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Topic 6 – Disease and the 19th Century.
Introduction.
The 19th century was the period of European dominance of the world: politically, militarily, economically, and scientifically with imperialism and the scramble for colonies a European phenomenon. The world witnessed the results of the time of the twin revolutions in Europe the French Revolution and the Industrial Revolution and their impact including nationalism, liberalism, conservatism, and urbanization. Europe would also witness a population takeoff that along with urbanization would result in a health crisis in European cities.
Epidemic disease would continue to play a role in history as these diseases would continue to dog armies from the Napoleonic wars to the Crimean war as well as such major endeavors as the building of the Panama Canal (yellow fever).
The 19th century was also a time when the discovery of the true cause of epidemic disease came into focus with the germ theory while advancements in medicine made the discipline more and more effective in fighting illness and disease, especially coupled with the sanitation movement in cities and the birth of the public health movement.
Napoleon and Disease.
The French Revolution began a period of warfare lasting from 1792 to 1815 including the dictatorship of Napoleon Bonaparte who controlled the destiny of Europe from the beginning of the 19th century to 1814. He involved France in a series of wars which once again raised the specter of yellow fever in the New World and typhus in the old while he himself was dogged with illnesses that played a part in his eventual defeat.
Yellow Fever and the Failure of French Expansion in the New World.
During a lull in fighting after 1801 Napoleon had dispatched a large army of 33,000 men to Haiti to suppress a rebellion there and then continue on to the Louisiana territory in North America. Toussaint LOuverture, an educated slave in Haiti, hearing about the French Revolution of 1789 and its motto of “Liberty, Equality, and Brotherhood,” started a slave rebellion in 1791 and was achieving great success. While this was going on Napoleon had his eyes on the New World and especially the Louisiana territory that Spain ceded to France by 1801. His intention was to move an army into that territory that would have effectively cut off the new United States but first he decided to crush the rebellion in Haiti. Thanks to the resistance of Haitian slaves and yellow fever that broke out among French troops, the effective number of soldiers was reduced to 3000 and Napoleon had to give up his plan to move them into the Louisiana territory. When President Jefferson sent emissaries to Paris to negotiate a commercial treaty for the use of the Mississippi River, to their surprise, Napoleon made an offer to sell the Louisiana territory for pennies an acre. The result was the Louisiana Purchase of 1803 doubling the size of the young United States. 2003 was the Bicentennial of the Louisiana Purchase and was celebrated in the states coming out of that territory. From my way of thinking each one of those states should have built two statues: one dedicated to Toussaint LOuverture and the other to the yellow fever mosquito.
Typhus Fever and Napoleon’s Campaign into Russia.
After a series of successful land battles Napoleon controlled most of Europe with the exception of Britain who was saved by their Navy. Napoleon then tried to use economic warfare by creating a continental system in which trade with Britain would be cut off with the European continent. This hurt European nations more than it did Great Britain and Russia decided to pull out. In response Napoleon prepared to invade Russia with a grand army of 650,000 men in 1812. Napoleon was militarily successful and reached Moscow in 1812 but took too many losses mostly to typhus, dysentery, and the Russian winter. He was forced to retreat and returned to France with only 40,000 men left.
Napoleons final defeat occurred in 1815 at Waterloo. This was a close battle but the French lost, in large part to the inability of Napoleon himself to lead his troops. Because of various personal illnesses he could not be at the front with his men. This brings up one of the basic questions in history the role of great men in making history.
Population Increase, the Industrial Revolution, Urbanization, and Disease in the 19th Century.
Probably the most cataclysmic event in the 19th century was the Industrial Revolution, first starting in England and spreading to the rest of Western Europe in the first half of the 19th century, and finally to America in the second half of the 19th century. At the same time Europe witnessed a major population increase starting in 1750 with the result that Europe would become the dominant power in the world. The Industrial Revolution and population increase brought on urbanization and then an immediate health crisis in European cities due to overcrowding and the lack of fresh water and sewage. To a large extent industrialization caused urbanization as former peasants left the land and moved to city factories for employment.
It should be mentioned that the population takeoff actually preceded the Industrial Revolution but why did it occur at this time and place? Lets’ say we are demographers who study population and have to study those factors that add or subtract from population growth. There are three factors that we have to look at: birth rate, death or mortality rate, and immigration/emigration (people moving in or moving out of a region or territory). Birth rates and mortality rates are usually figured by the number of live babies and deaths for every thousand people in a year. To make a long story short, the reason for the takeoff of Europes population is not an increase in the birth rate, it actually dropped during the 19th century, and not because of immigration because Europe lost some 30 million people to emigration, but because of a drop in the death rate or mortality rate.
The next question is why did the mortality rate drop? We have to look at things that kill people and these are: disease, famine, and war. There were improvements in all three of these factors. For example, there was no major war fought on the European mainland between 1815 and 1914. Famine disappeared from Europe by the middle of the 18th century, though there were some specific exceptions such as the Irish potato famine in the 1840s. Because of improving diets, especially with additional crops from the Western Hemisphere including maize and the potato, lives cut short by lack of food stopped. Disease continue to be a major killer of people especially with the introduction of a new disease, cholera, that came in half a dozen waves from India, and the spread of tuberculosis which continues to take a high total of people in overcrowded cities.
Mortality from disease also was dropping because of better diets, disease experience, advances in medicine, and the growth of public health systems making cities cleaner and safer. The result of improvement in those factors causing death rates to drop was a doubling of life expectancy in many parts of Europe. For example life expectancy in France went from 25 in 1750 to 50 in 1900 and the death rate dropped almost everywhere in Western Europe.
The Industrial Revolution.
One of the pivotal events in European and world history was the Industrial Revolution. I will provide a definition of this revolution, why it occurred in Europe first and its impact especially upon the health and well-being of Europeans. According to David Landes, an important economic historian, the Industrial Revolution can be defined as the substitution of the machine for human skill, steam power for biological or muscle power, advances in mining and metallurgy (the making of iron and steel), and a new form of organization of production the factory system. These changes would bring about a quantitative and qualitative leap in production that would change the economy of a nation from agriculture to an industrial base. Those nations that underwent this revolution would have a huge increase in wealth, technology and power.
Why Europe first? Europe by the 1750s was already economically advanced beyond minimal subsistence with a money economy and large amounts of capital raised by trade and commerce. Population takeoff was already occurring before the Industrial Revolution providing both labor and a growing market of consumers. Great Britain, for example, had a growing merchant marine and overseas markets for goods produced at home as well as a stable political situation and a prevalence of the rule of law. In effect, Great Britain and later Western Europe was faced with growing markets at home and abroad and a need to boost production to meet this need. There is nothing like the promise of great wealth to motivate individuals to invent and create tools and eventually machines to raise production to meet the needs of growing markets. The textile industry was the first to be industrialized and during the course of the 18th century we see the invention of machine after machine for this industry tremendously boosting production. The result was between 1780 in 1800 Great Britain would be the first to begin the process of industrialization and see its economy take off. This would eventually spread to the rest of Western Europe. By the early 19th century Britain was out producing the world in textiles.
The impact of industrialization would bring great change. In effect we see the beginning of the modern world with urbanization and the growth of modern cities. Great power and wealth would result that would translate to bigger and better armies and navies utilizing the most advanced weaponry leading to the age of imperialism. As will later be discussed urbanization, the growth of cities and the creation of factories would bring about a health crisis because of overcrowding and the introduction of new diseases. At the same time growing wealth could be taxed and governments at the local and national level would have the wherewithal to deal with health crises and provide resources for research and development including the study of diseases and their causes along with the expansion of the hospital system.
Cholera, Tuberculosis and Cities in the 19th Century.
As mentioned above, urbanization led to overcrowding in European cities overwhelming whatever health services existed. Virtually all of these cities in the early 19th century had no proper sewer systems or means of providing clean water. Going back to 3000 B.C.E. cities had always been an unhealthy place to live and were the places where epidemic diseases began. At the beginning of the 19th century these newly overcrowded cities became perfect for the growth of cholera that began in India, spread by steamboat through the Middle East, thence to Europe and finally across the Atlantic to US cities and then into the American West to become just another disease to decimate the Indians. Western Indians would call cholera the shitting sickness. To make matters worse, cholera would come in about a half a dozen waves during the course of the 19th century. Cholera is a Bacillus that could exist outside its host, surviving in water, eventually entering the body through drinking water that was contaminated. Using a medical/public-health term cholera would follow the so-called fecal/oral route where someones excrement would wind up in someone elses mouth. The Bacillus also had the ability to survive stomach acids in the body causing vomiting, diarrhea, fever and eventual death, mostly through dehydration. It had a high mortality rate. For example in 1831 Cairo Egypt lost 13% of its population to cholera.
Another disease that always had been endemic but began to peak in the 19th century was tuberculosis. Invading the body and mostly affecting the lungs tuberculosis found 19th century cities with their overcrowding, lack of sunshine and fresh air, and weakened immune systems of city dwellers the perfect place to spread. There are many 19th century examples of fiction where the hero or heroine is dying from consumption (TB). The famous opera by Puccini, La Boheme is a good example of this.
Public Health and Sanitation In the 19th Century.
In the first half of the 19th century we begin to see the development of a public health movement that would lay the foundation for the fight against disease as physicians and public health officials were coming closer and closer to the real cause of disease. Plague had disappeared in Europe and typhus was becoming less of a killer, in large part because there was no major war fought on the European mainland from 1815 to 1914. Cholera, tuberculosis and typhoid continued with yellow fever being a problem in the New World. There was growing realization that filth and disease went hand-in-hand and we see something that would become known as the filth theory of disease that was being developed in European cities. Places like jails, because of filth, were sources of disease and in a sense the public health movement started with cities and nations trying to clean them up.
The old miasmatic theory that supported the idea of disease spread by bad air fit in with the filth theory of disease as filthy conditions in cities certainly resulted in very smelly air, sometimes affecting a whole city. Periodically London would be covered with a great stench and it was easy to associate bad smell with illness and disease. By dealing with the causes of bad odors disease could possibly be prevented. Ironically, even though this filth theory of disease was not correct as it left out biological causes, attempts to try to clean things out inadvertently did kill disease agents.
One of the most important reformers who pushed this filth theory of disease and call for the cleanup of cities was Edwin Chadwick (1800-1890). Chadwick, while investigating slum conditions contracted typhus and made the connection between slums and disease. In 1838 he participated in a London study on epidemic outbreaks and then in 1839 he participated in a commission that studied the same problem for the nation as a whole. In 1842 he published Sanitary Conditions of the Laboring Population of Great Britain. This publication led to a wave of sanitary reforms. It blamed atmospheric impurity as the cause of epidemic disease reflecting the frightfully unsanitary conditions in cities of that day. There were very few public toilets or even private toilets resulting in the use of chamber pots which were often dumped into the streets or in the basements of buildings. A survey reported on two houses in London: I found the whole area of the cellars of both houses full of night soil [excrement], to the depth of 3 feet, which had been permitted for years to accumulate… upon being removed, the stench was intolerable, and no doubt the neighborhood must have been more or less affected by it. The important issue was government had responsibility to help the poor and clean up the cities. With the increased wealth that could be taxed government could now do something about this problem of public sanitation.
For most big cities, it came down to the lack of sewer systems and the provision of clean water.
An important report published by the physician John Snow (1813-1858) proved that dirty water was the source of cholera. The initial report published in 1849 was a 31 page pamphlet titled:On the Mode Of Communication Of Cholera. After the 1854 London cholera outbreak he published an enlarged edition of his pamphlet which is considered the first important work of epidemiology. Epidemiology is the study of the incidence of disease in a given population and in a sense John Snow began the science of epidemiology with his classic study. In areas of London he traced the spread of cholera and concluded it travels with people with the disease having to be swallowed and he blamed individuals on their lack of clean habits in overcrowded dwellings. He also traced the spread of the disease through water by creating what was later to be called the ghost map which showed over 500 fatalities in 10 days around a single street pump. When the handle was removed from this pump, incidents of cholera ceased. A later investigation showed that when the area around the pump was dug up there was evidence of pollution. He was also able to show that one of the several water companies were actually providing polluted water. In effect, this water company was using water polluted by human waste.
In the summer of 1858 London suffered a heat wave along with drought. The result was the great stink as the Thames River became so noxious to be almost unbearable. London, a city of 3 million people, needed a sewer system. A project to build such a system was turned over to Joseph William Bazalgette (1819 1892), chief engineer of the Commissioner of sewers. The challenge was to build some 1200 miles of sewers that could carry away every particle of waste generated by the London population. The sewer tunnels used 318 million bricks in the digging up of 3.5 million cubic yards of dirt. Bazalgette succeeded brilliantly and by 1875 London had a completely brand-new sewer system.
Toward the Germ Theory.
The idea of the germ theory as to the true cause of disease was only proven in the last quarter of the 19th century but there is indication that earlier researchers and thinkers were slowly coming close to this conclusion. In the 16th century Fracastorius in his Of Contagion refer to seeds or germs. The Dutch draper, Antony von Leeuwenhoek, in the 17th century helped develop the instrument, the microscope, that would enable future researchers to actually see germs. The philosopher, René Descartes, who was familiar with the work of Leeuwenhoek speculated that there was a world of a minute living organisms not seen by the naked eye. In the 18th century Marcus Anton von Plenciz (1705-86) in his Opera Medico-Physica (1762) supported the idea of contagion and referred to the concept of a biological basis for communicable disease. He believed that each disease had its own worm like animaliculae.
In the 19th century there was a rush of research closing in on the idea of the germ theory. .F.G. Henle (1809-85) in his Handbook of Rational Pathology published in 1840 linked the causation of disease to organic elements consisting of individual living units which practiced self reproduction. In 1850 Casimir Davaine (1812 1882) and Pierre Bayer ( 1793 1867) discovered the anthrax bacillus in the blood of dying animals. The stage was now set for the real breakthrough that would come with Louis Pasteur.
Louis Pasteur, Robert Koch and the Germ Theory.
Louis Pasteur (1822-1895) would be the one to prove conclusively through experimentation of the true cause of disease germs and other micro-organisms (the germ theory). One simply has to look at his tomb to see his discoveries as follows: molecular dissymmetry (important to chemistry); fermentation (1857); spontaneous generation (disproving it in 1862); diseases of wine (1863); diseases of silkworms (1865); microorganisms in beer (1871); the germ theory (1877); preventative vaccinations ( 1880); and cure of rabies (1885).
Pasteurs work on fermentation and diseases of wine, beer and silkworms had great economic impact as these industries were important to the economy of France. His work on fermentation may have led to his understanding of the germ theory. Fermentation is a process in which sugar is turned into alcohol to make beer, wine, and other spirits. Up to this time it was thought that this was a chemical process but he was leading the way to show that it was a biological one in which a living organism does the work. In effect, if the wrong biological organism involves itself in the process of fermentation the result is a spoiling of the product whether it be beer or wine. His discoveries on fermentation would lead to his discoveries of the action of biological organisms in a study of diseases of wine, silkworms, and beer. One could take the next step in that if it is such a biological organism such as a germ can cause damage to beer or wine could not a similar organism do the same to humans in effect promote the growth of disease. In 1877 Pasteur presented these ideas in The Theory of Germs and Their Application to Medicine and Surgery
Pasteurs successes in leading the way to disease causation was followed rapidly by discovery after discovery of specific germs that caused specific diseases. Following will be a discussion of Pasteurs chief rival, Robert Koch, who not only isolated the germs causing tuberculosis and cholera but also came up with his famous axioms on disease causing organisms.
Robert Koch (1843-1910) was a German country physician who would make many discoveries such as his 1876 work on anthrax proving that it was caused by a specific organism. In 1879 he discovered the bacteria causing wound infections after which he issued his famous axioms as follows: one the bacterial organism should be found in each case of the disease; two it should not be found in any other diseases; three it should be isolated; four it should be cultured; five it should, when inoculated, produce the same disease; six the same bacterial organism should be recovered in the inoculated animals.
In 1882 Koch discovered the bacillus causing tuberculosis and was able to cultivate it. In 1883 in a trip to Egypt Koch discovered the cholera bacillus and came up with a way of prevention by boiling water. In 1905 Koch won the Noble prize in medicine. Soon after others began to isolate specific germs for specific diseases and there was a realization by the 1890s that certain microorganisms passed through filters and were not viewable under a microscope this was a reference to viruses. The bottom line was that the true cause of epidemic disease was now discovered and thus for the first time in history the way was open for the conquest of epidemic disease.
Advances in Hospital Medicine in the 19th Century.
In addition to the advances of Pasteur and Koch the 19th century witnessed important advances in hospital medicine. Medicine was now centered around the hospital not the library or university. With the autopsy room, laboratory medicine, the Hospital clinic and such specialties as histology, pathology, physiology, and pharmacology we begin to see medicine essentially as we have it today. French hospitals would lead the way based on three pillars. The first is the physical diagnosis which included physical inspection, palpation, percussion and ausculation. Inspection is the most basic way to look at a patient including examination of the tongue, eyes and skin. Palpation involved locating disease under the skin including feeling for lumps or problems in organs. Percussion involved tapping on the chest or abdomen to determine when the heart, liver, or any other organs where enlarged or there was an accumulation of fluids. Ausculation would involve listening for sounds inside the body and this led to the invention of the stethoscope.
The second pillar involved the use of autopsy to allow the physician to correlate the original diagnosis and cause of death. For example, if the patient was diagnosed with heart disease and subsequently died of a heart attack an autopsy would reveal a damaged heart proving that the diagnosis was correct.
The third pillar involved statistics that allowed physicians and researchers to study a large enough sample of patients and diseases to make some sense of what was going on and whether treatments were working or not. The hospital was the best place for this as physicians could study relatively large numbers of patients as opposed to a physicians private practice. In my own hospital experience we had large departments involved in quality control where statistics were kept to help point to trends that would provide useful information. Here again French hospital led the way. For example the hospitals of Paris had more beds than existed in all of Great Britain so concentrated studies could be done in one city.
The 19th century, at least for Europe, would end with real hope in dealing with epidemic disease and advancing the science of medicine.
Documents
1-Chronology
2-Document on World Population