medicine, 19th-century

The 19th century was a period of enormous medical change and progress. Many diseases that had been fatal in 1800 were either treatable by 1900, or a cure would be found very early in the 20th century using techniques developed by 19th-century scientists. Doctors, chemists, and scientists investigated medicine using the new scientific technology made available by the Industrial Revolution, and made discoveries that changed the face of medical practice. Government involvement in medicine and public health also changed dramatically during the 19th century. In 1800 governments refused to act to protect the health of the public, but by 1900 the principle of government responsibility had been well established in many European countries. The training of doctors and nurses was fundamentally altered, along with the organization of hospitals. Most important was the development of germ theory by Louis Pasteur, a discovery that gave doctors and scientists the key to understanding, treating, and preventing disease.

Industrial Revolution The 19th century witnessed a more fundamental change in society than any previous age in European history. The Industrial Revolution that started in Britain in the middle of the 18th century and spread across Europe in the 19th century resulted in a mass movement of people from the countryside to the newly industrialized cities and towns. Cities such as London, Berlin, and Paris grew rapidly to house millions of people. The workers in the new factory systems suffered appalling conditions both at work and at home, leading to regular outbreaks of diseases such as cholera and typhoid fever.

However, the growth of the trade union movement and parliamentary reform forced many governments to recognize the needs of their people. As political power was placed increasingly in the hands of the poorer classes of European society, workers were able to exert political pressure to force their governments to develop public health programmes. The development of industrial technology created new scientific technologies, such as more powerful microscopes and chemicals, allowing medical knowledge to be expanded in ways never before possible. The development of new methods of communication allowed doctors to exchange knowledge in minutes. Europe was completely changed by the Industrial Revolution, and the effects on medicine were profound. The development of modern 20th-century medical technology rests largely on the work accomplished by 19th-century scientists, doctors, and chemists.

Disease The understanding and treatment of disease developed rapidly in the 19th century. The first major breakthrough was the work of the English doctor, Edward Jenner. In 1796 Jenner developed the first vaccine, using a preparation of cowpox virus to produce immunity against smallpox. Although Jenner could not explain why or how his vaccination worked, he had made a great leap forward in the treatment of disease. For the first time it was possible to prevent the spread of a killer disease using medical treatment.

In the 1860s the French chemist Louis Pasteur demonstrated that dust in the air contained spores of living organisms, providing the link between germs in the air and disease - a key breakthrough in the understanding of disease. Scientists were now able to discover the specific cause of a disease by finding the relevant virus or bacteria, and develop more vaccines, treatments, and cures from this research. Once Pasteur had shown that the causes of decay and disease were natural phenomena that could be scientifically explained, previous theories, founded on a lack of scientific knowledge, could be rejected.

The German bacteriologist Robert Koch further developed Pasteur's work. Koch showed how germs caused disease in humans. By 1875 Koch had found the bacillus that causes anthrax, and doctors were able to conclusively prove that bacteria caused human diseases. By 1894 scientists had discovered the bacteria or viruses that cause leprosy (1879), typhoid fever (1880), diphtheria (1882), tuberculosis (1882), cholera (1883), tetanus (1884), pneumonia (1884), and bubonic plague (1894). Vaccines were developed from this research to prevent infection by a specific disease.

Further work on disease continued as scientists tried to develop techniques for treating a patient already infected with a disease. In 1911 the German bacteriologist and immunologist Paul Ehrlich, who had worked under Koch, discovered a treatment for syphilis in Salvarsan 606. Salvarsan was the first so-called ‘magic bullet’, a chemical substance that could seek out and destroy specific bacteria without harming the rest of the body. Within 115 years scientists had leapt from the first vaccination by Jenner, with no understanding of its scientific basis, to the manufacture of antitoxins that could target disease within the human body. The rate of change in understanding and treatment of disease had exceeded anything previously achieved.

Surgery in the early 19th century Surgery was an extremely risky business in 1800. The level of hygiene was very poor. Surgeons operated in dirty theatres and used instruments that were rarely washed between operations. They did not wash their hands before or between operations, or wear clean clothes. Lack of effective anaesthesia was also a problem. Surgery had to be carried out quickly, so the only possible operations were amputation, the removal of growths, or operations on problems close to the body surface; complex surgery on internal organs was impossible. Patients had to be held down by a number of assistants while the surgeon amputated a limb, or performed other surgery, as rapidly as possible. Many died from the shock or pain of the operation. Even if a patient survived the operating table, they were likely to die of an infection picked up from unclean hands or surgical tools, or the aftercare on the dirty ward. Blood poisoning was common. If a patient lost a lot of blood there was no way of replacing it, as blood transfusions were not perfected until the early 20th century. The only effective method of stopping the bleeding was to use ligatures to tie the blood vessels, a practice introduced by the French military surgeon Ambroise Paré in the 15th century that had remained unchanged.

The introduction of anaesthetics The development of a safe and effective system of anaesthesia began with the work of Humphrey Davy in 1799. Davy experimented with nitrous oxide, also known as ‘laughing gas’, and discovered that it reduced sensitivity to pain. However, his ideas were not adopted by the medical profession. In 1846 the Scottish surgeon Robert Liston began to experiment with the use of ether as an anaesthetic. He first used it on a patient having his leg amputated but, although the ether sent the patient to sleep and made him unresponsive to pain, it also caused irritation of the lungs and the patient coughed throughout the operation. However, surgeons now had two limited methods of anaesthesia: laughing gas, which deadened pain but did not put the patient to sleep; and ether, which was dangerously flammable and caused damage to the patient's lungs.

The real breakthrough to effective anaesthesia without dangerous side effects was made in 1847. The Scottish obstetrician James Simpson, professor of midwifery at Edinburgh University, was the first to use ether for childbirth and experimented with various other gases. In 1847 he discovered that chloroform was highly effective in putting patients to sleep while removing their ability to feel pain. Chloroform also had no obvious negative side effects. Simpson used the gas on his patients, and actively encouraged other doctors to do so. However, many doctors were fearful of the risks associated with chloroform, and their misgivings were heightened in 1848 after the death of Hannah Green, a 16-year-old who inhaled too much chloroform during an operation to remove her toenail. Surgeons were unsure about the correct dose of chloroform to give a patient. A number of practitioners opposed anaesthetics completely, believing them to be unnatural and against the wishes of God. They argued that pain was a natural phenomenon and should not be interfered with.

However, Simpson, along with surgeons such as John Snow, continued to champion the use of chloroform as an anaesthetic. When Snow, the first specialist anaesthetist, administered chloroform to Queen Victoria during her labour while giving birth to Prince Leopold in 1853, its use became more widely accepted. With the widespread application of chloroform in the second half of the 19th century, surgeons were able to carry out surgical procedures that had been impossible in 1800.

Antiseptic and aseptic surgery Infection stemming from dirty operating conditions and poor hygiene remained a problem well into the second half of the 19th century. In 1847 the Hungarian obstetrician Ignaz Semmelweis, while working in Vienna, tried unsuccessfully to introduce asepsis (better medical hygiene). Semmelweis studied the high death rate among women who had just given birth and observed that the doctors were handling dead women in the mortuary and then delivering babies on the maternity wards without washing their hands in between. He concluded that they were transmitting infected matter from the bodies, and ordered all doctors and nurses on his ward to wash their hands in chlorinated lime. The results were dramatic - the death rate fell from 30% to 1.5% within 12 months. However, Semmelweis was opposed by his superiors, who refused to acknowledge the value of his work - sepsis at this time was thought to be a kind of combustion caused by exposing moist body tissues to oxygen. The use of chlorine of lime was also unpopular as it irritated the skin. In 1850 Semmelweis was forced to resign from his post and he returned to Budapest. In Vienna his regime was not enforced and the death rate rose again to around 15%. Meanwhile, in Budapest, where Semmelweis continued to practise simple asepsis, the death rate was less than 0.5%.

The work of the English surgeon Joseph Lister, who pioneered the use of antiseptics in the 1860s, met with greater success. Lister was aware of Pasteur's work on germs, and set about finding a method of reducing the risk of germs in the operating theatre. He knew that carbolic acid was used to treat raw sewage, and realized that it worked by breaking down the bacteria concerned; he had also noticed that sewage and certain septic wounds, such as gangrene, have a similar smell. Lister discovered that a spray of carbolic acid, applied to the bandages used on patients' wounds, cut infection dramatically. He then introduced carbolic acid into his operating theatre - carbolic acid was sprayed into the air around the patient, killing the bacteria on the patient as well as on the surgeon and the instruments used. The results were startling - death rates fell from 46% in 1864 to 15% in 1870. However, like Semmelweis, Lister faced opposition from others in the medical profession. Carbolic acid burned the skin of those who were exposed to it, and caused irritation to the lungs. Opposition declined, however, as doctors became increasingly aware of Pasteur's work. Lister was able to give a scientific explanation for his results, and eminent surgeons such as William Cheyne enthusiastically adopted his methods.

The final step towards bacteria-free surgery in the 19th century was the introduction of aseptic surgery. Semmelweis had been unsuccessful in his pioneering of asepsis through washing in chlorinated lime because he had been unable to prove his results scientifically, and he was also hampered by the unpleasant effects of chloride of lime and the innate conservatism of the medical profession. However, in 1880 Charles Chamberland, a French bacteriologist who worked with Louis Pasteur, developed the first medical sterilizer - the ‘Chamberland Autoclave’. The autoclave worked on a similar principle to the pressure cooker, boiling the surgeon's instruments and removing all traces of bacteria. The technique was further developed by the German bacteriologists Robert Koch and Curt Schimmelbusch. They designed a non-pressurized steamer that could sterilize the dressings for wounds. The German surgeons Gustav Neuber and Ernst Bergmann, who had worked with Koch in 1885, introduced the practice of sterilizing everything that came into the operating theatre, including the gowns and masks of the surgeons and nurses. In 1889 the US surgeon William Halsted introduced the practice of wearing gloves during an operation. The operating theatre had become a germ-free environment, and death rates plummeted around the world. Between Lister's announcement in 1867 that his wards at the Glasgow Royal Infirmary had remained clear of sepsis for nine months and his death in 1912, the number of operations had increased tenfold. Surgeons could perform operations with more confidence, as by 1900 the risk that successful surgery would be jeopardized by infectious conditions had been greatly reduced.

Blood transfusions Although the problems of infection and anaesthesia had been solved by 1900, the treatment of blood loss remained a challenge - blood loss could thwart the success of an operation, even if it was performed skilfully, painlessly, and in a clean environment. Although doctors had the ability to perform blood transfusions, they could not guarantee their success. The technique was first used by the French physician Jean-Baptiste Denys in 1667, who transfused blood from a sheep to a human. In 1818 the first successful transfusion from human to human was carried out in England, the two people being connected by a tube in the same room. However, further attempts failed regularly, as doctors were unaware of the existence of blood groups. If the blood types of donor and recipient were incompatible, coagulation of the blood would occur, along with the possible death of the recipient. It was not until the ABO blood group system was discovered by the US immunologist Karl Landsteiner in the years 1900-02 that the first steps to safe blood transfusion were achieved.

Hospital care and nursing Hospitals in 1800 were not clean and efficient places of care and recovery. They were intended for the poor, as the rich were treated in their own homes by trained doctors. Hospitals were charitable institutions, but there was usually little that could be done for the patients. Nursing was considered lowly work and was poorly paid; it did not attract those dedicated to care. Writing in 1867 Florence Nightingale described the type of women who became nurses as ‘...too weak, too drunk, too stupid, or too bad to do anything else’. With the low status given to nursing and hospitals in 1800, it was not surprising that both hospital conditions and nursing training were poor. However, the situation changed dramatically during the 19th century, primarily as the result of the work of a small number of individuals, in particular the US health worker Clara Barton, founder of the American Red Cross in 1881; the English nurse Florence Nightingale, who promoted nursing as a profession; and the Jamaican nurse Mary Seacole, who, like Nightingale, worked among the wounded of the Crimean War (1853-56).

In 1840 the English prison reformer Elizabeth Fry set up the first permanent training school for nurses at Guy's Hospital, London. Although the numbers were small, Fry's foundation marked the first move to produce properly skilled and trained nurses. Florence Nightingale trained in Germany and France to become a nurse, against the wishes of her parents, and was then put in charge of the British Army hospital at Scutari during the Crimean War. Nightingale took a team of Fry nurses with her to Scutari. She introduced cleanliness, hygiene, and skilled nursing into the hospital and cut the death rate from 42% to 2%. On her return to Britain in 1856 she was given £50,000 raised by The Times to set up the Nightingale School and Home for Nurses. Nightingale was a well-known public figure with government support for her work, and the school became the training centre for a new breed of educated and skilled nurses. Nightingale trained 15 nurses in 1860, the year that her school opened. Her nurses transferred to other hospitals in Britain, where they introduced the new methods of care, and also went to other countries such as Australia, Germany, Sweden, and the USA. Although Nightingale's ideas met opposition from some of the medical profession - in 1857 a leading British doctor compared nurses to domestic servants and claimed there was no need to train them - such opposition and blatant sexism was eventually overcome. By 1900 Britain was training over 2,000 nurses a year using Nightingale's methods.

Mary Seacole travelled to England in 1854 after medical authorities in Jamaica had asked her to provide nurses for the Crimean War. After the War Office rejected her offer of help, she travelled to the Crimea using her own funds, but was turned down by Florence Nightingale's assistant at Scutari, she believed because of her race. Seacole left Scutari and travelled to Kadikoy (modern Kadikeui), Turkey, where she set up a boarding house and store, selling medicines to the soldiers. However, because of their lack of money she was soon treating the soldiers on a charitable basis and ran up huge debts. She was also present at the Battle of Tchernaya and was the first woman to enter the town of Sevastopol when it fell. Seacole improved the conditions on the battlefield for the soldiers, but returned to England bankrupt until her plight was taken up by the British press, who raised funds on her behalf. For a while Seacole was as famous as Nightingale, but she then slipped from public gaze. However, her work on the battlefield had shown that skilled and determined nursing would improve the conditions of the wounded, and gave further evidence that nursing should be regarded as a valued profession.

Clara Barton served as a volunteer nurse in the American Civil War (1861-65), following the soldiers onto the battlefields with her medical wagon. She organized the facilities and supplies for the doctors and surgeons and helped with their work. Barton became a national hero during the war, and was known as the ‘angel of the battlefield’. After the war she travelled to Europe from 1869 to 1873, working for the International Red Cross during the Franco-Prussian War (1870-71). She returned to the USA and founded the American Red Cross in 1881.

Although hospitals remained charitable or religious institutions well into the 20th century, the work of nursing reformers such as Barton, Nightingale, and Seacole greatly improved the quality of nursing training and hospital conditions by the end of the 19th century.

Public health The 19th century was a turning point in the development of public health systems in Europe. Since the collapse of the Roman Empire in the 5th century AD, European governments had not taken any significant responsibility for the health of their people. However, with the growth of cities during the Industrial Revolution, outbreaks of disease such as cholera occurred on a regular basis. Hundreds of thousands died in the crowded and filthy cities of Europe. At first the medical profession continued to believe in theories of poisonous miasmas and spontaneous generation of disease to explain the epidemics. However, as a result of further outbreaks, the research of social reformers and scientists, and political pressure, governments were forced to take action, and the principle of laissez faire (non-intervention) was progressively eroded.

Four great cholera epidemics occurred in Britain between 1830 and 1866, and after each one the level of government action increased until the compulsory and universal Public Health Act of 1875. Reformers such as Thomas Southwood-Smith, Edwin Chadwick, Charles Booth, and Seebohm Rowntree wrote reports on the living conditions of Britain's poor, calling for government action. In 1854 John Snow linked cholera with dirty water, and the subsequent work on germ theory by Louis Pasteur and Robert Koch demonstrated that the filth and overcrowding of industrial cities was a breeding ground for disease. By 1900 public health measures in the UK forced councils to provide clean water and sanitation as well as allowing them to improve the housing of the poor. The scientific discoveries of the 19th century forced public health to become a central part of any government's programme. See also public health (history).