The practice of
medicine changed in the face of rapid advances in science, as well as new
approaches by physicians. Hospital doctors began much more systematic analysis
of patients' symptoms in diagnosis. Among the more powerful new techniques were
anaesthesia, and the development of both antiseptic and aseptic operating
theatres. Effective cures were developed for certain endemic infectious
diseases. However the decline in many of the most lethal diseases was due more
to improvements in public health and nutrition than to advances in medicine.
Medicine was
revolutionized in the 19th century and beyond by advances in chemistry,
laboratory techniques, and equipment. Old ideas of infectious disease epidemiology were
gradually replaced by advances in bacteriology and virology.
In the 1830s in
Italy, Agostino Bassi traced
the silkworm disease muscardine to
microorganisms. Meanwhile, in Germany, Theodor Schwann led
research on alcoholic fermentation by yeast, proposing that living microorganisms were responsible.
Leading chemists, such as Justus von Liebig,
seeking solely physicochemical explanations, derided this claim and alleged that
Schwann was regressing to vitalism.
In 1847 in Vienna, Ignaz Semmelweis (1818–1865),
dramatically reduced the death rate of new mothers (due to childbed fever) by
requiring physicians to clean their hands before
attending childbirth, yet his principles were marginalized and attacked by
professional peers.
Louis Pasteur’s experiiments confirmed Schwann's fermentation
experiments in 1857 and afterwards supported the hypothesis that yeast were
microorganisms. Moreover, he suggested that such a process might also explain
contagious disease. In 1860, Pasteur's report on bacterial fermention
of butyric acid motivated fellow Frenchman Casimir Davaine to
identify a similar species (which he called bacteridia)
as the pathogen of the deadly disease anthrax. Others dismissed
"bacteridia" as a mere byproduct of the disease. British
surgeon Joseph
Lister, however, took these findings
seriously and subsequently introduced antisepsis to wound
treatment in 1865.
German physician Robert Koch, noting
fellow German Ferdinand Cohn's report of a spore stage of a certain bacterial
species, traced the life cycle of Davaine's bacteridia, identified spores,
inoculated laboratory animals with them, and reproduced anthrax—a breakthrough
for experimental pathology and germ theory of disease. Pasteur's group added ecological investigations
confirming spores' role in the natural setting, while Koch published a landmark
treatise in 1878 on the bacterial pathology of wounds. In 1881, Koch reported
discovery of the "tubercle bacillus", cementing germ theory and Koch's acclaim.
Upon the
outbreak of a cholera epidemic
in Alexandria, Egypt, two medical missions went to investigate and attend the
sick, one was sent out by Pasteur and the other led by Koch. Koch's group
returned in 1883, having successfully discovered the cholera pathogen. In
Germany, however, Koch's bacteriologists had to vie against Max von Pettenkofer, Germany's leading proponent of miasmatic theory. Pettenkofer
conceded bacteria's casual involvement, but maintained that other,
environmental factors were required to turn it pathogenic, and opposed water
treatment as a misdirected effort amid more important ways to improve public
health. The massive cholera epidemic in Hamburg in 1892
devastasted Pettenkoffer's position, and yielded German public health to
"Koch's bacteriology"
On losing the
1883 rivalry in Alexandria, Pasteur switched research direction, and introduced
his third vaccine—rabies vaccine—the first
vaccine for humans since Jenner's for smallpox. From
across the globe, donations poured in, funding the founding of Pasteur Institute, the
globe's first biomedical institute, which opened in 1888. Along with
Koch's bacteriologists, Pasteur's group—which preferred the term microbiology—led
medicine into the new era of "scientific medicine" upon bacteriology
and germ theory.[99] Accepted
from Jakob Henle,
Koch's steps to confirm a species' pathogenicity became famed as "Koch's postulates". Although his proposed tuberculosis
treatment, tuberculin, seemingly failed, it soon was used to test for
infection with the involved species. In 1905, Koch was awarded the Nobel
Prize in Physiology or Medicine, and
remains renowned as the founder of medical microbiology.
Women had
always served in ancillary roles, and as midwives and healers. The professionalization
of medicine forced them increasingly to the sidelines. As hospitals multiplied
they relied in Europe on orders of Roman Catholic nun-nurses, and German
Protestant and Anglican deaconesses in the early 19th century. They were
trained in traditional methods of physical care that involved little knowledge
of medicine.
The
breakthrough to professionalization based on knowledge of advanced medicine was
led by Florence Nightingale in England. She resolved to provide more advanced
training than she saw on the Continent. At Kaiserswerth, where the first German
nursing schools were founded in 1836 by Theodor Fliedner, she
said, "The nursing was nil and the hygiene horrible." Britain's male
doctors preferred the old system, but Nightingale won out and her Nightingale
Training School opened in 1860 and became a model. The Nightingale solution
depended on the patronage of upper class women, and they proved eager to serve.
Royalty became involved. In 1902 the wife of the British king took control of
the nursing unit of the British army, became its president, and renamed it after
herself as the Queen
Alexandra's Royal Army Nursing Corps;
when she died the next queen became president. Today its Colonel In Chief
is the daughter-in-law of
Queen Elizabeth. In the United States,
upper middle class women who already supported hospitals promoted nursing. The
new profession proved highly attractive to women of all backgrounds, and
schools of nursing opened in the late 19th century. They soon a function of
large hospitals, where they provided a steady stream of low-paid idealistic
workers. The International Red Cross began operations in numerous countries in
the late 19th century, promoting nursing as an ideal profession for middle
class women.
The Nightingale
model was widely copied. Linda Richards (1841–1930)
studied in London and became the first professionally trained American nurse.
She established nursing training programs in the United States and Japan, and
created the first system for keeping individual medical records for
hospitalized patients. The Russian Orthodox Church sponsored seven orders
of nursing sisters in the late 19th century. They ran hospitals, clinics,
almshouses, pharmacies, and shelters as well as training schools for nurses. In
the Soviet era (1917–1991), with the aristocratic sponsors gone, nursing became
a low-prestige occupation based in poorly maintained hospitals.
It was very
difficult for women to become doctors in any field before the 1970s. Elizabeth Blackwell (1821–1910) became the first woman to formally
study and practice medicine in the United States. She was a leader in women's
medical education. While Blackwell viewed medicine as a means for social and
moral reform, her student Mary Putnam Jacobi (1842–1906) focused on curing disease. At a deeper
level of disagreement, Blackwell felt that women would succeed in medicine
because of their humane female values, but Jacobi believed that women should
participate as the equals of men in all medical specialties using identical
methods, values and insights. In the Soviet Union although
the majority of medical doctors were women, they were paid less than the mostly
male factory workers.
Paris (France)
and Vienna were the two leading medical centers on the Continent in the era
1750–1914.
In the
1770s–1850s Paris became a world center of medical research and teaching. The
"Paris School" emphasized that teaching and research should be based
in large hospitals and promoted the professionalization of the medical
profession and the emphasis on sanitation and public health. A major reformer
was Jean-Antoine Chaptal (1756–1832), a physician who was Minister of
Internal Affairs. He created the Paris Hospital, health councils, and other
bodies.
Louis Pasteur (1822–1895)
was one of the most important founders of medical microbiology. He is remembered for his remarkable breakthroughs in
the causes and preventions of diseases. His discoveries reduced mortality
from puerperal fever, and he created the first vaccines for rabies and anthrax.
His experiments
supported the germ theory of disease. He was best known to the general public for inventing a
method to treat milk and wine in order to prevent it from causing sickness, a
process that came to be called pasteurization. He is
regarded as one of the three main founders of microbiology, together
with Ferdinand Cohn and Robert Koch. He worked
chiefly in Paris and in 1887 founded the Pasteur Institute there
to perpetuate his commitment to basic research and its practical applications.
As soon as his institute was created, Pasteur brought together scientists with
various specialties. The first five departments were directed by Emile Duclaux (general microbiology research)
and Charles Chamberland (microbe research applied to hygiene), as well as a
biologist, Ilya Ilyich Mechnikov (morphological microbe research) and two physicians, Jacques-Joseph Grancher(rabies)
and Emile Roux (technical microbe research). One year after the
inauguration of the Institut Pasteur, Roux set up the first course of
microbiology ever taught in the world, then entitled Cours de Microbie
Technique (Course of microbe research techniques). It became the model
for numerous research centers around the world named "Pasteur Institutes
The First
Viennese School of Medicine, 1750–1800, was led by the Dutchman Gerard van Swieten (1700–1772), who aimed to put medicine on new
scientific foundations – promoting unprejudiced clinical observation, botanical
and chemical research, and introducing simple but powerful remedies. When
the Vienna General Hospital opened in 1784, it at once became the world's
largest hospital and physicians acquired a facility that gradually developed
into the most important research centre. Progress ended with the
Napoleonic wars and the government shutdown in 1819 of all liberal journals and
schools; this caused a general return to traditionalism and eclecticism in
medicine.
Vienna was the
capital of a diverse empire and attracted not just Germans but Czechs,
Hungarians, Jews, Poles and others to its world-class medical facilities. After
1820 the Second Viennese School of Medicine emerged with the contributions of
physicians such as Carl Freiherr von
Rokitansky, Josef Škoda, Ferdinand Ritter von Hebra, and Ignaz Philipp Semmelweis. Basic medical science expanded and specialization
advanced. Furthermore, the first dermatology, eye, as well
as ear, nose, and throat clinics in the world were founded in Vienna. The
textbook of ophthalmologist Georg Joseph Beer(1763–1821) Lehre
von den Augenkrankheiten combined practical research and philosophical
speculations, and became the standard reference work for decades.
After 1871
Berlin, the capital of the new German Empire, became a leading center for
medical research. Robert Koch (1843–1910)
was a representative leader. He became famous for isolating Bacillus anthracis (1877), the Tuberculosis
bacillus (1882) and Vibrio cholerae (1883)
and for his development of Koch's postulates. He was awarded the Nobel
Prize in Physiology or Medicine in
1905 for his tuberculosis findings. Koch is one of the founders of microbiology, inspiring
such major figures as Paul Ehrlich and Gerhard Domagk.
In the American Civil War (1861–65), as was typical of the 19th century, more
soldiers died of disease than in battle, and even larger numbers were
temporarily incapacitated by wounds, disease and accidents. Conditions were
poor in the Confederacy, where doctors and medical supplies were in short
supply. The war had a dramatic long-term impact on medicine in the U.S.,
from surgical technique to hospitals to nursing and to research facilities.
Weapon development -particularly the appearance of Springfield Model 1861,
mass-produced and much more accurate than muskets led to generals
underestimating the risks of long range rifle fire; risks exemplified in the
death of John Sedgwick and the disastrous Pickett's Charge. The rifles could shatter bone forcing amputation and
longer ranges meant casualties were sometimes not quickly found. Evacuation of
the wounded from Second Battle of Bull Run took a week. As in earlier wars, untreated
casualties sometimes survived unexpectedly due to maggots debriding the wound
-an observation which led to the surgical use of maggots -still a useful method in the absence of effective
antibiotics.
The hygiene of
the training and field camps was poor, especially at the beginning of the war
when men who had seldom been far from home were brought together for training
with thousands of strangers. First came epidemics of the childhood diseases of
chicken pox, mumps, whooping cough, and, especially, measles. Operations in the
South meant a dangerous and new disease environment, bringing diarrhea,
dysentery, typhoid fever, and malaria. There were no antibiotics, so the
surgeons prescribed coffee, whiskey, and quinine. Harsh weather, bad water,
inadequate shelter in winter quarters, poor policing of camps, and dirty camp
hospitals took their toll.
This was a
common scenario in wars from time immemorial, and conditions faced by the
Confederate army were even worse. The Union responded by building army
hospitals in every state. What was different in the Union was the emergence of
skilled, well-funded medical organizers who took proactive action, especially
in the much enlarged United States Army Medical Department and the United
States Sanitary Commission, a new
private agency. Numerous other new agencies also targeted the medical and
morale needs of soldiers, including the United
States Christian Commission as well as smaller private
agencies.
The U.S. Army
learned many lessons and in August 1886, it established the Hospital Corps.
A major
breakthrough in epidemiology came with the introduction of statistical maps and
graphs. They allowed careful analysis of seasonality issues in disease
incidents, and the maps allowed public health officials to identify critical
loci for the dissemination of disease. John Snow in London developed the methods. In 1849, he
observed that the symptoms of cholera, which had already claimed around 500
lives within a month, were vomiting and diarrhea. He concluded that the source
of contamination must be through ingestion, rather than inhalation as was
previously thought. It was this insight that resulted in the removal of The
Pump On Broad Street, after which deaths from cholera plummeted afterwards.
English nurse Florence Nightingale pioneered analysis of large amounts of statistical
data, using graphs and tables, regarding the condition of thousands of patients
in the Crimean War to evaluate the efficacy of hospital services. Her methods
proved convincing and led to reforms in military and civilian hospitals,
usually with the full support of the government.
By the late
19th and early 20th century English statisticians led by Francis Galton, Karl Pearson and Ronald Fisher developed
the mathematical tools such as correlations and hypothesis tests that made
possible much more sophisticated analysis of statistical data.[124]
During the U.S.
Civil War the Sanitary Commission collected enormous amounts of statistical
data, and opened up the problems of storing information for fast access and
mechanically searching for data patterns. The pioneer was John Shaw Billings (1838–1913). A senior surgeon in the war, Billings
built the Library
of the Surgeon General's Office (now
the National Library of
Medicine), the centerpiece of modern
medical information systems. Billings figured out how to mechanically analyze
medical and demographic data by turning facts into numbers and punching the
numbers onto cardboard cards that could be sorted and counted by machine. The
applications were developed by his assistant Herman Hollerith;
Hollerith invented the punch card and counter-sorter system that dominated
statistical data manipulation until the 1970s. Hollerith's company became International
Business Machines (IBM) in 1911.
Johns Hopkins Hospital, founded in 1889, originated several modern medical
practices, including residency and rounds.
European ideas
of modern medicine were spread widely through the world by medical missionaries,
and the dissemination of textbooks. Japanese elites enthusiastically embraced
Western medicine after the Meiji Restoration of
the 1860s. However they had been prepared by their knowledge of the Dutch and
German medicine, for they had some contact with Europe through the Dutch.
Highly influential was the 1765 edition of Hendrik van Deventer's pioneer
work Nieuw Ligt ("A New Light") on Japanese
obstetrics, especially on Katakura Kakuryo's publication in 1799 of Sanka
Hatsumo("Enlightenment of Obstetrics"). A cadre of Japanese
physicians began to interact with Dutch doctors, who introduced smallpox
vaccinations. By 1820 Japanese ranpô medical practitioners not only translated
Dutch medical texts, they integrated their readings with clinical diagnoses.
These men became leaders of the modernization of medicine in their country.
They broke from Japanese traditions of closed medical fraternities and adopted
the European approach of an open community of collaboration based on expertise
in the latest scientific methods.
Kitasato Shibasaburō (1853–1931) studied bacteriology in Germany
under Robert Koch. In 1891 he founded the Institute of Infectious Diseases
in Tokyo, which introduced the study of bacteriology to Japan. He and French
researcher Alexandre Yersin went to Hong Kong in 1894, where; Kitasato
confirmed Yersin's discovery that the bacterium Yersinia pestis is
the agent of the plague. In 1897 he isolates and described the organism that
caused dysentery. He became the first dean of medicine at Keio University, and
the first president of the Japan Medical Association.
Japanese
physicians immediately recognized the values of X-Rays. They were able to
purchase the equipment locally from the Shimadzu Company, which developed,
manufactured, marketed, and distributed X-Ray machines after 1900. Japan
not only adopted German methods of public health in the home islands, but
implemented them in its colonies, especially Korea and Taiwan, and after 1931
in Manchuria. A heavy investment in sanitation resulted in a dramatic
increase of life expectancy.
The Quaker-run York Retreat,
founded in 1796, gained international prominence as a centre for moral
treatment and a model of asylum reform following the publication of Samuel Tuke's Description of the Retreat (1813).
Until the nineteenth century, the care of the insane was largely a
communal and family responsibility rather than a medical one. The vast majority
of the mentally ill were treated in domestic contexts with only the
most unmanageable or burdensome likely to be institutionally
confined. This situation was transformed radically from the late
eighteenth century as, amid changing cultural conceptions of madness, a
new-found optimism in the curability of insanity within the asylum setting
emerged. Increasingly, lunacy was perceived less as a physiological condition
than as a mental and moral one to which the correct response was
persuasion, aimed at inculcating internal restraint, rather than external
coercion. This new therapeutic sensibility, referred to as moral treatment, was
epitomised in French physician Philippe Pinel's
quasi-mythological unchaining of the lunatics of the Bicêtre Hospital in
Paris and realized in an institutional setting with the foundation in 1796
of the Quaker-run York Retreat in England.
Emil Kraepelin (1856–1926)
introduced new medical categories of mental illness, which
eventually came into psychiatric usage
despite their basis in behavior rather than pathology or underlying
cause. Shell shock among frontline
soldiers exposed to heavy artillery bombardment was first diagnosed by British
Army doctors in 1915. By 1916, similar symptoms were also noted in soldiers not
exposed to explosive shocks, leading to questions as to whether the disorder
was physical or psychiatric.
In the 1950s
new psychiatric drugs,
notably the antipsychotic chlorpromazine, were
designed in laboratories and slowly came into preferred use.
The ABO blood group system was discovered in 1901, and the Rhesus blood group system in 1937, facilitating blood transfusion.
During the 20th
century, large-scale wars were attended with medics and mobile hospital units
which developed advanced techniques for healing massive injuries and
controlling infections rampant in battlefield conditions.
During
the First World War, Alexis Carrel and Henry Dakin developed the Carrel-Dakin
method of treating wounds with an
irrigation, Dakin's solution, a germicide which
helped prevent gangrene.
The Great War
spurred the usage of Roentgen's X-ray, and the electrocardiograph, for the monitoring of internal bodily functions. This was followed in
the inter-war period by the development of the first anti-bacterial agents such
as the sulpha.
In 1918 the flu pandemic
killed at least 50 million people around the world.
Internal
Medicine was made possible with the development of the microscope and lab
tests.
Comments
In the 1800s,
medicine finally embraced the scientific method and finally began to make
progress. Little progress was made in
the 1800s to improve sanitation to prevent post-op infections, find cures or
save limbs.
In 1900 medical
researchers had the tools they needed to begin to correctly identify the causes
of illness and make corrections. But the rebels had to fight the medical
bureaucracy as they worked to improve outcomes.
Norb Leahy,
Dunwoody GA Tea Party Leader
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