Bad housing, poor sanitation and overcrowding, that in turn bred epidemic disease, were closely associated with inner-city areas. Ursula Henriques wrote:
In the first half of the nineteenth century no aspect of life suffered such cumulative deterioration as did public health. 
It was unhealthy to live in Victorian cities, though chances of illness and premature death varied considerably depending on who you were, where you lived, how much you earned and how well you were fed. Social class mattered. Not all towns had equally high mortality rates and death rates in the countryside could match those in middle-class suburban areas of cities.
Contemporary opinion was most concerned about infectious diseases even though more people died from ‘other causes’ than from all infectious diseases combined. Such diseases as typhus and influenza were both endemic and epidemic: they killed large numbers of both rural and urban dwellers but affected the young and malnourished of the urban slums. Smallpox became less important, in part because of the vaccination developed by Edward Jenner in the 1790s though it was not eradicated. Typhus fever was endemic in London and epidemics occurred in all towns in 1817-1819, 1826-1827 and 1831-1832. Influenza epidemics occurred in 1803 and 1831. As towns grew, polluted water became an increasingly pressing problem and was the cause of many diseases from infantile diarrhoea and typhoid fever and especially cholera.
Nothing occupies a nation’s mind with the subject of health like a general contagion. In the 1830s and the 1840s, there were three massive waves of contagious disease: the first, from 1831 to 1833, included two influenza epidemics and the initial appearance of cholera; the second, from 1836 to 1842, included major epidemics of influenza, typhus, typhoid and cholera. As Garrison observed, epidemics in the eighteenth century were ‘more scattered and isolated’ than previously and in the early nineteenth century there had been a marked decline in such illnesses as diphtheria and influenza. Smallpox, the scourge of the eighteenth century, appeared to be controllable by the new practice of vaccination. Then, in the mid-1820s, England saw serious outbursts of smallpox and typhus, anticipating the pestilential turbulence of the next two decades.
The first outbreak of Asiatic cholera in Britain was at Sunderland during the autumn of 1831. From there the disease made its way north into Scotland and south toward London eventually claiming 52,000 lives. It had taken five years to cross Europe from its point of origin in Bengal and by 1831 British doctors were well aware of its nature, if not its cause. The progress of the illness in a cholera victim was a frightening spectacle: diarrhoea increased in intensity and became accompanied by painful retching; thirst and dehydration; severe pain in the limbs, stomach and abdominal muscles; a change skin hue to a sort of bluish-grey. The disease was unlike anything then known. One doctor recalled
Our other plagues were home-bred, and part of ourselves, as it were; we had a habit of looking at them with a fatal indifference, indeed, inasmuch as it led us to believe that they could be effectually subdued. But the cholera was something outlandish, unknown, monstrous; its tremendous ravages, so long foreseen and feared, so little to be explained, its insidious march over whole continents, its apparent defiance of all the known and conventional precautions against the spread of epidemic disease, invested it with a mystery and a terror which thoroughly took hold of the public mind, and seemed to recall the memory of the great epidemics of the middle ages.
Cholera subsided as rapidly as it had begun, but another sort of devastation had already taken hold. The previous June, following a particularly rainy spring, Britain experienced the first of eight serious influenza epidemics that occurred over the next sixteen years. The disease was often fatal, and even when it did not kill, it left its victims weakened against other diseases. Burials in London doubled during the first week of the 1833 outbreak; in one two-week period they quadrupled. Whereas cholera, spread by contaminated water, affected mainly the poorer neighbourhoods, influenza was not limited by economic or social boundaries. Large numbers of public officials, especially in the Bank of England, died from it, as did many theatre people.
In the 1830s, the term ‘fever’ included a number of different diseases, among them cholera and influenza and a ‘new fever’, typhus was isolated. During its worst outbreak, in 1837-1838, most of the deaths from fever in London were attributed to typhus and new cases averaged about 16,000 in England in each of the following four years. This coincided with one of the worst smallpox contagions, which killed thousands, mainly infants and children. Scarlet fever or scarlatina was responsible for nearly 20,000 deaths in 1840 alone.
Although mortality rates for specific diseases were not compiled for England and Wales between 1842 and 1846, during this period there was a considerable decline in epidemics. It has been suggested that one reason was the expansion of railway building, with the consequent increase in wage levels and a better standard of living. A hot, dry summer in 1846, however, was followed by a serious outbreak of typhoid in the fall of that year. Enteric fever, as it was then called, is a water-borne disease like cholera and tends to flourish where sources of drinking water are infected. That same year, as the potato famine struck Ireland, a virulent form of typhus appeared, cutting down large numbers of even well-to-do families. Irish workers moved to cities like Liverpool and Glasgow and the ‘Irish fever’ moved with them. By 1847, the contagion, not all of it connected with immigration, had spread throughout England and Wales, accounting for over 30,000 deaths. As had happened a decade earlier, typhus occurred simultaneously with a severe influenza epidemic that killed almost 13,000. Widespread dysentery and cholera returned in the autumn of 1848, affecting especially those parts of the island hardest hit by typhus and leaving about as many dead as it had in 1831.
Diseases such as cholera, typhus, typhoid and influenza were more or less endemic, erupting into epidemics when the right climatic conditions coincided with periods of economic distress. The frequency of concurrent epidemics gave rise to the belief that one sort of disease brought on another; indeed, it was widely believed that influenza was an early stage of cholera. There were other contagions, however, that yearly killed thousands without becoming epidemic. Taken together, measles and ‘hooping cough’ accounted for 50,000 deaths in England and Wales between 1838 and 1840, and about a quarter of all deaths during this general period have been attributed to tuberculosis or consumption.
Generally throughout the 1830s and the 1840s, trade was depressed and food prices were high. The poorer classes, often underfed, were less resistant to contagion. Also, during the more catastrophic years the weather was extremely variable, with heavy rains following prolonged droughts. Population, especially in the Midlands and in some seaport cities and towns, was growing rapidly without a parallel expansion in new housing and over-crowding contributed to the relatively fast spread of disease.
The Registrar General reported in 1841 that while mean life expectancy in Surrey was forty-five years, it was only thirty-seven in London and twenty-six in Liverpool. The average age of ‘labourers, mechanics, and servants’, at times of death was only fifteen. Mortality figures for crowded districts like Shoreditch, Whitechapel, and Bermondsey were typically half again or twice as high as those for middle-class areas of London. Such statistics made people aware of the magnitude of disease, but also served as effective weapons for sanitary reformers when they brought their case before Parliament. Two reports by the Poor Law Commission in 1838, one by Dr. Southwood Smith, the other by Doctors Neil Arnott and J.P. Kay, outlined causes and probable means of preventing communicable disease in poverty areas like London’s Bethnal Green and Whitechapel. Chadwick’s Sanitary Report in 1842 broadened the scope of inquiry geographically, as did a Royal Commission report in 1845 on the Health of Towns and Populous Places.
During the first decades of Victoria’s reign, baths were virtually unknown in the poorer districts and uncommon anywhere. Most households of all economic classes still used ‘privy-pails’; water closets were rare. Sewers had flat bottoms, and because drains were made out of stone, seepage was considerable. If, as was often the case in towns, streets were unpaved, they might remain ankle-deep in mud for weeks. For new middle-class homes in the growing manufacturing towns, elevated sites were usually chosen, with the result that sewage filtered or flowed down into the lower areas where the labouring populations lived. Some towns had special drainage problems. In Leeds, for example, the Aire River, fouled by the town’s refuse, flooded periodically, sending noxious waters into the ground floors and basements of the low-lying houses. As Chadwick later recalled, the new dwellings of the middle-class families were scarcely healthier, for the bricks tended to preserve moisture. Even picturesque old country houses often had a dungeon-like dampness, as a visitor could observe:
If he enters the house he finds the basement steaming with water-vapour; walls constantly bedewed with moisture, cellars coated with fungus and mould; drawing rooms and dining rooms always, except in the very heat of summer, oppressive from moisture; bedrooms, the windows of which are, in winter, so frosted on their inner surface, from condensation of water in the air of the room, that all day they are coated with ice.
In some districts of London and the great towns the supply of water was irregular. Typically, a neighbourhood of twenty or thirty families on a particular square or street would draw their water from a singly pump two or three times a week. Sometimes, finding the pump not working, they were forced to reuse the same water. When a local supply became contaminated the results could be disastrous. In Soho’s St. Anne’s parish, for example, the faeces of an infant stricken with cholera washed down into the water reserve from which the local pump drew and almost all those using the pump were infected. Millbank Prison, taking its water from the sewage-polluted Thames, suffered greatly during every epidemic of water-borne disease.
Since it was widely believed that disease was generated spontaneously from filth (pythogenesis) and transmitted by noxious invisible gas or miasma, there was much alarm over the ‘Great Stink’ of 1858 and 1859. The Thames had become so polluted with waste as to be almost unbearable during summer months. People refused to use the river-steamers and would walk miles to avoid crossing one of the city bridges. Parliament could carry on its business only by hanging disinfectant-soaked cloths over the windows. It should have been a blow to miasma theory when no outbreak of fever followed from this monstrous stench.
As late as 1873, however, William Budd could reluctantly report in his important book on typhoid that ‘organic matter, and especially sewage in a state of decomposition, without any relation to antecedent fever, is still generally supposed to be the most fertile source.’  Resistance to the theory of polluted water as a source of infection contributed to the incidence of typhoid in the second half of the century as well as to the high mortality rates from cholera in epidemics as late as 1854 or 1865-1866. The general cleaning up of the cities and towns, however, produced a marked reduction in deaths from typhus, a disease transmitted by lice. Although a systematic control of contagious disease had to await the introduction of preventive inoculation in the 1880s and 1890s, after mid-century the general health of the country measurably improved.
For much of the century, doctors were confused about the causes, course and treatment of the disease. The unpredictable behaviour of the severe contagions also intensified anxiety. They would appear, perhaps then subside for a month or two, only to reappear in the same locality or somewhere else. The individual sufferer had no way of predicting the outcome of the disease in his own case. Influenza patients, observed the London Medical Gazette during the 1833 epidemic, ‘might linger for the space of two or three weeks and then get up well, or they might die in the same number of days.’ Just as frightening was the uncertain progress of typhoid. Infectious diseases were spatially concentrated: deaths from tuberculosis, typhus and cholera focused mainly on inner-city slum districts. The main nineteenth century killer of adults was tuberculosis. Few families were untouched by its effects and even in 1900 it was responsible for around 10% of all deaths nationally, despite a significant decline since 1850. Spread by a bacillus through droplet infection from coughs or saliva, tuberculosis is not highly contagious but its spread is encouraged by a combination of poverty, malnutrition and overcrowded living conditions. Though not immune, the middle-classes were better able to withstand tuberculosis than the poor, malnourished working-class. 
The number of victims of chronic food poisoning was also significant. Mineral poisons were often introduced into food and water from bottle stoppers, lead water pipes and wall paints or equipment used to process food and beverages. Moreover, the deliberate adulteration of food was a common and, until 1860, virtually unrestricted practice. For example, because of the Englishman’s dislike for brown bread, bakers regularly whitened their flour with alum. In 1858, a Bradford sweetshop owner ordered a delivery of plaster of Paris that was commonly used to adulterate sugar but a novice supplied arsenic instead. It went on sale in a batch of peppermint drops and within a few days 20 people were dead and hundreds seriously ill.
The Use of Adulteration. Little Girl, ‘If you please, Sir, Mother says, will you let her have a quarter of a pound of your best tea to kill the rats with, and an ounce of chocolate as would get rid of the black beatles!’ Dated August 1855.
Conditions for the processing and sale of foods were unsanitary. An 1863 report to the Privy Council stated that one-fifth of the meat sold came from diseased cattle or had died of pleuro-pneumonia and anthacid or anthracoid diseases. In 1860, the first pure-food act was passed, but, as was often the case in these early regulatory measures, it provided no mandatory system of enforcement.  In 1872, further legislation was passed considerably strengthening penalties and inspection procedures. Cow’s milk, was perhaps the most widely adulterated food. In 1877, a quarter of all the milk examined by the Local Government Board was seriously adulterated; in 1882, one-fifth of the 20,000 milk analyses made by the 52 county and 172 borough analysts was adulterated. Not until 1894 was the Local Government Board able to report that adulterated milk accounted for less than 10% of all samples. However, throughout most of the nineteenth century, Britons had little protection against unwholesome food and drink.
What was the impact of such high rates of infectious disease? Death was only one, and not necessarily the most important, of the many effects of disease. For a poor family struggling to pay rent and buy food, illness (whether fatal or not) imposed additional strains: medical bills to pay; medicines to buy; extra heating costs; and the problem of childcare if the mother was taken ill. If the primary wage-earner was off work the crisis would be more acute as not only did outgoings rise but incomes also fell. Short-term crises were met by pawning clothes, borrowing from kin and raising short-term loans. Prolonged illness increased costs and reduced income to such an extent that it could cause or increased malnutrition for the whole family, leading to further illness or to eviction for non-payment of rent. Families might then have to move to inferior accommodation or to be separated from one another in the workhouse. There is little doubt that the high level and concentration of infectious disease was a significant extra burden for working-class families in the Victorian city.
In certain respects, the health of the urban population began to improve as a result of a number of changes occurring after 1890. General increases in standards of living and especially improvements in diet and nutrition led to greater resistance to disease and lower mortality. Advances in medical knowledge and technology began to make real inroads into diseases that had been barely understood in 1830. The development of a state welfare policy towards health created a buffer that prevented some of the worst impacts of disease in family life though the impact of the embryonic welfare state was patchy before 1914. The Public Health Act 1890 was more effective than previous legislation in ensuring that towns took responsibility for the basic provision of pure water supply and proper sanitary conditions. The Housing Act 1890 placed emphasis on slum clearance but this only had a limited effect by 1914. The development of town planning began to stress environmental considerations that influenced the layout of some suburban developments and created a healthier environment. This only had an effect if individuals were able to move from the inner-city areas to the new garden suburbs. While there had been some improvement in the quality of life for those living in urban communities between 1830 and 1914, the major determinant of health remained social class with the working-class generally less healthy than the middle-classes.
 Henriques, U., Before the Welfare State: Social administration in early industrial Britain, (Longman), 1979, p. 117.
 On health see Howe, G.M., Man, environment and disease in Britain, (Penguin), 1976 and Woods, R. and Woodward, J., (eds.), Urban disease and mortality in nineteenth-century England, (Batsford), 1984. Ibid, Smith, F.B., The People’s Health 1830-1910 is a valuable study of social problems and the limited resources of nineteenth century medicine. Youngson, A.J., The Scientific Revolution in Victorian Medicine, (Croom Helm), 1979 is useful on medical developments.
 Brown, Michael, ‘From Foetid Air to Filth: The Cultural Transformation of British Epidemiological Thought, ca. 1780-1848’, Bulletin of the History of Medicine, Vol. 82, (2008), pp. 515-544, Condrau, Flurin and Worboys, Michael, ‘Epidemics and Infections in Nineteenth-Century Britain’, Social History of Medicine, Vol. 20, (2007), pp. 147-158 and Mooney, Graham, ‘Infectious Diseases and Epidemiologic Transition in Victorian Britain? Definitely’, Social History of Medicine, Vol. 20, (2007), pp. 595-606.
 Hardy, A., ‘Smallpox in London: factors in the decline of the disease in the nineteenth century’, Medical History, Vol. 27, (1983), pp. 111-138. See also, Brunton, Deborah, The politics of vaccination: practice and policy in England, Wales, Ireland, and Scotland, 1800-1874, (University of Rochester Press), 2008.
 Hardy, A., ‘Urban famine or urban crisis? Typhus in the Victorian city’, Medical History, Vol. 32, (1988), pp. 401-425.
 On cholera, see, Hamlin, Christopher, Cholera: The Biography, (Oxford University Press), 2009 is a valuable global study. Longmate, N., King Cholera, (Hamish Hamilton), 1966, Morris, R.J., Cholera, 1832, (Croom Helm), 1976, Pelling, M., Cholera, Fever and English Medicine 1825-1865, (Oxford University Press), 1977, Durey, Michael, The Return of the Plague: British Society and Cholera 1831-2, (Gill and Macmillan), 1979 and Gilbert, Pamela K., Cholera and nation: doctoring the social body in Victorian England, (State University of New York Press), 2008. Hardy, A., ‘Cholera, quarantine and the English preventive system, 1850-1895’, Medical History, Vol. 37, (1993), pp. 250-269 looks at later developments.
 Garrison, F.H., An introduction to the history of medicine: with medical chronology, bibliographic data, and test questions, 2nd ed., (W. B. Saunders Company), 1913, p. 334.
 On the impact of 1831-1832 outbreak on localities see, Hardiman, Sue, The 1832 cholera epidemic and its impact on the city of Bristol, (Historical Association, Bristol Branch), 2005, Kidd, Alan J. and Wyke, Terry J., ‘The cholera epidemic in Manchester 1831-32’, Bulletin of the John Rylands University Library of Manchester, Vol. 87, (2005), pp. 43-56, O’Neill, Timothy P., ‘Cholera in Offaly in the 1830s’, Offaly Heritage, Vol. 1, (2003), pp. 96-107 and Walker, Martyn., ‘The 1832 cholera epidemic in the east midlands’, East Midland Historian, Vol. 1-2 (1991-2), pp. 7-14.
 Gairdner, William, T., Public health in relation to air and water, (Edmonston and Douglas), 1862, pp. 15-16.
 See, Duncan, C.J., Duncan, S.R. and Scott, S.,’ The dynamics of scarlet fever epidemics in England and Wales in the 19th century’, Epidemiology and Infection, Vol. 117, (1996), pp. 493-499.
 On local effects of the 1848-1849 cholera epidemic see, Haines, Gary., ‘Cholera and Bethnal Green in 1849’, East London History Society Newsletter, Vol. 2, (3), (2002), pp. 20-24, Thomas, Amanda J., The Lambeth Cholera Outbreak of 1848-1849: The Setting, Causes, Course and Aftermath of an Epidemic in London, (McFarland & Co Inc), 2009, Cochrane, Margaret Ruth and Cochrane, Robert Evan, Death comes to Hedon: the cholera epidemic of 1849, (Highgate), 1993, James, D.C., ‘The cholera epidemic of 1849 in Cardiff’, Morgannwg, Vol. 25, (1981), pp. 164-179 and Lloyd, T.H., ‘The cholera epidemic of 1849 in Leamington Spa and Warwick’, Warwickshire History, Vol. 2, (1973), pp. 16-32.
 See Lewes, Gertrude Hill, Dr. Southwood Smith; a retrospect, (Blackwood), 1898 and Webb, R.K., ‘Southwood Smith: The Intellectual Sources of Public Service’, in Porter, Dorothy and Porter, Roy, (eds.), Doctors, Politics and Society: Historical Essays, (Ropodi), 1993, pp. 46-80.
 Chadwick, Edwin, The General History of the Principles of Sanitation, (Cassell and Company), 1889, p. 10.
 On this, see, Halliday, Stephen, The Great Stink of London: Sir Joseph Bazalgette and the cleansing of the Victorian capital, (Sutton), 1999.
 Dunnill, Michael S., Dr William Budd: Bristol’s most famous physician, (Redcliffe), 2006.
 Cit, Gaw, Jerry L., “A time to heal”: the diffusion of Listerism in Victorian Britain, (Diane Publishing), 1999, p. 24.
 There are fewer studies on the later outbreaks of cholera but see, for example, Roberts, Glynne, ‘“Closing the stable door after the horse has bolted”: preventing the spread of smallpox and cholera in Caernarfonshire, 1870-1910’, Transactions of the Caernarvonshire Historical Society, Vol. 55, (1994), pp. 109-128, Callcott, M., ‘The challenge of cholera: the last epidemic at Newcastle upon Tyne’, Northern History, Vol. 20, (1984), pp. 167-186 and Luckin, W., ‘The final catastrophe: cholera in London, 1866’, Medical History, Vol. 21, (1977), pp. 32-42.
 Vaccination and inoculation remained contentious issues throughout the nineteenth century and there was an anti-vaccination movement as well as parental resistance to compulsion. On this see, Durbach, Nadja, Bodily matters: the anti-vaccination movement in England, 1853-1907, (Duke University Press), 2005.
 Cit, Thompson, Theophilus, Annals of influenza or epidemic catarrhal fever in Great Britain from 1510 to 1837, (Sydenham Society), 1852, p. 289.
 Smith, Francis Barrymore, The retreat of tuberculosis, 1850-1950, (Croom Helm), 1988.
 Ibid, Whorton, James C., The Arsenic Century: How Victorian Britain was Poisoned at Home, Work and Play, pp. 139-141.
 See, Waddington, Keir, The bovine scourge: meat, tuberculosis and public health, 1850-1914, (Boydell & Brewer), 2006.
 Collins, E.J.T., ‘Food adulteration and food safety in Britain in the 19th and 20th centuries’, Food Policy, Vol. 18, (1993), pp. 95-109 provides a useful overview.