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THE NINETEENTH CENTURY MEDICAL REVOLUTION
by Dr. I. Carr
PATHOLOGY
The founder of pathology was Giovanni Batista Morgagni (1682-1771),
professor of medicine and anatomy at Padua for 56 years. He published at
the age of 79 the De Sedibus Causis Morborum containing accounts of
aneurysm, acute yellow atrophy of the liver, heart block and valvular
disease of the heart, pneumonia and the connection between miliary disease
and cerebral abscess. He detailed the case histories and pathological
appearances of no less than 700 cases.
A man who had been too much given to the exercise of tennis and
the abuse of wine, was, in consequence of both these
irregularities, seized with a pain of the right arm, and soon
after of the left, joined with a fever. After these there appeared
a tumour on the upper part of the sternum, like a large boil. The
patient came into the Hospital of Incurables, at Bologna ... in
the year 1704. The swelling on ...the chest wall was equal in size
to a quince...and began to exsude blood in one place ... very near
having broken through the skin ... He (being quite ignorant of the
danger which was at hand) began to pull off the bandages, for the
sake of showing his disorder. But his circumstance being observed,
he was prevented going on, and ordered to keep himself still, and
to think seriously and piously of his departure from this mortal
life, which was very near at hand, and inevitable. On the day
following, he felt the blood gushing forth, and had the presence
of mind not only to commend himself to God, but to take up with
his own hands a basin that lay at his bed-side; and, as if he had
been receiving the blood of another person, put it beneath the
gaping tumour, while the attendants immediately ran to him as fast
as possible, in whose arms he soon expired.
On examining the body before I dissected it, I saw that there was
no longer any tumour, inasmuch as it had subsided after the blood,
by which it had been raised up externally, and had been
discharged. The skin was there broken through, and the parts that
lie beneath it with an aperture, which admitted two fingers at
once....In both the cavities of the thorax, also, was a great
quantity of water, of a yellowish colour. And there was a large
aneurism, into which the anterior part of the curvature of the
aorta itself being expanded, had partly consumed the upper part of
the sternum, the extremities of the clavicles which lie upon it,
and the neighbouring ribs, and partly had made them diseased, by
bringing on a caries.
Morgagni had no microscope. Microscopes were needed for further advance in
pathology. Marcello Malpighi (1628-1694) of Bologna saw capillaries in the
frog's lung and completed Harvey's discovery of the circulation. He also
saw the layers of the skin, white pulp of the spleen and renal glomeruli.
Athanasius Kircher (1602-1680) studied the blood of plague patients and saw
countless masses of small worms - red blood corpuscle. He described
striations in muscle fibres, bacteria and protozoa. Rudolph Virchow
(1821-92) brought the microscope to pathology and showed that cell changes
were the centre of the alterations of the tissues in disease. Omnis cellula
e cellula.
THE MEDICAL AND SURGICAL REVOLUTIONS
The next steps were the demonstrations that disease was caused by
micro-organisms, and that immunity could be provided. In 1835 Bassi showed
that a disease of silk worm was due to a fungal infection and in 1839
Schonlein showed that a human skin disease, favus, was due to a fungal
infection. The man who revolutionised our understanding of disease by
finding bacterial causes was Louis Pasteur (1822-95). Pasteur was a French
microbiologist who made his name initially investigating a disease of
silkworms.
Pasteur described his great discovery, immunization against rabies.
A dog may be rendered refractory to rabies in a relatively short
time in the following way:
Every day morsels of fresh infective spinal cord from a rabbit
which has died of rabies developed after an incubation period of
seven days, are suspended in a series of flasks, the air in which
is kept dry by placing fragments of potash at the bottom of the
flask. Every day also a dog is inoculated under the skin with a
Pravaz' syringe full of sterilized broth, in which a small
fragment of one of the spinal cords has been broken up, commencing
with a spinal cord far enough removed in order of time from the
day of the operation to render it certain that the cord was not at
all virulent. (This date had been ascertained by previous
experiments). On the following days the same operation is
performed with more recent cords, separated from each other by an
interval of two days, until at last a very virulent cord, which
has only been in the flask for two days, is used. The dog has now
been rendered refractory to rabies.
Joseph Meister, aged 9 years, also bitten on July 4th, at eight
o'clock in the morning, by the same dog. This child had been
knocked over by the dog and presented numerous bites, on the
hands, legs, and thighs, some of them so deep as to render walking
difficult. The principal bites had been cauterized at eight
o'clock in the evening of July 4th, only twelve hours after the
accident, with phenic acid, by Dr. Weber, of Ville.
The third person, who had not been bitten, was the mother of
little Joseph Meister.
At the examination of the dog, after its death by the hand of its
master, the stomach was found full of hay, straw, and scraps of
wood. The dog was certainly rabid. Joseph Meister had been pulled
out from under him covered with foam and blood.
The death of this child appearing to be inevitable, I decided, not
without lively and sore anxiety, as may well be believed, to try
upon Joseph Meister the method which I had found constantly
successful with dogs ...
Consequently, on July 6th, at 8 o'clock in the evening, sixty
hours after the bites on July 4th, and in the presence of Drs.
Vulpian and Grancher, young Meister was inoculated under a fold of
skin raised in the right hypochondrium, with half a
Pravaz'syringeful of the spinal cord of a rabbit, which had died
of rabies on June 21st. It had been preserved since then, that is
to say, fifteen days, in a flask of dry air.
In the following days fresh inoculations were made. I thus made
thirteen inoculations, and prolonged the treatment to ten days. I
shall say later on that a smaller number of inoculations would
have been sufficient. But it will be understood how, in the first
attempt, I would act with a very special circumspection...
On the last days, therefore, I had inoculated Joseph Meister with
the most virulent virus of rabies, that, namely, of the dog,
reinforced by passing a great number of times from rabbit to
rabbit, a virus which produces rabies after seven days incubation
in these animals, after eight or ten days in dogs ...
Joseph Meister, therefore, has escaped, not only the rabies which
would have been caused by the bites he received, but also the
rabies with which I have inoculated him in order to test the
immunity produced by the treatment, a rabies more virulent than
ordinary canine rabies. The ethical implications are evident; the
lesson --- medical ethics change.
We owe clean surgery to Joseph Lister (1827-1912) who after training in
London and Edinburgh in 1860 became professor of surgery at the Royal
Infirmary, Glasgow. Patients then faced danger equal to the battlefield
when they went into the operating theatre. Lister had read Pasteur's
papers and came to the conclusion that wound sepsis and putrefaction in wine
were similar processes. He therefore applied phenol (carbolic acid), a
potent antiseptic, directly to wounds and sprayed it into the air. He tried
out his new treatment on compound fractures, saving 9 of 11 limbs, losing
only one patient. Prior to this time compound fractures necessitated
amputation and were often fatal.
In the course of the year 1864 I was much struck with an account
of the remarkable effects produced by carbolic acid upon the
sewage of the town of Carlisle, the admixture of a very small
proportion not only preventing all odour from the lands irrigated
with the refuse material, but as it was stated destroying the
entozoa which usually infest cattle fed upon such pastures.
James G., aged 11 years, was admitted into the Glasgow Royal
Infirmary, on the 12th of August, 1865, with compound fracture of
the left leg, caused by the wheel of an empty cart passing over
the limb a little below its middle. The wound, which was about an
inch and a half long, and three-quarters of an inch broad, was
close to, but not over, the line of a fracture of the tibia. A
probe, however, could be passed beneath the integument over the
seat of fracture and for some inches beyond it. Very little blood
had been extravasated into the tissues. My house-surgeon, Dr.
Macfee, acting under my instructions, laid a piece of lint dipped
in liquid carbolic acid upon the wound, and applied lateral
pasteboard splints padded with cotton wool, the limb resting on
its outer side, with the knee bent. It was left undisturbed for
four days, when, the boy complaining of some uneasiness, I removed
the inner splint and examined the wound. It showed no signs of
suppuration, but the skin in its immediate vicinity had a slight
blush of redness. I now dressed the sore with lint soaked with
water having a small proportion of carbolic acid diffused through
it; and this was continued for five days, during which the
uneasiness and the redness of the skin disappeared, the sore
meanwhile furnishing no pus, although some superficial sloughs
caused by the acid were separating. But the epidermis being
excoriated by this dressing, I substituted for it a solution of
one part carbolic acid in from ten to twenty parts of olive oil,
which was used for four days, during which a small amount of
imperfect pus was produced from the surface of the sore, but not a
drop appeared from beneath the skin. It was now clear that there
was no longer any danger of deep-seated suppuration, and simple
water dressing was employed. Cicatrization proceeded just as in an
ordinary granulating sore. At the expiration of six weeks I
examined the condition of the bones, and, finding them firmly
united, discarded the splints; and two days later the sore was
entirely healed, so that the cure could not be said to have been
at all retarded by the circumstance of the fracture being
compound. Two of Lister's dressers (assistants) Blanchard and
Chown were pioneer Winnipeg surgeons.
By 1870 Pasteur had proven the microbial aetiology of bacterial diseases in
silkworms. Pasteur's German rival contributed equally to the development
of bacteriology. Robert Koch (1843-1910) was a family physician, who
stimulated by clinical experience of an outbreak of anthrax, began to
investigate its aetiology.
Koch developed what have become the standard techniques for culture of
bacteria, in particular the use of solid agar media. By these he
demonstrated that a specific sporing bacillus was the cause of anthrax, and
in 1882 demonstrated the cause of tuberculosis. The criteria which he used
for proof of bacterial aetiology are now known as Koch's postulates.
To prove that tuberculosis ...is caused by invasion of bacilli and
the growth and multiplication of bacilli, it was necessary to
isolate the bacilli from the body; to grow them in pure
culture...; and, by administering the isolated bacilli to animals,
to reproduce the same morbid condition....
In 1885 Koch became Professor of Hygiene in the University of Berlin, from
which in 1890, he announced his discovery of tuberculin, at first a secret
formula, and later described as a glycerin extract of tubercle bacilli. He
believed at first that this would prove effective in the treatment of human
tuberculosis; amid much controversy, this proved not to be so.
The treatment of tuberculosis remained unsatisfactory ; patients were
isolated for long periods in sanatoria, in conditions which were at once
rigorous and non-specifically favourable. In the 1920's a vaccine, BCG came
into use in the prevention of childhood tuberculosis; streptomycin was
discovered in 1943. The techniques evolved by Pasteur and Koch and
elaborated by many others, led to the proof of the bacterial cause of much
human disease during the subsequent fifty years.
The idea that there were smaller infective agents than viruses came from
work on the mosaic virus of the tobacco plant, which was proved to pass
through a fine filter, by Mayer and Ivanovski working separately over the
ten years from 1886. Extensive proof of the viral aetiology of human disease
depended on the development of satisfactory techniques for tissue culture in
the early part of the twentieth century.
ANAESTHESIA
Anaesthesia started in North America. Various potions including opiates and
alcohol have been used since ancient times to dull pain and lull into sleep.
The hypnotic effect of ether, "sweet vitriol", has been known since the
sixteenth century, but the first effective anaesthetic dates back only to
1842.
In that year Crawford Long, a physician in the small town of Jefferson,
Georgia noticed that when people inhaled ether as a "recreational" drug,
they became insensitive to pain. He removed a tumour from a patient's neck
under ether anaesthesia, but did not immediately publicize his discovery.
Two or three years later others, Wells, Morton and Jackson tried first
nitrous oxide then ether for first dental and then other purposes. Over the
years Congress voted $100,000 to the inventor of anaesthesia; but there was
profound disagreement as to who the inventor was.
Long wrote some time later:
In the month of December, 1841, or January, 1842, the subject of
the inhalation of nitrous oxide gas was introduced in a company of
young men assembled at night, in the village of Jefferson, Ga.,
and the party requested me to prepare them some. I (Long) informed
them that I had not the requisite apparatus for preparing or using
the gas, but that I had an article (sulphuric ether), which would
produce equally exhilarating effects and was as safe. The company
was anxious to witness its effects: the ether was produced, and
all present, in turn, inhaled. They were so much pleased with its
effects that they afterwards frequently used it and induced others
to use it, and the practice became quite fashionable in the
country and some of the contiguous counties. On numerous occasions
I inhaled the ether for its exhilarating properties and would
frequently at some short time subsequently discover bruises or
painful spots on my person which I had no recollection of causing,
and which I felt satisfied were received while under the influence
of ether. I noticed my friends while etherized, receive falls and
blows, which I believed sufficient to cause pain on a person not
in a state of anaesthesia, and, on questioning them they uniformly
assured me that they did not feel the least pain from these
accidents.
Observing these facts I was led to believe that anaesthesia was
produced by the inhalation of ether and that its use would be
applicable in surgical operations.
The first person to whom I administered ether in a surgical
operation was Mr. James M. Venable, who then resided within two
miles of Jefferson, and at the present time in Cobb county, Ga.
Mr. Venable consulted me on several occasions as to the propriety
of removing two small tumors on the back part of his neck, but
would postpone from time to time having the operating performed
from dread of pain. At length I mentioned to him the fact of my
receiving bruises while under the influence of the vapor of ether,
without suffering, and, as I knew him to be fond of and accustomed
to inhale ether, I suggested to him the probability that the
operation might be performed without pain, and suggested to him
operating while he was under its influence. He consented to have
one tumor removed and the operation was performed the same
evening. The ether was given to Mr. Venable on a towel and fully
under its influence, I extirpated the tumor. It was encysted and
about one-half an inch in diameter. The patient continued to
inhale ether during the time of the operation, and seemed
incredulous until the tumor was shown to him. He had had no
evidence of pain during the operation and assured me after it was
over that he did not experience the least degree of pain from its
performance ...
The discovery soon crossed the Atlantic and was first used in the University
College Hospital, London, 1846. It was followed a year later by chloroform
introduced in Edinburgh by James Young Simpson.
PREVENTIVE MEDICINE
Up till 1800 human communities existed with very little control of public
health. There were some municipal regulations against the disposal within
towns of sewage and garbage and during plagues municipal officials were
appointed to seek out cases, but there was little organization or
enforcement. Cities of the European Industrial Revolution were overcrowded
and had poor water supplies. In the early 19th century over half a million
people in London got their water from stand pipes in the street. Excrement
was discharged into open sewers. Epidemic cholera and typhoid were frequent
and the rates of morbidity and mortality among the general population, and
especially among infants were high. These things happened early in England,
which was an early country to industrialize. Poor relief cost so much that
a number of Royal Commissions were set up to look into various public health
matters. These investigations were supported by the leading humanitarians of
the day, notably a lawyer named Edwin Chadwick, who led the agitation for
control of public health. This started in Britain with the 1848 Public
Health Act. There was a major epidemic of cholera in London in 1854; Dr
John Snow demonstrated that many cases occurred among people who drank water
from a pump in Broad Street; those who obtained water from other pumps did
not contract the disease. The pump handle was removed and in that area
there were no more cases of cholera. When adequate water supplies and
sewage systems were installed and slums were cleared, the epidemics abated.
John Snow was also a pioneer in surgical anaesthesia.
VACCINATION
Smallpox was the most virulent of the infectious diseases, with a mortality
rate well over 50% in previously unexposed populations. Attempts at
prevention were made in the early eighteenth century by inoculation with pus
from active cases of smallpox. This process, variolation, was often
effective, but was lethal in a significant proportion of patients.
Edward Jenner (1749-1823), a Gloucestershire physician, observed that local
country people believed that those who had had cow-pox would not contract
small-pox. Jenner vaccinated a boy James Phipps with material taken from a
cow-pox vesicle on the hands of a dairy maid and then showed that the boy
was immune to small-pox.
In this dairy country a great number of cows are kept, and the
office of milking is performed indiscriminately by men and maid
servants. One of the former having been appointed to apply
dressings to the heels of a horse affected with the grease, and
not paying due attention to cleanliness, incautiously bears his
part in milking the cows, with some particles of the infectious
matter adhering to his fingers. When this is the case, it commonly
happens that a disease is communicated to the cows, and from the
cows to dairy maids, which spreads through the farm until most of
the cattle and domestics feel its unpleasant consequences. This
disease has obtained the name of cow-pox. It appears on the
nipples of the cows in the form of irregular pustules.
Case I. Joseph Merret, now an under gardener to the Earl of
Berkeley, lived as a servant with a farmer near this place in the
year 1770, and occasionally assisted in milking his master's cows.
Several horses belonging to the farm began to have sore heels,
which Merret frequently attended. The cows soon became affected
with the cow-pox, and soon after several sores appeared on his
hands. Swellings and stiffness in each axilla followed, and he was
so much indisposed for several days as to be incapable of pursuing
his ordinary employment. Previously to the appearance of the
distemper among the cows there was no fresh cow brought into the
farm, nor any servant employed who was affected with the cow-pox.
In April, 1795, a general inoculation taking place here, Merret
was inoculated with his family; so that a period of twenty-five
years had elapsed from his having the cow-pox to this time.
However, though the variolous matter was repeatedly inserted into
his arm, I found it impracticable to infect him with it; an
efflorescence only, taking on an erysipelatous look about the
centre, appearing on the skin near the punctured parts. During the
whole time that his family had the smallpox, one of whom had it
very full, he remained in the house with them, but received no
injury from exposure to the contagion.
Case II. Sarah Portlock of this place, was infected with the
cow-pox when a servant at a farmer's in the neighborhood,
twenty-seven years ago.
In the year 1792, conceiving herself, from this circumstance,
secure from the infection of the smallpox, she nursed one of her
own children who had accidentally caught the disease, but no
indisposition ensued. During the time she remained in the infected
room, variolous matter was inserted into both her arms, but
without any further effect than in the preceding case.
Case XVII. The more accurately to observe the progress of the
infection I selected a healthy boy, about eight years old, for the
purpose of inoculating for the cow-pox. The matter was taken from
a sore on the hand of a dairymaid, who was infected by her
master's cows, and it was inserted on the 14th day of May, 1796,
into the arm of the boy by means of two superficial incisions,
barely penetrating the cutis, each about an inch long.
On the seventh day he complained of uneasiness in the axilla and
on the ninth he became a little chilly, lost his appetite, and had
a slight headache. During the whole of this day he was perceptibly
indisposed, and spent the night with some degree of restlessness,
but on the day following he was perfectly well.
In order to ascertain whether the boy, after feeling so slight an
affection of the system from the cow-pox virus, was secure from
the contagion of the smallpox, he was inoculated the 1st of July
following with variolous matter, immediately taken from a
pustule. Several slight punctures and incisions were made on both
his arms, and the matter was carefully inserted, but no disease
followed.
The practice spread within two years and by the time of Jenner's death in
1823 was being used in many countries around the world.
by Dr. Ian Carr icarr@cc.umanitoba.ca
