XVIIIth Century foundations of Modern Medicine : malnutrition, vaccination and surgery
Recommended bibliography
- Thomas L.Hankins, Science and the Enlightenment, Cambridge University Press, 1990.
- Roy Porter. The Greatest Benefit to Mankind: a medical history of humanity, London, 1997,1999.
- Roy Porter, ed. Eighteenth-Century Science, The Cambridge History of Science .Volume 4. CUP.
General Introduction
Enlightenment Philosophy And Medical Reform
Although elaborate systems fascinated many eighteenth-century physicians, this period also produced pragmatic reformers who realized that one could not heal sailors and soldiers or peasants and workers with learned speculations. Social and medical reformers, inspired by the Enlightenment belief that it was possible to improve the human condition through the application of reason to social problems, turned their attention to public health and preventive medicine. In the eighteenth century, to an unprecedented extent, the ship, the army barrack, the factory, the prison, the hospital, and the boarding school were closed worlds in which unrelated people were confined, sharing unhygienic conditions, unhealthy diets, polluted air, and communicable diseases.
Reformers and philanthropists argued that scientific investigations of the abominable conditions of cities, navies, armies, prisons, lunatic asylums, and hospitals could improve the health and prosperity of society as a whole. Sometimes this battle was led by medical men familiar with specific constituencies, such as Sir John Pringle, surgeon general of the British armies, or James Lind, Charles Blane, and Thomas Trotter, pioneers of naval medicine and hygiene. The English philanthropist John Howard called for the reform of prisons, while French physician Philippe Pinel attempted to reform the abysmal conditions in mental asylums.
The goals and ideals, as well as the sometimes authoritarian methods that characterized the developing field of public health medicine, are reflected in the work of Johann Peter Frank (1745-1821), a pioneer of what is now called social medicine. His philosophy was encapsulated in his 1790 oration, ’’The People’s Misery—Mother of Diseases,’’ and expounded in great detail in the six volumes of his System of Complete Medical Police (1777-1817). This monumental work was a widely known and influential exposition of the social relations between health and disease. Weaving together the noblest ideals of Enlightenment thought, enlightened absolutism, and pragmatic public health goals, Frank devoted his life to teaching Europe’s monarchs that the people constitute the state’s greatest wealth and that it was in the state’s best interest to see that its subjects should be ’’as numerous, healthy, and productive as possible.’’ Human resources could best be maintained through ’’rational hygienic measures’’ by combining the power of the state with the knowledge of the physician. For the welfare of the people, the physician must be responsible for the two branches of state medicine: forensic medicine and the medical police who enforced the dictates of the state.
Even as a student, Frank felt himself driven by a profound inner restlessness. He attended various universities in France and Germany before he obtained his medical degree from Heidelberg in 1766. When Frank became personal physician to the Prince-Bishop of Speyer, he began to test his ideas about a new social medicine by studying the conditions of the serfs and determining how the government could affect the health of its subjects. Among other things, Frank established a school to train midwives, hospitals to serve the poor, and a school for surgeons.
In 1779, Frank published the first volume of his Medical Police. Subjects covered included marriage, fertility, and childbearing. The next two volumes dealt with sexual intercourse, prostitution, venereal diseases, abortion, foundling hospitals, nutrition, clothing, and housing. Although these books made Frank famous, they did not please the Prince-Bishop. A position in the service of Emperor Joseph II provided better conditions for Frank’s studies of medical practitioners and institutions, public health measures, and the condition of working people and peasants.
By the second half of the twentiethth century, the population explosion was generally recognized as a major threat to global economic and social welfare, but Frank was most concerned with the opposite problem. Medical Police reflects the economic and political concerns of the rulers of Austria, Prussia, France, and Spain, who were convinced that they needed more people for their armies, industries, and farms. The so-called enlightened despot and his physicians understood that people could only be productive if they were healthy and able-bodied; in other words, the welfare of the people was the welfare of the state. No detail was, therefore, too small to escape Frank’s attention if it might conceivably affect the future fertility of the people.
Medical police would be authorized to supervise parties, outlaw unhealthy dances like the waltz, enforce periods of rest, and forbid the use of corsets or other fashionable articles of clothing that might constrict or distort the bodies of young women and jeopardize child-bearing. If Frank’s concept of medical police seems harsh, his definition of the qualities of the true physician reflects his heartfelt belief that the most important qualities of the physician were the love of humanity and the desire to alleviate suffering and provide consolation where there was no cure. Concerned that people might make mistakes in determining when death had occurred, Frank provided advice about resuscitation and rescue, dealing with accidents, and the appointment of specialized rescue workers.
By studying the lives of peasants and workers, Frank hoped to make physicians and philosophers see how diseases were generated by a social system that kept whole classes of people in conditions of permanent misery. Eighteenth-century social classes, as Frank knew them, consisted of the nobility, bourgeoisie, and paupers. The great majority of all people fell into the last category. Convinced that one of the worst aspects of the feudal system was the harsh conditions imposed upon peasant women and children, Frank argued that all pregnant women needed care and kindness in order to successfully carry out their duty to the state, which was to produce healthy new workers. Reports of the accidents that maimed and killed children left alone while their mothers worked in the fields prove that the past was not a golden age of prefeminist family life. Babies cried themselves almost to death with fear, hunger, thirst, and filth. Sometimes pigs or dogs got into the house and attacked infants; sometimes small children wandered away from home and died by falling into wells, dung pits, or puddles of liquid manure.
Other aspects of medicine and its place in eighteenth-century society are reflected in the changing pattern of medical professionalization in Europe. France, for example, entered the eighteenth century with a medical system dominated by learned physicians steeped in traditional Hippocratic doctrines. Endless academic debates about abstract medical philosophies obscured a broad range of therapeutic practices, as well as the work of unorthodox and unlicensed healers. By the end of the century, however, French medicine had been transformed by two very powerful catalysts: revolution and war. Ignorant of medical philosophy, military men were known to say that many lives could be saved by hanging the first doctor found bleeding the wounded with his right hand and purging them with the left. Promoting the ideology of equality, revolutionary leaders denounced academic medicine as the embodiment of all the worst aspects of the Old Regime, from favoritism and monopoly to neglect and ignorance. Ironically, the revolutionary movement that intended to eradicate doctors, hospitals, and medical institutions generated a new public health policy, better trained doctors, new medical schools, and hospitals that offered unprecedented opportunities for clinical experimentation, autopsies, and statistical studies. Hospital reform was especially difficult, costly, and painful, but the revolutionary era established the hospital as the primary locus of sophisticated medical treatment, teaching, and research.
Malnutrition
Scurvy and other diseases
In 1842 George Budd, Professor of Medicine at King’s College, London, gave a memorable lecture titled “Disorders resulting from defective nutriment,” from which these are some of his opening comments: “There is no subject of more interest to the physiologist or of more practical importance to the physician … than the disorders resulting from defective nourishment. … These disorders are, no doubt, frequently presented to us by the destitute poor in our large towns; but … from our not being acquainted with all the circumstances in which they arise, their real cause escapes us. It is only—as in ships, garrisons, prisons and asylums—when large numbers of men … become affected with one disease, that our attention is fixed upon it, and that we can succeed in discovering its cause by considering what is peculiar in their circumstances” (40).
There is one exception to the generalization at the beginning of the chapter that no systematic work relevant to nutrition had been carried out before 1785, and this must now be described. It is the pioneering controlled clinical trial of the various therapies recommended for the disease of scurvy, which was carried out in 1746 by James Lind on sailors at sea. Lind was, at that time, a 30-y-old ship’s surgeon in the British navy, with no academic education, but with a special interest in the problem of scurvy. He took 12 sailors, all with a similar severity of the disease, divided them into pairs and, for 2 wk, gave each pair one of the many treatments that had been recommended for the condition. His trial is described in more detail elsewhere, but the salient point for modern readers is that the pair receiving lemons and oranges were almost recovered after only 6 d, whereas those receiving either dilute sulfuric acid or vinegar had shown no improvement after 2 wk (41,42).
The importance of Lind’s trial has often been described as showing that citrus fruit was a cure, or preventive, for scurvy. This had, in fact, been known already for some 200 y but could not always be made use of. Neither oranges and lemons nor fruit juice could be stored on long voyages before the days of refrigeration because they went moldy. Because of this, the College of Physicians in London had reasoned that other acids could act as substitutes, given that it was thought that scurvy was a “putrid” disease, and animal tissues that went putrid became alkaline. It seemed therefore to follow that citrus juice acted as it did as a result of its acidity, and that other more stable acids like sulfuric acid (diluted before use!) or vinegar could be used equally well. As a consequence, ships’ surgeons were issued with sulfuric acid for many years without its actual value having been put to a critical test.
In 1753, after Lind had qualified as a university-trained physician, he wrote in his treatise on scurvy: “The Channel fleet for many years was supplied with vitriol [sulfuric acid]. Yet it often had a thousand men miserably over-run with the disease. … Of theory in physic [medicine] … it is indeed absolutely necessary yet, by carrying it too far, it may be doubted whether it has done more good or hurt in the world” (43).
If other acids could not replace lemon juice, and if lemons or their juice were too unstable for carriage on long voyages, what could be done? Lind himself suggested that the juice could be slowly concentrated in shallow bowls over boiling water until they had condensed to a thick syrup, or “rob” as he called it. This was tried but found to be of little value in practice. A more effective product, and one welcome to sailors, was to preserve the juice with a proportion of rum or brandy. Another approach was to extract citric acid from the juice and to issue that to ships. Unfortunately, many writers, assuming that citric acid was the active factor, would refer to “administering the citric acid,” even when they were actually giving lemon juice. In some instances this is clear, but in others not. Finally, after many years of uncertainty it was agreed that true pure citric acid was not antiscorbutic (44).
Lind had believed that the true value of citrus fruit was that it had “a saponaceous, attenuating and resolving virtue” [or “detergent action”] that helped to free perspiration pores in the skin that had become clogged in sea air so that poisons accumulated without being able to escape. He believed that the disease did not occur on land, so that land dwellers did not therefore require an antiscorbutic as sailors did. But this was not the case. It was clear by 1843 that there had, from time to time, been at least 20 outbreaks of scurvy in British prisons. The condition seen in the prisoners was exactly the same as that seen at sea. The only common factor that could be found to explain these outbreaks was that, for some time previous to the outbreaks, potatoes had been omitted from the diet; and when these were added back to the diets, the disease disappeared (45).
The importance of potatoes as antiscorbutics was confirmed in the period from 1845 to 1848, when successive European potato harvests failed because of fungal attack. In Ireland, where potatoes had become the major source of energy for much of the population, there was disastrous starvation on top of the expected scurvy. In England, where more grain was grown and there was no overall shortage of energy, the major effect was again a series of outbreaks of scurvy, this time in the general population as well as in prisons. The serious outbreak in a Scottish prison has already been discussed in relation to the belief of a disciple of Liebig that protein was “the only true nutrient” and therefore, if a diet was inadequate in quality, the deficiency must be in the supply of protein. In practice, green vegetables were found to be effective alternative antiscorbutics when neither potatoes nor fruit were available.
Land scurvy would continue to be a problem whenever food supplies were limited by supply problems. Thus it occurred among prospectors during the California gold rush, soldiers during the Crimean War, prisoners in the American Civil War and ordinary civilians during the Siege of Paris in 1871. In every case, the problems were resolved when either fresh vegetables or fruit juice became available again.
Vaccination
Science Museum
Brought to life
Exploring the history of medicine
Edward Jenner (1749-1823)
Edward Jenner was an English country doctor who introduced the vaccine for smallpox. Previously a keen practitioner of smallpox inoculation, Jenner took the principle a stage further by inducing immunity against this killer disease via exposure to a harmless related disease, cowpox. His technique provided safer and more reliable protection than traditional inoculation.
Working in an agricultural community, Jenner knew of the country folklore that milkmaids never caught smallpox. They were known for their relatively flawless complexions, which were unmarked by smallpox scarring. However, they inevitably caught cowpox through their close work with cows. Jenner speculated that a bout of cowpox produced immunity against smallpox and even encountered locals who claimed to have deliberately infected themselves to provoke such a response. As a forward-thinking doctor who liked to experiment, Jenner wanted to prove his theory. In 1796 he inserted pus taken from Sarah Nelmes, a milkmaid with cowpox, into a cut made in the arm of a local boy, James Phipps. Several days later, Jenner exposed the boy to smallpox. He was found to be immune.
Jenner called his new method ‘vaccination’ after the Latin word for cow (vacca). But Jenner had no explanation for why this method worked - no-one could see the virus with the microscopes of the time. He submitted a paper to the Royal Society the following year. It was met with some interest but further proof was requested. Jenner proceeded to vaccinate and monitor several more children, including his own son. The full results of his study were published in 1798, but his apparent discovery was met with much opposition, and even ridicule. In time the value of his vaccine was recognised, but as many poorer communities had limited access to medical treatment it was several decades before its full benefits were realised. In 1853, 30 years after Jenner’s death, smallpox vaccination was made compulsory in England and Wales.
Bibliography
- H. Bazin, The Eradication of Smallpox: Edward Jenner and The First and Only Eradication of a Human Infectious Disease (London: Academic Press, 2001)
- H. Davies, ’Ethical reflections on Edward Jenner’s experimental treatment’, Journal of Medical Ethics, 33 (2007), pp 174-176
- R.B. Fisher, Edward Jenner (1749-1823) (London: Andre Deutsch, 1991)
- E. Jenner, An Inquiry into the Causes and Effects of the Variolae Vaccinae, a Disease Known by the Name of Cow Pox (London: Sampson Low, 1798.
Anesthesia
In the 18th century surgery was the always the last desperate resort. Doctors and dentists had never liked the agonized screams and yells of their patients and it hurt to see them that way. The doctors and dentists had straps to secure their patients in before surgery. Some doctors gave their patients some alcohol to drink before preceding the surgery.
Healers attempted to induce a psychological state of anesthesia by mesmerism or hypnosis. But by 1846 alcohol and opium were the only agents which continued to be regarded as practical value in diminishing the pain of operations. Unfortunately, the large doses of alcohol needed to produce stupefaction were likely to cause nausea, vomiting, and death sometimes instead of sleep. Opium, still a stronger analgesic, had significant side effects itself and was typically not powerful enough to completely blunt a surgical stimulus.
Gases were the first used anesthetics in the 19th century such as nitrous oxide, ether, and chloroform. Nitrous oxide, or laughing gas, was discovered as an anesthetic by English chemist Humphrey Davy in 1799. Davy’s discovery was ignored until the next century, when Connecticut dentist Horace Wells began to experiment using nitrous oxide as an anesthetic during tooth surgeries. In 1845, he attempted to demonstrate the qualities the nitrous oxide would hold to a public audience but was unsuccessful when he began to pull the tooth out the patient had moaned and the audience had thought he had failed and Horace Wells fled. Since the patient had moaned, as a result, another 20 years passed before nitrous oxide was accepted for use as an anesthetic.
The first use of ether as an anesthetic during an operation was claimed by Crawford W. Long of Georgia in 1842. The operation, though, was unrecorded, so official credit went to Massachusetts dentist William Morton for his 1846 public demonstration of an operation using ether performed in a Boston hospital. While Morton administered the gas to the patient through an inhaling device, John C. Warren removed neck tumor without the patient feeling any pain. Following this discovery, the use of ether as an anesthetic, general anesthesia began to be practiced all over the United States and Europe.
Chloroform was introduced as a surgical anesthetic by Scottish obstetrician James Young Simpson in 1847. After first experiment with ether, Simpson searched for an anesthetic that would make childbirth less painful for women. Although it eased the pain of labor, chloroform had higher risks than those associated with ether. Neither ether nor chloroform is used today.
Ether was one of the earliest anesthetics to be used but was difficult to administer as it usually made the patient choke.
18th Century
Joseph Priestley (1733–1804) was an English polymath who discovered nitrous oxide, nitric oxide, ammonia, hydrogen chloride and oxygen. Beginning in 1775, Priestley published his research in Experiments and Observations on Different Kinds of Air. The recent discoveries about these and other gases stimulated a great deal of interest in the European scientific community. Thomas Beddoes (1760–1808) was an physician and teacher of medicine. With an eye toward making further advances in this new science as well as offering treatment for diseases previously thought to be untreatable (such as asthma and tuberculosis), Beddoes founded the Pneumatic Institution for inhalation gas therapy in 1798 at Dowry Square in Clifton, Bristol. Beddoes employed chemist and physicist Humphry Davy (1778–1829) as superintendent of the institute, and engineer James Watt (1736–1819) to help manufacture the gases.
During the course of his research at the Pneumatic Institution, Davy discovered the anesthetic properties of nitrous oxide. Davy, who coined the term “laughing gas” for nitrous oxide, published his findings the following year. Davy was not a physician, and he never administered nitrous oxide during a surgical procedure. He was however the first to document the analgesic effects of nitrous oxide, as well as its potential benefits in relieving pain during surgery.
Medical Treatment in the 18th Century
In the 18th century, John Brown, writer, and lecturer believed that there were only two types of diseases: strong and weak. He also believed that there were only two types of treatments: stimulant and sedative. His prescription? Either alcohol or opium.
Today, we clearly know that disease, sickness, and medical treatment are far more complex than just two types and two solutions. Alcohol and opium are also not seen as legitimate treatments any longer.
Also, not everyone felt the same as Brown back then. Samuel Hahnemann, the creator of homeopathy, took a different approach: He treated medical conditions with small doses of drugs that had effects that resembled the same effects of the disease. While homeopathy has never seen widespread acceptance, it continues to have an impact on how people seek treatment today.
