Treating Bodies and Minds: Health Care
Treating Bodies and Minds: Health Care
Dirt and Disease. Population growth, urbanization, and industrialization vastly increased health problems in Europe between 1750 and 1914. Dirt from coal smoke darkened buildings and their surroundings, already muddy from unpaved streets. Crowding exacerbated sanitation problems in the cities and industrial districts. Coal fumes joined the smells of garbage and human and animal waste, which littered the streets, particularly in poorer areas, and contaminated the drinking water, already in short supply in most cities. Disease preyed on malnourished urban populations, leading to spectacular declines in life expectancy among the lower classes, especially during catastrophic natural disasters such as the European Potato Blight of the late 1840s. In 1840 in Manchester, England, high rates of infant mortality lowered the average life span among the working class to only seventeen years, whereas the average for all England was forty years. Scientists were slow in understanding how poor sanitation affected human health, and even after scientists applied their knowledge to solving these problems, it took a long time for governments to implement solutions. By the eve of World War I, however, Europeans of all classes were living longer and healthier lives than they had 150 years earlier, paving the way for much greater and more widespread improvements after the war.
Smallpox Prevention. For millennia, many natural substances had been known to be effective against disease. The practice of inoculation—the injection of a weakened form of a disease to prevent a more drastic occurrence of it—had been practiced since the Renaissance. In 1798 English physician Edward Jenner (1749-1823) took the first step in controlling the deadly disease smallpox by injecting cowpox, a milder form of the disease, into a healthy individual as a means of creating a resistance to it and preventing the more-virulent smallpox. The effectiveness of Jenner’s new vaccination was hotly debated by his contemporaries because nearly everyone believed that people contracted diseases when they breathed odors of decay or putrefying excrement (the miasmatic theory of disease). Yet, vaccination slowly became standard practice throughout western Europe. The British Parliament signaled its acceptance with the Vaccination Act of 1853. The development of a smallpox vaccination was the culmination of centuries of trial and error rather than the product of a scientific understanding of why this method worked. Only in the later nineteenth century did directed scientific inquiry discover how antigens (bacteria or viruses) cause diseases.
From his observations while working in London and Edinburgh hospitals, British physician Joseph Lister concluded that cleanliness was essential to preventing postsurgical infections. The following excerpt from his “On the Antiseptic Principle of The Practice of Surgery” (1867) describes how he was influenced by the “germ theory” of French scientist Louis Pasteur to devise a method for reducing the number of such infections.
In the course of an extended investigation into the nature of inflammation, and the healthy and morbid conditions of the blood in relation to it, I arrived several years ago at the conclusion that the essential cause of suppuration in wounds is decomposition brought about by the influence of the atmosphere upon blood or serum retained within them, and, in the case of contused wounds upon portions of tissue destroyed by the violence of the injury.
To prevent the occurrence of suppuration with all its attendant risks was an object manifestly desirable, but till lately apparently unattainable, since it seemed hopeless to attempt to exclude the oxygen which was universally regarded as the agent by which putrefaction was effected. But when it had been shown by the researches of Pasteur that the septic properties of the atmosphere depended not on the oxygen, or any gaseous constituent, but on minute organisms suspended in it, which owed their energy to their vitality, it occurred to me that decomposition in the injured part might be avoided without excluding the air, by applying as a dressing some material capable of destroying the life of the floating particles....
The material which I have employed is carbolic or phenic acid, a volatile organic compound, which appears to exercise a peculiarly destructive influence upon low forms of life, and hence is the most powerful antiseptic with which we are at present acquainted....
There is, however, one point more than I cannot but advert to, viz., the influence of this mode of treatment upon the general unhealthiness of an hospital. Previously to its introduction the two large wards in which most of my cases of accident and of operation are treated were among the unhealthiest in the whole surgical division of the Glasgow Royal Infirmary, in consequence apparently of those wards being unfavorably placed with reference to the supply of fresh air, and I have felt ashamed when recording the results of my practice, to have so often to allude to hospital gangrene or pyaemia. It was interesting, though melancholy, to observe that whenever all or nearly all the beds contained cases with open sores, these grievous complications were pretty sure to show themselves; so that I came to welcome simple fractures, though in themselves of little interest either for myself or the students, because their presence diminished the proportion of open sores among the patients. But since the antiseptic treatment has been brought into full operation, and wounds and abscesses no longer poison the atmosphere with putrid exhalations, my wards, though in other respects under precisely the same circumstances as before, have completely changed their character; so that during the last nine months not a single instance of pyaemia, hospital gangrene, or erysipelas has occurred in them.
As there appears to be no doubt regarding the cause of this change, the importance of the fact can hardly be exaggerated
Source: Charles W. Eliot, ed., Scientific Papers: Physiology, Medicine, Surgery Geology (New York: Collier, 1897), pp. 271, 281-282.
Malaria. One disastrous and unforeseen result of imperial expansion was the spread of malaria among European colonists. This disease decimated people of European descent who entered the interior of Africa. It is likely that malaria (from the Italian mal’aria, or bad air) has killed more humans than any other disease. In 1880 French scientist Alphonse Laveran (1845-1922) isolated the protozoan that causes the disease. In 1897-1898 British physician Ronald Ross (1857-1932) and the Italians Giovanni Batista Grass! (1853-1925) and Amico Bignami (1862-1929) identified that the disease is spread by the Anopheles mosquito. Before scientists had finally determined the cause of malaria, trial and error
had already produced an effective treatment for it. In the seventeenth century Jesuit priests had brought to Europe a treatment for one strain of malaria—the bark of the cinchona tree, which grows only in the Andes Mountains of South America. The practical breakthrough in treating malaria came in 1820 when two French chemists, Pierre-Joseph Pelletier (1788-1842) and Joseph-Bienaime Caventou (1795-1877), finally determined how to extract a key alkaloid (quinine) from cinchona bark. By 1830 the drug was being manufactured in sufficient quantity for general use. Quinine was tested during the French invasion of Algeria (1830), but not until 1845 did doctors realize that the bloodstream needs to be saturated with quinine for best effect. Once dosages had been standardized, the interior of Africa was opened to exploitation by people of European descent.
Public-Health Policy. European outbreaks of cholera in 1832 and 1848-1849, along with the omnipresence of many other diseases in urban industrial Europe, pushed states and concerned individuals to devote increased attention to problems of public health. English Poor Law commissioner Edwin Chadwick (1800-1890) took the lead in publicizing urban decay and its attendant health risks. In response, Britain took the first steps toward cleaning up its cities by passing the Public Health Act of 1848, which set up a national-health board with broad authority to create modern sanitary systems. Chadwick and others emphasized the need for clean drinking water. During the 1840s and 1850s close observation by public-health officials, many of them doctors, revealed the limitations of the miasmatic theory of disease. Instead, they suggested that the vector of contagion for a disease was passed through excrement or decaying matter rather than by its odor. This observation set the stage for the bacterial revolution, which transformed the health of Europe and ultimately the world.
Germ Theory. The “germ theory of disease,” advanced by French chemist Louis Pasteur (1822-1895) during the mid nineteenth century, was embraced and applied almost immediately, with Germany leading the way. During the mid 1870s German physician Robert Koch (1843-1910) isolated pure strains of bacteria and detailed their characteristics. He later isolated the agents of tuberculosis (1882) and cholera (1883), while other researchers, most of whom were Germans working for large companies, identified the sources of many other diseases. This work made possible the development of effective vaccines and gave birth to the modern science of immunology. Around 1867, Pasteur’s germ theory also inspired English surgeon Joseph Lister (1827-1912) to add a chemical disinfectant to wound dressings to prevent infection from airborne bacteria.
Antiseptic Principle. Lister’s antiseptic principle was extended by German surgeons, who began to apply antiseptics to all materials in an operating room—including hands, instruments, and clothing—with clear and direct impact on a patient’s chance of survival. These methods significantly lowered the death rates for surgical patients and women in childbirth. Thanks to the bacteriological revolution, diphtheria, typhoid, typhus, cholera, bubonic plague, and yellow fever were largely eliminated in Europe. By 1890 the mortality rate in European urban areas was lower than in rural areas, and life expectancy had risen impressively. By 1913 both infant and child mortality had fallen to less than half of what they had been 150 years before.
Healthy Minds. In the late nineteenth century, some doctors took advantage of public support for new ideas associated with scientific medicine to focus on the workings of the human mind. Sexuality was investigated by such important figures as British physician Havelock Ellis (1859-1939). His landmark seven-volume study of sexual issues, the nature of gender, and the practice of homosexuality, Studies in the Psychology of Sex (1897— 1928), helped to create a new field called “sexology.” In Die Traumdeutung (1900; The Interpretation of Dreams) Austrian psychoanalyst Sigmund Freud (1856-1939) legitimized the study of dreams, emphasizing their sexual meanings.
Psychiatry. Freud wrote extensively on the nature of sexual desire, arguing that its repression could produce severe psychological consequences. Italian physician Cesare Lombroso (1835-1909) delved into the nature of the criminal mind; French psychologist Alfred Binet (1857-1911) developed tests to measure the capacity of the intellect; and Russian physiologist Ivan Pavlov (1848-1936) discovered how behavior could be modified by conditioned responses. Taken together, these inquiries and their results helped to found the modern scientific fields of psychology and psychiatry, which treated troubled or mentally ill individuals. The findings of these men also revealed the dark underside of the human psyche and undermined faith in human progress.
THE UNCONSCIOUS MIND
At the turn of the twentieth century Sigmund Freud’s the turn of the twentieth century Sigmund Freud’s theories about the workings of the unconscious mind began a revolution in the way mental-health workers treated their patients. The concept of the unconscious was not new, but earlier theorists tended to see it as subordinate to conscious mental processes. For example, Freud’s slightly older American contemporary William James described the unconscious as a “fringe” around the edges of conscious thought. For Freud, however, the unconscious was like the underwater part of an iceberg while the conscious was like the much smaller tip that extends above water. The unconscious, Freud said, is the realm of powerful, primitive, often sexual impulses that are frequently contrary to the morals and mores of the individual and society. In addition, he said that the unconscious is the place to which the individual banishes painful mental conflicts and memories. Freud called this process of “forgetting” repression and explained that the psyche also practices repression to keep painful thoughts and socially unacceptable urges from resurfacing in the conscious mind. According to Freud, as the psyche represses more and more, the individual begins to experience anxiety, hysteria, or various other forms of mental illness. Deciding that uncovering his patients’ unconscious thoughts was essential to effective treatment, Freud observed that they tended to come out in slips of the tongue, everyday mistakes, and dreams, where they were often distorted or veiled in a kind of psychic symbolism. Thus, he developed an elaborate system of dream interpretation. He also devised a form of “talk therapy” called psychoanalysis. Having theorized that repressed thoughts come out in dreams because the psyche relaxes its guard against them during sleep, Freud tried to create a dreamlike state in his patients by having them lie on a sofa and encouraging them to free-associate, saying anything that came to mind no matter how irrelevant, inappropriate, or immoral it seemed. Versions of Freud’s talk sessions are still part of the modern mental-health repertoire. Though the specifics of his theories have been challenged and in many cases disproved, they created a context in which later, more scientific, psychological studies could take place and provided metaphors that psychologists still employ in their discussions of human thought processes.
Source: Peter Gay, Freud: A Life for Our Time (New York &. London: Norton, 1988).
Institutions and Commercial Applications. In addition to improving public health through the regulation of water supplies and sewer systems and the construction of public baths and toilets, nation-states also increased access to medical education and treatment and supported medical research in institutions of higher learning or specialized facilities. Individuals and private charities also contributed to health research. Most new medicines, however, emerged from the close ties between big business and scientific researchers. Although Pasteur worked at public educational institutions of learning, his breakthroughs came in response to requests for assistance from brewers and the silk industry. The German researchers who identified diphtheria and tuberculosis worked for drug companies, which reaped vast profits from sales of vaccines to prevent these diseases. The invention of a tablet-making machine in Germany by a team of talented mechanics during the 1890s led to the marketing of name-brand drugs in precise doses, replacing concoctions mixed by local druggists. The combination of government patronage, private donations, and corporate sponsorship during the second half of the nineteenth century helped to create important improvements in the health of the European population. At the end of the initial era of industrialization (1750-1914) Europeans’ bodies, on average, were healthier than ever before, but, according to doctors such as Freud, their minds had never been more ill.
Theodore S. Hamerow, The Birth of a New Europe: State and Society in the Nineteenth Century (Chapel Hill: University of North Carolina Press, 1983).
Colin Heywood, Childhood in Nineteenth-Century France: Work, Health and Education among the ’classes populaires’ (Cambridge & New York: Cambridge University Press, 1988).
Joan Lane, A Social History of Medicine: Health, Healing and Disease in England, 1750-1950 (London & New York: Routledge, 2001).
Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity—from Antiquity to the Present (London: HarperCollins, 1997).