieth centuries. Indeed, new forms of surgical treatment, diagnostic technologies, drugs and alternative medicines did not appear until the late nineteenth and twentieth centuries. Nevertheless, the demand for health care expanded significantly right through the modern period. In part, the growth in sales of medical goods and services reflected a broader consumer revolution, in which all groups in society purchased more domestic items. The increasing demand for care also reflected changing attitudes: there was a decline of religious resignation in the face of discomfort, a growing intolerance of pain and an increasing expectation that illness could and should be cured. A broad range of goods and services were available to those who felt ill, or wished to improve their health. The sick could employ a variety of practitioners, both orthodox and heterodox, and purchase a wide range of drugs and medical equipment. Historians have used the concept of a ‘medical marketplace’ to describe this situation. The term was first applied to histories of eighteenth-century medicine, but has come into use in studies of later periods (Porter, 1989). Recent historiography has described twentiethcentury medicine as a form of consumption, with patients selecting care from a range of treatment options. The concept of a marketplace also gives a particular perspective to medicine in the past – it is no longer a modern, government-funded public service. Instead patients acquire the status of consumers of medicine, and practitioners become the vendors of medical services, seeking commercial success by responding to patient demand.

The pursuit of health People turned to the medical marketplace not only when they fell ill, but in an effort to stay healthy. Health is not a modern obsession: in the eighteenth

46 Narrative and nineteenth centuries, when a small cut could become dangerously infected or an apparently minor illness could become a life-threatening disease, people had, if anything, even greater incentives to stay well. Sickness also brought doctors’ bills and until the introduction of welfare in the twentieth century, the inability to work inevitably meant poverty for many. From the late nineteenth century, keeping healthy was presented not only as an individual responsibility but also as a duty to the state and Empire. An unhealthy population was unable to work efficiency or to defend the nation. With the availability of welfare services in the twentieth century came the concept of health citizenship – the responsibility to make use of welfare services in order to protect one’s own health and to seek treatment for illnesses before they became serious and required more intensive and expensive forms of treatment (Porter, 1999). The key to preserving health was to pursue an appropriate lifestyle. Guidance was offered through books on health, newspaper and magazine articles. In the twentieth century, the government and voluntary organisations such as the New Health Society, and even the Boy Scouts, sought to educate the public in health matters. While there was plenty of advice available, it is impossible to know to what extent it was put into practice. From the late eighteenth into the twentieth centuries a range of strategies were widely recommended as means to maintain health, all ultimately rooted in the humoural theory that flourished in the early modern period (see Chapter 3). Diet was central to health. Certain types of foods should be avoided: rich dishes containing a lot of meat, strong seasonings and spices, tea, coffee and alcohol, especially in the form of spirits, were all thought to over-stimulate the body and bring on gout, fevers, gastric disorders and nervous diseases. By contrast, a diet of simple, ‘natural’ foodstuffs – boiled meats, vegetables, milk and grains – would help the body to function properly. Vegetarianism, which had a small but dedicated following in Britain from the 1850s, was promoted as a way to prevent ill health. From the nineteenth century, consumers could buy foods marketed as being particularly beneficial for health. ‘Hovis’ brand bread, made with wholemeal flour, was advertised as a way to prevent indigestion, while a bedtime cup of cocoa was sold as a way to ‘build up’ the blood. Concerns about air, temperature and climate also persisted from the eighteenth into the twentieth centuries. Fresh air was a guarantor of good health: housewives were encouraged to keep rooms well ventilated at all times. While middle-class households adopted this practice, working-class mothers were more concerned about the unhealthy effects of cold draughts (which could cause ‘chills’) and were often criticised for keeping their homes warm and stuffy. The quality of the air in particular environments was believed to be healthy and in an age of widespread urban air pollution, it is easy to see why. The fresh air at the seaside or in the countryside was promoted as a way of improving health. Sea bathing was advocated as a way of stimulating the nervous system and visits to medicinal spas, to drink and bathe in mineral water, promised to tone up the body.

Medical practices  47 Extremes of temperature were widely believed to be bad for health. Exposure to cold and damp was linked to respiratory diseases, and wearing warm, woollen clothing was the best means of avoiding these ailments. In the twentieth century, the benefit of keeping the body warm was re-interpreted as a means of preventing invading ‘germs’ taking hold and causing illness. The hot, humid climates found in British colonies posed other problems – they were believed to cause fevers, and British families in India moved to the cooler mountainous areas to avoid the worst of summer heat. Children were often sent back to Britain to attend school in a temperate climate. Rapid change in temperature could also predispose the body to illness. Any sudden cooling of the body – for example, by drinking cold water when hot, rendered the body susceptible to fevers, colds and chills. Cleanliness – both of the home and the body – was increasingly seen as an important means of maintaining health. The link between cleanliness and health emerged at the end of the eighteenth century. Bathing (especially in cold water) was believed to tone up the fibres of the body and open the pores, allowing the skin to get rid of toxins and waste products. By the nineteenth century, keeping body and homes clean was a personal and social responsibility, and the advent of the germ theory simply reinforced this trend (see Chapter 2). Cleanliness was easier to achieve for middle-class families, who could afford homes with separate bathrooms and complex plumbing, and employed servants to clean their homes. Well into the twentieth century, many working-class homes had no bathroom and no piped hot water. Children bathed in shallow tin baths in the kitchen, while adults went to public bathhouses (Smith, 2007). Around the turn of the century, health acquired a new meaning. In the eighteenth and nineteenth centuries health was a state of not being ill, to be preserved by avoiding dangerous behaviours. At the end of the nineteenth century, health became something that could be built up by pursuing a range of activities, to reach a state of vigour and overflowing vitality. At this time, a new culture of the healthy body emerged, one that was physically fit and muscular (for men) or slim (for women), as portrayed in photographs of swimmers, golfers and body builders [Document 13, p. 132]. Health increasingly overlapped with beauty, and physical fitness with mental fitness. Women were advised to cultivate a fit and healthy body in pursuit of beauty but also as a means of guaranteeing the birth of healthy children. The fit and active man was better able to perform his work and would gain greater satisfaction from it (Zweiniger-Bargielowska, 2010). This new healthy body was achieved by a combination of old strategies – a healthy diet and fresh air – plus a new emphasis on vigorous physical exercise. In the 1880s various systems of gymnastic exercise were promoted as the way to health, alongside a boom in sports such as tennis, hockey and golf. The interwar period also saw a craze for sports and activities. The Women’s League of Health and Beauty, founded in 1930, organised classes in gymnastic exercises that were attended by thousands. Cycling, walking and swimming

48 Narrative were also popular, providing a cheap way to access a combination of exercise, fresh air and exposure to sunlight [Document 14, p. 133]. A belief that sunlight acted as a ‘tonic’ became widespread in the 1920s, with manuals offering instructions on how to take a ‘sun-bath’. In the twentieth century, controlling body weight became an increasingly important aspect of health. Being very overweight was associated with poor health from the late eighteenth century, but the collection of data by life insurance companies in the nineteenth century conclusively demonstrated the increased risk of heart disease and early death for those whose bodies were above a desirable weight to height ratio. The new concern about body weight reflected changing lifestyles: more of the population had sedentary jobs and were able to afford a better diet and thus were more likely to be overweight. The habit of regular self-monitoring of weight began in the late nineteenth century, initially using the cargo scales at railway stations and later purpose-built machines placed in public places such as chemists’ shops. With the design of smaller, cheaper scales for use in the home, people were able to keep track of their weight ever more frequently (Bivins and Marland, 2016). Weight reduction diets were devised from the mid-nineteenth century. Initially the advice was aimed at middle-class, middle-aged men, whose lifestyle had led to the development of a paunch, and only later targeted women. Virtually all diets recommended cutting back on starchy and sweet foods, avoiding alcohol and taking more exercise. The boundary between promoting good health and treating ill-health was blurred. Therapies used to treat disease also had a role in the maintenance of health. Bloodletting – cutting open a vein to remove a controlled quantity of blood – had been used from medieval times as a way of treating diseases. However, as the quantity of blood within the body was believed to increase naturally in response to the turn of the seasons, so regular spring and autumn bloodletting was widely used in the eighteenth century to maintain a healthy balance within the body. Similarly, purgative medicines were frequently prescribed to treat illness by removing morbid matter from the body in the nineteenth century, but regular doses of laxatives such as castor oil or syrup of figs were also recommended ‘to keep the bowels open’ (Beier, 2008). Pharmaceutical companies in the twentieth century responded to the desire for health by marketing medicinal ‘tonics’ and electrical devices to promote health and prevent disease. Manufacturers played on concerns about modern lifestyles, which were believed to place a particular strain on physical and mental health, leaving people open to a range of ailments. Proprietary medicines promised to ‘feed’ the brain and nerves and thus to cure ‘brain fag’, dizziness, and nausea, to restore ‘lost energy’ or dissolve impurities in blood. While appealing to old medical ideas such as impure blood, these medicines were marketed using up to date science: some advertisements included drawings of nerve and blood cells. In the 1880s, equipment for the home application of electricity became available. Drawing on research on

Medical practices  49 the electrical communication between nerves and muscles, manufacturers produced electrical belts, bandages and even hairbrushes, which promised to stimulate tired nerves and replenish stores of ‘vital force’ depleted by the demands of modern life (Ueyama, 2010).

Domestic medicine In the past (as in the present), when people felt unwell their first response was to try to diagnose and treat their own illness. Thus the most frequent providers of medical care were not practitioners, but the sick person and his or her friends and family. Historians refer to this as domestic medicine as it happened largely within the home. Women took the leading role in domestic medicine: mothers looked after children; wives and daughters cared for husbands and siblings. In the eighteenth-century, middle and upper-class women also helped to care for their poorer neighbours, providing food and homemade remedies as a form of charity. This practice declined in the nineteenth century, when better-off neighbours increasingly paid practitioners to provide care. Family members diagnosed ailments, either through personal experience of common illnesses, such as colds, flu, stomach upsets or childhood diseases, or by consulting advice books. Books explaining how to diagnose and treat illnesses appeared in the eighteenth century and remained popular right through the twentieth century. One of the first and most successful was William Buchan’s Domestic Medicine (1769), which went through a staggering 142 editions in Britain and America (Rosenberg, 1983). Many other texts contained medical information. Books on housekeeping such as Isabella Beeton’s famous Book of Household Management (1861) included advice on treating the sick [Document 15, p. 134]. In the twentieth century, women’s magazines and newspapers carried articles on health matters, often written by medical practitioners, while advice was also dispensed through agony columns. This type of popular health information was carried over into new forms of media. Dr  Charles Hill, known as the Radio Doctor, began to broadcast advice in 1942 as part of the messages from the wartime Ministry of Food. Advice books suggest a shift in the scope of domestic medicine over time. Books written in the late eighteenth described how to deal with severe illness and injuries such as broken bones. By the middle of the nineteenth century, similar works restricted their advice; confronted with serious ailments, families were told what to do until a doctor arrived and took charge of the case. By the mid-twentieth century, advice in women’s magazines and newspapers assumed that only minor illnesses such as headaches, colds and stomach upsets were appropriate for home treatment – everything else required a visit from a doctor. This increasing reliance on practitioners happened gradually across the social scale, beginning with the upper and middle classes and moving into the working classes.

50 Narrative Nursing was a key aspect of domestic medicine. Family carers and trained nurses sought to relieve the discomfort associated with illness and support the body’s efforts to recover. Nurses treated symptoms as they arose, providing cooling cloths or baths for feverish patients, or warming them if cold, and kept patients clean and comfortable by changing bedding and garments. Home nursing also included giving medicines at appropriate times and at the correct dosage, and choosing a suitable diet, of bland, easily digested foods for the patient. At the end of the nineteenth century, carers took on the responsibility of monitoring their patient’s temperature. Ailments were treated at home using a range of remedies, often made up from household materials. Like the strategies used to preserve health, some had a very long history, recommended from the eighteenth century through to the twentieth. Among the simplest, and most commonly used, were applications of heat or cold to ease pain and discomfort. Steam was inhaled to ease the congestion associated with a cold, and a warm sock wrapped around the neck to soothe a sore throat. Cold compresses – cloths soaked in cold water – were applied to sprained joints. Foodstuffs formed the basis of many homemade remedies. Goose grease or plasters – brown paper spread with vinegar and mustard – were applied to the chest and back to treat a bad cold. Homemade cough medicines included ingredients such as treacle, onions, sugar and whisky. Inhaling strong smells, such as fumes from a local gas works or the tar used to mend roads, were also recommended to clear a persistent cough. A few magical remedies continued in use in the nineteenth century, such as applying a slice of bacon to a sore throat or passing children under the belly of a donkey or piebald horse to cure whooping cough. If homemade remedies failed to cure the ailment, patients and their families could purchase medicines from an array of sellers. In the eighteenth century, ‘quacks’ were a popular source of remedies – so much so that the period has been described as a golden age of quackery. The archetypal eighteenth-century quack was itinerant, moving from town to town, selling medicines made from a secret recipe. Exotic displays and heavy advertising spread the message that their remedies could cure a range of vague ailments or diseases such as cancer which practitioners were unable to treat (Porter, 1989). The flamboyant quack of the eighteenth century transformed into the patent or proprietary medicine seller of the nineteenth and twentieth centuries. The market in patent medicines – also made to standard or secret recipes – boomed in the nineteenth century, with sales income reckoned to have increased from £600,000 in 1860 to £5  million in 1914, despite attempts to discredit the trade (Ueyama, 2010). A few travelling patent medicine sellers continued to use the techniques of the eighteenth-century quack. In the 1890s ‘Sequah’, an American medicine man, sold medicines based on Native American remedies to cure rheumatism and stomach disorders, two of the most common complaints of the day. Music and the public extraction of teeth helped to pull in large audiences, before Sequah gave a lecture on the power of his medicines and the business of selling began. In fact,

Medical practices  51 ‘Sequah’ was a franchise: multiple ‘Sequahs’ operated across the country and the medicines were mass produced in a factory (Schupbach, 1985). Many patent medicines were mass produced and distributed through chemists and druggists shops. These businesses enjoyed huge success in the nineteenth century. The town of Wakefield had just two chemists in 1790 but no fewer than 20 by 1847 – a rate of increase that far outstripped the growth in population (Marland, 1987). Medicines were also sold by grocers, general stores and via mail order, and chemists and druggists produced their own remedies. One Wakefield chemist advertised that he sold Faithfully prepared from the recipes of the late G. B. Reinhardt, his invaluable medicine BALSAM OF HOREHOUND, for curing Coughs, Colds, Asthmas, Hooping Cough, Declines and Consumptions. Also . . . also his excellent medicines for Worms, all of which Medicines, from trial and experience, have obtained very high reputations, and can only be prepared by G. B. Reinhardt, as he is the sole possessor of his late Father’s Recipes. (Marland, 1987, p. 433) Claims that their medicines were in some way superior to all others, either due to the skill of the manufacturer or the use of knowledge from foreign medical cultures, were common among patent medicine sellers. Bile Beans were supposedly based on an Australian aboriginal remedy that purified the blood and cured liver complaints. In practice, these remedies usually contained much the same ingredients as the medicines prescribed by doctors. Beecham’s Pills, a popular general tonic, was actually a soap-based laxative [Document 16, p. 136]. Some remedies contained potent ingredients: Godfrey’s Cordial, Atkinson’s Infants Preservative, and Peace and Steedman’s Soothing Powders all helped ‘fretful’ children to sleep by dosing them with opium. A few chemists specialised in the sale of medicines used in alternative practice: Boots, which became a large chain of dispensing chemists, began by selling the herbal remedies used in Thomsonian medicine (see Chapter 3). Homeopathic medicine chests of standard remedies were also available from chemists or by mail order (Beier, 2008; Marland et al., 2016). The mid-nineteenth century saw the emergence of the pharmaceutical industry. Drug companies produced medicines on a huge scale, investing in machinery to mass produce pills and capsules, which were more palatable than traditional liquid medicines. They established research laboratories as a means of ensuring the quality of their products, and to conduct systematic research on the effects of known drugs. In the early nineteenth century, pharmaceutical researchers identified the active ingredients in existing drugs including morphine in opium and digitalis from foxgloves. This allowed the production of medicines in a purer form, which could be given in more accurate doses.

52 Narrative

Figure 4.1  Advertisement for lung tonic, c.1918. This advertisement makes a broad appeal to the market through vague wording. The usefulness of this medicine against ‘coughs, colds & chest troubles’ suggests that it cures disease, but the word ‘tonic’ implies it would also strengthen the lungs. Credit: Wellcome Library.

From the mid-nineteenth century, pharmaceutical companies developed a variety of new drugs. Chloral hydrate, launched in 1869, was the first synthetic drug, used to combat sleeplessness. Salicylic acid was produced in various forms to treat fevers – including Aspirin, first sold in 1899 by the Bayer Company in Germany, which became one of the most popular painkillers. From 1895, a range or sera or anti-toxins were marketed for the treatment of infectious diseases such as diphtheria. Sera were produced from the blood of animals infected with a specific disease: this contained antibodies which, when injected into patients, helped them to fight off the infection. In 1910, Salvarsan, the first effective drug against syphilis, reached the market. Salvarsan is sometimes referred to as the first ‘magic bullet’ drug, as it killed the parasite responsible for syphilis without harming the rest of the body – although it did cause side effects including nausea and vomiting (Anderson, 2005). From 1935, pharmaceutical companies developed drugs to treat bacterial infections. Prontosil, the first sulphonamide drug, was based on an organic

Medical practices  53 chemical used as a textile dye. It was highly effective against streptococcal infections, especially puerperal fever, a serious and often fatal disease which effected women shortly after giving birth. Prontosil was the starting point for the development of other sulphonamide drugs, which were used to treat other infectious diseases including tuberculosis. The impact of the sulphonamides has been overshadowed by the discovery of penicillin – a drug that treated a much wider range of infections. The potential anti-bacterial properties of penicillin mould had been discovered in 1928 but it was not subjected to detailed research until 1939. Further improvements to the production process ensured that penicillin was available to treat soldiers in 1944 and became widely available by the 1950s. Penicillin had a massive impact: it cured infectious diseases such as gonorrhoea quickly and saved the lives of patients suffering from infected wounds.

Medical practitioners If self-treatment seemed inappropriate, or had failed to offer relief, patients and their families called on practitioners, who offered diagnosis, advice and medical or surgical treatments. Sometimes this did not mean calling in a trained expert. Most working class neighbourhoods had one or two women who had some special knowledge of medicine, perhaps through training as a professional nurse or simply through extensive experience of dealing with illness. They acted as ‘informal health authorities’, offering help with diagnosing problems, treating injuries and deciding when to call in a doctor. Chemists, although trained in pharmacy rather than medicine, also acted as informal practitioners in working class areas, dispensing advice and providing first aid in cases of injuries (Beier, 2008). Today, when we fall ill, we are most likely to seek help from a practitioner trained in scientific or orthodox medicine, although we might chose to consult a practitioner of some form of complementary medicine. In the past, the reverse was true. In the eighteenth and nineteenth centuries, the medical marketplace was dominated by informal practitioners and those trained in heterodox or alternative medical theories and folk practices. In 1802, it was claimed that heterodox practitioners outnumbered the orthodox by a ratio of 9 to 1. While this figure can be questioned, there is no doubt that orthodox practitioners were in the minority (Loudon, 1987, p. 211). The number of heterodox practitioners declined from the mid-nineteenth century, but they did not disappear: a survey of 1910 showed that significant numbers were still present in all parts of Britain. In one area of Wales there were 26 heterodox practitioners, including ‘herbalists and botanic specialists, chemists, a bonesetter, [and] an ex-dispenser . . . All give advice and prescribe medicine’ (Digby, 1999, p. 34). Older forms of heterodox practice declined significantly between 1780 and 1950. Traditional folk healers – cunning folk, wise women and bonesetters – were once common all over the country. Folk practitioners offered a variety

54 Narrative of services: they made and sold medicines, often using local herbs and plants. Some practised faith healing, sold magical cures and told fortunes. Female folk healers also acted as midwives and laid out the dead, while bonesetters dealt with fractures and muscular injuries. By the twentieth century, small numbers of folk healers were still practising in rural areas and working-class neighbourhoods in towns and cities. Bonesetters survived in mining areas, where they treated industrial injuries (Beier, 2008). Although they are usually associated with selling medicines, some quacks also practised medicine or surgery. A few achieved wealth and fame. Among the most famously flamboyant quacks was James Graham (1745–1794), who set up his ‘Temple of Health’ in 1779, offering a range of electrical and magnetic therapies guaranteed to cure disease and to ensure the conception of children. Graham’s practice shows how the boundaries of orthodox and heterodox medicine were often blurred: he had studied medicine at university and his treatments were based on scientific research into the effects of electricity on the body (Porter, 1989). From the mid-nineteenth century, practitioners of alternative systems of medicine joined the medical marketplace. Where quacks, medicine sellers and traditional healers worked within broadly the same theoretical framework as orthodox practitioners, these heterodox practitioners used of different understandings of disease and distinctive therapeutics (see Chapter 3). Hydropathic practitioners treated a wide range of complaints using a carefully controlled regime of hot and cold baths and showers and wrapping parts of or the whole body in wet cloths. An 1865 guide to the hydropathic establishment at Malvern claimed: The water treatment is . . . adapted to meet the medical wants of the age. The wear and tear of life, induced by undue business, or professional excitement, results in a large preponderance of disease characterised by bodily exhaustion and weakness of the nerves. (Bradley and Dupree, 2001, p. 435) Hydropathy could be practised at home, but many patients chose to spend some time at a hydropathic establishment (Adams, 2015b) [Document 17, p. 136]. Other heterodox practitioners used drugs to cure diseases. Homeopathic treatment consisted of giving drugs in highly dilute forms to provoke responses similar to naturally occurring symptoms. In this way, homeopathic practitioners sought to stimulate the natural healing processes within the body. The exact choice of drugs for each patient was determined by their prevailing symptoms and prescriptions were changed in response to the progress of the disease. By 1853, there were over 150 homeopathic doctors in Britain and Ireland (Digby, 1999, p. 32). The popularity of the practice declined from the late nineteenth century, but revived in the late twentieth (Nicholls, 1988; Bivins, 2007). While homeopaths used a wide range of

Medical practices  55 drugs, Thomsonian practitioners prescribed a small number of herbal drugs in all complaints, including cayenne pepper and lobelia (which caused vomiting) and steam baths to restore the body’s natural heat. Both homeopathic and Thomsonian practitioners claimed that their treatments were more natural than those of orthodox medicine – their herbal remedies or very small quantities of drugs worked in harmony with the body, in contrast to the more interventionist therapeutics such as bloodletting, or large doses of chemical medicines used by their orthodox counterparts. Although relatively few in number in the late eighteenth century, orthodox practitioners gradually came to dominate the medical marketplace. By the mid-twentieth century, general practitioners were found in even the remotest areas of the country such as the northern highlands of Scotland. Practitioners treated patients in their consulting rooms (often referred to as a ‘surgery’), in institutions such as hospitals and asylums, and in patients’ homes. Orthodox practitioners working in the late eighteenth century based their diagnosis on observation of the patient, plus the patient’s own account of his or her symptoms. In the early nineteenth century, as orthodox medical theory shifted to understanding disease as a phenomenon effecting specific parts of the body, physical examination became an increasingly important means of diagnosis. A range of new medical technologies gave practitioners insights into the condition of internal organs. To a trained ear, the noises heard through a stethoscope (developed in 1816 but improved in the 1850s) could be translated into a picture of the condition of the lungs and heart. In the late nineteenth century new instruments allowed practitioner to see structures within the throat (laryngoscope), eye (ophthalmoscope) and ear (auriscope). X-rays, discovered by Wilhelm Roentgen (1845–1923) in 1895, provided the first means of imaging internal structures. The ability of X-rays to reveal bone fractures and locate foreign objects such as bullets meant that the technology quickly caught on, although the size of X-ray machines meant that most were located in hospitals. Technologies for recording physiological data moved from the laboratory to the bedside. Body temperature had been recorded using clinical thermometers since the seventeenth century, but from the 1870s, following clinical studies on the characteristic variation in temperature in disease by Carl Wunderlich (1817–1877), practitioners began to routinely use thermometers to diagnose fever and to chart changes in body temperature. Technical improvements to the sphygmomanometer and later the electrocardiogram allowed the recording of blood pressure and the heartbeat at the bedside. Hospital laboratories carried out chemical analyses on urine to identify kidney disease, and cultured bacteria to diagnose tuberculosis and other infections. Equipment designed for use in consulting rooms meant that GPs could carry out their own tests, such as blood cell counts to diagnose anaemia. For much of the period from 1780 to 1950, orthodox practitioners treated patients using drugs that produced immediate physiological effects intended to influence the internal state of the body. Patients swallowed

56 Narrative emetics to induce vomiting and purgatives that produced bowel movements. Specific medicines were not used to treat particular ailments; rather, one drug might be given for a number of conditions. Emetics, for example, were used for a wide range of illnesses where the body was thought to have become over-stimulated. In the first half of the nineteenth century, practitioners moved away from prescribing large doses of active drugs in favour of expectant practice which used smaller amounts of drugs to control symptoms, and placed a greater emphasis on supporting the body’s natural ability to fight disease. The archetypal image of the nineteenthcentury practitioner in novels and paintings was of a figure watching at the patient’s bedside, carefully monitoring changes in their condition and seeking to ease discomfort [Document 18, p. 137]. At a time when theories of disease had gone through a radical transformation, the lack of new treatments was a source of frustration to practitioners. In 1849 John Hughes Bennett, a medical teacher in Edinburgh lamented: Whilst pathology has marched forward with great swiftness, therapeutics has followed at a slower pace. What we have gained by our rapid progress in the science of disease has not been followed up with an equally flattering success in an improved method of treatment. (quoted in Warner, 1980, p. 241) Bennett was being slightly pessimistic: by 1849, developments in surgical technique meant that it was used to treat an increasing range of conditions. In the late eighteenth century, surgical treatment was limited to minor operations such as lancing boils or treating fractures and a small number of major operations including the amputation of badly damaged limbs and the removal of bullets, tumours and bladder stones. The high risk of infection meant that such operations were used as a last resort in very serious cases. Innovations and improvements began in the early nineteenth century, when blood loss was reduced through the use of better tourniquets and new operations were devised for the removal of ovarian cysts and the repair of hernias and aneurysms (dangerously weak points in blood vessels). The range of surgical operations went through a more significant expansion in the second half of the century. This is often attributed to two technical developments – anaesthesia and antisepsis. Drugs known to deaden pain, such as alcohol and opium, had a long history of medical use. However, doctors were reluctant to give large doses prior to surgery as pain was believed to stimulate the body and to help recovery. Instead, pain was limited by operating at tremendous speed – stories abound of amputations conducted in a few minutes. In the mid-nineteenth century, practitioners realised that chemicals such as nitrous oxide and ether, which were used as recreational drugs, also had painkilling effects. In 1844, nitrous oxide was used as an anaesthetic for dental surgery, and in 1846 a number of operations were conducted under ether anaesthesia in America. The practice

Medical practices  57 quickly spread to Britain. However it had drawbacks: some patients did not lose consciousness, while others went through a period of excitement before becoming unconscious. James Young Simpson (1811–1870), an Edinburgh practitioner with a large obstetrical practice, embarked on a search for a better drug and in November 1847, he published an account of his experiments on the effects of inhaling chloroform. Chloroform quickly became the preferred anaesthetic agent in Britain. Research has shown that anaesthesia was a mixed blessing. On the plus side, it freed patients from pain and provided surgeons with a calm, quiescent patient, allowing them to take more time and perform more complex and delicate operations. However, some patients died as a result of anaesthetisia, and both ether and chloroform caused acute nausea. The practice aroused an impassioned debate about whether it was right to give anaesthetics to women in childbirth when the associated pain was sanctioned in the Bible. There was also fear that anaesthesia gave surgeons too much power over their patients, and that they would be tempted to perform experimental surgery. As a result, anaesthetics were not routinely used for all operations until the 1860s (Snow, 2009). Antisepsis – practices to ensure that surgical wounds did not become infected – are often associated with Joseph Lister (1827–1912). Lister applied laboratory techniques to research into inflammation and wound infection. In 1867, he published a description of his antiseptic surgery, in which carbolic acid was applied to dressings and instruments in order to kill any germs that might cause infection [Document 19, p. 138]. Despite their success, many of Lister’s techniques were rejected by his contemporaries (including James Young Simpson) as unnecessarily complicated. Other surgeons claimed to achieve similar results simply by ensuring scrupulous cleanliness in the operating theatre. Gradually, antisepsis was replaced by asepsis – the creation of a germ-free environment. It became the norm to sterilise instruments and dressings using heat, and for staff in operating theatres to wear gowns, caps, masks and gloves. A combination of antisepsis, asepsis and anaesthesia reshaped the operating theatre: from a place of pain and disorder, it became a calm, highly controlled environment (Schlich, 2012). While anaesthesia and antisepsis addressed the problems of pain and infection, they were not solely responsible for the expansion of surgical treatment. Even before their introduction, styles of surgical practice were changing. Where eminent surgeons of the 1800s gained renown for their speed, dexterity and coolness, from the 1820s, practitioners began to operate more slowly and with greater care, aiming to conserve tissues where possible (Schlich, 2015). Amputations were replaced by operations to remove damaged bone but leave the limb as intact as possible. Anaesthesia and antisepsis further encouraged this trend towards slow and careful surgery, as surgeons no longer had to deal with a conscious, struggling patient, or feared that wounds left open for long periods would become infected.

58 Narrative Researches into pathological anatomy opened up new areas of surgery. With disease now understood to be located within a specific organ or tissue, it made sense to treat some illnesses by removing the diseased part – a technique known as resective surgery. Some operations were strikingly successful: the removal of an infected appendix quickly restored patients to health. Other interventions, such as treating goitre by removing the enlarged thyroid gland, produced serious and puzzling side effects. This drove new research into the function of glands: researchers removed the tissue from experimental animals, observed the physiological changes, then attempted to reverse them through the implantation of gland tissue. These techniques were transferred from the laboratory to the operating theatre and, between 1880 and 1930, surgeons experimented with the transplantation of thyroid and pancreatic tissues from animals into their patients. Often this had a short-term, beneficial effect, but the transplanted tissue was always rejected by the body. As a result, by 1930 the use of transplant surgery was all but abandoned. It was revived after 1945, as improved knowledge of immunology allowed doctors to understand why transplanted tissues were rejected (Schlich, 2010).

Figure 4.2  Charing Cross Hospital; Stanley Boyd in the old operating theatre, 1900. This photograph reveals the slow and gradual introduction of aseptic techniques. While the doctors wear gowns and gloves, they do not have caps or masks. The theatre is still open to students, and contains few pieces of highly specialised equipment. Credit: Wellcome Library, London.

Medical practices  59 At the end of the nineteenth century, orthodox practitioners finally had access to an array of new drugs devised in the laboratories of pharmaceutical companies. These new drugs had a specific and often powerful effect on the body, and anti-toxins, salvarsan and the sulphonamide drugs offered the first effective treatment in infectious diseases. Such drugs were not available for every ailment, however, and for many common diseases, doctors had no option but to fall back on traditional therapies. During the serious flu epidemics in the early twentieth century, the chief recommendation was bed rest and a traditional sickroom diet of milk, eggs and puddings. The high temperature was treated with quinine, and aromatic chemicals such as eucalyptus or carbolic acid were inhaled to kill the flu ‘germs’ (Loeb, 2005). A lot of medical practice continued to rely on such simple medicines. General practitioners dispensed large quantities of traditional liquid medicines for common complaints such as coughs and digestive upsets. Many of these had a limited curative effect and were effectively placebos, but combined with a faith in doctors’ increasing ability to cure, they satisfied patients (Digby, 1999).

Consuming medicine The medical marketplace provided many different forms of medical goods and services, which were, in theory, available to all. But how much agency – the freedom to choose the treatment that they wanted – did patients and their families actually have? Patients had a high level of autonomy in caring for their own health, and over the treatment of minor ailments and injuries, as the foodstuffs and remedies used in these circumstances were readily accessible and could be purchased cheaply. More significant inequalities emerged when practitioners were employed. The ability to access care varied with geography. Practitioners of all types tended to cluster in towns, where there were larger numbers of patients to bring in an income, while rural areas were less well served. Remote areas like the highlands of Scotland were notoriously poorly provided with practitioners, and until the twentieth century, residents had to rely on domestic medicine, purchased remedies and the advice of ministers of religion and schoolmasters, who acted as informal practitioners. However, economic factors were the most important determinant of access to medical care. The upper and middle classes were major consumers of medical services, willing to spend large amounts of money in the pursuit of health – around 8% of their income in the 1820s (King, 2001) and a similar proportion of their household expenditure in the 1930s (Digby and Bosanquet, 1988). These patients exploited the medical marketplace to the full, shopping around in search of aids to health and relief from pain and discomfort. Well-off patients were able to exercise choice over the types of practitioner they employed. Many families called on trusted local practitioners, but in serious cases might choose to consult with a practitioner

60 Narrative with specialist knowledge, or a high reputation, based some distance away. Patients were able to mix and match different forms of treatment, shifting from self-help to calling in a practitioner, and from orthodox to heterodox treatment as they saw fit. Hydropathy appealed mainly to the middle classes, while homeopathy proved popular among the social elite. The naturalist Charles Darwin (1809–1882), for example, who suffered from a chronic stomach complaint, employed no fewer than ten practitioners at different times, including hydropathic doctors. Working-class families devoted around 3% of household expenditure to medical care (Digby and Bosanquet, 1988). Even though orthodox practitioners routinely charged their poorer patients lower fees, many working class patients could only afford to call in a practitioner when faced with serious illness. Male breadwinners were more likely to seek care from a practitioner, often through some form of insurance scheme which covered the costs of treatment in return for a small weekly payment. After 1911, working men and women gained access to general practitioners under the National Insurance Act, which covered around half of the population by the 1930s. While insurance gave the reassurance that care would be available, it limited patients’ choice of practitioner – they had use the doctor employed by the insurance scheme or join the ‘panel’ of a specific general practitioner. Working-class women and children relied more on domestic medicine or sought help from charitable hospitals or dispensaries. The quality of care provided by insurance and charities was often of lower quality than that given to fee-paying patients: patients were more likely to receive a shorter consultation from a more junior practitioner and a standard bottle of medicine as the only treatment. When care became freely available with the launch of the National Health Service in 1948, there was a huge and unanticipated level of demand, revealing how many patients – especially women – had been unable to afford care (see Chapter 7). While many patients had some choice of practitioner between 1780 and 1950, their power to influence their diagnosis and treatment declined over time. Historians have argued that in the late eighteenth century, patients were very much in control of the medical encounter. Under medical theories that emphasised lifestyle factors in the cause of disease, and where signs and symptoms were the key to diagnosis, patients possessed information which was crucial for diagnosis. During consultations, patients provided descriptions of their past and present symptoms, and their own explanations as to the cause of their illness. This exchange of information between patient and practitioner was facilitated by a common understanding of disease and a shared language of medical terms. As the practitioner was dependent on pleasing the patient in order to be sure he would receive his fee, he had little choice but to tailor his diagnosis and therapy to the patient’s conception of his or her ailment (Jewson, 1974; Jewson, 1976). Letters between eighteenth century patients and practitioners show how diagnosis and treatment was negotiated, with patients quick to demand a new course of therapy if the original did not produce the desired results.

Medical practices  61 By contrast, the dominant image of nineteenth and twentieth century medical practice is of a passive patient, subjected to ever more intrusive physical examination and tests, unable to understand the highly technical information possessed by practitioners and thus unable to participate in shaping medical treatment. In Nicholas Jewson’s phrase, the sick man ‘disappeared’ from the medical encounter, as new developments in medical theory and practice gradually rendered the patients’ narrative redundant. By the early nineteenth century, case histories taken in hospitals consisted largely of the doctor’s observations of the patient’s appearance and symptoms, often including technical or Latin terms (Fissell, 1991a and b). More recent research has modified this picture: the transformation from an active to a passive patient was by no means as rapid or as complete as once thought. In the 1820s, upper-class patients continued to provide detailed accounts of their condition as an adjunct to physical examination, and discussed their case with their practitioner (Jacyna, 1992). Poor patients in hospital continued to provide a narrative of their case: Jean Alibert’s (1768–1837) works on skin disease, based on his practice at the St. Louis Hospital in Paris, included details from patients’ accounts of their symptoms and the progress of their ailments (Hannaway and La Berge, 1998). Even in the late nineteenth century, hospital patients contributed information to their case histories. Margaret Mathewson’s account of her treatment for a diseased shoulder joint at the Royal Infirmary in Edinburgh in 1877 records the questions she was asked about the history of her condition, and the treatments she had tried. The surgeon, Joseph Lister, also conducted a physical examination of her shoulder. While Mathewson was not silent in her encounters with medical men, she clearly had little power over how they perceived her case, and her doctors did not explain how they proposed to treat her. Mathewson’s status was graphically displayed when her case was used in a clinical lecture to students, and she first became aware of the plan for her surgery (Goldman, 1987). Just as the patient’s narrative was slow to disappear, physical examination and laboratory tests only gradually became the centrepiece of diagnosis. Although new diagnostic technologies became available in the late nineteenth century, they were slow to come into general use. It took time for their usefulness to be accepted and for a cadre of practitioners to be trained in the use of new instruments. The strong clinical tradition within British medicine may have further slowed the adoption of medical technologies (Digby, 1994). Well into the twentieth century, some surgeons used the pathological examination of tumours not as a diagnostic tool, but as a means of confirming a diagnosis made on clinical grounds (Jacyna, 1988). Surveys of general practitioners suggested that, as late as the 1930s, they routinely used only basic instruments such as the stethoscope, ophthalmoscope and laryngoscope. One practitioner reported that patients did not value X-rays, blood or urine tests, so they were rarely carried out (Digby, 1999). With the arrival of state-sponsored medicine under the National Health Service in 1946, it is easy to assume that the medical marketplace

62 Narrative ceased to operate. Under the NHS, which covered the whole population, all patients signed up with a general practitioner, who acted as a gatekeeper to specialist services. But patients continued (and still continue) to act as consumers in other ways: they consulted practitioners in alternative or complementary medicine, and bought over-the-counter medicines, tonics and food supplements in vast quantities. The study of past medical practices quickly reveals the disjunction between the development of medical theories and the creation of new therapies. While hospital and laboratory medicine provided improved methods of diagnosing disease or of confirming a diagnosis made through clinical techniques, hopes of new cures took some time to materialise. Alongside new surgical operations to remove diseased body parts, practitioners continued to prescribe traditional drugs which had limited benefits. The history of medical care also reveals the continuing importance of practice outside the sphere of orthodox medicine. The vast majority of ailments were never treated by a qualified practitioner. Instead, family members and informal practitioners offered advice and treatment, and, in most cases, patients recovered. In cases of more serious illness, however, patients sought the more intensive care available through medical institutions.

5 Medical care in institutions

In 1780, institutions were marginal to medicine; there were few hospitals or other institutions to care for the sick, no institutions dedicated to research, and medical school training was just beginning to become the norm for practitioners. By the 1950s, institutions had become central to every aspect of medicine and this chapter focuses on those institutions providing medical care. Between the late eighteenth and mid-twentieth century, there was an expansion in these types of institutions: in addition to general hospitals, dispensaries and asylums for the mentally ill, this period saw the establishment of specialist hospitals for the treatment of different conditions such as fever hospitals, tuberculosis sanatoria, as well as Poor Law infirmaries. The number of institutions grew dramatically as did their size. The level of care they offered changed radically: from providing the same type of care as that available to patients at home, hospitals became centres of high-tech, high-quality care. In the past, the development of these institutions was seen as almost inevitable: a simple consequence of changes in medical theory and practice, driven by the work of practitioners. More recent research has shown that while ideas about disease informed the architecture of institutions – the physical form of buildings and the facilities – their history was fundamentally shaped by their social context. Institutions owed their existence to the ability and willingness of communities to fund charitable care, which in return, brought individual and collective kudos to donors. The expanding range of institutions reflected changing expectations of the state to provide the sick poor with acceptable standards of care.

Voluntary hospitals and dispensaries Hospitals in Britain have a very long history, dating back to medieval times. They were associated with religious houses and offered hospitality – a bed, food and care – to the poor, the sick and pilgrims. Only two survived into the eighteenth century: St  Thomas’ and St. Bartholomew’s, both in London. In the late eighteenth century, these ancient institutions were joined by a wave of new, charitably funded (or voluntary) hospitals. The first were

64 Narrative founded in major cities: London had five new hospitals by 1750, and others were established in Dublin in 1718 and Edinburgh in 1729. Hospitals in provincial centres came rather later: infirmaries were opened in Manchester in 1752, Cork in 1762 and Birmingham in 1779. Most were general hospitals, treating a range of conditions, but a few specialised in the treatment of specific conditions, including fevers, smallpox and venereal disease. Lying-in hospitals provided care for women giving birth. These institutions were funded by a mix of legacies, one-off donations and annual subscriptions. Their charitable funding shaped every aspect of the hospitals. The founding of hospitals depended not on the size of a town or the level of need for such an institution, but the presence of a critical mass of middle-class subscribers. Hence a small, prosperous provincial city such as Winchester acquired a hospital long before the rapidly growing industrial centres of Rochdale and Preston (Pickstone, 1985). Donors were prompted to give for a variety of reasons. They had a desire to help the poor, inspired by religious sentiments or a sense of social responsibility. There were also more self-interested reasons: a hospital was a sign of the wealth and humanity of a community and thus a source of civic pride. Hospitals also provided a practical means of contributing to the local economy, as they helped to get sick and injured workers back to work [Document 20, p. 139]. Donors directly benefited from their contributions. Hospitals were run by their subscribers and donors, who voted on major issues at annual meetings, and had the right to sit on the smaller committees that were responsible for the day-to-day running of the hospital, including deciding whether to admit patients and when to discharge them. A subscription also brought the right to nominate patients for entry to the hospital (Brunton, 2004). While subscribers had power over the running of voluntary hospitals, the medical staff had little influence. Late eighteenth century hospitals had a very small staff: even the larger institutions had three or four physicians and an equal number of surgeons, who attended the hospital for a few hours each week, plus a resident apothecary. Physicians and surgeons were unpaid but a hospital post was much sought after, as a means of bringing practitioners to public attention and making contacts with potential patients among the hospital’s subscribers. Voluntary hospitals provided care to a limited section of society. Only the deserving poor, able to support themselves and their families but unable to pay for medical treatment, were admitted. To ensure that patients were of good character, they had to obtain a letter or ticket from one of the hospital’s subscribers. Many potential patients were excluded: those suffering from an infectious disease (as they might spread illness through the institution), anyone close to death, children and pregnant women. The ideal patient was someone suffering from a serious, but not life-threatening disease, likely to benefit from a few weeks of care, who would be recorded as leaving the institution cured or at least ‘relieved’ of their illness. Hospitals in industrial towns also took in large numbers of injured workers. Those

Medical care in institutions  65 patients fortunate enough to be admitted had the sort of medical care that the middle and upper classes enjoyed in their own homes. They received regular attendance from a practitioner, and were treated with medicines or by undergoing surgery. In return, patients were expected to follow the hospital’s rules, and when discharged they had to formally express their thanks to the hospital and to its subscribers [Document 21, p. 140]. The numbers of hospitals grew throughout the nineteenth century. London had seven general hospitals in 1809; by 1890 this had grown to 21 (Waddington, 2000). Hospitals were founded in industrial centres such as Blackburn (1858) and Preston (1870). Existing infirmaries were enlarged: Manchester Infirmary, for example, was rebuilt in 1855, increasing the number of beds from 238 to 310 (Pickstone, 1985). Overall, the number of beds in voluntary hospitals in England and Wales rose from 14,800 in 1861 to 43,200 in 1911 (Cherry, 1996). These Victorian institutions proved remarkably resilient, with many surviving to become part of the NHS in 1946. From 1859, the numbers of general hospitals were boosted by the development of small cottage hospitals. Staffed by local general practitioners, these institutions provided inpatient care to the population of small towns and villages. While individual cottage hospitals were small, with an average of 15 to 25 beds, they were founded in large numbers; there were 148 by 1875 and over 600 by 1934 (Cherry, 1992). Overall, they provided around a tenth of all voluntary hospital beds. The second half of nineteenth century also saw the creation of many new types of specialist hospitals, reflecting developments within medical practice. Hospitals were founded for the treatment of diseases of particular organs, such as the ear or chest, and for specific complaints, such as cancer and nervous diseases. The first children’s hospital was opened in London at Great Ormond Street in 1852; this was followed by similar institutions in Edinburgh (1860) and Glasgow (1883). Overall, in London the number of specialist hospitals grew from just 6 in 1809 to 67 by 1890. While the number of hospitals grew, the numbers of patients increased even more. Admissions to the five main London hospitals more than trebled between 1809 and 1895, partly through the growth of these institution but also through a reduction in the time that patients spent in hospital. The average length of stay dropped by around one-third between 1861 and 1911. This trend continued in the twentieth century. Between 1918 and 1938 the number of beds in English voluntary hospitals almost doubled from 36,400 to 59,000 but the number of inpatients treated more than trebled, rising from 235,000 to 875,000 (Hayes and Doyle, 2013). In the late nineteenth century, hospitals went through a dramatic transformation, into centres for high-tech medicine, where the acutely ill from all sections of society received the best quality of treatment. This new function was facilitated by changes in hospital design, and the emergence of a distinctive hospital architecture. Eighteenth-century hospitals were modelled on large country houses, with wings built out from a central block,

66 Narrative creating courtyards where patients could take exercise. However around the middle of the nineteenth century many institutions suffered from ‘hospitalism’, when large numbers of patients developed infections, believed to be the result of a ‘morbid condition’ of the building. The solution, promoted by a number of leading hospital administrators and Florence Nightingale

Figure 5.1 Plan of Royal Infirmary, Edinburgh, 1893. The Royal Infirmary of Edinburgh was built in 1879 using the pavilion plan. The pavilion wards run off long corridors, with the administration building in the centre of the complex. Credit: Wellcome Library, London.

Medical care in institutions  67 (1820–1910), who was deeply interested in questions of hospital design as well as the reform of nursing, was to rebuild hospitals on the pavilion plan. Hospital buildings were divided into pavilions containing the wards, which were kept separate from the administration and service areas. Each ward was accessed from a central corridor, thus preventing infection from being carried in from any other ward. Interiors were designed to prevent accumulations of dirt, stale air and bad smells, which were believed to cause disease. Walls and floors were made of impermeable materials that could be washed, and every space had good ventilation to ensure the passage of fresh, clean air [Document 22, p. 142]. From the mid-nineteenth century, hospitals increasingly cared for the seriously ill or injured, offering levels of care that were unavailable outside the institution. Surgery became an increasingly important form of treatment: in Huddersfield Infirmary 55 operations were performed in 1874, rising to 400 in 1895 – an eight-fold increase in just 20 years. Initially, surgical operations had been performed on the wards, but from the middle of the century hospitals included increasingly elaborate operating theatres. As the name suggests, the first operating theatres were spaces where medical students could observe operations, but they had little specialist equipment. With the introduction of anaesthetics and antiseptic (and later aseptic) surgery, the operating theatre was transformed. It ceased to be a public space, with students confined to closed viewing galleries. To ensure scrupulous cleanliness walls and floors were tiled, wooden operating tables and instrument cabinets were replaced with ones made of glass and metal, and equipment for administering anaesthetics and monitoring the patient’s condition was introduced. Service areas were added where equipment was sterilised, and theatre staff donned sterile gowns, caps, gloves and masks. Not all hospitals had cutting-edge equipment: cottage hospitals had only basic facilities for minor surgery. The treatment of patients suffering from acute illnesses was helped by new technologies. Hospitals were quick to adopt the use of X-rays to diagnose fractures and later to take images of the gastro-intestinal tract. Small laboratories were established to allow the testing of tissue, urine and blood samples to aid diagnosis. Physiotherapy suites were fitted out with equipment to improve the strength and mobility of patients’ damaged limbs. Hospitals invested in machines to provide new therapies such as ultra-violet light treatment for skin complaints and radium therapy for cancers. A less visible but nonetheless key factor in the treatment of serious illness was the improvement in standards of nursing. By the 1900s, increasing numbers of nurses were employed who were responsible for monitoring patients, dressing wounds using antiseptic techniques and distributing the correct doses of medicine at the right time (see Chapter 6). The end of the nineteenth century saw a drive for greater efficiency in hospitals, using techniques borrowed from industry (Sturdy and Cooter, 1998). The creation of specialist wards or departments within general hospitals

68 Narrative

Figure 5.2  The Henry Quinn Ward, Great Northern Central Hospital, Holloway Road, London, 1912. This photograph is one of many similar views of hospital wards from the late nineteenth and early twentieth century, conveying an overwhelming sense of neatness and cleanliness. Unusually, this image shows two members of the medical staff as well as the ward nurses. Credit: Wellcome Library, London.

meant that patients with similar conditions were grouped together under the care of skilled staff. Convalescent patients were sent to recuperate in separate facilities. The staffing of wards was reorganised, each with its own team of sisters, nurses and trainees. Medical staff were also organised into hierarchies, led by a senior consultant and with ranks of junior doctors and students. Despite these efforts, from 1860, the costs of all aspects of care spiralled – from equipment and medicines, to the salaries of nurses and junior doctors. The average amount spent per patient at Guy’s Hospital, London almost doubled in the 20  years after 1868 while at the London Fever hospital expenditure per patient almost trebled over the same period (Waddington, 2000). The increasing costs of care put a severe strain on hospitals’ finances. From the late nineteenth century, patterns of funding changed radically. Traditional sources of income from investments and subscriptions declined, and hospitals ceased to be institutions funded by the wealthy to provide care to the poor. The subscribers’ role in the running of hospitals was transferred to

Medical care in institutions  69 professional administrators, and patients were admitted by medical staff on clinical grounds, without the need for a subscriber’s letter. Some fortunate hospitals continued to receive occasional large donations, which were often used for major building projects. However, hospitals increasingly relied on small donations from many people across the social classes to pay for the daily running of services. Collection boxes placed in public spaces such as shops and public houses brought in significant sums. Small donations were collected in churches on a specific Sunday, with the proceeds divided between local medical institutions. ‘Hospital Saturday’ collections targeted workers who gave small sums from their wages. Hospitals also launched fundraising drives, in which the public were encouraged to donate for a specific purpose, such as sponsoring a bed (Hayes and Doyle, 2013). The pattern of income varied across Britain: Scottish general hospitals raised less from workers’ contributions, but more from subscriptions than English hospitals (Cherry, 2000). As the identity of donors changed, so did their motivations for contributing. Working people had a direct interest in giving as they or their family might well receive care in the hospital at some point. Those who made regular small donations through their workplace could be recommended for admission – thus donations functioned as a form of insurance. In the interwar period, many hospitals turned collection schemes into insurance schemes. These were very popular, with several million workers participating in England and Wales, and the resulting income covered up to one-third of the running costs of some hospitals (Gorsky and Mohan with Willis, 2006). Hospitals increasingly drew income through direct payments from patients. By the 1920s, most hospitals had beds or wards set aside for paying patients. Previously, the middle and upper classes had received all medical care at home as they had no wish to mix with poor patients in charitable institutions. However, as hospitals developed treatment facilities that were far superior to those in any domestic setting, wealthy patients became willing to pay for access to this care. Working class patients were also increasingly expected to contribute towards the costs of their care. Despite these efforts to find new sources of income, by the 1930s voluntary hospitals were struggling to make ends meet. While the inpatient services offered by voluntary hospitals are wellresearched, the work of dispensaries and hospital outpatient departments have received much less attention, despite the fact that they treated far larger numbers of patients. Dispensaries had existed from the late seventeenth century, but a wave of new institutions were created from the 1770s. By 1800 there were over 30 general dispensaries in Britain. Dispensaries were run on the same basis as voluntary hospitals: they were funded through charitable donations and run by committees of subscribers, who recommended patients for admission. Like hospitals, medical staff gave their services free. Dispensaries had one or two physicians and surgeons who attended for a few hours each week and, by the late nineteenth century, perhaps a resident medical officer (Loudon, 1981; Croxson, 1997).

70 Narrative Unlike hospitals, dispensaries provided only outpatient care – practitioners treated patients on the dispensary premises or visited them at home. As a result, dispensaries were much cheaper to establish and run than hospitals. They required only a waiting room and consulting room, and could be set up in rented houses. The costs of care were much lower: in Liverpool in 1810 the costs of treating a dispensary patient was around one-twentieth that of caring for a hospital inpatient. Minimum subscriptions were lower, so dispensaries were established in towns where there were not enough wealthy subscribers to support a hospital. Dispensaries treated far larger numbers of patients than the voluntary hospitals. By 1800, the London dispensaries were dealing with around 50,000 cases a year – roughly double the number treated in the city’s hospitals. Patient numbers grew over the nineteenth century: Bristol Dispensary, founded in 1776, dealt with 632 patients in 1796, rising to over 3,000 in 1856 and over 8,000 by 1874. In the past, historians assumed that dispensaries treated the cases excluded by voluntary hospitals. Many dispensaries employed midwives to care for women in childbirth, and some, but not all, treated fever cases. However, new studies have shown that there was considerable overlap in the type of patients admitted to hospitals and dispensaries. Common respiratory and digestive complaints and minor injuries made up the bulk of dispensary cases. The numbers of patients treated by dispensaries grew despite competition from hospital outpatient departments. Some hospitals had treated outpatients from the early nineteenth century, but the numbers of dedicated outpatient departments grew rapidly from the middle of the century. Although often staffed by junior practitioners these departments proved very popular, with patients prepared to wait many hours for their short consultation. Outpatient departments helped hospital staff to find interesting cases for use in clinical teaching, but they were also controversial. From the 1850s, there were complaints that some patients able to afford to pay for treatment abused the free service. Over the nineteenth century, a number of dispensaries evolved into voluntary hospitals. Others survived into twentieth century, only closing with the founding of the National Health Service in 1948. Like the hospitals, they struggled for funding in the later nineteenth century, and patients were increasingly asked to make a contribution to the costs of their treatment. A new class of institution, the provident dispensaries, relied on a mixture of donations and small subscriptions from potential working class patients – contributions of 1d or 2d per week – which guaranteed treatment when required (Whitfield, 2016).

Poor Law hospitals Voluntary hospitals excluded a large category of sick people – the disabled, the chronically ill, the elderly and infirm – who had to rely on help through

Medical care in institutions  71 the Poor Law. Before 1834, a few parishes had a poorhouse to accommodate paupers which included wards for the sick. Care was basic, and as many patients arrived when they were very ill, mortality rates were high. Other parishes subscribed to a local voluntary hospital, which allowed them to send their sick paupers there for treatment (Reinarz and Schwarz, 2013). In 1834, poor relief was restructured under the New Poor Law in England and Wales. Parishes were grouped into Poor Law unions and support was provided through workhouses. The sick poor were cared for in wards within the workhouse or in separate infirmary buildings. The numbers of beds in Poor Law infirmaries increased rapidly, from around 50,000 beds in 1861 to over 83,000 by 1921 – around three times as many as in the voluntary hospitals. In addition, in many areas of England and much of Scotland (which acquired its own Poor Law Act in 1845) sick paupers received care in their own homes. Medical care in Poor Law infirmaries in the mid-nineteenth century has a very bad reputation. The quality of care inevitably suffered under the over-riding concern to limit the costs of relief. Infirmaries were housed in unsuitable buildings, with poor sanitation and minimal treatment facilities. Patients – many of whom were old and suffering from chronic illnesses – were cared for in large wards by other paupers who acted as nurses. Few infirmaries had full time medical staff, and only very basic drugs and treatment were provided. More recent research suggests that the picture of Poor Law infirmaries was not so uniformly bleak: some workhouse infirmaries in cities had relatively good facilities modelled on voluntary hospitals (Crowther, 1981). Like the voluntary hospitals, the Poor Law infirmaries went through a process of medicalisation, gradually transforming from providers of basic care to the poor to offering good quality care to a broad spectrum of society. The improvements reflected a shift in attitudes towards poor relief, as the principle of ‘less eligibility’ – ensuring that the regime in the workhouse was less comfortable than any form of work outside – gave way to a concern that paupers should receive a basic level of support. By the late nineteenth century, the best Poor Law infirmaries had moved into new pavilion plan buildings, with wards assigned to patients suffering from different complaints, and operating theatres. The number of staff increased, with the appointment of resident medical officers and trained nurses, although staffing levels were always lower than in voluntary hospitals. Further improvements to Poor Law hospitals came about during the First World War. Infirmaries were requisitioned for the use of troops and improved by employing additional staff and installing new equipment, which were often retained after 1918. As the Poor Law infirmaries became more like voluntary hospitals, they opened up to a wider range of patients – not just paupers but poor people able to support themselves but unable to afford treatment or to obtain care through a voluntary hospital. The transformation into general hospitals serving the local community was completed under the 1929 Local Government

72 Narrative Act, which passed control of Poor Law institutions to local government authorities. Change did not come overnight: local authorities only gradually took over the better institutions which were further improved by the addition of specialist departments, extra staff and better equipment [Document 23, p. 142]. Other hospitals became Public Assistance Institutions, providing basic care for the elderly, or were closed down (Levene et al., 2011).

Fever hospitals and tuberculosis sanatoria Voluntary and Poor Law hospitals treated patients suffering from a range of conditions: fever hospitals (or, as they were later known, isolation hospitals) offered specialist facilities to care for cases of infectious diseases. A few specialist voluntary hospitals were established for patients suffering from fever in the 1800s in Liverpool, London, Manchester and Newcastle. However, they faced serious problems. Fevers tended to occur in epidemics, during which the small hospitals struggled to deal with the rush of patients (see Chapter 2). At other times, the hospitals lay empty. A more common response was to establish temporary hospitals during outbreaks of fever and periodic visitations of Asiatic cholera. These outbreaks had a serious impact on local economies, as visitors and traders were reluctant to risk catching the infection, so authorities and citizens had a strong motive to limit disease outbreaks. Local government bodies launched intensive programmes of street cleaning, to remove the rotting organic matter believed to produce the miasma that caused or spread fever and cholera. Temporary hospitals were set up in rented buildings or even military tents. Such accommodation had the advantage of being flexible: in a village a cottage was sufficient to house a handful of patients, while in cities, a number of buildings could be used to accommodate hundreds of patients, with extra beds added if the outbreak proved particularly serious. The function of these hospitals was to remove patients out of their home surroundings where they had been exposed to miasma and provide them with basic nursing, food and medicines to help them recover. From the 1870s there was a fundamental shift in the response to epidemics, founded on new understandings of disease causation. Medical practitioners had concluded that infections were spread by biological or chemical agents, and from the 1880s, researchers identified the bacteria responsible for a range of diseases (see Chapter 3). This led to the creation of new strategies to control disease outbreaks: the patient, not the environment, was now seen as the source of infection, and the best way of halting the spread of disease was to isolate patients and disinfect their surroundings. Under the 1875 Public Health Act, local authorities in England and Wales built isolation hospitals, using cheap loans provided by central government. Legislation requiring all cases of infectious disease to be reported to Medical Officers of Health ensured that all patients were taken to hospital or isolated at home. Isolation hospitals were initially used to care for adults suffering from fever

Medical care in institutions  73 and smallpox, but as the incidence of these diseases declined, they were increasingly used for children suffering from diseases such as diphtheria and scarlet fever. By 1911, local authority fever hospitals accounted for 17% of all hospital beds in England and Wales, and 35% in Scotland (Currie, 2005). At first, the quality of care in isolation hospitals was very poor. During an inquiry into the treatment provided at the Hampstead Hospital in London in 1871, patients complained of dirty bed sheets, a lack of facilities for bathing, dead bodies left in bathrooms and inadequate numbers of staff. Clearly, the hospital was not well prepared to deal with a sudden large influx of patients during the worst smallpox outbreak for many years. In the following decades, the quality of care offered in isolation hospitals, as with other hospitals, went through a transformation. The building of pavilion plan isolation hospitals – some with several hundred beds – meant that separate wards were allotted to patients suffering from different diseases. High standards of hygiene and the use of cubicles for each bed further helped to reduce the chances of patients picking up another infection while staying in the institution. To ensure that infections were not brought into the institution, or did not spread outside, visiting was very strictly regulated. In some hospitals, visitors were only permitted if a patient was very seriously ill and parents were often not allowed to touch their children (Mooney, 2015; Hardy, 1993). While isolation hospitals helped to reduce the spread of disease, staff could offer few effective treatments. Severe cases of diphtheria were treated with anti-toxin after 1895, but patients suffering from other infections received only nursing care and medicines to ease their symptoms. In the 1930s, as the incidence of infectious disease declined the number of beds in fever hospitals was reduced from over 39,000 in 1938 to 13,500 by 1949. With the availability of new anti-bacterial drugs, infectious diseases were increasingly treated within general hospitals and fever hospitals were closed or turned to other uses. While isolation hospitals catered for patients suffering from a number of infectious diseases, a special type of institution was developed for the treatment of tuberculosis (TB). People suffering from TB were excluded from voluntary hospitals, but were admitted to a small number of specialist hospitals for chest diseases, receiving basic care and drugs to moderate the fever and cough associated with the disease. A new type of institution, the tuberculosis sanatorium, was developed in Germany in the 1860s and was copied in Britain from the 1890s. The debt to German models was displayed in the names of institutions such as the Nordrach-upon-Mendip Sanatorium in Somerset (Bynum, 2012). Reflecting the prevalence of tuberculosis – it was one of the most common causes of death in the nineteenth century affecting both rich and poor – different sanatoria were provided to cater for different classes of patient. Upper and middle-class patients who could afford to pay for their own care went to small, private sanatoria in Britain and Europe. Lower-middle class and working-class patients were cared for in institutions run by charitable

74 Narrative organisations such as the National Association for the Prevention of Consumption, where they might be asked to contribute towards the cost of care. By the end of the nineteenth century, there were around 2,000 beds in sanatoria in England and Wales; but this was a drop in the ocean given that there were around a quarter of a million cases of TB in 1900. The number of sanatorium beds rose sharply after 1911, when funding for TB treatment in local government institutions was provided through the National Insurance Act. There were over 9,000 beds in England by 1914 and 38,000 by 1938 (Worboys, 1992). For the many sufferers unable to find a place in a sanatorium, local government TB dispensaries and TB officers gave advice on how to manage their disease. The poor, as ever, had to rely on the Poor Law. Many of those who entered the workhouse unable to work were suffering from advanced cases of TB, and Poor Law authorities were encouraged to provide separate wards or buildings for these patients. Sanatorium treatment was based on observations that tuberculosis lesions in the lung often healed spontaneously. The regime provided in these institutions sought to encourage this natural healing process through a carefully controlled environment and lifestyle. The sanatorium removed patients from the stuffy, damp, polluted conditions believed to lead to infection and exposed them to pure fresh air. The first British sanatoria were located in remote areas such as the Welsh mountains. However the isolation caused problems – it was hard to attract staff, and patients and their visitors were forced to undertake long journeys. As a result, later sanatoria were built in rural areas close to towns and cities. Patients spent most of their time in the open air, on verandahs or balconies, or in shelters built in the sanatorium grounds. They even slept on balconies or under open windows, and some reported waking to find snow on their bedclothes. To combat the weight loss associated with TB, patients were fed a rich diet, with large, regular meals. The regime also included carefully graded levels of exercise. Patients with a high temperature and cough were prescribed long periods of bed rest. Those with less severe symptoms were required to undertake controlled levels of exercise, usually walking specific distances. Patients were also encouraged to work in order to help their transition back to normal life. Patients dug gardens and even built roads – leading the historian Linda Bryder to write of the ‘pick-axe cure’ for tuberculosis (Bryder, 1988). Sanatorium treatment was not a quick cure. Private patients stayed in institutions for months at a time, until discharged as cured, or least with some improvement in their symptoms. Charitable and local government institutions took in patients for a few weeks or months – those covered by National Insurance Act usually spent three months in sanatoria. While it was acknowledged that this was too short a time to have a significant effect on the disease, such a stay allowed sanatoria staff to educate patients in how to manage their condition. Patients were taught to reduce the likelihood of spreading infection by not spitting or kissing, and to carefully dispose of sputum which might contain bacteria. They were encouraged to copy the

Medical care in institutions  75 sanatorium regime at home by sleeping outside or beside open windows. By 1920s, a flourishing market in equipment for TB sufferers had grown up, ranging from awnings to allow them to sleep outside to back rests to make long periods in bed more comfortable (Mooney, 2013). From the 1900s there was a persistent debate about the effectiveness of sanatorium treatment. Critics pointed out that many patients were discharged when their symptoms had improved, only to return when they suffered a relapse. Statistics suggested that around 40% of sanatorium patients were dead within a few years of their discharge. Practitioners therefore sought alternative methods of encouraging the lungs to heal. In the 1920s and 1930s increasing numbers of sanatorium patients were treated by surgery to collapse an infected lung in order to allow it to heal. This was a painful procedure and was often used as a last resort in advanced cases. Even when successful, patients were left with reduced lung capacity. The sanatorium treatment for TB was finally superseded after the Second World War by effective drug treatment, first using streptomycin and later antibiotics. The incidence of tuberculosis was further reduced by mass screening to identify active cases of the disease, testing of milk to ensure that it did not carry the infection, and, in the 1950s, by BCG vaccination.

Hospitals and dispensaries in Ireland So far, this chapter has dealt with hospitals and dispensaries in England, Wales and Scotland. In Ireland, although the same types of institutions were established at around the same time, the system of funding was different. In the rest of Britain, hospitals depended on charitable donations, with local government funding supporting fever hospitals and sanatoria. In Ireland, most institutions depended on funding from the Grand Juries, the bodies responsible for county administration, and by the Poor Law. The Irish model of funding may have inspired developments elsewhere in Britain, and shows the importance of social and political factors shaping the provision of medical care through institutions. In the eighteenth century, a number of voluntary hospitals were established in Ireland, similar to those in the rest of Britain. However, Ireland was a rural and poor society: there were simply too few middle- and upperclass subscribers to support hospitals outside the major cities. In 1765, the Infirmaries Act allowed for the creation of a hospital in each county, funded through a combination of subscriptions and support from the Grand Juries. The 41 county infirmaries established under the act provided care to all poor patients able to obtain an admission tickets from a subscriber. Grand Jury contributions also subsidised the building and running of other types of institutions. Under legislation passed in 1805 and 1807, the Grand Juries supported dispensaries and, by 1841, there were 615 dispensaries serving hundreds of thousands of patients, not only the very poor, but many working people. Fever hospitals also received Grand Jury funding. Fever was

76 Narrative perceived to be particularly severe and prevalent in Ireland, and by 1845 there were 101 hospitals for the disease, spread across the country. In 1838, a further group of medical institutions were created through the Irish Poor Law Act. Modelled on the English Poor Law, the legislation divided Ireland into unions, each with its own workhouse. As in England and Wales, wards or separate infirmaries were built to care for sick paupers. By the 1840s, Ireland had greater provision of institutional care than the rest of Britain, with around 750 institutions providing free care to a large proportion of the population. However, the system was far from perfect. Institutions tended to cluster in wealthier areas, and the quality of the facilities varied widely, from airy, purpose built hospitals, to a single roomed cabins that served as dispensaries. The Great Famine of 1845–1852, when widespread and repeated failure of the potato crop led to mass starvation, deaths and emigration, was also a crisis for Ireland’s medical institutions. At a time when they were swamped by patients, subscriptions collapsed. As a consequence, the dispensaries were brought under the control of the Irish Poor Law Commissioners in 1851 and the Poor Law authorities also took over the running of most fever hospitals. In a sharp contrast to the English Poor Law, the Irish authorities funded high levels of institutional care. Institutions continued to be open to all who could not afford medical care: in the 1860s, it was reckoned that around 16% of the population used the dispensaries. Under the Poor Law the number of dispensaries grew to well over one thousand by 1872 and expenditure increased from over £88,000 in 1852–1853 to over £127,000 in 1871–1872, despite a sharp decline in the total population. The new administration sought to improve the quality of care by rationalising the distribution of institutions, and by setting out the drugs and equipment which should be held at each dispensary (Cassell, 1997). In 1862, new legislation opened the way for the gradual transformation of Poor Law infirmaries into general hospitals. As in the rest of Britain, this required significant improvement to facilities and services. Irish Poor Law infirmaries, like their counterparts in England, offered basic care, in buildings which were sometimes quite insanitary, with few medical staff, assisted by untrained pauper nurses. City Poor Law infirmaries offered better standards of care, and after improvements Belfast Infirmary was able to offer clinical training for medical students from 1877. In the twentieth century, government grants subsidised further modernisation (Reinarz and Schwarz, 2013)

Asylums In the late eighteenth century, most mad people were cared for at home. (Historians refer to these people using the contemporary terms ‘mad’ or ‘lunatic’, as we cannot be sure they were suffering from diseases that would now be classed as mental illnesses.) Most received little active treatment – they were

Medical care in institutions  77 simply fed, clothed and kept out of harm’s way. Relatively few lunatics were cared for in asylums or madhouses. In the eighteenth century, there was only one surviving medieval institution for the care of the mad – St. Mary’s Bethlehem (known as Bedlam) in London. Seven new charitable asylums were established in major cities across Britain in the early eighteenth century, founded on the same basis as the voluntary hospitals of the period and open to the deserving poor. Private madhouses provided accommodation for upper- and middle-class patients who paid for their care. Most of these were small, but a few accommodated several hundred patients (Scull, 1993). In the eighteenth century, madness was understood as a failure of reason brought on by some form of shock or stress. ‘Mad doctors’ (who might or might not have medical training) sought to restore sanity through further shocks – patients were whirled in rotating chairs, or plunged into cold baths – or by forcing patients to adopt rational behaviours through punishments or (as in the treatment of King George III) by sheer force of will. Not surprisingly, asylums were seen as primarily places of confinement where inmates were treated harshly. At the end of the eighteenth century, a new and gentler approach to the treatment of madness emerged across Europe. In Britain ‘moral therapy’ was associated with the York Asylum, founded in 1792 and run by the Tuke family. Rather than trying to force patients to act normally, moral therapy sought to encourage patients to exercise selfrestraint and to behave rationally in order to win the approval of the asylum staff. The design of the asylum played a central role in the curative process. Ideally, the buildings were in a quiet, rural setting, providing attractive, domestic surroundings with no suggestion of confinement [Document 24, p. 144]. Patients should live an orderly existence, which included exercise and entertainment, monitored by sympathetic staff. In practice, moral therapy did include punishment by confinement or loss of privileges, although the use of physical restraint was acceptable only to ensure that patients did not harm themselves or others. Proponents of moral therapy claimed that many patients could be successfully cured by this method, especially if treated while the illness was in its early stages. Moral therapy became the dominant form of treatment, practised throughout a rapidly expanding asylum system. The numbers of private madhouses in England grew from 45 in 1807 to a peak of 139 by 1844. The mid-nineteenth century also saw the creation of new asylums under legislation requiring local authorities and the Poor Law to provide institutional care and treatment for all those unable to afford the fees charged by private madhouses. In England and Wales, 15 county asylums were built under the 1808 Lunacy Act, funded through a combination of county rates and donations. A  further major expansion of asylum provision followed the 1828 County Asylums Act and 1845 Lunatics Act, which required counties and boroughs to provide asylum accommodation for pauper lunatics. Although controlled by local government, in practice these became quasi-Poor Law institutions, dominated by pauper

78 Narrative patients and with Poor Law administrators responsible for many admissions (Bartlett, 1999). By 1850 there were 24 asylums containing over 7,000 patients: by 1870 this had risen to 50 asylums with over 27,000 patients (Brunton, 2004, 302). Over the same period, the average size of asylums rose from less than 300 to over 500 beds. In addition, substantial numbers of pauper lunatics were cared for within workhouses. Poor Law officials chose to keep them in there for reasons of economy – it was cheaper than paying for their care in an asylum. Patterns of asylum growth varied across the United Kingdom. In Wales, families were much more reluctant to make use of institutional care, and there were fewer madhouses (Michael and Webster, 2006). In Scotland, eight Royal asylums were established in the late eighteenth and early nineteenth century, funded through donations and patient fees. Other Scottish lunatics were boarded out with unrelated families who were paid for their care. Efforts to introduce legislation for Scotland requiring the Poor Law authorities to build asylums was resisted amid fears of a loss of local control. After an act was finally passed in 1857, the new Poor Law (and later local authority) asylums took in paupers while the older Royal asylums cared for a mix of pauper and private patients (Melling and Forsyth, 1999). Local government-funded asylums tried to provide the type of curative environment required by moral therapy. Most asylums were sited in rural areas, with large grounds where patients could walk or work on farms and gardens. Patients slept in large wards, but spent the day in association rooms, with domestic furnishings and decoration. Entertainments were provided – sports, concerts and even balls (a curiosity described by Dickens). However, with fewer staff than in private asylums, it was difficult for staff to form the personal relationships with their charges that was central to moral therapy. The reasons behind the nineteenth century expansion in asylums have been much debated by historians. In Museums of Madness (1982), Andrew Scull suggested that the increased number of insane seeking care in asylums was a consequence of industrialisation: families living in cities, and working long shifts in factories, were simply unable to care for relatives suffering from madness. He also proposed that there were medical factors behind the expansion in asylum care, as the specialist group of asylum superintendents or alienists (derived from the French word ‘aliene’ meaning insane) that emerged in the mid-nineteenth century sought to increase their influence by taking as many patients as possible into asylums (Scull, 1982; Scull, 1993). Further research has challenged Scull’s conclusions. It has been shown that asylums were growing well before the majority of the population was urbanised, and that many asylums served rural areas. While difficult behaviours such as violence and irrational actions were often the trigger for families to seek help, records show that many were reluctant to commit relatives to an asylum and were anxious to take them back into the home. Researchers have also questioned Scull’s claims for the influence of alienists as decisions

Medical care in institutions  79 whether to admit patients to asylums did not rest in the hands of these practitioners, but with magistrates, Poor Law officials and family members. The new asylums failed to live up to their promise to cure patients. Researchers have shown that in the mid-nineteenth century at some asylums, up to one-third of patients were discharged within 12 months, either cured or with some improvement in their condition. However, by the 1870s, reported rates of cure had fallen to around 8%. A  substantial number of inmates, mainly the elderly and those suffering from advanced forms of syphilis and alcoholism, died within a year of entering an asylum. This left a significant proportion of patients who remained in asylums for years, labelled as chronic cases who were unlikely to recover. This rising number of incurable cases also led to a shift in the understanding of madness; instead of being the consequence of stress or shock, which could be reversed, lunacy was now seen as a hereditary condition and therefore untreatable. Asylums continued to grow throughout the late nineteenth century, accommodating ever-increasing numbers of patients. By 1880, the number of beds in English asylums had increased to 71,000 and reached over 85,000 by 1890 (Scull, 1993). By 1913 patient numbers had reached over 130,000, increasing to 150,000 by 1934. As asylums grew in size, their architecture became plainer and more utilitarian, and their appearance more and more like prisons or other custodial institutions. Colney Hatch, built in 1851 for over 1,000 patients (and later expanded to accommodate 2,500) was described as comfortless, gloomy, cold and oppressive. In such large institutions the personal relationship between staff and patient that was key to moral therapy broke down completely. Staff were increasingly concerned with simply keeping order and not with providing entertainment or work. Many patients spent long hours doing nothing. The early twentieth century saw a renewed optimism that madness (now renamed mental illness) was the result of some sort of organic change in the brain and that it could be successfully treated. In mental hospitals built after 1900 new patients were taken into an ‘acute hospital’ where their case was assessed. Patients were then moved into small villas, home to around 30 patients suffering from similar forms of mental illness, where they were free to move around the rooms and gardens (Hide, 2013). Rest, good diet, fresh air and occupational therapy were the basic treatment, augmented by new medical interventions such as electric shock therapy, frontal lobotomy surgery (which severed nerve pathways within the brain) and deliberately induced fever and coma (Jones and Rahman, 2008). None of these treatments ultimately proved effective and asylums remained at the forefront of caring for the mentally ill until the late twentieth century. There are many striking parallels in the history of different types of institution between 1780 and 1950. Asylums, specialist and general hospitals and dispensaries all expanded in size, shifting from treating small numbers of patients, often from a particular section of the population, to caring for large numbers from the whole of society. The form of care provided by

80 Narrative institutions developed from basic nursing and treatments similar to those received by better-off patients in their own homes, to the most up to date forms of treatment using new medical technologies within buildings designed to provide a curative environment. With the medicalisation of institutions came shifts in their administration: control of charitable institutions moved away from lay subscribers and in all institutions, medical practitioners gained in power and influence. Although there are many similarities in the development of medical institutions, recent research has also shown the many variations within the overall pattern. There are important geographical variations in the funding and use of institutions in the different nations within the British Isles. Welsh and Scottish lunatics were less likely to be cared for in asylums than those in England, while nineteenth-century Ireland had more hospitals and dispensaries than any other nation thanks to greater levels of local government funding. In the twentieth century, local politics shaped the transformation of Poor Law infirmaries into general hospitals. Until 1946, institutional care was never a uniform system, but a patchwork of local provision.

6 Medical practitioners

Medical practitioners working in 1950 had little in common with their counterparts of the 1780s, beyond their shared task of caring for the sick. They possessed completely different bodies of medical knowledge and used different forms of treatment. In 1780, there were no formally trained female practitioners, whereas in the 1950s, women made up a small but growing number of doctors and the majority of nurses. Few practitioners of the 1780s had connections to institutions such as hospitals, professional societies or medical schools; by 1950, all practitioners belonged to some institutions and in addition most worked for the state through the National Health Service. As a consequence, there was much stronger collective identity among practitioners: unlike their earlier counterparts they trained and often worked in groups, and had a sense of belonging to an occupation with shared standards and practices. The changes to the identity and careers of medical practitioners have been analysed in two distinct ways. From the 1970s, historians borrowed the concept of professionalisation from sociology and used it to analyse how practitioners sought to acquire a set of characteristics that defined modern professions, including the self-regulation of training, a clear professional boundary defined by licensing, a common code of ethics and a monopoly of practice. More recent work has seen practitioners as essentially entrepreneurs, seeking (to borrow the title of Anne Digby’s work on the subject) to make a medical living (Digby, 1994). In this account, practitioners engaged in fierce competition with their colleagues to secure patients’ fees and institutional posts within a medical marketplace. These different readings have been described as a paradoxical (Crowther and Dupree, 2007, p. 2) but they are not incompatible. Changes that helped individual practitioners succeed in their careers also fed into the collective interest of practitioners. For example, individual students chose to undertake a long and expensive medical training as a means of obtaining a competitive edge over rival practitioners but such decisions collectively drove up standards of education.

82 Narrative

Making a medical living In the eighteenth century, medical practitioners were split into groups who carried out different aspects of medical practice. Physicians had knowledge of internal diseases, acquired at university by attending lectures and studying books. They diagnosed illness and prescribed medicines. Surgeons dealt with injuries and external diseases such as skin complaints. They performed operations, from major interventions such as amputating a limb to minor ones including lancing boils. Apothecaries prepared medicines, which they sold in their shops. Both surgeons and apothecaries learned their trade through apprenticeships, traditionally a seven-year period working under an established practitioner, observing and learning the techniques of their occupation. All groups therefore went through a long and often expensive training. Only the sons of wealthy families could afford a university education. Apprentice surgeons and apothecaries had to pay a fee to their mentors, which could be several hundred pounds to learn from an eminent practitioner, or much less to work with a provincial surgeon or apothecary (Loudon, 1987). By 1780, this traditional division of practice, which dated back to medieval times, had broken down. While a small proportion of practitioners worked as physicians and others specialised in surgery, most were general practitioners, offering both medical and surgical treatments (Loudon, 1987). New forms of medical education were developed to train general practitioners, which combined traditional methods of education. Students spent an initial period as an apprentice (although rarely the full seven years) but also attended lectures at medical schools. These establishments varied widely in their size and the education they provided. A practitioner might teach a single course of lectures to a handful of students. Private medical schools, owned and run by practitioners, and hospital medical schools offered courses in a range of subjects. London, with its numerous hospitals, became a centre for medical education from the late eighteenth century, with around 1,000 students studying in the city by 1823. Dublin had a medical school attached to Irish College of Surgeons from 1784, while Edinburgh and Glasgow had medical schools within the cities’ universities, which attracted hundreds of students. As well as teaching through lectures, the larger schools had dissection rooms and museums containing a wide range of objects for study, from human bones to animal curiosities (Reinarz, 2005). The standard curriculum of subjects at the end of the eighteenth century consisted of anatomy, chemistry, botany, materia medica (the knowledge of drugs and medicines), and the theory and practice of medicine. Most subjects were taught through lectures, augmented by displays of preserved specimens or images. Anatomy was the exception: by the end of the eighteenth century, students demanded opportunities for hands-on dissection. This presented problems for anatomy teachers, who struggled to meet the demand for corpses. Some schools were granted the bodies of executed

Medical practitioners  83 criminals for anatomical teaching, but these were few and far between. British hospitals, unlike their counterparts in Paris, were reluctant to allow the bodies of patients to be dissected for fear this would damage the reputation of the institution (see Chapter  3). However, staff were able to make use of body parts removed in surgery and to use post-mortem examinations as the basis of anatomical demonstrations [Document 25, p. 145]. These were quite inadequate sources, and anatomy teachers therefore turned to the use of bodies dug up from graves. Bodysnatching was a highly organised business: gangs of workers, sometimes aided by medical students, targeted newly buried bodies in quiet graveyards and sold the corpses to the schools for large sums. The grisly trade only died out with the passing of the 1832 Anatomy Act, which allowed the bodies of paupers who died in the workhouse to be used for dissection (Richardson, 2001; Hutton, 2013). Finding facilities for clinical teaching, which became a standard part of medical training around the same time, also posed problems. Hospital administrators were unwilling to allow large numbers of students to disturb the wards, so access to patients was carefully controlled. The Edinburgh medical school had one ward within the city’s Royal Infirmary set aside for teaching. In other hospitals, small numbers of students were allowed to follow staff as they made their ward rounds. Teaching consisted of short lectures at the bedside, describing the patients’ symptoms and treatment. Students also observed surgical operations carried out in hospital operating theatres. Only a fortunate few students were able to gain practical clinical experience by becoming a clerk or dresser to a member of hospital staff. The purpose of training at most medical schools was not to gain a qualification: only university medical schools could grant degrees to students who wrote an original dissertation on some medical subject (with or without attending courses there). The majority of students qualified to practise by acquiring a licence from one of the Colleges of Physicians and of Surgeons in London, Edinburgh and Dublin, or the London or Dublin Societies of Apothecaries. Candidates got their licence by passing an oral examination, and they were free to prepare for this in any way that they saw fit. Students could work their way through all or part of the curriculum of subjects in one or more medical schools, in any order they pleased and repeat courses if they wished (Lawrence, 1996). A modern, set programme of study, leading directly to a qualification, emerged in the late nineteenth century. By this time, the medical school curriculum had expanded to include the medical sciences, including pathology, physiology, histology and biochemistry. Initially these subjects were taught as part of anatomy or the theory of medicine: the introduction of full courses was hindered by the need to invest large sums in new facilities. Medical schools had to purchase expensive instruments, such as microscopes, and add teaching laboratories where students could conduct their own experiments. Consequently, these subjects were not added to the curriculum at university medical schools until the 1870s and 1890s (Bonner, 1995). The

84 Narrative smaller private medical schools struggled to provide such expensive facilities, and many either closed or combined with new universities in provincial cities which had facilities for teaching the biomedical sciences (Butler, 1986). By 1900, the modern structure of medical education was in place, with students progressing from the basic sciences (chemistry, physics and anatomy), through the laboratory sciences to clinical teaching and ending their studies by spending time in a junior hospital post. While medical education did become more uniform over the nineteenth century, there was still some variety within the basic structure. The curriculum in Scottish medical schools included pharmacy, which was not taught in their English counterparts. There continued to be some flexibility in patterns of study, with students able to repeat courses to reinforce their knowledge, and to take optional courses in specialist subjects such as diseases of the eye and ear (Crowther and Dupree, 2007). From the late eighteenth century, orthodox medicine was dominated by general practitioners, with a much smaller number of physicians and surgeons specialising in medicine or surgery. In the mid-nineteenth century, a further group of consultants or specialists emerged. They practised within a particular area of medicine, such as diseases of the eye or ear, or among a specific group of patients such as women or children. Initially, the division between GPs and consultants was far from clear cut: some GPs simply developed particular skills in some aspect of medicine (Digby 1999). In the twentieth century, consultants became the acknowledged leaders of the profession, marked out by their superior training and expertise (Weisz, 2006). A consistent difference between the two groups was the level of fees they commanded: consultants charged much more and by late 1930s, their average salary was around double that of a GP. Practitioners of all types drew the majority of their incomes came from fees paid by patients. It was vital that practitioners established a practice – a group of clients who regularly used their services. A medical practice, like other small businesses, had to be built up and carefully nurtured. Newly qualified students with some capital could buy into an existing practice or purchase one from a retiring practitioner. Alternatively, a doctor could set up a new practice in an area under-supplied with practitioners, such as a new suburb or a working class district. Many struggled in their early years: for example, a young doctor named Arthur Conan Doyle (1859–1930) wrote detective stories to supplement his earnings [Document 26, p. 146]. The most lucrative general practices were based in towns, where practitioners could rely on bringing in an income from a large middle-class clientele. These patients paid substantial sums for consultations in the practitioner’s surgery and even more for a home visit. At the other end of the scale were practices in working-class districts, where practitioners charged very low fees – 6d or 1/- – for a brief consultation and saw very large numbers of patients. Practitioners in rural areas worked particularly hard. Visiting their patients required spending many hours travelling on foot and horseback or later by bicycle or car. Not surprisingly, remote areas were under-served by

Medical practitioners  85 practitioners, with no doctor to be found in large areas of highland Scotland for much of the nineteenth century (Digby, 1994). Although practitioners sent out bills for their services once or twice a year, many patients were slow to settle their accounts, and almost every practice carried some bad debts. Often practitioners had to agree to allow payment in small instalments, or even accepted goods and services as payment in kind. As well as diagnosing and prescribing treatment, general practitioners also dispensed medicines. After seeing a patient, either at home or at his surgery, practitioners would make up and send out the prescribed medicines. Medicines were so central to the medical encounter that in the eighteenth and early nineteenth century, practitioners charged their patients for medicines rather than for consultations. Some practitioners took dispensing a step further and ran a chemists’ shop alongside their practice, where patients could not only get their prescriptions filled but buy over-the-counter medicines and toiletries (Jenkinson, 2016). Well into the twentieth century, in practices with a working class clientele, medicines for common complaints were made up in bulk and dispensed on the surgery premises. By this time practitioners with a more upmarket clientele had abandoned dispensing and patients took their prescription to a chemist to be filled. Incomes from fees were supplemented by salaries from a variety of parttime posts. In the nineteenth century, well over half of all GPs held at least one, and some up to six or seven different positions. The most commonly held post was that of Poor Law medical officer, treating sick paupers in return for a salary. Although not well paid, Poor Law medical posts were valued by young practitioners as they brought in a regular income. Businesses such as the post office, factories and railway companies, as well as friendly societies and insurance companies employed medical officers to examine or care for their staff and members. Local government employed practitioners as medical officers of health and welfare officers (see Chapter  7). In the twentieth century, many of these part-time appointments became full-time, and as a result, provided an income for fewer general practitioners (Dupree and Crowther, 1991; Digby, 1999). Many practitioners also held hospital or dispensary appointments. In the eighteenth and early nineteenth century, physicians or surgeons to these institutions were unpaid, but working there helped to bring in private patients by raising the profile of practitioners within the community and by building links to wealthy donors and administrators. Hospital posts were so crucial for ambitious young practitioners who wanted to join the local medical elite that some founded small specialist hospitals in order to secure an institutional position (Granshaw, 1989). Towards the end of nineteenth century, as the medical staff of hospitals expanded, posts remained highly desirable and were increasingly salaried. Teaching was another important source of income. In the eighteenth and well into the nineteenth century, established practitioners took on apprentices or pupils who paid a fee for the chance to observe and learn. Other practitioners set up courses of lectures in medicine, or established their own

86 Narrative medical schools, pocketing the fees paid by their students. By the late nineteenth century, teaching posts in university and hospital medical schools were salaried but staff were required to teach or research full time, rather than combining teaching with medical practice. In the eighteenth century, medicine was regarded as one of the traditional professions alongside the Church and the law: it was an occupation that required a level of specialist knowledge and carried some social status. By the late nineteenth century, practitioners still saw themselves as members of a profession, although the character of their occupation had changed considerably. Practitioners were still highly educated and enjoyed high social standing, but they also shared a collective identity, codes of ethics and an ethos of public service. In the past, historians have assumed that practitioners consciously sought to transform medicine into a modern profession. In recent years this approach has largely been discarded, and practitioners are now seen as simply seeking to improve their status and incomes. The new sense of a collective identity was a product of the changes to medical education from the late eighteenth century. Before that time, apprentices trained with one practitioner and university students studied in small numbers, but by the end of the nineteenth century students sat in lecture halls and laboratories alongside tens or even hundreds of students for several years. Students spent time together outside teaching hours, living in shared accommodation and letting off steam in sports teams as well as in pubs. Consequently, students left medical schools with strong personal links to their teachers and fellow students (Waddington, 2002). Once in practice, the sense of belonging to an occupational group was fostered by membership of medical societies. Beginning in the eighteenth century, practitioners formed local associations where they discussed clinical cases and issues concerning their occupation. From the 1860s there was a huge growth in the numbers of societies – 20 were founded in Scotland between 1858 and 1868 (Jenkinson, 1993). The first national society, the Provincial Medical and Surgical Association was established in 1832 and became the British Medical Association in 1856, with branches spread across Britain. In 1901, the BMA represented half of all qualified practitioners; by 1948 three-quarters of the profession were members and the Association had become the unofficial spokesman for medical practitioners (Digby, 1999). From the mid-nineteenth century, practitioners also founded societies to foster interest in specialist aspects of medicine, such as the Epidemiological Society (1850), for practitioners concerned about public health problems or the Pathological Society (1846). Medical journals were founded around the same time and fulfilled similar purposes. They carried a mix of articles on practice, professional issues, and other news. A few, notably the Lancet, founded in 1823 by a surgeon, Thomas Wakley (1795–1862), took on a role in medical politics, campaigning to improve the status of general practitioners. Journals linked to societies, such as the British Medical Journal, published by the British Medical Association, recorded the activities of the society alongside other medical topics (Bynum, Lock and Porter, 1992) [Document 27, p. 146].

Medical practitioners  87 The nineteenth century also saw the emergence of accepted standards of behaviour for practitioners. Although they acted as individual entrepreneurs, competing with their fellows for fees and for posts, practitioners were anxious not to be seen to behave like tradesmen, bent on profit rather than providing a high quality service to their patients. Practitioners were banned from advertising their services and there was increasing opposition to doctors keeping shops (Jenkinson, 2016). The Royal College of Physicians censured fellows who provided testimonials to the value of patent medicines on the grounds that this constituted ‘unprofessional’ behaviour. There was also widespread concern about individual doctors attracting patients by charging unusually low fees: ultimately the income of all practitioners would fall if patients expected to pay less, and a number of medical societies published schedules of suggested fees. Fears about doctors poaching patients from other practitioners when called in as consultants prompted the first efforts to draw up codes of ethics. These early rules said little about protecting patients’ interests, but specified in detail how fees should be divided when more than one practitioner was involved in a case.

Figure 6.1  L  uke Fildes, ‘The doctor’, 1891. This painting epitomised the qualities the late nineteenth-century medical profession sought to project. In the image, a doctor sits patiently by the bedside, selflessly losing time and sleep to ensure the recovery of his patient, with little hope of receiving a fee from such a poor family. Reproductions of this painting were reputedly often hung in doctor’s waiting rooms. Credit: Wellcome Library, London.

88 Narrative

Excluding competitors For much of the nineteenth century, practitioners perceived themselves to be in an intense struggle to make a decent living. From the 1820s, there were regular complaints that the profession was overcrowded, with too many doctors chasing too few fees. In fact, although the numbers of practitioners rose significantly over the century – from over 17,000 in 1841 to over 23,000 by 1911 – the population grew even faster, and the ratio of practitioners to population actually fell (Digby, 1994, p. 32). In an effort to reduce competition, and thus increase their incomes, practitioners engaged in a long battle to exclude unqualified and heterodox practitioners from the medical marketplace. In the early nineteenth-century, practitioners complained of unfair competition from druggists, who sold over-the-counter medicines at lower prices than those charged by practitioners. Later, heterodox practitioners, especially homeopaths, were portrayed as taking patients away from orthodox practitioners and treating them with useless, or even dangerous, remedies. From the 1810s to the 1850s, practitioners sought to push out these competitors through the reform of licensing. From the 1800s, practitioners campaigned to establish a clear boundary between qualified practitioners and the medically untrained druggists, and to create a new medical licence for general practitioners, replacing the existing system of licensing through the Colleges of Physicians and of Surgeons and the Societies of Apothecaries [Document 28, p. 147]. However, the new regulations introduced by the Apothecaries Act of 1815, which was drawn up by the London Colleges of Physicians and Surgeons, failed to provide a basis for prosecuting druggists. Although the Society of Apothecaries was given powers to prosecute unlicensed practitioners, the costs of legal action meant that by 1822 only two practitioners had been taken to court. Perhaps not surprisingly, the act reaffirmed the role of the old corporations in licencing practitioners. Candidates for the Society of Apothecaries’ licence had to prove that they had completed a five-year apprenticeship, attended courses in a range of medical subjects and received six months clinical training. The Apothecaries Act reflected current patterns of education, although the insistence on an apprenticeship was seen as a retrograde step by many practitioners, confirming their status as members of a trade where apprenticeship was the standard form of training (Holloway, 1966; Lawrence, 1991). The Apothecaries Act did little to halt the demand for reform, although the target of practitioners’ discontent shifted from druggists to heterodox practitioners, especially homeopaths [Document 29, p. 148]. They were always a small minority within the profession – in 1853, there were around 170 homeopathic practitioners, a figure roughly equal to 1% of orthodox practitioners (Digby, 1994). Between 1840 and 1858 no fewer than 15 bills, drawn up by practitioners or the London Colleges, were presented to parliament but none attracted enough support to become law. The Medical

Medical practitioners  89 Reform Act that finally passed in 1858 was a compromise. The act did not include any sanctions against heterodox practitioners unless they falsely claimed to have a licence. Instead, it established the General Medical Council (GMC), made up of elite practitioners, which issued guidelines on the minimum level of education. The colleges continued to license practitioners, although students increasingly chose to take a degree from a university medical school. All qualified practitioners were listed in the Medical Register, and only those on the register could hold hospital or local government posts. Any practitioner found guilty of misconduct was struck off the list (Roberts, 2009). The 1858 act is often seen as the key to creating consistent standards for licensing across the profession, but as in education, a measure of diversity survived well the twentieth century: the continued rights of the Colleges to license practitioners meant that students retained a choice of how to qualify (Dupree and Crowther, 1991). Having failed to get legal powers to prosecute heterodox practitioners, orthodox practitioners turned to other strategies to push them to the margins of medical practice. They sought to discredit alternative systems of medicine, claiming that they were both ineffective and dangerous. Any practitioner known to practise homeopathy, hydropathy or any other form of alternative medicine was barred from holding hospital posts. Homeopathic practitioners were excluded from medical societies, including the BMA, and other members were not allowed to consult with them. Similar tactics were employed against a new group who attempted to enter orthodox medicine in the late nineteenth century: women doctors. On the one hand, practitioners feared that allowing women to enter the profession would decrease its status. Women were widely believed to be physically and mentally incapable of the prolonged and intensive study required to train in medicine, or to have the coolness to make life and death decisions. Thus if women could practise medicine, then clearly it was not a learned or a skilled profession. On the other hand, practitioners also worried that their female patients would prefer to go to a women doctor, and that they would lose income. Many, although by no means all, male practitioners attempted to exclude women from medicine [Document 30, p. 149]. Women were denied access to medical training. Elizabeth Garrett Anderson (1836–1917) attended some medical classes, but when she gained her licence to practise from the Society of Apothecaries, the institution promptly banned any other women from applying for the qualification. In 1869 Sophia Jex-Blake (1840–1912) obtained permission for a group of women students to enrol at the Edinburgh medical school. However, they were forced to study in separate classes and were not allowed to take their final degree exams, and had to obtain qualifications at Irish or European universities. The history of women’s entry to medical education has been portrayed by participants and historians as a heroic struggle by a few pioneers in the face of almost blanket opposition. Recent research is re-evaluating that image. For example, it is now clear that a much larger group of women studied

90 Narrative alongside Jex-Blake than she herself claimed, and that they had support from some of the Edinburgh teaching staff (Crowther and Dupree, 2007). Later generations of women were able to study in female-only medical schools such as the London Medical School for Women (1874) and the Edinburgh School of Medicine for Women (1889). From the 1880s, women were also admitted to a number of medical schools across Britain and Ireland, although they were often taught in separate classes. Women gained a temporary foothold in medical education during the First World War. Medical schools everywhere struggled to fill their places as young men went off to fight so they opened their doors to female students – only to close them again in the 1920s. After graduation, women had a hard struggle to establish their careers. Most women worked in general practice, and found it hard to obtain institutional posts. Positions in male-dominated hospitals were effectively closed to them: female doctors were more likely to find positions in institutions run by women or for women and children. Others ended up in low status posts such as medical officers to asylums. In the early twentieth century, female practitioners found new areas of employment as school medical officers or in infant welfare clinics. The First World War opened up opportunities for female practitioners to display their abilities: all-women hospitals in France, Belgium and Serbia treated thousands of sick and wounded soldiers. Women were also appointed to the staff of London hospitals and took over the practices of GPs who had joined up. However, these opportunities dried up after 1918. Over time, women were gradually accepted within the profession, but in the 1930s, they remained a small minority and their incomes lagged behind those of their male colleagues (Digby, 1999). In the twentieth century, orthodox medical practitioners had acquired high status and authority. The adoption of scientific medicine was a crucial part of this process – it was not just the basis of explaining disease and directing treatment but a source of authority for new generation of medical experts. Practitioners were acknowledged authorities not only in the treatment of disease, but also in new areas of practice such as occupational medicine. The expanding role of government in medical matters opened up opportunities for practitioners in disease prevention through immunisation, in ever more sophisticated forms of public health, and in welfare schemes to improve the health of the population (see Chapter 7). The expanding role of the state also created tensions for practitioners: when government paid for medical care, how much say should civil servants and administrators have over doctors’ work? Should practitioners have complete freedom to exercise their professional judgement? These issues arose as early as the 1840s, when practitioners were employed by the Poor Law authorities to vaccinate children against smallpox. The Lancet protested against a system that made medical practitioners answerable to laymen, who lacked any knowledge of vaccination. The journal also led a campaign for better payments, arguing that practitioners should enjoy a

Medical practitioners  91 level of income which reflected their long and expensive training and their status as members of a profession (Brunton, 2008). Similar arguments were made in later campaigns to improve pay and conditions for Poor Law medical officers. Practitioners campaigned to improve their pay and maintain their autonomy over their work during the passage of the National Insurance Act in 1911 and the introduction of the National Health Service. Doctors who signed up to the National Insurance scheme were paid a capitation fee for each patient who signed up to their ‘panel’, and the BMA successfully campaigned for the rate to be increased. In 1946, many practitioners strongly opposed the plans for a National Health Service set out by the government, and voted eight to one to reject it. GPs were worried that the proposed payment of a salary plus a fee for each registered patient was a forerunner of a fully salaried service that would make them effectively civil servants. They were also concerned that the government would control the distribution of practitioners, determining where GPs could set up in practice. Again, the BMA successfully campaigned to protect practitioners’ independence. In practice, GPs benefitted from the National Insurance scheme. The increased capitation payments ensured that the large majority of practitioners who signed up to the scheme were guaranteed increased incomes – between 1914 and 1922 average earnings rose by over 90% (Digby and Bosanquet, 1988; Digby, 1999). The National Health Service Act had a less dramatic impact on practitioners. Hospital consultants enjoyed greatly increased salaries, and kept the right to carry out private work. GPs were paid according to the number of patients who signed up to their practice. Although they too were allowed to continue their private practice, the number of private patients diminished rapidly, and many GPs switched entirely to NHS work. The NHS did create of a growing division between GPs and hospital consultants, with a reduction in the number of practitioners holding part-time hospital posts and fewer GPs performing even minor surgery.

Nursing While medicine was seen as a profession at the beginning of the nineteenth century, nursing was not even a clearly differentiated occupation. Nursing the sick was a form of domestic work, mostly performed by family members and servants. A small number of women worked as domiciliary nurses, temporarily employed to care for sick members of upper- and middle-class households. Many of these nurses combined this work with other tasks, including midwifery and laying out the dead – washing the corpse before it was placed in a coffin for burial. Hospital nurses were also effectively domestic servants, responsible for cooking the patients’ food and keeping the ward clean. Medical tasks, such as dressing wounds, were carried out by practitioners. None of these nurses had received formal training. Instead, they acquired skills through informal instruction by an older nurse and by

92 Narrative accumulating experience (Helmstadter  & Godden, 2011). Nurses working at this time have left few records, and historians have often turned to Charles Dickens’ unflattering portrait of Sarah Gamp in Martin Chuzzlewit (1843) for a picture of the typical nurse. Gamp was a not-quite-respectable working-class woman, middle aged and untrained, with her own views on how to treat her patients and fond of drinking. While some elements of the character of Sarah Gamp were created for comic effect, Dickens accurately portrayed her social origins and age. Gamp’s enjoyment of alcohol reflected its use at the time – many workers including nurses were given alcohol to help them undertake long shifts and unpleasant tasks (Rafferty, 1996). Nursing became a distinct occupation in the middle decades of the nineteenth century, with changes in the function of hospitals (see Chapter 5). In 1800, hospitals admitted patients who were mainly suffering from chronic disease, who were likely to benefit from a period of bed rest and care. By the mid-nineteenth century, they treated patients suffering from acute illnesses and those undergoing surgery, who required more intensive care. Hospital nurses took on more medical tasks – monitoring their patients’ condition, ensuring that they were clean and comfortable, administering simple treatments such as blisters and enemas, bandaging wounds, and giving patients food and drink appropriate to their condition. Although nurses continued to be responsible for the cleanliness of beds and patients to ensure that infection did not spread through the ward, other cleaning tasks were passed to ‘scrubbers’. The creation of a distinctive role for nurses within hospitals was the cause of occasional conflict with hospital administrators and medical staff, who feared that senior nurses might usurp their authority over what happened on the ward (Waddington, 1995). By the end of the nineteenth century, hospitals employed large numbers of nurses, who worked in teams, in a strict hierarchy. Matrons were in overall charge of the whole nursing staff. Sisters led a team of nurses working on one or more wards, co-ordinating the work of day and night nurses, and communicating with the medical staff over the treatment of patients. Qualified nurses, assistant nurses and trainees carried out the bulk of patient care, including many of the clinical tasks once performed by junior medical staff – taking patients’ temperatures at regular intervals, cleaning and dressing wounds using antiseptic and aseptic techniques, and sterilising surgical instruments. As nursing became a more complex task requiring greater skills, formal training programmes emerged. The first were developed by religious sisterhoods. Catholic sisterhoods had a long history of providing care in hospitals and in the homes of the sick poor, as a means of expressing their vocation to serve God. Protestant sisterhoods – groups of women with a strong faith who lived and worked together, but did not take the same formal vows as their Catholic counterparts – also took on the task of nursing the poor. The sisterhoods had a reputation for high standards of care, and between the 1850s and 1890s two groups in London provided nursing staff for Kings

Medical practitioners  93 College, University College and Charing Cross hospitals. By the nineteenth century, sisterhoods had developed a systematic training for new nursing recruits. Training was carried out on the wards, with new trainees (called probationers) performing tasks under the supervision of more senior nurses and sisters. There was little or no formal training in the classroom: probationers might attend a few classes in basic medical subjects, such as anatomy, given by medical practitioners (Helmstadter & Godden, 2011; Nelson, 2001). The role of the nursing sisterhoods in developing nurse training has been overshadowed by the figure of Florence Nightingale, who is often portrayed as single-handedly reforming nursing. However, Nightingale herself briefly trained with a Lutheran sisterhood at Kaiserswerth in Germany, before embarking on her famous work at the military hospital at Scutari during the Crimean War. The Nightingale Nursing School at St. Thomas’ Hospital, London, opened in 1860, was funded by a large public subscription, raised in recognition of her work. Training at the school reflected Nightingale’s views on the proper role of nurses. Nightingale firmly believed that nurses should not be low-grade medical practitioners: they had a distinctive part to play in patient care using a set of practical skills. Nurses should be motivated by a strong desire to care for others, and should not enter nursing for purely economic reasons. Training at the Nightingale school was similar to that of the nursing sisterhoods in that it was based around long hours of work under the supervision of the ward sister. It also included lectures on nursing, given by the ‘home sister’ within the training school, and a small number of lectures on medical knowledge given by hospital staff, sometimes delivered during the trainees’ off-duty hours. The training placed a strong emphasis on developing nurses’ character – they had to display selfdiscipline, obedience and have high moral standards [Document 31, p. 150]. This form of training helped to turn nursing into a respectable career for single women. Nursing was fraught with moral dangers: nurses lived outside the private sphere of home and family and worked in hospitals that were often located in working class districts. They carried out intimate services for male and female patients that required close contact with human bodies. Nursing schools substituted the close control of the hospital community for the safety of the domestic world. Trainees and nurses slept and ate in accommodation within, or close to, the hospital, and were subjected to strict discipline during work and leisure time As a result, nursing became an acceptable occupation for middle-class as well as working-class women. Middle-class trainees paid for their training: they entered nursing schools as ‘lady probationers’ and were more likely to be promoted to the ranks of sisters and matrons. The majority of nurses came from the respectable working-classes and paid for their training through their labour – a large proportion of hospital staff were made up of probationers. Once their training was completed, nurses were required to work in the same institution for a set period, often one or more years (Hawkins, 2010).

94 Narrative The Nightingale style of training became dominant in Britain, as graduates of St. Thomas’ set up schools in other hospitals. While these nursing schools retained the basic form of training used at St. Thomas’, over time, the length of training increased from one to three years and the academic component expanded, with more lectures on medical topics and written examinations to check trainees’ knowledge. The age of trainees was also reduced. The Nightingale School initially required that entrants had to be aged 25 to 35 years, when they were physically and emotionally mature and thus capable of working long hours and witnessing sometimes harrowing scenes. However, other nursing schools increasingly admitted much younger probationers. The establishment of nurse training schools created a division between formally and informally trained nurses. From the 1880s, there was a prolonged campaign for nursing to become more of a profession, with the licensing of trained nurses. The campaign was led by the British Nursing Association (BNA), founded in 1888, under its secretary, Ethel Bedford Fenwick (1857–1947). The BNA pursued similar reforms to those demanded by medical practitioners in previous decades. Like the doctors, they wanted training to be self-regulated, and for a register of qualified nurses to be established to stop competition with untrained nurses. The BNA also proposed that training should be reformed to create nurses with greater medical knowledge. Overall, these reforms would make nurses more independent of the hospitals, raise their income and improve the status of the occupation. The BNA’s campaign provoked considerable opposition. Hospitals, which kept their own registers of nurses who had qualified through their training schools, objected to a national register which would weaken the links between individual nurses and their training institutions. The campaign also prompted a wider debate about the distinctive character of nursing and the best form of training. A shift to a more academic training was opposed by many nurses, including Florence Nightingale, who believed that it would make nurses into inferior doctors, rather than the possessors of the skills of caring for patients. There were also fears that a more highly trained workforce would generate problems in maintaining sufficient numbers of nurses: while medical practitioners believed that their profession was overcrowded, many hospitals struggled to recruit enough nurses. More formal teaching would make nursing less attractive to working-class entrants, who made up the majority of trainees. Debates about training and registration rumbled on into the twentieth century. A number of bills to establish registration were presented in parliament between 1905 and 1914 but none garnered enough support from the hospitals and nursing organisations to pass into law. With the outbreak of the First World War the issue of registration was shelved. In the late nineteenth and twentieth century, nursing expanded in both size and scope. The total numbers of nurses increased from 35,000 in 1881 to 110,000 in 1921 (Maggs, 1980). Many of these nurses were employed in new institutions including isolation hospitals and tuberculosis sanatoria

Medical practitioners  95 which required particular sets of skills. From the 1880s the larger fever hospitals offered their own training courses lasting two or three years. As well as basic nursing care, fever nurses were trained in techniques to prevent the spread of infection (Currie, 2005). Nurses in tuberculosis sanatoria were also trained to control infection through the disposal of any materials likely to carry bacteria. They supervised the regime of diet and exercise prescribed for patients in sanatoria and taught patients how to reduce the risks of infecting family and friends. TB nurses played an important role in supporting patients through their long periods of treatment, often in sanatoria that were distant from family and friends. From the 1930s they also cared for patients after surgery intended to encourage healing of the lungs (Kirby, 2010). Nursing the mentally ill in asylums required a very different set of skills. Most nurses (also called attendants) were male rather than female, and mostly working-class. Asylums offered their own form of nurse training, based on a course devised by the Medico-Psychological Association (Dingwall et al., 1988). As asylums took in large numbers of patients suffering from chronic forms of mental illness or disability, the role of nurses focused on keeping order, which sometimes included restraining unruly patients. Male nurses also helped to supervise the work which was part of the patients’ treatment. In the twentieth century, as new therapies for mental illness were introduced, the role of nurses switched to involve more medical tasks, such as the administration of drugs and electroconvulsive therapy. Until the early twentieth century, large numbers of nurses worked in patients’ homes. Upper and middle-class patients continued to employ domiciliary nurses until the 1920s, when they increasingly chose to be cared for in the private wards of hospitals. The poor received nursing care at home through charitable organisations. Schemes to provide district nurses began in the mid-nineteenth century. From 1889, many of these associations were affiliated to the Queen Victoria’s Jubilee Institute for Nursing. By 1900, over 900 Queen’s Institute district nurses were working in England and Wales, increasing to over 2,100 by 1914. District nurses’ training was composed of a mix of time spent in hospital, in midwifery training, and working under the supervision of experienced district nurses. Unlike hospital nurses, district nurses worked with minimal supervision from their employing organisation. They visited patients in their homes, dealing with everything from minor wounds and to terminal illness, and ensuring that bedridden patients were clean and comfortable. In rural areas, district nurses often combined their work with health visiting and midwifery (Sweet with Dougall, 2008; Heggie, 2011). Midwives had traditionally delivered babies and cared for new mothers. While male medical practitioners took an increasing role in childbirth from the eighteenth century, midwives continued to deliver the majority of babies in the early twentieth century. Midwives charged less than doctors, and often carried out domestic chores in the days or weeks after the birth,

96 Narrative allowing new mothers to rest and recover. Their standard of training varied: some middle-class midwives had trained in hospitals or through courses run by the Obstetrical Society of London, while others had simply acquired experience through attending births, possibly with an experienced midwife. Most worked part-time, combining midwifery with nursing or other work (Reid, 2012). Under the 1902 Midwives Act, as part of a wider package of government measures to improve the health of infants, midwives were the first group of nurses to be registered and licensed. The act aimed at increasing standards of training and hence the quality of care provided by midwives. A Central Midwives Board (CMB) for England and Wales was responsible for accrediting the training courses offered by hospitals, for setting licensing examinations, and holding a register of qualified midwives. Those midwives who passed the CMB examinations were placed on the register, as were those who had been practising for a year or more before 1902, who were registered as bona fide midwives. The act also clearly established midwives’ subordinate status to medical practitioners. Midwives could deliver babies as a result of normal labours, but if any complications arose they were required to call in a general practitioner. The work of midwives was supervised by local government Medical Officers of Health, who ensured that they had appropriate sets of instruments and maintained their own personal hygiene by bathing at least twice a week. A similar system was set up for Scotland under separate legislation in 1915. The issue of registration and licensing for other groups of nurses was pushed to fore in the aftermath of the First World War. At the outbreak of war, the government was faced with an acute shortage of nurses to care for the armed forces. In 1914 there were only around 1,000 military nurses plus 800 reserves, who were quickly overwhelmed by the huge numbers of sick and wounded soldiers. The gap was filled by volunteers, mainly Voluntary Aid Detachment nurses (VADs). As the work was unpaid, the volunteers were mainly middle-class women whose families were able support them while nursing. Compared to qualified nurses, VADs had very limited training – just Red Cross courses in first aid, and short periods working in hospitals. Nevertheless, large numbers of VADs served during the conflict: by 1918, 12,000 had worked in military hospitals, some under atrocious conditions close to the front lines, and a further 60,000 had practised in auxiliary hospitals in Britain. Relations between VADs and trained nurses were sometimes strained: those who had gone through long training courses resented the public acclaim given to VADs with their more limited skills (Hallett, 2014). After the war, the fear that large numbers of VADs would move into civilian nursing and compete for jobs with better trained nurses gave new impetus to the campaign for registration. The newly created Ministry of Health sponsored bills which became the 1919 Nurses’ Registration Acts in England and Wales, Scotland and Ireland. The Registration Act for England

Medical practitioners  97 and Wales set up a General Nursing Council (GNC), which maintained not one but five registers for different groups of nurses. Registered nurses were required to have been trained at an approved institution for a minimum of one year. The GNC also had powers to advise hospitals on their nurse training programmes. In practice, the GNC had little impact on nursing. It had no powers to prosecute untrained nurses and its recommended curricula, which were designed for training schools in large hospitals, were not widely adopted. When the GNC tried to remove unsatisfactory training schools from its list of approved institutions, the institutions appealed to the Ministry of Health which regularly ruled against the GNC. As a result, the quality of training in the 1,500 or so nurse training schools remained very varied. Voluntary hospitals in large cities offered a greater range of teaching while schools in small general hospitals and Poor Law infirmaries offered more limited practical experience, and poorer quality formal teaching (Rafferty, 1996). Efforts to raise standards of training were undermined by the interwar shortage of nurses. Although women continued to enter nursing in substantial numbers, a large proportion dropped out during training or in their first years of work. This, coupled with an expectation of better nurse to patient ratios, up to three times more than in 1900, meant many hospitals were almost permanently seeking more trainees. The long hours (up to 56 per week in 1920s), low pay and strict discipline made nursing a less attractive career than office and retail work (Dingwall et al., 1988). The outbreak of the Second World War exaggerated the shortage of trained nurses. In 1939, as in 1914, the armed forces were desperately short of nursing staff. Civilian staff were moved in to fill the gap, creating severe staff shortages elsewhere, particularly in tuberculosis sanatoria and asylums. The problems were solved by the creation of the Civilian Nursing Reserve, made up of large numbers of assistant and auxiliary nurses who had received a shorter training than registered nurses. They played a major part in dealing with civilian casualties of bombing as well as caring for sick and wounded soldiers and sailors. From 1943, in an effort to attract more nurses, the Ministry of Health increased levels of pay and regulated working hours – the first time that the state had set conditions of work for nurses (Starns, 2000). The advent of the National Health Service in 1948 did little to change nursing. For the first time, the government funded nurse training, but nurses continued to follow much the same type of apprenticeship-style education as previous generations. To ensure sufficient numbers of recruits, the entrance requirements that had been dropped during the war were not reinstated. However, the NHS did bring uniform and substantially higher levels of pay which replaced the variable rates previously offered by different institutions (White, 1985). The professions of medicine and nursing came together under the NHS: both nurses and doctors were employed by the state, and their training,

98 Narrative qualifications and conditions of work were controlled by government. However, the two professions had a very different history, and remained very different in character. The possession of a highly specialised body of knowledge was always the key feature of medicine, although the character of the occupation changed markedly with the development of a strong collective identity and codes of behaviour. The identity of nursing, by contrast, was tied not to knowledge but to practical skills, and was dominated by women. As a result, it has struggled to achieve the same professional status as medicine.

7 Health and the state

The growth of state involvement in medical services is one of the major developments within modern medicine. At the end of the eighteenth century, central government had no responsibility for health while local parish authorities provided care and support to the sick through the Old Poor Law. By 1950, the state had become the major provider of services to prevent disease through a wide range of public health and welfare schemes and of health care through the NHS. In the past, historians have seen the expansion of government care as a rational and somehow inevitable response to the health problems generated by industrialisation. However, comparison of the different paths of state intervention in different nations, and changing attitudes to state medicine at the end of the twentieth century have informed a shift away from seeing the NHS as the logical culmination of a process of ever-increasing government intervention. Instead historians now view the development of the welfare state as a distinctive set of historical events, specific to a particular time and place. Recent research has emphasised the factors shaping health care provision. Even where legislation set out programmes of care, the economic strength, political character and the geography of communities – whether rural or urban – shaped the range and quality of medical services. Cultural attitudes fed into the perception of health problems; thus, a profound fear of a decline in the size and health of population was a key driver in the development of infant welfare schemes. Researchers have also challenged the notion that government actions to improve health were greeted with universal approval. There was a persistent tension between acceptable intervention and undesirable interference which prompted conflicts between the state and the public, and the state and the medical profession.

Sanitary reform Although public health reform is usually associated with the work of nineteenthcentury central government, a range of local government bodies – select vestries, parishes, town councils and improvement commissions – had a much longer history of cleaning up towns and cities, in an effort to make them healthier

100 Narrative and more pleasant places in which to live. These bodies organised the removal of ‘nuisances’ – anything that caused annoyance or discomfort to inhabitants, including accumulations of dirt which offended the nose and eyes and were believed to generate the miasma or bad air that caused disease (Hamlin, 2013). They were also responsible for cleaning the streets. Town streets acted as receptacles for domestic refuse, as well as collecting the large amounts of dung deposited by the horses that supplied the power for urban transport. From the seventeenth century onwards, gangs of men had periodically shovelled up the refuse and taken it outside the town boundaries. Over time, cleaning became more frequent. The routine business of keeping towns clean formed an important strategy against outbreaks of fever and cholera. Local government, aided by charities, set up temporary hospitals to care for victims, arranged depots to give away free medicines to anyone showing early symptoms of cholera, and distributed food and clothing to the poor to help them fight off infection. They also made special efforts to remove dirt from urban spaces: streets were thoroughly cleaned, drains flushed with water and any dirt removed. The level of activity varied between communities: larger cities had more developed agencies, better able to organise programmes of actions. The type of response also varied between nations: Scottish towns and cities were more likely to provide food and clothing to the poor as part of their response to disease, whereas English communities focused on sanitary measures. This has prompted one historian to suggest that there was a distinctive ‘Celtic’ public health (Hamlin, 2006). Central government took little responsibility for health matters until the middle decades of the nineteenth century. Eighteenth century ideas of medical police – state policies designed to ensure the health of the population – failed to gain much traction in Britain. Bills presented in parliament in 1808 and 1813 proposing measures to control smallpox were firmly rejected on the grounds that this fell outside the proper scope of government. By contrast, governments in Sweden and Denmark adopted compulsory vaccination at this time (Brunton, 2008). However, the threat of Asiatic cholera, a foreign and deadly disease that had travelled across Europe from India, pushed parliament into action. In 1831, the government set up a central Board of Health, whose role was to advise local authorities on how to prevent and control the disease. The central Board was a purely temporary measure: as soon as the danger had passed, the Board was disbanded (Wohl, 1984; Durey, 1979). Permanent central government involvement in health dates from 1848, with the passage of the first Public Health Act for England and Wales. The legislation was inspired by the Report on the Sanitary Condition of the Labouring Population (1842), which charted the link between dirt and disease and concluded that there was a desperate need for improved provision of water supplies and of sewerage [Document 32, p. 151]. The Report’s author, Edwin Chadwick (1800–1890), is often portrayed as a hero of

Health and the state  101 public health, who compiled an objective account of the appalling sanitary conditions in towns and cities and presented a rational solution. However, research has shown that the Report was shaped by political considerations. Chadwick was a lawyer, and secretary to the Poor Law Commissioners, who were responsible for providing relief to paupers (see Chapter 5). At this time, the Commissioners were struggling with the costs of treating ill health among the poor. Poor Law doctors were ignoring the central premise of the Poor Law that paupers should receive the minimum amount of support, by prescribing food as well as medicines to treat sick paupers. The Report was intended to demonstrate that ill health was caused by environmental filth: therefore, there was no point in giving food to sick paupers (Hamlin, 1998). The principles put forward in the Sanitary Report were enshrined in the provisions of the 1848 Public Health Act. It set up the General Board of Health (GBH), headed by Chadwick, which had powers to approve local authorities’ plans for sanitary improvements or to force them to act if mortality reached unacceptable levels. In practice this meant that towns were pressed to adopt Chadwick’s preferred solution – large scale schemes to drain large areas, using new, small-diameter sewers, and to provide plentiful supplies of water to ensure that the sewers would flush away all filth. This was an expensive and complex task, and implementation was slow: between 1848 and 1853 only 103 communities attempted to install comprehensive water and sewerage systems. Meanwhile, the GBH proved increasingly unpopular: although it had limited powers, it was perceived to be autocratic and corrupt, and its original members were dismissed in 1854 (Hamlin, 1998). The reformed General Board of Health marked a milestone: from this point, central government agencies responsible for health were always led by medical experts. John Simon (1816–1904) a medical practitioner with a long standing interest in public health and the Medical Officer of Health for the City of London was appointed as chief medical officer to the GBH. He retained his post when the Board was dissolved and its powers and staff transferred to the Medical Office of the Privy Council. In 1871, the Medical Office was merged with other departments with health responsibilities in the Local Government Board (Porter, 1999). During his time in government, Simon drafted a large number of acts which greatly expanded the remit of public health reforms. The Sanitary Act of 1866, for example, was not just about improving sanitation, but gave local authorities powers to require home owners to install drains, to deal with overcrowding in rented properties, to improve conditions in lodging houses and to act against smoke pollution. Increasingly, this new legislation was not permissive – giving local authorities the power to act – but compelled them to take action. Simon’s efforts to increase the involvement of the state in public health reforms were assisted by a growing staff of inspectors who travelled the country, checking on sanitary conditions and advising, persuading and cajoling local government to make improvements.

102 Narrative Simon, like a number of contemporary commentators, was scathing about the efforts of local government to improve sanitary conditions, complaining that ratepayers preferred to put up with dirt rather than to pay for water and sewerage [Document 33, p. 151]. In fact, local authorities actively developed their repertoire of sanitary measures over the mid- to late nineteenth century. Greater numbers of inspectors of nuisances were appointed under the Nuisance Removal Acts, and street cleaning became ever more regular and systematic. It still relied on men with brooms, barrows and buckets to cart away the filth, but it was highly effective (Wohl, 1984). In cities like Edinburgh and Glasgow, the streets were swept every weekday, and twice on Saturdays (the second collection allowing workers to rest on the Sabbath): even in small villages, streets were cleaned weekly. Huge amounts of refuse were removed; around 40,000 tons of refuse were lifted every year from the streets of Edinburgh in the 1840s and 1850s (Brunton, 2015). Local authorities also undertook a range of infrastructure projects. They made myriad small-scale improvements such as building public lavatories and public washhouses, with baths and laundry facilities. As well as laying miles of sewers, erecting sewage treatment works and bringing in supplies of water, they organised the paving of streets. Some local authorities struggled with such major projects, which were expensive, and required a level of technical expertise that few such bodies possessed. Not surprisingly, they often failed to reach decisions on the technical points of schemes and the relative costs of different solutions (Hamlin, 1988). Local authorities were willing to tackle the difficulties of sanitary reform because it brought a range of benefits. Sanitary reforms overlapped with civic amenity: clean streets were not only associated with health but were also pleasant for pedestrians, encouraged the flow of traffic and drew in visitors – holidaymakers, shoppers, and businessmen – to boost local trade. While much has been written about sanitary improvements in public spaces, at the same time campaigns were waged to raise standards of cleanliness in working-class homes. Improvements to the urban environment were intended to influence the behaviour of residents: local authorities hoped that if residents lived on streets that were regularly swept, they would follow this example and make greater efforts to keep their homes clean. Providing public baths gave the poor the means of keeping themselves clean, while strict rules on bathing taught them how to behave in a decorous manner (Crook, 2006). Dedicated charities used a variety of strategies – lectures, pamphlets and visits to homes of the working classes – to press home the benefits of cleanliness [Document 34, p. 152].

Public health By the end of the nineteenth century, public health reforms shifted from a broad concern with cleaning up the urban environment to more targeted actions against potential sources of infection. New strategies against these

Health and the state  103 dangers were coordinated by medical practitioners, appointed as Medical Officers of Health. While a few cities had created these positions in the 1850s, from 1872 in England and Wales and 1889 in Scotland, local authorities were required to appoint a Medical Officer of Health (MOH, plural MOsH). At first MOsH were appointed on a part-time basis, but by the twentieth century, they were full-time local experts with specialist qualifications in public health, who had a small staff of inspectors to help identify and deal with health problems within the community. Medical officers of health oversaw a major expansion in the public health responsibilities of local government. Local authorities continued to organise street cleaning, and to maintain and upgrade drainage and water supplies. However, by the end of the century, the scope of sanitary reform had expanded to include the private space of the home. Nuisance inspectors visited homes, looking not just for dirt but also to check whether water closets (that is, flushing lavatories, which became increasingly popular from the middle of the century) had been correctly installed. MOsH enforced regulations on the use of buildings, specifying the maximum number of people who could sleep in a house, and condemning cellar dwellings or other buildings deemed too damp or insanitary for human habitation. The quality of food also came under the scrutiny of the MOH. Contaminated food was a potential transmitter of disease: butter and milk could carry dirt and bacteria; meat might contain parasites; and shellfish could transmit the agent responsible for typhoid fever. Using powers under the 1875 Public Health Act, MOsH and their staff inspected, analysed and if necessary seized dangerous foodstuffs before they could be consumed by unwitting customers (Waddington, 2011; Wohl, 1984) [Document 35, p. 153]. In the late nineteenth century, local authorities adopted new strategies to prevent the spread of infectious disease. The idea that disease was spread by some specific agent, rather than atmospheric miasma appeared in the midnineteenth century. In 1855, John Snow (1813–1858) published his famous evidence from the Broad Street pump suggesting that cholera was spread through water. Snow’s conclusions were only gradually accepted: John Simon at the Medical Office of the Privy Council, continued to issue advice on improving the general cleanliness of the urban environment as a means of controlling the 1866 cholera outbreak. By the 1880s, the germ theory had been generally accepted by practitioners, who understood that that diseases were transmitted by bacteria excreted from the body of sick individuals, and then spread either through the air, by water or objects contaminated with body fluids (Worboys, 2000). Patients suffering from infectious diseases were therefore the main source of infection. From the 1870s, local authorities built permanent isolation hospitals to care for adults suffering from typhoid fever, smallpox and scarlet fever (see Chapter 5). With the decline in smallpox and typhoid fever, isolation hospitals switched to caring for children suffering from a range of infectious diseases. Local authorities were also responsible for disinfecting the rooms and furnishings used by infected

104 Narrative persons. Disinfecting squads were sent round to the patient’s home to spray the rooms with chemicals while bedding, clothing and other belongings were brought to municipal steam or heat disinfectors (Mooney, 2015). Cleanliness and isolation were the main strategies of disease prevention throughout the nineteenth and early twentieth centuries. Until the midtwentieth century the widespread use of immunisation was possible against only one disease – smallpox. Inoculation, the practice of deliberately infecting individuals with smallpox in the hopes of ensuring a mild form of the disease, was practised in Britain from the 1720s. Inoculation was an inherently risky procedure as the recipients suffered smallpox, and some died as a result. However, the overall mortality from inoculated smallpox was lower than that from natural cases, for reasons that remain obscure. In the late eighteenth century, some communities, mainly in the south of England, held mass or general inoculations as a means of stopping outbreaks of smallpox (Razzell, 2003). At the beginning of the nineteenth century, inoculation was superseded by vaccination, the practice of infecting children with cowpox. This provided immunity against smallpox but was much safer and was much more widely practised. In 1840, free vaccination was made available to the whole population of England and Wales through the Poor Law under the first Vaccination Act. Further legislation made vaccination compulsory in England and Wales in 1853 and in Ireland and Scotland in 1863. The impact of the acts was to substantially raise levels of vaccination, resulting in a decline in both smallpox incidence and deaths from the disease (see Chapter 2). In 1869–1870, over 472,000 infants were vaccinated in England and Wales – a number equivalent to 60% of registered births. The vaccination rates in Scotland and Ireland were much higher – equivalent to 93% and 85% of registered births respectively – and smallpox incidence was lower, prompting the Irish Poor Law Commissioners to boast that the disease was all but eradicated from the country (Brunton, 2008). Their optimism proved short-lived: in 1871–1873 a major outbreak of the disease over much of Britain caused over 40,000 deaths in England and Wales, mainly among young adults. However, the decline in smallpox mortality was resumed in the 1880s and vaccination rates also fell. Efforts to control smallpox were an anomaly in nineteenth-century medicine. Immunisation against other diseases such as typhoid, diphtheria, tuberculosis and tetanus became available in the 1920s and 1930s, but were not widely used until after the Second World War. While it was generally accepted that governments should take measures to prevent disease by the late nineteenth century, in the short term some public health reforms stirred up popular opposition. Erecting a public lavatory might stop inhabitants urinating or defecating in the surrounding streets, but anyone living close to the facility was exposed to unpleasant smells and disease-inducing miasmas. The drains that connected one home to another were also a source of disquiet. Filth flushed out of neighbouring homes might collect, rot and produce sewer gas, which could seep back through

Health and the state  105 domestic plumbing and cause disease (Allen, 2002). Government actions appeared, at least to some sections of the population, to trespass into the private sphere of family life. The anti-vaccination movement voiced loud objections to compulsory smallpox vaccination in the 1860s and 1870s. Campaigners had no faith in vaccination – they claimed that it provided no immunity to smallpox and that some children had caught syphilis or even died as a direct result of the procedure. They also objected to compulsion on political grounds: the state should not interfere with the rights of parents to bring up their children as they saw fit. Compulsion was thus an attack on fundamental personal liberties (Durbach, 2005). Similar objections were raised to plans to require medical practitioners and householders to notify the local authorities of any cases of infectious disease. Commentators saw this as an unreasonable interference in the lives of citizens, and harmful to the patient–practitioner relationship (Mooney, 2015). In the past, historians assumed that public health reforms were responsible for the observed decline in mortality and incidence of infectious disease in the late nineteenth and twentieth centuries (see Chapter 2). However in 1976, Thomas McKeown challenged this assumption (McKeown, 1976). He argued that the most significant decline in mortality occurred among respiratory diseases, especially tuberculosis. As public health measures could do little to influence rates of TB infection, improved living conditions must have been responsible for the observed mortality decline. McKeown’s thesis was widely accepted until 1998, when Simon Szreter disputed his conclusions (Szreter, 1988). Szreter agreed that mortality from tuberculosis had declined, but pointed out that deaths from other respiratory diseases, which should also have been influenced by better living standards, had not. However, morality from a wide range of infections, spread through contaminated water and food, declined just at the time when sanitary reforms were widely adopted. The debate over the relative impact of sanitary reform and standards of living remains unresolved; both undoubtedly played some part in the reduction of deaths from infectious disease.

Welfare At the beginning of the twentieth century, although deaths from infectious disease were in decline and mortality rates improving there was still serious concern about the health of the population. Birth rates were falling and infant mortality remained high, prompting widespread alarm that the population was declining in size. There were also fears about the quality of the population. While the fit and healthy middle classes were having fewer children, the unhealthy poor continued to raise large families, and (it was believed) passed on their poor physique and undesirable characteristics such as tendencies to alcoholism, insanity or criminality to their children. Proof of the poor heath of the population came through medical inspection of recruits for the Boer and First World Wars. A  large proportion of

106 Narrative working-class volunteers were found to be unfit to fight – they were too short, had flat feet, bad teeth (good teeth were needed to cope with army rations) or showed signs of tuberculosis or heart disease. This situation fed support for eugenics, schemes to improve the quality of the population. In some countries, governments tried to stop the ‘unfit’, such as those with disabilities or mental illness, from having children. British supporters of eugenics advocated encouraging the fitter sections of the population to have more children and welfare programmes to improve the health of infants and children. Improving the health of future generations would, in time, guarantee a strong, healthy adult workforce, able to defend the nation in time of war (Harris, 2003). A number of welfare measures were introduced by the Liberal government of David Lloyd George (1863–1945) – including the Maternal and Child Welfare Act (1918), which gave local authorities in England and Wales the powers to set up infant welfare centres. Similar legislation had been passed for Scotland three years earlier. Infant welfare schemes had been set up by various charities at the end of the nineteenth century, inspired by those in France (where the birth rate had declined even more than in Britain). The new centres created by local authorities were similar in their aims. Services were based on the belief that high infant mortality was due to poor mothering skills among the working classes, rather than poverty or poor housing conditions [Document 36, p. 154]. The solution was education, and centres provided lectures on ‘mothercraft’ – cooking, dressing and bathing infants. Advice was also handed out by paid or volunteer health visitors, who went to the homes of new mothers to offer advice on child rearing, including encouraging breast feeding (Dwork, 1987). Additionally, the growth of infants was checked through regular weighing, although no medical treatment was provided for sick babies. Historians have described these practices as ‘surveillance medicine’ in which apparently healthy individuals were monitored by medical professionals (Armstrong, 1995). Infant welfare schemes have been criticised by historians as patronising and impractical, endeavouring to teach middle-class childrearing practices to working-class mothers. Women were lectured on the benefits of feeding to a regular schedule, weaning their infants at around their first birthday, and providing separate cots. This advice ignored the value of working-class practices such as long breastfeeding, the early introduction of solid foods, and allowing children to sleep with their parents – all behaviours which would ensure infants were warm and well fed, and therefore more likely to be quiet in a crowded home (Ross, 1993). While infant welfare programmes represented an expansion of the role of government in health care, they also demonstrated the limits to state action. The choice to educate mothers in good childrearing practices allowed local and central government to ignore the impacts of poor housing and low income on the health of infants – problems which the state was reluctant to tackle. Similarly, few infant welfare schemes provided

Health and the state  107 milk for mothers unable to breastfeed or gave meals to pregnant women and nursing mothers. Distributing free food was a contentious issue, seen as interfering with the responsibility of the father to support his family. The programmes offered by welfare centres thus reinforced a family model of the stay-at-home mother, supported by a male breadwinner (Davin, 1978). The reluctance to offer food to pregnant women and infants gradually declined over time, with nutritional supplements offered by many local authorities by the 1930s. The welfare of older children was provided for through the Education Act of 1906. This created a school medical service responsible for carrying out the inspection of children, to identify those suffering from parasitic infections such as ringworm and head lice, or with poor hearing or eyesight or bad teeth. Like infant welfare schemes, the school medical service aimed at identifying problems but did not offer treatment: it was up to parents to take their child to a doctor or dentist, or a local authority clinic, which treated minor ailments and offered dental and ophthalmic care. Ironically, the new government service added to the burdens of working class households, which had to find the money to pay for treatment and the time to take their children to a practitioner (Ross, 1993). The Education Act of 1906 also allowed local authorities to provide free meals to ‘necessitous’ children – those judged to be receiving a poor diet but were not actually malnourished – and to distribute free or subsidised milk. This was justified on the grounds that well-fed children were better able to benefit from their school education, and would help to teach children to be polite, well-adapted citizens. Campaigners argued that feeding children the type of meals served in middle-class households – meat and vegetables followed by puddings – would wean them away from the ‘unsuitable’ working class diet of bread and jam. Children would also learn how to use a knife and fork, to ‘talk quietly’ and to help each other at table (Vernon, 2005). While legislation allowed local authorities to provide meals, relatively few children received them. Lack of suitable cooking and dining facilities in schools meant that relatively small numbers of children received school meals until the 1940s. Similarly, the costs to local authorities of buying milk restricted its distribution. In 1934 only around 180,000 children received free milk under welfare legislation. Much greater numbers – around a million – drank subsidised milk, with their parents contributing towards its cost (Atkins, 2007). There was considerable geographical variation in the provision of welfare. At a national level, England had far greater provision of infant welfare services than Scotland. Between 1918 and 1938 in England the number of infant welfare centres service expanded from 1,400 to over 3,200 while the number of health visitors grew from over 3,000 to almost 5,500 (Harris, 2003). By comparison, Scotland had just 196 welfare centres in 1921, provided by a mix of local authorities and charities, clustered in large towns. A low proportion of infants were brought to the centres or were attended

108 Narrative at home by health visitors (Jenkinson, 2002). In Northern Ireland too, welfare services developed slowly. There was also considerable variation in provision between different local authorities. Medical Officers of Health, who oversaw these schemes, had the right to prioritise different of welfare aspects – for example, to spend less on infant welfare centres and more on school meals. Ironically, the poorest communities with the greatest need were unable to fund more than very basic services. The limitations of welfare services in the poorest areas of large cities were graphically revealed during the Second World War, when many children evacuated from slum eras were found to be dirty, malnourished and infested with head lice. In addition to welfare schemes aimed to improve health, in the interwar years local authorities set up programmes of social medicine – a combination of prevention and therapy. The approach was used to tackle high levels of tuberculosis: sufferers received treatment in sanatoria, but were also taught to follow lifestyles which would help to cure the disease and to reduce the chances of spreading infection. The public were encouraged to come forward for screening to identify active TB cases which would benefit from treatment. The approach was also applied to tackle venereal disease (VD). Rates of VD infections rose during the First World War, prompting the passing of the 1917 Venereal Diseases Act. This allowed local authorities to set up clinics offering free and confidential treatment, and to join with charities in mounting education programmes warning of the dangers of VD (Davidson, 2000). With the increasing role of government in protecting and promoting the health of the nation through programmes of public health and welfare came expectations that while the population had a right to state health care they also had a duty to take responsibility for their own health by making use of these services, to ensure that their children remained healthy and that any ailments were treated promptly – the concept of health citizenship. The public were guided in the use of services by an expansion in health education. Local authorities and charities paid for posters, pamphlets and films, and organised lectures to encourage the public to protect their own health by adopting high standards of hygiene and diet, and to come forward for testing or treatment for a range of diseases. Education did generate tensions, especially around cancer. It was widely accepted that there was a need to inform the public about the signs of cancer, as it was known that the disease could be more successfully treated if detected early. However, there were also concerns that this would cause many people to fear that they might have cancer and so put pressure on diagnostic services. As central government did not offer free cancer services, civil servants did not see public education as part of its role. Cancer charities, such as the British Empire Cancer Campaign also worried that education might increase fears of cancer, and preferred to fund research. Local authorities were left to lead the way in educating the public on recognising the early signs of the disease (Moscucci, 2010).

Health and the state  109

Government medical care The twentieth century saw a fundamental change in the scope of state medicine, from ‘productionist’ medicine – welfare schemes aimed at increasing the health and strength of the population and especially the workforce – to the collective actions of ‘communitarian’ medicine, where services were provided to all with a view to enhancing social solidarity (Cooter and Pickstone, 2003). The shift began in 1911, when central government took on an important new role as a provider of subsidised medical care through the 1911 National Insurance Act. Up to this point, the very poorest sections of society had obtained medical care through the locally funded Poor Law, while other workers paid for treatment through hospital or friendly societies’ insurance schemes. In return for a small weekly payment, workers were guaranteed to receive treatment from a general practitioner, and under some schemes, a small benefit if they were unable to work. The National Insurance scheme was modelled on that of Germany, and on existing systems of insurance. Workers in Scotland, England and Wales signed up with a participating general practitioner, who provided care when required; members also received benefits if unfit for work due to illness or if unemployed. In Ireland, only sickness benefits were provided, as it was argued that sufficient medical services were provided by other agencies (Barrington, 1987). Only workers earning less than £160 a year – the threshold for paying income tax – could join, and the scheme was funded by a mix of contributions from government (2d), employers (3d) and workers (4d): hence Prime Minister Lloyd George’s slogan ‘ninepence for fourpence’. Over time the scheme was gradually extended, so that by 1938, around 21 million workers were covered (Harris, 2003). The setting up of such a major new initiative in the provision of medical care was fraught with potential difficulties: it ran counter to the financial interests of the existing insurance schemes and the professional interests of medical practitioners, who were deeply suspicious of becoming government employees working under the scrutiny of civil servants and of losing fees from patients. The former problem was solved by giving friendly societies the responsibility of administering the scheme. Doctors’ fears about National Insurance disappeared when they realised that the fees received for each patient who joined their ‘panel’ were more generous than those offered by other insurance schemes. Large numbers of general practitioners signed up to the scheme – up to 80% of GPs in some areas – with an average ‘panel’ of around 1,000 patients. Provision was not of the same standard across Britain: in Scotland a wider range of drugs was funded by National Insurance and the service was believed to be of a better quality (Gorsky and Sheard 2006). The services on offer also varied between the different approved societies which administered the scheme: the wealthier societies funded a range of additional services such as dental and ophthalmic care (Digby, 1999).

110 Narrative National Insurance undoubtedly improved access to medical care for low paid workers at a time when the demand for services was rising. While it had been anticipated that workers would have two consultations per year with their GP, by the 1930s the average was five visits per year. Inevitably there were accusations that workers were exploiting the scheme, making unnecessary visits to their GP. The quality of the service also came under fire. ‘Panel patients’ were often treated by junior staff while private patients received longer consultations with more senior practitioners. However, the greatest shortcoming of the scheme was the restriction of coverage to working men and women. Wives and children were left to pay for their own care or seek free help through local authority and hospital outpatient clinics. The role of central government in providing health care was further increased during the two world wars, when medical services had to be rapidly expanded to cover both military personnel fighting abroad and the civilian population at home. Some problems were difficult to resolve. During the First and Second World Wars, a large proportion of medical practitioners joined the armed forces – over half of all doctors were serving in the military in 1917. The remaining GPs increased their workload, and medical schools shortened the curriculum, but it was impossible to train enough new doctors to fill the shortfall. By contrast, the demand for large numbers of extra nurses was filled by training volunteer nurses, who served at home and abroad (see Chapter 6). Nevertheless, civilians struggled to get access to care: hospitals had less beds for civilians, there were fewer GPs and there were cutbacks in local authority welfare provision (Hardy, 2000).

Figure 7.1  ‘Express panel doctor’, Punch, 1913 vol. 144, p. 138. Doctors (and their patients) were a frequent subject for humour in the satirical magazine Punch. Here, the doctor wearing the standard dress of elite practitioners of top hat and tail coat is shown dealing with his working class panel patients as fast as possible – inspecting tongues with the help of roller skates and doling out pills without entering houses. There was a serious message behind this cartoon – that panel patients received a poor service under the National Insurance Act. Credit: Wellcome Library, London.

Health and the state  111 War also led to the reorganisation of medical services. The army medical services during the First World War have been held up as an exemplar of modernity – applying the forms of organisation used in industry to efficiently select recruits and to treat soldiers at the battlefront. All recruits were graded on the basis of an initial medical inspection, which determined their suitability for service on the battlefield or behind the lines in support roles. In the static trench warfare in France, medical services were organised to efficiently treat the wounded, then move them off the battlefield. A wounded soldier received initial treatment and assessment at a first aid post, then at the nearest Casualty Clearing Station. The more seriously hurt were sent by train or ambulance to hospitals behind the lines, where better facilities were available. Only the most severely wounded were transferred back to Britain for further treatment which would return them to service or rehabilitate them for civilian life. A similar organisation of medical services was used in the Second World War for civilian casualties of bombing raids. In the Second World War, the government’s Emergency Medical Service (EMS) was responsible for organising hospital accommodation for sick or wounded soldiers and injured civilians. To meet the demand for extra beds, patients were turned out of voluntary and Poor Law hospitals and asylums, and the beds taken over for the use of wounded military personnel. Additional accommodation was created in country houses and temporary huts. The EMS paid hospitals for the care they provided, and coordinated their staffing and work. The old divisions between voluntary and local authority hospitals were replaced by a regional structure. Specialist services, such as plastic surgery, were concentrated in a few centres, while other institutions functioned as general hospitals (Hardy, 2000). By 1945, health services were an established part of central government. Medical matters in England were dealt with by the Ministry of Health in Westminster, established in 1919. Its expanding role was reflected in the increasing budgets for health care: from £1 per head in 1920, to £2 in 1938. Although medical provision in Wales was covered by the same legislation as for England, there was a separate Welsh Board of Health. Scotland had its own acts of parliament, reflecting its distinctive administrative structures. In 1919 the Scottish Board of Health was created, based in Whitehall until 1928 when it relocated to Edinburgh as the Scottish Board of Health (Jenkinson, 2002). Ireland had its own Local Government Board responsible for health matters from 1898 (Lucey and Crossman, 2014). Outside Whitehall, in the century or so since the passage of the 1848 Public Health Act, a complex network of health and welfare services had grown up, divided between charities (including the voluntary hospitals), local authorities, which ran the ex-Poor Law hospitals as well as a range of welfare services, and medical practitioners, who worked as independent providers under the National Insurance scheme and as private practitioners. By 1945, there was a broad consensus on the need to rationalise the uneven and overlapping provision of services across the country through a more

112 Narrative extensive state-funded medical service. There were precedents for such a scheme. The Highlands and Islands Medical Service (HIMS) was set up in the north of Scotland in 1913, to provide salaries to doctors who otherwise struggled to make a living in these poor and sparsely populated areas. The HIMS also funded district nurses and additional staff and facilities in hospitals (McCrae, 2003). During the Second World War, the EMS showed the benefits of co-ordinating the work of hospitals to ensure more equal provision across the country and to raise standards of care. The war also brought about a change in public attitudes: good quality medical care for the whole population was now seen as a right, not a benefit. Plans for a uniform, co-ordinated medical service had been discussed since 1920, when Lord Dawson proposed the creation of a service integrating general practitioner and hospital care. Others followed in the 1930s and 1940s. While the 1942 report by the economist William Beveridge (1879–1963) is perhaps the best known, plans were put forward by a variety of organisations, each reflecting the interests of the authors. The British Medical Association’s proposals sought to ensure that any new service protected key characteristics of medical practice: that patients had a free choice of practitioner and that doctors should not receive salaries, which would effectively turn them into civil servants. The BMA favoured a new service based on an expanded system of national insurance, covering the majority of population, and including some element of private practice. To protect and enhance practitioners’ power in the running of the new service, the BMA proposed a new system of local committees, with doctors playing a key role in the administration of services. By contrast, the Socialist Medical Association (SMA), a small but influential group of left-wing practitioners, favoured the creation of a universal service, paid from general taxation. They proposed a greater integration of services through health centres, with an emphasis on the prevention as well as the treatment of disease. Under their proposals, all staff would receive a salary and not carry out any private practice. The administration should be democratic, with both providers of services and patients sitting on local governing bodies (Stewart, 2002). The Ministry of Health proposed that health services should be rationalised in the hands of local government – the largest providers of medical services – to ensure a unified service delivering uniform levels of care across Britain. The service would be administered by regional bodies; however, there was considerable disagreement over the size of these regions and their relationship to existing local authorities. The election of a post-war Labour government, and the appointment of a new Minister of Health, Aneurin Bevan (1897–1960), brought a fresh perspective to the issue. Bevan refused to become involved in the existing debates and within a matter of months had drawn up his own National Health Service Bill, which passed into legislation in 1946. (Scotland acquired a separate, but similar NHS Act in 1946, while the Irish parliament passed

Health and the state  113 its own Health Act in 1953.) Commentators have often focused on the radical elements of Bevan’s design for the new NHS, particularly his decision to deal with the problem of co-ordinating voluntary and local authority institutions by nationalising the whole hospital service. This also reflects Bevan’s own rhetoric: he presented the new NHS as a fundamental step forward. But Bevan was also a pragmatist, and he rowed back from the radical wartime plans for a unified, national service. Under his bill, a universal service, covering medical, dental and ophthalmic care, was funded by taxpayers and delivered through a tripartite system based on existing provision [Document 37, p. 155]. Hospitals were organised into regions, run by hospital boards (modelled in part on the wartime Emergency Medical Service). The only exceptions were the English teaching hospitals, which were answerable directly to the Ministry of Health. Plans to invest in new buildings and services were held up by post-war economic conditions, but the NHS did gradually reduce the inequalities in hospital provision across Britain. By nationalising the hospitals, the role of local authorities in health provision was greatly reduced but they continued be responsible for welfare and public health services. General practitioners’ status as independent providers was preserved, although their work was overseen by local Executive Councils and the size of practices was regulated (Webster, 1988). Bevan had devised a system that was acceptable to almost everyone. Politicians and the public were in favour of a universal service, and not overly concerned with how it was delivered. The voluntary hospitals were relieved not to have be placed under local authority control; local authorities, most of which were under Labour control, accepted their new, more limited role. Only general practitioners were strongly opposed to the potential level of government control that would be imposed on their practice. Last minute concessions on both sides ensured that the NHS launched as planned on 5 July 1948 (Webster, 2002). The smooth running of the new service from its opening day was a reflection of the close links between the NHS and earlier medical services: for patients, the delivery of care changed very little, although women and children enjoyed greatly improved access to GP services. The only surprise was the volume of demand for services, summed up by the rush for ‘free teeth and glasses’ – 5 million pairs of spectacles were dispensed in the first year. It had been predicted that pent-up demand for care would cause an initial scramble to take advantage of the new services, which would then decline. However, high levels of demand persisted and the principle of a service free of change at the point of delivery was quickly abandoned, with charges for prescriptions and dental care introduced in 1952. The uniformity of services introduced by the NHS can mask the historical diversity of state provision of care and of disease prevention. Over the nineteenth and early twentieth centuries, the role of local and central government changed dramatically in scope – from temporary actions against

114 Narrative disease outbreaks, to extensive services to prevent and control infection, to the provision of GP, hospital and specialist services for all. Distribution of these services varied between nations and regions, reflecting how they were shaped by many factors – perceived local need, national and local economic conditions, the views of MPs and local politicians, and of the medical profession. State medicine was never just a product of the state, but of society.

Part III

Assessment

8 Medicine in modern Britain: change, continuity, variation

It is many years since academics portrayed the history of medicine as a simple story of progress: from ineffective therapeutics informed by wrongheaded theory to live-saving treatments backed up by the latest science, delivered by highly skilled practitioners and accessible to all through government schemes. That such tales still persist in popular accounts of medicine, inviting readers to cringe at the consequences of being ill in earlier times, is testament to the power of the notion of progress: who would not be thankful to live in a world with aspirin, anaesthetics and antibiotics? Rather than a story of progress, the history of medicine in Britain between 1780 and 1950 is one of change and continuity. Some aspects of medicine changed radically and sometimes rapidly, in others, new ideas and practices came more slowly. In all cases there were variations in the experience of medicine across class, gender, and geography. The most radical changes occurred in the role of institutions within medical practice. In 1780, there were few hospitals, offering care to the deserving poor little different from that available in a middle-class home. By 1950, hospitals offered the highest standards of care to the whole population, employing well trained staff and modern equipment. Fundamental change also occurred in the role of the state in medicine. In 1780, government had no role in providing care or preventing disease, which was left to individuals and to charities. In the first decades of twentieth century, local government was responsible for carrying out legislation to control the spread of a range of diseases. After 1948, central government was the chief provider of care through the NHS. Partly (but only partly) as a consequence of the actions of government and medical care, patterns of disease shifted over time. Public health measures at least helped to reduce the incidence of diseases spread through contaminated water and food, and smallpox mortality declined with compulsory vaccination. By the end of the nineteenth century, deaths from infectious diseases had declined significantly and life expectancy rose, creating a greater population of elderly people likely to suffer from chronic ailments such as cancers. But while causes of death changed markedly, there was striking

118 Assessment continuity in morbidity: in 1950, as in 1780, most illness were minor ones – colds, stomach upsets and bad backs. A complex mix of change and continuity characterised developments in the medical professions. Elite physicians in 1780 and all qualified practitioners in the mid-twentieth century could claim to be well educated and enjoyed high social standing, but in other respects their professional life was very different. Practitioners in the twentieth century, unlike their predecessors, had a strong, shared identity with fellow practitioners, and their training, licensing and many aspects of their work were regulated by professional organisations or government. Unlike earlier generations of practitioners, they were no longer entrepreneurs but employed by the state. Different patterns of change occurred even in related aspects of medicine. Over the course of the nineteenth century, understandings of the body and of disease were revolutionised. Practitioners (and patients) abandoned the idea that disease was a holistic phenomenon, in which lifestyle changes upset a balance of vital processes, and accepted notions of localised disease – that illness arose from a malfunction of a specific organ or tissue or was the result of invading bacteria. However ideas from different medical cosmologies (to borrow Jewson’s terminology) persisted alongside each other: remnants of humoural theory persisted in beliefs that lifestyle caused some illnesses in the minds of some patients if not their practitioners. At the same time, therapeutics showed a much greater level of continuity. Traditional medicines, prescribed to provoke evacuations, remained in use long after the theory that supported their use had fallen out of favour among practitioners. New surgical procedures to remove diseased tissues had mixed success, and in the case of efforts to transplant gland tissues, were abandoned. It was not until the twentieth century that patients and practitioners had access to a range of new drugs, developed within the laboratories of pharmaceutical companies. The complex pattern of change over time is further complicated by variations in access to care across class and gender and in the provision of care between nations and geographical regions. As a general rule, wealthier patients enjoyed greater access to medical services than poorer people, and working-class men were more likely to consult a practitioner than their wives or children. Rural areas were always less well supplied with practitioners (who found it easier to make a living in towns and cities) and limited sources of funding meant that there were fewer charitable institutions and local government schemes to provide care. Such considerations applied across Britain, but there were also variations between the different nations. Health matters in Scotland and Ireland (and later Northern Ireland) were covered by separate legislation, framed to take account of the different central and local government agencies outside England and Wales. Apparently equivalent measures could be applied differently in each nation: Scottish mothers and infants were less able to access local government welfare centres in the early twentieth century, for example. Patterns of use of asylums also suggests variation in cultural attitudes across the nations.

Medicine in modern Britain  119 Historians of medicine have sought to analyse these changes, and the factors behind them, by placing medicine in its intellectual, social and political context. Thus the new medical theories enshrined in hospital and laboratory medicine were able to flourish in particular institutional contexts – in medical schools associated with hospitals (especially, but not exclusively, in Paris) and the universities in the German states and later in universities throughout the Western world. Voluntary hospitals were established in urban communities with enough wealthy local people to support the building and running of large and increasingly expensive institutions, not just because donors saw a need for such facilities but because they gained personal and collective kudos from contributing to them. Schemes to promote infant welfare were established through a combination of different motivations. They emerged in the political context of the development of welfare policies by a Liberal government and the desire to ensure a healthy future population to provide manpower for the defence of the nation and Empire. The schemes themselves reflected political realities in their reluctance to address the underlying problems of poverty and poor housing that were associated with high infant mortality. The decision not to provide free meals and milk to mothers was informed by a vision of family life, pushing working-class men to accept their role as breadwinner and not to become dependent on state aid to support their families. A range of factors, then, fostered the emergence and establishment of modern medicine in Britain by 1950. Developments in medicine did not end in 1950, of course, and issues from earlier times continue to trouble presentday policy makers. While the introduction of the National Health Service succeeded in reducing some of the inequalities of care provision, politicians still struggle with variations in service across nations and regions. Just as late nineteenth-century hospitals were constantly in need of funds to meet demands for care, administrators are now faced with finding sufficient support to provide care for an aging population, many of whom suffer from chronic diseases. History cannot give answers to modern policy questions, but it can at least explain the process by which these issues arise.

Part IV

Documents

Documents  123

Document 1 Description of fevers William Buchan (1729–1805) published Domestic medicine in 1769: it was a medical bestseller going through multiple editions and remaining in print for almost a century. Intended for a general reader, it gave practical advice on the treatment of a wide range of ailments Fevers are not only the most frequent of all diseases, but they are likewise the most complex. In the most simple species of fever there is always a combination of several different symptoms. The distinguishing symptoms of fever are, increased heat, frequency of pulse, loss of appetite, general debility, pain in the head, and a difficulty in performing some of the vital or animal functions. The other symptoms usually attendant on fevers are, nausea, thirst, anxiety, delirium, weariness, wasting of the flesh, want of sleep, or the sleep disturbed and not refreshing . . . Fevers are divided into continual, remitting, intermitting, and such as are attended with cutaneous eruption or topical inflammation as the small pox, erysipelas, &c. By a continual fever is meant that which never leaves the patient during the whole course of the disease, or which shews no remarkable increase or abatement in the symptoms. This kind of fever is likewise divided into acute, slow, and malignant. The fever is called acute when its progress is quick and the symptoms violent; but when these are more gentle, it is generally denominated slow. When livid or petechial spots shew a putrid state of the humours, the fever is called malignant, putrid, or petechial. A remitting fever differs from the continual only in a degree. It has frequent increases and decreases, or exacerbations and remissions, but never wholly leaves the patient during the course of the disease. Intermitting fevers or agues are those which, during the time that the patient may be said to be ill, have evident intervals or remissions of the symptoms. Source: William Buchan, Domestic Medicine Or, a Treatise on the Prevention and Cure of Diseases, London: R. Butters, 1808, pp. 128–129.

Document 2 Victims of cholera Henry Acland (1815–1900) taught medicine at Oxford University. His description of the cholera outbreak in Oxford, part of a wider epidemic in 1854–55 captures the connections made between susceptibility to cholera and poor living conditions and immoral behaviours such as drinking. Soon after 5 one morning, a woman awoke in the agony of cramps, with intense and sudden collapse. She was seen at 6. There was in her room no

124 Documents article of furniture, but one broken chair; no bed of any kind, no fire, no food; she lay on the bare boards; a bundle of old sacking served for a pillow; she had no blanket, nor any covering but the ragged cotton clothes she had on. She rolled, screaming. One woman, scarcely sober, sat by; she sat with a pipe in her mouth, looking on. To treat her in this state was hopeless. She was to be removed. There was a press of work at the Hospital, and a delay. When the carriers came, her saturated garments were stripped off, and in the finer linen and the blankets of a wealthier woman she was borne away, and in the Hospital she died. Her room was cleaned out: and the woman that cleaned it had next night the Cholera. She and her husband were drunk in bed. The agony sobered her, but her husband went reeling about the room: in a room below were smokers and drinkers. Then a woman of the streets in her gaudiness came to see her. They would not hear reason, but drank more spirits. The victim of the Disease cried out to the end, that her soul was everlastingly lost; and she died. Source: Henry Acland, Memoir on the Cholera at Oxford in the Year 1854 with Considerations Suggested by the Epidemic, London: J. Churchill, 1856, p. 47–48.

Document 3 The Spanish Flu The influenza pandemic of 1918–20 was one of the deadliest pandemics in history. Instead of a relatively mild illness, this form of flu was severe, killing huge numbers of young adults in the prime of life. These men start with what appears to be an ordinary attack of La Grippe or Influenza, and when brought to the Hosp[ital], they very rapidly develop the most vicious type of pneumonia that has ever been seen. Two hours after admission, they have Mahogany spots over the cheek bones, and a few hours later you can begin to see the Cyanosis1 extending from their ears and spreading all over the face . . . It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. Source: Letter from Camp Devens, Mass., 29 September 1918 reproduced in Tom Quinn, Flu: A Social History of Influenza, London: New Holland, 2008, p. 129.

1  a blue colour to the skin, due to lack of oxygen in the blood

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Document 4 The increase in cancer Picture Post was a popular magazine in the 1930s and 1940s. Although best known for its photojournalism, the magazine carried articles on a wide range of issues, including health and medicine. Let us be perfectly honest. Cancer is the great unsolved problem of human suffering. In spite of all the brilliant research, we still know almost nothing about its causes which can be turned to practical use in preventing it. It is also true that more people die of this disease very year, and that at present a very large number of sufferers never discover what is wrong with them until it is too late. When we have said this we have said the worst. The happier side of the cancer problem is not so generally understood. In this article we shall not hide unpleasant facts, but we shall show that there is no reason why so any people should allow themselves to be haunted with terror about cancer, and that the very first step towards reducing the likelihood of any given person becoming its victim is to change this attitude of fear into one of courage. Is Cancer Increasing? The secret fears which exist in so many people’s minds are stimulated by the knowledge that more people die every year of cancer: 55,000 in 1926, 69,000 ten years later; 867 deaths per million living in the first five years of the century; more than 1,600 per million living now. It is probable, however, that in spite of these figures the situation is not as serious as it looks . . . [O]ne of the reasons why the number of deaths from cancer goes up is that we know more about the disease, and therefore attribute more deaths to it. But the chief reason for the increase of deaths is that the population of England grows older every year. Cancer is a disease of later life, and therefore more people who fail to die of other diseases have to die later of cancer . . . To those, therefore, who are frightened because cancer seems to be so seriously on the increase, we must point out that things are not as bad as they may seem, first, because much of this increase is due to better diagnosis, second to the successful war waged against other disease, and third, to the fact that so long as we have all to die of something, more of us will die of those diseases which are the hardest to treat and most likely to attack older people. Source: ‘Cancer’, Picture Post, 19 August, 1939, p. 60.

126 Documents

Document 5 Variations in mortality William Farr (1807–1883) was the first superintendent of statistics at the Registrar-general’s office for England and Wales. His exhaustive analyses of mortality in different areas was intended to prove the links between disease and dirt, and to force local authorities to take action. Mortality of Children (0–5) in different districts Death in childhood is an unnatural event, inasmuch as the regular series of development of the human structure from the germ-cell to the perfect man in his prime, and in his last declining stage of existence, is . . . interrupted. But life at all ages depends upon so many conditions, and is exposed to so many risks, that out of given numbers living some die at every age, and we can only take for a practical standard the lowest authenticated rates of mortality . . . Thus in the 63 Healthy Districts of England the annual mortality of boys under five years of age was at the rate of 4.348 and of girls 3.720 per cent.; the mean being 4.034. Twenty-eight districts have been selected, showing the low annual rate of mortality 3.348 for the mean of the rates of the two sexes: the boys dying at the rate 3.576, the girls at the rate 3.120 . . . The twenty-eight districts are found in all the regions of England and Wales, from the northern limits of Northumberland to the New Forest on the Southampton Waters . . . Very different are the rates of mortality among children in one hundred and fifty-one districts; where the lowest mortality among boys is at the rate of 7.084, and the highest at the rate of 13.741 per cent. annually. The mean mortality of the districts was for boys 8.593, for girls 7.432, for both sexes 8.013 . . . The population of children in the one hundred and fifty-one districts was 1,391,420 in 1861; and the annual deaths at the rate (3.348) of twenty-eight healthy districts . . . would be 46,585; while at the mean rate (8.013) would be 111,494. Thus there is an annual sacrifice of about 64,909 children’s lives by various causes in one hundred and fifty-one districts of the kingdom . . . There is no doubt great negligence on the part of the parents, great ignorance of the conditions on which health depends, and great privation among the masses of the poor, but there is no reason to suspect that any great number of the infants in these districts fall victim to deliberate crime; yet the children of the idolatrous tribe who passed them through the fire to Moloch scarcely incurred more danger than is incurred by the children born in several districts of our large cities. Source: William Farr, Letter to the Registrar-general on the mortality in the registration districts of England during the ten years 1851–1860 in Supplement to Registrar-general’s Twenty-fifth Annual Report, London: For Her Majesty’s Stationery Office, 1864, pp. ix–xiii.

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Document 6 The health of working class women Margery Spring Rice (1887–1970) was a social reformer, particularly interested in issues around women’s health and access to birth control. Her book was based on a survey of 1250 married women from across Britain [W]omen show a general disinclination to fuss about themselves . . . Advice therefore is not sought as often as it should be, or if sought is not taken . . . The most controlling factor in this is poverty, especially in those illnesses which the women thinks she can fairly safely overlook, such as headaches, constipation, anaemia, and bad teeth. Here is a typical example of this attitude, governed by lack of funds . . . Mrs. F. of Sheffield. She is 47 and has had seven children, of whom two have died . . . She has rheumatism, (since she had an operation for gallstones two years ago,) toothache, headache and back-ache. For none of these does she consult anyone. She owes her private doctor for the last five years’ attendance, including the last confinement, £14, which she pays off in 1/- weekly instalments. Rheumatism, gynaecological troubles and bad legs being much more crippling to work, show a larger percentage of advice sought and treatment taken. Gynaecological trouble has other features in respect of treatment. The woman probably does not recognise the symptoms herself. (‘Backache since birth of baby’. ‘Internal trouble through confinements’, are frequent complaints for which no advice and treatment have been sought,) and in the absence of a thorough post-natal examination, the trouble is not discovered until the birth of the next child, often not then if she has not been attended by a doctor. When it is discovered, much greater pressure is brought to bear on her by the doctor or nurse to have the matter attended to. An example of this is given by a Manchester woman of 35 who has three children. She has had very bad backache since her first confinement, and at her second confinement the doctor diagnosed a prolapse and advised an operation. She could not face this then, but the condition has got worse since the birth of the third child, and she is now ‘waiting for the bed in the hospital’. Source: Margery Spring Rice, Working Class Wives. Their Health and Conditions, 1939, pp. 39–41.

Document 7 The action of fever William Cullen was one of the most respected teachers and practitioners in eighteenth century Britain. First Lines of the Practice of Physic, published in 1777 and frequently reprinted, was a textbook based on his lectures, which reflected his views on the causes of disease. 35. To discover the cause of the cold stage of fevers, we may observe, that it is always preceded by strong marks of a general debility prevailing in the system. The smallness and weakness of the pulse, the paleness and coldness

128 Documents of the extreme parts, with the shrinking of the whole body, sufficiently show that the action of the heart and larger arteries is, for the time, extremely weakened. Together with this, the languor, inactivity, and debility of the animal motions, the imperfect sensations, the feeling of cold while the body is truly warm, and some other symptoms, all show that the energy of the brain is . . . greatly weakened; and I can presume, that, as the weakness of the action of the heart can hardly be imputed to any other cause, this weakness is also a proof of the diminished energy of the brain . . . 39. That the increased action of the heart and arteries which takes place in the hot stages of a fever, is to be considered as an effort of the vis medicatrix naturae,2 has been long a common opinion among physicians, and I am disposed to assert that some part of the cold stage may be imputed to the same power. I judge so, because the cold stage appears to be universally a means of producing the hot; because cold, externally applied, has often very similar effects; and more certainly still because it seems to be in proportion to the degree of tremor in the cold stage . . . 40. It is to be particularly observed, that, during the cold stage of fever, there seems to be a spasm induced every where on the extremities of the arteries, and more especially of those upon the surface of the body. This appears from the suppression of all excretions, and from the shrinking of the external parts; and although this may perhaps be imputed, in part, to the weaker action of the heart in propelling the blood to the extreme vessels; yet as these symptoms often continue after the action of the heart is restored, there is reason to believe, that a spasmodic contraction has taken place; that it subsists for some time, and supports the hot stage; for this stage ceases with the flowing of the sweat, and the return of other excretions which are marks of the relaxation of vessels formerly constricted. Source: William Cullen, First Lines of the Practice of Physic, vol. 1, Edinburgh: Bell & Bradfute, 1816, pp. 36–38.

Document 8 Pathological changes in the lung Matthew Baillie was a teacher and anatomist. His Morbid Anatomy, published in 1793, was the first systemic survey of different types of pathological changes within the body, and their relation to disease. Tubercles There is no morbid appearance so common in the lungs as that of tubercles. These consist of rounded firm white bodies, interspersed throughout their 2  The natural power of the body to heal itself.

Documents  129 substance. They are probably formed in the cellular structure, which connects the air cells of the lungs together, and are not a morbid affection of glands, as has been frequently imagined . . . They are at first very small, being not larger than the heads of small pins, and in this case are frequently accumulated in small clusters. The smaller tubercles of a cluster probably grow together and form one large tubercle. The most ordinary size of tubercles is about that of a garden pea, but they are subject in this respect to much variety. They adhere pretty closely to the substance of the lungs, have no peculiar covering or capsule, and have little or no vascularity. When cut into, they are found to consist of a white, smooth substance, having a firm texture, and often contain in part a thick curdly pus. When several tubercles of considerable size are grown together, so as to form a pretty large tuberculated mass, pus is very generally found upon cutting into it. The pus is frequently thick and curdly; but when in considerable quantity, it is thinner, and resembles very much the pus from a common sore. In cutting into the substance of the lungs, a number of abscesses is sometimes found, from pretty large tubercles having advanced to a state of suppuration. In the interstices between these tubercles, the lungs are frequently of a harder, firmer texture, with the cells in a great measure obliterated. The texture of the lungs on many occasions, however, round the boundaries of an abscess, is perfectly natural. Source: Matthew Baillie, The Morbid Anatomy of Some of the Most Important Parts of the Human Body, Walpole, NH: G. W. Nichols, 1808, pp. 49–50.

Document 9 The technical language of medicine This extract is from an anonymous diary kept by a student studying in Paris. The author is probably James Surrage, who had previously studied at the Edinburgh Medical School. The diary records his daily experiences, and how he had absorbed the new ideas of pathological anatomy and the new language used to describe disease symptoms. Went this morning to the Hopital La Charité – saw a case of fever (typhus) with complications in the chest, & suspected also, in abdomen – he has been admitted about ten days – lips & cheeks are livid, skin moderately warm – respn [respiration] vey oppressed, 50 in a minutes – considerable mucous râle3 in the smaller ramifications of the bronchi – pulse 120 – skin is dry and very dirty, has had no bath or tepid ablutions &c – tongue is protruded with consid.[considerable] difficulty . . . Case of diseased heart – came in today – it is easy by means of the stethoscope to detect consid[erable] bruit de soufflet4 in the region of the left side 3  Rattle or abnormal sound 4  Literally ‘breath noise’ – a description of the abnormal sound from the heart

130 Documents of the heart, whilst under the sternum the sounds are nat[ural] apex . . . is perceived immedly [immediately] under the margin of the 6th rib – hence of course enlargement of the left side of the heart was diagnosed. There is a remarkably curious case on the wards, which has puzzled the stethoscopists, not a little. A  man who has been in the house [hospital] some time with cough, & . . . muco purulent expectoration, has had, ever since his entrance, a very loud pectoriloquy5 & apparent cavernous respiration6 in the region of the subspinous fossa7 of the right scapula – superiorly he had loud bronchophony8 – the chest is universally duller – today the pectoriloquy has extended over the whole extend of the posterior part of the right side of the chest – the man has not a phthisical countenance,9 his pulse is only 76 & and he has no hectic [fever] . . . this curious case has received no elucidation from either pupils or physician. Source: Diana E. Manuel (ed.) Walking the Paris Hospitals: Diary of an Edinburgh Medical Student, 1834–1835, London: The Wellcome Trust Centre for the History of Medicine at UCL, 2004, pp. 41–42.

Document 10 The physiology of the kidney John Hughes Bennett (1812–1875) studied in Edinburgh, Paris and Berlin. He pioneered teaching in the use of the microscope at Edinburgh and was later appointed Professor of Medicine. Outlines of Physiology was a popular textbook of medicine, based on his teaching. Excretion from the kidneys – The two kidneys contain in their cortical substance globular convolutions of capillary vessels, which hang in the blind extremities of the tubular glands. This arrangement permits the ready passage of a large amount of water from the blood, which, as it flows out through the duct, receives the secretion formed by the cells which line them. The whole accumulates in the urinary bladder in the form of urine, and is expelled from time to time voluntarily . . . The daily amount of urine discharged in a healthy person is about 35 fluid ounces. It is of a wine-yellow colour, and slightly acid . . . The proportion of [its] constituents varies considerably, even in health, according to the amount and quantity of food and drink, the occupation,

5  A condition where the voice can be heard through the lungs 6  A hollow resonance in the chest 7  Cavity beneath the shoulder blade 8  A condition where the voice can be heard through the small branches of the windpipe that lead into the lungs 9  Face or facial expression associated with phthisis or tuberculosis

Documents  131 period of life, sex, and other circumstances. In disease the variations are still greater. The quantity, as a whole, may be increased or diminished, and the saline constituents may be so augmented as to be deposited on cooling, causing the formation of various salts. The urine may also be loaded with foreign substances, as blood, albumin, pus, sugar, &c. Hence why a careful examination of this fluid is so important to the physician, as indicating a variety of morbid conditions, not only of the urinary organs themselves, but of the constitution generally. Source: John Hughes Bennett, Outlines of Physiology, Edinburgh: Adam and Charles Black, 1858, pp. 91–93.

Document 11  The benefits of physiological research For much of the nineteenth century, some practitioners questioned the usefulness of research into the function of the body, as it inspired no new treatments. Matthew Baillie, one of the pioneers of pathological research was convinced of its merits. Some diseases consist only in morbid actions, but do not produce any change in the structure of the parts; these do not admit of anatomical inquiry after death. There are other diseases, however, where alterations in the structure take place, and these become the proper subject of anatomical examination. The object of this work is to explain, more minutely than has thitherto been done, the changes of structure arising from morbid actions in some of the most important parts of the human body. This, I hope, will be attended with some advantages to the general science of medicine, and to its practice. It is very much to be regretted that the knowledge of morbid structure does not lead with certainty to the knowledge of morbid actions, although one is the effect of the other; yet surely it lays the most solid foundation for prosecuting such enquiries with success. In proportion, therefore, as we shall become acquainted with the changes produced in the structure of the parts from diseased actions, we shall be more likely to make some progress towards a knowledge of the actions themselves, although it must be very slowly. The subject in itself is extremely difficult, because morbid actions are going on in the minute parts of an animal body excluded from observation; but still the examination of morbid structure is one of the most probable means of throwing light upon it. Source: Matthew Baillie, The Morbid Anatomy of Some of the Most Important Parts of the Human Body, Walpole, NH: G. W. Nichols, 1808, Preface to the first edition, p. v.

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Document 12 A holistic view of the body Ernest Starling (1866–1927) Professor of Physiology at University College London carried out important research into the controls on fluid balance and on heart function. He is best known for his discovery of hormones, and their role in co-ordinating body function. In one sense we may say that every cell in the body is chemically connected with and dependent on all the other cells of the body. This interdependence is a necessary consequence of the differentiation of function associated with the increased complexity of the organism. Thus the food-stuffs are digested and absorbed by the cells lining the alimentary canal and are then transmitted, more or less changed by these cells, to all the other tissues of the body. The liver stores up glycogen and is ready to give of its store to any tissue in need of carbohydrate . . . All tissues produce carbon dioxide, which passes to the lungs to be excreted, but as it traverses the respiratory centre it arouses respiratory movements which are exactly proportioned to the tension of the carbon dioxide and therefore to the need of the whole body to eliminate this waste product . . . When the adaption to a change at A consists in the activity of an organ B, the activity of B can be evoked either by nerve impulse passing from A to the central nervous system and from this to B, or by the production at A, as a direct consequence of the stimulus, of a specific chemical substance, which passes into the circulating blood to B, where in its turn it will excite the required state of action. Such chemical messengers are designated hormones . . . Source: Ernest H. Starling, Principles of Human Physiology, Philadelphia, PA: Lea & Febiger, 1912, p. 229.

Document 13 The benefits of exercise Hartvig Nissen (1857–1924), born in Norway, was one of the popularisers of ‘Swedish gymnastics’ – a system of exercises designed to promote health and strength developed in the nineteenth century. Not only by lack of exercise in general, but especially by want of motion of the arms, respiration is weakened and rendered imperfect, and as a consequence the elastic wall of the chest is either not fully expanded and developed, or becomes abnormally contracted. The blood being, from this cause, insufficiently oxygenised in the lungs, it is obvious that the conditions established are favourable to diseases of the heart and lungs, and other organs. The muscles of the abdomen, lying between the ribs and pelvis, aid, by their contractile power, in strengthening the functions of the abdominal

Documents  133 organs, such as digestion, secretion, and peristaltic action, besides cooperating most effectively with the thoracic muscles in the act of respiration . . . The importance of preserving the elasticity and strength of this class of muscles is, therefore, obviously great . . . The muscles of the back move the trunk axially, and in other directions, and by keeping it erect, co-operate with those which govern respiration; they hinder any cramping of the stomach and other abdominal organs, whereby the latter are enabled to perform their functions as freely as possible. It is thus easy to perceive that the development of these muscles of the trunk will not only prevent curvature or crookedness, but a train of evils of greater consequence. It is, however, a fact of still more importance that their due exercise tends directly to strengthen the spinal column, and hence nearly all nervous diseases, dependent on weakness of the spine, may be avoided, besides providing the best of all protections against general debility or illness, and consequent nervous irritability. Source: Hartvig Nissen, Health Exercises and Home Gymnastics: How to Train, Strengthen, and Develop the Body Without Use of Dumb-bells or Other Appliances, With Some Exercises for Women, New York: Ward Lock, 1901, pp. 58–60.

Document 14 Health and sunlight Caleb William Saleeby (1878–1940) trained in medicine and practiced in London for a number of years, before turning to writing. He campaigned for a number of health-related causes, including access to clean air and sunshine. THE SUNLIGHT LEAGUE Sir,—Very late in the day, but not too late I hope, we are remembering that “In the beginning, God said, Let There be Light.” The protests of John Ruskin, so long ago, against the “plague cloud,” are found to understate the truth. Smoke and slums and brick and even window-glass—opaque to ultra-violet rays—are seen to immure and stifle, to bleach whilst they blacken, the children whom Heaven meant to be children of light. The lifelong arguments of some few of us have been verified by the laboratories of a dozen countries during the last few years. Everywhere medical men are ordering lamps of various types for the practice of artificial phototherapy upon patients who cannot go to Switzerland. New discoveries, certainly epoch-making, have already been made by the Committee on Light, the first in the world, appointed by the Medical Research Council, at my suggestion, early in 1922. The sunlight is our common heritage and our common need. The nation’s children, our future, all need it even more than the fortunate few

134 Documents who can repair to their villas on the Riviera when the “November particulars” [fogs] return. The restoration of sunlight to our malurbanized millions is the next great task of public health in our country. The Sunlight League has been formed to point to the light of day, to advocate its use for the cure of disease—“helio-therapy”; and, immeasurably better, for preventive medicine and constructive health, the building of whole and happy bodies from the cradle and before it, which we may call helio-hygiene. Many distinguished persons have joined the movement, which is being inaugurated at Carnegie House this week. It is national, and aimed against no party nor class, nor interests but such as rob us of our sunlight, turn our cities in winter into cold hells, and call the process industry, or imprison children in shadow and call the process education. We ask you, Sir, and your readers, to support a campaign for sunlight and for education about it. We have not forgotten, in our zeal for the light of the sun and our hatred of the diseases of darkness, that Shakespeare said “There is no darkness but ignorance.”—I am, Sir, &c., C. W. SALEEBY The Sunlight League, Temporary Office, 20 Park Crescent, London. Source: Letter to The Spectator, 17 May 1924, p. 14.

Document 15  Domestic remedies First published in 1861, Mrs. Beeton’s Book of Household Management was a best seller. Although now widely known for its recipes, the book covered all aspects of running a middle class home, including first aid and treatments for common ailments. 2597. Mustard poultice. Mix equal parts of dry mustard and linseed-meal in warm vinegar. When the poultice is wanted weak, warm water may be used for the vinegar; and when it is required very strong, mustard alone, without any linseed-meal, is to be mixed with warm vinegar. [. . .] 2602. Fomentations are generally used to effect, in a part, the benefit produced on the whole body by the bath; . . . the object being to relieve the internal organ, as the throat, or muscles round a joint, by exciting a greater flow of blood to the skin over the affected part. As the real agent of relief is heat, the fomentation should always be as hot as it can comfortably be borne, and, to insure effect, should be repeated every half-hour. Warm fluids are applied in order to render the swelling which accompanies inflammation less painful . . . They are of various kinds; but the most simple, and oftentimes the most useful, that can be employed, is “Warm Water.” Another kind of fomentation is composed of dried poppyheads, 4 oz. Break them to pieces, empty out the

Documents  135 seeds, put them into 4 pints of water, boil for a quarter of an hour, then strain through a cloth or sieve, and keep the water for use. Or, chamomile flowers, hemlock, and many other plants, may be boiled, and the part fomented with the hot liquor, by means of flannels wetted with the decoction. [. . .] 2625. TO CURE A COLD. – Put a large teacupful of linseed, with ¼ pound of sun raisins and 2oz of stick liquorice, into 2 quarts of soft water, and let it simmer over a slow fire till reduced to one quart; add to it ¼ lb. of pounded sugar-candy, a tablespoonful of old rum, and a tablespoonful of the best white-wine vinegar, or lemon juice . . . The dose is a half a pint, made warm, on going to bed; and a little may be taken whenever the cough is troublesome. The worst cold is generally cured by this remedy in two or three days; and if taken in time, is considered infallible. [. . .] 2686. Class 1. Incised wounds or cuts. – The danger arising from these accidents is owing more to their position than to their extent. Thus, a cut of half an inch long, which goes through an artery, is more serious than a cut of two inches long, which is not near one. Again, a small cut on the head is more often followed by dangerous symptoms than a much larger one on the legs. Treatment. If the cut is not a very large one, and no artery or vein is wounded, this is very simple. If there are any foreign substances left in the wound, they must be taken out, and the bleeding must be quite stopped before the wound is strapped up. If the bleeding is not very great, it may easily be stopped by raising the cut part, and applying rags dipped in cold water to it. All clots of blood must be carefully removed; for, if they are left behind, they prevent the wound from healing. When the bleeding has been stopped, and the wound perfectly cleaned, its two edges are to be brought closely together by thin strips of common adhesive plaster, which should remain on, if there is not great pain or heat about the part, for two or three days, without being removed. The cut part should be kept raised and cool . . . If the wound is not healed when the strips of plaster are taken off, fresh ones must be applied. Great care is required in treating cuts of the head, as they are often followed by erysipelas taking place round them . . . keep the patient quite quiet, on a low diet, for a week or so, according to his symptoms. Purge him well with the no. 2 pills . . . If the patient is feverish, give him two tablespoonfuls of the fever mixture three times a day . . . A person should be very careful of himself for a month or two after having had a bad cut on the head. His bowels should be kept constantly open, and all excitement and excess avoided. Source: Isabella Beeton, The Book of Household Management, London: S. O. Beeton, 1861, pp. 1063, 1064, 1074, 1093–1094.

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Document 16 Patent medicines Robert Roberts grew up in Salford in the years before the First World War, where his mother ran a corner shop. He became a teacher and writer, and in 1971 published an account of his early life, which aimed to counter sentimental portrayals of working class communities. This was the heyday of quack medicine . . . Innumerable nostrums, some harmless, some vicious, found ready sale among the ignorant. One had to be seriously ill before a household would saddle itself with the expense of calling a doctor . . . At week ends people purged themselves with great doses of black draught, senna pods, cascara sagrada, and their young with Gregory powder, licorice powder and California syrup of figs. For all these on Friday night they came to the shop in constant procession. Through the advice of doctors and wide advertisement the working class had an awful fear of constipation. A condition brought on by the kind of food they ate . . . Pills sold at a penny a box . . . Nearly all the pills appeared to possess a dual purpose; they ‘attacked’ at one and the same time the ills of two intestines – ‘Head and Stomach’, ‘Blood and Stomach’, ‘Back and Kidney’, ‘Back and Bladder’, and indeed almost any pair of organs that could in decency be named. Whatever their aim . . . all pills contained the same ingredients, soap and a little aperient [laxative]; but they differed in colour, the ‘blood and stomach’ variety being red, say, and the ‘back and bladder’ a pea green . . . The boldest purveyor, who took a quarter-page spread in the local newspaper, appeared to be a ‘Mr. W. H. Veno’. A  charismatic figure, he was shown standing before a screen in a great beam of light. ‘His marvellous diagnostic power’, the advertisement assured us, ‘borders on the superhuman. He sees a sick person at a glance, reads his disease without asking a question and with the utmost accuracy.’ He . . . had withal a ‘rare gift’ which enabled him to ‘cure the sick and diseased in a manner that reads like miracles’ . . . his patients . . . took ‘People’s Strengthener and Health Giver’ – Sea-Weed Tonic at 1s 1 1/2 d and 2s 9d a bottle. Doctors used it too, because ‘they recognised in Sea-Weed Tonic the most successful medicine that science has yet produced for liver, kidney and blood diseases’. Source: Robert Roberts, The Classic Slum. Salford Life in the First Quarter of the Century, Manchester: Manchester University Press, 1971, p. 97–99.

Document 17  Hydropathic treatment Charles Darwin (1809–1882), the naturalist and originator of the theory of evolution by natural selection, suffered from chronic digestive illness

Documents  137 from the 1840s. He consulted many doctors, and spent some time at a hydropathic spa, under the care of its owner, Dr. James Gully. His letter describes a typical hydropathic treatment regime. To Susan Darwin, Malvern, 19 March 1849 As you say you want my hydropathical diary, I will give it to you . . . 1/4 before 7. get up, and am scrubbed with rough towel in cold water for 2 or 3 minutes, which after the first few days, made and makes me feel very like a lobster – I have a washerman, a very nice person, and he scrubs behind and I scrub in front. – drink a tumbler of water and get my clothes on as quick as possible and walk for 20 minutes – I c[oul]d walk further, but I find it tires me afterwards – I like all this very much. – At the same time I put on a compress, which is a broad wet folded linen covered by mackintosh and which is ‘refreshed’ – ie dipt in cold water every 2 hours and I wear it all day, except for about 2 hours after midday dinner; I don’t perceive much effect from this of any kind. – After my walk, shave and wash and get my breakfast, which was to have been exclusively toast with meat or egg, but he has allowed me a little milk to sop the stale toast in. At no time must I take any sugar, butter, spices tea bacon or anything good. – At 12 oclock I put my feet for 10 minutes in cold water with a little mustard and they are violently rubbed by my man; the coldness makes my feet ache much, but upon the whole my feet are certainly less cold than formerly. – Walk for 20 minutes and dine at one. – He [Dr Gully] has relaxed a little about my dinner and say I may try plain pudding, if I am sure it lessens sickness. After dinner lie down and try to go to sleep for one hour. – At 5 oclock in cold water – drink cold water and walk as before Supper same as breakfast at 6 oclock, – I have had much sickness this week, but certainly have felt much stronger and the sickness has depressed me much less. Source: Frederick Burkhardt and Sydney Smith, (eds) The Correspondence of Charles Darwin, vol. 4, Cambridge: Cambridge University Press, 1988, p. 224.

Document 18 Treatment of heart disease John Milner Fothergill (1841–1888) was a general practitioner, educated in Edinburgh and Berlin. He had a special interest in heart disease, and this extract reflects new ideas about heart function, and the use of new drugs. It also reveals how practitioners felt that they had authority to tell patients how to live their lives. . . . In acute affections of the heart, the same line of practice is clearly to be adopted – for acute conditions are ever conditions of adynamy. These affections may be either conditions of acute heart-failure as syncope; or

138 Documents inflammatory states, as pericarditis. In the first division no one would dream of resorting to any other than restorative measures, alcohol, sal-volatile, & c. In the acute inflammatory states of the heart, depletory or depressant remedies would not now suggest themselves to any unprejudiced mind. [. . .] When there is a growth of connective tissue-corpuscles in the fibrous structure of the valves . . . it is desirable that the vascular system be kept as quiet as possible; so as to avoid all strain on the inflamed valves. To get the patient up and to administer tonics is to increase the blood-pressure within the heart and arteries; and with them the pressure upon the intra-cardiac valves. The rational treatment is to keep the patient in bed a week at least after all the inflammatory symptoms have passed away: and to give choral or other vascular depressant, to keep the blood-pressure low. A few days more or less in bed is of little consequence compared to a mutilated valve and a crippled existence . . . The gradually failing heart losing ground day by day under the necessity for exertion, will commonly, when the individual is put to bed, commence to regather strength and force; as is often seen in hospitals, without any other treatment being adopted. If the condition be such as to permit of exertion, and the sufferer must make a living, then the lightest form of labour should be chosen . . . The effect of rest in heart affections is such that there is a very painful difference in the prognosis according to the circumstances of the patient; the inequality between rich and poor is here very vividly demonstrated . . . Not only is labour to be avoided, but anything which tends to tax the powers must be shunned. A debauch is very objectionable; and the question so frequently put to one, about a sufferer from organic disease of the heart, “may he, or she, marry?” must ordinarily be answered in the negative . . . Mental strain and anxiety are also to be avoided, and the cares of business are injurious. If the disease be pronounced, the sufferer should be ordered to quit business; and this should be insisted on with less compunction, as any grave disease of the heart enfeebles the intellect, and renders the brain incapable of sustained effort. Source: J. Milner Fothergill, The Practitioner’s Handbook of Treatment, or, The Principles of Therapeutics 4th edition, London: Macmillan and Co. Ltd. 1897, pp. 347–349.

Document 19 The experience of surgery Margaret Mathewson (1848–1880) came to Edinburgh in 1877 from her native Shetland, seeking a cure for her diseased shoulder joint. Lister successfully operated on the tuberculous abscess on the joint. Although Margaret had the benefit of anaesthetics and antiseptic treatment, she suffered a great deal of pain. She returned home after spending eight

Documents  139 months in hospital and in its convalescent home, and died of tuberculosis three years later. I felt very sick and kept on vomiting. The nurse brought a jug of ice and gave me a teaspoonful as soon as I stopped vomiting . . . I got more feverish and sick, and felt the vomiting grow more – straining on the stomack, and always grew weaker. Dr. Cheyne came and took my pulse, marked it down in the card . . . I vomited all the evening now and again. I went asleep but soon awoke and felt more feverish, also a bad headache, a strange pain about the joint and smarting all around as if it were cut. As the night wore on the pain increased, and at times I was on the eve of shouting, the pain was so severe . . . Nurses went and she seemed a long time away . . . she returned with a medicine glass of morphia, laudanum etc. She told me to take this quite up and it would better me . . . About 12.45 Professor [Lister] came and a train of students with him. He asked ‘Now do you find any pain?’ ‘Yes sir’ ‘What like is it. Is it a severe pain, an acute pain, an aching pain or starting pain?’ ‘It is neither sir, it is a squeezing pain as if it was squeezed with a cord sir.’ . . . Prof. Then dressed it with the [carbolic] spray, then put on chloride of zinc and moved the arm to and fro. The pain was indescribable. I never felt such excruciating pain before. I also felt the arm quite loose from my body. The pain caused me almost to faint. Prof. said to the students: ‘Gentlemen, I have a great fear of putrefaction setting in and you all know its outcome. Thus I will look anxiously for the second day or third day between hope and fear. I hope the chloride of zinc will preserve it but it is only an experiment . . . ’ Source: Margaret Mathewson, ‘Sketch of Eight Months a Patient, in the Royal Infirmary of Edinburgh, A.D. 1877’, extracts reprinted in Martin Goldman, Lister Ward, Bristol: Adam Hilger, 1987, pp. 79–80.

Document 20 An appeal for funds When proposing the creation of new hospitals, their promotors sought to appeal not just to the conscience or the sympathy of potential subscribers, but to make a case for how the new institution would serve the community. This appeal for funds to create an infirmary in Huddersfield (which finally opened in 1831) presents a typical mix of arguments. Institutions, for the reception and relief of the diseased and wounded, have long existed . . . throughout Europe; and the benefit derived from them

140 Documents is so important . . . that they seem to bear almost a regular proportion to the increase . . . of society. Hence their number and magnitude in large cities, and hence the interest taken in their welfare among all classes of the community . . . Benevolence, though generally engaged on the formation and promotion of these establishments, is not the only agent to which they are ascribed; for motives of a different kind . . . are equally obvious and powerful . . . All who have the opportunity of personally examining into the wants of the Poor, well know, that a large portion of their distress, in common times, arises from ill health. Many a decent family . . . has been brought to real misery by the sickness of the father or mother; or . . . the earnings of the parents are all consumed in the means of cure, or in alleviating the anguish of a child suffering under a long, painful, and necessarily expensive disease . . . – In many of those instances, timely assistance would have rendered the cure short and easy; but unable to bear, and fearful to incur the expense of Medical Advice, they are often induced to delay their application, till the case is beyond the reach of remedial means . . . Hence a poor family is driven, during sickness, to depend for the very necessaries of life upon their credit with the neighbouring Shopkeeper; and a system is thus introduced, which, more than any other, tends to degrade and demoralise the character . . . when the possibility of supporting themselves creditably is gone . . . a sort of moral despair succeeds, and they are content . . . to rely on a Parish [the poor law] for the future; thus they become useless, if not hurtful, members of the community. The expediency then, of aiding and accelerating the recovery of the health of the lower classes, especially the member on whose industry others are dependent for support, is quite unquestionable, though there were no higher reasons to enforce it than the policy of preventing . . . the necessity of an augmentation of poor rates. Further, the instruction which such establishments afford those persons who are destined to practice the various branches of the healing art . . . ultimately becomes advantageous to all ranks of society. Source: [W. Turnbull] An Appeal on Behalf of the Intended Hospital at Huddersfield, Huddersfield: n.p. 1825, in Deborah Brunton (ed.) Health, Disease and Society in Europe 1800–1930. A Source Book. Manchester: Manchester University Press; and Milton Keynes: The Open University, 2004, pp. 28–29.

Document 21  Rules from Huddersfield Infirmary The Huddersfield and Upper Agbrigg Infirmary opened in 1831. These rules give a sense of the power of the weekly Board of Governors over the admission of patients, and the behaviour of patients who were clearly not seriously ill.

Documents  141 Admission and discharge of patients That in-patients be admitted and discharged every Friday, at the weekly Board, between eleven and one o’clock. That no patient be admitted without a recommendation, except in cases of accident or great emergency; and a certain number of beds shall be reserved for such cases as will not admit of delay . . . That no person be admitted either as in or out-patient, who is able to pay for medical aid. That no apprentices or domestic servants be admitted as in-patients, except for capital [major] operations; in which cases their master or mistress shall pay ten shillings and sixpence per week for their subsistence . . . That no soldier . . . be admitted as an in-patient, unless his officer, or some other responsible person, engage to pay one shilling per day for his subsistence during his continuance on the house. That no woman advanced in pregnancy, no child under six years . . . or persons disordered in their senses, subject to epileptic fits, suspected to have the smallpox, measles, itch, or other infectious distemper, having habitual ulcers, syphilis . . . or those suspected to be in a consumption, or in an incurable or dying state, be admitted as in-patients; or, if admitted inadvertently, be allowed to remain . . . That all in-patients be discharged at the end of two months after their admission, unless their Physician or Surgeon certify to the weekly Board that there is great probability of cure, or considerable relief . . . That it be recommended to all patients, when discharged . . . to return thanks in their respective places of worship, and to carry a letter of thanks to their recommending Governor Rules for in-patients . . . That no patient go out of the Infirmary without leave from the Physician or Surgeon, or the Apothecary; or lie [sleep] out of the house on any account whatever, on pain of expulsion . . . . That there be no cursing, swearing, rude or indecent behaviour, on pain of expulsion after the first admonition. That there be no playing at cards or any other game within the limits of the Infirmary; nor any smoking, without leave from a Physician or Surgeon . . . neither shall spirituous liquors, nor any provisions, be introduced by the patients or their friends. That such patients as are able, be employed in nursing the other patients, washing and ironing the linen, cleaning the wards or any other work, but not without the leave of the Physician or Surgeon Source: Rules and Regulations of the Huddersfield and Upper Agbrigg Infirmary 1834, in Deborah Brunton (ed.) Health, Disease and Society in Europe 1800–1930. A Source Book. Manchester: Manchester University Press; and Milton Keynes: The Open University, 2004, pp. 24–26

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Document 22  Hospital design First published in 1859, Florence Nightingale’s Notes on hospitals summed up her views on hospital design. The work begins with a critique of the common faults of hospital design, and then goes on to discuss ideal forms for different types of hospitals. For Nightingale, the key aspects of hospital design was to ensure fresh air, cleanliness, and the prevention of the spread of infection. 3. Defects of Ward Construction injurious to Ventilation. – One of the most common causes of unhealthiness in hospitals is defective construction and arrangement of ward-space of such a nature as to lead to difficulty of ventilation, or want of light. The expression, ‘a good ward,’ comprehends something quite different from mere appearance. No ward is in any sense a good ward in which the sick are not at all times supplied with pure air, light, and a due temperature . . . Defective Height of Wards. – It is not possible to ventilate sufficiently a large ward of ten or twelve feet high . . . A ward of thirty beds can be well ventilated with a height of fifteen or sixteen feet, provided the windows reach to within one foot of the ceiling. Otherwise, the top of the ward becomes a reservoir for foul air . . . 6. Using Absorbent Material for Floors, Walls, and Ceilings of Hospitals, and Washing Floors. – The amount of organic matter given off by respiration and in other ways from the sick is such that the floors, walls, and ceilings of hospital wards – if not of impervious materials – become dangerous absorbents. The boards are in time saturated with organic matter, from this cause, as well as from accidental filth, and want of due attention to cleansing, and only require moisture to give off noxious effluvia. When the floors are being washed, the smell of something quite other than soap and water is perfectly perceptible, and there cannot be a doubt that washing dirty floors is one cause of erysipelas  & c., in some hospitals . . . Plastered walls, when not cleansed sufficiently, have led to increased impurity of the ward-air, and to hospital diseases. Source: Florence Nightingale, Notes on Hospitals, 3rd edition. London: Longman, Green, Longman, Roberts & Green, 1863 pp. 35, 44–45.

Document 23 The patient’s experience In 1928 Bella Aronovitch was admitted to hospital suffering from appendicitis. She underwent an operation, but the wound did not heal, and

Documents  143 she spent five years in a number of different hospitals. Her book gives a rare account of the conditions inside hospitals at this time. A few days after this first operation I had a visit from the hospital almoner . . . Following a few minutes’ talk with Sister she came over to me . . . and for the next quarter of an hour, her conversation consisted entirely of questions . . . How many of us were there at home? Who went to work and who were still at school? . . . the final question . . . was; could my family afford to pay towards my upkeep while I was in hospital and if so, how much. Having had a major operation I was stiff and sore with numerous stitches and draining tubes . . . I found all those questions rather trying . . . I recovered fairly well after the first operation. However the incision did not close properly . . . The specialist than suggested I should have a second operation; as he cheerfully said, ‘Just to clear things up.’ I hardly received this news with wild enthusiasm, but philosophically decided that something else must be attempted, since I  could hardly be very mobile with an open wound. Moreover, I  faithfully believed in that mystique about the medical profession which is known as ‘having faith in doctors’. Like numbers of working-class people I  was overawed by the fact that they wrote in Latin and carried on conversations among themselves that nobody else understood. They swept into the ward in a procession akin to Royalty. First came the specialist, flanked by his first-assistant on one side and the house-surgeon on the other side: some two paces behind were a varying number of students and this group were immediately joined by the ward sister. The rest of the nursing staff also become alerted . . . A conspiracy of silence was being maintained by the doctor and the staff – if doubts existed, they were certainly not expressed either to myself or Mother. The sister on this ward rarely did any dressings though she occasionally looked on. During these viewing periods, she was always sure so far as I was concerned, it was a question of time . . . The deadly monotony of hospital routine made it hard to keep up morale and remain cheerful. There was nothing to look at. The walls of the ward were painted dead white and were completely bare. There was no decor, no pictures or ornaments of any kind. [. . .] Arriving by ambulance at this third hospital I could not see the outside of the building, though what I  saw of the inside resembled a morgue. The entrance was dark with dingy yellow paintwork; there seemed to be miles of corridors and passageways. It was curiously quiet, having none of the bustle and sense of purpose one usually notices of entering a hospital. There were several old people ambling about who seemed to be dressed in a kind of uniform . . . This was my first experience of a Poor Law hospital . . . As I  was wheeled through the door I  was astounded by the size of the ward – it was simply enormous. It was not only long but exceptionally wide.

144 Documents There were four rows of beds very close together, with only just enough room between each row to move around . . . The nursing staff were of a different background and educational level than those in the voluntary hospitals, though they were certainly not unkind and did their best in antiquated buildings with outmoded, limited equipment. There was one doctor for the entire ward, a man in his early thirties, uncommunicative and tired-looking, which was not surprising as he always seemed to be on duty. I almost expected him to be on duty for ever and was mildly surprised to see another doctor on night duty. Source: Bella Aronovitch, Give It Time. An Experience of Hospital, 1928–32, London: Andre Deutsch, 1974, pp. 38, 39, 41, 42, 62, 63, 65.

Document 24  Asylum design William Alexander Francis Browne (1805–1885) trained in medicine at Edinburgh. He was interested in mental illness and in 1834 was appointed superintendent to the Royal Lunatic Asylum at Montrose, where he introduced moral therapy. He became a leading authority on the treatment of the insane. But a commanding elevation, from which the captive may recognise the scenes associated with health and vigour, and retain a connection with the distant external world, is not enough; and in addition to what is pleasing and cheerful there must be a stipulation for what is varied and irregular in surface. Robert Hall attributed his second attack of derangement to the flat monotony around his residence in Cambridgeshire . . . Nor must the structure and internal arrangements of the house be left in ignorant hands. It must not be a prison surrounded by airing yards . . . Among the moral objects to be secured are centralisation, classification, the avoidance of central courts, cross sights, & c., but, above all, that the arrangement should, as much as possible, resemble a private dwelling; that special provisions, iron windows and fireguards, should be limited to the departments where protective and restrictive are employed; but that other portions should present a normal and home-like aspect, should show solicitude for the comfort and happiness of the occupants, and should contain objects associated with rational deportment and pursuits, and suggestive of agreeable and hopeful feelings. Source: W. A. F. Browne, The Moral Treatment of the Insane: A Lecture, London: J. E. Adlard, 1864, p. 10.

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Document 25 Medical training in London The extracts from these letters are written by medical students, studying in London. Owen Evans was a student at St. Bartholomew’s Hospital, and Hampton Weekes studied at St Thomas’ Hospital. They give a vivid picture of the busy life of an industrious student, and of how students became used to the unpleasantness of human dissection. Letter No. 1. [To Hampton Weekes] From Owen Evans, 8 October, 1796. I . . . begin . . . the morning before breakfast at which time I have to visit several patients in the Hospital, at 10 O Clock Dr. Roberts Lectures on the Practice of Physic & Materia Medica, at 1 O Clock we go into the Dissecting Rooms to hear Demonstrations, at 2 O Clock Mr. Abernethy begins his Anatomical Lectures; dine at 4. half past 5 Dr. Clarke on Midwifery, 7 Dr. Powell on Chemistry . . . & every Friday evening the Medical Society to which I am a Member, from here we do not get away until 11 O Clock . . . I almost forgot Mr A[berneth]y’s Surgical Lectures which begin next month to add to the lot. Letter no. 6 To Richard Weekes [from Hampton Weekes], 24 September, 1801. I went into ye dissecting Room at Guys where was a gentleman dissecting the extremity wh. Was amputd at Thomas’s and the Muscles appeared as familiar to me you cant think how much so . . . I have ordered a Head wh. I am to pay 9s for about the age of eighten[sic], ’tis for separation by maceration after dissecting it. Letter no. 10 To Richard Weekes [from Hampton Weekes], 10 October, 1801. [B]efore we left the Hospital, I says to him [a visiting friend] what will you go up into the dissecting Room, ah he sayd, he did not care, but seemed not much to like the idea, as away we trudged, and got opposite to it & saw a light, dam it says he have you got any snuff, no I says come along, so as we ascended the stairs, says he I never smell’t such a stinck in my life, began to spit about and hung back I could not help laughing, however I got him as far as the door just peep’d in & saw 3 or 4 subjects, there was only one young man there who was wishing to finish a subject, for bloovessels [sic] . . . we soon came down, tho: I did not tell you that he said he was shure he should be sick . . . he thought he was very brave indeed boasted when he came down. Source: J. M. T. Ford, A Medical Student at St. Thomas’ Hospital, 1801– 1802. The Weekes Family Letters, London: Wellcome Institute for the History of Medicine, 1987, pp. 33–34, 44, 51.

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Document 26 Setting up in practice Arthur Conan Doyle (1859–1930) trained at the Edinburgh Medical School, graduating in 1881. After some short-term posts, he set up in practice in Southsea, Portsmouth. Conan Doyle wrote two accounts of his early days in practice: this extract is taken from his autobiography. A fictionalised account appeared in The Stark Monro Letters (1895). Month followed month and I picked up a patient here and a patient there until the nucleus of a little practice had been formed. Sometimes it was an accident, sometimes an emergency case, sometimes a newcomer to the town or one who had quarrelled with his doctor. I mixed with people so far as I could, for I learned that a brass plate alone will never attract, and people must see the human being who lies in wait behind it. Some of my tradespeople gave me their custom in return for mine, and mine was so small that I was likely to have the best of the bargain. There was a grocer who developed epileptic fits, which meant butter and tea to us. Poor fellow, he could never have realized the mixed feelings with which I received the news of a fresh outbreak. Medical life is full of dangers and pitfalls, and luck must always play its part in a man’s career. Many a good man has been ruined by pure bad luck. On one occasion I  was called in to a lady who was suffering from what appeared to be dyspepsia of a rather severe type. There was absolutely nothing to indicate anything more serious. I therefore reassured the family, spoke lightly of the illness, and walked home to make up a bismuth mixture for her, calling on one or two other cases on the way. When I got home I found a messenger waiting to say that the lady was dead. This is the sort of thing which may happen to any man at any time. It did not hurt me, for I was too lowly to be hurt. You can’t ruin a practice when there is no practice. The woman really had a gastric ulcer, for which there is no diagnosis; it was eating its way into the lining of her stomach, it pierced an artery after I saw her, and she bled to death. Nothing could have saved her, and I think her relatives came to understand this. I made £154 the first year, and £250 the second, rising slowly to £800, which in eight years I never passed. Source: Arthur Conan Doyle (1924), Memories and Adventures, Cambridge: Cambridge University Press, 2012, p. 69–70.

Document 27  Unity in the profession This anonymous letter (signed only with the letters indicating a dual qualification in medicine and surgery) presents the feelings of many

Documents  147 practitioners in the 1850s, of the need to increase the political power and status of the medical profession by unifying the different groups of practitioners. SIR,– It is a complaint acknowledged on all hands, that the medical profession, as a body, does not hold that place in society to which it is entitled by its intelligence, respectability and usefulness. By this Government, its existence is all but ignored; by the Law, its opinions are sneered at; by the Church it is condescendingly patronised; its members are kept down in the army, and tyrannised over in the navy. Any intelligence it does manifest, and any good it does achieve, is the intelligence or good of individual exertion, isolated, and therefore inoperative, except for the time being, and for the case on hand. Such are facts, and such is the condition of the medical profession, notwithstanding its intelligence, its learning, and its good works. And why? Just because there is no union within its members . . . Union is strength; combination is power; and the profession will never be able to manifest its strength or exercise its power until united into one compact phalanx, which might then compel internal improvement and repel external aggression. . . . in the British Medical Association . . . there is a nucleus round which the whole members of the profession may rally, and with which they ought to unite. Thus renovated and strengthened the British Medical Association may then effect that reform for which so many earnest and thoughtful men have so long striven in vain. No government would dare refuse its support to laws prepared and presented by the Council of the Association, and what became the law of the Association must then become the law of the land. Source: M.D., M.R.C.S. ‘The British Medical Association: The duty of medical men’, Association Medical Journal, January 19, 1856, p. 55.

Document 28 Opposition to the Colleges Thomas Wakley (1795–-1862), founder and first editor of The Lancet, was a fierce critic of London’s old medical institutions, the Colleges of Physicians and Surgeons and the Society of Apothecaries, whom he memorably described as ‘crafty, intriguing, corrupt, avaricious, cowardly, plundering, rapacious, soul-betraying, dirty-minded BATS’ (Lancet vol. 1, Oct. 1, 1831, p. 2). In this editorial, he attacked the existing licensing system as a money-making enterprise. The pupil has now before him the conditions which will qualify him for examination at the Hall and College; but we are not able to say, that even were they complied with to the very letter, they would qualify him

148 Documents to practice his profession with credit to himself, or safety to his patients. Monopolising companies, however, look not to the public benefit, but to individual gain, – the regulations of the Colleges inevitably squaring with the interests of the hospital. The BATS, in fact, have established a number of medical firms. The College in Lincoln’s Inn Fields is the WAREHOUSE for surgical diplomas. The hospitals are the WAREHOUSES for broken heads, legs, and arms. The museums and theatres of anatomy are the WAREHOUSES for “certificates,” but they belong to one connexion, and, in several instances are kept by the same individuals. Thus, in the Council of the College, there are four of the surgeons of Westminster Hospital. Source: ‘Preface, advertisement and address, and a rare whack at the voracious bats’, The Lancet vol. 1, 1 October 1831, p. 8.

Document 29  Opposition to homeopaths The Provincial Medical and Surgical Association was a national society, with local branches, for general practitioners. It took up the cause of medical reform, including efforts to root out heterodox medicine. To this end, homeopathic practitioners, and any orthodox practitioner who worked with them, were excluded from the Association. An earnest and truthful endeavour to improve our professional knowledge is the best foundation for public support, and the surest weapon wherewith to defeat the bold pretenders who rise up daily around us. Men of this description . . . have only themselves to serve: medical men serve their country and mankind. Let not any man wonder that quacks and imposters should abound even in these enlightened days. They have abounded in all times and in all professions, and probably will never cease, for there is nothing so irrational or extra-ordinary that some men will not maintain it for truth, feeling sure that the credulous and ignorant vulgar, rich and poor, will receive it with implicit belief. I do not mean to treat of the fashionable follies of the day, the mystifications and legerdemain of Mesmerism, the unreal mockeries and sublimated jargon of homeopathy, nor the more dangerous excesses of hydropathy . . . such aberrations from the path of true medical science should be abjured and repudiated with firm and solemn resolution . . . There is treachery within and war without . . . I am grieved to hear that some, even of the legitimate sons of physic, are tainted with the leaven of these new doctrines; that others . . . take either side as it may suit their purpose; while a few have not scrupled, from indifference or crooked policy, to countenance this defection . . . Against this laxity of conduct, the opinion of the profession, should be unmistakeably pronounced. To admit seceders, or doubtful allies, to the privileges of regular practitioners, or to an equality in consultation, is the same sort of treason to the profession, as the admission of the wooden horse into the walls of Troy.

Documents  149 Enough has been said of late, I hope, to induce those who have extended an ill-timed indulgence to these false brethren to withdraw from further communication with them; for there must never be peace with quackery in any of its monstrous shapes. As to the apostates themselves, it would be well, that by a self-ostracism, they quitted altogether the ranks of a profession, which, by a two-faced fellowship, they dishonour and betray . . . Source: Homoeopathy: Report of the Speeches on Irregular Practice Delivered at the Nineteenth Anniversary Meeting of the Provincial Medical and Surgical Association, Held at Brighton, August 13 & 14, 1851, London: John Churchill, 1851, p. 5–6.

Document 30  Opposition to women doctors The Lancet was a vocal supporter of rank and file practitioners. Not surprisingly, editorials spoke out against women entering medicine, which would lower the status of the profession and harm the livelihood of practitioners. Again, the woman question in relation to the practice of physic and surgery, is forced upon us by the wise decision of the British Medical Association to exclude female practitioners; and . . . by an able article in the last number of Spectator, to consider the peculiar physical state and mental susceptibilities of ‘Invalids’. The two topics, thrown together . . . suggest the comparison . . . of woman as doctor and woman as nurse. In the one character she is as awkward, unfit, and untrustworthy, as she is at home, capable, and thoroughly worthy of confidence in the other. Setting aside the anomalies and, as we believe, the gracelessness, of the position which a well-meaning but misguided young woman assumes when she undertakes the practical study of medicine, and waiving the question of feminine personal and social disabilities for the vocation of physician and surgeon, there is the all-important issue of natural and constitutional fitness. In the economy of nature – whether expounded by the Oracular utterance,10 or evolved by experience – the ministry of woman is one of help and sympathy. The essential principle, the key-note of her work in the world, is aid; to sustain, succour, revive and even sometimes shelter, man in the struggle and duty of life, is her peculiar function. The moment she affects the first or leading role in any vocation she is out of place, and the secondary, but essential, part of helpmeet cannot be filled. A more womanly sister may nominally assume the position of help, but, however willing, she cannot sustain the part, because the lead is out of natural concord, and harmony is impossible. Source: Editorial, The Lancet, 17 August 1878, pp. 266–267. 10  The bible

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Document 31  Nurse training This extract describes the main elements of training under the Nightingale system at the end of the nineteenth century. The outline clearly shows the emphasis on teaching nursing skills rather than medical knowledge. The following is what is required of probationers who enter under the Nightingale Fund . . . You are required to be sober, honest, faithful, trustworthy, punctual, quiet and orderly, cleanly and neat, patient, cheerful and kindly. You are expected to become skillful– 1. In the dressing of blisters, burns, sores, wounds; in applying fomentations, poultices and minor dressings; in the administration of subcutaneous injections. 2. In the application of leeches, externally and internally. 3. In the administration of enemas for men and women, and the use of the catheter for women. 4. In the management of trusses, and appliances in uterine complaints. 5. In the best method of friction to the body and extremities. 6. In the management of helpless patients, i.e., moving, changing, personal cleanliness, feeding, keeping warm (or cool), preventing and dressing bed sores, managing position of. 7. In bandaging, making bandages, rollers, lining of splints, etc. 8. In making the beds of patients, and removal of sheets whilst patient is in bed. 9. You are required to attend at operations. 10. To be competent to cook gruel, arrowroot, egg flip, puddings, drinks for the sick. 11. To understand ventilation, or keeping the ward fresh by night as well as by day; you are to be careful that great cleanliness is to be observed in all the utensils, those used for the secretions as well as those required for cooking. 12. To make strict observation of the sick in the following particulars :The state of secretions, expectoration, pulse, skin, appetite; intelligence, as delirium or stupor; breathing, sleep, state of wounds, eruption, formation of matter, effect of diet, or of stimulants, and of medicines. To ‘take’ the temperature, pulse, respiration. 13. And to learn the management of convalescents. Source: Percy G. Lewis, Nursing: Its Theory and Practice Being a Complete Text-book of Medical, Surgical, and Monthly Nursing, London: The Scientific Press, 1897, pp. 5–6.

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Document 32 Insanitary conditions in cities Edwin Chadwick’s Report on the sanitary condition of the labouring population (1842) is often described as a milestone in public health reform, revealing the appalling levels of filth found in towns and cities. In fact, many descriptions of insanitary slum dwellings were published around this time, although Chadwick’s work was the most influential. With regard to the streets inhabited by the working classes, I believe that the great majority are without sewers, and that where they do exist they are of a very imperfect kind unless where the ground has a natural inclination, therefore the surface water and fluid refuse of every kind stagnate in the street, and add, especially in hot weather, their pestilential influence to that of the more solid filth . . . With regard to the courts, I doubt whether there is a single court in Liverpool which communicates with the street by an underground drain, the only means afforded for carrying off the fluid dirt being a narrow, open, shallow gutter, which sometimes exists, but even this is very generally choked up with stagnant filth. There can be no doubt that the emanations from this pestilential surface, in connexion with other causes, are a frequent source of fever among the inhabitants of these undrained localities . . . In consequence of finding that not less than 63 cases of fever had occurred in one year in Union-court Banastre-street, (containing 12 houses,) I visited the court in order to ascertain, if possible, their origin, and I found the whole court inundated with fluid filth which had oozed through the walls from two adjoining ash-pits or cess-pools, and which had no means of escape in consequence of the court being below the level of the street and having no drain . . . I was informed by one of the inhabitants that the fever was constantly occurring there. The house nearest the ash-pit had been untenanted for nearly three years in consequence of the filthy matter oozing up through the floor, and the occupiers of the adjoining houses were unable to take their meals without previously closing the doors and windows. Source: M. W. Flinn (ed.) Report on the Sanitary Condition of the Labouring Population of Gt. Britain, Edinburgh: Edinburgh University Press, 1965, p. 104.

Document 33  Public health in central and local government John Simon (1816–1904) was one of the most important figures in driving public health reform in the late nineteenth century, heading a succession of central government agencies.

152 Documents It would, I think, be difficult to over-estimate, . . . the progress which during the last few years has been made in sanitary legislation . . . It is the almost completely expressed intention of our law that all such states of property and all such modes of personal action or inaction as may be of danger to the public health should be brought within scope [sic] of summary procedure and prevention. Large powers have been given to local authorities and obligation expressly imposed on them . . . to suppress all kinds of nuisance, and to provide all such works and establishments as the public health primarily requires; while auxiliary powers have been given . . . in matters deemed of less primary importance to health; as for baths and wash-houses, common lodging-houses, labourer’s lodging-houses, recreation grounds, disinfection–places, hospitals, dead-houses, burial-grounds, &c. And in the interests of health the State has . . . limited the freedom of persons and property in certain common respects . . . [when] we turn from contemplating the intentions of the Legislature to consider the degree in which they are realized, the contrast is curiously great. Not only have permissive enactments remained for the most part unapplied in places where their application has been desirable: not only have various optional constructions and organizations which would have conduced to physical well-being . . . remained in an immense majority of cases unbegun; but even nuisances which the law imperatively declares intolerable have, on an enormous scale, been suffered to continue. Source: John Simon, (1868–69) ‘Eleventh Report of the Medical Officer of the Privy Council’, House of Commons Parliamentary papers, 1868–69 no. 4127, pp. 20–21.

Document 34 Health education This extract, from a pamphlet issued by the Ladies’ Sanitary Association, is typical of literature aimed at encouraging the working poor to take responsibility for their health by washing and keeping their homes clean. It takes the form of a dialogue between two working men. ‘[O]ne of the great doctors from the West-end gave us six lectures about fresh air, food and drink, washing and such like. He talked real good stuff, such as all of us understood . . . See that square of zinc with tiny holes in that window? Well, I put that up the next day I heard the first lecture. That lets the fresh air in, lad, without draughts enough to hurt a fly; that’s for ventilation. Then too, I bought half a butter firkin [barrel] for a bath, and now I have a good wash down every morning from top to toe, that takes off all the perspiration which chokes up the skin; nothing so good for the preservation of health . . . ’ ‘I do believe some things I  heard at the lectures have done a deal to keep me off the sick list. I never knew till then the harm it does a man

Documents  153 to breathe hot, dirty air or to go about day by day with his skin choked with dirt.’ Source: Something Homely. A Fireside Chat, London: Jarrold & Sons, n.d. 1872 pp. 11.

Document 35  The work of the Medical Officer of Health This extract from the Report of the Medical Officer for a London borough outlines the expansion in the scope of public health, from improving water and sewerage and to maintaining a close surveillance of people, homes and businesses. Notification of Infectious Diseases.—565 Notices of infectious disease were made in the year, excluding those notified more than once: 5 of Small Pox; 225 of Scarlet Fever; 149 of Diphtheria; 66 of Typhoid Fever; 8 of Continued Fever; 103 of Erysipelas; 11 of Membranous Croup; and 3 of Puerperal Fever. Reports.—The ever-increasing work of our intelligent and most active inspectors is given below:— Wards 1, 2 and 3 (Inspector Bartlett’s District). 78 water closets were provided with water supply. 185 [water closets were provided] with new pans or old ones cleaned. 77 extra [water closets were] provided. 194 defective drains remedied. 131 dirty houses cleansed. 77 defective traps renewed. 78 defective pavings remedied. 106 new dustbins provided. 11 defective roofs repaired. 20 underground rooms emptied. 42 cases of overcrowding abated. 81 accumulations of rubbish removed. 76 water supplies restored. 8 nuisances from keeping animals abated. 3 cesspools abolished. 5 dead bodies removed from rooms where persons lived. 9 smoke nuisances abated. 51 dung receptacles made to comply with by-laws. 2 percolations of water stopped. 272 fumigations after infectious disease 2 smallpox. 161 scarlet fever. 105 diphtheria.

154 Documents 37 typhoid. 53 erysipelas. 3 puerperal fever 1658 houses were visited, 769 on complaint. 857 preliminary notices served. 235 statutory notices served . . . [. . .] 83 yards limewhited and cleansed. 40 accumulation of refuse removed. 1,290 houses were visited, 650 on complaint. 750 preliminary notices served. 205 statutory [notices served] 34 cisterns cleansed or abolished. 79 defective water apparatus to water closets remedied 16 leaky roofs repaired. 13 defective stack pipes remedied. 31 sink wastes disconnected from drain. 42 defective water closets remedied 63 choked water closets unstopped. 21 water supplies to houses. 6 broken water service pipes repaired. 22 water supplies to water closets provided. 16 illegal occupation of kitchens abated. [. . .] 6 choked sink wastes and gullies unstopped. 7 dilapidated floorings repaired. 2 smoke nuisances abated. 22 dirty workshops limewhited and cleansed. 3 houses closed under magistrate’s order. 2 offenders against London Council Council [sic] by-laws in removing obnoxious matter through streets, proceeded against 20 bullocks heads, 50 boxes of greengages, 1 basket of sweet bread, 1 sheep, and 2 lots of fish were destroyed Source: Report of the Medical Officer of Health for Clerkenwell, St. James and St. John, 1894, in The Thirty-ninth Annual Report of the Vestry of the Parish of St. James and John, Clerkenwell, for the Year 1894–95, London: Vail & Co. 1895, pp. 121–124.

Document 36 The cause of infant mortality George Newman (1870–1948) was the first chief medical officer to the Ministry of Health, and promoted a number of government welfare

Documents  155 schemes designed to prevent disease. Despite evidence that infant mortality was associated with poverty, Newman was convinced that mothers held the key to infant health. . . . infant mortality is a social problem concerning maternity. From questions of occupation and environment . . . we must turn in the last instance to the actual feeding and management of an infant by its mother . . . more than any other single agency, infant mortality depends on infant rearing . . . And, expressed bluntly, it is the ignorance and carelessness of mothers that directly causes a large proportion of the infant mortality which sweeps away every year in England and Wales alone 120,000 under twelve months of age. This ignorance reveals itself in many ways, but chiefly, perhaps, in feeding, uncleanliness and exposure. These influences operate amid every sort of external environment, good, bad, and indifferent. It has been found, for example, that in the worst districts there are many instances in which parents have successfully reared every member of a large family, whilst side by side with these there are numerous examples of death in infancy, and the distinction between these families has nothing to do with season, and it is not wholly one of physical condition of parents, or sanitary condition of home, or even poverty, but it is a distinction of the amount of knowledge and intelligence, attention and care, which the mother is able to bestow upon her offspring. Source: George Newman, Infant Mortality: A Social Problem, London: Methuen & co, 1906, pp. 221–223.

Document 37 The new National Health Service Launching the National Health Service was a massive task. This leaflet explained to the public how to access the new services, and reassured them of their rights to free treatment. The New National Health Service Your new National Health Service begins on 5th July. What is it? How do you get it? It will provide you with all medical, dental and nursing care. Everyone – rich or poor, man, woman or child – can use it or any part of it. There are no charges, except for a few special items. There are no insurance qualifications. But it is not a “charity”. You are all paying for it, mainly as tax payers, and it will relieve your money worries in time of illness. Choose your Doctor Now You and everyone in your family will be entitled to all usual advice and treatment from a family doctor . . .

156 Documents Your dealings with your doctor will remain as they are now: personal and confidential. You will visit his surgery, or he will call on you, as may be necessary. The difference is that the doctor will be paid by the Government, out of funds provided by everybody. Choose a doctor now – ask him to be your doctor under the new arrangements . . . If you are already on a doctor’s list under the old National Health Insurance Scheme, now is the time to decide. Get an application form for each member of the family from the doctor you choose, or from any Post Office, Executive Council Office, or public library. Fill in the forms and give them to the doctor. Help to have the Scheme ready by 5th July by choosing your doctor at once. [. . .] Hospital and Specialist Services You will also be entitled to all forms of treatment in general or special hospitals, whether as an in-patient or as an out-patient. These include, for instance, maternity care, sanatorium care, care of mental health, and all surgical operations. Medicines, Drugs and Appliances Your doctor will give you a prescription for any medicines and drugs you need. You can get these free from any chemist who takes part in the Scheme. In some country areas the doctor himself may dispense medicines. The same is true for all necessary appliances. Some of them will be obtainable through hospitals; some your doctor can prescribe for you. There will be no charge, unless careless breakage causes earlier replacement than usual. Source: The New National Health Service. Leaflet issued by the Ministry of Health, February, 1948.

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Glossary

alternative medicine  see heterodox medicine. anaesthetic   a chemical that produces insensitivity to pain, and, in the case of general anaesthetics, renders the recipient unconscious. Ether and chloroform were the first general anaesthetics. antiseptic   an agent which kills bacteria, used to prevent infection in wounds. apothecaries  practitioners who prepared drugs and medicines. asepsis  the exclusion of micro-organisms from an environment such as an operating theatre. This is made possible by a set of techniques and technologies such as sterilising instruments and using impermeable surfaces within the space. bacteriology   the study of bacteria, especially those responsible for human diseases. consumption   an eighteenth century disease associated with weight loss: probably most (although not all) cases were caused by respiratory tuberculosis. domestic medicine   a form of medicine practiced within the home, usually by women, involving nursing, the preparation of special diets, and homemade medicines. endemic   diseases present in a location at all times. epidemics   outbreaks of infectious disease, affecting large numbers in a relatively short time. epidemiological transition   the shift from a pattern of high mortality caused by infectious disease often affecting children to one dominated by chronic disease affecting older adults, with an extension of life expectancy. germ theory   the idea that some diseases are caused by specific agents. Although we now know these to be bacteria and viruses, in the past, practitioners speculated about the role of then-unknown biological agents or ‘germs’. herbal medicine   the use of plant-based remedies to cure particular ailments, usually prepared by folk practitioners. heterodox medicine   medical theories and practices which differ from mainstream scientific or orthodox medicine, including systems such as homeopathy and hydropathy.

Glossary  167 histology   the study of the minute structures of the human body, including cells, using microscopy. holistic medicine  a belief that the whole body is fundamentally interconnected. Thus even if symptoms appear in specific parts of the body, disease affects the whole body. homeopathy   a heterodox system of medicine based on the idea of ‘like cures like’. Drugs were given in very small doses to induce symptoms similar to those observed in the illness. humoural medicine  a theory of disease causation developed in Greece around 400BC, in which health and disease was determined by a balance of fluids or humours within the body. hydropathy  heterodox medical system based on the application of water to the body in the form of baths, showers and wrappings to cure a wide range of ailments. These treatments, plus a programme of diet and exercise, were offered at hydropathic establishments. infant mortality rate  the level of deaths among children in their first year, usually expressed as the number of deaths per thousand live births. localisation  the theory that disease is located within a specific organ or tissue rather than affecting the whole body. A belief in the localisation of disease is associated with hospital and laboratory medicine. mesmerism  the use of hypnosis in the mid-nineteenth century as a means of diagnosing disease, treating a range of ailments and anaesthetising patients during surgery. miasma  bad air caused by rotting filth and organic matter, believed to cause disease. morbidity  the level of illness within a population. mortality  the rate of deaths within a given population, usually expressed as deaths per thousand or per million living. orthodox medicine  scientific or Western medical theory, as opposed to heterodox systems such as homeopathy. pandemics  outbreaks of disease that spread over several countries and sometimes around the world. patent medicine  a remedy, usually sold in shops, made to a standard, sometimes secret, recipe. Despite the name, patent medicines were not protected by any form of patent. pathological anatomy  the study of changes in the structures of the body caused by disease. phthisis  a common disease in the nineteenth-century. Most cases were probably respiratory tuberculosis. physician   university-educated practitioner, who specialised in the treatment of internal disease. physiology   the study of the normal functioning of the different parts of the body. resective surgery  surgery to remove diseased tissues or organs.

168 Glossary Thomsonian medicine   a heterodox system of medicine, devised by Samuel Thomson, which saw disease as a result of an imbalance of heat and cold. Ailments were cured by a small number of herbal drugs.

Further reading

Britain and Western medicine A number of books explore British medicine within a European or worldwide context. Bynum, W. et  al. (2006) The Western Medical Tradition, 1800–2000 Cambridge: Cambridge University Press, Brunton, D. (ed.) (2004) Medicine Transformed. Health, Disease and Society in Europe 1800–1930 Manchester: Manchester University Press, and Milton Keynes: The Open University and Waddington, K. (2011) An Introduction to the Social History of Medicine: Europe Since 1500 Basingstoke: Palgrave Macmillan all set medical theory and practice in Britain in the nineteenth and twentieth centuries into its broader context. These works are complemented by the more historiographical approach taken in the essays in Jackson, M. (ed.) (2011) The Oxford Handbook of the History of Medicine Oxford: Oxford University Press; and Cooter, R. and Pickstone J. (2003) Companion to Medicine in the Twentieth Century London: Routledge. Porter, R. (1997) The Greatest Benefit to Mankind: A  Medical History of Humanity from Antiquity to the Present London: HarperCollins remains a mine of basic information on all aspects of medicine. The literature on medicine in Scotland and Ireland is growing, although that on Wales remains thin on the ground. Jenkinson, J. (2002) Scotland’s Health 1919–1948 Oxford: Peter Lang is an excellent account of welfare and health issues in twentieth-century Scotland. Lucey, D. S. and Crossman, V. (2014) Healthcare in Ireland and Britain from 1850: Voluntary, Regional and Comparative Perspectives London: Institute of Historical Research provides an interesting selection of essays on a various aspects of Irish medicine. Michael, P. and Webster, C. (2006) Health and Society in Twentieth-century Wales Cardiff: University of Wales Press breaks new ground in its focus on medicine in the principality.

Disease Higgs, E. (2004) Life, Death and Statistics. Civil Registration, Censuses, and the Work of the General Register Office, 1836–1952 Hatfield: Local

170  Further reading Population studies offers an insight into the collection and presentation of disease statistics. Hardy, A. (1993) The Epidemic Streets: Infectious Disease and the Rise of Preventive Medicine, 1856–1900. Oxford: Oxford University Press and Alex Mercer’s (2014) Infections, Chronic Disease, and the Epidemiological Transition: A New Perspective Rochester, NY: University of Rochester Press and his (1990) Disease, Mortality and Population in Transition Epidemiological-Demographic Change in England since the Eighteenth century as part of a Global Phenomenon Leicester: University of Leicester Press, all explore the changing epidemiology of the major infectious diseases. The best account of morbidity is provided by Riley, J. (1997) Sick, Not Dead: The Health of British Workingmen During the Mortality Decline, Baltimore MA: Johns Hopkins University Press.

Theory and practice All the books listed in the section on Britain and western medicine include discussions of developments in medical ideas and treatments. A  detailed revisionist account of new theories developed in Paris is Hannaway, C. and La Berge, A. (1998) Constructing Paris Medicine Amsterdam: Rodopi. Lawrence, C. (2005) Rockefeller Money, the Laboratory, and Medicine in Edinburgh 1919–1930: New Science in an Old Century Rochester, NY: University of Rochester Press gives an insight into the difficulties of integrating laboratory and clinical medicine. Worboys, M. (2000) Spreading Germs: Disease Theories and Medical Practice in Britain, 1865–1900 Cambridge: Cambridge University Press charts the very gradual emergence of germ theory while Schlich, T. (2010) The Origins of Organ Transplantation: Surgery and Laboratory Science, 1880–1930 Rochester, NY: University of Rochester Press reveals the complexities of applying new ideas to therapeutics. An excellent account of working-class domestic medicine is Beier, L. M. (2008) For Their Own Good: The Transformation of English Working-class Health Culture, 1880–1970 Columbus, OH: Ohio State University Press. Adams, J. (2015b) Healing With water: English Spas and the Water Cure, 1840–1960 Manchester: Manchester University Press provides an informed and up to date analysis of hydropathy.

Institutions A good, short overview of medicine and hospitals is provided by Cherry, S. (1996) Medical Services and the Hospitals in Britain, 1860–1939 Cambridge: Cambridge University Press. Waddington, K. (2000) Charity and the London Hospitals, 1850–1898 Woodbridge: Boydell Press gives a more detailed analysis of the financing and work of nineteenth-century institutions in London. Poor law hospitals have not been well researched: Reinarz, J. and Schwarz, L. (2013) Medicine and the Workhouse Rochester, NY: University of Rochester Press is a welcome addition to the literature. Cassell, R.

Further reading  171 D. (1997) Medical Charities, Medical Politics The Irish Dispensary System and the Poor Law, 1836–1872 Woodbridge: The Boydell Press gives a good account of the distinctive Irish system of institutions funded through the Grand Juries and Poor Law. A classic of asylum history is Scull, A. (1993) The Most Solitary of Afflictions: Madness and Society in Britain, 1700–1900 New Haven: Yale University Press. A sense of newer thinking on the development of asylums is given by Melling, J. and Forsyth, B. (1999) Insanity, Institutions, and Society, 1800–1914 London: Routledge. Although there are a number of newer works on tuberculosis treatment, Bryder, L. (1988) Below the Magic Mountain: A Social History of Tuberculosis in Twentiethcentury Britain. Oxford: Clarendon Press remains the most comprehensive account of sanatorium life.

Practitioners The most extensive account of the development of medical education is Bonner, T. N. (1995) Becoming a Physician. Medical Education in Britain, France, Germany and the United States, 1750–1945 Oxford: Oxford University Press. Crowther, M. A. and Dupree, M. (2007) Medical Lives in the Age of Surgical Revolution Cambridge: Cambridge University Press provides a complement to Bonner’s work. Their account of Scottish medical education reveals the continuing variations within medical training, as well as charting the careers of students trained under Joseph Lister. Two works by Anne Digby provide invaluable insights into the working lives of practitioners. Digby, A. (1994) Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720–1911 Cambridge: Cambridge University Press explores how practitioners functioned as entrepreneurs. Digby, A. (1999) The Evolution of British General Practice 1850–1948 Oxford: Oxford University Press is a companion study of the development of the profession. The standard account of the nursing profession is Dingwall, R., Rafferty, A. M., and Webster, C. (1988) An Introduction to the Social History of Nursing London: Routledge. Helmstadter, C. and Godden, J. (2011) Nursing Before Nightingale, 1815–1899 Farmham: Ashgate provides interesting insights into nursing outside the influence of Florence Nightingale.

Government By far the best account of the shaping of nineteenth century public health policy is Hamlin, C. (1998) Public Health and Social Justice in the Age of Chadwick: Britain, 1800–1854 Cambridge: Cambridge University Press. Harris, B. (2003) The Origins of the British Welfare State: Society, State and Social Welfare in England and Wales, 1800–1945 London: Palgrave Macmillan charts the later development of welfare. Dwork, D. (1987) War is Good for Babies and Other young Children: A  History of the Infant and Child Welfare Movement in England, 1898–1918 London: Tavistock

172  Further reading Publications gives a detailed account of infant welfare provision, while Levene, A., Powell, M., Stewart, J. and Taylor, B. (2011) Cradle to Grave: Municipal Medicine in Inter-war England and Wales Oxford: Peter Lang provides an overview of the work of local authorities. Charles Webster is the acknowledged expert on the NHS and his The Health Services Since the War. Vol. 1, Problems of Health Care: The National Health Service Before 1957. London: HMSO is the best single work on its creation.

Index

access to care 59, 60, 64, 118 Acland, Henry 123–4 acupuncture 43 Addison, Thomas 33 advertising 52, 87 advice books 49 air pollution 23, 46, 47, 101 alcohol 43, 56, 79, 92, 105 Alibert, Jean 61 alienists 78 alternative medicine see heterodox medicine American Rockefeller Foundation 39 amoebic dysentery 25 amputations 56, 57 anaesthesia 56–7, 67, 166 anatomy 29, 31, 32, 33, 39, 82–3 Anatomy Act (1832) 83 Anderson, Elizabeth Garrett xii, 89 animal experiments 34, 35 anorexia nervosa 41 anthrax 34 antibiotics 75 antisepsis 56, 57, 67, 166 anti-toxins 52, 59, 73 anti-vaccination movement 43, 105 apothecaries 82, 83, 88, 166 apprenticeships 82, 85, 86, 88 Aronovitch, Bella 142–4 asepsis 57, 58, 67, 166 Asiatic cholera 14, 23, 72, 100 aspirin 52 asylums: design 144; government medical care 111; history of medicine 118; medical care in institutions 63, 76–80; medical practitioners 90, 95, 97 auriscope 55 Austen, Jane 41

bacteria 9, 20, 25, 33–4, 55, 72, 103 bacteriology 33–4, 38, 166 Baillie, Matthew xii, 29, 30, 32, 128–9, 131 bathing 47, 102 Bayer Company 52 Bayle, Gaspard Laurent 31 Bayliss, William xii, 37 BCG vaccination 75 Bedlam (St. Mary’s Bethlehem, London) 77 bedside medicine 5, 27, 28, 38, 39, 44 Beeton, Isabella (Mrs Beeton) 49, 134–5 Belfast Infirmary 76 Bennett, John Hughes 56, 130–1 Bernard, Claude 35 Bevan, Aneurin xii, 112, 113 Beveridge, William 112 Bichat, Marie François Xavier 31 bills of mortality 9 biology 40, 41 biomedical sciences 33–5, 36, 44, 84 Birmingham 64 The Birth of the Clinic (Naissance de la clinique) (Foucault) 31 birth rates 105, 106 bloodletting 48, 55 blood tests 61, 67 BMA see British Medical Association BMJ see British Medical Journal BNA see British Nursing Association Board of Health 100 body 29, 31, 47, 132 bodysnatching 83 body temperature 55 body weight 48 bonesetters 53, 54 Book of Household Management (Beeton) 49, 134–5

174 Index Boots (chemist) 51 Boyd, Stanley 58 Boy Scouts 46 breast feeding 106, 107 Bright, Richard 32–3 Bristol Dispensary 70 British and Foreign Medical Review (journal) 32 British cholera 14 British Empire Cancer Campaign 108 British Institute of Preventative Medicine 36 British Medical Association (BMA) 86, 89, 91, 112, 147, 149 British Medical Journal (BMJ) 86 British Nursing Association (BNA) 94 Broad Street pump 103 bronchitis 14, 15 Broussais, Francois-Joseph 32 Brown, John 28 Browne, William Alexander Francis 144 Bryder, Linda 74 Buchan, William 49, 123 Cajal, Santiago Ramon y 37 Cambridge University 35, 36, 37 cancer: causes of death 10; epidemiological transition 18–19, 20; health citizenship 108; history of medicine 117; hospital medicine 31; increase in 125; laboratory medicine 36; patterns of disease 24; public health movement 14 care costs 68, 69, 70, 76 care provision 118, 119 Carlisle 10, 11 Carswell, Robert 32 causes of death 9–14, 15–19, 24–5, 117 cells 33, 37 Central Midwives Board (CMB) 96 Chadwick, Edwin xii, 100–1, 151 Charing Cross Hospital 58, 93 charitable institutions: consuming medicines 60; health and the state 102, 111; history of medicine 118; laboratory medicine 36; medical care in institutions 63; nursing 95; voluntary hospitals and dispensaries 64, 69 chemical communication 36–7 chemists 51, 53, 85 Chichester Hospital 32 ‘chi’ (energy) 43 childbirth 24, 70, 95–6 childhood diseases 14, 17, 24 child rearing 106, 154–5

children’s health: health and the state 103, 107; isolation hospitals 73; mortality 126; patterns of disease 24, 25; pursuit of health 47; voluntary hospitals 65 Chinese medicine 43 chloral hydrate 52 chloroform 57 chlorosis 41 cholera: deaths 16; fever hospitals 72; history of medicine 4; illustration 16; laboratory medicine 34; patterns of disease 23; public health 13, 14, 103; sanitary reform 100; social and cultural factors 40; victims of 123–4 chronic disease 14, 18–20, 92, 117, 119 chronology ix–xi cigarettes 24 cities 21, 23, 24, 100–2, 151 Civilian Nursing Reserve 97 classification of disease 29 cleanliness 47, 67, 100, 102–4, 152–3 climate 29, 46, 47 clinical medicine 38, 39 clinical teaching 83, 84, 88 clinic and laboratory 38–40 clinician’s gaze 31 CMB see Central Midwives Board codes of ethics 86, 87 Coffin, Albert 42 Colleges, opposition to 147–8 Colney Hatch asylum 79 communitarian medicine 109 competition, excluding 88–91 complementary medicine see heterodox medicine consultants 84, 91 consumerist medicine 5 consuming medicines 59–62 consumption (disease) 10, 11, 15, 41, 166 Contagious Diseases Acts 40 corpses 32, 82–3, 91 Corvisart, Jean-Nicolas 31 costs of care 68, 69, 70, 76 cottage hospitals 65, 67 County Asylums Act (1828) 77 creativity 41 Cullen, William xii, 28, 127–8 Dale, Henry xii, 37 Darwin, Charles 60 Dawson, Lord 112 death, causes of 9–14, 15–19, 24–5, 117 Denmark 100

Index  175 dental care 56, 109, 113 De sedibus and causis morborum (On the seats and causes of disease) (Morgagni) 29 diagnosis 19, 29, 60, 61, 62 diarrhoea 23, 25, 29 Dickens, Charles 78, 92 diet 24, 37, 39, 46–8, 50, 74, 107, 108 Digby, Anne 81 digitalis 51 diphtheria 15, 17, 20, 25, 52, 73, 104 disability 106 ‘The disappearance of the sick-man’ (Jewson) 27 disease: beyond the biological 40; causes of 9–14, 28, 72, 100, 103; classification of 29; emergence of hospital medicine 28–33; further reading 169–70; heterodox medicine 44; laboratory and clinic 38; laboratory medicine 33; localisation of 31, 43, 118, 167; medical ideas 27, 40–2; prevention 90, 103–4, 108 disease in modern Britain 9–26; changing patterns of disease 23–6, 117; death and disease 9–14; epidemiological transition 14–21; measuring morbidity 21–2; overview 9 disinfection 103–4 dispensaries 60, 63, 69–70, 74, 75–6, 79, 80, 85 dispensing medicines 85 dissection 32, 82–3 district nurses 95 ‘The doctor’ (Fildes painting) 87 documents 121–56; action of fever 127–8; appeal for funds 139–40; asylum design 144; benefits of exercise 132–3; benefits of physiological research 131; cause of infant mortality 154–5; description of fevers 123; domestic remedies 134–5; experience of surgery 138–9; health and sunlight 133–4; health education 152–3; health of working class women 127; holistic view of body 132; hospital design 142; hydropathic treatment 136–7; increase in cancer 125; insanitary conditions in cities 151; medical training in London 145; new National Health Service leaflet 155–6; nurse training 150; opposition to homeopaths 148–9; opposition to the Colleges 147–8; opposition to women doctors 149; patent medicines 136; pathological

changes in the lung 128–9; patient’s experience 142–4; physiology of the kidney 130–1; public health in central and local government 151–2; rules from Huddersfield Infirmary 140–1; setting up in practice 146; Spanish flu 124; technical language of medicine 129–30; treatment of heart disease 137–8; unity in the profession 146–7; variations in mortality 126; victims of cholera 123–4; work of Medical Officer of Health 153–4 domestic medicine 49–53, 59, 60, 134–5, 166 Domestic Medicine (Buchan) 49, 123 domiciliary nurses 91, 95 Doyle, Arthur Conan 84, 146 dropsy 32–3 druggists 51, 88 drugs see medicines Dublin 64, 82, 83 Duffin, Jaclyn 40 Dunn Nutritional Laboratory 36 economic factors 59, 60 Edinburgh 64, 65, 102 Edinburgh Royal Infirmary 66, 83 Edinburgh School of Medicine for Women 90 Edinburgh University 32, 35, 39–40, 82–3, 89–90 education 82, 84, 89–90, 107–8, 152–3 Education Act (1906) 107 elderly population 11, 19, 25, 26, 117, 119 electricity 48–9, 54 electrocardiograph 39, 55 electroconvulsive therapy 79, 95 electron microscope 34 Elliotson, John 43 Emergency Medical Service (EMS) 111, 112 endemic (definition) 11, 166 Engels, Friedrich 23 England: asylums 79, 80; epidemiological transition 20, 21; fever hospitals and tuberculosis sanitoria 73, 74; government medical care 109, 111; health and the state 100, 104, 106, 107, 109, 111; history of medicine 5, 118; infant welfare 106, 107; medical schools 82; morbidity and mortality 17, 22; nursing 96; patterns of disease 25; Poor Law hospitals 71; public

176 Index health 13, 104; registrars 11; sanitary reform 100; voluntary hospitals and dispensaries 64, 69 epidemics 11, 16, 17, 72, 166 Epidemiological Society 86 epidemiological transition 14–21, 22, 166 ether 56, 57 ethics 81, 86, 87 eugenics 106 Evans, Owen 145 examination, physical 31, 38, 55 excluding competitors 88–91 exercise 24, 28, 47–8, 74, 132–3 Farr, William xii, 12–13, 126 fees 84–5, 86, 87, 109 female practitioners see women practitioners Fenwick, Ethel Bedford xii, 94 fever hospitals 63, 72–3, 75–6, 95 fevers: action of 127–8; asylums 79; causes of disease and death 10, 11, 16, 17; climate 47; and creativity 41; description of 123; fever hospitals 63, 72–3, 75–6, 95; patterns of disease 23; sanitary reform 100 Figlio, Karl 41 Fildes, Luke 87 First Lines of the Practice of Physic (Cullen) 127–8 First World War 24–5, 71, 90, 94, 96, 105, 108, 110–11 flu see influenza folk healers 53–4 food 17, 28, 39, 46, 50, 103, 107 Forbes, John 31, 32 Foster, Michael xii, 35, 36 Fothergill, John Milner 137–8 Foucault, Michel 31 Foula, Shetland 11 France 32, 34, 35, 106, 111 free meals 107–8, 119 friendly societies 21–2, 109 funding: history of medicine 118; hospitals in Ireland 75; Huddersfield Infirmary 139–40; institutions 63, 80; medical schools 35–6; outpatient care 70; voluntary hospitals and dispensaries 64, 68–9 Funk, Casimir 37 Gamp, Sarah (fictional nurse, Dickens) 92 General Board of Health (GBH) 101

general hospitals 63–5, 69, 71, 76, 79–80, 111 General Medical Council (GMC) 89 General Nursing Council (GNC) 97 general practice 84, 90, 146 general practitioners (GPs): diagnosis and treatment 61; dispensing medicines 59; excluding competitors 88, 91; making a medical living 82, 84, 85; National Health Service 62, 113; National Insurance 109, 110; orthodox medicine 55 genetics 25 George III, King 77 Germany 34, 35, 39, 73, 109, 119 germ theory 33, 47, 103, 166 Glasgow 20, 23, 39, 65, 82, 102 GMC see General Medical Council GNC see General Nursing Council government role: excluding competitors 90; further reading 171–2; geographical variations in institutions 80; government medical care 109–14; health and the state 99; health citizenship 108; history of medicine 117; lifestyle factors 46; public health in central and local government 151–2; sanitary reform 99–102 GPs see general practitioners Graham, James 54 Great Famine (Ireland) 17, 76 Great Northern Central Hospital 68 Great Ormond Street Hospital 65 ‘green sickness’ 41 grinders’ asthma 23 Guinness family 36 Gully, Dr James 137 Guy’s Hospital, London 32, 68 gymnastic exercise 47, 132–3 Hahnemann, Samuel 42 Hampstead Hospital, London 73 Harvey, William 34 healers 53–4 health: measuring morbidity 21; patterns of disease 24–5; pursuit of 45–9 health and the state 99–114; further reading 171–2; government medical care 109–14; overview 99; public health 102–5; sanitary reform 99–102; welfare 105–8 health citizenship 46, 108 health education 108, 152–3 health visitors 95, 106, 107, 108

Index  177 heart attacks 4, 19, 42 heart disease 14, 18, 19, 24, 39, 48, 137–8 Henle, Jacob 33 herbal medicine 42, 51, 55, 166 heterodox medicine: consuming medicines 62; definition 42, 166; excluding competitors 88, 89; history of medicine 3; medical ideas 42–4; medical practices 45; medical practitioners 53, 54; opposition to homeopaths 148–9 Heysham, John 10 Highlands and Islands Medical Service (HIMS) 112 Hill, Dr Charles 49 histology 33, 34, 35, 167 history of medicine 3–5, 117–19 Hodgkin, Thomas 32 holistic medicine 28, 118, 132, 167 homeopathy: consuming medicines 60; definition 42, 167; excluding competitors 88, 89; heterodox medicine 42–3; medical practitioners 54–5; opposition to homeopaths 148–9; quacks 51 Hopkins, Frederick Gowland xiii, 35, 37 hormones 37 hospital medicine 5, 27, 28–33, 38–9, 44, 62 hospitals: design of 65–7, 142; fever hospitals and tuberculosis sanitoria 72–5; further reading 170–1; history of medicine 117; hospital posts 85–6; hospitals and dispensaries in Ireland 75–6; Huddersfield Infirmary appeal for funds 139–40; Huddersfield Infirmary rules 140–1; isolation hospitals 72–3, 94, 103; medical care in institutions 63, 80; National Health Service 113; nursing 90–2, 94, 97; Poor Law hospitals 70–2; voluntary hospitals and dispensaries 63–70; wards 66–8, 71, 73, 83 housing 17, 23, 25, 101, 103, 106, 119 Huddersfield Infirmary 67, 139–41 humoural medicine 28, 44, 46, 118, 167 Hunter, John 29 hydropathy (water cure) 42, 43–4, 54, 60, 89, 136–7, 167 hypnosis 43 illness see disease immunisation 90, 104 immunology 34, 58

Imperial Cancer Research Fund 36 incomes 84–5, 87, 90–1, 106 infant mortality 11, 20–1, 24–5, 105–6, 119, 154–5, 167 Infant Mortality Rate (IMR) 20, 167 infant welfare schemes 90, 99, 105–7, 108 infection control 53, 56–7, 66–7, 73, 95, 102, 105 infectious disease: access to care 64; bacteriology 33; disease in modern Britain 9, 11, 14, 17–20; domestic medicine 52, 53; epidemiological transition 19–20; fever hospitals and tuberculosis sanitoria 72, 73; history of medicine 5, 117; isolation hospitals 73; measuring morbidity 22; medicines 59; patterns of disease 23–5; public health 14, 103, 105 Infirmaries Act 75 influenza 14, 17–18, 22, 25, 59, 124 inoculation 104 insanitary conditions 23, 151 institutions: asylums 76–80; fever hospitals and tuberculosis sanitoria 72–5; further reading 170–1; history of medicine 117; hospitals and dispensaries in Ireland 75–6; overview 63; Poor Law hospitals 70–2; voluntary hospitals and dispensaries 63–70 insurance schemes 21, 60, 69, 109 Ireland: asylums 80; disease in modern Britain 11, 17, 20; further reading 169; government medical care 109, 111, 112–13; history of medicine 5, 118; hospitals and dispensaries 75–6; infant welfare 108; medical schools 82; public health 104; registration 96; voluntary hospitals and dispensaries 64 Irish College of Surgeons 82 Irish Poor Law Act 76 isolation hospitals 72–3, 94, 103–4 Jewson, Nicholas 5, 27, 44, 61, 118 Jex-Blake, Sophia xiii, 89, 90 Journal of Physiology 36 journals 36, 40, 86 kidney disease 30, 55, 130–1 King’s College London 92–3 Koch, Robert 34 kymograph 34

178 Index laboratory medicine: heterodox medicine 43, 44; history of medicine 5; laboratory and clinic 38–40; licensing 83; medical ideas 27, 28, 33–8; NHS 62 Ladies’ Sanitary Association 152–3 ‘lady probationers’ (nursing trainees) 93 Laennec, René Théophile Hyacinthe 31, 32 Lancet (journal) 86, 90, 149 laryngoscope 55, 61 lavatories 102, 103, 104 Leeds University 35 licensing 81, 83, 88–9, 96 life expectancy 4, 20–1, 24, 117 lifestyle factors 29, 38, 46, 48, 60, 108, 118 Lister, Joseph xiii, 57, 61, 138 Lister Institute 36 Liverpool 23, 35, 70, 72 living conditions 17, 23, 24, 105 Lloyd George, David 106, 109 lobotomy 79 Local Government Act 71–2 localisation of disease 31, 43, 118, 167 London: disease in modern Britain 9, 11, 12; fever hospitals 72; medical schools 82–3; medical training 145; voluntary hospitals and dispensaries 64, 65, 70 London Fever Hospital 68 London Medical School for Women 90 Ludwig, Karl 34 Lunacy Act (1808) 77 Lunatics Act (1845) 77 lung disease 13, 15, 16, 23–4, 31, 52, 73–5 lying-in hospitals 64 ‘madness’ see mental illness malaria 25 Malvern water cure 54, 136–7 Manchester 21, 23, 35, 64, 65, 72 Martin Chuzzlewit (Dickens) 92 Maternal and Child Welfare Act (1918) 106 Mathewson, Margaret 61, 138–9 matrons 92, 93 McKeown, Thomas 105 meals, school 107–8, 119 measles 11, 14, 15, 17 medical care in institutions 63–80; asylums 76–80; fever hospitals and tuberculosis sanitoria 72–5; further reading 170–1; hospitals

and dispensaries in Ireland 75–6; overview 63; Poor Law hospitals 70–2; voluntary hospitals and dispensaries 63–70 medical education 82, 84, 89–90 medical ideas 27–44; beyond the biological 40–2; emergence of hospital medicine 28–33; heterodox medicine 42–4; laboratory and clinic 38–40; laboratory medicine 33–8; overview 27–8 medical marketplace 45, 53, 59 Medical Officers of Health (MOsH) 72, 85, 96, 101, 103, 108, 153–4 medical practices 45–62; consuming medicine 59–62; domestic medicine 49–53; further reading 170; medical practitioners 53–9; pursuit of health 45–9 medical practitioners 81–98; diagnosis and treatment 60–1; domestic medicine 49; excluding competitors 88–91; further reading 171; history of medicine 5, 118; making a medical living 82–7; medical practice 53–9; nursing 91–8; overview 81; unity in the profession 146–7 Medical Reform Act (1858) 88–9 Medical Research Council (MRC) 36 medical schools: emergence of hospital medicine 31, 32; excluding competitors 89–90; history of medicine 119; laboratory medicine 35–6; making a medical living 82, 83, 84, 86; medical care in institutions 63; medical training in London 145; teaching practice 39–40; wartime 110 medical sciences 34, 35, 38, 39 medical societies 36, 86, 87, 89 medicine: history of 3–5, 117–19; professionalisation 5, 81, 86–7, 94, 98; theory of 83, 170 medicines: consuming medicine 59–62; dispensing 85; herbal medicine 42, 51, 55, 166; history of medicine 118; medical practitioners 55–6, 59; patent medicines 50–1, 87, 136, 167; pharmaceutical industry 48, 51–3; quacks/sellers 50–1 Medico-Psychological Association 95 mental illness 12, 76–80, 95, 106 Mercer, Alex 20 mesmerism 43, 167 miasma (bad air) 72, 100, 103, 104, 167 microscopes 33, 34, 83

Index  179 midwives 70, 95–6 military hospitals 96, 111 milk 75, 107, 119 miner’s nystagmus 41 Ministry of Health 96, 97, 111, 112, 113 moral therapy 77, 78, 79, 144 The Morbid Anatomy of Some of the Most Important Parts of the Human Body (Baillie) 29, 30, 128–9, 131 morbidity 9, 21–2, 118, 167 Morgagni, Giovanni 29 morphine 51 mortality: causes 9–14, 15–19, 24–6, 117; definition 9, 20, 167; epidemiological transition 18–20; measuring morbidity 22; public health 105; variations in 126 MOsH see Medical Officers of Health mothering skills 106, 154–5 MRC see Medical Research Council Museums of Madness (Scull) 78 Naissance de la clinique (The Birth of the Clinic) (Foucault) 31 National Association for the Prevention of Consumption 74 National Health Service Act 91 National Health Service (NHS): economic factors 60; government medical care 112–13; health and the state 99; history of medicine 5, 117, 119; launch of 61–2, 113; medical practitioners 81, 91, 97; The New National Health Service (leaflet) 155–6; voluntary hospitals and dispensaries 65, 70 National Insurance 109–10, 112 National Insurance Act (1911) 60, 74, 91, 109, 110 naturopathy 42 nerves 28, 34, 36, 37 New Health Society 46 Newman, George 154–5 The New National Health Service (leaflet) 155–6 New Poor Law 71 NHS see National Health Service Nightingale, Florence xiii, 66–7, 93, 94, 142, 150 Nissen, Hartvig 132–3 nitrous oxide 56 Nordrach-upon-Mendip Sanatorium 73 Northern Ireland 108, 118 Nuisance Removal Acts 102

Nurses’ Registration Acts (1919) 96 nursing: domestic medicine 50; medical practitioners 91–8; Nightingale system of nurse training 150; schools 93, 94; standards 67 nutrition 24, 25, 37, 39, 46, 107 Obstetrical Society of London 96 occupational medicine 90 Omran, Abdel 14, 19 operations 56, 57, 58, 67 ophthalmoscope 55, 61 opium 51, 56 Original Cases With Dissections and Observations Illustrating the Use of the Stethoscope and Percussion in the Diagnosis of Diseases of the Chest (Forbes) 32 orthodox medicine: definition 42, 167; excluding competitors 88, 89, 90; general practitioners 84; and heterodox medicine 42–4; medical practices 45; medical practitioners 53, 54, 55 Outlines of Physiology (Bennett) 130–1 outpatient care 69–70 Oxford University 35 pain 56, 57 pandemics 16, 124, 167 panel patients 110 Paris school 31, 32, 34, 83, 119 Pasteur, Louis 33, 35 patent medicines 50–1, 87, 136, 167 pathological anatomy 29, 31, 32, 39, 167 Pathological Society 36, 86 pathology 35, 56 patient numbers 65, 70, 79 patients’ accounts 60, 61, 142–4 patterns of disease 14, 23–6, 117 pavilion plan wards 66, 67, 71, 73 Pavlov, Ivan 37 penicillin 53 pharmaceutical industry 48, 51–3, 59, 118 pharmacy 84 phthisis 13–16, 20, 167 physical activity 24, 28, 47–8, 74, 132–3 physical examination 31, 38, 55 physicians 82, 85, 118, 167 Physiological Society 36 physiology 34, 35, 55, 131, 167 Pickstone, John 5

180 Index Picture Post (magazine) 125 plague 9, 14 plastic surgery 111 pneumonia 14, 16 pollution 23, 101 Poor Law 71, 74, 76–8, 90, 99, 101, 104, 109 Poor Law hospitals 63, 70–2, 80, 97, 111 post-mortems 29, 31, 83 poverty: access to care 64; asylums 77–8; diagnosis and treatment 61; government medical care 109; history of medicine 118, 119; infant welfare 106; medical practitioners 83; nursing 92, 95; patterns of disease 23, 25; Poor Law hospitals 70–2; public health 13; pursuit of health 46, 47; sanitary reform 101; social and cultural factors 40 practitioners see medical practitioners pregnancy 22, 24, 25, 107 prescriptions 85, 113 Priessnitz, Vincenz 42 Principles of Human Physiology (Starling) 132 probationers (nursing trainees) 93, 94 productionist medicine 5, 109 professionalisation 5, 81, 86–7, 94, 98 Prontosil 52–3 provident dispensaries 70 Provincial Medical and Surgical Association 86, 148–9 Public Assistance Institutions 72 public education 108, 152–3 public health: health and the state 99; history of medicine 3, 5, 13, 117; insanitary conditions 23, 151; medical practitioners 90; patterns of disease 24; sanitary reform 99–102; state role 102–5 Public Health Acts 72, 100, 101, 103, 111 public lavatories 102, 104 puerperal fever 53 Punch (magazine) 110 purgative medicines 48, 56 quacks 50, 54 Queen Victoria’s Jubilee Institute for Nursing 95 radium therapy 67 Registrar-general’s office (RGO) 11, 12, 14

registration 94, 96–7 religious sisterhoods 92–3 Report on the Sanitary Condition of the Labouring Population (1842) 100–1, 151 research 3, 32, 34–7, 131 resective surgery 58, 167 respiratory diseases 15, 17, 19, 23, 47, 105 Rice, Margery Spring 127 rickets 23, 24, 36, 39 Riley, James 22 Roberts, Robert 136 Roentgen, Wilhelm 55 Rosenberg, Charles 41 Royal College of Physicians 87 St Bartholomew’s Hospital, London 63 St. Mary’s Bethlehem (Bedlam), London 77 St Thomas’ Hospital, London 63, 93, 94 Saleeby, Caleb William 133–4 salicylic acid 52 salvarsan 52, 59 sanatoria 63, 73–5, 94–5, 97, 108 Sanderson, John Burdon xiii, 36 Sanitary Act (1866) 101 sanitary reform 99–102, 103, 105 scarlet fever 11, 13–15, 17, 20, 25, 73, 103 school meals 107–8, 119 school medical service 90, 107 Schwann, Thomas 33 scientific medicine 90, 119 Scotland: asylums 78, 80; consuming medicine 59; disease in modern Britain 11, 12, 16, 20–2, 25; further reading 169; government medical care 109, 111, 112; history of medicine 5, 118; infant welfare 106, 107; isolation hospitals 73; medical practitioners 55, 82, 84–6, 96; medical schools 82, 84; nursing 96; Poor Law hospitals 71; public health 104; sanitary reform 100; voluntary hospitals and dispensaries 64, 69 Scottish Board of Health 111 Scull, Andrew 78 Second World War 24, 25, 97, 108, 110, 111, 112 Sense and Sensibility (Austen) 41 ‘Sequah’ (medicine man) 50–1 sera (anti-toxins) 52, 59, 73 sewerage 24, 100, 101, 102

Index  181 shellshock 25 Sherrington, Charles xiii, 37 Shetland 11 sickness transition 22 Simon, John xiii, 101–2, 103, 151–2 Simpson, James Young xiii, 57 Sir William Dunn School of Biochemistry 36 sisterhoods 92–3 slums 23, 108, 151 smallpox 10–11, 14–15, 17–19, 26, 73, 90, 100, 103–5, 117 smoke pollution 101 smoking 24 Snow, John 103 Socialist Medical Association (SMA) 112 social medicine 108 Society of Apothecaries 88, 89, 147 Spanish flu 17–18, 25, 124 sphygmomanometer 39, 55 sports 47 standards of living 17, 23, 24, 105 Stark, James xiii, 13 Starling, Ernest xiii, 37, 132 state role: further reading 171–2; government medical care 109–14; health and the state 99–114; history of medicine 117; medical care in institutions 63; medical practitioners 90; overview 99; public health 102–5; sanitary reform 99–102; welfare 105–8 stethoscope 31, 32, 55, 61 street cleaning 72, 100, 102, 103 sulphonamide drugs 52–3, 59 sunlight 39, 48, 133–4 surgery: history of medicine 118; hospital design 67; medical practitioners 54, 56–8, 82, 83, 85; patient’s experience 138–9 Surrage, James 129–30 ‘surveillance medicine’ 106 Sweden 100 Swedish gymnastics 132–3 syphilis 40, 52, 79, 105 Szreter, Simon 105 TB see tuberculosis teaching 34, 35, 39, 83, 85–6, 113 technical language of medicine 129–30 temperature 28, 46, 47, 50, 55 ‘Temple of Health’ (Graham) 54 tetanus 104 theory of medicine 83, 170

thermometers 55 Thomson, Samuel 42 Thomson, William 32 Thomsonian medicine 42, 51, 55, 168 tissick 12, 13 tonics 48, 52 training: medical practitioners 81–3, 92–7; medical training in London 145; nursing 92–7, 150 transplant surgery 58, 118 tuberculosis (TB): and creativity 41; disease in modern Britain 10, 15, 17, 20, 22, 25, 26; hospital medicine 31; laboratory medicine 34, 36; pathological changes in the lung 128–9; pharmaceutical industry 53; physiological data recording 55; public health 104, 105; sanatoria 63, 73–5, 94–5, 97, 108; social medicine 108 Tuke family 77 typhoid 17, 26, 103, 104 typhus 10, 14, 17 University College London (UCL) 32, 35, 36, 37, 93 university medical schools 35–6, 82–4, 86, 89, 119 urine tests 55, 61, 67 vaccination 35–6, 75, 90, 100, 104–5, 117 Vaccination Act 104 VADs see Voluntary Aid Detachment nurses VD see venereal disease vegetarianism 43, 46 venereal disease (VD) 12, 25, 40, 108 Venereal Diseases Act (1917) 108 Virchow, Rudolf 33 viruses 20, 34 vitamins 36, 37, 39 Voluntary Aid Detachment nurses (VADs) 96 voluntary hospitals 63–70, 72, 75, 97, 110–11, 113, 119 Wakefield 51 Wakley, Thomas xiii, 86, 147–8 Wales: asylums 78, 80; disease in modern Britain 11, 13, 17, 20–2, 25; government medical care 109, 111; history of medicine 5, 118; infant mortality 106; isolation hospitals 73; midwives 96; public health 13, 104; tuberculosis sanitoria 74

182 Index Wallace, Alfred Russel 41 wards, hospital 66–8, 71, 73, 83 wars 24–5, 71, 90, 96–7, 105–6, 110–11 water cure see hydropathy water supply 17, 23, 24, 100, 102, 103 Weekes, Hampton 145 weight 48 welfare 25, 46, 85, 90, 99, 105–9, 118–19 Welsh Board of Health 111 Western medicine 169 whooping cough 11, 14, 15, 17, 50 women practitioners: domestic medicine 49; history of medicine 4; nursing 91–8; women doctors 81, 89–90, 149

women’s health 24, 47, 49, 127 Women’s League of Health and Beauty 47 work 22, 46, 64, 109 workhouses 71, 74, 76, 78, 83 working class: cleanliness 47, 102; economic factors 60; health of women 127; history of medicine 118; making a medical living 84, 85; measuring morbidity 22; nursing 93, 94; voluntary hospitals 69; welfare 106, 107 Wunderlich, Carl 55 X-rays 55, 61, 67 York Asylum 77