Adapted from

James Burke

The Day the Universe Changed

Boston: Little, Brown and Co., 1995.

Chapter 7: What the Doctor Ordered

A good bedside manner was essential for the doctor of the eighteenth century. Before the coming of scientific medicine, it was likely to be his most successful therapeutic tool.

Medicine and Modern Life Expectancy

Many say that the number of old people alive today best shows the miracle of modern medicine. Thanks to medical advances the percentage of the population over the age of retirement will shortly exceed those young enough to work. Every day, it seems, a new discovery extends life.

The real miracle, however, is that the rising population of the industrial nations has not suffered from a major epidemic, until AIDS, since the last century. The modern world supports millions who come into close contact with one another every day, in offices and shops, on public transport, in crowded streets. Each one of us is a potential source of wholesale death, but through medicine and pharmacology we can stop the spread of most contagious diseases before they begin.

Medication prevents minor symptoms from developing into serious and contagious conditions, which could threaten the whole community, because of the overcrowded and confined demographic circumstances in which we live today. Sophisticated public health measures preserve overall control of the situation. All this is possible only because we attack disease at source by striking at the micro-organism which causes it.

Medicine Only Two Hundred Years Ago

Only two hundred years ago the view of disease was radically different. Then, each individual's illness was a unique condition, which the doctor would treat as the patient's situation demanded. One of the doctors in an eighteenth-century French play, Le Malade imaginaire, summed it up: “The trouble with people of consequence is that when they're ill, they absolutely insist on a cure.” It was this control by the patient of the doctor's efforts in eighteenth-century Europe that prevented an already ignorant community of physicians from making any scientific headway.

Medical theory at the time had advanced little beyond the system worked out by the second-century Alexandrian, Galen. Scientists made some discoveries in the sixteenth and seventeenth centuries, which improved anatomical knowledge: the circulation of the blood, for example, and primitive theories of respiration. But medicine reflected almost none of the other general scientific advances of the period.

The late eighteenth-century pharmacy of Michael Schuppach.  His success in diagnosing ailment by analyzing urine made him famous throughout Europe, bringing as many as a hundred cases a day to his rustic Swiss laboratory.

Doctors saw disease as a generalized condition of the whole body arising from a lack of balance among the essential elements of the human constitution, the four humors—blood, phlegm, choler and black bile. These humors controlled different aspects of an individual’s character and were a subdivision of the general cosmogony in which earth, water, air, or fire everything made up everything. Doctors defined normal health as a balance among the four humors.

As there was no way of viewing the inside the living patient, medicine relied on a series of taxonomic systems, listing conditions according to their outward symptoms. These were the only data available to the doctor for use in his diagnosis. Medicine consisted of phenomenological disease lists and speculative pathology based on guesswork. Doctors saw disease as a single entity, displaying itself in different symptoms according to which part of the body it struck, in which person, and under which circumstances. They thought, therefore, that there must be some single irreducible first cause for disease. Patients might have an underlying tendency to ill-health, because each individual had a unique pattern of bodily factors which the doctor could identify. The body was a microcosm, obeying its own laws of growth and decay, comparable to the macrocosm Newton revealed in the previous century. All this hopelessly confused the practice of medicine. Doctors sought a cure for disease which would cure all symptoms.

The remedies for this “disease” were at best idiosyncratic and at worst dangerous. In a Clinical Guide of 1801 published in Edinburgh cures included digitalis, crabs' eyes, syrup of pale roses, castor oil, opium, pearls, and “sacred elixir.” Armed with a bag full of such cures and a knife, the doctor could do little more than relieve constipation or pain, steady the pulse, and amputate. The trick lay in how he presented his special remedies to his dominant and socially superior patient. If the best he could do with a diagnosis was, for instance, to classify typhus as “always smelling of mice,” he would make little impression on the fee-paying invalid in bed.

Social Status of Doctors

Although doctors were gentlemen, qualifying as physicians at Oxford or Cambridge where the course lasted six years, they did no, in general, come from the aristocracy. Many of them mimicked their aristocratic patients in wild clothing and stylish manners. They spiced their overblown vocabulary with the Latin tags their superiors with a classical education used. As soon as a doctor made any money he bought land, to move up the social ladder.

A medical career flourished or foundered according to the relationship the doctor managed to strike up at the bedside. It was therefore vital for any doctor to compete successfully with others whom the patient might call to replace him in his lucrative position. For these good reasons he presented himself as a man wrestling with the forces of nature, triumphing over disease by his skill and “curative powers” by using heroic and secret cures known only to him. This free market in physicians' services and remedies produced much expensive and vituperative advertisement, in which one doctor would claim that all other doctors were quacks and their remedies ill-advised and dangerous.

Theories of Illness and Therapy

A wide number of competing and mutually exclusive theories of illness and therapy flourished. The more exotic the approach, the more the patient would feel he was benefiting from personal treatment. The patient had the final veto on diagnosis and treatment, and his own view of what was wrong with him was the basis on which the doctor recommended curative measures. Hypochondriasis was the most commonly diagnosed ailment in the eighteenth century. Each patient regarded his own suffering as unique, and demanding unique cures.

The two faces of eighteenth-century medicine. Left, the doctor who spends time and money healing the poor. Right, the more typical profiteering quack, who takes a side of bacon from a patient without the cash to pay him.

This “bedside” era of medicine made little scientific progress, thanks to the competitiveness and lack of exchange of experience and ideas among doctors. Professional advancement depended on the successful recommendation of such dubious aids as patent stomach brushes or electro-medico-celestial beds or life-generating cordials, which remained jealously guarded secrets of the trade. Any real research pursued by individual practitioners remained unshared, but most considered research as irrelevant anyway.

The only medical practitioners who made routine observations on the anatomy were the surgeons. Classed as manual workers, as late as 1745 they still held a social rank equal to barbers. Surgeons could not attend patients and never mixed with physicians, so their anatomical knowledge rarely helped the sick. Medical practitioners could dissect only the poor and destitute from whom doctors could extract no profit, so they took little interest in their diseased corpses. As one of the great doctors of the day in England, Thomas Sydenham, said, the job of the doctor was “to cure disease and do naught else.” Doctors shared no secrets and made no common advances.

The self-taught French country surgeon wields his scalpel. In the eighteenth century, this was the only medicine available to most of the population. Note the instruments in a pouch at his waist and hooked in his hat for ease of access.

The women’s ward at St. Luke’s hospital for the insane, London, 1800.  Untypically, workers are cleaning and making beds.  The most fashionable treatment of the day was the new electric shock therapy.

In these circumstances, doctors rightly faced skepticism. The safest thing to do when sick was to keep well away from them and their remedies. Hospitals were for the destitute, the fever-ridden, and the insane. No one in his right mind would enter a ward. As Florence Nightingale remarked decades into the next century: “The first requirement in a hospital [is] that it should do the sick no harm.”

End of the Eighteenth Century Sees Medical Improvements

However, as the eighteenth century ended, various factors combined to bring about improvement in medical science. To begin with, the new political fashion was to regard England, with its rising population, burgeoning industrialization and urban growth, as the ideal model. In a strongly mercantilist atmosphere, many felt that national strength lay in numbers. The bigger the population, the wealthier the country.

Wolfgang Rau

In emerging nations, the emphasis began to switch to health. If the population could work productively in the new factories, then “the health of a nation [was] the wealth of a nation.” In Prussia, Frederick II, an enlightened despot capable of effecting speedy reforms, brought order to medical confusion. As early as 1764, Wolfgang Rau introduced the idea of a state health policy, arguing his case from the economic point of view. The state, he claimed, needed healthy subjects to succeed in war and peace, so it should legislate against quackery and develop administrative skills to enforce such legislation. The state had to safeguard public health as an economic resource and therefore should regulate the education and competence of doctors.

Johann Peter Frank

Johann Peter Frank of Vienna was the first great practical exponent of the new approach. As a hospital administrator, clinician and teacher, he traveled extensively throughout Europe, teaching at Pavia, Vienna, and Vilnius in Lithuania. In each country he worked for the absolute rulers of relatively small states, who wanted the means to control the productivity of their populations.

“How merrily we live, that Doctors be.

We humbug the public and pocket the fee.”

Frank produced his major work after 1790. He directed it at administrators rather than the medical profession. Translated into the principal European languages, the seven volumes of A System of Medical Police concentrated on the public aspect of health. His despot rulers wanted to be able to supervise even the most personal of their subjects' activities. Frank provided them with the means to do so.

Wishing to increase the population, Frank included guidelines on everything from procreation to marriage. He advised that women should stay in bed during and after childbirth, with state support for up to six further weeks. He paid great attention to child care, policing schools, lighting, heating, and ventilation regulations. Frank included detailed programs for provisioning and distributing food, which the state would supervise at every stage from field to mouth. The state would also control housing, sewage, garbage, and water supply.

Frank dealt with the roots of the problem, medicine and the general environment. States should root out poverty, he said, and force doctors forced to undergo new kinds of training in hospitals. Here they should learn practical medicine with live patients, follow cases through, and carry out post-mortems. Teaching and practice should go together so there should be provision in the hospitals for many students to be at the same bedside, for having many patients of mixed sex and age, and for treating the maximum variety of illnesses. Doctors should prescribe treatment, observe the patient through convalescence, and, above all, practice regular dissection after death. The motto Frank put on the cover of his great work was “To serve and magnify the state.”

John Locke

Events in France forestalled further advance in Germany. By the late eighteenth century, the views of John Locke, the Englishman who had developed the concept of sensationalism a hundred years earlier, dominated European philosophy. According to Locke, knowledge had no source but experience. This experience could be either external gained from the world around and contact with it or internal, that is, mental reflection. From sensory contact with the outside world came “ideas” which were either simple or complex. Simple ideas, such as whiteness, space, and so on, were irreducible in nature, while complex ideas were combinations of simple ideas. Locke's rational system of analysis gave birth to an intellectual movement, which became known as the Enlightenment.

Etienne Condillac

One of the great Enlightenment thinkers in France, Etienne Condillac, took Locke's ideas further. He said that the only way to understand the world was to regard sensations as the primary data of cognition. All ideas and faculties of understanding, he held, were compounds of simple ideas, which in turn were the result of sensations found through analysis of compound ideas. Everything, in the end, was sensory, said Condillac: “Penser c'est toujours sentir” (to think is to feel).  Scientists must carefully examine each sensory source datum and note its relationship with other sensory data.  They must discard preconceived notions of the relationship to get the clearest analysis.

Immanuel Kant

After Condillac's death, in 1780, Immanuel Kant popularized the system throughout Europe. In Germany his philosophy appealed to physicians keen to reduce medical practice to a simpler, more certain system. For Kant, the doctor functioned in a world of physical appearances and should therefore be aware of his own perception, understanding and judgment of these appearances before he made a diagnosis.

The doctors saw Kant as a welcome enemy of dogma, who would lead them to certainty and efficacy through reason. But Kant was to take them much further. He postulated that understanding of the world could come only because there were certain concepts already embedded in the mind: time, space, and causality. These acted like a matrix into which all perceived sensations fitted. Kant stated that there were, therefore, no laws in nature itself, but merely mental constructions in the human mind set up to give shape to disordered natural data. Science, he said, was a way of systematizing phenomena into constructs allowing the clearest understanding of the phenomena and their interconnection. All knowledge, therefore, could be reduced to a few principles functioning in every case.

Friedrich von Schelling

One of Kant's followers, Friedrich von Schelling, Professor of Medicine at Bamberg, developed these ideas into a system of thought, known as Naturphilosophie, which was to have a profound effect on the Romantic Movement and on European science in general. Schelling directed his efforts towards finding a few, fundamental principles. He believed that man had originally been at one with nature, but, by developing the ability to reflect, had gradually moved apart from it. The aim of all thought should therefore be to eliminate this artificial “reflective” gulf between man and nature. In understanding his lost “oneness of all” lay the secret of life, common to all creatures. Looking to reveal the secret, Schelling wrote in 1805, “Medical science is the crown, the copestone of all natural sciences, just as organic life and the human organism in particular is the copestone of all creation.” There must, he reasoned, be a few, simple, basic laws, which man could derive from observation and which would determine what was the fundamental life force. The dream of discovering the force spurred German medicine to concentrate unsuccessfully on microscopic phenomena for the next forty years, to the detriment of all other fields of research.

The French Revolution and the New Medicine in France

The more practical application of the theory attracted the French, who stopped short of the German obsession with investigating the secret of the universe at the expense of the patient. Their research therefore took a different route, concentrating on careful observation and analysis of the kind of data available to the senses. This approach was due in the main to the medical, social and intellectual changes brought about by the unique events of 1789, the beginning of the French Revolution. To this time, French physicians had been no different from other doctors. They were a small, powerful elite serving the aristocracy, and as such they were to suffer at the hand of the revolutionary committees.

The ensuing political turbulence brought about two major medical changes.

The most famous of French battle surgeons, D. J. Larrey, inventor of the ambulance, kneels to staunch a wound. His few instruments are in the box on the ground.

Closed Hospitals and the Rise of Surgeons

First, the new revolutionary state compulsorily closed all medical organizations during the revolution, leaving the country in medical anarchy when the country most urgently needed the profession. Doctors were members of the upper classes, so the new state reeducated them. But by the same revolutionary token, surgeons were craftsmen, and the new ideology elevated them.

The surgeons had enjoyed minor improvements in their social condition for some time before the storming of the Bastille. In 1743, they could enter the university to take MA degrees and receive the title of “Doctor.” This met great opposition from the physicians, who did their best to see that the surgeons' professional opportunities limited strictly to those hospitals where patients were poor. The university faculty of medicine offered condescending advice: “Let the hospitals serve as your libraries and cadavers as your books.” The surgeons took the advice. They also went out into the towns and villages too small to provide enough revenue for doctors. As a result, when the wars broke out after the revolution, there were many more surgeons than physicians in France.

Innovative Surgeons Treat the Wounded

The second factor of importance in medicine was the numerical superiority of the surgeons when soldiers most needed them, on the battlefield, where their practical training in anatomy put them at a distinct advantage over the physicians. Whereas the physician went to war with his potions, symptom lists, and bedside manner, the surgeon had only his knife and some bandages. When the doctor exhausted his supply of remedies there was no available source of replacements. Soldiers were often too shocked by their wounds to talk, let alone describe their symptoms. The surgeons, on the other hand, learned rapidly. There was a great variety of wounds to deal with. There were clean wounds, such as those inflicted by saber bayonet, or dirty wounds caused by gunshot, which forced pieces of clothing into the flesh. Lead ball shattered bone and stayed in the flesh. The different size and shape of wounds produced different symptoms and pains.

It soon became clear to the surgeons that any object left in the flesh would become a source of infection. Surgeons developed wound cutting to open and clean the area around the trauma. There was much improvisation. They used their fingers or simple tweezers to pick out fragments. Thumbs were as effective as tourniquets. They used grass and moss when without lint. They developed simpler, less wasteful bandaging techniques. Shortages stimulated other new solutions. Cauterizing with hot iron, often too general a treatment for most conditions, killed as often as it cured. Surgeons adopted a new, more efficient method of cauterization using a “moxe,” which consisted of a small cylinder open-ended cone holding combustible material which the surgeon could selectively apply to the wound. They could burn it as deeply as needed for as long as necessary.

An English doctor burning out spots with a moxe. Note the medicinal brandy on the table and the obvious distress of the patient.

Without ointment, surgeons widely used water treat wounds. The recommended cold water for saber, bayonet, and sword cuts as well as shock. Warm water was best for gunshot. They found that wounds healed more quickly if they irrigated the wounds in this way.

Surgeons developed new techniques for handling fractures. Early in the war much of the fighting had taken place on the Franco-German border near the Val d'Ajol in the Vosges Mountains. There, the local rebouteurs, or 'quacks', were expert in treating the effects of falls and taught the surgeons the value of alcohol to induce stupor and relaxation to make manipulation easier. They had also solved the problems of poisoning associated with the use of nicotine in surgery on the abdominal area. Surgeons had given patients oils of nicotine to relax and anaesthetize the abdomen to make hip and pelvic setting possible. The poisonous nicotine often killed the patient. The rebouteurs inserted a cigar into the patient's rectum to the same effect and without risk of intoxication.

Battlefield surgeons learned that the old idea of operating immediately was wrong and that they should first treat the patient for shock. They also discarded trepanning. The operation had been popular in cases of skull fracture, when surgeons drilled holes in the skull to relieve pressure. In battle, without such drilling instruments, they could do little trepanning. As a result, more patients survived without the operation than had previously survived with it.

Bandaging and using splints, from an eighteenth-century Italian manual of anatomy.

Amputation in the field.  This early nineteenth-century illustration shows the surgeon about to make the first incision with a curved knife, while his helpers prepare to restrain the patient.  On the table to the left, a hacksaw lies read for use on the bone.

Amputation techniques changed too. The surgeons no longer waited as long as possible before cutting off the limb. Three years after the beginning of the war the rule was to cut within twenty-four hours or not at all. With inadequate supplies of needle and thread, surgeons found that two flaps of flesh laid against each other would heal united; an ordinary bandage would hold them in place. They tried skin grafting as a treatment for burns.  They also used simple soothing oils and lint.

The strangest discovery involved the condition known as “wind death.” After battles, many soldiers lay dead, with no external marks on their bodies. Most thought they had died of the wind of a passing bullet drawing out all their breath and causing them to suffocate. After a time, the frequent opportunity for dissection because of the plentiful supply of corpses revealed cases of severe internal damage which had produced no external symptoms.

The New Hospitals

During the revolutionary wars, both physicians and surgeons received the new rank of “health officer.” Gradually both sides of the profession became used to working together. Both took up posts in the new postwar hospitals. The mass of casualties from armies hundreds of thousands strong urgently needed treatment. In January 1793, the National Convention began moving veterans out of the Invalides and replacing them with war wounded. The state commandeered the Val de Grâce monastery in the Rue St Jacques for hospital work. It took 1200 men. Soon there were too many patients to handle, so the government expanded hospitals all over Paris and redesignated them as specialist hospitals for fever, skin diseases, venereal disease, the wounded, and so on.

An illustrated guide to the hospitals and hospices of Paris, in 1818 the medical center of Europe.  New the new School of Medicine, top left.

In 1794, all hospitals became state property and the expansion of facilities continued. By 1807, Paris hospitals alone offered over 37,000 beds. In all Britain at the same time, hospitals had room for less than 5000 patients. The reorganization of 1794 was to make Paris the world capital of scientific medicine, attracting visitors and students from all over Europe and America.

In the new Ecole de Santé, the surgeons were now in charge. Of the twenty-two professional chairs, surgeons occupied twelve.: anatomy and physiology, medical chemistry and pharmacy, medical physics and hygiene, external pathology, obstetrics, legal medicine and history of medicine, internal pathology, medical natural history, surgery, external clinic, internal clinic, and advanced clinical.

The initial three-year course for students included training on tasks once thought fit only for surgeons. These included dressing wounds, making minor incisions, keeping daily records, collecting anatomical specimens, and carrying out post-mortems. The motto of the school was, “Read little, see much, do much.” The success of the new approach was immediately obvious. The survival rate of fever victims treated by physicians was much lower than those in the hands of the surgeons.

The new circumstances also offered a unique opportunity to implement the earlier philosophical inclinations towards sensationalism and detailed analysis. Surgeons were, after all, sensationalists by profession. Their job had always been to look, to feel, and to deal with the immediate, local cause of pain, the lesion itself.

Philippe Pinel

One of the first surgically trained chiefs at the Paris school, Philippe Pinel, was close to the circle of ideologue philosophers under the influence of Condillac. In 1798, Pinel wrote a book called Philosophical Nosology, or the application of analysis to medicine. Six editions were printed during the next twenty years, influencing doctors all over Europe. Pinel claimed that concepts of sickness based on phenomena alone were inadequate. For a proper understanding of disease, physicians had to observe the data clinically and traced back to their sources in the organs of the body.

Xavier Bichat and Dissection

This analysis was not thorough enough for one of Pinel's pupils, Xavier Bichat, who was also a surgeon. Bichat applied Pinel's elementary analysis to the static texture of the body, less complex to study than the living organism. Bichat believed that the tissue in the organs would represent the irreducibly simple element of which Condillac had written.

He set out to discover all he could about human tissue. First he dissected it to the fibrous state. Then he tested its reaction to putrefaction, soaking, boiling, baking, acid, alkalis, and so on. The chemical composition of tissue interest Bichat less than did its “organization” and “character.” He regarded the tissue as a source of simple, sensory information, and finally identified twenty-one tissue types, among them: cellular, nervous, arterial, venous, exhalant, dermoid, epidermoid, absorbent, osseous, medullary, cartilaginous, fibrous, pilous, fibro-cartilaginous, muscular, mucous, serous, synovial and glandular.

The doctor's reputation grows. An early nineteenth-century surgeon presents the successful result of a cataract operation to a formal gathering of public authorities.

In his Treatise on Membranes, published in 1800, Bichat presented the first systematic view of disease as a localized phenomenon. No longer would doctors regard sickness as a single entity, which displayed itself in different forms all over the body. Disease was specific to the lesion and was active in the tissues. Postmortems carried out to test Bichat's theory showed that diseases spread from tissue to tissue through the body. Bichat had invented pathological anatomy.

This new view of disease removed the patient from direct involvement with the doctor. In the hospitals, conditions favored his isolation. Hospital doctors were now more dominant, the elite of the profession. The patients themselves were a new breed. They were mostly poor and destitute, or inarticulate soldiers accustomed to taking orders, lying in the hospitals in their obedient and passive thousands, poked and prodded by students who would come to their bedside at will. It was often the practice to hang a lantern outside a hospital to signal that there were viewable cases or pregnancies within. All hospitals except the exclusive Maison Royale were open to students.

If a patient objected to his treatment, his doctors generally discharged him immediately. Most patients came from the laboring poor, who lived in dirty conditions in houses so packed that urinating, defecating, and fornicating in public. For them, being handled naked by students was no trial. This availability made effective teaching much easier.

Hospital medicine in Hamburg. The ward is mixed, as is the treatment. On the left, a patient is receiving the last rites. Center, an amputation takes place next to an eye operation.

Rear, the mad stare from their cell doors.

The lecture hall in the Paris School of Medicine, crowded with local and foreign students, most of them middle-aged.

When a patient died his relatives had to pay a large sum of sixty francs for burial. Otherwise the hospital would send the corpse to the dissecting rooms where doctors would conduct a postmortem to see why death had occurred. Pathological anatomy flourished, and foreign anatomy students flocked to Paris from places like England, where the only way to get a body was to buy it from body snatchers and grave robbers. In France, if the patient's relatives objected to dissection they had to produce effective arguments to overcome the doctor's automatic right to examine the corpse of a patient.  A patient, who, after all, had died under the knife in a surgical operation he had had no power to refuse.

In this new tissue-oriented atmosphere, medicine moved away from therapy, or what the patient wanted, toward diagnosis and classification of disease, or what the doctor wanted. All physicians needed now was sufficient clinical observation to provide data on which to build statistically valid disease and treatment profiles.

Statistical Analysis

John Graunt

The English had made crude attempts at statistics since the sixteenth century, using the mortality bills compiled during epidemics to estimate the total number of deaths. In the seventeenth century, under the stimulus of commerce and mercantile expansion, the Englishman John Graunt had begun to study the use of statistical data. In 1662, he made the basic discovery that large numbers displayed regularities or patterns not obvious from small numbers. Analysis of the records of births and deaths in London for fifty years showed him that such data could help predict and diagnose epidemics. He also saw relationships between the chronic and regular diseases and the weather.

The frontispiece of one of the earliest English reports of plague deaths, compiled in 1664 from parish registers.

A view of the Salpetrière, Paris. Six thousand female patients lived here.  Doctors treated one in ten as a lunatic. The institution was as much a workhouse and prison as it was a hospital.

Statistics and Enlightenment Thinking

In the early eighteenth century the new insurance companies had begun using statistics to aid them in fixing premiums, basing these on the actuarial analysis of probability of death. Then in the great Diderot Encyclopedia, published in France in the middle of the eighteenth century, an article on probability brought statistical analysis into the mainstream of Enlightenment thinking, especially on its potential use in social circumstances. It would, of course, also help the state properly to evaluate the size and condition of the population, which is why the term “statistics” probably originated in Prussia, where its absolute monarch keenly sought to control his population.

The Kantians and Enlightenment ideologues placed man at the center of their unified, naturalistic world-picture, and in doing so encouraged the interdisciplinary thinking that made it desirable for thinker to apply every field of knowledge. Encouraged by the philosophers, medicine looked to the new science of numbers.

Marquis de Condorcet

In 1785 the Marquis de Condorcet, another philosophe and contributor to the Encyclopédie, wrote an essay entitled “The application of mathematics to the theory of decision-making.” If the study of statistics had already worked well for insurance companies, said Condorcet, it should do well elsewhere. It would prove an invaluable aid to the decision-making brain “. . . where it weighs the grounds for belief and calculates the probable truth of testimony or decisions.”

Pierre-Simon Laplace

There were good political reasons for this use of the new mathematics. After the revolution, that no one knew how big the population was, thwarted efforts at social reform on a national scale. Planning was difficult, if not impossible. Counting every single person was out of the question, both financially and organizationally. Then in 1795, the leading French physicist, Pierre-Simon Laplace, gave a series of lectures at the Ecole Normale in Paris. His last lecture was about the calculus of probability, which, he said, he had developed through his interest in games of chance. Its use in human affairs would help eliminate ignorance of the causes of error in statistical analysis, since it was possible to reason from frequency of event to probable cause. The more frequently things happened, the more could he could say about their constancy and regularity of repetition.

Over the next few years Laplace went on to suggest specific uses for his calculus. He showed how to use it to guide and improve observational methods, to evaluate the reliability of experimental results, to discover underlying natural regularities or laws hidden by irregular accidental disturbances or by large observational errors, and to suggest causes. He worked out an equation that would derive the most accurate estimated total population from an extremely small sample, and in doing so invented the concept of a statistically meaningful percentage.

Philippe Pinel

The idea of using numbers in this way to improve diagnostic or therapeutic efficacy rapidly spread to the hospitals, where the multitude of patients was a prime source of large amounts of data. The earliest attempt at analysis was by the young Philippe Pinel, a friend of Benjamin Franklin's. In 1792, he had become head of the Bicêtre, the hospice in Paris for the aged and infirm. It was the biggest asylum in Europe, with over 8000 patients, most of whom doctors thought to be beyond aid.

Pinel's view progress in medicine was slow, because physicians were applying inexact and untested methods. He advocated repeated observation of the sick, regular recordings of findings and comparison of data over time. This, he claimed, was the only way to arrive at the correct forms of therapy for many patients. While his methods were simple, producing little more than a proportional statement of success or failure, Pinel brought public attention to the problem. His decision to remove the shackles from his patients made him a household name among his fellow-professionals.

Pinel unshackles the insane at the Salpêtrière. A grateful patient kisses his hand. A worker is removing a restraining leather strap from the patient in the center.

Pierre Louis

In the early 1820s, Pierre Louis, the second head of the Paris medical school, adopted and extended Pinel’s methods. Over seven years Louis conducted no private practice at all, spending up to five hours a day in the hospital wards, gathering data on patients and then, after they died, correlating the course of their symptoms with postmortem evidence. The surgeons had already begun doing this, but Louis' use of statistical analysis enabled him to show that his predecessors had claimed therapeutic success based on inexact and inadequate data. Treatment and diagnosis could now be more accurate.

New Medical Advances in Pathological Anatomy in France

Joseph Leopold Auenbrugger and Jean-Nicolas Corvisart

Meanwhile, other advances were improving the collection of symptomatic data. The new concern with localized sites of disease aroused interest in the use of a technique originally developed by a Viennese doctor, Joseph Leopold Auenbrugger. In 1761, he had shown that tapping the chest produced sounds by which he could identify the position of the heart and the condition of the lungs. Jean-Nicolas Corvisart popularized the technique. Napoleon's doctor, he was a specialist in heart conditions and founder, in 1808, of the Paris School of Morbid Medicine.

Théophile-René-Hyacinthe Laennac

In 1816 another doctor, Théophile-René-Hyacinthe Laennac, discovered that a cylinder made of stiff paper would magnify the natural sounds made by the body. He had invented the stethoscope.

The early stethoscope in use. While the doctor's eyes are watchful, the patient is passively obedient, not comprehending the complexities of the new medical technology.

Because of these developments, examination of the patient became much more detailed. Laennac examined dissected corpses for evidence of a particular disease, and then he listened to the activity of the relevant organ in a living patient presenting symptoms of the same diseases. By correlating symptom with sound, he was able to identify emphysema, edema of the lungs, gangrene of the lungs, pneumonia, and, above all, tuberculosis, the mass killer of the age.

Laennac had succeeded in his aim of placing internal organic lesions on the same level as surgical diseases. The British reaction shows how far behind French hospital practice they were. “There is something even ludicrous,” they said in England, “in the picture of a grave physician formally listening through a long tube applied to the patient's thorax.”

New Medical Practice and the Patient

By the end of the first quarter of the nineteenth century, an entirely new view of disease and treatment had developed in Paris. Thanks to the success of the surgeons in localizing disease and through correlating living symptoms with postmortem evidence, pathological anatomy had become a scientific field of investigation. Symptoms were no longer the prime source of data, merely the surface condition provoked by the interior activity of disease, which affected tissue and organs, though not necessarily the entire body.

The new techniques of examination rendered irrelevant the patient's own view of his disease, as percussion and stethoscopic techniques gave the physician access to events inside the body of which the patient was usually unaware. The use of statistics made large-scale observation essential to collecting accurate data on disease and therapy. Because of all these advances, the relationship between doctor and patient changed radically, as did the social position of the medical profession itself. The sick patient was no longer the assessor of the doctor's competence.

As an increasing number of clinical techniques became generally accepted, it was the medical profession which became the arbiter of the individual doctor's performance. The most important relationship in the physician's life was now that with his fellow-professionals. Bedside secrets gave way to a wish among doctors to share techniques and information in return for recognition and advancement in their careers. In the 1820s a battery of medical journals appeared in Paris. These encouraged the division of medical labor, as the first specialists began to concentrate on the behavior of particular organs.

Doctors had redefined the body as the locus of disease. The bilateral evaluation between doctor and patient had gone. The doctor was now in control. The temptation to extend that control was seductive. Already, in the eighteenth century, the revolutionaries had been aware of the need to improve the living conditions of the urban masses. Jean-Jacques Rousseau, in his Discourse on the Origins of Inequality in mid-century, had characterized illness as a feature of civilized society, attributable to the harmful effects of unhealthy environment and incompetent medicine. Society, he suggested, was naturally pathogenic.

New Medical Practice and Large Populations

C. F. V. G. Prunelle

For the first time, the meaning of the term population, as the mercantilists used it, took on the added implication of “commonality,” the non-noble classes, the laboring poor who were too ignorant to be responsible for their own well-being. In 1818, C. F. V. G. Prunelle, lecturing in medicine at Montpellier, referred to the relationship between a healthy populace and a productive nation. Echoing Frank he promoted direct state intervention in housing, marriage, clothing, occupation, leisure, and so on, to ensure and maintain a healthy environment. Curative medicine should move out of the hospitals and take on a preventive role among the population at large.

Benoiston de Châteauneuf

While this wish to improve sewerage, water supply, ventilation, procreation, private conditions and the working environment appeared enlightened, it stemmed largely from the mercantile tendency to see welfare as a predominantly economic and political matter. In 1820, Benoiston de Châteauneuf wrote, “It is important for the happiness of all that man be under the sacred care of the physicians. . . . Who is better qualified ... than the physician who has made a profound study of his physical and moral nature?” Nine years later two simultaneous events were to help to bring this radical approach to public health and state intervention into common use throughout entire populations before the end of the nineteenth century.

The New, Radical Approach to Medicine Galvanized in the Nineteenth Century

Cholera

The first event was the arrival of a disease that had been traveling toward Europe from northern India at a speed of five miles a day for more than a decade. In 1829 it struck Europe for the first time and Austria, Poland, Germany and Sweden learned the full horror of cholera.

In 1817 a cholera epidemic broke out in the Ganges delta and spread inexorably towards Europe. The growing panic with which people awaited it was due to the unknown nature of the disease and its origin in the mysterious East.

Joseph Jackson Lister

The second event was the invention of the achromatic microscope in the same year by a London wine-merchant called Joseph Jackson Lister. From its appearance in the seventeenth century the microscope had suffered from two major problems. Rays of light coming through the outer area of the lens would bend asymmetrically and converge at different focal points, thus producing an image that was out of focus. As the prism bent the rays, the different colors making up white light would also bend to different extents, causing color fringes to make the fuzzy image even less clear. These effects are spherical and chromatic aberration.

Mathias Schleiden and G. R. Treviranus

Lister's improvement consisted of a plano-concave lens of flint glass joined with a convex lens of crown glass. The effect was to eliminate the aberrations and provide a clear image. The new achromatic microscope stimulated the obsessive German wish to discover the fundamental processes of life. In 1831, Mathias Schleiden first saw the cell nucleus. Others had already seen in plants these curious holes in tissue. In the late seventeenth century, Marcello Malpighi had described them as little “sacks.” Others had likened them to beer froth. In 1809, G. R. Treviranus had separated out the cells of a buttercup and revealed the partition between the cells to be a double wall. Cells, whatever their function, were separate entities.

Theodor Schwann

Not long after Schleiden had seen the nucleus at the center of the cell he discussed it with a colleague, Theodor Schwann. Schwann decided to examine every kind of tissue known to him. His microscopic and thorough research was to bring about a major change in the concept of the origin of disease. In his book, published in 1839, Schwann stated that all vegetable and animal tissue was essentially the same. “There is one universal principle of development for the elementary parts of organisms, however different,” he wrote, “and that principle is the formation of cells.” Interestingly, before he published, Schwann submitted the book to his local bishop in case the church subsequently might accuse him of heresy.

Schwann saw that cells grouped differently in different tissue. In blood or lymph, the cells were independent and isolated. In the epithelium, they were independent but in combination. In bone, intercellular substance welded them together. In tendon and elastic tissue, they were fibrous. Each cell had an independent life of its own and came into existence, Schwann theorized, either inside or near another cell, through a process of differentiation of common basic substance. Cells showed Schwann that life was not psychistic, the manifestation of some “idea,” but material.

J. E. Purkinje, Karl von Beer, and Robert Remak

In 1839, the same year, the Czech J. E. Purkinje found a jelly-like substance in animal ova and embryonic cells. He called it “protoplasm” or “substance permitting the manifestation of life. In this half-solid, half-liquid substance lay the elementary particles of the organism. Was this the locus of life itself? Scientists avidly studied the protoplasm. In 1846, Karl von Beer described the cleavage of a living sea urchin egg, and noted that, before division, the nucleus had already split into halves. In 1852, Robert Remak made the famous statement: 'Omnis cellula e cellula' (all cells come from other cells).

One of Purkinje's great microscopic discoveries: the neurons in the cerebellar cortex of the brain, known as Purkinje cells. They look like nests of fibers, top right.

Rudolf Virchow

The man who brought cell theory to its triumphant maturity was another German, Rudolf Virchow, who was to become known as “the Pope of German medicine” because of his extraordinary influence on the entire science. A radical in early life, Virchow took part in the German revolution of 1848. His work was to set the German medical community firmly on the road to experimental physiology.

An audience enjoys the effects of nitrous oxide, which the speaker has passed around in gas-filled bladders. Davy's lectures were more sober affairs, and became fashionable social occasions.

Virchow concentrated on the area of each cell and its nucleus. He showed that some cells were specialists, producing secretions, pigments, nails or lenses. Particularly specialized were the group of cells that made cartilage, bone, connecting tissue, blood vessels and muscle fiber. Virchow also examined cellular activity in phlebitis, leucocytosis, thrombosis, blood pigmentation, inflammation, tumors and eudation. Wherever he looked he became more and more convinced that disease was a phenomenon which attacked the cell and caused it to degrade, or behave differently, so as for example to produce pus.

“We can go no farther than the cell,” he said. “It is the final and constantly present link in the great chain of mutually subordinated structures comprising the human body.” Virchow offered a new view of illness and health, and their relationship, in an observation which altered the medical profession's view of every aspect of their work: “. . . the subjects of therapy are not diseases but conditions ... we are everywhere concerned only with changes in the conditions of life. Disease is nothing but life under altered conditions.” And in a bow towards his absolutist political masters, he added, “An organism is a society of living cells, a tiny well-ordered state.”

Ether and Humphry Davy and Anesthetics

A technical development furthered this progress toward investigating the deep structure of the body and away from involvement with the conscious patient. At the beginning of the nineteenth century, in an England industrially well-advanced, there had been much interest in “pneumatic chemistry,” and scientists had tried to discover the composition of air. During these investigations, conducted principally by Lavoisier and Priestley and included identifying gases given off when burning certain materials, they had isolated nitrous oxide. In 1798, an assistant at the Dr Thomas Beddoes Pneumatic Institute in Bristol breathed in the substance. His name was Humphry Davy, and when he later became a lecturer at the Royal Institute in London, he gave lectures on this strange “laughing gas.” Although Davy himself had remarked on its potential for medical application, people mainly used the gas at fairs and parties. The effects of the gas on those inhaling it gave such affairs the name of “ether frolics.”

Ether and Crawford Williamson Long and Anesthetics

The first recorded medical application was by an American called Crawford Williamson Long, likely himself an addict, as was his patient. Long was a general practitioner in Jefferson County, Georgia, and later claimed to have tried inhaling ether as early as 1842. It was he who discovered its anesthetic effect when he removed a tumor in the neck of a patient, who had breathed the ether.

Lavoisier’s experiments on air found out the life-giving properties of oxygen. Unfortunately, his tax-collecting activities cost him his own life during the French Revolution.

John Collins Warren and Robert Liston and Anesthetics

On October 16, 1846, John Collins Warren, a surgeon at the Massachusetts General Hospital in Boston performed the first publicly witnessed operation, when he too removed a tumor in the neck. The operation was a complete success. The news spread fast. In December of the same year one of Britain's leading surgeons, Robert Liston, of University College Hospital, amputated the leg of a butler called Fred Churchill by cutting through the thigh. For the first time in his career, he noted, he was able to take his time. When it was over he uttered the immortal words: “This Yankee dodge beats Mesmerism hollow!” A year later, doctors were also using chloroform as an anesthetic.

Major surgery was no longer a hideously painful experience during—or after—which the patient would most likely die of shock and in terrible pain. Besides, with his patients unconscious the surgeon could now try the previously unthinkable: he could open major body cavities such as the thorax and the abdomen. Such operations had until then invariably ended in death. Anesthetics had transformed medicine, though not altogether for the better.

More Medical Technology

Because doctors were now more readily inclined to operate, they were also more interested in discovering more about the body on which they could perform curative incisions. This stimulated the development of medical technology. Hypodermic needles had been available since 1840. In 1844, John Hutchinson adapted an idea of James Watt's for measuring vital capacity in the respiration of healthy adults. In 1848 came Karl Ludwig's kymograph, which traced pulse beats on a graph. From 1850, photography became increasingly available for recording clinical data. In 1855, Karl Vierordt produced a means of recording blood pressure through measurement of the weight needed to block a pulse at the wrist.

A contemporary illustration showing one of the first uses of anesthesia in Boston. The patient is breathing the gas through a tube attached to a flask containing liquid ether.

The technique most encouraged by the existence of anesthetic, however, was that of endoscopy. Chloroform or ether rendered painful incursions such as rectal examination much more bearable. In 1850, doctors developed the otoscope for internal examination of the ear. In 1851, Hermann von Helmholtz was studying the various efforts made to look inside the eye, including the work of Jan Purkinje, who had found that the retina reflected light. Helmholtz placed the source of light and the observer's eye at the same point in his new ophthalmoscope and thus made it possible to examine the interior of the living eye.

Czermak's laryngoscope in use. Note the candlelight reflected into the patient's throat by the mirror gripped in the doctor's teeth.

In 1855, a singing teacher in London used a double mirror to reflect sunlight down the throat. Two years later, in Vienna, the operatic centre of Europe, a Polish physiologist called Johann Czermak added an artificial light source, reflected from a mirror on the observer's head on to a hand mirror held in the patient's throat. With this new laryngoscope, doctors could carry out operations on the vocal chords. In the first one carried out on a member of the Austrian royal family, doctors successfully removed a small tumor with the aid of a wire loop.

As the decade progressed, doctors made advances for internal examination of the bladder, vagina, rectum, and stomach. The new watchword was: “Not seeing is not believing.”

A malignant tumor is removed in a Dublin doctor's drawing-room under primitive conditions. Typically, the patient died within a month of the operation.

Problem of Infection

The problem created by all these new aids to surgery was that as the number of operations increased so too did the death rate. The conditions under which surgeons worked and patients recuperated were usually more dangerous than the knife. In early mid-century, Florence Nightingale described what she had seen in hospital wards where sixty patients occupied a single room: “Floors . . . of ordinary wood ... saturated with organic matter ... walls of plaster ... saturated with impurity ... windows often closed for months, for heat. Walls streaming with moisture ... covered with ‘Minute vegetation’.”

Patients usually slept in the same sheets as those used by the previous occupant, on sodden mattresses, which nurses never changed. In 1851, Nightingale described the nurses as “whores brought in from the streets,” generally drunk, continuing to ply their trade in the hospital, and only giving patients medication when it occurred to them to do so.

The surgeons and doctors did little to help. Most of them walked the wards with handkerchiefs to their noses. There was little water for washing. Operating rooms were ill-lit and filthy. Surgeons wore their own “operating coat,” an ordinary outdoor coat, which often went blood-encrusted and unwashed for six months. Fires would burn in the corner of the operating room. Sawdust on the floor soaked up the blood as well as the mud from the shoes of the students who came straight to the operating room from the street. In these conditions, compound fractures had always been the surgeon's dread. They involved breaking the skin, with the consequent danger of infection. Blood poisoning, erysipelas, and hospital gangrene were the scourge of the wards. The standard phrase was: “A successful operation, though the patient died.”

Causes of Infection

There were two conflicting views of how infection spread. One was that the sick gave off an invisible gas, a miasma, which all filth gave off. The other, slow to gain ground before the advent of bacteriology, was that putrefied matter in contact with wounds would cause infection.

Ignaz Semmelweis

In the 1850s, Ignaz Semmelweis in Vienna had shown that students eager to correlate physical symptoms with conditions observed at post-mortems were returning to the wards from the dissecting rooms without washing, thus carrying infection to the living patients. Once Semmelweis had persuaded his students to wash their hands in chlorinated lime the mortality rates at his clinic dropped like a stone.

However, no one knew why the infection had occurred in the first place. In all hospital wards, broken skin usually led to death within two weeks. It seemed safest to remove the patient from the hospital as soon as possible after an operation.

Death Rates

There were various approaches to the problem of infection. The Germans favored fresh air. Doctors tried cold water bandages, with hot linseed poultices. They used continuous irrigation and even ice compresses. In mid-century, conditions were so bad that at University College Hospital, London, doctors thought a death rate of 25 percent was satisfactory.  This compared with rates of 39 percent in Glasgow, 43 percent in Edinburgh, and a staggering 59 percent in Paris.

Cholera

In 1829, events outside the hospitals made concern for the mechanism by which disease spread even more desperately urgent. That year, a new and unknown disease arrived in Europe. The symptoms were severe diarrhea for two or three days, gradually growing more intense, with extremely painful retching. The stricken victim experienced terrible thirst because of dehydration and loss of body fluid. There followed severe pains in the limbs, stomach and abdominal muscles. The color of the skin changed to bluish gray and the patient died soon after.

A poster circulated throughout London in November 1831, just before the arrival of cholera in the capital, describing the symptoms of the disease and its remedy. A note at the bottom claims prevention through “moderate and temperate living.”

Cholera’s Spread

This terrifying new plague, so different from the diseases to which Europe had become accustomed, reached Paris and took the lives of 7,000 people in eighteen days. Two years later it would be in New York. Meanwhile, it took its greatest toll on Britain, the most heavily industrialized nation in the world, whose crowded cities were the perfect incubator for the new pestilence.

Cholera in England

Cholera claimed its first English victim in Sunderland on October 20, 1831, arousing fears of riot and anarchy among the poorer members of the population. However, the plague was no respecter of persons: it hit rich and poor alike. During the first two years, it killed over 22,000 people in a spectacular and devastating attack on a country which was unprepared for it.

Squalid Living Conditions

Since the first years of the Industrial Revolution nearly a hundred years earlier, Britain's population had increased by 100,000 a year. Most of the extra people arrived or were born in the rapidly growing industrial cities of Glasgow, Manchester, Birmingham, Liverpool, and London. The rate of migration to the urban centers encouraged the hurried and slipshod building of dangerous, unhealthy, jerry-built dwellings for farm laborers, who had come from similarly primitive conditions in the countryside. Houses sprang up close to mills and factories to save time and travel. Here the builders crammed in as many tenements or back-to-back terraces as they could. In their haste, they dispensed with the need for foundations, and they commandeered skimpy local materials for self-supporting walls.

The new mid-nineteenth-century interest in the living conditions of the poor, shown by this rather too wholesome contemporary illustration of a London slum. Note the patched clothing on the line.

A street in Exeter, where people live in a lean-to shed among the pigs which they rear, and where there is no drainage.

Initially, builders planned the new dwellings on the village model, with one house, or sometimes half a house, per family. The rising tide of numbers soon altered these plans. As land near the canals or rivers ran out and the migrants poured in, sub-letting and taking in lodgers became common.

As the wealthy left for the newly growing suburbs, the poor crowded into the city centers. Many of the new tenements stood round a common “court,” an open space where stood the only well, often deep in undrained filth. The courts also housed herds of pigs living in their own dung. In the unpaved central area lay stagnant water, as well as waste and refuse thrown out of the windows for the pigs. People without accommodation lived in these open courtyards. In Liverpool, when cholera struck, no fewer than 60,000 people inhabited unprotected open spaces. Those who did so were only marginally worse off than the 40,000 who lived underground, sometimes twelve to a cellar, in conditions of unspeakable degradation.

A single common pump, available for one or two hours a day and usually not on Sundays, supplied water. People fought for it, even though as often as not it was filthy with waste from polluted rivers or sewers. By the time cholera first struck, every major river was dirty with effluent from mills and factories and untreated sewage. Originally, large towns had flat-bottomed brick sewers, designed only to handle excess water overflow in times of flood. People deposited human waste in dry privies and periodically carted it away. From 1750 on, however, with increasing use of the apparently healthier water closet, the waste found its way into the sewerage system in rapidly accelerating amounts. No sector of the city was immune. Even Belgravia stank.

Death at the local pump. Contaminated water was the prevalent source of cholera.

A Punch cartoon showing the urban poor in a typical courtyard. A woman picks for food in a rubbish heap where boys have found a dead rat.

In the courtyards standards of health were appalling, due to the already weakened state of those who lived there. Many families were chronically underfed. Damp conditions rendered them easy prey to rheumatics and diseases of the chest. Lack of space obliged many to use the same bed. Contagion and incest were rife. In the factories, working long hours in unsanitary conditions, breathing dirty, humid air among open machinery that often mutilated the user terribly, men, women and children were driven to exhaustion by the pace of the technology.

Bad Living and Working Conditions and Alcohol

Conditions in the mines were equally horrifying. As many as three thousand young girls hauled coal on their backs for twelve hours a day, in circumstances of brutality, debauchery and obscenity, often suffering harassment from the men who employed them. At the end of the working day there was little to do but fall exhausted into a filthy, crowded bed or on to the floor, to sleep until it was time to return to work. Workers received wages once a week and because of the lack of small coin in circulation they often received their pay from the cash funds of local pubs and inns, whose proprietors agreed to the arrangement, because of the tendency among the wage-earners to spend most of their money on drink. Even if the poor had wanted to spend their brief free time in other pursuits, there was little opportunity to do so. With no clubs or organized sport, drink was the only pastime for the illiterate, urban masses. They spent most of their income on alcohol and funeral insurance.

Early Preparations for Cholera

In the autumn of 1831, when cholera struck England, the country had already made hasty and inadequate preparations as the disease slowly moved toward the country. On June 21, 1831, the government set up a Board of Health. It represented the first attempt to influence public health by local government action. There was to be a local board in every town or village, and each town would split into districts. The government set up special houses for the isolating victims, although as it turned out quarantine would fail to stop the spread of the disease. Workers were to clean infected houses by washing or scouring with lime, their windows and doors left open for many weeks after infection. The government could forcibly remove victims to isolation houses.

Inadequate Preparations

These preparations proved hopelessly inadequate. Apart from not understanding the disease itself, the principal fault lay with the local authorities whom the government had empowered to take sanitary measures to defend their communities. Local Improvement Commissioners had been around since the middle of the eighteenth century, but overlapping areas of responsibility and vested interests made reform impossible. So too did the corruption endemic to urban society at the time. For example, the man responsible for street cleansing in New York early in the nineteenth century had a million dollar fund to spend as bribe money. The major problem was that the public authorities had failed to appreciate the scale and speed with which industrialization and the move to the towns had occurred. Greedy developers with vested interests, seizing the opportunity for factory expansion, added to the chaos.

Girls and women, cheaper to employ than pit-ponies, carry coal in the mines.

The nation-wide English riots of 1831, brought on by appalling living conditions, undemocratic political institutions and cholera. Though force was used to quell them, they brought about parliamentary reform within four years.

Reform?

During and after the cholera epidemic of 1831, widespread riots throughout Britain woke the country to the urgent need for social change. The following year reform of Parliament was voted for in a tangible atmosphere of fear. The middle classes could see “anarchical, Socialist, and infidel forces” at work in their own streets. However, they failed to see the connection with the inevitable effects of industrialization. Apart from concern over conditions of child labor, the general feeling was that industry brought benefit to all. The fault, most believed, lay in the nature and character of the lower classes and in their environment of ignorance and degradation. New committees established together with the reform of Parliament turned, for recourse, to the same source of help and guidance as had the medical profession in Paris twenty years before. They turned to statistics.

Cholera and Statistics

The science of statistics studied the actual condition of the population. Statistics seemed to offer a way of controlling the disordered masses, in danger of riot and confusion. In spite of pious utterances about “preventing misfortune and vice, sickness and improvidence,” the aim was now, as it had previously been that of the French, to find effective measures of social control. The government had to isolate infected minds if the revolutionary contagion was not to spread. Moreover, because medicine could offer little assistance against cholera, numbers would at least show the exact extent of the situation. Commissions produced reports.

William Chadwick

The most wide-ranging analysis was prepared by William Chadwick, who had been secretary to the great reformer Jeremy Bentham. After the riots of 1834, the Poor Law Commissioners asked Chadwick to examine the need for legislative reform. Chadwick began by alienating the poor with a new organization, known as the Union, which brought together all facilities provided by the local authorities into a central, combined workhouse, asylum, and orphanage. Although the new Union gave too much power to the hated masters and matrons of the institutions, it provided a more easily managed structure.

William Farr

In 1836, the General Register Office was established to collect data, compulsorily provided, on births, marriages and deaths, which would go to Parliament in an annual abstract. The Controller of these abstracts was William Farr, the statistician son of a poor Shropshire farmer, who had studied at the Paris medical school. Farr was to bring his considerable faith in numbers to the aid of the reformers and leave an indelible mark on modern Western life. “There is a certain relation,” he said, “between the value of life and the care bestowed on its preservation.” Like many of his Newtonian contemporaries, Farr looked for “laws” that governed life. He was convinced that, just as planets and chemical reactions obeyed ineluctable laws, so life and death also followed regular patterns. His experience in compiling actuarial tables for insurance companies led him to note that there appeared to be numerical continuity in the age of death under given conditions from one generation to another. “Observation proves that generations succeed each other, develop their energies, are afflicted with sickness, and waste in the procession of their life, according to fixed laws; that the mortality and sickness . . . are constant in the same circumstances . . . varying as the causes favorable or unfavorable to health preponderate.”

A workhouse in London. Children mixed with criminals, destitute mothers with prostitutes, old people with violent drunkards. Many preferred the alternative of starvation to life in such an institution.

A sanitary map of Leeds, from Chadwick's report, showing (dark) the houses of 'the working class' as well as those (light) of 'the first class'. Population figures are included, as are birth and death rates.

It was this regularity in life which gave statistics their power. To discover the laws of life would be to discover the power of social manipulation for the common good. Farr studied the national birth rates, fertility rates and death rates to see whether diseases affected the population in particular localities, when they were endemic and when they extended over entire countries as epidemics, and whether they spread through contagion or arose sporadically through existing causes which had been exacerbated by, for instance, weather or famine.

The Sanitary Conditions of the Laboring Population of Great Britain

While Farr prepared his tables, Chadwick conducted the first major inquiry into the environmental circumstances in which Farr would find his diseases at work. Chadwick's report, “The Sanitary Conditions of the Laboring Population of Great Britain,” was published in 1842 and shocked the complacent middle-class British to the core. Based on data from 553 districts throughout the country, it showed conditions to be worse than anyone had imagined. Street by street, town by town, with the aid of description, statistics, illustrations, and maps, it revealed the incredible extent of disease, infection, child deaths, widowhood, and orphanhood.

Data from Farr's life tables. This column shows that, in a healthy district, of nearly two and a half million newborn (the first number) only a quarter (the last number) have survived to the age of forty-nine.

The report proved beyond doubt that bad sanitation, polluted water supplies, and filth shortened life-expectancy by at least a decade; that thousands of children were on the streets, begging or living as prostitutes; that the country was on the way to revolution. The average age of death among the gentry was forty-three. Tradesmen died at thirty and laborers could not expect to live beyond twenty-two. For every person dying of old age or violence, eight died from disease. In a typical industrial town like Manchester three times as many children under five died than they did in Surrey, where the population of that age group was approximately the same. Farr noted: “In Liverpool the death of children is so frequent and dreadful that a special system of insurance has been devised to provide ... coffins and burial ceremonies. The mother, when she looks at the baby, is asked to think of its death, and to provide by insurance not for its clothes but for its shroud.”

Thomas Edmonds and the Biometer

Farr offered the sanitarians a scientific tool with which to attack the problem. He called it a “biometer.” It was, in fact, a life-table of the type developed by actuaries to construct levels of premiums on insurance policies. Thomas Edmonds, later actuary to the new Legal and General Assurance Society, developed the idea in 1825. He showed that the rate of mortality changed regularly through life in three stages. From the age of six weeks to nine years, it dropped at 32.4 per cent a year; from then until the age of fifteen it remained at a constant minimum; from sixteen to sixty it rose at 2.99 per cent a year; and from then until death it rose at 7.99 per cent a year. Edmonds developed a theoretical table, based on these “laws” which compared closely with actual surveys taken in the towns. He also showed that the line of “highest mortality” ran from Brighton to Liverpool. The further away from it the safer one was.

William Farr and the English Life-Tables

Farr improved on Edmonds's work. He produced the “English Life-Tables,” in which arranged the data in seven categories: years of life; number reaching that age; number dead at that age; and the various conclusions to be drawn from the previous three sets of figures, such as rate of death and expectancy of life at all ages. By setting these tables alongside the figures for what he called a “healthy district,” Farr provided the medical profession with a health profile for society at large. His definition of a healthy district was one in which seventeen deaths occurred per thousand; more than this would be “due to preventable causes.” Farr showed that in a “normal community” there was an “indissoluble connection” between the numbers living, the mean life-expectancy, births, deaths and the rate of mortality. If numbers in any area varied from this, “preventable causes” were at work. Doctors should know where and when to strike.

William Farr’s Statistics in Practice

The problem was that they had no means of doing so. Even when Farr's figures showed an interesting anomaly, no one could act. He analyzed where cholera had struck most severely, noting that it respected neither class nor quarantine. Nor did he find any correlation with factors such as living by the sea, wealth, location, or occupation. But when Farr looked at where cholera victims lived in relation to the Thames he saw something strange. There was an arithmetically decreasing incidence of cholera relative to the height above the river at which the victims lived. Farr believed that the stink from the river was somehow causing the cholera.

Mid-nineteenth-century water cures. Walking barefoot in wet grass or snow became a fashionable social pastime and was also a cure for toothache.

Vincent Pressnitz and the Water Cure at Grafenberg

Oddly enough, the panic-stricken upper classes had already turned to water as a possible cure. Earlier in the century a Silesian farmer called Vincent Pressnitz had invented the idea of a “water university,” sited high in the Bohemian mountains at Grafenberg, now Jesenik, in Czechoslovakia. His principle of health was that because animals stayed healthy by going to water the same should apply to people. A contemporary reference to called him “a man whose discovery has done more to ameliorate, both physically and morally, the condition of mankind, perhaps more than any other made since the dawn of Christianity.”

By 1839 Pressnitz numbered among his clients a monarch, a duke, 22 princes and princesses, 149 counts and countesses, 80 barons and baronesses, 14 generals, 535 staff officers, and other lesser hypochondriac fry. The Grafenberg course of treatment was uncomfortable, including “the wet sheet,” “the sweating blanket,” “'the plunge bath,” “the sitz bath,” “the falling and rising douche,” and the “head bath.” One day's treatment would include all versions of the therapy and always involved cold water. Patients also drank large quantities of water during the treatment: eight to ten glasses before breakfast. In one case, a lady drank twenty-one pints in a morning, developed numbness in the feet, and became unconscious.

Cramped and spartan accommodations ruled at Grafenberg. The rules forbade reading, smoking, gambling, and, because many of the patients were syphilitic, immoral activity. In the food hall, more than five hundred patients ate appalling meals to martial music.  The smell of cows in the rooms below mingled with the fresh air howling in through the open windows. Because the aim of the treatment was to cause a “bodily crisis,” which would force the poisons out of the body, when boils and diarrhea occurred–and they did so frequently–patients welcomed them as signs of recovery.

James Wilson and James Gully and the Malvern Water Cure

Inevitably, the idea of the water cure spread. By 1842, there were fifty establishments in Germany. Two English doctors came to Grafenberg in search of a cure. One of them, James Wilson, was constipated and had “no calves.” The other, James Gully, edited a medical journal. Wilson reported later that during his course he had taken 500 cold baths, 2400 sitz baths, and 3500 glasses of water. The treatment convinced both men. On their return to England, they leased the Crown Hotel, in Malvern, a spot already renowned for its wells and drinking water.

More Grafenbergs in Great Britain

By 1850 the Malvern water cure was the rage of English society, attracting such notables as Dickens, Florence Nightingale, Tennyson, and Carlyle. An anonymous author wrote a book about the place, entitled Three Weeks in Wet Sheets. The fashion spread to the “Northern Grafenberg,” in Otley, Yorkshire, where there was also a compressed-air bath. Soon there were “Grafenbergs” in Matlock, Derbyshire, in various parts of Scotland, and, fittingly enough, in Blarney, Ireland.

Being Sick Becomes a Sin

While the cure was of doubtful efficacy, it shows the changing view of disease among Victorian Europeans faced with an epidemic on the scale of cholera. Society became hypochondriac. Concern for health and fitness verged on the paranoiac. Sickness took on a new significance in the strict God-fearing society of the time. To be ill was sinful. One of the great Victorian philosophers, Herbert Spencer, said: “Perhaps nothing will so much hasten the time when body and mind will be adequately cared for as a diffusion of the belief that the preservation of health is a duty. The fact is that all breaches of the law of health are physical sins.”

A new gymnasium in Liverpool, 1865, where men practiced almost all modern forms of gymnastics. Note that though ladies are present, they do not indulge in exercise.

New Interest in Sports

The surge of interest in physical fitness that followed the cholera epidemic found expression in sport, ordinarily associated only with hunting, shooting, and fishing. Games had previously been pastimes for children. Cholera changed all that.

In 1855, the Boy's Own Book listed archery, gymnastics, fencing, driving, and riding as valuable therapeutic activities. Twenty-five years later, the publication included football, hockey, baseball, golf, shinty, croquet, lawn billiards, rackets, fives, tennis, pallone, lawn tennis, badminton, lacrosse, bowls, broadsword, singlestick, bicycling, dumbbells, Indian clubs, wrestling, and boxing. Trollope's British Sports and Pastimes of 1868 added horse racing, rowing, yachting, Alpine climbing, and, above all, cricket.

The health-conscious Victorians invented athletics. The first organized meeting was at the Woolwich Arsenal in 1849; the first inter-university games took place in 1864. In 1854, Alfred Wills captured the public imagination by climbing the Wetterhorn. In 1859, the term “calisthenics” came into use.  It meant, “beautiful strength.”

The institutionalization of sport made it seem a worthier activity. Victorians associated it with Christian virtues and ethics and began using phrases as “fair play,” “It's not cricket,” and “Play the game.” Exercise, practiced beyond exhaustion, was a test of moral strength. The virtues expressed in sport made it all the more admirable.

John Snow More Evidence that Water Carried Cholera

In 1853, a doctor called John Snow, who had worked during a cholera epidemic at the Killingworth colliery in Northumberland, began to suspect that people transmitted cholera on hands, which had shared food after contamination by diarrhea or vomit. Snow's suspicions received confirmation in 1854, when a London well, sited in Golden Square, which had always produced clean water, suddenly killed six hundred local inhabitants. Snow found that a cesspit was overflowing into the well. When authorities sealed the pit and filtered the water, the problem disappeared.

Desperate and unsuccessful measures to prevent the spread of cholera. Burning the clothes of plague victims in Exeter, 1832.

John Simon

Two years later, the Medical Officer for London, John Simon, ran tests in nine London parishes which showed that in Lambeth, where workers used sand filters the water supply system, death rates had dropped dramatically.  Simon convinced everyone to support public health measures, and he introduced a series of reforms, including expanding the hospital system.  Parliament passed many relevant acts. Notable among these was the provision for the first ever rights of entry to private property without permission by state officials, who needed to establish the existence of sanitary conditions.

People burned barrels of pitch and tar in the street, hoping that the fumes would have a cleansing effect.

Lambeth Water Company

Snow's hunch received confirmation in 1855. Only one water company had not obeyed the recent legislation aimed at preventing suppliers from lifting their water from the Thames in the urban stretch where pollution was worse. The company supplied an area of south London, street for street, with another company which had obeyed the law. On the side of the streets supplied by the tainted water ten times more people died of cholera than on the other side.

London Sewerage System

By the summer of 1858, the Thames smelled so bad that members suspended all work at the Houses of Parliament. Members of Parliament finally acted and hurriedly passed to renew and develop the entire London sewerage system. When finished, all London sewage went to outfalls in the river, eleven miles downstream from the city at a point where tidal flow would take it out to sea. The cholera never returned. The sanitarians were jubilant, and science was still ignorant of the cause of the epidemic.

Building London's sewers, 1859. In all, workers used 318 million bricks to build 1300 miles of sewers, which carried 420 million gallons of effluent a day.

Louis Pasteur

A professor at the University of Lille in 1857 strengthened the contagionist argument. The professor, Louis Pasteur, was examining fermentation in milk and wines to find out what caused them to go sour. He showed that each liquid needed a specific fermentation agent. He saw that the agent was alive, self-replicating, and that it needed warmth and air to thrive. Sealed off from air, subjected to excessive heat, the liquid stopped fermenting. Reproduction obviously depended on the presence of air, or an airborne agent. Pasteur announced the discovery of “airborne germs.” Was there also a microscopic airborne agent at work, spreading epidemic in the hospitals and communities of Europe? In 1864, Pasteur announced that he had preserved a sealed glass of boiled milk for several years without fermentation, because he had kept it from “the germs which float in the air.”

Joseph Lister

The following year the Professor of Chemistry at Glasgow remarked on the new “germ” theory to his surgical colleague, Joseph Lister, who immediately applied it to his work in the operating theater. Lister was the son of the Joseph Jackson Lister who had developed the achromatic microscope thirty years before. Joseph Lister had noticed during an epidemic in cattle at Carlisle that when worker added carbolic to the town sewage, the cows recovered. Was the carbolic killing germs?

Above: An 1850 cartoon of a microscopic view of a drop of London drinking water. Even though doctors did not know water was the source of cholera, its filthy state caused serious concern.

Following Pasteur's lead, Lister tried cleaning wounds after surgery by applying carbolic-soaked lint dressings, covered with thin tin sheet to exclude the air. Of a set of eleven test cases involving compound fractures (the most dangerous kind), only two contracted hospital infection. Lister next treated the general hospital environment with a hand-operated carbolic spray. Surgeons began to work enveloped in a fine carbolic mist. Before an operation began, Lister's students would say, “Let us spray.” The technique revolutionized surgery and medicine in general.

As one of Lister's German disciples wrote:

Mankind looks grateful now on thee,

For what thou did'st in surgery,

And death must often go amiss

By smelling antiseptic bliss.

The obvious success of carbolic sterilization brought medicine closer to the microscopic world of the laboratory and further from the treatment of the patient as an involved individual. The sick person had no personal control over his condition, because doctors directed all efforts toward identifying microscopic organisms.

The new antiseptic, surgical techniques, illustrated in 1882. Note that for all the care in positioning the spray so doctors made the incisions within the vapor, the doctors still wear outdoor clothes.

Organic Analysis

By this time, scientists were applying earlier advances in inorganic chemistry in organic analysis. They had microscopically examined most biological tissue and fluids–blood, urine, milk, gastric juices, bile, saliva, tears, sweat, nasal mucus, pus, synovial fluid, and semen. Scientists proved especially adept in analyzing blood and urine.

Gabriel Andral

In 1843, Gabriel Andral in Paris had led the field with his analysis of blood. He examined it for visible, microscopic and chemical characteristics. He established the proportions of “globules, fibrous material, solids, and water” in sick and healthy patients, and he averaged out the data using statistical techniques. He also found out the relationship between different diseases and blood conditions and developed a numerical portrait of blood behavior.

Alfred Becquerel and Hermann Fehling

Andral's contemporary, Alfred Becquerel, approached urine in the same way. By 1860, he had identified thirty-four constituents of urine. There were also twelve separate tests for the presence of glucose. Then Hermann Fehling produced a reagent which would show the presence of diabetes.

Robert Koch

This last development represented a major advance in the chemical analysis of the body by using marker agents. It was to achieve worldwide recognition through the activity of a German general practitioner working on the problems of anthrax in animals in Prussia. His name was Robert Koch, and in 1876 he cultured the anthrax bacillus and concluded that the bacillus produced spores in animal tissues. These spores needed only warmth and oxygen to reproduce bacilli, even when left in the ground for long periods after diseased animals had deposited them there.

Koch was able to produce anthrax from infected soil and show conclusively that specific bacilli caused specific disease. He was successful, because of his technique for producing pure cultures of the bacillus in large enough numbers for identification and treatment. He had changed from the traditional method of growing cultures in broth. Now he produced a solid culture of gelatin and nutrient, on which he laid the bacteria with a sterilized platinum needle. The cultures grew on the medium in groups sufficiently isolated to be free of contamination. In this way, they responded better to new staining techniques, developed as the result of an accident suffered by Koch's colleague Paul Ehrlich. In 1882, he had left a culture overnight on a warm stove in contact with some of the newly invented aniline, artificial dye. Next morning, he discovered that the dye had selectively stained certain bacteria.

In the same year, Koch and Pasteur announced the result of their