The Victorian Era

Victorian Medicine and Public Health

Article · Science & Invention · The Victorian Era, 1837–1901

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The Victorian period transformed medicine and public health from an unregulated trade of physicians, surgeons, apothecaries, and quacks into a recognisably modern system of qualified practitioners, trained nurses, licensed hospitals, municipal sanitary authorities, and a body of legislation that ran from the Public Health Act of 1848 to the Notification of Births Act of 1907. The transformation rested on three pillars: the sanitary reform movement, the germ theory of disease, and the reform of medical education and the medical profession. The general history of the period is set out in The Victorian Era: A Complete Historical Overview, and the parent overview of the sciences is Victorian Science, Invention, and Technology.

The State of Medicine in 1837

The medicine that Victoria inherited was, by later standards, unregulated, untrained, and dangerous. The physicians, who held university degrees from Oxford, Cambridge, Edinburgh, or one of the foreign universities, were few, expensive, and concentrated in the larger towns. The surgeons, who had emerged from the old barber-surgeon trade and were now organised in the Royal College of Surgeons, were more numerous and more accessible but had no compulsory training until the Apothecaries Act of 1815. The apothecaries, who had been loosely organised since 1815, were the medical practitioners of the working class, and the General Medical Council, created by the Medical Act of 1858, would later describe the typical apothecary as a man who had served an apprenticeship and walked the wards of a hospital for a few months before setting up shop. The fourth group, the quacks, were untrained and unlicensed, and they sold proprietary pills, electuaries, and mineral waters at every market stall in the kingdom.

The hospitals reflected the same disorder. The great voluntary hospitals of London, Guy’s, St Bartholomew’s, St Thomas’, the London, the Middlesex, St George’s, King’s College, University College, the Charing Cross, the Westminster, and the Royal Free, together with the special hospitals for children, women, the eyes, the chest, and the insane, were charitable foundations funded by subscriptions and endowments. The teaching hospitals were attached to the medical schools and supplied most of the physicians and surgeons of the country. The workhouse infirmaries, regulated by the Poor Law of 1834, were underfunded and overcrowded, and the new municipal fever hospitals of the 1860s and 1870s were built only after cholera and typhus had forced local sanitary authorities to act.

The Sanitary Awakening: 1842 to 1854

The sanitary awakening of the mid-Victorian period was the work of a small group of civil servants, physicians, and statisticians who argued that epidemic disease was preventable, that the urban environment was the principal cause, and that only the state could remedy the problem. The campaign was launched by Edwin Chadwick’s Report on the Sanitary Condition of the Labouring Population of Great Britain of 1842, which had been commissioned by the Poor Law Commission. Chadwick, a former utilitarian disciple of Jeremy Bentham, used the new tools of the Registrar General’s office to show that the average age at death of a labourer in Liverpool, Manchester, or Bethnal Green was below that of a West Indies slave, and he attributed the excess mortality to the overcrowded, undrained, and unventilated housing of the new industrial towns.

The Public Health Act of 1848 created a General Board of Health, sitting in Whitehall, with Chadwick as its first secretary and a remit to declare any district a “public health district” if the local death rate exceeded the national average. The Act was permissive rather than compulsory, and the local sanitary authorities it set up were dominated by ratepayers suspicious of central interference. The Board was reconstituted in 1854 under the presidency of the epidemiologist John Simon, with the physician Thomas Southwood Smith as a member, but it was dissolved in 1858 and its powers were transferred to the Privy Council. Simon continued as the government’s medical officer until 1876, and the Local Government Act of 1858, the Privy Council’s Medical Department, and the successive Medical Officers of Health appointed under the Act together laid the foundation of the modern English public health service.

Cholera, Water, and the Sanitarian Alliance

The sanitary campaign received its decisive scientific support from the study of cholera. The physician John Snow, working in Soho during the outbreak of 1848-49, had traced a cluster of deaths to a single pump in Broad Street, and in 1854 he repeated the demonstration with greater precision. The Broad Street pump was removed on the night of 7 September 1854, the outbreak subsided, and Snow’s On the Mode of Communication of Cholera of 1855 became a founding text of epidemiology, even though the causative organism, Vibrio cholerae, was not isolated until Robert Koch’s work of 1883-84. William Budd, a Bristol physician, published a parallel study of typhoid in 1873 that pointed to contaminated water as the vehicle of infection, and the work of Budd, Snow, and the Registrar General’s statistician William Farr together established the case for clean water, separate sewers, and the regulation of the water companies.

The sanitary reform of the 1840s and 1850s was carried into law by a long sequence of statutes. The Nuisances Removal and Diseases Prevention Act of 1846 gave local justices of the peace the power to close filthy premises, the Public Health Act of 1848 set up the General Board of Health, the Metropolis Water Act of 1852 required the metropolitan water companies to filter the water drawn from the Thames and to move their intakes above the tidal reaches, the Common Lodging Houses Act of 1851 and its successor of 1853 regulated the worst of the slum housing, the Labouring Classes Lodging Houses Act of 1855 gave local authorities a power to build model lodging houses, and the Metropolis Local Management Amendment Act of 1858 transferred the powers to a new Metropolitan Board of Works under the leadership of its engineer, Joseph Bazalgette.

Bazalgette and the London Sewers

The sanitary reform of London culminated in the new sewer system, the How was the London sewer system built?, built between 1859 and 1875 in response to the What was the Great Stink of London?. Bazalgette’s three intercepting sewers, the Northern, the Southern, and the Western, ran for 83 miles along the banks of the Thames and discharged the sewage at outfall works at Beckton on the north bank and Crossness on the south. The new works, paid for out of a loan of £3 million raised by the Metropolitan Board of Works, transformed the public health of the capital. The last great cholera epidemic in London was in 1866, typhoid fell sharply over the next two decades, and infant mortality began a long decline that continued into the twentieth century.

The Reform of the Medical Profession

The reform of the medical profession was carried by the Medical Act of 1858, drafted by the Edinburgh physician William Pulteney Alison and the lawyer and reformer Frederic Smith, and pushed through Parliament by the then Home Secretary, Spencer Walpole. The Act created a General Medical Council of seventeen members, drawn from the universities, the Royal Colleges, the Society of Apothecaries, and the Crown, with the power to maintain a register of qualified practitioners and to discipline members of the profession. The Council was presided over, until his death in 1883, by the Liverpool physician William Stokes, and it was authorised to publish a Pharmacopoeia and to set standards for medical education. The 1858 Act did not create a single portal of entry to the profession, and the nineteenth-century medical practitioner might still qualify by examination at any one of sixteen examining bodies, but the registration system gave the public a way to distinguish the qualified from the quack. The further reforms of the Medical Act of 1886 extended the powers of the Council and began the long process of consolidating the licensing bodies into a single portal.

The Crimean War and the Nursing Reform

The Crimean War of 1854 to 1856 brought the sanitary question before the British public in dramatic form. The reports of William Howard Russell in The Times of 1854 described the cholera-ridden barracks at Scutari, the lack of nursing care, and the high mortality of the army hospitals. The Secretary at War, Sidney Herbert, recruited Florence Nightingale to lead a party of thirty-eight nurses to the hospital, and the work of Nightingale, Mary Seacole in the Crimea itself, and the sanitary commission sent out by the government in 1855 reduced the mortality of the army in the field. The Royal Commission on the Health of the Army, of 1857, was the first sanitary enquiry of the British state, and the Army Medical School, founded at Netley in 1860, was the first state institution for the training of army medical officers. Nightingale used the fund of £45,000 raised in her honour after the war to found the Nightingale Training School for Nurses at St Thomas’ Hospital in 1860, the first secular training school for nurses in the world, and the graduates of the school established the nursing model that was copied across the empire. The story of the nursing reform is told in How did Florence Nightingale change nursing?.

Antiseptic Surgery and the Germ Theory

The germ theory of disease, which was established in stages between 1860 and 1884, transformed the practice of surgery and the design of hospitals. Louis Pasteur’s work on fermentation in the 1850s, and on the diseases of silkworms, of chickens, and of sheep in the 1860s and 1870s, established the principle that micro-organisms caused specific infectious diseases, and Robert Koch’s identification of the bacilli of anthrax (1876), tuberculosis (1882), and cholera (1883-84) anchored the theory in a programme of laboratory work. The practical application of the new theory to surgery was the work of Joseph Lister, who read Pasteur in 1864 and began the systematic use of carbolic acid to dress compound fractures at the Glasgow Royal Infirmary. Lister’s antiseptic method, published in The Lancet in 1867, cut the mortality of compound fractures from over 40 per cent to under 15 per cent within a decade, and the later development of aseptic surgery, in which the surgeon, the instruments, the dressings, and the operating theatre were all kept free of germs, was a direct extension of Lister’s work. The history of the new theory is told in How did germ theory change medicine?.

Anaesthesia and the Victorian Surgeon

Anaesthesia was the second of the three Victorian revolutions in surgery. Nitrous oxide had been demonstrated by Humphry Davy in 1800 and used in dentistry by Horace Wells in 1844, ether by William Morton at the Massachusetts General Hospital in 1846, and chloroform by James Young Simpson at Edinburgh in November 1847. The first surgical use of ether in London was at University College Hospital on 21 December 1846, and the first use of chloroform in London was at St Bartholomew’s Hospital in January 1847. The priority dispute over the discovery of anaesthesia was a Victorian controversy in its own right: Morton, Charles Jackson, Wells, and Simpson all claimed credit, and the matter was debated in the medical press and in Parliament until the 1850s. The introduction of anaesthesia ended the speed-at-all-costs surgery of the pre-Victorian era and made the careful, deliberate, antiseptic surgery of the 1870s and 1880s possible. The principal British anaesthetist of the period was John Snow, who administered chloroform to Queen Victoria at the birth of Prince Leopold in 1853 and to the Queen again at the birth of Princess Beatrice in 1857, an endorsement that did much to silence the religious objections to the new practice.

The Later Sanitary Legislation

The sanitary legislation of the 1870s consolidated the gains of the 1840s and 1850s into a single code. The Public Health Act of 1872 reorganised the local sanitary authorities in the country at large, the Public Health Act of 1875 consolidated the previous forty years of sanitary legislation into a single statute of 309 sections, the Sale of Food and Drugs Act of 1875 created a system of public analysts and inspectors, the Rivers Pollution Prevention Act of 1876 made it an offence to discharge sewage into a river, the Factory Act of 1878 consolidated the factory code, the Artisans’ Dwellings Act of 1875 gave local authorities the power to demolish slum housing, the Infectious Disease Notification Act of 1889 made the notification of certain infectious diseases compulsory, the Public Health (London) Act of 1891 created the London County Council as the sanitary authority for the capital, the Free Vaccination Act of 1891 removed the fees for vaccination, and the Vaccination Act of 1898 introduced a conscientious objection clause that allowed parents to refuse vaccination on grounds of conscience. The Notification of Births Act of 1907 and the National Insurance Act of 1911, the latter of which introduced compulsory health insurance for the working class, were just outside the Victorian period but rounded off the Victorian sanitary achievement.

The Hospitals of the Victorian Period

The hospitals of the Victorian period were transformed by the three revolutions of sanitation, anaesthesia, and germ theory. The great teaching hospitals of London, St Bartholomew’s, St Thomas’, Guy’s, St George’s, the London, the Middlesex, University College, King’s College, the Charing Cross, Westminster, and the Royal Free, were rebuilt or extensively remodelled between 1860 and 1900, with new operating theatres, new isolation wards, and new nurses’ homes. The children’s hospitals included Great Ormond Street (founded 1852), the Evelina (1869), the Hospital for Sick Children in Great Ormond Street (1852), and the Alexandra (1867). The provincial teaching hospitals included the Manchester Royal Infirmary, the Leeds General Infirmary, the Birmingham General Hospital, the Bristol Royal Infirmary, the Newcastle Royal Victoria Infirmary, and the Sheffield Royal Infirmary, all rebuilt in the same decades. The new fever hospitals of the Metropolitan Asylums Board, opened at Hampstead, Homerton, Stockwell, and Fulham between 1868 and 1895, were the architectural expression of the new public health, and the new workhouse infirmaries of the Local Government Board, built to a series of standard plans from 1865 onwards, were the largest hospital building programme of the century.

The Legacy

Over the sixty-four years of the Victorian reign, life expectancy at birth in England and Wales rose from about 40 to about 45 for males and from 42 to 49 for females, the infant mortality rate fell from about 150 per thousand in the 1840s to about 140 by 1900, the death rates from infectious disease fell sharply in the second half of the period, and the medical profession, the nursing profession, and the sanitary service together created a system that, with the National Insurance Act of 1911 and the Local Government Act of 1929, became the foundation of the National Health Service of 1948. The history of medicine and public health is examined in Victorian Science, Invention, and Technology and in The Victorian Era: A Complete Historical Overview.