Dealing with disease

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X is black rats, which carry the plague bacteria. Y is buboes, the painful swellings in the armpits, groin or neck that gave bubonic plague its name.

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Source A is useful because it shows how 18th-century voluntary hospitals were organised. It shows that patients could only be admitted with a letter from a subscriber. From my own knowledge, voluntary hospitals such as Guy's Hospital (1721) and the many county infirmaries founded later in the century were charities paid for by wealthy subscribers, who in return could recommend 'deserving' poor people for treatment. The rule excluding anyone with smallpox or another infectious disease, or who was incurable or dying, is also typical: hospitals wanted to protect their other patients and to keep their death rates low so that subscribers would go on supporting them. The rules on daily prayers and on swearing, gaming and drinking show that these hospitals had a strong religious and moral purpose, reflecting the Christian charity that motivated many founders.

The provenance affects its usefulness. The rules were printed for subscribers, so they show the image the hospital wanted to present: respectable, orderly and moral. This makes it good evidence of what hospitals intended, but it may hide problems, since rules do not tell us whether they were actually followed.

The source also has important gaps. It says nothing about what treatment patients received, which was still mostly based on bleeding and purging, or about conditions on the wards, where infections often spread. It does not mention the physicians and surgeons who gave their time to these hospitals, gaining experience and teaching students who 'walked the wards', which was one of the most important results of the growth of hospitals. Overall, Source A is useful for showing how voluntary hospitals were funded and whom they would and would not treat, but much less useful for understanding what life and treatment in them were really like.

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Changes in training were significant because they made surgeons more skilled and more scientific, which raised their status. At the start of the period surgeons were craftsmen, trained by apprenticeship and joined with barbers in the Company of Barber-Surgeons, created in 1540. They had far lower status than physicians, who had university degrees. Over the 17th and 18th centuries, their training improved. The 1540 Act had given the Company four executed criminals' bodies a year for dissection, and in the 18th century private anatomy schools, such as William Hunter's in London, allowed students to dissect bodies themselves. Students also 'walked the wards' of the new voluntary hospitals, such as Guy's and St George's, learning from experienced surgeons, and textbooks in English, such as William Cheselden's anatomy of 1713, made knowledge more widely available.

This improved training raised surgeons' reputations. Famous surgeons such as Cheselden, who could remove a bladder stone in about a minute, and John Hunter, who taught a scientific, experimental approach at St George's and became surgeon to George III, won public respect. As a result, in 1745 the surgeons broke away from the barbers to form the Company of Surgeons, and in 1800 it received a royal charter as the Royal College of Surgeons, which examined new surgeons.

However, the significance had limits. Surgeons were still called 'Mr' rather than 'Dr' and ranked below physicians. Operations were still very dangerous because of pain, infection and blood loss, which were not overcome until the 1840s and 1860s. The reliance of anatomy schools on body-snatchers also damaged their reputation.

In the long term, these changes were very significant. The Medical Act of 1858 put qualified surgeons and physicians on the same register, and once anaesthetics and antiseptics made complex operations possible, surgeons became among the most respected members of the medical profession. The improved training of the 17th and 18th centuries laid the foundation for this.

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Science and technology have been the most important factor in improving understanding of the causes of disease, because the decisive breakthrough, germ theory, depended on new scientific methods and equipment. However, individuals were needed to use them, and for centuries religion and tradition held understanding back.

For most of the period, understanding of the causes of disease hardly changed. In the Middle Ages people believed disease could be a punishment from God, or caused by the planets, by an imbalance of the four humours or by miasma. The Black Death of 1348-49 was blamed on God's anger, the alignment of the planets and bad air. Remarkably, the same ideas were used to explain the Great Plague of 1665. Even Thomas Sydenham, who observed diseases carefully in the 17th century, thought epidemics were caused by the atmosphere. This shows that without the right technology, careful observation alone could not reveal the true causes.

Science and technology transformed this. Leeuwenhoek saw tiny 'animalcules' through his microscopes in the 1670s, but nobody linked them to disease. Improved microscope lenses from the 1830s made bacteria much clearer. In 1861 Louis Pasteur published his germ theory, based on experiments showing that microbes in the air caused decay. Robert Koch then used dyes, photography and new ways of growing bacteria to identify the microbes causing specific diseases, including tuberculosis in 1882 and cholera in 1883. In the 20th century electron microscopes revealed viruses, and the discovery of the structure of DNA in 1953 and the Human Genome Project, completed in 2003, showed how genes can cause disease. Statistical methods also revealed new causes, such as the link between smoking and lung cancer shown by Richard Doll and Austin Bradford Hill in 1950.

However, individuals were essential. Technology had to be used by people with the skill and determination to design experiments, such as Pasteur and Koch. John Snow proved in 1854 that cholera was spread by water, by mapping deaths around the Broad Street pump, before germs had been identified, which shows that a talented individual could make progress even with simple methods.

Other factors played a part. Religion and superstition held back understanding for centuries, because supernatural explanations discouraged people from looking for natural causes, and the Church supported Galen's ideas. War encouraged progress, since rivalry between France and Germany after the war of 1870-71 drove Pasteur and Koch to compete. Communication spread their findings, and government funded research and collected statistics on deaths from 1837.

Overall, science and technology has been the main factor in improving understanding of the causes of disease. Ideas barely changed between 1348 and 1665, and the transformation only came when microscopes and laboratory methods allowed germs to be seen and tested. Individuals such as Pasteur and Koch were vital, but their achievements depended on the technology they used.