A Picture of Health: Exeter’s Medical History

In 2022 RAMM held an temporary exhibition exploring Exeter’s medical past. It was inspired by a collection of recently acquired oil paintings donated by the Royal Devon & Exeter Hospital. This Collections Story gives you the opportunity to revisit a selection of themes and objects in the show online or browse the content for the first time.

All of the 89 objects used in the exhibition from the collection at RAMM are available to explore individually.

The development of modern medicine is something that is easy to take for granted today. It’s hard to imagine a world without antibiotics to treat infection, X-rays to diagnose broken bones or anaesthetic to prevent pain.

300 years ago, when the Devon and Exeter Hospital first opened its doors, medicine was very different. The past three centuries have seen huge leaps in medical understanding and the way in which conditions are treated and cured. Yet some of these advances were only made possible by exploiting society’s most vulnerable people. The history of medicine definitely has ‘skeletons in the cupboard’.

The 18th century portraits of physicians, surgeons and founders that inspired this exhibition once hung in the boardroom of the Royal Devon and Exeter Hospital, looking down on staff and patients as the hospital changed beyond recognition.

Their modern counterparts may look very different, the NHS has a more diverse and inclusive workforce than ever before. However, they share a commitment and dedication to caring for their patients, which is a thread running through medicine throughout history.

COVID-19 has dominated the news over the last couple of years, but Exeter has been ravaged by many other outbreaks of disease throughout its long history. Bubonic plague was a frequent visitor during the medieval period. In 1775 physician Thomas Glass recorded a ‘coughing epidemic’. Smallpox, cholera and typhoid, eradicated in the UK today, were common childhood illnesses. In 1918 the Spanish Flu pandemic caused schools, theatres and other public buildings to close and killed many, particularly the young and previously healthy. 100 people were reported to have died in Paignton in just a fortnight.

A lack of understanding of how diseases spread, the limited availability of effective medical treatments, and frequently poor sanitation and nutrition meant that these disease outbreaks spread very quickly through communities. They often led to a devastating loss of life. There were no antibiotics, antivirals or many of the supportive treatments we rely on today.

Until the discovery of germ theory by scientists such as Louis Pasteur in the 1860s, the dominant belief in Britain was that illness was spread by ‘miasma’ (noxious fumes in the air). Miasma was used to explain how infectious diseases like smallpox, cholera or plague could easily spread between people who lived close together in urban areas. The first viruses were not identified until the 1890s.

Medical knowledge was constantly developing throughout the 18th and 19th centuries and the advances made have greatly contributed to the modern healthcare we enjoy today.

RAMM continues to collect objects which help to tell Exeter’s story. During the COVID-19 pandemic we collected a number of objects which reflected the city’s experience of the pandemic. Here you can see some of them.

Smallpox was eradicated worldwide by 1980 but in the 18th century it was a disfiguring and often deadly disease. It spread most commonly through inhalation of the virus in droplets from coughs and sneezes.

Outbreaks would frequently ravage the country, before dying down again for a number of years. For centuries, smallpox inoculation had been practiced in China and India using the method of variolation. A small amount of smallpox-infected material, often scabs or pus, from a patient or recently inoculated person, was rubbed into shallow scratches in the skin of a healthy person, resulting in a mild and localised infection. It was hoped this would provide protection against more dangerous infections in the future.

Lady Mary Wortley Montagu came across the practice of variolation during her time in Istanbul, where her husband was the British Ambassador. She is credited with introducing the idea to Britain in 1721. Smallpox variolation was not without risk as there was always the chance it could result in a more serious infection.

In 1796, Edward Jenner developed a much safer method of inoculation using cowpox. He realised that people who had been exposed to cowpox were also protected against the more deadly smallpox. This was the world’s first vaccine.

Cholera is a highly contagious bacterial infection, usually spread by consuming contaminated food or water. Cholera is no longer found in the UK, but during the 1800s there were a number of severe cholera pandemics which spread across the world, killing millions of people.

Cholera reached the UK in 1831 and quickly swept throughout the country causing mass panic and 55,000 deaths.

Exeter’s first cases were recorded on 19 July 1832 in St Thomas and in North Street. Both patients had recently arrived in the city, bringing the disease with them. The sewage from houses in North Street flowed into the Longbrook, and it is now thought that this is how cholera entered the water supply and spread through the population.

The Exeter Board of Health, responsible for public health in the city, had been anticipating an outbreak of cholera in Exeter since the first British cases of the previous autumn. They brought in measures to try and contain the disease. They included special forms to record cases, and plans for isolating the homes of victims, burial of the dead and disposal of infected clothing and blankets. 24 nurses and four druggists were appointed to help, but it wasn’t enough to keep up with the number of patients needing care.

Between July and October 1832, the outbreak caused nearly 1,200 cases and 402 deaths.

Dr Thomas Shapter (1809-1902) was a young physician in Exeter who tended many of poorest and most vulnerable during the 1832 cholera epidemic. He was determined that more should be done to learn from what happened in the city to prevent a similarly devastating outbreak in the future.

In 1848 Shapter published an account of the epidemic, History of Cholera in Exeter 1832, which took an evidence based approach and used ground breaking statistical analysis to study the outbreak.

Using both the statistical data and first-hand accounts of doctors and public health officials, Shapter plotted the spread of the outbreak on a ground-breaking map. It clearly showed that cases were focused on the West Quarter of the city. He did not, however, make the connection between a contaminated water supply and the spread of cholera.

These illustrations from Thomas Shapter’s book show the streets of Exeter being fumigated with tar and cholera victims being buried in the Southernhay burial ground.

In a world before antibiotics, paracetamol, antiseptic and all the other modern medicines we rely on today, doctors were limited in the treatments they could prescribe. The earliest medicines were made from plant extracts soaked in water or alcohol. It was extracts from these medicinal plants that formed the basis of some of today’s most commonly used medicines including quinine, morphine and aspirin.

Originally, individual apothecaries or druggists would mix their own recipes and sell them from their shops. Industrialisation in the 19th century allowed companies like Wellcome-Burroughs and Beechams to manufacture their drugs on a much larger scale.

The commercialisation of pharmacy also led to the introduction of many ‘quack’ cures on the market. These cures, also known as patent medicines, were marketed as treating all sorts of conditions. Rarely was there any scientific basis to these claims. They often contained alcohol or opium and sometimes caused more harm than good.

There was increasing recognition of the importance of fresh air and sunlight in aiding recovery from illness. Household manuals advised keeping sickrooms well ventilated, and hospitalised patients were often wheeled outside in their beds to enjoy the sunshine. Before the discovery of penicillin, it was common for patients suffering from tuberculosis to be sent to sanatoriums in the countryside for open air treatment. The Hawkmoor County Sanatorium opened in Bovey Tracey in 1913.

For much of human history, childbirth was a dangerous business. It’s only within the last century that maternal and infant mortality rates have greatly improved.

Historically, in Britain birth took place at home. It was common for a woman to be attended to in labour by her mother and any sisters who had already given birth. There may also have been a midwife in attendance. These midwives were not formally trained and their skills were often passed down from mother to daughter.

From the 1700s, male physicians and surgeons began adding midwifery to their services, and became known as ‘man-midwives’. They were especially in demand amongst wealthy women, who felt that a doctor would be more knowledgeable than a midwife with no formal training. However, it is thought that these man-midwives actually contributed to many deaths amongst their patients. Before the importance of hygiene was fully understood, it was common for man-midwives to come directly from another patient, sometimes even a post-mortem, to attend a birth without washing their hands or changing their clothes.

Even with a doctor in attendance there was little that could be done in cases of a complicated or obstructed birth. Caesarean sections had a high chance of killing the mother, in 1865 the mortality rate in Britain was as high as 85%, so were only used as a last resort to try and save a baby when a mother was dead or dying.

The late 1800s saw a resurgence of female-led midwifery, with recognised training programmes and qualifications being introduced. Over the course of the 20th century, birth gradually moved from the home into hospital settings.

In Britain’s past, the majority of people died at home cared for by friends and family. Life expectancy was shorter and a significant number of babies and children died before reaching adulthood. Death was a part of day to day life in a way that it isn’t for most people today.

Before technology gave us the ability to see inside the body of a living person, the only way doctors could truly learn how the human body worked was through dissection. Before 1832, surgeons and anatomists were restricted to using the bodies of executed criminals to learn anatomy. There were nowhere near enough available to meet the needs of Britain’s medical schools, so by the 18th century this shortage fuelled an illicit trade in corpses.

Surgeons turned to the services of resurrection men or body snatchers, who would dig up freshly buried bodies from graveyards and sell them to nearby medical schools. This practice caused widespread public outrage and local communities employed watchmen to guard graveyards to ensure their loved ones could rest in peace. Special metal devices called ‘mortsafes’ were also available to go over graves to protect them.

This practice finally ended with the passing of the Anatomy Act in 1832. The act allowed the medical use of unclaimed bodies from workhouses, hospitals and prisons – a practice which continued into the 20th century. Human dissection has contributed to some of the greatest advances in medical science, but many of the bodies were of the most vulnerable in society and used without consent.

In the UK, the earliest hospitals were associated with religious communities and were often the only places where people suffering from stigmatised diseases, like leprosy, could receive help.

Secular hospitals began to open in the 18th century, staffed by trained physicians and surgeons and untrained nurses. Patients often had to pay for treatment and would not be admitted if they were suffering from an infectious disease. Hospitals were seen as dirty and unhygienic places where infection could spread easily. Those wealthy enough to employ private nurses and receive medical care at home avoided them entirely.

As understanding of how diseases spread improved, increasing emphasis was placed on the importance of fresh air and cleanliness in the sickroom, and public health reformers worked to extend these principles into hospitals. Florence Nightingale advocated for long wards with tall windows either side for cross ventilation and beds spaced a uniform distance apart to stop the spread of infection. These became known as Nightingale wards and were common in hospitals up until the 1960s.

In the Victorian period people who had mental health problems, and those with physical and learning disabilities, were frequently isolated away from mainstream society in hospitals or asylums. Here they received little effective medical care, and were often physically restrained or exposed to cruel and experimental treatments. Many asylums were completely self-sufficient, even producing their own food. Asylum reformers campaigned for an improvement in conditions with limited success, and an enduring belief in eugenics ensured patients remained isolated from their communities. Families were not encouraged to visit, and some patients would stay institutionalised for their entire lives.

At the beginning of the eighteenth century there was a strict medical hierarchy in Britain.

Physicians were the most respected due to their university education. They were considered gentlemen meaning they could socialise with the higher ranks of society. They mainly diagnosed internal problems by checking a patient’s pulse or urine and wrote prescriptions, but generally did not dispense the medicine themselves. Employing a physician’s services could be expensive and often out of reach of many.

Surgeons performed operations, set broken bones and carried out bloodletting. They learnt their trade through an apprenticeship to an older colleague, and their job was very practical and hands on. William Cookesley, a Devon surgeon, carried out the first documented successful removal of an appendix on a patient in 1731.

Apothecaries mixed and dispensed medicine, often prescribed by a physician, although some apothecaries also visited patients and gave medical advice. For families who could not afford to pay for a physician, apothecaries were often the only source of medical help available to them.

Women had long campaigned to be allowed to study medicine, but it was not until the mid-19th century that the first women were admitted to British medical schools. Elizabeth Garret Anderson was one of the first to receive her licence in 1865 but she was still forbidden to work in hospitals. In 1876 the law was changed to give women full access to the medical profession but underlying prejudice from male colleagues remained for many decades.  

Although nursing is one of the oldest medical occupations, it has not always had the best reputation. In Britain, nursing only became the profession we are familiar with today in the second half of the 19th century.

Prior to the 1850s, nurses received little training and were poorly paid. Those working in hospitals suffered poor working conditions and had little support. It was even worse in the workhouse and asylum infirmaries where it was common for the sick to be cared for by unpaid fellow inmates.

Charles Dickens summed up the typical early Victorian nursing stereotype with the notorious Mrs Gamp in his novel Martin Chuzzlewit serialised in 1843-4. Mrs Gamp is portrayed as dissolute, sloppy, uncaring and often drunk.

Florence Nightingale broke the mould when, as a wealthy young woman, she announced she wished to pursue nursing instead of finding a husband. Her experience of caring for British soldiers at Scutari Hospital during the Crimean War led her to develop many of the ideas that revolutionised nursing and hospital design. It was one of Nightingale’s Scutari nurses who first introduced some of her principles to the Devon and Exeter Hospital in 1855. Florence Nightingale founded the first professional training school for nurses at St Thomas Hospital, London in 1860. Soon similar training schools opened at hospitals all around the country, including Exeter. This professionalisation of nursing caused a seismic shift in how nurses were viewed by British society and, by the turn of the 20th century, nursing was seen as one of the few acceptable professions for middle-class women to pursue.

The NHS was founded in 1948 with the aim of providing universal access to healthcare for every man, women and child in the country. An introductory leaflet sent to every household explained:

“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.”

This was a major change in how healthcare was accessed in Britain. For the first time, the ability to pay would not affect the treatment available. The NHS has transformed the health and wellbeing of the nation.

Many of the existing medical institutions in Exeter were absorbed into the NHS, including the Royal Devon and Exeter Hospital, which moved to its current site in Wonford in 1974. Today the Royal Devon University Healthcare NHS Foundation Trust employs over 15,000 people and provides care for around 615,000.

One of the most common surgical procedures today is a hip replacement. This operation replaces a damaged hip joint with an artificial one, called an implant.

Hip replacements have taken place since the 1890s, but widespread use of a successful design only started in the early 1960s. One of the most successful and widely used implants was conceived in Exeter. First implanted in 1970 it is still used in around 40% of UK operations today. 

The visionary Exeter hip was the brainchild of orthopaedic surgeon Professor Robin Ling and engineer Professor Clive Lee, who met while working at the Princess Elizabeth Orthopaedic Hospital and University of Exeter respectively. Taking a revolutionary collaborative approach Ling and Lee used their combined expertise to design an implant which both lasted longer than earlier implants and was less likely to need additional surgical intervention in the future. This enabled many patients to remain mobile and pain free for much longer than had previously been possible.

Over the past 50 years the work of Ling, Lee and their team has enhanced the lives of over 2 million people worldwide. The Exeter hip stem continues to be considered the ‘gold standard’ in replacement hip stems. 

Exeter continues to be a city pioneering medical research and innovation. The University of Exeter’s ground-breaking health research spans from making fundamental discoveries on how cells and genes function in major diseases, including dementia and diabetes, to accelerating the search for new treatments and improving how health services function.

For centuries, human dissection has been an essential part of medical students’ anatomical education. But in recent years, the University of Exeter has been leading the way in teaching their students clinically relevant anatomy with a combination of innovative approaches, including the use of living anatomy models; physical examinations; medical, radiological and computer anatomical imaging technologies; plastic human anatomical models; animal organ dissections; and dissected plastinated human cadaveric specimens. Plastinates are resin preserved body parts, which were made famous by anatomist Gunther von Hagens who invented the technique in 1977, and went on to use it in his touring Body Worlds exhibition.

Research has found that the dissecting room can be traumatic for first year students, especially as for some it may be their first experience of death. There are also practical considerations as to why full cadaver dissection might not be the optimal way to train students. Post-mortem changes and the chemicals used to preserve bodies, mean that tissue and organs can look very different from those in a living person. 

For those medical schools that continue to practice human dissection, the treatment of cadavers is very different from 200 years ago. Bodies are donated to universities with informed consent, and it is common for there to be an annual thanksgiving service held to remember those who have donated their bodies to help train the next generation of doctors and surgeons.

This film was commissioned for the A Picture of Health exhibition in 2022. The 18th century portraits of physicians, surgeons and founders that inspired this exhibition once hung in the boardroom of the Royal Devon and Exeter Hospital, looking down on staff and patients as the hospital changed beyond recognition. Their modern counterparts may look very different now the NHS has a more diverse and inclusive workforce than ever before. However, they share a commitment and dedication to caring for their patients, which is a thread running through medicine throughout history. With thanks to staff at the RD&E, and Preston Street Films.

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