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  1. Medicine, Disease and Society in Britain, 1750 - 1950 Medical Science in the Nineteenth Century Lecture 13

  2. Lecture themes/outline • New ‘developments’ • The rise of surgery and medical science (new ideas about disease and the body) • The rise of the modern hospital • Increase in status of ‘modern medicine’ • Social and Cultural History of Medicine • The importance of social and cultural context in the reception and adoption of innovation • The complex relationship between new theories of disease and the development of effective therapies. • Effect on the patient/ practitioner relationship

  3. Important Questions • What impact does science have on medicine? • How swiftly and to what extent is change accepted? • Does science change medical practice in general? • How does it change the image of the medical profession? • How does it influence the public understanding of medicine? i.e. How does science filter down? • Did it impact on the general practitioner or was it restricted to hospital medicine? • Did it lead to a separation of ideas between lay people and medical men on illness?

  4. Definition of Science from the Latin scientia, meaning "knowledge" An enterprise that builds and organizes knowledge in the form of testable explanations and predictions about the world

  5. Theophile Hyacinthe Laennec (1781-1826)

  6. Christopher Lawrence: • Even the simplest surgical practices employ a theory of the body and of disease. • Extracting a tooth ‘implies a theory of the local origin of pain and the relative harmlessness of removing a body part’. Christopher Lawrence (ed.), Medical Theory, Surgical Practice: Studies in the History of Surgery (London: Routledge, 1992).

  7. Thomas Schlich: • Resective surgery demonstrates how surgery and medicine interacted. • Medicine adopted a localistic approach from surgery and developed a new understanding of disease as pathological change of tissues and cells. • By including the surgical point of view in medical education, physicians gained a new and productive approach to disease. • Learning medicine helped surgeons to see the body in a way that made surgery on the body’s interior possible. Thomas Schlich, ‘The Emergence of Modern Surgery’ in Deborah Brunton (ed.), Medicine Transformed: Health, Disease and Society in Europe 1800-1930 (Manchester: Manchester University Press, 2004).

  8. An early operation under anaesthesia, c. 1847.

  9. Martin Pernick: • Sudden increase in the number of operations at the Massachusetts General Hospital. • The growth in the number of operations was greatest among those groups who were most likely to receive anaesthetics. • Anaesthesia thus brought about a sort of levelling up, where the groups of patients previously thought too weak or too sensitive to stand surgery could be operated on. • Anaesthesia allowed surgeons to perform different types of operation. • Mortality rates from surgery did not increase with the arrival of anaesthetics. The greater numbers of victims of serious accidents – receiving surgery as a last resort – helped to push up the number of deaths. Martin Pernick, A Calculus of Suffering: Pain, Professionalism and Anaesthesia in Nineteenth-Century America (New York: Columbia University Press, 2004).

  10. Antisepsis: Destruction of disease-causing microorganisms to prevent infection. • Asepsis: Prevention of contamination with infectious agents.

  11. Igniz Semmelweis, (1818-1865)

  12. The use of the Lister carbolic acid spray

  13. Opposition to Carbolic Spray • Difficult to carry out procedure - complicated • Relied on germ theory that many still resisted- based on ‘too much’ science - significant that it was adopted by the Germans. • Threatened old surgery- would open up new procedures- threatened status and incomes of guard. • More immediately, the spray smelt vile and could irritate skin • Hospital politics- where medical men made the decisions – and this would bring surgeons greater autonomy. • Some management committees got cold feet due to deaths.

  14. Photograph of operating theatre, 1904.

  15. Abdominal surgery to remove diseased ovarian tissue (ovariotomy). Surgeon and anesthesiologist in street clothes. From Thomas Spencer Wells, Diseases of the Ovaries, 1872.

  16. The Germ Theory of Disease • Louis Pasteur • Micro organisms enter the body in a number of ways. • Specific diseases are caused by specific micro-organisms. • Natural immunity is an inherited resistance to infection. • Justus von Liebig • The body as a chemical system, measure what comes in and goes out • Rudolph Virchow • Disease arises due to abnormal changes in cells

  17. Claude Bernard, An Introduction to the Study of Experimental Medicine (trans. H.C. Greene) (New Work: Dover publications, 1957; first edn 1865), pp. 145-9: ‘The laboratory is the real nursery of true experimental scientists, i.e., those who create the science that others afterward popularize…[I]t is to-day everywhere recognized that pure science germinates and develops in laboratories, to spread out later and cover the world with useful applications. We must, therefore, first of all attend to the scientific source, since applied science necessarily proceeds from pure science…Only laboratories can teach the difficulties of science to those who frequent them; they show that pure science has always been the source of all the riches acquired by man and of all his real conquests over the phenomena of nature.’

  18. Koch’s postulates: • The organism suspected of causing a particular disease could be discovered in every instance of the disease. • When extracted from the body, the germ could be grown in the laboratory and maintained for several generations. • When this culture was injected into animals, it should induce the same disease observed in the original source. • The organism could then be retrieved from the experimental animal and cultured again.

  19. Chemistry laboratory, Glasgow University, 1864. A very early photograph of a chemistry laboratory.

  20. Ronald Ross, Charles Sherrington and Robert Boyce in a laboratory at the Liverpool School of Tropical Medicine, 1899.

  21. The Pasteur Institute, Paris, 1888. The institute was built in Paris in 1888 both to honour the work of Louis Pasteur and to provide a base for his further research.

  22. Research in Britain • The Lister Institute of Preventive Medicine was an independent, non-profit-making organisation established in 1893. • 1893-1914 the only institute of its kind in Britain, ranking internationally with the Pasteur Institute in Paris and the Rockefeller Institute in New York. Focus on microbiology (bacteriology and virology). • Worldwide renown working on smallpox, typhoid and diphtheria in the 19th century; cancer, rheumatism and nutritional disorders in the 20th century. Invaluable work was done on viruses and genes, on blood and disinfection, vitamins and nutrition. • 1914 National Institute for Medical Research Set up • Almroth Wright at St Mary’s London- work on vaccines

  23. The Anti-Vivisection and Humanitarian Review vol 9 (1930) no 1.

  24. Dr Robert Knox (1791-1862)

  25. Broadside regarding the Burke and Hare trials (1829).

  26. Michel Foucault (1926-1984).

  27. Foucault: • The Paris hospitals saw the emergence of the ‘clinician’s gaze’ – a way of looking at the patient and ‘seeing’ disease which no longer dealt with environment or lifestyle, but focused on the organic changes occurring in the spaces within the body. • This new way of seeing and thinking turned the body into an object that could be understood by scientific knowledge, and the foundation for the emergence of the human sciences. • As practitioners developed a new discourse of disease, they acquired a new power within the clinical relationship. The patient became teaching material to be probed and examined during life and a ‘commodity’ to be dissected after death. • In return for free medical assistance, the poor made their bodies available to the medical gaze.

  28. Mary Fissell, ‘The disappearance of the patient’s narrative’ ‘The third Day after the Wether happened to be very warm he changed his Thick waistcot for a Linning one and being careless sat a quarter day in a Room that was wett the same evening he found himself not well and a little Feverish & thirsty for which he Went to Bed and Drank Plentifull of Sack Whey. The Next Morning he was very horse and out of order’ (1744) ‘His appearance was florid, his complexion clear. He complained of a light headache and a sore throat. His pulse was full and rather frequent, the tongue white, the tonsils slightly inflamed, the parotid glands were very much enlarged, the bowels were confined, and there was a little oppression about the chest’. (1816)

  29. Nicholas Jewson: • Jewson concerned with what he calls ‘the disappearance of the sick-man’ from medical cosmology in the period 1770-1870. • Shift from ‘bedside medicine’ to ‘hospital medicine’ to ‘laboratory medicine’. • Bedside Medicine- marketplace • Hospital Medicine- Paris • ‘Laboratory medicine’- Germany • By ‘medical cosmology’ Jewson means knowledge, practice, practitioners and patients. Nicholas Jewson, ‘The disappearance of the sick-man from medical cosmology, 1770-1870’, Sociology, (1976) 10; 225-44.

  30. Nicholas Jewson, ‘The disappearance of the sick-man from medical cosmology, 1770-1870’, Sociology, (1976) 10; 225-44. Bedside Medicine: Early modern marketplace- competition Paying patient had a voice in the medical encounter Common language and concepts of health and illness Patient an individual Holistic approach- disease affected the whole organism Hospital Medicine: Post Revolution French hospitals- Paris Development of the construct of ‘the patient’ – ‘the clinical gaze’ Clinicians hold the power The patient became an object Disease located in specific organs Laboratory medicine: Late C19 German universities and research institutes Scientists hold the power Disease is located in cells

  31. Conclusion • Slow uptake of theories and associated practices • Germ theory • Antisepsis and Asepsis – Semmelweis and Lister • Why? Numerous factors including: moral grounds (anaesthetics in childbirth, vivisection), challenge to existing medical authority, ‘the way things are done’ • For more on this see, A. J. Young, The Scientific Revolution in Victorian Medicine, and John Pickstone, Medical Innovation in Historical Perspective - diffusion, fitting in with social and cultural context • Nonetheless, bedside medicine had become more ‘scientific’ – measurement devices